Linking Quality to Health Care’s “2nd Curve”

From Innovation to Transformation: Delivering and Sustaining Results

Institute of Public Administration of CanadaQuality Healthcare Network

Minto Suites HotelOttawa, Ontario21 January 2011

Martin D. Merry, MD, CMAdjunct Associate Clinical Professor of Health Management and Policy

University of New Hampshire

Faculty, American College of Physician ExecutivesFaculty, Center for Healthcare Governance, American Hospital Association

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An Invitation

“No problem can be solved from the same level of consciousness that created it. We must learn to see the world anew.”

- Albert Einstein

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1st

2nd

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1st Curve Founders: “The Four Doctors”

Welch

Halsted

Osler Kelly

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“The most important event in the history of

American and Canadian medical education”

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"... for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefitting from the encounter."

1912 : The 'Great Divide'

Harvard Professor L. Henderson

(Harris, Richard. A Sacred Trust. New York, NY: New American Library, 1966)

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Time

Circa 1910

2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)

(Bifurcation curve: 2011)

First Curve/ 4 sigma

(Craft-Age Culture)

(Craft+Information-Age Culture )

-

Future Performance (Second Curve/

6+ Sigma)

“Crossing the Chasm”

Per

form

ance

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1st Curve Health Care’s Performance Problem

1st Curve Health Care (Craft Culture)90% OK 100,00095% OK 50,00099% OK 10,000

Sigma Defects per million

1 690,000

2 308,000

3 66,800

4 6,210

5 230

6 3.4

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1st Curve LegacyMedical errors as 5th-8th leading cause of

death in US

44,000 – 98,000 deaths annually

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May 25, 2004: We learn that Canada, too, is “infected.”

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The 21st Century/ 2nd Curve Flexner Report?

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Columns 2 & 3 = 2nd Curve

Regulation Hammurabi

Legal system

State Boards

JCAHO

“Inspection”

Fed/State/Provincial regs

EMTALA, HIPAA, Etc.

LHINs, ECFAA

Medical Science

Hippocrates

Nightingale, 4 doctors

Flexner, Codman, ACS/Hospital

Standardization

M&M conferences

Donabedian,structure process, outcome

Outcomes, Disease

management

Evidence based care, Hospitalists

Management Science

Industrial Revolution

Taylor: “Scientific

Management”

Shewhart

Deming, Juran, Total Quality

Complexity theory

Six Sigma, Safety Mgt, Lean, Appreciative Inquiry, Resilience

Columns 2+3 = 2nd Curve

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What we MUST understand: The emergence of 2nd Curve Health Care represents a Management, not Clinical paradigm shift. This fact has huge implications for leaders at all levels of the organization.

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How 2nd Curve Is HappeningEvidence-based medicine

Clinical protocols “Disease-Line” ManagementRapid cycle PDCA Lean Six Sigma IT:EHR, TelehealthClinical Microsystem DesignTeam-based care New models of System-

Community relationshipsCommunity health innovation Strength based change (e.g., Appreciative Inquiry)

Health Care’s beginning ascent of its 2nd Curve:

Re-designing care systems around those served – while restoring the “joy of practice” to caregivers

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Board of Trustees

• Credentialing• Departmental (Peer)

Review• Surgical Case Review• Blood UR• Drug Usage Review• Pharmacy and

Therapeutics• Medical Records

Medical Staff Functions(“Silo 1”)

• Nursing• Ancillary• Laboratory• Radiology• Physiotherapy• Risk Management• Finance, Planning• Regulatory Agencies• Etc.

Hospital Functions(“Silo 2”)

Chief Executive Officer

Medical Staff Executive Committee

Our Structural Heritage, 1917-2011 Our structural “fatal flaw”

Management:Departments

Physicians:Specialties

2011: The Structure Hierarchy, Fragmentation, Communication gaps,

Misunderstanding, Power Struggles, etc.

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Fast Forward: Community Memorial Hospital, Menomonee Falls,

Wisconsin

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Car

diop

ulm

onar

y C

are

Obstetrics, Gynecology,

Perinatology,Pediatrics,

Neonatology

Management and Coordination of Care

Participation

Leadership Patient/Community

Primary CareInternal Medicine, Medical

Specialties, Family Practice,

Hospitalist, Psychiatry,

Emergency Medicine*

Women & Children

Care

Management

Design

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COMMUNITY MEMORIAL HOSPITALMenomonee Falls,

Hospital

Administration

Hospital Board

Medical Executive Committee

Co

llab

ora

tive

Pra

ctic

eC

redentialing

Performance Improvement

Car

diol

ogy,

Car

diot

hora

cic

Sur

gery

, Pul

mon

olog

y,

Vas

cula

r

Musculoskeletal C

are

Orthopedics, P

odiatry,

Neurosurgery, P

M&

R,

Radiology*

General Surgery, S

urgical

Specialties, A

nesthesia*

Surgical Care

Radiation Oncology, Medical

Oncology, Pathology*Cancer Care

Performance

Improvement Teams /

Clinical

Microsystem

sCaregivers

* Specialties provide care in all service lines

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Patients and Families as Part of the Care Team

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“Seek first to understand, then to

be understood.”

- Stephen Covey

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1st Curve 2nd Curve Evolved around medical and

hospital practices Disease focus, one patient at a

time Hierarchical, physician

controlled Performance problems

assumed as people-caused “Culture of blame” Fragmentation of care givers

and health care functions, “hand-off” gaps common

Medical records paper, frag-mented, “owned” by caregiver

Complexity frequent errors, harm to patient

Quality is compliance-oriented, 2-4 sigma common

Reactive to “sentinel events”

Designed around patient/ community, population need

Health, prevention focus, patient plus population

Team-based systems outperform hierarchy

Recognition that performance problems 95% systems-based

“Just Culture” Integration of all system

elements, care “seamless” for patients

EHR, “smart cards” owned by patients

Integration of “quality sciences” minimizes error, harm

Quality, value oriented toward 6+ sigma, O preventable harm

Pro-active, Resilience-led

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Senge’s “Five Disciplines”

Personal MasteryMental ModelsTeam LearningShared VisionSystems Thinking

(1st Curve health care, for all of its positives, focused almost solely on “Personal Mastery.” As many have shared at the meeting, all five disciplines are essential to “Learning Organizations.,” and the 2nd Curve.)

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As John Maynard Keynes once noted . . .

“The hardest thing is not to get people to accept the new ideas, it is to get them to forget the old ones.”

Or, as Max Planck, a pioneering 20th Century physicist once

remarked, “Scientific progress moves forward, one funeral at a

time.”

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“Command & Control” Pyramid (Taylorism, circa 1900)

Top Management

Obedience

Commands

Hint: Doesn’tWork Anymore

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The “New Leadership:” Creating Context

“Farmers don’t grow crops; they create conditions under which crops can grow.”

- Stephen Covey

Question: In my leadership role, am I creating a “fertile field” for a) the growth of modern quality/safety practice and b) a fundamentally different form of top-down/bottom up collaboration?

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“Stewardship/Servant Leadership” (Covey, Block, others)

Top Management

Resources/Support

Caregivers/InnovationThose We Serve

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The ThedaCare Breakthrough

“Realizing that ThedaCare needed change, leaders tried one improvement program after another over the course of many years. Most of the programs offered incrementally better results for a while, until everyone slid back into old habits.” Finally . . Leaders started thinking about breaking down the divisions between caregivers’ specialties, divisions of labor and habits of working to create a unified focus on the patient. Because this would require change in everyone involved, it was clear that hospital units needed a revolution instead of isolated, incremental adjustments.”

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Today’s Leader

Today’s leader is not someone who knows all the answers…or who makes decisions and gives orders in the old military model of leadership.

Rather, the new leader is someone who can assess a situation, bring people together, build consensus, and discover solutions, building on the talents of everyone involved. The new leader is a facilitator, a communicator, a team builder.

- Diane Dreher, The Tao of Personal Leadership

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Best of 1st Curve Aviation

2nd Curve

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There are many ways to ascend Mt. Washington – auto road, cog railway, and many hiking trails. My best

wishes to you Leaders on Ontario Health Care as you ascend your path toward 6 sigma health care!

6+ sigma!

merrymd@comcast.net

Thank You!