An International Perspective: Leading for Better Healthcare

Maureen Bisognano President and CEO

IHI

2nd Annual NHS Leadership and Management Summit 23 May 2012

The King’s Fund

The Problem

• In the US, we spend over $2.7 trillion per year on health care

• Over 75% is spend on chronic disease management

• And all of our chronic diseases are getting worse

The Problem

• In the UK and across other countries in Europe, the same 70% of health care budgets are going to chronic disease care

• Diabetes, cardiac disease, and obesity are expected to increase by 50% by 2035

• The “burden of the illness” in these diseases is 24/7 and requires a new way to look at the “burden of the treatment,” including designs and costs

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Not Just an American Problem

Health Care Spenders and Costs

Spenders Costs

The top 1% of spenders accounts for 21.8% of the costs

The next 4% account for 28.2% of the costs

The bottom 50% account for just 3% of the costs

Source: AHRQ – “The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008-2009” http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.shtml

Courtesy of the Institute for Healthcare Improvement, April 2009

Courtesy of the Institute for Healthcare Improvement, April 2009

Michael Porter’s Thinking

• Disutility of a primary care model with an incredibly diverse patient mix

• Challenges of managing excellent clinical care with the latest evidence in the face of heterogeneity

• Chaos of daily life for clinicians

Joanne Lynn’s Thinking

• “Bridges to Health Model” ─Splits populations into 8 segments

1. Healthy 2. Maternal-infant health 3. Acutely ill, likely to return to health 4. Chronic conditions with normal daily function 5. Serious relatively stable disability 6. Short decline to death 7. Repeated exacerbations, organ system failure 8. Multi-factor frailty, with or without dementia

Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and Kambic, Robert T., Using Population Segmentation to Provide Better Health Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2, pp. 185-208, June 2007.

Viab

ility

Where Are We?

Models Adapted from The Second Curve, Ian Morrison 1996

Clinical Model Episodic Care Coordinated Care Population Directed Care

Business Model Fee for Service Bundled Payment/Capitation Disruptive Innovation?

Infrastructure Segmented Integrated Cloud

Adaptive Challenge

Technical Leadership

Patient

Inflection Point

Technical Leadership: • Problem solving through

expertise

Optimizing the Current Model

Transforming the Organization

Adaptive Leadership • New beliefs & behaviors • New relationships • New customers

Thriving on the First Curve

Build widespread improvement capability − Leadership − Middle management − Front-line teams − Integrated clinical teams − Engaged, empowered, and enthusiastic staff

Work on Safety − Reduce medical errors and harm − Eliminate “never events” − Work on preventable admissions

and readmissions

Engage members/patients and families − Ensure access − Design for continuous care − Improve patient engagement and

satisfaction

Improve efficiency − Reduce artificial variation (LOS, use rates,

readmissions, etc.) − Eliminate “flow faults” − Set a goal of reducing waste by 1-3% of operating

expense budget for I year, year on year

Henry Ford Health System

Harm Issue Total Associated Costs Pressure Ulcer stage 2 or higher $10,624,410

Coded Procedural Complication ICD9 (998-999.99) $7,670,520 UTI using coded data and AHRQ definition. $5,662,895 Glucose below 40 $3,846,375 Coded Acute Renal failure $2,665,680

Coded DVT/PE in both medical and surgical patients $2,365,470 No Pulse Blue Alert $1,535,808 Coded Medication issue $1,216,078 Clostridium difficile infection $824,544 Reported Fall with injury $696,527 Bloodstream Infections using NHSN criteria $640,000 Coded Pneumothorax using AHRQ definition $340,260 SSI using NHSN criteria $280,000 VAP using NHSN criteria $190,352

Total Harm-Associated Costs 2009*

*Henry Ford Hospital Only

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What Improvement Skills are Needed for Each Role?

Experts Operational

Leaders (Executives)

Change Agents (Middle Managers, Stewards, project leads)

Everyone

(Staff, Supervisors,

UBT lead triad)

• Setting goals and measures

• Identifying problems

• Mapping process • Testing change • Simple waste

reduction • Simple

standardization • Team behaviors

• Setting goals and measures • Identifying problems • Mapping process • Sequencing tests of change • Simple understanding

variation • Implementation and spread • Simple waste reduction • Simple standardization

• Setting direction and big goals

• Execution leadership • Portfolio selection and

management • Managing oversight of

improvement • Being a champion and

sponsor • Understanding variation

to lead • Managing

implementation and spread

• Analysis, prioritization of portfolios

• Deep statistical process control

• Deep improvement methods

• Leadership team advisory re portfolio selection, process

• Effective plans for implementation and spread

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On-boarding

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Wave III focuses on full deployment and execution and IV on expansion and continuous improvement

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February 2008 September 2008 June 2009

• 3 Regions • 6 Improvement Advisors

(Medical Center) • 3 Faculty Mentors

(internal and external) • Front line staff RIM • Middle managers PSU • Reliable design

• 5 regions • 80 Improvement Advisors

(Medical Center) • 11 Faculty Mentors (KP) • 4 Regional mentor students • 300 operations managers • 3,500 Front line RIM+ staff • Middle manager PSU • Reliable design

• 7 regions* • 150 Improvement Advisors

(medical center, regional, national)

• 12 Faculty Mentors (KP) • 1000+ Operations

managers • 10,000 Front line RIM+

staff • Middle manager PSU • Reliable design

Waves of Improvement Institute

Learning and sharing systems regionally and program-wide Improvement Institute

Implementation Expansion Continuous Improvement Complete

We are here

Level of Project Difficulty

Thriving on the Second Curve

Leadership and capability − Build innovation capability and set aims − Analyze key areas for design (population

segments, geographic areas) − Identifying “light green potential” & translating

to “dark green dollars”

New partnerships − Payer “deep dive” such as

“marketplace collaboratives” − Build on ABCD or community

organizing skills

New designs − Coordinated care for frail, older population − Triple Aim designs for the sickest − The “year of care” for the well 50%

Work on spread − Ensure best practices and results

everywhere

Organizations Learning from Patients

The Old Way • Ryhov Hospital in Jönköping had traditional hemodialysis

and peritoneal dialysis center. • But in 2005, a patient, Christian, asked about doing it

himself.

The New Way

• Christian taught a 73-yr-old woman how to do it…

• …and they started to teach others how to do it.

The New Way

• Now they aim to have 75% of patients to be on self-dialysis

• They currently have 60% of patients

Lessons to Date

• From Christian (patient): ─“I have a new definition of health.” ─“I want to live a full life. I have more energy

and am complete.” ─“I learned and I taught the person next to me,

and next to her. The oldest patient on self-dialysis is 83 years old.”

─“Of course the care is safer in my hands.”

Lessons to Date

• From Anette (nurse leader): ─ Surprised at design differences between patients,

family, and staff ─ Managing at 1/2 – 1/3 less cost per patient ─ Evidence of better outcomes, lower costs, far fewer

complications and infections ─ “We brought in the county’s employment, helped the

patients make or update the CVs, and trained them for a new career.”

Update

• Now calculated costs at 50% of costs in other hemo-dialysis units

• Complications dramatically reduced and subsequent expensive care avoided

• Measuring success by “number of patients working”

Jonkoping Visit, October 2011

PFCC

Tony DiGioia

Dr. Anthony M. DiGioia III, orthopedic surgeon and developer of the patient- and family-centered care program for UPMC, in

his office at Magee-Womens Hospital in Oakland.

Wellness Focus

Results

• Safe: ─Mortality rate: 0% ─ Infection rates: 0.3% (0.2% for TKA and 0.7%

for THA) ─Zero dislocations ─SCIP compliance: 98% for antibiotics within one

hour of surgery

DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.

Results

• Effective: ─95% of patients discharged without handheld

assistance directly to home (national rates: 23-29%)

─99% of patients reported that pain was not an

impediment to physical therapy, including same-day-of-surgery physical therapy

DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.

Results

• Patient-centered: ─ Press-Ganey mean satisfaction score is 91.4% (99th

national percentile ranking) with 99.7% positive responses to “Would you refer family and/or friends?”

• Efficient: ─ Average length of stay:

2.8 days for TKA (national average is 3.9 days) 2.7 days for THA (national average is 5.0 days)

─ One MD able to perform 8 joint replacements before 2:00pm

DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.

Study Tour in Denmark

Thriving on the Third Curve

Leadership − Redesigning the workplace to optimize

teamwork − Engage the community (ABCD and

organizing)

Optimize health and care skills with the community − Shared decision making − Move from “What’s the matter?” to

“What matters to you?” − Real goal-setting

Innovate for technology integration − Optimize the use of technology, the

patients’ perspective and use of data, and other technologies

Experience of Care

Per Capita Cost

Health of a Population

IHI’s Partners/Activation Mechanisms: Memphis / Shelby County, TN

• Memphis Activation Mechanism: ─ A virtual faith-based network.

• Focus of Activation mechanism – Project Goals: 1. Reduce untreated and unmanaged hypertension

among low-income African American men 2. Reduce health risk and incidence of uncontrolled

chronic disease for vulnerable women in Memphis

Activating Memphis’ Congregational Health Network (CHN)

• Scaling up the reach to young women: ─ Beginning with 30 existing CHN members in Year 1 and scaling

up engagement to over 2,000 designated health volunteers in approx. 300 churches over 3 years. Reaching over 8,000 women across the community with information and

skills for self-care and health improvement through family and community networks.

• Scaling up the reach to men: ─ Onsite screening for hypertension and other health risks will be

carried out at approx. 400 congregations over the first two years (150 in Year 1 and 250 in Year 2). Paired with additional outreach in Year 3 through male church members’

connections to other community groups, including workplaces, neighborhood associations, and social groups, these efforts are expected to reach approx. over 2,700 individuals with previously undiagnosed or untreated hypertension who can be brought into community-based

treatment.

Malawi Progress • Population ~13 million • Maternal mortality: ~350/100,000

(USA <10/100,000) • Neonatal Mortality: ~30/1000 ( in

the US ~4/1000)

Partners: Women and Children First, Inst Child Health UCL, IHI. Funders: The Health Foundation.

3 Districts • Aim: Reduce maternal and

neonatal mortality by 30% in three Districts (pop 3 million) by February 2012.

• 5-year RCT to test health facility (QI), and community interventions (women’s groups)

Focus of our Interventions

3 Delays model • Delay in deciding to seek

care

• Delay in reaching the facility

• Delay in receiving timely and appropriate care

Women Groups & Task Forces

QI intervention

SMALL TEST CYCLES THAT TAP LOCAL KNOWLEGE

PLAN

DO

STUDY

ACT

Focus on Demand, Supply and Linkages

Increasing Demand

Referral & Access

Quality services

Malawi: Results Over 4 Years Infrastructure for change • Established new NGO – MaiKhanda • Community structures: 650 Women’s groups • Facility structures: 55 QI teams formed (13 hospitals, 42

health centers) • Linkage structures: 707 safe motherhood task forces RCT evaluation results show: • 22% reduction in NMR for combined FI and CI

intervention (no effect for either intervention alone)

• 16% reduction in perinatal mortality for CI alone, no effect of FI alone

• No reduction of MMR over secular trends

Southcentral Foundation Anchorage, Alaska

• “Nuka” – Alaskan word for strong, giant structures and living things. ─ Also the name for the

health care model that transformed the system from health care transactions for patients to a healthy system with the population

Elder Program • Healthy Elders through supportive gathering, activities, sharing, caring -

relationships

Pathway Home • Recovering youth through development of community, healthy relationships,

personal and group responsibility

RAISE • Youth internships emphasizing team, group, learning, responsibility, skills –

within SCF Nuka System of Care (relationships)

Dena-A-Coy • Residential treatment for pregnant women to return to healthy relationship

with self, family, pregnancy, newborn infant.

Some Programs (Relationships)

Nutaqsiivik • Two year partnering in intensive personal relationship between SCF staff and

new mothers with infants

Quyana Clubhouse • Long term personal relationships with individuals with limited cognitive

capabilities and mental health challenges to support healthy living

Primary Care • Complete rethinking of what our roles are – everyone – in the integrated care

team environment where trusting, accountable, long-term, personal relationships are the core service delivered – with full same-day access – and the whole person and family are supported.

Some Programs (Relationships)

Why listen to our story Evidenced-based generational change reducing family violence 50% drop in Urgent Care and ER utilization 53% drop in Hospital Admissions 65% drop in specialist utilization 20% drop in primary care utilization 75-90%ile on most HEDIS outcomes and quality Childhood immunization rate of 93% Over 50% of Diabetics with HbA1c below 7% Employee Turnover rate less than 12% annualized (very low) Customer and staff overall satisfaction over 90% In an urban Alaska Native community with huge challenges Sustained for over a decade and continually improving Very long list of external recognitions – Baldrige Award now

Copyright © 2011 Southcentral Foundation. All Rights Reserved.

Per Capita Expenditures

Looking Ahead

• New definitions of “organization”

• New ways to lead multigenerational work forces

• New methods and a new culture of engaging patients and families in designs

• New learning networks for all of us