moving up the curve: second curve strategies for change
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Moving Up Healthcare’s Second Curve:Strategies for Change
IE 6
11/6/201211/6/2012
1 t1st
2nd
2
3
2nd Curve: an IHI View
4
High Reliability in Medicine:Where Do You Need to Be?
Future Performance (Second Curve/
6+ Si )First Curve/
4 sigma
6+ Sigma)
4 sigma
(Craft-Age
(Craft+Information-Age Culture )
man
ce
(Bifurcation curve: 2000s)
(Craft-Age Culture)
Perf
orm
Time
Flexner 1910P
5-
Columns 2 & 3 = 2nd CurveColumns 2+3 = 2nd CurveRegulation Hammurabi
Medical Science
Hippocrates Management
Science
Legal system
State Boards
Nightingale, 4 doctors
Flexner Codman
Industrial Revolution
Taylor: “Scientific
JCAHO
“Inspection”
Flexner, Codman, ACS/Hospital
Standardization
M&M conferences
Taylor: Scientific Management”
Shewhart Inspection
Fed/State regs
M&M conferences
Donabedian,structure process, outcome
Deming, Juran,
Total Quality
ORYX, EMTALA,
HIPAA, Etc.
Outcomes, Disease
management
Complexity theory
Lean, Action Learning, Appreciative
6
JC, CMS “core
measures,” HCAHPS
Evidence based
care, Hospitalists
Learning, Appreciative Inquiry, Adaptive Design, High Reliability, Resilience
2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)
Future Performance (Second Curve/
6+ Si )First Curve/
4 sigma
6+ Sigma)
4 sigma
(Create and
(Transfer/Sustain Momentum)
man
ce
Human Factors 2000
Resilience,2010
(Bifurcation curve: 2012)
(Create and Build
Momentum)
Perf
orm
TQM, 1990
Factors, 2000
Time
Circa 1910P
7-
High Reliability and The Performance Curve
Safety Culture Safety Operating Sigma Level Operating Level Performance
LevelPerformance Level
Margin
Need A
Chaotic Below Average 0 None or in d fi itAwareness deficit
Reactive Normal Average 2 2%
Implementing Reliable Good P f
4 5%Performer
Proactive Highly Reliable High Performer 6 10%
Generative Ultrasafe Standard‐ 7‐9 20%Setter
The Healthcare Reform Paradigm Shift:another View
(From David Bates, MD)
Current Organization Integrated Care• Incented by volume• Focus on acute illness, high margin services• Focus on individual patient• Fill beds
P h i k
• Incented by value• Focus on prevention, care coordination• Focus on population• Prevent unnecessary admissions, readmissions
P id h i k• Payer has more risk • Provider has more risk
>>> HIT will be a key tool!
The Three Bucket Model
Bucket 1: Optimizing the First Curve
Bucket 2: Preparing to Move Up the Second Curve
Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in the New Landscape of Healthcare
• Lean St d
• Co‐managementDi l i th t il
• Tri‐management3 l d l• Studer
• Emphasis on accountability
• EMR
• Dissolving the two siloes• Service Line
Organization• Collaborative Rounding/
• 3 column model >>> new management science
• Strategy Learning • IHI• Root cause analysis/ gap
analysis• PDSA
g/G.L.I.T.C.H. harvesting
• Safety Culture/ Safety Management System
• Relational law
gy gSystem
• Resilient System Design• Systemic Law• Systemic thinking• PDSA • Relational law
• Adaptive Design• Whole‐system Lean (Va.
Mason, Thedacare)
• Systemic thinking• Cross‐ silo information
management: beyond silos; manage better the information we have
Leading for Change
Bucket 1: Optimizing the First Curve
Bucket 2: Preparing to Move Up the Second Curve
Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in g gthe New Landscape of Healthcare
• Focus on dataE h i bl l i
• Widen the lens: focus on both lit ti d tit ti
• Use information with it ti l ti• Emphasize problem‐solving
• Root cause analysis• More effective execution of
established methods (i.e. for preventing central line
qualitative and quantitative information
• Precede problem‐solving withproblem‐finding
• Reach out: more information,
situational awareness, creating contextual knowledge
• Combine problem‐solving and problem‐finding with problem‐framing and situational
infections) wider network, more resilient (cf. Kim Cameron, FAA)
• Add appreciative inquiry• A shift of assumptions on the
design criteria for care systems
deployment• Add positive deviation, success
story analysis, and action learning/ ongoing experimentationdesign criteria for care systems
and what performance levels are possible and necessary (e.g. from % to Sigma thinking)
experimentation
Buckets 1 & 2: Central Line InfectionsBuckets 1 & 2: Central Line Infections
• Bucket 1: Moving from the assumption of “aBucket 1: Moving from the assumption of a minimal number of inevitable infections that are inherent in the procedure” by just applyingare inherent in the procedure by just applying known preventive measures more rigorously
• Bucket 2: Achieving 0 infections and in so• Bucket 2: Achieving 0 infections, and in so doing, changing our assumptions about achievable performanceachievable performance
1st Curve Breast Diagnosisg
Initial Concern
Surgery Consult
OR/O BiOR/OpenBiopsy
Biopsy ReadBiopsy Read
Patient Learns(Cycle time of process built around practi-tioners: 1-8 weeks)
13
Patient Learnstioners: 1 8 weeks)
Bucket 3: 2nd Curve Breast Diagnosis, Park-Ni ll t H lth S t 1995 P tNicollet Health System, 1995 - Present
Screening Xray
Immediate Reading
S i BiStereotactic Biopsy
Biopsy Read(Cycle time f Biopsy Read
Patient Learns
of process built around patients: 2
14
Patient Learnshourspossible.)
Hypothesis: We cannot problem-solve our way to 2nd Curve High Reliabilityour way to 2 Curve High Reliability
Problem Solving “Appreciative Inquiry”
Problem identified
Appreciating/valuing best of “What is”
Analysis of causes
Possible solutions
Envisioning “What might be”
Dialoguing “What should be”Possible solutions
Action planning
Dialoguing What should be
Innovating “What will be”
Assumption: Success = problems solved
Assumption: Success = a possibility envisioned/created
f
15
‐adapted from Bernard Mohr
Creating 2nd Curve Culturesg
“Changing how 2nd Curve Vision
g gwork is done changes the
Change Processes
Ch S
gculture.”
- Jeff Goldsmith, PhD
Change Structures
Change WorkChange Work
2nd Curve Culture16
2 Curve Culture
The Policy Environment: Affordable Care ActAffordable Care Act
• New insurance rules guaranteeing coverage• High-risk pool for people with pre-existing conditionsHigh risk pool for people with pre existing conditions• Protection for children with pre-existing conditions• Coverage for young adults, to age 26
S ll b i t dit• Small business tax credits• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health CentersAccess to care: $ Billions for Community Health Centers
and the National Health Service Corps for low-income and uninsured
• New incentives for providers (ACOs, CMS rewards and
17
New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions)
“Physician leadership is essentialPhysician leadership is essential. Improving the value of health care is something only medical teams can dosomething only medical teams can do. . . Physicians can lead this change and return the practice of medicine to its appropriatethe practice of medicine to its appropriate focus: enabling health and effective care.”
18
- Michael Porter, PhD, MBA
Bucket 3: 2nd Curve Structure InnovationInnovation
Community Memorial HospitalCommunity Memorial HospitalMenomonee Falls, WI
19
A 1917 Design, as of 2012
Board of TrusteesChi f E tiM di l St ff E ti
Chief Executive
OfficerMedical Staff Executive
Committee
• Credentialing
Medical Staff Functions(“Silo 1”)
• Nursing
Hospital Functions(“Silo 2”)
• Credentialing• Departmental (Peer)
Review• Surgical Case Review
• Nursing• Ancillary• Laboratory• RadiologyDepartmentsSpecialties
• Blood UR• Drug Usage Review• Pharmacy and
Therapeutics
• Physiotherapy• Risk Management• Finance, Planning• Regulatory Agencies
2012: The Structure Hierarchy, F t ti C i ti
20
Therapeutics• Medical Records
Regulatory Agencies• Etc.Fragmentation, Communication gaps,
Misunderstanding, Power Struggles, etc.
“Doctor, I’d like you to resign from thi di l t ff f f illthis medical staff for reasons of ill health. You make me sick.”
21
The Vision
1. Reduce physician time spent in wasteful Medical Staff activities.
2. Increase the influence of physicians in the development of service lines and the redesign of clinical g fmicrosystems.
3 Clinical microsytems that perform3. Clinical microsytems that perform more efficiently and effectively for both patients and caregivers
22
both patients and caregivers
Board of Trustees
The Starting Pointoa d o us ees
Quality Improvement Oversight
Medical Care
Medical Executive Committee
Senior Mgt. Team
Patient/Medical Staff Functions
Operational Management
Patient/ Community
Leadership Caregivers
23
COMMUNITY MEMORIAL HOSPITAL,
Hospital Board
Management and
Hospital
AdministrationMedical Executive Committee
Management and Coordination of Care
Participation Managementrativ
ecep
Leadership Patient/Community
Management
Design
Col
labo
rP
ract
i
Performance Improvement
24K:\S\wp\7350(953)\misc\janice8.ppt* Specialties provide care in all service lines
SuppliersPayors and Funders
An Emerging Model‐SCS Innovation Strategy
Payors and FundersIncrease Access to centers of excellence
Increase Access to Outpatient CareLong waits for Services in the community
Translate Data into practice
Lack of accountability in Hospital Planning
Lack of community servicesthe community
Taking a regionalperspective on research
Increase connections withPrimary care
•Improve CareIncrease in options for community re‐integration
Unique challenges for
Delivery
Need for communitynavigation
Primary care
Expanding Caregiver
p•Reduce Cost•Create Jobs
Need to create systemsperspective on care
Unique challenges for specific populations of care System
Hospitals, Community services need to focus on recovery and medical issues
Increase access to
Expanding CaregiverPilots
Expand wellness programs– e.g. Fit for Function
Need for strategicCollaborations/partnerships
p ,Providers,
Carerehab for acute chronic conditions
Lack of awareness of Community programs
Collaborations/partnerships
Increase need for Peer support – survivor groups
Need to focus on transitions Need to collaborate withother strategies i e COPD
Care Networks
other strategies – i.e. COPD, Diabetes, cardiovascularImportance of timeliness
of treatmentIncrease partnerships with case management
Coordinated Pediatric Care
1 t1st
2nd
26
27
2nd Curve: an IHI View
28
High Reliability in Medicine:Where Do You Need to Be?
Future Performance (Second Curve/
6+ Si )First Curve/
4 sigma
6+ Sigma)
4 sigma
(Craft-Age
(Craft+Information-Age Culture )
man
ce
(Bifurcation curve: 2000s)
(Craft-Age Culture)
Perf
orm
Time
Flexner 1910P
29-
Columns 2 & 3 = 2nd CurveColumns 2+3 = 2nd CurveRegulation Hammurabi
Medical Science
Hippocrates Management
Science
Legal system
State Boards
Nightingale, 4 doctors
Flexner Codman
Industrial Revolution
Taylor: “Scientific
JCAHO
“Inspection”
Flexner, Codman, ACS/Hospital
Standardization
M&M conferences
Taylor: Scientific Management”
Shewhart Inspection
Fed/State regs
M&M conferences
Donabedian,structure process, outcome
Deming, Juran,
Total Quality
ORYX, EMTALA,
HIPAA, Etc.
Outcomes, Disease
management
Complexity theory
Lean, Action Learning, Appreciative
30
JC, CMS “core
measures,” HCAHPS
Evidence based
care, Hospitalists
Learning, Appreciative Inquiry, Adaptive Design, High Reliability, Resilience
2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)
Future Performance (Second Curve/
6+ Si )First Curve/
4 sigma
6+ Sigma)
4 sigma
(Create and
(Transfer/Sustain Momentum)
man
ce
Human Factors 2000
Resilience,2010
(Bifurcation curve: 2012)
(Create and Build
Momentum)
Perf
orm
TQM, 1990
Factors, 2000
Time
Circa 1910P
31-
Leading for Change
Bucket 1: Optimizing the First Curve
Bucket 2: Preparing to Move Up the Second Curve
Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in g gthe New Landscape of Healthcare
• Focus on dataE h i bl l i
• Widen the lens: focus on both lit ti d tit ti
• Use information with it ti l ti• Emphasize problem‐solving
• Root cause analysis• More effective execution of
established methods (i.e. for preventing central line
qualitative and quantitative information
• Precede problem‐solving withproblem‐finding
• Reach out: more information,
situational awareness, creating contextual knowledge
• Combine problem‐solving and problem‐finding with problem‐framing and situational
infections) wider network, more resilient (cf. Kim Cameron, FAA)
• Add appreciative inquiry• A shift of assumptions on the
design criteria for care systems
deployment• Add positive deviation, success
story analysis, and action learning/ ongoing experimentationdesign criteria for care systems
and what performance levels are possible and necessary (e.g. from % to Sigma thinking)
experimentation
Buckets 1 & 2: Central Line InfectionsBuckets 1 & 2: Central Line Infections
• Bucket 1: Moving from the assumption of “aBucket 1: Moving from the assumption of a minimal number of inevitable infections that are inherent in the procedure” by just applyingare inherent in the procedure by just applying known preventive measures more rigorously
• Bucket 2: Achieving 0 infections and in so• Bucket 2: Achieving 0 infections, and in so doing, changing our assumptions about achievable performanceachievable performance
The Policy Environment: Affordable Care ActAffordable Care Act
• New insurance rules guaranteeing coverage• High-risk pool for people with pre-existing conditionsHigh risk pool for people with pre existing conditions• Protection for children with pre-existing conditions• Coverage for young adults, to age 26
S ll b i t dit• Small business tax credits• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health CentersAccess to care: $ Billions for Community Health Centers
and the National Health Service Corps for low-income and uninsured
• New incentives for providers (ACOs, CMS rewards and
34
New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions)