Improvement Leader Fellowship

1. Improvement LeaderFellowship AHA/HRET HEN week

2. Seven Pillars: Addressing Patient Safety CultureTimothy McDonald, Vice President at University of Illinois Hospital and Health Sciences system • Reporting (as soon as possible) • Investigation • Initial communication with family • Identify preventative measures • Resolution • Follow-up and ongoing data collection • Education of event/improvements

3. Old Approach to “things gone wrong” at UI • The beginning, circa 2000 • KC case, COO of sister hospital • Pre-op testing prior to plastic surgery procedure • Evening before surgery, lab test done • Critical WBC < 1,000 (normal 4-12K) • Only Hgb and Hct on day of surgery • Repeat CBC post op • WBC <600 • Called to “Mary, RN” • Investigation –Mary was never identified

4. The New Way – New perspective • Michelle Ballog – 37 -YEAR-OLD Mother of 3, youngest 1 year old. • Unnoticed hear attack during surgery • Placed on a Vent in the ICU • Taken off life support • Kidney donated to family friend • Importance of Honesty and keeping family informed. • YouTube Qualitynet Malizzo • Family now on the Hospital Board • Involved in investigations and root cause analysis • Father just had heart surgery at UI • “Creates an atmosphere of trust”

5. Safety Culture The new way • Robust reporting and follow-up • Hot-lines, on-line reporting (Midas), phone calls and paper • Root cause analysis done concurrently • Investigation done properly, including checking physical environment • Sequestering equipment/supplies • Valuable information may be in trash

6. Safety Culture Part of the solution • Make reporting safe • Allow confidential reporting • Provide feedback • Link to quality and process improvements • Ensure non-retribution • Study it

7. Measuring Harm – Carol Haraden, PhD, V.P. Institute for Improvement Mortality and Severe Harm Creating a portfolio of Harm

8. Ways to Measuring Harm • Occurrence rates – preferably real time • Midas • Measure all-cause harm over time • IHI Global Trigger tool (also one for med safety and OB) • Self Reporting Systems You need them all Why? They all do different things

9. What promises are you prepared to make to patients and their families? • A place with no needless… • Deaths • Pain • Delays • Helplessness • Waste “Our patient should hold us to the best practices and we should expect it.”

10. Serious Events in Average Hospital 350 Beds with 13,600 admissions and 5,400 surgeries Source: Advisory Board Company Analysis

11. Keeping up with Science# of New Articles 1989 - 98 Source: Advisory Board Company Analysis

12. Design for Safety • “Every system is perfectly designed to achieve the exact results it gets” • The level of safety, timeliness, responsiveness and cost are all qualities of a system. • Instead of focusing on tasks, focus on risks • i.e. During a shift change hand off, ask “what is the patient at risk for in the next 12 hours”? • Having a multidisciplinary team with the same shared mental model is effective • i.e. How can we learn about our system performance?

13. Deeper Dive into the Science of Improvement – Robert Lloyd, PhD. • Objectives • The model for improvement • Writing Aim Statements • Developing measures • Deciding which ideas will lead to improvement • Applying the sequence for improvement • Remember the “messiness of life”

14. Two Types of Knowledge • Subject Matter Expert • Knowledge basic to the things we do in life • Professional knowledge • Profound Knowledge • The interplay of the theories of systems, variation, knowledge and psychology • Improvement • Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes

15. Variation and reliability • “If I had to reduce my message for management to just a few Words, I’d say it all had to do with Reducing variation.” W. Edwards Deming Value of control charts vs. bar graphs

16. 9 Change Concepts(A good place to start) • Eliminate waste • Improve workflow • Optimize inventory • Change the work Environment • Producer/customer interface • Focus on time • Focus on variation • Mistake proofing • Focus on product or service

17. The three questions provide strategy The PDSA cycle provides the tactical approach to work • Aim Statement: • Define the system where improvement will occur • Specify a numerical goal • Identify the Timeframe • Provide any guidance that identifies constraints in system or any issues that might affect the performance of the team’s work.

18. Small Tests of Change • Theory = Developing a Change (P) • Test = Try small scale changes (1 pt, 1 day, 1 MD) • Study = Adopt, Abort or Modify • Act = Implement, Make routine part of operations

19. SPH 2012 Goals in Aim Statements • By December 2012, SPH will… • Improve the HCHAPS Scores for willingness to recommend the hospital to family and friends from 73% to 82% • Improve patient perception of wait times from 3.32 to 3.64 (on a 4-point scale) in Ambulatory services • Increase the % of Core Measures that are at or above 90th percentile performance nationally from 47% to 74%