PRESENTATION FOR LAFAYETTE MEDICAL EDUCATION FOUNDATION Wednesday September 11, 2013

1. Presenters: Daniel Wickert, MD, OBGYN, FPN Lafayette OBGYN Brian Hudson, Lean Six Sigma, Franciscan St. Elizabeth Health PRESENTATION FOR LAFAYETTE MEDICAL EDUCATION FOUNDATION Wednesday September 11, 2013

2. The Opportunity (care falls short of its theoretic potential) • Well-documented, massive, variation in practices (beyond the level where it is even remotely possible that all patients are receiving good care) • High rates of inappropriate care • Unacceptable rates of preventable care associated patient injury and death • A striking inability to “do what we know works” • Huge amounts of waste leading to spiraling prices that limit access (46.6 million uninsured Americans)

3. 50+% of all resources expenditures in hospitals is quality-associated waste: • Recovering from preventable foul-ups • Building unusable products • Providing unnecessary treatments • Simple inefficiency Anderson, C. 1991 James BC et al., 2006

4. Guiding Principles Intermountain Healthcare Approach Strive to Follow the Intermountain Philosophy • Board Level Commitment – 100% • Core business is to continuously improve clinical processes • Quality care is determined by: • Evidenced-Based Processes • Processes are written • Processes are changed as needed, by facts and data • Believable data is king • Drive out variation • Drive out fear • Educate physicians, staff, patients • Team Effort • Downplay titles • Physician lead – Member of a team, not captain of a ship • Culture of excellence

5. Guiding Principles Eight-Stage Process of Creating Major Change Leadership Stages: (pointing the sail) – Establish Direction, Align People, Motivate and Inspire • Establishing a sense of urgency • Creating guiding coalition • Developing a vision and strategy • Communicating the change vision • Empowering broad-based vision Management Stages: (getting the ship to shore) – Plan, Budget, Organize, Staff, Control, Problem-Solve • Generating short-term wins • Consolidating gains and producing more change • Anchoring new approaches in the culture

6. Best Practice Team

11. Women’s Services Clinical Operation Group

14. The healing professions are changing From: Craft-based practice • individual physicians, working alone (housestaff ::= apprentices) • handcraft a customized solution for each patient • based on a core ethical commitment to the patient and • vast personal knowledge gained from training and experience To: Profession-based practice • groups of peers, treating similar patients in a shared setting • plan coordinated care delivery processes (e.g., standing order sets) • which individual clinicians adapt to specific patient needs • early experience shows • less expensive • less complex • better patient outcomes

15. Quality improvement process

16. The problem solving process • Identify/find high leverage opportunities • Gather the team • Develop the Aim statement • Develop measurement and Collect data • Analyze data and Gather evidence • Build evidence-based protocol • Implement the protocol • Monitor measures and give feedback to clinicians • Quantify project impact (lives, $, etc.)

17. 1. Identify High Leverage Opportunities • Lives affected/mortality • Number of patients affected • Opportunity for improvement • Procedure/test cost • LOS • Readmission • Quality of life Effort Impact

18. 2. Develop the Aim Statement Our goal is to . . . Clearly and concisely setting the aim by: • Aligning with strategic goals • Improve patient care and outcomes • Use organizational data with measurable metrics • Have a timeframe

19. 3. Develop measurement and collect data

20. 4. Analyze data and gather evidence

21. 6. Develop and Implement the protocol • Order sets • Forms • Protocols or Procedures • Needed supplies and equipment • Training/rollout

22. 7. Monitor performance and provide feedback • Performance Metric 65 60 55 50 45 40 1 11 21 31 41 51 61 71 81

23. 8. Quantify impact of protocol • Impact on Patient • Mortality/readmission • Length of stay • Recovery time and quality of life • Financial impact • Direct cost/Compared to Medicare rates • LOS • Quality measures • CMS, Anthem, other • HAI

24. The problem solving process • Identify/find high leverage opportunities • Develop the Aim statement • Develop measurement and Collect data • Analyze data and Gather evidence • Build evidence-based protocol • Implement the protocol • Monitor measures and give feedback to clinicians • Quantify project impact (lives, $, etc.)

25. P P A D Rapid Cycle Testing P A D S P A D S A D S S • Model for Improvement- • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement?

26. Reducing the Time from Arrival to Start of Induction

27. Aim Statement • Our mission is to improve the time from arrival to the unit to the start of the induction to 60 minutes for 60% of patients.

28. Conceptual process

29. Induction Methods

30. Measurement – all methods 39.2% of the patients meet the time goal for the baseline period of October 2012-January 2013

31. High leverage points • Policy of the MD seeing the patient prior to starting Pitocin-Seen within 7 days • Lab start to draw blood– RN delays IV start • Pitocin induction initiation protocol—allow RN to start Pitocin without waiting for MD assessment first. • Contacting MD morning of when ready • Patient pre-education at the office • Variation in nursing induction initiation/management • Staffing and timing of deliveries/volume.

32. Making change happen Improvements Implemented • RN education • Scheduling changes implemented not allowing induction scheduling > 1 week out. • Pitocin induction protocol adjusted for RN initialization. • Enhance patient education at the office.

33. Changes Implemented: MD seeing pt in previous 7 days Allow RN to start pit Pit management education

34. Impacting quality care • Improved patient satisfaction • Improved efficiency of staff • Reduction in unplanned c-section rate • Decreased ‘admission to delivery’ time, reducing nursing labor and associated costs.

35. Lessons Learned • Be a committed leader to change • Use the Service Line approach • Have a Continuous Improvement mindset • Engage and empower the workforce • Find like-minded people that want change • Take it at your speed, but keep moving forward

36. Organized Care How could we create a system that • Consistently documents “the best medical outcome at the lowest necessary cost” for each patient, under each patient’s full, personal, control (true “patient-centered’ care, within professional parameters) • Learns from every case • Generates scientifically reliable knowledge from routine practice, quickly filling the 80-90% evidence gap regarding best practice; while empirically validating every new treatment. • Creates a life-long “residency training while in practice” • Organization-level capacity to (1) identify critical new knowledge, (2) blend it into daily workflows, (3) package it for rapid learning, and (4) push it out to all who need it – reduce the time for widespread adaption of major new, scientific findings from ~ 17 years to less than 6 months. • Generates true transparency • Anytime any clinician says “in my experience” they mean “in my measured experience.” Eliminate reliance on subjective recall; make physicians and nurses better counselors as they advise and support patients faced with treatment decisions. • Address innate clinical complexity • Provide support around critical clinical decisions (Shared Baselines)

37. Only One Pertinent Question: Assume that front-line clinicians are: • as smart as you are • as dedicated to patients as you are • as hard-working as you are • as motivated as you are • are the only ones with fundamental knowledge of how the front-line process actually works; But they usually don’t control the systems that set the context within which they work… How will your proposed intervention make it easier for them to do it right?

38. Professional Accountability I will not tell you how to practice medicine… I will argue the science, but if I cannot convince physicians “on the data”, I will not expect them to change how they manage patients. I will try to create an environment of professional accountability… • Where groups of physicians and other professionals; • Who manage similar patients in similar settings; • Discuss best patient care practices; with resource to the medical literature, expert opinion, and credible data showing their own performance and outcomes. (a redefinition of traditional peer review)

39. Key Take-Aways • No protocol perfectly fits any patient • Solution: Shared Baseline “bundles” (mass customization = “patient centered care”) • Serious limitations to protocol development • Solution: a Learning System (embedded variance and outcomes tracking; continuous protocol review and tested improvement) • Reliance on human memory (craft of medicine) produces “55% execution” • Solution: tools to embed protocols in workflows • Only two differences from traditional practices: It requires (1) coordinated teams with (2) reliable data systems.

40. Reasons for Our Success We dedicated time - We embraced change - We took action Created Core Values, Core Purpose and Vision Statement – total time: physicians and administrator time, approximately 160 hours (10 people) (all physician time was after hours) Developed Strategic Project Teams - total time: physicians and administrator time, approximately 20 hours (10 people) (all physician time was after hours) Visited Intermountain Healthcare, education to motivate change from silos & volume to quality care, drive out variation & fear - - total time: physicians, administrator, managers and staff time, approximately 288 hours (18 people) Learned/Developed Leadership, Management and Team skills – total time: physicians, administrator, nurse practitioners, managers and staff time, approximately 750 hours (16 people) (all physician and manager time was after hours) Developed Strategic Team projects, meeting and developing solutions - – total time: physicians, administrator, nurse practitioners, managers, Six Sigma participant and staff time, approximately 2,900 hours (20-30 people, over a period of 18 months) (all physician and most manager time was after hours) Developed the Women’s Services Clinical Operations Group and related projects - total time: physicians, senior management, administrator, hospital management, Six Sigma participant, L&D nurses, manager and staff time, approximately 160 hours (13 people, over a period of 5 months) (most time for all involved after hours)

41. The 3-legged stool Physicians Clinical Support Staff Administration All having to work together