Moving the Big Dots: What Leaders Must Do To Achieve System Level Improvement IHI Fellows Seminar January, 12 2004 Mau

1. Moving the Big Dots:What Leaders Must Do To Achieve System Level ImprovementIHI Fellows SeminarJanuary, 12 2004Maureen Bisognano

2. Why?After 17 years of health care QI, we�ve... Done lots of great projects� Generate nice graphs, awards, photo-ops Require special effort and resources But improvements seldom sustain, scale, spread Moved few �big dots� very far

3. Big Dots:Whole System Measures of Performance

4. Context: New Pressures on Leaders to Deliver Measured Performance Pay for Performance CMS/Premier Bridges to Excellence Other P4P Transparency Voluntary CMS reporting HealthGrades� DoctorQuality

5. Result: Jobs Have Changed CEO attention to clinical quality AHA: from 6 lines to 6 pages New, difficult, clinical quality targets �No preventable deaths by 2008� Board attention The 4 reasons CEOs in health care get fired

6. Leading Whole System Improvement:Seven Leverage Points Establish, oversee and communicate measured system-level aims for improvement Align system measures, strategy and projects in a leadership learning system Channel leadership attention to improvement Engage an effective and committed executive team Engage the CFO in this work Engage with physicians Build deep improvement capability This is a theory, not a recipe It comes from three sources: complex adaptive systems theory, observation and case study of P2 and other organizations attempting to move big dots, and personal hunches/ideas and experience combined with data from management and leadership literature. It�s offered as a theory: �If you were to some combination of these things well, you would have a shot at moving big dots.� Or, perhaps it could be stated in the negative: �If you fail to do several of these things well, no matter what else you do, you will fail to move the big dots.� We are looking for feedback from you, for suggestions on how to improve the theory. This is a theory, not a recipe It comes from three sources: complex adaptive systems theory, observation and case study of P2 and other organizations attempting to move big dots, and personal hunches/ideas and experience combined with data from management and leadership literature. It�s offered as a theory: �If you were to some combination of these things well, you would have a shot at moving big dots.� Or, perhaps it could be stated in the negative: �If you fail to do several of these things well, no matter what else you do, you will fail to move the big dots.� We are looking for feedback from you, for suggestions on how to improve the theory.

7. Big Dots

8. Leverage Point 1Establish, oversee and communicate measured system-level aims for improvement Project-level e.g. % AMI patients getting evidence-based care % Diabetics with HbA1c less than 7.5 Time to answer call light on 5 West System-level e.g. Hospital mortality rate Cost per admission Adverse drug events per 1000 doses Third available appointment for all offices

9. Variation in death rates and charges in US hospitals

10. Leverage Point 1Establish, oversee and communicate measured system-level aims for improvement Establish solid measures of system level performance that can be tracked monthly Establish raise-the-bar aims of those measures Establish oversight of those aims at the highest levels of governance and leadership Commit personally to these aims, and communicate them to all stakeholders in a way that engenders heartfelt commitment to achieving them.

11. What would a transformed organization look like? A place with no needless� Deaths Pain Delays Helplessness Waste Each patient designs and owns her plan of care The front line staff initiate and drive change, and the managers teach and facilitate improvement The CEO is �master teacher� of quality, which is a line responsibility throughout the organization The Dots, Big and Small, are connected: strategic goals, system-level measures, and project-level measures have a logic�a �Theory of the Strategy� deployed rigorously through a method such as Balanced Score Card, or Strategy Maps The physicians lead/push community-wide re-design of care, rather than react to initiatives brought to them by management The organization has �square root of n� expert improvers, where n is the total number of employees All Staff seek innovation and ideas worldwide �Our Board couldn�t imagine a new CEO who wasn�t an even better champion of QI� We have full transparency on all measures, using industry-wide standards Physicians are �captains of the teams,� rather than highly autonomous �captains of the ship� All teach, all learn You cannot be promoted unless you�re a star quality improver We have a waiting list to get on staff Improvement is often through radical re-design, in addition to incremental process improvement Improvement Cycles are part of everyone�s daily work life, not thought of as �projects� Cycles of Improvement are so many that they are �uncountable� Projects cross many organizations, engage the entire community Improvement occurs at the process, system, and �interface of many systems� levels simultaneously Quality is the Strategy When times are tough, we invest more in Quality Everyone in the organization can explain how his/her work is integrated with strategy, logically and quantifiably >50% of all committees have patient majorities Each patient designs and owns her plan of care The front line staff initiate and drive change, and the managers teach and facilitate improvement The CEO is �master teacher� of quality, which is a line responsibility throughout the organization The Dots, Big and Small, are connected: strategic goals, system-level measures, and project-level measures have a logic�a �Theory of the Strategy� deployed rigorously through a method such as Balanced Score Card, or Strategy Maps The physicians lead/push community-wide re-design of care, rather than react to initiatives brought to them by management The organization has �square root of n� expert improvers, where n is the total number of employees All Staff seek innovation and ideas worldwide �Our Board couldn�t imagine a new CEO who wasn�t an even better champion of QI� We have full transparency on all measures, using industry-wide standards Physicians are �captains of the teams,� rather than highly autonomous �captains of the ship� All teach, all learn You cannot be promoted unless you�re a star quality improver We have a waiting list to get on staff Improvement is often through radical re-design, in addition to incremental process improvement Improvement Cycles are part of everyone�s daily work life, not thought of as �projects� Cycles of Improvement are so many that they are �uncountable� Projects cross many organizations, engage the entire community Improvement occurs at the process, system, and �interface of many systems� levels simultaneously Quality is the Strategy When times are tough, we invest more in Quality Everyone in the organization can explain how his/her work is integrated with strategy, logically and quantifiably >50% of all committees have patient majorities

12. What would a transformed organization look like? A place where collaboration thrives; where physicians, nurses and all staff cooperate A place where the patient�s voice is heard and drives design A place where staff experience reward and joy in their work A place with adequate resources and stable finances

13. Raise the Bar Aims HSMR <80 Adjusted Bed Turns with no delays >90 Reliability across the organization at 10-2 or better Adjusted cost per case in lowest decile 80% of any variation in processes is result of patient-preferences AA bond rating Work-related injuries in lowest decile and waiting list for employment

14. Example: Tallahassee Memorial Aim: Reduce mortality rate by 30% in three years Oversee: Gross mortality rate versus 2002 baseline, monitored at Board level, CEO accountable Communicate: staff, community all aware of goal and performance reports. �No needless deaths.� Leverage Point 1Establish, oversee and communicate measured system-level aims for improvement

15. Relative Mortality Rate: Tallahassee Memorial In December we began participating in the IHI�s Innovation group for reducing Hospital Inpatient Mortality. Several of the change concepts we have been working on have been packaged and six other hospitals have been asked to implement as many of the packages as feasible. One set of measures that the IHI faculty and researchers focuses on the �relative mortality rate�. The organizations 2002 unadjusted mortality rate is the baseline rate. Then each month from 2003 and 2004 (year to date) is placed in the numerator as a way to compare relative performance since 2002. For instance, a month that saw a 2% mortality rate would be right at the 1.0 level because 2% / 2% = 1. The months we are below the 2% mortality, would be below the 1.0 index line. This graphic shows only two data points over the 2002 rate (2002 rate is the green line representing an index of 1.0) in the last 12 months. Analysis of March data indicates a continuing trend for the rate to be below the index line of 1.0. (We are reporting everything relative to 2002 unadjusted mortality) In December we began participating in the IHI�s Innovation group for reducing Hospital Inpatient Mortality. Several of the change concepts we have been working on have been packaged and six other hospitals have been asked to implement as many of the packages as feasible. One set of measures that the IHI faculty and researchers focuses on the �relative mortality rate�. The organizations 2002 unadjusted mortality rate is the baseline rate. Then each month from 2003 and 2004 (year to date) is placed in the numerator as a way to compare relative performance since 2002. For instance, a month that saw a 2% mortality rate would be right at the 1.0 level because 2% / 2% = 1. The months we are below the 2% mortality, would be below the 1.0 index line. This graphic shows only two data points over the 2002 rate (2002 rate is the green line representing an index of 1.0) in the last 12 months. Analysis of March data indicates a continuing trend for the rate to be below the index line of 1.0. (We are reporting everything relative to 2002 unadjusted mortality)

16. The Big Dot is Moving!

17. 2. Align system measures, strategy and projects in a leadership learning system Work from the Big Dots in Develop a coherent �Theory of the Strategy� for how to achieve your aim Implement, monitor, and revise the strategy as needed, if the Dots aren�t moving! Requires that leaders make predictions of the quantitative impact of projects and initiatives Requires a plan for scale and spread

19. Projects Connected to Big Dots

20. Walsall HSMR 2000-01

21. Mike Brown, medical director at Walsall Hospitals NHS Trust �After the first [HSMR data were published] we spent a lot of time setting up what I think is a first class clinical governance framework. We focussed on mortality and looked at all the outlying areas [ie the groups of patients with high mortality ratios].� �We set up seven groups. Each group was given outliers to look at and identify where things could be done. Each group had a senior director on it to give it clout. There was no simple way to change things � no single cause. It was one long slog across the board�

22. Walsall 2003-04

23. Walsall change of HSMRObserved � expected deaths (top 80% deaths) = 234 in 2000/1, 8 in 2003/4 � reduction = 226 (283 100% deaths)

24. Walsall service improvements(Mike Browne) Heart disease - general CHD (Coronary Heart Disease) Angina Clinic Paramedics are better trained at being able to diagnose heart problems Aspirin being given to patients suspected of an MI (myocardial infarction) Increased use of 12-lead ECGs Morphine being administered Work done on educating the public into recognising signs of an MI earlier and calling an ambulance Improved awareness on health lifestyle through the CHD Patients Forum Introduction of 8 minutes response time for paramedics Introduction of Thrombolysis Nurse Specialist Improvement in MI thrombolysis door-to-needle times CHD National Service Framework � Commission for Health Improvement Review Report commended progress (Dr Paul Giles) CHD NSF setting standards and working with the Local Implementation Team to deliver progress against standards Research � Currently the Trust is involved in 5 CHD Research Projects

25. Walsall service improvementsHeart disease - Heart failure & Chronic IHD Heart Failure Clinic has a more structured approach Introduction of dedicated post-MI Clinic CHD outreach project (Jackie Dyke)

26. Walsall service improvementsMalignant disease - general Chemotherapy Steering Group: Patient Mapping project (Lucy Plummer) End Stages of Life Care Pathway (Nicky Groves / Pat Bennett) Improvements to treatment regimes in general Multi-disciplinary Team Co-ordinator post recently created covering some national cancer dataset duties Introduction of Cancer Service Co-ordinator Introduction of dedicated Fast Track and walk-in Outpatient clinics Research � current Trust involvement in 14 Oncology research projects

27. A Plan for Mortality Reduction Implement: Rapid Response Teams (RRTs) Improved Care for Acute Myocardial Infarction Prevention of Adverse Drug Events Prevention of Central Line-Associated Bloodstream Infection Prevention of Surgical Site Infection Prevention of Ventilator-Associated Pneumonia

28. The key ideas here are three: If you are measuring system-level indicators, you must do so in relation to an aim, and you must also have a plan for how you are going to USE the measures. The measures give you a feedback loop to your theories about what will move the measures (corollary�if the measures don�t move, change your theory!) You should always do your quality planning from right to left on this slide. Far too often we list our current quality efforts on the left side, and then rationalize why they are somehow related to strategic aims on the right side.The key ideas here are three: If you are measuring system-level indicators, you must do so in relation to an aim, and you must also have a plan for how you are going to USE the measures. The measures give you a feedback loop to your theories about what will move the measures (corollary�if the measures don�t move, change your theory!) You should always do your quality planning from right to left on this slide. Far too often we list our current quality efforts on the left side, and then rationalize why they are somehow related to strategic aims on the right side.

29. �Attention is the currency of leadership.� Heifetz

30. 3. Channel Leadership Attention to the Aim Change your calendar Do executive reviews of key projects Connect executive performance feedback, compensation to the aim Re-focus hiring and promotional practices� Body language, personal and organizational, formal and informal, must all be consistent with the aim

31. Channeling Attention & Establishing Patient Safety as a Strategic Priority Review agendas of the last four meetings of the senior leadership team for the following: 1. Were patient and/or staff safety issues on the agenda? 2. Where was the placement of these issues on the agenda- first, middle, last? 3. Is data from patient and staff safety indicators routinely reviewed and discussed? 4. Are safety agenda items followed by action plans with an assigned senior leader accountable for follow-up? 5. Check the percentage of time that the team spends on discussion of patient care issues, including safety, and other operational matters. Repeat this exercise with the Board minutes and other high level operational meetings.

32. Channeling Leadership Attention: Examples and Ideas Prominent placement of safety issues on senior staff and board meeting agendas Spend time visiting with staff and asking about safety Assign executives to safety issues and ask for updates Request brief presentations from staff working on key projects relating to safety and ask how the senior staff could be helpful in supporting this work When successful safety projects are presented, discuss the development of a plan for spread of this work throughout the organization Routinely monitor the spread of important safety changes through the use of an organized spread time table and work plan Connect executive performance and compensation to improvements in patient safety Re-focus hiring and promotional practices to reflect patient safety as a priority

33. 4. Engage an effective and committed executive team You might have had the right team for the old job, but does that team Understand the new job? Want to do it? Have the skills to do it?

34. Executive Team: Characteristics for Transformation Shared values and ability to raise dissonant issues Commitment (measured by actions not words) to improved safety Enthusiastic participants in a shared learning agenda and to develop content understanding at senior level Have ways to hear the voice of the patient in design of health care

35. 5. Engage the CFO in this work The Fourth Column: integrating the financial plan (budget) and the quality plan When quality improvement reduces waste, who is responsible for �harvesting� the waste reduction in a way the CFO would believe? Quality and cost: Either/or? Both/and?

36. The Fourth Column

38. 6. Engage with physicians: How? Engage hearts in a common agenda Equip leaders to lead Keep it evidence-based and data-driven Standardize within, not to, the evidence Avoid �monovoxoplegia:� Openly confront the autonomy issue

39. Finding a Common Quality Agenda With Physicians Needless deaths or length of stay? Muda�particularly waste of time Examples: BIDMC Cardiac Surgery and mortality rates Park Nicollet, hand-washing, and �make the right thing the easy thing to do� Idea: lease hospital quality staff to physicians to improve their ability to hit pay-for-performance quality targets in their office practices

40. Equip MD leaders to lead:John Whittington�s method Identify MDs with social skills and courage Equip them to improve performance Display the difference between their performance and the �pack,� safely Invite other MDs to join in

41. McLeod Regional Clinical Excellence:MD-led, Evidence-Based, Data-Driven

42. McLeod Regional Medical Center Acute Myocardial Infarction Mortality

43. 7. Build improvement capability Start with the leadership team Senior executives must possess a fair amount of technical improvement capability Become a vector of infectious ideas Example: Reliability and Patterns: connecting discharge orders for CHF, timing of pre-op antibiotics, and ringing the bell on the CMS/Premier measures

46. Levels of Reliability in Health Care (Amalberti, Nolan)

47. How to Improve Reliability From �Complete Chaos� to �10-1� Define a process for the common things you do Commit to evidence-based medicine From �10-1� to �10-2� Standardize to protocols for the usual circumstances for entire populations Protocols plus contingencies for exceptions Strong emphasis on teams and interdependence E.g. multidisciplinary rounds Recognize and harness patterns of work

48. The Project Method: The Model for Improvement (Nolan, et al.)

49. Repeated Use of the Cycles

50. A Senior Leader Perspective on Projects