A shared pathway - Debbie Barnard Christopher Bourdon

Leadership & Physician Engagement: A shared Pathway
Debbie Barnard Chief, Quality & Patient Safety Officer, HSN
Dr. Christopher Bourdon Chief of Staff & VP Medical and Academic Affairs, HSN
June 4 2014
Session Objective: Our
Hope for Today
1. Better Understanding of the Role of
Leadership in Healthcare Improvement?
2. Shared Early Learnings from HSN’s
Journey of Improving How Leaders Work
Personal Driver as a Process
Improvement Leader
Original research
Negative
results
18%
Dickerson, 1987
46%
Negative
results
Koren, 1989
Submission
0.5 year
Balas, 1995
Kumar, 1992
Acceptance
0.6 year
Publication
35%
Lack of
numbers
variable
0.3 year
This image cannot currently be displayed.
Kumar, 1992
17:14
Poyer, 1982
Bibliographic databases
50%
6. 0 - 13.0 years
Expert
opinion
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
Inconsistent
indexing
9.3 years
Implementation
It takes 17 years to turn 14 per cent of original research to the benefit of patient care.
…Agency for Health Research & Quality (AHRQ)
CONTROLLING SCURVY
• 1601 Captain James Lancester
experimented with lemon juice to
prevent scurvy
• 1747 James Lind, another
experiment on HMS Salisbury
• 1865 British Board of Trade
adopted the policy for all ships in
the merchant marine – 264 Years
later
The Surgeon's Mate was first published in 1617. Volume 1639 describes the treatment and prevention of scurvy.
More Recent Healthcare Example
• Jama 1996 article (18 years ago):
Goldmann, D. A., Weinstein, R. A., Wenzel, R. P., Tablan, O. C., Duma, R. J., Gaynes, R. P., ... & van den Berg, J. M. (1996). Strategies
to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals A challenge to hospital
leadership. Jama, 275(3), 234-240.
–
–
Five five strategic goals to optimize antimicrobial: optimizing antimicrobial prophylaxis for operative
procedures; optimizing choice and duration of empiric therapy; improving antimicrobial prescribing
by educational and administrative means; monitoring and providing feedback regarding antibiotic
resistance; and defining and implementing health care delivery system guidelines for important types
of antimicrobial use.
Five strategic goals to detect, report, and prevent transmission of antimicrobial resistant
organisms: to develop a system to recognize and report trends in antimicrobial resistance within the
institution; develop a system to rapidly detect and report resistant microorganisms in individual
patients and ensure a rapid response by caregivers; increase adherence to basic infection control
policies and procedures; incorporate the detection, prevention, and control of antimicrobial
resistance into institutional strategic goals and provide the required resources; and develop a plan for
identifying, transferring, discharging, and readmitting patients colonized with specific antimicrobialresistant pathogens.
• So we must ask ourselves
• Why the Knowledge vs Action Gap in Healthcare?
Leadership – Role of Leadership
• Deliver Results
• Build Capability
• Reinforce Values
Three Interdependent Dimensions of
High-Impact Leadership in Health Care
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,
and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
High-Impact
Leadership Behaviors
• Person-centeredness:
– Be consistently person-centered in word and deed.
• Front Line Engagement: Be a regular, authentic presence at the
front line and a visible champion of improvement
• Relentless Focus: Remain focused on the vision and strategy.
• Transparency: Require transparency about results, progress,
aims, and defects.
• Boundarilessness: Encourage and practice systems thinking and
collaboration across boundaries
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,
and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
IHI High-Impact Leadership Framework
Where Leaders Focus Efforts
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,
and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
Need a Specific Intentional Engagement Plan
• Develop Physician Leadership
– It doesn’t just happen!
– Focus: “Asset vs Deficit” Thinking
– Shared Purpose – “Better Patient Care”
• Define Engagement Strategies
– Cultivate a physician champions for key improvement
initiatives
– Create compact for physician champion role
– Create containing vessel for communication
– Develop communication plan
– Listen to physicians to surface and mitigate loss
Resources
June 2014
Engaging Doctors in the Health Care
Revolution
by Thomas H. Lee and Toby Cosgrove
Shifting Mental Models/Behaviors
What we are learning at HSN?
Focus on the Vital Few:
• QIP Indicators* Improve Quality (Reduce Harm – Infections)
• Key thinker: responsible for working across boundaries
• Check/Adjust (Learning Journey)
– Target/Actual, If not please explain and problem solve
• Developing Process Improvement facilitators to
support local improvement work
Mental Model: “If I jam the pipeline full of stuff, more will
come out the other end! Things will flow!”
Learning: Of course, this contravenes the laws of production
physics. In fact, the pipeline turns to cement. Nothing flows.
Source: Lean Pathways available at
http://blog.leansystems.org/2014_03_01_archive.html
QIP: Quality Improvement Plan
Engagement is the Key to Shift
From Buy-in to Ownership
Buy-in
It is important because “buy-in” is what everybody talks
about and because, more often than not, it doesn’t work
at all, or doesn’t work well, precisely because it is the
opposite of “ownership”.
Ownership
When you own or share the ownership of
an idea, a decision, an action plan, a
choice; it means that you have
participated in its development, that it is
your choice freely made.
Source: Henri Lipmanowicz available at http://www.liberatingstructures.com/hl-articles/
Early Shift From Behavioral Intentions to Actual Behavior
Leadership
S
O
D
C
Monthly/Quarterly
Reviews
(Check/Adjust)
Management
Problem Solving Using the
Scientific Method at all Levels
Monthly Reviews
Check/Adjust
Frontline
R
R
G
R
Daily to Weekly
Huddles
Early Results (Macro-level) – Focus Can Work!
Review QIP Results of the
last Three (3) Years
• 2013-2014 – 67% or 4 of 6 priority
goals achieved (i.e. closed gap by 75%)
• 2012-2013 – 25% or 1 of 4 priority
goals achieved
• 2011-2012 – 9 Goals (15 poorly
aligned indicators)
2012-2013
2011-2012
HSN QIP Priority Area
Improve or maintain our infection control practices across the hospital
Reduce unnecessary time in acute care (ALC days)
HSN QIP Priority Area
Reduce wait times in our Emergency Department
scans
Reduce wait times for CT and MRI
Zero
Harm
HSN QIP Priority Area
Zero Harm to Patients as a
2013-2014
Result of Care
Key Performance Measures
Achieve a HSMR (hospital standardized mortality ratio)
to equal or below 100 by 4th quarter of FY 2012/13
Improve
Access to Care and
Key Performance
MeasuresReduce the Average Length of Stay in ER for Admitted
Services
Patients by 10% by the 4th quarter FY 2012/13
Increase(CDI)
the result for the NRC Picker question,
New hospital-associated Clostridium difficile
rate per 1,000
patient
“Overall, how would you rate the care and services you
Improve
Patientdays
Experience
with Care
received
at the
ER Wait times:
90th Percentile ER Lengths
of Stay
forhospital?" by 10% improvement by
Access
Improve compliance with surgical checklist
4th quarter of FY 2012/13
Admitted patients
Improve access to outpatient care and chronic disease management
Increase enrollment in the CHF and COPD Chronic
Patient Experience
NRC Picker: “Overall, how would you rate
the care
services
Disease Management Clinics by 25% for high risk
and services
you
received
at
the
hospital?”
Reduce
Avoidable
Admissions/
Implement improvements to increase access to community-based
patients by the 4th quarter of FY 2012/13
Readmissions to Hospital
services
Percentage
ALC Days
Implement the care transition service by the 4th
Admissions/Readmissions
Strengthen linkages with our community
partners
Ratio of Acute Length of Stay (ALOS)/ quarter of FY 2012/13
Expected Length of Stay (ELOS)
Total Margin
Other Budget
Reduce wait times for hip and knee surgery
16
The Team’s Strategy : Courtesy of Miriam
McDonald Pharmacy Director and Team
Antibiotic Stewardship Program
Outcomes
Key Drivers
Change Concepts
Parenteral to Oral Conversion
Measure:. 100% of patients converted to oral therapy
within 72 hours according to guidelines
Change Work
Environment
Optimize the use of
antimicrobials to achieve the
best patient outcomes,
reduce the risk of infections,
reduce or stabilize levels of
antibiotic resistance and
promote patient safety at
HSN by March 2015.
Dose Optimization
Measure:. 100% of doses assessed for appropriateness
with renal impairment and indication
Surgical Antibiotic Prophylaxis
Measure:. 100% of patients will receive pre-op antibiotic
within at least 15 minutes prior to incision. (Tracked by
Managing Variation
Preprinted Orders - Community
Aquired Pneumonia
ARTIC - ASP Project
Measure:. Continue to measure IV antibiotic use, HA
C-Diff in ICU as outlined by CAHO
Optimizing Inventory
Maintain formulary of
Antimicrobials
Measure:. Zero requests for Non-formulary
Antimicrobials
Thank You
&
Questions
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Baker, G. R. (2012). The challenges of making care safer: leadership and system transformation. Healthcare Quarterly, 15, 8-11.
Baker, G. R. (2011). The roles of leaders in high-performing health care systems. London: The King’s Fund.
Baker, G. R., Denis, J. L., Pomey, M. P., & MACINTOSH-MURRAY, A. N. U. (2010). Effective governance for quality and patient safety in
Canadian healthcare organizations. A report to the Canadian Health Services Research Foundation and the Canadian Patient Safety Institute.
Ottawa and Edmonton, Canadian Health Services Research Foundation and the Canadian Patient Safety Institute. Ref Type: Serial (Book,
Monograph).
Davies, H., Powell, A., & Rushmer, R. (2007). Healthcare professionals’ views on clinician engagement in quality improvement. A literature
review.
Denis, J. L. (2013). EXPLORING THE DYNAMICS OF PHYSICIAN ENGAGEMENT AND LEADERSHIP FOR HEALTH SYSTEM IMPROVEMENT
PROSPECTS FOR CANADIAN (Doctoral dissertation, École nationale d'administration publique).
Grimes, K., & Swettenham, J. Physician Engagement: Barriers and Facilitators. Compass for Transformation: Barriers and Facilitators to
Physician Engagement, 4.
Mohr, J. J., & Batalden, P. B. (2002). Improving safety on the front lines: the role of clinical microsystems. Quality and safety in health care,
11(1), 45-50.
Goldmann, D. A., Weinstein, R. A., Wenzel, R. P., Tablan, O. C., Duma, R. J., Gaynes, R. P., ... & van den Berg, J. M. (1996). Strategies to prevent
and control the emergence and spread of antimicrobial-resistant microorganisms in hospitalsA challenge to hospital leadership. Jama, 275(3),
234-240.
Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)
Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper.
Cambridge, MA: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)

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