Celebrate and Accelerate Spread and Sustain: Building on the First Eighteen Months of the 100,000 Li

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Celebrate and Accelerate Spread and Sustain
Building on the First Eighteen Months of the
100,000 Lives Campaign

• Joe McCannon, 100,000 Lives Campaign Manager
• Institute for Healthcare Improvement
• August 15, 2006

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Outline

• The Campaign Celebrating Your Accomplishment
• Key Learning
• Accelerating Our Work
• Spread and Sustainability
• The Next Phase
• Your Thoughts, Questions, Comments

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First Things First

• THANK YOU (from the Campaign and from us)
• for your tireless support,
• for your ambition (counting),
• for your commitment to excellence,
• for your genuine collaboration,
• for the great ideas and leadership in this group.

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The Campaign A Recap
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Campaign Origins

• Origins of IHIs 100,000 Lives Campaign
• Frustration with persistent variability in the
  quality of care and the national rate of change
  in the U.S.
• Belief that our sense of urgency was shared by
  leaders and providers throughout the system
• Belief in the value of a shared, explicit set of
  aims, an all-at-once Campaign model, and the
  power of the six Campaign interventions.

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Campaign Objectives

• Save 100,000 Lives
• Enroll more than 2,000 hospitals in the
  initiative
• Build a reusable national infrastructure for
  change
• Raise the profile of the problem - and our
  proactive response

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Six Changes That Save Lives

• Deployment of Rapid Response Teamsat the first
  sign of patient decline
• Delivery of Reliable, Evidence-Based Care for
  Acute Myocardial Infarctionto prevent deaths
  from heart attack
• Prevention of Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevention of Central Line Infectionsby
  implementing a series of interdependent,
  scientifically grounded steps called the Central
  Line Bundle
• Prevention of Surgical Site Infectionsby
  reliably delivering the correct perioperative
  antibiotics at the proper time and taking several
  other associated actions
• Prevention of Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps called the
  Ventilator Bundle

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Campaign Objectives

• Save 100,000 Lives
• Enroll more than 2,000 hospitals in the
  initiative
• Build a reusable national infrastructure for
  change
• Raise the profile of the problem - and our
  proactive response

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Key Campaign Principles

• Some is not a number soon is not a time
• Welcome anyone at any level
• We do this together
• Graduated involvement
• Lets get down to work
• The Campaign starts with you
• Run it like a Campaign (internal)

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Some Is Not a Number Soon Is Not a Time

• The Number
• 100,000 Lives
• The Time
• June 14, 2006 9 a.m. ET

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The 100k Lives Campaign Scorecard

• Over 3,100 Hospitals Enrolled
• Over 78 of all discharges
• Over 78 of all acute care beds
• Participation in Campaign Interventions
• Rapid Response Teams 60
• AMI Care Reliability 77
• Medication Reconciliation 73
• Surgical Site Infection Bundles 72
• Ventilator Bundles 67
• Central Venous Line Bundles 65
• All six 39
• Over 85 of Participating Hospitals Are Sending
  IHI Mortality Data

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Lives Saved Calculation
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Did Needless Deaths Fall?
?
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Did Needless Deaths Fall?
122,342
Lives Saved
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The Range of Uncertainty

• Statistical Range

122,342 /- 2074
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The Range of Uncertainty

• Statistical Range

122,342 /- 2074
Methodologic Range
115,363 to 148,758
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Additional Campaign Status

• Over 55 field offices (nodes) and vibrant
  national partner support
• Thousands on national calls
• Unprecedented web activity and new tool
  development
• Unprecedented media coverage of the problem and
  hospitals response (Newsweek, US News and World
  Report, Wall Street Journal, New York Times,
  JAMA)
• Related campaigns forming nationally and globally
  (Canada, Australia, Sweden, Denmark)
• Changes in standard of care in participating
  facilities (over 25 hospitals going a year
  without a VAP)

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Campaign Participants(a sample)

• American Medical Association, American Nurses
  Association, American College of Physician
  Executives, Association of American Medical
  Colleges, JCAHO, Leapfrog Group, NPSF, Premier,
  University HealthSystem Consortium, VHA, AHA
• Large systems SSM Health Care, Ascension Health,
  Adventist Health System, Hospital Corporation of
  America, Tenet Health Care
• State Hospital Associations and Nurses
  Associations
• Federal Agencies CMS, CDC, AHRQ, VA
• Scientific Societies ACC, American Heart
  Association, APIC, SHEA
• Pediatric and rural nodes
• AHQA (Quality Improvement Organizations across
  the country)
• Financial support BCBS of MA, Moore Foundation,
  Leeds Family, Rx Foundation, Blue Shield of CA
  Foundation, The Colorado Trust, Cardinal Health
  Foundation, Baxter International, Robert Wood
  Johnson Foundation

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Campaign Field Operations Structure
Introduction, expert support/science, ongoing
orientation, learning network development,
national environment for change
IHI and Campaign Leadership
Ongoing communication
Local recruitment and support of a smaller
network through communication/collaboratives
NODES (approx. 75)
Each Node Chairs 1 Network
Mentor Hospitals
Implementation (with roles for each stakeholder
in hospital and use of existing spread strategies)
FACILITIES (2000-plus)
30 to 60 Facilities per Network
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Mentor Hospital List

• http//www.ihi.org/IHI/Programs/Campaign/Campaign.
  htm?TabId4

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Sources of Optimism Hospitals with No VAP for
One Year

• Baptist Memorial DeSoto Southhaven, MS
• Baptist Memorial Hospital Golden Triangle
  Columbus, MS
• Bay Regional Medical Center Bay City, MI
• BryanLGH Medical Center Lincoln, NE no VAP as
  of 3/2/06
• Caruya Medical Center Ithaca, NY
• Columbus Regional Hospital Columbus, IN
• Community Hospital Anderson Indianapolis, IN
  one unit has not had a VAP in two years
• Community Hospital East Indianapolis, IN one
  ICU went 25 months with no VAP
• Dominican Hospital Santa Cruz, CA no VAP since
  10/12/04
• Geneva General Hospital Geneva, NY
• McLeod Regional Medical Center Florence, SC
  ICU has gone 21 months as of April without a
  VAP
• Memorial Hermann Texas Medical Center Houston,
  TX
• Oconee Memorial Hospital Seneca, SC
• OSF Saint Francis Medical Center Peoria, IL
• Overlake Hospital Medical Center Bellevue, WA
• Palmetto Health Baptist Columbia, SC
• Passavant Area Hospital Jacksonville, IL
• Providence Milwaukie Hospital Milwaukie, OR no
  VAP since February 2004
• Ridgeview Medical Center Waconia, MN no VAP in
  2.5 years

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Sources of Optimism Hospitals with No VAP for
One Year

• Capitol Region Medical Center Jefferson City,
  MO
• Cooley Dickinson Hospital Northampton, MA
• Community Hospital East Indianapolis, IN
• Community Hospital Anderson Anderson, IN
• East Alabama Medical Center Opelika, AL
• Immanuel St. Josephs, Mayo Health System
  Mankato, MN
• Indiana Heart Hospital Indianapolis, IN
• Overlake Bellevue, WA
• Passavant Area Hospital Jacksonville, IL
• South Shore Hospital South Weymouth, MA
• Southwestern Vermont Bennington, VT

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Sources of Optimism

• Ridgeview Medical Center
• AMI Care Reliability 100
• Heart Failure Care Reliability 99
• Pneumonia Care Reliability 97
• No CL infections in 24 months
• No VAP in 24 months
• No code calls outside the cardiac ICU in 4 months
• Door-to-balloon time 91 minutes

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Sources of Optimism

• Pronovost Report from 70 Hospitals Working on
  Central Line Infections
• 1,578 lives saved
• 81,020 hospital days saved
• Over 165,000,000 in costs averted

Source Peter Pronovost, Keystone ICU Project
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Celebrating What American Hospitals Have
Accomplished!

• 100,000 Lives Campaign
• SCIP
• Keystone Project
• Numerous Other Hospital-Based Initiatives

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Key Learning
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Challenges

• Rural and critical access hospitals and specialty
  environments
• Variability of engagement across organizations
• Feedback system limitations
• Perceived lack of alignment among the initiatives
  of IHI, JCAHO, CMS, Leapfrog, SCIP
• Engagement of physicians, patients and families
• An evolving standard of practice

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Major Lessons

• Bold aims and deadlines
• Constant testing (every node is a laboratory)
• Focus on the field operation and infrastructure
  development
• Teaching the what and how of improvement on this
  scale
• Devolution of control
• Value of stratification
• Importance of logistics/implementation

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Survey Feedback

• Total respondents 220
• General concerns around alignment, medication
  reconciliation, human resources required to drive
  change (not financial resources)
• 94 say they plan to continue their Campaign work
• Getting-started kits the most popular Campaign
  resource

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Survey Feedback (cont)

• Reported awareness levels
• 99 of senior leaders
• 80 of trustees
• 60 of doctors and nurses
• MRSA, sepsis and pulmonary embolism among the
  most popular prospective interventions

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Accelerating the Work

• (June December 2006)

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Campaign Objectives (June to December)

• Save 100,000 Lives
• Enroll more than 2,000 hospitals in the
  initiative
• Build a reusable national infrastructure for
  change
• Raise the profile of the problem - and our
  proactive response
• Complete implementation of 6 Campaign
  interventions in participating hospitals by
  January 2007
• Focus on spread and sustainability

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Keys to SuccessIndividual Hospitals

• Organizations involved groups across the
  organization and community
• The Board
• The leadership team
• The front line providers of care (e.g.
  physicians, nurses, pharmacists, respiratory
  therapists)
• All staff
• Patients and families
• Community groups

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Activity/Resources for June-December Acceleration
Phase

• Campaign Best Practices Guide (based on our first
  18 months of learning)
• How-to guide on spread and sustainability
  (structural recommendations)
• http//www.ihi.org/IHI/Programs/Campaign/Campaign
  .htm?TabId2
• Updated How-to Guides on each intervention (with
  tips and tricks, new frequently asked
  questions, and current bibliographies)
• Over 100 mentor hospitals ready to help

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Activity/Resources for June-December Acceleration
Phase (cont)

• Continued 100k Live! calls and open office hours
  on existing interventions
• Summer tour activity (ongoing field operation and
  site visits)
• Exploration of new interventions
• Campaign redesign and build-up to December
  (capitalizing on our momentum and infrastructure)

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Sustainability and Spread
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Sustainability

• Supportive Management
• Structures to Foolproof Change
• Robust, Transparent Feedback System
• Shared Sense of System
• Culture of Improvement
• Formal Capacity-Building Programs

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Supportive Management

• Board and executive team creates accountability
  systems.
• Board and executive team effectively communicates
  measurable improvement aims.
• Executive team celebrates successful attainment
  of improvement aims.

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Structures to Foolproof Change

• Managers of improvement activities document
  successful processes in guidelines and training
  materials.
• Managers of improvement activity develop tools
  (e.g., checklists, pre-packaged kits of
  materials used in applying the intervention) and
  technology to support sustained implementation.

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Robust, Transparent Feedback System

• The hospital has in place a measurement system
  that regularly generates data on performance.
• The hospital publicly displays improvement data
  on all improvement interventions.

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Shared Sense of System

• Managers of improvement activity use tools to map
  the process that has been improved (e.g., flow
  charts), allowing for shared analysis of systems
  as sustainability work proceeds.

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Culture of Improvement

• Everyone in the organization is clear on major
  performance improvement activity and can explain
  their role in it.
• Staff view quality improvement work as part of
  their job.
• Managers of improvement activity write job
  descriptions to reflect improvement
  responsibilities.
• Managers of improvement activity create
  opportunities for all stakeholders in improvement
  to share ideas and express concerns.

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Formal Capacity-Building Programs

• Managers of improvement activity closely consider
  the composition and skill base of participating
  teams, working to enhance confidence and core
  competencies.
• Every stakeholder in the organization is
  introduced to the content of any new improvement
  intervention and provided ongoing training in
  quality improvement methods.

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What are we talking about when we say spread?

• Not butter
• The science of taking a local improvement
  (intervention, idea, process) and disseminating
  it across a system
• There are many possible definitions for a
  system (e.g. a hospital, a group of hospitals, a
  region, a country)

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When do we spread?
Successful changes
High
Degree of belief that the changes will result in
improvement
Changes still need further testing. There is a
risk of moving to spread/scale-up.
Moder- ate
Unsuccessful proposed changes
Low
Pilot
Prototype
Spread
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When do we spread?

Improvement
Spread
Hold Gains

BETTER
Improvement
Hold Gains
Spread
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How do we spread?

• Many possible ways
• Natural diffusion
• Breakthrough Series Collaborative model
• Scale-up model
• Campaign model

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Adopter Categories
Innovators
Early Majority
Late Majority
Early Adopters
Laggards
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2.5
13.5
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from E. Rogers, 1995
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Breakthrough Series(9-18 months time frame)
Participants
Select Topic
Prework
P
Develop Framework Changes
P
A
D
A
D
Summits, Guides, Publications, etc.
S
S
Planning Group
LS 1
LS 2
LS 3
Supports E-mail Visits Phone Assessments
Senior Leader Reports
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Scale-Up Wedges
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A Common Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives
aligned -Executive sponsor assigned -Day-to-day
managers identified
Social System -Key messengers -Communities
-Technical support -Transition issues
Set-up -Target population
-Adopter audiences -Successful sites
-Key partners -Initial spread
strategy
Better Ideas -Develop the case -Describe the
ideas

Communication Strategies (awareness technical)
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Common Phases of Spread Activities

• Phase 1 Planning and Set-up
• Phase 2 Communication through the Social
  System/Infrastructure
• Phase 3 Continuous Monitoring and Feedback

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Common Principles to Guide the Spread Plan

• Begin with full scale in mind
• Develop prototype in slices representing
  different levels of the system of care
• Use the line authority of the system
• If possible, organize waves in multiplicatives of
  5-10
• Be cognizant of constraint factors when spreading
  
• Consider Communication needs, information system
  needs, leadership/supervision needs

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Common Aim-Setting Technique

• Spread What
• Spread to Whom
• Target Levels of Performance
• Time frame

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Campaign Spread Objectives

• Spread What Six interventions known to reduce
  morbidity and mortality
• Spread to Whom Over 2,000 hospitals
• Target Levels of Performance Best in industry
  (e.g. zero infections)
• Time frame 18 months

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Moving Forward
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Possible Ways Forward

• Celebrate/Accelerate (Spread and
  Sustainability phase from June through December
  2006 simultaneous internal planning for December
  forward)
• Expanded 100,000 Lives Campaign an installed
  audience, adding interventions and welcoming
  others to use the chassis
• Campaign (or similar approach) for outpatient
  settings, for reducing waste and/or disparities
• Campaign College for other countries and for
  nodes
• Another direction (using the Campaign
  infrastructure for another type of initiative)

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Key Questions Moving Forward

• Do we pursue another Campaign starting in
  December?
• If so, what is our content and messaging?
• How do we maintain the energy and excitement (the
  charisma of the Campaign)?
• How do we continuously improve hospital results
  on every Campaign intervention?

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Your Thoughts, Questions, and Comments
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We Aim to Achieve Care That Is

• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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IHIs No Needless List

• No needless deaths
• No needless pain
• No helplessness
• No unwanted waiting
• No waste
• for anyone