So The Campaign is Over What do we do now ormaybe it wasnt just about VAPs and RRTs and HAIs'

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So The Campaign is OverWhat do we do
now?(ormaybe it wasnt just about VAPs and
RRTs and HAIs.)

• Steven Tremain, M.D., F.A.C.P.E.
• Colorado 5M Lives Webinar
• March 4, 2009

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So if the Campaign wasnt about projects, what
was it about?

• Learning to think differently
• Learning new tools
• Learning from others
• Learning failure is your friend
• Learning to learn
• Learning the skills to tackle anything

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So if the Campaign wasnt about projects, what
was it about?

• Moving the Big Dot

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Insanity is doing the same thing over and over
and expecting different results

• Albert Einstein

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We needed to learn how to act differently. The
individual interventions of the Campaign were
simply the stage on which we did that learning.

• Jeff Smith, MD
• CEO
• Contra Costa Regional Medical Center

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The Case for Transformation

• How safe is American healthcare?
• Why is it not safer?
• How do we make it safer?

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So How Safe Is It?

• 44,000 - 98,000 people die in hospitals each year
  as a result of preventable medical errors (IOM)
• At least 1.5 Million ADEs annually
• gt3.5 billion in costs each year
• Averages gt one med error/ inpatient/day
  (IOM)
• The Defect Rate in the technical quality of
  American outpatient health care is approximately
  45 (NEJM)

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Every system is perfectly designed to get the
results it gets.

• Don Berwick, M.D.

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If you dont like the current reality, change it

• Leland Kaiser

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Why Is It Not Safer?

• Focus on Outcomes not Processes
• Reactivity
• Ignorance
• Arrogance
• Taylorism
• Push vs. Pull
• And..

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Blame

• Long history of looking for the bad apples
• Lack of understanding of the role of systems

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And Blame leads tothe Conspiracy of Silence
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So who is responsible for preventing avoidable
harm?

• Everyone!
• The Trustees
• The Administration
• The Medical Staff and all other licensed
  clinicians
• Housekeeping, clerical, everyone!

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Engaging Improvement Methods

• Standardize what is standardizable
• Make the right thing easy to try
• Make the right thing easy to do
• Fewer forms
• Part of the workflow
• Less Work!!

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Engaging Improvement Methods

• Involve staff from the beginning
• Work with the real leaders, early adopters
• Choose messages/messengers carefully
• Make clinical leadership involvement visible
• Build trust within each quality initiative
• Communicate candidly, often
• Value peoples time

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If you can't describe what you are doing as a
process, you don't know what you're doing.

• W. Edwards Deming

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Successful Approaches

• Human Factors
• Reliability
• Process Design
• Just Culture
• Top Down Bottom Up
• LKEs

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The Model for Improvement

• Segmentation
• Small Tests of Change
• Rapid Cycle Improvement
• Opt Out (not Opt In)
• Multidisciplinary Teams
• Collaboration
• Learning at all Levels

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FAIL EARLY -- FAIL FORWARD
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Measurement

• Process measures
• Outcome measures
• Generate light, not heat, with data
• Need good data not perfect data
• You cant improve what you cant measure

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Reliability

• Must control chaos
• Must study refine
• Independent Redundant checks

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Role of Best Practices

• Start with the science
• Develop the practice
• Study the variance
• Use variance to refine, educate
• Ideal 85-95 compliance
• (not 100!!)
• Mass customization
• (Brent James, MD Intermountain Health)

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Just Culture (David Marx)

• Human Error
• At Risk Behavior
• Reckless Behavior

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Error ResponseHow it is vs.How it might be

• Punish, Punish, Punish
• Vs.
• Systems or Ignore
• Systems or Coach
• Punish

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Framework for Change Within the Organization

• Vision
• Will
• Ideas
• Execution

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Vision

• Identify the Big Dot
• Move it by coordinated efforts

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Will

• Resources
• Competing Interests/Opportunity Costs
• Financial
• Political

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Ideas

• Governance
• Leadership
• Mid-Managers
• Line Staff
• Patients Families

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Execution

• 1. Setting Priorities and Breakthrough
  Performance Goals
• 2. Developing a Portfolio of Projects to Support
  the Goals
• 3. Deploying Resources to the Projects That Are
  Appropriate for the Aim
• 4. Establishing an Oversight and Learning System
  to Increase the Chance of Producing the Desired
  Change

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Example Reduce (Eliminate?) Avoidable Harm

• Identify causes (ADEs, Falls, Nosocomials, etc)
• Develop and implement strategies to address each
  cause
• Rapid PDSA each implementation
• As each is successful, you will Reduce Avoidable
  Harm.....Move the Big Dot

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What Pull Looks Like

• Nursing staff demand that roll out of medication
  reconciliation processes be expedited
• Nurses and doctors demand that planned spread of
  Rapid Response teams be abandoned pilot to
  big bang

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Change Competency

• Each level in the organization will have
  internalized its role in change and developed the
  skills and knowledge necessary to react to
  constant change.
• The organization has become ready and able to
  embrace change.

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Learning Organization

• one that can create the results it truly
  desires
• Peter Senge

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Your Next Steps....

• Whats Your Vision ?
• Is there Will ?
• Can the Ideas be mined ?
• Is their commitment to Execution ?
• Can this execution lead to organizational
  self-learning ?

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This is hard work. You have choices.

• You can stop (and go backwards)
• You can build on what you have done
• You can make your system of care safe and
  effective
• What is your big dot?
• What is your legacy?

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For More Information....

• Institute for Healthcare Improvement
• www.ihi.org
• Tool kits
• White Papers
• Conferences

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For More Information....

• Intermountain Institute for Healthcare Delivery
  Research
• www.intermountainhealthcare.org

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For More Information....

• www.justculture.org

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More Medicine is not Better Medicine.Better
Medicine is Better Medicine.
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• Steven Tremain, MD
• 925-370-5122
• stremain_at_hsd.cccounty.us