Making change at scaleA model for systems improvement

Mexico City, Mexico

August 21, 2014

Kedar S. Mate, MDSenior Vice President

Agenda

The social and financial need for change & improve

Prevailing models for achieving better quality

The model for improvement as fundamental for change

Case studies of “how” to make it happen

The Social Need

Major Biomedical Successes

Vaccines

Antimicrobial therapy

Management of Ischemic Heart Disease

AMTSL for maternity

Oral rehydration therapy

Antiretroviral therapy for HIV infection

Treatment for Diabetes Mellitus

Advances in chemotherapy

Organ transplant

Geographic Variation: PCI per 1,000 Medicare Beneficiaries

Dartmouth Atlas, 2011. Improving Patient Decision-Making in Health Care

The Institute of Medicine – 1999

44,000 to 98,000 deaths per year in hospitals from medical injuries

Using “IHI Global Trigger Tool” – we estimate about 40 patient injuries per 100 admissions

What should we aim for?

Safe

Effective

Patient Centered

Timely

Efficient

Equitable care

…For EveryoneInstitute of Medicine

March 2001

The Financial Need

Medicare Expenditure per capita 2010

Dartmouth Atlas, 2010

9

What do you get for $3000 Extra?

32% more hospital beds per capita65% more medical specialists75% more internists

Technically less evidence-based careOverutilization – more hospital days, procedures, visitsSlightly higher mortalityLower satisfaction with hospital care

10

Universal healthcare coverage11

Universal quality coverage12

Mate KS, Rooney A, Supachutikul A, Gyani G. Accreditation as a Path to Achieving Universal Quality Health Coverage. 2014

12 actions to cross the threshold

Standard-setting & Accreditation

Professional Licensure

Enabling legislation

Measurement, benchmarking & feedback

Public reporting 

Use of Information technology; HMIS; meaningful use

Large-scale improvement initiatives

Learning systems across public-private sector

Workforce development including improvement skills

Patient and consumer engagement

Responsive regulation  

Payment or incentive mechanisms

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Prevailing Models

Model I: Inspection & Elimination

The Problem

Quality

Frequency

The Cycle of Fear

Increase Fear

Micromanage Stop theMessenger

Filter theInformation

Fear poisons ImprovementDon Berwick

Model 2: Continuous Improvement“Every Defect is a Treasure”

Quality

Fr

eq

uen

cy

Model for Improvement

Act Plan

Study Do

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?

Case Studies100K Lives

South Africa

IHI Framework for Execution21

Build Will & Motivation Harvest Best Ideas

Focus on Execution

The “100,000 Lives Campaign”22

The Campaign “Planks” -- Six Changes That Save Lives

1. Deployment of Rapid Response Teams

2. Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction

3. Medication Reconciliation

4. Prevention of Central Line Infections

5. Prevention of Surgical Site Infections

6. Prevention of Ventilator-Associated Pneumonias

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How It’s Done

Meetings

Committees

Consensus

Broadcast info

Business as Usual Incident Command

Fast tempo

Adaptive in real time

Focus on logistics

Results: Ascension Health (71 hospitals)

Pressure Ulcer

Neonatal mortality

Birth Trauma

Ventilator-acquired pneumonia

Falls with serious injury

Blood-stream infections

Preventable Error Reduction in rate

95%

79%

74%

56%

54%

32%

CareScience Observed minus Expected Mortality Rate per 100 DischargesAscension Health System

-0.9000

-0.8000

-0.7000

-0.6000

-0.5000

-0.4000

-0.3000

Apr

-03

May

-03

Jun-

03

Jul-0

3

Aug

-03

Sep

-03

Oct

-03

Nov

-03

Dec

-03

Jan-

04

Feb

-04

Mar

-04

Apr

-04

May

-04

Jun-

04

Jul-0

4

Aug

-04

Sep

-04

Oct

-04

Nov

-04

Dec

-04

Jan-

05

Feb

-05

Mar

-05

Apr

-05

May

-05

Jun-

05

Jul-0

5

Aug

-05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Obs

erve

d m

inus

Exp

ecte

d R

ate

per 1

00 D

isch

arge

s

Actual Monthly Difference p-bar (Center Line for Difference) LCL UCL

Baseline

1,038 Mortalities Avoided (Year 2)

374 Mortalities Avoided(9 mos. of Year 3)

1,412 Mortalities Avoided Since Baseline Period

Ascension Hospital Mortality Reduction27

Principles for Large-Scale Change

Bold, compelling aim

Strong evidence-based set of practices

Clear description of how to implement them

Leadership support from the start

Incident command approach

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HIV Infection in South Africa in 2007

1/3 of pregnant mothers were infected with HIV

20% of babies were infected with HIV during pregnancy and delivery

50% of HIV+ babies died in first year of life

Necessary Ingredients…

Leadership/Policy: National Strategic Plan

Access: 90% women attend ANCs; 84% deliver in facility

Funding: $748 per capita, 8.7% of GDP

Supply Chain: Widespread availability of ART

Evidence-base: ACTG076, PHPT-2, HIVNET-012

Workforce: 4.9 care givers / 1000 (WHO min 2.5)

Missing: A strategy for change from local to national level

Social System: Collaborative

Click icon to add picture

Collaborative Organizer

Team1

Team2

Team3

Team4

Team 5

Common Aim

Share ideas

Use a common data framework

Share ownership

Government target: Reduce HIV transmission to

<5% by 2011

Mate KS, Ngubane G, Barker P. International Journal for Quality in Health Care 2013; pp. 1–8

Social System: Collaborative

Click icon to add picture

Collaborative Organizer

Team1

Team2

Team3

Team 4

Team5

Government target: Reduce HIV transmission to

<5% by 2011Distr office

Distr office

Distr office

Distr office

Distr office

Jan-10

May-10

Sep-10

Jan-11

May-11

Sep-11

Jan-12

May-12

Sep-12

0%

2%

4%

6%

8%

10%

12%

14%

Reducing mother-to-child HIV transmission

Policy: New protocol introduced: HAART if CD4<350

Health System/QI: HIV testing>95% pregnant women in all 3 Districts

Training/decentralization Nurses at PC clinics trained in providing ARVs

Health Systems/QI: Starting mothers on HAART reaches 90% in 3 Districts

Health System/QI: QI approach spread to 3 Districts

Infant Mortality RatesJa

n-12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb

-14

20

30

40

50

60

70

80

56.2

45.1

RATE OF INSTITUTIONAL DEATHS AMONG 0-1 1 MONTHS OLD INFANTS PER 1000 ADMISSIONS (BASED ON 132

HOSPITALS IN 7 REGIONS)

Rate

19.8% mortality reduction

Project Fives Alive! Program data, 2014

Principles for Large-Scale Change

Bold, compelling aim

Strong evidence-based set of practices

Clear description of how to implement them

Leadership support from the start

Incident command approach

Social system for spread

Timely, transparent, data

Focus on testing solutions

Emphasis on ideas from the front-lines

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IHI Framework for Execution36

Build Will & Motivation Harvest Best Ideas

Focus on Execution

Change is Hard…but it is possible

Dan Heath, Switch: How to change things when change is hard

Thank you

Kedar S. Mate, MDSenior Vice President, Institute for Healthcare Improvement

Assistant Professor of Medicine, Weill Cornell Medical College

Editorial Board, Joint Commission Journal on Quality & Patient Safety

20 University Road, 7th Floor

Cambridge, MA 02138

617-301-4800

kmate@ihi.org

@KedarMate

www.ihi.org

Our Mission:To improve health and health care worldwide

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Build a Learning System that Speeds Reform

Set bold aimsKnow the hard count of what you are trying to improveBuild data systems for continuous learning: “war rooms”Learn from patients & communities (co-production)Respect the insights of the front-lines of careRely on the evidence-base and add to itChoose a technical method for improvement & changeAlign financial incentives to support continuous learningSeek partnership with others who are avid learners