the science of improvement part 3 “call to action” dwight evans the speaker does not have any...

The Science of Improvement Part 3 The Science of Improvement Part 3 “Call to Action” “Call to Action” Dwight EvansThe speaker does not have any relevant financial relationships with any commercial interests

Can Quality be Found in Can Quality be Found in Resource Challenged Areas?Resource Challenged Areas?

Resource poor countries have 90% of the people but only 10% of the world’s wealth

Question: Is it easier or harder to improve healthcare in resource poor settings?

Science of Improvement Science of Improvement ReflectionReflection

oHigher quality (often far higher quality) can cost less (often far less) than defective healthcare

oCan we achieve bold improvements in areas with constrained resources?

“Do what you can,with what you have,where you are”

Theodore Roosevelt

Science of Improvement Example

Rwanda determined that 16% of its Physician capacity would be required to care for all of its patients with HIV/AIDS

By shifting to RN driven clinic care for ~80% of visits, they could reduce demand on physicians for HIV services by 80%

The “freed up” physician time could be spent to improved and expand patient care throughout their HC system

Paul Farmer, M.D. Carabayllo neighborhood of Lima, Peru Partners in Health (“Socios en Salud”)

have demonstrated that multidrug resistant TB can be cured in about 80% of cases

How? Community health workers, expert-based treatment planning, anticipatory management of complications, maintenance of local registries

Carabayllo Model

Multidisciplinary teams in 41 community based clinics in 5 districts of Lima - which account for about 30% of TB cases in Peru

These teams have mastered the “Model for Improvement” and thus understand measurement, reporting, and local tests of change (rapid cycle improvement)

Ghana’s Project Fives Alive! In 2008 IHI and NCHS launched PFA

Goal: meet Millennium Development Goal #4: reducing

under-5 mortality by two-thirds from 1990 baseline

(from 110 per 1,000 live births to < 40 per 1,000 births

Action: collaboration with communities, frontline

workers, and health system leaders to improve

maternal/child health

4 sequential collaboratives

Results: 27-39% decrease in Under 5 Mortality across

Ghana

Preconditions to Improve HealthcarePreconditions to Improve Healthcare

1. Will: durable improvement is not an accident; left alone systems tend to deteriorate

2. Ideas: new results can’t come from old methods. All improvement is change!

3. Execution: Improvement requires that changes be put into practice. Until real care is actually changed for real patients in real HCS, injury rates will stay the same

A Framework for HC Leadership

1. Set Direction: Mission, Vision and StrategyMake the Status Quo uncomfortable \ Make the Future Attractive

3. Build

Will

4. Generate

Ideas

5. Execute

change

2. Establish the Foundation

Barriers to (S of I) Progress:Barriers to (S of I) Progress:

1. Politics does really matter; desired leadership change does not always occur

2. Infrastructure: in spite of clever innovation, a core amount of resources are needed

3. Red Tape: Do senior leaders show the willingness to give local teams the license they need to try new methods?

4. Self Sufficiency: despite

helpfulness of consultants, it is crucial for spread and sustainability that dependency on outside advisors falls steadily (grow your own coaches!)

5. Travel: Getting people together for planning and implementing spread (innovation) can be difficult


6. Leadership: There may be a finite pool of leaders who can devote their time to improvement

The pool of skilled, mature system-oriented leaders may be small in a given organization

Leadership development is an inescapable part of any plan for improvement


7. Roles: Does the culture have built-in

fossilized, dysfunctional rules and habits about job roles?

8. Scalability: A technical barrier to “Scale Up” system changes (innovative changes) When innovative/creative improvements were

designed did they take into consideration how they will be scaled up to a larger system?

Resource availability? Leadership availability?


Roadblocks between Will / Ideas Roadblocks between Will / Ideas and Executionand Execution

1. Invisibility of Delay: in the local in the local setting, the local workforce may be setting, the local workforce may be blind to the problemblind to the problem Why?

If one patient at each hospital every 4 months has an adverse problem has anyone noticed?

If 20 patients are waiting for a given procedure and this delays definitive therapy has anyone noticed [or measured] this?


2. Our current modus operandimodus operandi isscientifically out of date:

Bad people cause errors

While in reality, most errors are While in reality, most errors are committed by competent, caring peoplecommitted by competent, caring people

It is the System that must be Changed!It is the System that must be Changed!

Roadblocks between Will / Ideas Roadblocks between Will / Ideas and Executionand Execution3. Myth: Improving System always costs

money

Technical changes: (new equipment) – Yes

Redesigning jobs – No

Cultural Change / “Improvement” [System Change in

patient flow] - No


4. Changing Systems is Hard:Dozens of entrenched systems (all hospital departments including support systems) and patterns of activity must change how we:

Engage in clinical Rounds,

The Ways we: Keep records,

Do Meetings, Run training programs, Write Policy manuals, Do Procedures

Change is both inevitable and painful

Resistance is futile: it usually does not stop that process from occurring

Passive aggressive resistance is the most difficult to overcome

Change

Nearly all men can stand

adversity, but if you want to test a

man’s character, give him power

Abraham Lincoln

Successful “Science of Improvement”:

Coming together is a Beginning

Keeping together is Progress

Working together is Success

Lessons Learned in Successful Lessons Learned in Successful “Science of Improvement”:“Science of Improvement”:

1. Simplify Everything: Improvement does not need to be complex:

1. Set aims2. Track results3. Find great ideas4. Change something every day to find a better way,5. Involve everyone you can,6. Don’t assume the rules of today must be the rules of

tomorrow

Those with few resources demonstrate a knack for elegance in the simplicity of approach to needed improvement

Complexity is Waste! Phil. 4:11-12

Lessons Learned in S of I:Lessons Learned in S of I:

2. Take Teams Seriously: Improvement is about cooperation; no one is more important than the team.

Uncooperativeness is waste! Phil. 2:2

3. Be Pragmatic about Measurement: Sophisticated IT is nice, but not the point of SI. Use the least amount of measuring that helps

Too Much Counting is Waste! Luke 12:19


4. Strip the Support System for Improvement to a Minimum: Flatten the organization. Consultants should become unnecessary ASAP.

Dependency is a form of Waste!

I thess. 4:12


5. Manage the Political Interface Wisely: It is wise to know how your system works

6. Help Patients become

advocates for Change:

Political Inexperience is Waste! ! Ecc. 3:8

Keeping Patients Silent is Waste! Ecc. 3:7

Lessons Learned in S of I:Lessons Learned in S of I:7. Go Quickly / Start Now:

Delay is Waste! 2 Peter 3:4

8. Make S of I spread part of your new way of operating : find the channels in your system where change can flow

Isolation is Waste! Prov. 18:3

9. Don’t Complain:

Complaining is Waste! Phil. 2:14

Change Change

Thus, change…

from within,

discovered,

celebrated, and

implemented

by the people

who need to do the change

is a surefire win!

““End with Hope”End with Hope”

If we: If we: Deliver the care right the first timeDeliver the care right the first time Do it right every time for every patient Do it right every time for every patient Give the right Tx (and the right indication)Give the right Tx (and the right indication)

We can then expect (HRO) to Achieve the We can then expect (HRO) to Achieve the “Triple Aim”: “Triple Aim”:

Better Outcomes Better Outcomes (and Few Complications)(and Few Complications) A Delighted patient! A Delighted patient! (Patient Experience)(Patient Experience)

Lower Cost per CapitaLower Cost per Capita

The Science of Improvement is a Journey, not a Destination

Some Marvel at the Mountains before them,

Others climb them

Science of ImprovementScience of ImprovementChallenge:Challenge:

If not now, When?

If not me, Whom?

the science of improvement part 3 “call to action” dwight evans the speaker does not have any...

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