what you will learn today¾full clinical deployment in existing and new hospitals (total of 35)...

Institute for Healthcare Improvement

Kaiser Permanente’s Road to Transformation

IHI ForumOrlando FloridaDecember, 2009

What You Will Learn Today

Understand the six capabilities of a high performing organizationIdentify essential factors to create high functioningIdentify essential factors to create high functioning frontline teamsUnderstand the principles of employee engagement and the opportunity for continuous improvement with a unionized workforce Create a plan to establish high performing teams, an oversight process and lead 90-dayan oversight process and lead 90 day improvement portfolios with teams


Kaiser Permanente: the nation's largest not-for-profit health plan

Total health care delivery system

8.6 million members

Few Facts About Kaiser Permanente

headquarters in Oakland, CA

165,000 employees, 15,000 physicians

45,000 nurses, 35 hospitals, and 431 medical office buildings

Dedicated to care innovations, clinical research, health education and the support of community health

Kaiser Permanente gives almost $1 billion a year to the community through programs, grants and donations

Established 1997

31 local unions representing 96 000 frontline

Labor Management Partnership

31 local unions representing 96,000 frontline employees

Largest and most comprehensive partnership in U.S.

Shared accountability for performance improvement, learning, engagement and decision making

4

g g g g

Measurable improvements in clinical quality, member service, cost-efficiency and workplace quality


Membership by Region• Northern California:

3 285 068

Kaiser Permanente’s Eight Regions

3,285,068• Southern California:

3,281,915• Hawaii: 222,594• Northwest: 472,555 • Colorado: 479,980 • Georgia: 269,802 • Mid-Atlantic States:

485,401• Ohio: 137,669

(as of December 2008)

8.6 million ambulatory recordsThe world’s largest civilian deployment of an electronic health record

Integrated inpatient/outpatient record available for

KP HealthConnectTM by the Numbers*

Integrated inpatient/outpatient record available for more than 5 million members

Full clinical deployment in existing and new hospitals (total of 35) expected by early 2010

Over 3 million members actively using My Health Manager on kp.org

Almost 39 million lab test results viewed online and almost 15 million secure messages sent by members to their providers

*As of May 2009


PrinciplesDefining purpose Creating system view

What you will learnStrategy alignmentDrivers and portfolios

What We Will Discuss Today

LeaTo

p do

wn

Red

uce

varia

tion

Learning system

Economic and social context for changeModels of workplace

Planning and managing Building capability

Engaging the hearts and minds of the front lineCreating “line of sight” to

Bottom

uparning and im

provemen

Models of workplace learningTeam performance

Creating line of sight to strategic goalsDefining high performing unit-based teams

t

Kaiser Permanente’s Road to Transformation: Systems and Execution

Lisa Schilling, RN MPHVice President Healthcare Performance ImprovementIHI ForumDecember, 2009


Key Elements of Our Execution PathKey Area LeversAligning strategy Building will

Use of transparency and big dotsFocusing on quality, safety, service g q y, y,and efficiency

Execution Developing organizational capabilities

Understanding drivers of performanceOperational management of improvement

System roles in reducing variationy g

Building improvement capability Building Skills to improve by audience

Getting to scaleEvaluating effectiveness

Where we Started: Circa 1995

Quality was an assumed competencyDeveloped a strategic partnership with the Institute forDeveloped a strategic partnership with the Institute for Healthcare ImprovementParticipated in an Execution learning sessionBenchmarked organizations that were higher performers


Aligning Strategy

Setting the Quality Vision

“We will be recognized by our members payers and employees

We will be recognized by our members, payers, and employees as the safest, most effective and personal health care delivery system in the country.

We will be recognized by our members, payers and employees as the safest, most effective and personal health care delivery system in the country.”


Overall System Performance: Board Dashboard

13

TJC Index Across Hospitals: Demonstrated Progress in Reducing Variation

Range 94% - 98%

Range 85% - 95%

14


Discussion: Where is your organization?

Does everyone know what your strategic priorities are?How do you measure progress organizationally?y p g g yAre your priorities the same as your patients?

Execution

“Plans are only good intentions unless they i di t l d i t i t h d k”immediately denigrate into hard work”

- Peter Drucker


What we learned: attributes of high performing organizations

Build capability in these six areas in order to achieve breakthrough performance

Best qualityBest service

Most affordableBest place to

work

Execution focused on three critical needs

Achieve Breakthroughgoals

The ability to identify priority improvement areasImprovement part of business strategy

Spread and sustainProvide Leadership forLarge system Projects

Improvement Institute to develop skills

Existence of improvement FTEsLocal oversight groups

Systems viewmanaging portfolios

page 18

Manage Local Improvement

Develop Human Resources

Provide Day-to-DayLeaders for Micro Systems

managing portfolios

Source: Institute for Healthcare Improvement 2007


Managing local improvement allows a focused and resourced approach

Develop clear alignment between strategic priorities, performance goal setting, drivers and project portfolio execution to get results

page 6






Focus on systems view and end to end improvement based on drivers of performanceIdentify the vital few areas to focus improvement resourcesCreate clear lines of accountability and oversight

Region/Service Area/Local•Mission critical, high priority initiatives

Expert

Facility

TPL

TPL

Ops improvementresource

Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training

Expert

TPL

TPL

TPL

TPL

Expert

Expert

Anatomy of a Driver Diagram

PortfolioMeasures

Portfolio accountability

Goal

Sequence


Building capacity to improve by developing people

Developing our people by:Using common language for the organization to lead improvementAligning executive through front line capability by matching

page 6






infrastructure with new skills

Experts Operational

Leaders (Executives)

ChangeAgents

(Middle M

Everyone

(Staff,

Many People Few People

Source: API 2006

(Executives)Managers, Stewards, project leads)

( ,Supervisors,

UBT lead triad)

Unit Based Teams

SharedKnowledge Continuum of PI Knowledge and Skills

Deep Knowledge

From Microsystem Theory to Operating Systems

Regional/National• Transparency• Incentives• Reduce variation• Adopt and spread all sites• Surfacing best performers

Medical Center

• Improvement priorities• Goals and drivers • Portfolios oversight, accountability• Systems view and improvement• Spread to all applicable departments

Red

uce

Varia

tion Learn and adop

Unit/Department• Multiple tests• Day to day management /improvement• 100% participation• culture

Adapted from: Batalden et al Clinical Microsystems 2005

R

pt


Discussion: How is your organization?

What infrastructure is in place to oversee improvement?improvement?Whose role is it to manage improvement?Whose role is it to solve problems, leadership or teams?

Building Improvement Capability


What Improvement Skills are Needed for Each Role?

ChangeAgents

Everyone

• Setting direction and big goals

• Execution leadershipP tf li l ti d

Experts

OperationalLeaders

(Executives)

Agents

(Middle Managers, Stewards, project leads)

(Staff, Supervisors,

UBT lead triad)

• Analysis, prioritization of portfolios

• Deep statistical process control

• Portfolio selection and management

• Managing oversight of improvement

• Being a champion and sponsor

• Understanding variation to lead

• Managing implementation and spread

• Setting goals and measures

• Identifying problems

• Mapping process• Testing change• Simple waste

reduction• Simple

standardization• Team behaviors

• Setting goals and measures• Identifying problems• Mapping process• Sequencing tests of change• Simple understanding

variation• Implementation and spread• Simple waste reduction• Simple standardization

• Deep improvement methods

• Leadership team advisory re portfolio selection, process

• Effective plans for implementation and spread

How we develop Skills in KP Leaders, IA’s and Teams

Performance Improvement

Executive Days

– Understand evidenced based strategies for performance improvement– Develop their operating strategy for the prototype process– Understand leadership sponsor and champion roles– Understand drivers of performance locally

Curricula & Learning Objectives

National T

Improvement Institute

Operational Leaders Workshop

– Gain a depth of knowledge with performance improvement methodology– Understand tools to apply and lead performance improvement projects– Understand how to determine systems and drivers of performance

– Receive exposure to PI concepts, the KP approach to PI and available resources, roles and responsibilities, PI tools

– Obtain the knowledge to drive improvement and manage information in driving decision making and the organizational culture necessary to drive world class improvement

Ch i

– Understand the KP approach to PI and leader’s role in execution– Understand the role of champions in improvement efforts

Local TrainingTraining

Champion Workshop

Front-Line StaffRIM plus

– Describe Performance Improvement timeline and process– Describe their role in the implementation of the performance improvement work– Define the difference between measurement for improvement and measurement for

accountability

– Understand the approach to address their unit’s performance improvement project.– Develop and make robust tests of change for their performance improvement project – Measure improvement using run charts– Use simple tools to standardize and simplify work areas and work flows

g


A Wave approach allows for testing, expansion and scale

September 2008 June 2009 2010 & 2011

Waves of Improvement Instituteop

and

Test

the

Syst

em

acili

ty le

vel

and

Impr

ovem

ent s

yste

m

faci

litie

s

pen

impr

ovem

ent

wle

dge

with

in fa

cilit

ies

• All Regions• 400 IA’s• Medical Center,

Regional, National• 15 internal faculty

Mentors• 2000+ Operations

Managers• 20,000+ Frontline RIM

Plus• PSU

• 7 regions• 200 Improvement

Advisors (Medical Center, Region, National)

• 35 UBTI’s• 15 Faculty Mentors• 1000+ Operations

managers• 10,000 Front line RIM+ staff

• 5 regions• 70 Improvement Advisors

(Medical Center)• 11 Faculty Mentors (KP)• 4 Regional mentor students• 300 operations managers• 3,500 Front line RIM+ staff

On-boarding

Dev

elo

at a

Fa

Expa

to a

ll

Dee

pkn

ow

Learning and sharing systems regionally and program-wide Improvement Institute

Implementation Expansion ContinuousImprovementComplete

We are here

Level of Project

Difficulty

• Reliable Design• Middle manager PSU• Reliable design

3,500 Front line RIM staff• Middle manager PSU• Reliable design

Organizational Capability: Knowing whether the system is sustainable

Performance Improvement Initiative Assessment Score Card

National

Leadership

0.00

1.00

2.00

3.00

4.00

5.00

LearningCulture & CommunicationBaseline pre-wave II

Current post-wave II

Targeted for sustainable performance

Systems & Process

Measurement

Capacity & Sustainment

Current Qtr Previous Qtr Target


Discussion: Where is your organization?

How capable are they of improving the system?Where are you in implementing an improvement systemWhere are you in implementing an improvement system, how do you plan to get to scale?How do you know when the system is capable and can continue without your support?

Example of Execution in Practice


Regional World Class Focus

QualityQuality

Recognized Leader in Quality

MemberEfficiency Serv

ice

MemberEfficiency Serv

ice

“10” Patient Care Experience

Leading Patient-Centered, Efficient

Care Processes

KP’s integrated model is uniquely positioned to drive improvements across quality, service and efficiency

Highly Skilled and Motivated Workforce

Drivers of EfficiencyGoals Drivers Focus Areas & Initiatives

High-risk population management

Anticipating end of life: Palliative care, advance directives

Admission alternatives

Right Venue of Care

Leading Patient-Centered,

Efficient Care Processes

Optimize Hospital

Throughput

Manage Hospital Output

Patient flow: Well-sequenced care, no delays

Evidence-based care, no needless harm

Discharge Processes

Access to and management in alternative care settings: SNF, HH, rehab, sub-acute, i ti t h

Manage Cost Structure

in-patient psych

Direct patient care expenses: HPPD, OT, Registry, attendance

Other hospital expenses: Supplies, materials, non-patient care staff, attendance

Workplace Safety: Patient and non-patient care


Example – Identifying and Managing Portfolios

Where? South Bay, KP-SCAL w/CMIHow? •Coordinated concurrent medication

ili i b H H l h RN

Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08

Case Study: Readmission Reduction CHFIt takes a village to manage our heart failure patients, with the help of our local, regional and national leadership teams and the strength of our administrative infrastructure, we have been able to make an improvement with 3 key components: real time medication reconciliation at the home health visit, home health visits in a timely manner and the use of the diagnostic readmission tool. Joan Fredella, Pharm. D., Clinical Ph i t reconciliation by Home Health RN,

PharmD, and Patient in the patients home. •Improved identification of Heart Failure patients in the Hospital•Increased reliability of Home Health visit within 48 hours•Increased reliability of Out-patient Heart Failure Clinic follow up in one week•Implemented readmission diagnostic tool to identify system gaps

Pharmacist

30 Day readmission rates-HF reason

(12 month roll up)

5 0

7.0

9.0

SBAY 30 day HF readmission rates declining!Pre Work

StartedPDSA cycles

started

for H

F in

30

days

RIMPre-workstarted

•Kick Off Mtg•PDSAs Started:

1. ConcurrentMed Rev

2. Pt ID/HH ref.

Results •Reduced 30-day re-hospitalization rate to 9% (and 90 day readmission to 20%).•Improved the reliability of the Transitions Care Program component bundle measures from 61%-95%•Hard and soft $ value estimated at $1,800,000

1.0

3.0

5.0

Sept Oct Nov Dec Jan Feb Mar April

SCAL Regional SouthBay

BEST inRegion!

% p

ts. R

eadm

itted

f

TCP Pilot Started

PharmacistRole restructuredTo focus on HF

Gap AnalysisComplete

ReliableDesignWkshopPt. ID


Drivers of Efficiency

Leading Patient-Centered,

Efficient Care Processes

Goals Drivers Focus Areas & Initiatives

High-risk population management

Anticipating end of life: Palliative care, advance directives

Admission alternatives

Right Venue of Care

Optimize Hospital

Throughput

Manage Hospital Output

Patient flow: Well-sequenced care, no delays

Evidence-based care, no needless harm

Discharge Processes

Access to and management in alternative care settings: SNF HH rehab sub-acute EFFICIENCY

Regional focus

Prioritization and Implementation: Portfolios and Projects

Processes Hospital Output

Manage Cost Structure

care settings: SNF, HH, rehab, sub acute, in-patient psych

Direct patient care expenses: HPPD, OT, Registry, attendance

Other hospital expenses: Supplies, materials, non-patient care staff, attendance

Workplace Safety: Patient and non-patient care

EFFICIENCY

M di l C tSustained performance

30 Day readmission rates-HF reason

(12 month roll up)

1.0

3.0

5.0

7.0

9.0

Sept Oct Nov Dec Jan Feb Mar April

SCAL Regional SouthBay

SBAY 30 day HF readmission rates declining!Pre Work

StartedPDSA cycles

started

BEST inRegion!

% p

ts. R

eadm

itted

for H

F in

30

days

TCP Pilot Started

PharmacistRole restructuredTo focus on HF

Gap AnalysisComplete

RIMPre-workstarted

•Kick Off Mtg•PDSAs Started:

1. ConcurrentMed Rev

2. Pt ID/HH ref.

ReliableDesignWkshopPt. ID

Medical Center drivers and portfolioprioritized

Department scoped 90-120 day projects

Sustained performance

what you will learn today¾full clinical deployment in existing and new hospitals (total of 35)...

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