L2: Building Capacity and Capability: The Really Big Challenge Uma - - PDF document

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James M. Anderson Center for Health Systems Excellence

L2: Building Capacity and Capability: The Really Big Challenge

Uma R. Kotagal, MBBS, MSc SVP, Quality, Safety and Transformation Executive Director, James M. Anderson Center for Health Systems Excellence Cincinnati Children’s Hospital Medical Center

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James M. Anderson Center for Health Systems Excellence

Our Vision

To be the leader in improving child health

James M. Anderson Center for Health Systems Excellence

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It’s all about the kids

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– Full service, pediatric academic medical center with annual 1,161,000 patient encounters* – 598 registered beds (549 in service) including inpatient and residential psychiatry beds* – Served patients from 53 countries and all 50 states* – Nationally ranked in all 10 subspecialty programs – 3rd highest recipient of NIH grants for pediatric research – Ranked 3rd best Department of Pediatrics among all University Colleges of Medicine – Total Employees of 12,873, with 11,799 full time equivalents* – Employees from 97 different countries – Over 790 volunteers contributed 72,806 hours*

* For fiscal year ending June 30, 2013

Cincinnati Children’s At a Glance

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• Vision – to be the leader in improving child health
• Mission – Cincinnati Children’s will improve child health and

transform delivery of care through fully integrated, globally recognized research, education and innovation. For patients from our community, the nation and the world, the care we provide will achieve the best:

• medical and quality of life outcomes
• patient and family experience and
• value today and in the future.
• Values – Respect everyone. Tell the truth. Work as a team.

Make a difference.

What Inspires Our Success…

Our Goals

Safety To be the safest hospital Care Coordination & Outcomes To improve outcomes for our patients with complex and chronic diseases Community Care Delivery To strengthen our community’s system of care for children Community Health To measurably improve the health of local children Research & Infrastructure To accelerate the impact of our investment in discovery Leadership Development & Learning To help employees reach their potential and Cincinnati Children’s achieve its vision Reach & Revenue To leverage our unique expertise to serve more children Philanthropy To provide abundant resources for the care and cures for children Cost To be more affordable for patients and maintain our financial strength Productivity To improve the experience for patients and more effectively utilize

• ur people and physical assets

Respect & Professionalism To ensure that every employee feels valued and respected

Focus Statement: We will deliver demonstrably superior outcomes and experience at the lowest possible cost and discover and apply better ways to improve the health of more children, here and around the world.

What Guides Us…2015 Strategic Plan

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James M. Anderson Center for Health Systems Excellence

Our Mission

Cincinnati Children’s will improve child health & transform delivery of care through fully integrated, globally recognized research, education & innovation. For patients from the community, the nation & the world, the care we provide will achieve the best:

• Medical & quality of life outcomes
• Patient & family experiences &
• Value

today & in the future.

James M. Anderson Center for Health Systems Excellence

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James M. Anderson Center for Health Systems Excellence

Develop Human Resources Achieve Strategic Goals Manage Local Improvement

Provide Leaders for Large System Projects Spread and Sustain Provide Day to Day Leaders for Microsystems

• Strategic Execution

IHI Execution Framework

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James M. Anderson Center for Health Systems Excellence

Context: Key Issues in Quality Education Development

OVERALL CONTEXT

• Degree of leadership support for both the
• verall quality effort & for quality education
• Overall aim for the organizational quality

improvement process

– Organizational transformation vs – Incremental improvement

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James M. Anderson Center for Health Systems Excellence

Cincinnati Children’s Context

• Organizational transformation implies radical

changes in how members perceive, think and behave at work.

• Transformational change must attend to the

interests of multiple stakeholders and needs to

• ccur at multiple levels of the organization if new

strategies are to result in wide-spread and lasting changes in behavior.

The competencies and strategies derive from this vision Context is key

Source: Organization Development & Change, T.G. Cummings & C.G. Worley, South-Western, 2005. 10

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James M. Anderson Center for Health Systems Excellence James M. Anderson Center for Health Systems Excellence

Capability vs Capacity

• Improvement Capability

– An individual’s knowledge & skill to to design improvement initiatives to achieve measurable results & the ability to execute (i.e. develop, test, measure & implement changes) improvement efforts & sustain results.

• Improvement Capacity

– An organization’s resources which enable it to initiate & sustain a transformation effort. This includes capable individuals but also structures, processes, infrastructure including quality experts & measurement experts.

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James M. Anderson Center for Health Systems Excellence

Operating Assumptions

• Building improvement capability at CCHMC goes beyond acquisition of

knowledge and skills to action-oriented improvement that achieves critical results and accelerates transformation.

• As an Academic Medical Center, CCHMC’s strategy for building improvement

capability focuses on engaging and developing faculty as improvement leaders, educating trainees and advancing the scholarship of health care improvement through rigorous methods and quality improvement research.

• Different groups of people will have different levels of need for improvement

knowledge and skill to achieve results, and each group should receive the training they need when they need it and in the appropriate amount.

• All members of the organization should incorporate improvement into their daily

work and have the ability to advance their improvement knowledge and skills to achieve critical results, and function at any level of the CCHMC improvement ladder.

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James M. Anderson Center for Health Systems Excellence

Our Thinking

• We will target a diverse group of leaders

including physicians, nurses, allied health professionals, clinical & nonclinical support services staff, executives, formal & informal leaders

• The diversity of the cohort requires an

instructional design which appeals to all of the learning styles

• We are an academic medical center so the course

must academically rigorous but practically

• riented with support for all learners.

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James M. Anderson Center for Health Systems Excellence

Our Thinking

• Academic rigor requires data & measurement

rigor.

• Leadership for improvement must have a

foundation in “hands-on” technical QI skills

• Focus on leaders not all front-line people for this

course with the expectation that leaders will coach & develop their staff

• Use Deming’s System of Profound Knowledge as

an integrating philosophy to develop a new way

• f thinking

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James M. Anderson Center for Health Systems Excellence

Leverage Point Target Audience Competencies CCHMC Target Categories CCHMC Interventions

Macrosystem CCHMC (Whole System) Mesosystem (CSI site of care teams, Institutes, Business Units, and medical & surgical divisions) Microsystem (Dept units, clinics, ORs, etc.) Individual Contributors – Front Line Improvers

• Sr. Leaders (e.g. CEO,

SVPs, VPs)

• CSI Leaders
• Division Heads
• AVPs
• Strategic Improvement

Project Team leaders

• Clinical managers
• Lead MDs

All front-line non- management staff Lead the whole system based

• n Deming’s System of

Profound Knowledge

• Lead strategic improvement

teams/complex/ cross- functional projects to get results

• Articulate the role of the

department/unit/division as a sub-system that is an interdependent part of the larger system of CCHMC

• Coach others to do

improvement

• Disseminate results via

external presentations & professional journal publications

• Lead small teams/narrow

scoped projects in a small microsystem & get results

• Lead microsystem efforts to

remove defects & waste from processes of daily work

• Effectively participate in cross-

functional & strategic improvement teams

• Engage in the improvement of

daily work

• Effectively participate in

improvement teams Approximately 28 SVPs & VPs

• Dept. Heads/Division

Heads, SVP’s, VP’s, AVP’s, selected MD’s, Sr. Directors, Directors (includes typically M3-M5 –

• approx. 380 people +)

(Includes selected APN’s & possibly Clinical Directors) Includes all clinical & nonclinical front-line supervisors & managers typically in the M1 & M2 bands-approx. 250 people) (Includes Clinical Managers, Supervisors, Leads, Coordinators, Lead APN’s, CNS’s, Care Managers when appropriate, Clinical Directors or at the next level & “Faculty-Routine QI activities”: (~200) Includes APN’s, RN’s all attending physicians (~400), residents and fellows;medical, nursing & allied health students & Non clinical employees Intermediate Improvement Science Series (I2S2)

• Intermediate

Improvement Science Series (I2S2)

• JIT coaching and

continued use of I2S2 learning while developing a portfolio of projects

• Advanced Improvement

Leadership

• Rapid Cycle

Improvement Collaborative (RCIC) & team leader development

• JIT coaching while

participating in a QI project by I2S2 graduate, QIC, etc On-line Modules

• ”Intro. to Quality”
• Basic Measurement

(In development)

Building System Improvement Capability: Creating leaders for health system transformation

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James M. Anderson Center for Health Systems Excellence

Core Course

• Intermediate Improvement Science Series (I2S2)

– An improvement Science course based loosely on the Brent James, MD Advanced Training Program (ATP) – Developed after we sent a core group of 16 people through ATP – Assumed participants would have a basic understanding of improvement science from working on QI projects – Designed to develop QI leaders

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James M. Anderson Center for Health Systems Excellence

Strategy For I2S2

• Experiential learning through application
• Achieving significant results on projects
• Multi-disciplinary cohorts
• Leadership development experiences

James M. Anderson Center for Health Systems Excellence

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James M. Anderson Center for Health Systems Excellence

Session Structure Content CCHMC Project Learnings Respond to Different Learning Styles Meaningful Application Outside Class Solid Improvement Science Relevant Apply as you learn Interactive Positive results Variety of presenters Stimulating readings Project with consultation Large Group Small Group Critique Questions

Aims

• To develop an

intermediate level of knowledge & skill to do & lead improvement

• To get results on a

specific project

• To develop a common

language & culture/behaviors Measures

• Improvement on the I2S2

assessment tool

• % of projects with results
• % of projects which are

sustaining results 6 months after the course ends

• % of participants who

have initiated and successfully completed an additional project and/or have coached an additional project within

• ne year of completing the

course

Instructional Design- Intermediate Improvement Science Series Key Drivers

Balance of “Academic” & Application with results Large & Small Projects Clinical & Nonclinical “Failures” Variety learning experiences 18

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James M. Anderson Center for Health Systems Excellence

Leadership Topics

• Business Case for Quality
• Transformational leadership
• Chronic care improvement
• Managing a portfolio of projects
• Implementation & sustaining
• Patient safety
• Research & improvement

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James M. Anderson Center for Health Systems Excellence

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James M. Anderson Center for Health Systems Excellence

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James M. Anderson Center for Health Systems Excellence

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James M. Anderson Center for Health Systems Excellence IHI SCALE 5=Modest improvement; 6=Improvement 7=Significant improvement; 8=Sustainable improvement 9 = Outstanding improvement; national benchmark

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James M. Anderson Center for Health Systems Excellence IHI SCALE 5=Modest improvement; 6=Improvement 7=Significant improvement; 8=Sustainable improvement 9 = Outstanding improvement; national benchmark

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James M. Anderson Center for Health Systems Excellence

Participant Reactions

Category Item N Mean Standard Deviation Satisfaction Overall, I was satisfied with the instructor performance.a 8998 6.32 .85 Overall, I was satisfied with the quality of this educational program. 1381 6.50 .68 The physical environment was conducive to learning 1363 6.47 .80 Learning I learned new knowledge and skills from this training. 1367 6.54 .72 Application I will apply the knowledge and skills learned in this class. 1368 6.60 .65 Impact This training program will play a substantial role in dramatically improving medical and quality of life outcomes. 1301 6.40 .72 This training program will play a substantial role in dramatically improving the experience of the patient, the family, or providers in

• ur health care delivery system.

1301 6.41 .71 This training program will play a substantial role in dramatically improving the value of services delivered by CCHMC. 1297 6.45 .70 Value This training was a worthwhile investment in my professional development. 1385 6.63 .67 This training was a worthwhile investment for CCHMC. 1371 6.66 .64

• Note. Item scales ranged from 1 (strongly disagree) to 7 (strongly agree).

aEach participant rated multiple instructors for each class.

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James M. Anderson Center for Health Systems Excellence

Results of Participant Self-Assessments

Pre Post Mean Difference Repeated Measures Analysis of Variance Results Effect Size (2) Mean SD Mean SD Understanding data and variation 2.14 .95 4.13 .71 1.99 F [1, 236] = 1259.12 .84 Understanding systems and processes 2.15 1.00 4.17 .83 2.02 F [1, 236] = 979.40 .81 Methods of improvement 2.31 .88 4.26 .71 1.95 F [1, 236] = 1128.58 .83 Theory of leadership 2.66 .99 4.46 .72 1.80 F [1, 236] = 861.26 .79 Practice of leadership 2.34 .89 4.19 .73 1.85 F [1, 236] = 1218.07 .84

• Note. Assessment on a six-point scale: 1= no knowledge; 2 = knowledge; 3 = basic application; 4 = analysis and application; 5 =

highly experienced; 6 = expert. N = 237; p < .0001 for all univariate tests.

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James M. Anderson Center for Health Systems Excellence

Change in Behavior

Question Respondents Since completing I2S2, have you made updates to your I2S2 project’s run chart? Yes 110 (64.7%) Please indicate the current status of your I2S2 project Complete and transitioned as a sustainable part of everyday operations 85 (50.0%) Complete, but no longer a part of everyday operations due to process changes 18 (10.6%) Not complete, but continuing to monitor and do quality improvement work on it 38 (22.4% Not complete and no longer monitored 7 (4.1%) Other 22 (12.9%) Did you spread your I2S2project to other units or programs within the

• rganization?

Yes 57 (34.3%) Did you spread your I2S2project to other organizations? Yes 23 (13.6%) Since completion of the I2S2program, have you participated in or led one or more formal quality improvement projects? Yes - Participated in 149 (88.2%) Yes - Led 107 (64.1%) How many articles (peer-reviewed or other) have you published on your quality improvement work? 1 or more 21 (13.1%) How many professional conference presentations and/or posters have you delivered on your quality improvement work? 90 (57.3%) 1 to 3 58 (36.9%) 4 to 6 6 (3.8%) 7 to 9 1 (0.6% 10 or more 2 1.3%)

• Note. Results from classes 1-10. The instrument had not been administered to class 11 at the

writing of this manuscript. 27

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James M. Anderson Center for Health Systems Excellence Total I²S² Graduates: 394 No longer at CCHMC: 40

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James M. Anderson Center for Health Systems Excellence

Cheryl L. Hoying, PhD, RN, NEA-BC Senior Vice President Patient Services

Linda Workman PhD, RN, NEA-BC Vice President, Center for Professional Excellence Susan Allen, MSN, RN-BC Assistant Vice President Education Joy Hamilton, MS, RN, FACHE Assistant Vice President Professional Practice Myra Huth, PhD, RN Assistant Vice President Research & EBP Char Mason, MBA, RN Vice President Neighborhood Locations & Liberty Campus Neighborhood Locations

2

Liberty Campus

2

Stefanie Newman, MSN, RN, NEA-BC Assistant Vice President Nursing Clinical Research Center Diabetes Center

1

Hematology/ Oncology Pediatric Intensive Care Unit 1 Regional Center Newborn Intensive Care 3 Heart Center

3

Jackie Hausfeld, MSN, RN, NEA-BC Assistant Vice President Ambulatory Transport Team

2

Audiology Dialysis Occupational Therapy Outpatient Department

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Recreational Therapy Physical Therapy Speech Pathology

1

Emergency Department

2

Barb Tofani, MSN, RN Assistant Vice President Peri-op Vascular Access Anesthesia

1

Fetal Care Center Post Anesthesia Care Unit 1 Radiology

1

Sterile Processing Same Day Surgery

1

Surgical Short Stay Operating Room

2

Jack Horn, R.Ph, MS Assistant Vice President Ancillary Child Life Clinical Nutrition Pharmacy

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Project Search Social Services Respiratory Therapy

2

Volunteers Integrative Care

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Curtis Ohashi, PhD Assistant Vice President Patient Services Joe Kroner, MSN, RN Assistant Vice President Operations Clinical & Business Integration 1 Managers of Patient Services

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Recruitment & Retention Staffing Resources Patient Flow 1 Joe Naranjo, MSN, RN, NEA-BC Assistant Vice President Nursing Interim

2

Interim Gastroenterology, Hepatology & Nutrition 2 Interim

9

Interim Medical/Surgic al Units 9 Interim Rehabilitation

1

Psychiatry Home Health Care Project Administrator Home Health Care

3

Psychiatry

5

Project Administrator

I2S2 = Yellow ATP = Light Green

Example of Capacity Building

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James M. Anderson Center for Health Systems Excellence

All I2S2

I2S2 Cohort #1 I2S2 Cohort #2 I2S2 Cohort #3 I2S2 Cohort #4 I2S2 Cohort #5 Faculty I2S2 Cohort #6 I2S2 Cohort #7 I2S2 Cohort #8 I2S2 Cohort #9 I2S2 Cohort #10 I2S2 Cohort #11 I2S2 Cohort #12 I2S2 Cohort #13

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James M. Anderson Center for Health Systems Excellence

After removing the core faculty (i.e., the most central persons), the network remains well connected

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James M. Anderson Center for Health Systems Excellence

Sample of I2S2 Projects

Aim Baseline Data Results at end of course Team Leader Increase the percentage of patients in the cardiac intensive care unit who have a discussion of pain/comfort on morning work rounds from 9% to 75% by June 30, 2008. 9% 97% Cardiology physician Decrease the incidence of surgical site infections in cardiothoracic patients within the “risk period” from ~3% to <1% by June 2008. 3% 0% for four months Cardiothoracic surgeon Increase by 80% the number of days between “near misses” in all neurosurgical patients admitted to A7N due to failure to address or communicate abnormal vital signs or parent concerns during night shift by June 30, 2008. Median of 4 days between 61 days between and no events Emergency Medicine physician and Residency Director Increase the percent of patients discharged from A7 neuroscience by the predicted time from 60% to 70% by June 1, 2009. 60% 75% Advanced practice nurse Increase clinician inclusion of critical pain data to 100% post-session documentation for all outpatients treated for chronic pain by June 2008. 45% 90% Professor of Behavioral Medicine and Clinical Psychology Increase the percentage of caregivers who can independently demonstrate their core home exercise program from 10% to 60% by June 30, 2010 10% 58% Director of Occupational Therapy/Physical Therapy Achieve a response time of 2.5 hours 90% of the time for all 3rd shift regular Pyxis refills by October 1, 2008. 15% 88% Supply chain management director Improve documentation of body mass index and nutritional status in inflammatory bowel patients from 49% to 74% by July 2009. 49% 85% Outpatient Nursing director Increase the percentage of patients diagnosed with juvenile idiopathic arthritis that are screened for iridocyclitis at appropriate intervals from 68% to 95% by June 30, 2010. 68% 95% Optometrist

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James M. Anderson Center for Health Systems Excellence

Example of Building Capability: Joe N AVP Patient Services

• Interim AVP in Patient Service in 2009
• Initial I2S2 Project: Reduce the % of ED

patients waiting for admission to Neurology

• Post Graduation – Became leader of house

wide Flow project

• Subsequently became Patient Services

Leader for the Division of Psychiatry managing entire portfolio of work

• All Psychiatry Directors now I2S2

grads

• Each of those directors leads

projects within the portfolio of projects.

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James M. Anderson Center for Health Systems Excellence

RCIC

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James M. Anderson Center for Health Systems Excellence

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Career Satisfaction Career Success Retention

Facilitates Challenging Assignments Coaching Role Modeling Capability-knowledge, skills, abilities Exposure Visability Sponsorship protection Providing information regarding interorganizational opportunites Providing information regarding Intraorganization opportunities Human Capital ( performance) Movement Capital Social Capital Goal Clarity Values Clarity

(Adapted from Ramaswami and Dreher)

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James M. Anderson Center for Health Systems Excellence

Basic & Mid-level Courses

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James M. Anderson Center for Health Systems Excellence

AIM

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James M. Anderson Center for Health Systems Excellence

Methods

• 1. Small group (n=16)
• 2. 9 month course (4 two day sessions and 4

conference calls

• 3. Access to instructors between sessions
• 4. Simulation (“The Brick Factory”) to teach

planned experimentation

• 5. Project work and presentations
• 6. Book reports
• 7. Team based problem sets
• 8. Brief didactic session

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James M. Anderson Center for Health Systems Excellence

AIM Results

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AIM Wave VI AIM Wave VII

• Immediate applicability: 91% of students indicating they will be able to

apply learning from class within one month of last session.

• Self Assessments indicate greatest gains in the use and application of

control charts to understand variance.

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James M. Anderson Center for Health Systems Excellence

Quality Scholars Program Goals

Build improvement capability in faculty who will transform health and the health care delivery system for children Develop faculty leaders who will advance the scholarship of health care improvement ….at CCHMC and nationally

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James M. Anderson Center for Health Systems Excellence

Program Objectives

The specific objectives of the program are to develop scholars with the conceptual, methodologic, practical and leadership skills to

• Design, develop, test, sustain, scale and spread effective

innovations in health care delivery using a variety of methods

• Accurately measure health and health care quality, cost and

value

• Create and lead organizational environments engaged in

continuous improvement

• Undertake research that creates new knowledge and translates

evidence of improved approaches to health care

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James M. Anderson Center for Health Systems Excellence

Candidates

• Postdoctoral scholars in children’s healthcare
• medicine, surgery, public health, the social sciences, nursing,

pharmacy and other allied health areas

• Faculty and fellows are eligible
• ~ 70% dedicated time for the duration of the program (2-

3 years)

• Clinical fellows are eligible; 3 years of 75% dedicated time

to meet program requirements

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James M. Anderson Center for Health Systems Excellence

Candidates

Two training tracks 1) “Independent Improvement Investigator” - focused research agenda, funded externally as a principal investigator 2) “System-wide Improvement Leader” - lead organizational and policy environments engaged in continuous improvement Both tracks designed to

• advance the scholarship of health care improvement
• make real impact on the outcomes, experience and value
• f care

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James M. Anderson Center for Health Systems Excellence

Curriculum

• Formal coursework
• Master’s in Clinical Research
• Improvement methods (I2S2 and AIM)
• Series of mentored research / improvement projects
• Mentorship
• Team of methods/content and internal/external members
• Leadership training and multi-disciplinary team work
• Networking and Collaboration
• Site visits
• HSR Matrix speakers
• Conference opportunities
• Quality Circles
• HSR matrix activities

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James M. Anderson Center for Health Systems Excellence

Cluster RCTs Time Series Factorial Designs Step Wedge Designs “Adaptive” Trials Bayesian Analyses Mixed Methods Rigorous Learning Poor Learning Simple Linear Cause and Effect Complex Non-Linear Chaotic Traditional RCTs Case Series “Anecdotes” Adapted from Berwick

Experimental Design

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James M. Anderson Center for Health Systems Excellence

Measures of Success for All Scholars

• % of scholars who have at least 2 first-author

peer-reviewed publications by completion of training

• % of scholars who have at least 2 first-author

national venue presentations by completion of training

• % of scholar projects with results (greater

than 50% improvement from baseline), incorporating advanced improvement methods in their work

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Advanced Improvement Leadership Systems (AILS) Roadmap

Session 1 - Assessing the current state Current state assessment of division’s system to deliver results for 2015 CCHMC strategic plan using Endpoint Scenarios, and strategic plan gap worksheets

• Current state of your

system

• List of existing

projects/ initiatives (measures)

Session Outputs/Inputs Session 2 - Safety and Productivity

• Identification of key safety and productivity

critical processes

• Building your safety and productivity project

portfolio’s for FY’14 and FY’15 Session 3 - Care Coordination and Outcomes (CCO)

• Understand the Chronic Care Model and how

it applies to your system of care

• Identification of key outcomes and critical

processes

• Final safety and productivity

project portfolio

• Complete list of existing projects

in all strategic domains

Session Outputs/ Inputs

• ID CCO gaps in your system
• Current QI capability (QI

Education Record)

Session Outputs /Inputs Session 4- Patient and Family Experience/Managing your system of work

• Identification of key experience critical

processes

• Managing your system of work
• Project Portfolio • Dashboard
• Governance
• FY’14 and FY’15 Project

Portfolio (Care Delivery Dashboard)

• Capability Plans
• Redo endpoint

scenarios assessment

Session Outputs /Inputs Session 5 – Execution of System’s Goals

• Report on work completed in AILS
• Plan for execution of work started in AILS

MEASURES OF PROGRAM SUCCESS Number of AILS 2 IBUDs (Institutes, Business Units, and Divisions) teams have…

• A portfolio of projects to address strategic gaps (Goal: 8 out of 8)
• Dashboards with run charts in each of the 4 key areas: 1) outcomes/clinical excellence,

2) safety, 3) flow, 4) experience (Goal: minimum of 7 out of 8)

• Engaged active improvement in at least 2 of 4 key areas, one of which must include
• utcomes (Goal: minimum of 6 out of 8)

12/6/2013 25 Example Spider Diagram of Endpoint Scenarios ! "#$% &#'(

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Immunosuppression Cardiovascular Disease Behavior Management Chronic Kidney Disease

DK Hooper, 2011

12/6/2013 28 Color Coded Risk Stratification Color Coded Suggested Actions

DK Hooper, 2011

Our Vision

To be the leader in improving child health

James M. Anderson Center for Health Systems Excellence

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