Strategy, Curriculum, and Structure for Continuous Improvement Steven J. Choi, MD, FAAP Assistant Vice President Director, Montefiore Network Performance Improvement Executive Director, Montefiore Institute for Performance Improvement Associate Professor of Pediatrics, Albert Einstein College of Medicine
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Agenda 1. Brief Overview of Montefiore Health System 2. Evolving Healthcare Quality Landscape 3. Role for Improvement Capacity in Healthcare 4. Creating a Sustainable Structure for a CQI Culture 5. Sample of PI Results 6. Questions/Discussion
Montefiore Medical Center • Beds: 1,491 (4 Hospitals) • Medical School: Albert Einstein College of Medicine • Faculty: 1,600 • Academic Departments: 21 • Resident and Fellowship Programs: 94 (ACGME) • Residents and Fellows: 1412 (7 th largest teaching hospital in the US) • Annual hospital admissions: 93,000 • Annual ER visits: 300,000 • Annual Ambulatory visits: More than 2.6 million
Montefiore Health System • Affiliated Hospitals (9): – Burke Rehabilitation Hospital – Montefiore Mount Vernon Hospital – Montefiore New Rochelle Hospital – Nyack Hospital – St. Luke’s Cornwall Hospital – White Plains Hospital – St. John’s Hospital – St. Joseph’s Hospital – Westchester Square Hospital
Traditional Healthcare Quality Systems (Most US Hospitals and Medical Centers, Pre-2000) • Focus: primarily on retrospective ( often random ) review of voluntarily reported cases/events • Majority of resources allocated to regulatory mandates, surveys, and peer review • Notion that there was always a single cause and effect relationship for every major event (culture of blame) • Lack of focus on systems and processes • Lots of measurement but not much, if any, improvement
Plague of 3 Classic Healthcare Improvement Myths: 1. Meetings = Improvement 2. Spreadsheets = Solutions 3. Emails = Execution
So what happened in 2000 (around 2000)? What changed in healthcare?
How do (did) we try to improve healthcare??? • Assign and Task • Increase Awareness • Provide Performance Feedback • Develop New Policies and Procedures • Create Incentives • Resort to Punishment and Penalties • Promote Good Will • Work Harder, Try Harder, Do Gooder
4 Common Themes for Poor Performance (The IHI experience with 40 organizations working to achieve higher levels of reliability for CMS Core Measures) 1. Current improvement methods in health care are VIGILANCE and HARD WORK excessively dependent on vigilance and hard work. 2. The current practice of benchmarking to mediocre FALSE SENSE of PROCESS RELIABILITY outcomes in health care gives clinicians and leaders a false sense of process reliability . CLINICAL AUTONOMY and VARIATION 3. A permissive attitude toward clinical autonomy creates and allows for wide, and unjustifiable, performance variation . PROCESSES not designed to meet 4. Processes are rarely designed to meet specific, OUTCOMES articulated reliability goals . Health Serv Res. 2006 Aug; 41(4 Pt 2): 1677–1689.
Re-Engineer our Delivery System
Application for Performance Improvement Operational Clinical Quality Patient Safety Efficiency Performance Improvement
Tribute to 2 Great Pioneers and Pioneer Organizations in Healthcare Re-Design
Intermountain Healthcare • In 1991, through the Institute for Health Care Delivery Research developed the Advanced Training Program (ATP). Led by Dr. Brent James , developed the 1 st training programs for • healthcare leaders, executives, and front-line providers in quality improvement. • Partnered with IHI for rapid scaling throughout the world. • Over 3,500 graduates.
Institute for Healthcare Improvement (IHI) • Founded in 1991, led by Dr. Don Berwick • Redesigning health care • 100K/5 Million Lives Campaign. • Created the Triple Aim • Developed the Model for Improvement with API (Associates in Process Improvement), led by Lloyd Provost
Performance Improvement Peer Review Regulatory and Endorsed Quality Metrics Assurance
How important is CHANGE? “All improvement requires change, but not all change results in improvement” Don Berwick, MD Past President and CEO, IHI Former Director, CMS
Why change our system? “Every system is perfectly designed to get the results it gets.” Don Berwick, MD Paul Batalden, MD Joseph Juran
Improvement Science • Getting people to do what they are supposed to do is a science as much as it is an art . • Implementation of best practices is really, really, really hard. • Innovation is critical to change and successful execution • NOT by the following: 1. Try harder……….. 2. Be better……….. 3. Do gooder………… • WORKING SMARTER
Montefiore Institute for Performance Improvement: Faculty and Staff • Executive Director • Instructors • Facilitators • Coaches • Program Coordinator • Background: MD’s, Administrators (MPH, MHA, MBA), and Engineers (HSE) • PI Training: IHI, Intermountain, Lean, Six Sigma, Simpler
Montefiore Institute for Performance Improvement Key Programs 1. PI Fellowship-Intensive training program for improvement leaders 2. CQI Events (Kaizen)-Large transformation collaboratives 3. Improvement Advisor-Consultation and Coaching services for individual projects, ad hoc
PI Fellowship 1. 12 month improvement science curriculum which includes: 2. Completion of IHI (Institute for Healthcare Improvement) – Training certificate in Quality and Safety 3. Design, implement, and complete QI Project (Institutional Goals) 4. Meet with assigned PI Coach (minimum-monthly) 5. Standing meetings with improvement team (minimum-monthly) 6. Disseminate PI education with local service area 7. Function as a QI mentor (advisor) for next year’s class
Guidance Team PI Course Instructors/Facilitators Project PI Fellows Assigned PI Leader PI Coach Coaches (PI Course Training) (Monthly/Bi-monthly check-ins) Project Team Members Multidisciplinary Team (Monthly team meetings) Process Owners Frontline Workers (Disseminate PI knowledge) Process(es) Outcome(s) Transformation Model Adapted from: https://intermountainhealthcare.org/about/transforming-healthcare/institute-for-healthcare-delivery-research/courses/advanced-training-program
Who Do We Train? • Front-line (Process Owners) • Administrative Leadership (CEO, VP’s) • Physician Leaders (Chair, Vice-Chair, Chiefs) • Nursing Leaders • Quality and Safety Leaders • Pharmacy • Respiratory Therapy • Operations Managers • Class Size: 15-20
4 Major Components of Fellowship Improvement Self-Learning Project (2-4 hrs/month) (8-10 hrs/month) Group Coaching Workshops (1-2 hrs/month) (2-4 hrs/month)
Self-Learning IHI Modules Assigned IHI Modules • QI 101: Introduction to Health Care Improvement • QI 102: How to Improve with the Model for Improvement • QI 105: Leading Quality Improvement • PS 101: Introduction to Patient Safety • QI 103: Testing and Measuring Changes with PDSA Cycles • QI 104: Interpreting Data: Run Charts, Control Charts, and Other Measurement Tools • PS 102: From Error to Harm • PS 103: Human Factors and Safety • PS 104: Teamwork and Communication in a Culture of Safety • PS 105: Responding to Adverse • L 101: Introduction to Healthcare Leadership • TA 101: Introduction to the Triple Aim Populations • PFC 101: Introduction to Patient-Centered Care http://www.ihi.org/education/IHIOpenSchool/Pages/default.aspx
Key Skills for Health Care Delivery Improvement PI Methods Change Management and Tools Leadership
LEARNING BY DOING: DEVELOPING A PI LAB PI DIDACTICS PI LAB EXERCISES • Introductions/Ice Breaker • Overview of Course Goals/Expectations • Designing a PI Project (Creating Donabedian Model) • History and Evolution of Healthcare Quality Improvement • Marshmallow Tower #1 • Smart Aim • IHI Model for Improvement • Brainstorming/Affinity Diagrams • Key Drivers/ Metrics/ Change Concepts/Affinity Diagram • Designing a PI Project #2 • 5 Why's/RCA/GEMBA • Process Mapping • Process Maps • 5 Why’s • Stages of Team Development • Pareto Principle Case Studies • Pareto Principle • Modified Red Bead Game • Mastering PDSA Cycles • Change Management Exercise • Run Charts/Control Charts • Leading Change in Change Management • (More of/Less of, PICK Chart, Threats/Opportunities) • Lego Factory • Introduction to Lean Healthcare (7 Wastes) • Human Factors Exercise • Human Factors in Healthcare • Team STEPPS • Team STEPPS (Paper Chain) • Marshmallow Tower #2 • Leadership • 5S Picasso Game • 5S In Healthcare • Statapult • 6 Sigma in Healthcare (reducing variation) • Being a QI Coach/Facilitator • Jigsaw Puzzle Kata • Coaching Kata • Marshmallow Tower #3 • Sustainability of Success • Scavenger Hunt • High Reliability
Sequence for Learning PI Skills Self- Formal PI Lab Application Learning Didactic Exercise in PI Project
Stop Chasing the Outcomes
Outcome Measures • Key Performance Indicators (KPI’s) • Lagging Indicators (Takes time to see real change) • “The Scoreboard” • Don’t just stare at the scoreboard
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