Catalyzing Frontline QI Work: How Do We Get It All Done? Design Lessons from CU s Institute for Healthcare Quality, Safety, and Efficiency Read G. Pierce, MD Associate Director, Institute for Healthcare Quality, Safety, & Efficiency Assistant Professor of Medicine University of Colorado, Anschutz Medical Campus Objectives 1. Explore development of a comprehensive program to accelerate clinical quality improvement in an large, quaternary medical center 2. Describe methods for integrating education, clinical operations, and quality improvement to increase the capacity of clinicians to effectively redesign care delivery systems (The Real) Objective How do we deploy educational programs that: 1. Advance knowledge of systems redesign 2. Actually change clinical systems 3. Are accessible to a wide range of learners 4. Become self-propagating Transformation
My Mission Is That Really My Job? Context: Changing Healthcare Environment Past Future Quality: Structure and Process Safety: Issue = Discussion Efficiency: Throughput, volume, cost/revenue shifting Service: Producer-oriented Policy Secular Trends Quality: Outcomes Safety: Behavior = Culture Efficiency: Marginal marketplace value, prediction modeling, supply chain management, population risk management Service: Patient-focused Disruption
How Do We Maximize Engagement of Insiders? Institute for Healthcare Quality, Safety, and Efficiency How do we create local leaders who can enhance these?
IHQSE: July 2012 Anschutz Executive Committee Program Administration IHQSE Education Programs IHQSE Operations Integration IHQSE Innovations Certificate Training Program & the IHQSE IHQSE Vision 1. Create a capable work force to 2. Improve & create models of care to 1. Transform our clinical enterprise CTP Supports Vision by: 1. Building highly effective teams to 1. Improve performance (enhance existing systems) And 3. Create new forms of value for patients (systems innovation) Can Clinicians Actually Improve Systems? Intake Survey: Clinical Leaders of Units/Programs Business Drivers 27% reported grasp of strategies to deal with complex change Q&S / Cost Expertise 23% reported ability to use QI/PI tools 42% reported ability to use PS tools 23% reported ability to reduce operational waste Change Management 26% reported confidence in ability to manage change Teams 68% reported ability to create & enhance high- functioning teams Data 43% reported ability to identify data needed for systems improvement
Institute for Healthcare Quality, Safety, and Efficiency Anschutz Executive Committee Program Administration IHQSE Education Programs IHQSE Operations Integration IHQSE Innovations Lesson 1: Many clinical leaders are not certain how to guide this work Certificate Training Program Hook Enhance Leadership Teams Enhance Care (QI Projects)
IHQSE: July 2013 Anschutz Executive Committee Program Administration IHQSE Education Programs IHQSE Operations Integration IHQSE Innovations CME / MOC Certificate University of Colorado Hospital Children s Hospital of Colroado Unit-Based CLTs Unit-Based CLTs Program- Based CLTs Program- Based CLTs Learning Model: Not (Really) About Projects CTP Participants Rigorous Education + Intensive Coaching + Data and PI Support Clinical Leadership Teams (CTP Participants are Members) Clinical Unit or Program Ø CTP participants learn via didactics + projects Ø CTP participants help enhance the broader Clinical Leadership Team Ø Teamwork + Leadership -> Culture Ø Mastery of CTP content -> Projects Ø Projects + Culture -> Continuous & Sustained Improvement Institute for Healthcare Quality, Safety, and Efficiency Lesson 2: Transformation is about creating leaders who can integrate existing work, NOT simply do more QI projects Invest in people first to get...
ENT Clinic: The Problem Value Stream Map: Return Patient Experience Non-Value Added Time: 23 minutes (53% of total visit) The Other Problem Our People Were Unhappy
Drive through a PI Project Impact: Starting with Empathy Efficiency: Decreased wait times by ~8 min/patient Business Performance: Extra ~3 patients/day à Revenue + Access Staff Engagement: Tier 3 -> Tier 1 in 12 months Turnover 50% -> 0% over 2 years Patient Experience: 100% would recommend
Institute for Healthcare Quality, Safety, and Efficiency Lesson 3: Methodology counts - Make the focus empathy (for all humans in the system) Improvement: Common Sentiment Light (Good) Heat (+/-) Pressure (Bad)
Stable Elements: Frontline Leaders Catalyst: Community + Exchange Spark : Permission to Fail
Spark : Permission to Fail Institute for Healthcare Quality, Safety, and Efficiency Lesson 4: Embrace failure (go slow to go fast later) Scaling Beyond The Early Adopters
What About Other, Un-Trained Teams? Which Team Are We Talking About? Acute Care for the Elderly Team(s) CTP Project Team CTP Participants Clinical Leadership Team Geriatric Leadership Council (10-15 leaders from the Unit) Clinical Unit or Program
IHQSE: July 2016 Anschutz Executive Committee Program Administration IHQSE Education Programs IHQSE Operations Integration IHQSE Innovations CME / MOC Fellowship University of Colorado Hospital Children s Hospital of Colroado Innovations Innovations Grant Grant Program Program Fundraising Committee Data and Systems Design Pilots Certificate Introductory Training Clinical Leadership Development Unit-Based CLTs Program- Based CLTs Unit-Based CLTs Program- Based CLTs GME UME Acute Care for the Elderly Team Institute for Healthcare Quality, Safety, and Efficiency Lesson 5: Make it easy for others to join (catalyst effect)
2013, 2014 & 2015 Combined Outcomes Intake Survey Business Drivers 27% reported grasp of strategies to deal with complex change Q&S / Cost Expertise 23% reported ability to use QI/PI tools 42% reported ability to use PS tools 23% reported ability to reduce operational waste Change Management 26% reported confidence in ability to manage change Teams 68% reported ability to create & enhance high- functioning teams Exit Survey Business Drivers 75% reported grasp of strategies to deal with complex change Q&S / Cost Expertise 81% reported ability to use QI/PI tools 91% reported ability to use PS tools 74% reported ability to reduce operational waste Change Management 82% reported ability to lead organizational change Teams 93% reported ability to create & enhance high- functioning teams Data 43% reported ability to identify data needed for systems improvement Data 87% reported ability to identify & use data needed for systems improvement Table 2: Project Outcomes Quality Safety Efficiency Experience Cancer Clinics 13% reduction in time from referral to patient seen x x x Emergency Department 10% reduction in CT turnaround time resulting in decreased ED LOS x x 50% increase in % of chest pain patients receiving EKG within 10 minutes x x x ENT Clinic 14% reduction in patient time (non-value added) in ENT clinic x x x Patient satisfaction scores increased to 100% x Provider engagement scores increase from lowest to highest tier x Esophageal Surgery 17% LOS reduction for patients undergoing esophageal surgery x x Elimination of unplanned returns to the OR for esophageal surgery patients x x x Geriatric Inpatient Service 40% increase in % of patients d/c to sub-acute nursing facility before 2 pm x x Infusion Center 20% decrease in patient chair time (non-value added) x x x Neonatal Intensive Care Unit Reduction in readmissions from 3.3% to 0% x x x Operating Room 43% improvement in urologic first case on-time starts x x x Orthopedics 33% LOS reduction for geriatric hip fracture patients x x Palliative Care 12% LOS reduction for patients receiving palliative care consultation x x Significant improvements in palliative care pain and symptom scores x x Pediatric Antibiotic Stewardship 15% reduction in antibiotic days of therapy x x $200,000+/year cost avoidance for pediatric antibiotic stewardship program x Pediatric Bone Marrow Transplant x x 24% day reduction in length of stay (LOS) Radiation Oncology 24% reduction in time from referral to patient seen x x x 18% increase in patient volumes after the intervention x Spine Clinic 16% reduction in patient time (non-value added) in spine clinic x x x The Nature of Our Work Ø Healthcare systems are complex, and don't work as well as they could Ø Poor systems performance creates waste and error for all! Ø Clinicians will be and should be asked to help solve this problem Ø Sustainability requires creating a system to foster authentic engagement
Lessons from CU s IHQSE 1. Many clinical leaders are not certain how to guide this work 2. Transformation is about creating leaders, NOT simply projects 3. Methodology counts - Make the focus empathy (for all humans in the system) 4. Embrace failure (go slow to go fast later) 5. Make it easy for others to join (catalyst effect) CTP Curriculum: AIMs & Objectives Curriculum Domains Prologue: Changing Healthcare Landscape, Basic Leadership Leading Improvement Work: Effective Personal & Team Leadership, Project Management, Improvement Methods Developing High Performance Systems: Understanding Complex Systems, Safety Science, Learning Organizations, Innovation, Advanced Leadership Capstone: Integrating Concepts, Present CTP Work Discrete Skills 1. Enhance & maintain effective teams 2. Do QI project(s) 3. Drive change through: -Leadership of Culture Change -Systems Improvement -Systems Innovation 4. Make data-driven decisions 5. Sustain & spread improvement & innovation efforts over time Competencies 1. Leadership & Change Mgmt 2. Social Intelligence & Teamwork 3. Communication & Sense-making 4. Adaptive Thinking 5. Deploy QI Methods Effectively 6. Innovation & Design Thinking 7. Data Mgmt
Faculty Coaches CTP Coaching Model CTP Participants Process Improvement + Data Specialists Clinical Leadership Teams (CTP Participants are Members) Clinical Unit or Program Faculty Coaching Expectations Ø Meet project coach at least monthly outside CTP didactics Ø Intermittent, scheduled meetings with teamwork, finance, and safety faculty coaches PI & Data Coaching Expectations Ø PI & Data Experts may join faculty coaching sessions Ø Meet PI/Data Experts + unit/program project team at least twice/mo Ideal State Reality
Innovation: A Similar Paradox Everett Rogers. Diffusion of Innovations. 1962. See the Light Aspiration Creation of New Way Unfamiliar Landscape Fear Destruction