The Trilogy Managing Innovation, Assurance, and Design

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The TrilogyManaging Innovation, Assurance, and
Design

• Maureen Bisognano
• Scottish Patient Safety Programme Masterclass
• 28 September 2009
• Edinburgh

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Aims for the Session

• Review quality tools for leaders
• Define new skills for managing and teaching

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So You Are Juggling A Lot

• Leaders are responsible for running their
  organizations and producing reliable outcomes
• New program ideas surface and need activation
• Customer expectations (internal and external)
  rise and we need to do better to meet them

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Three Tools to Help With the Juggling

• Quality Planning
• Quality Control
• Quality Improvement

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QUALITY PLANNING
QUALITY CONTROL (DURING OPERATIONS)
Sporadic Spike
40
COST OF POOR QUALITY
Original Zone of Quality Control
20
New Zone of Quality Control
Operations
Begin
Chronic Waste (an opportunity for improvement)
QUALITY IMPROVEMENT
0
0
TIME
Juran Trilogy
LESSONS LEARNED
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
6
Comparison to Finance

• Quality Planning Financial Planning
• e.g., preparing the annual budget, defining the
  deeds to be done, translating deeds into , etc.
• Quality Control Financial Control
• e.g., evaluating financial performance,
  comparing to goals, taking action on the
  difference, etc.
• Quality Improvement Financial Improvement
• e.g., improving financial results,
  cost-reduction projects, new facilities to
  increase productivity, etc.

Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
7
QUALITY PLANNING
QUALITY CONTROL (DURING OPERATIONS)
Sporadic Spike
40
COST OF POOR QUALITY
Original Zone of Quality Control
20
New Zone of Quality Control
Operations
Begin
Chronic Waste (an opportunity for improvement)
QUALITY IMPROVEMENT
0
0
TIME
Juran Trilogy
LESSONS LEARNED
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
8
Quality Planning

• Definition A structural process to develop
  products that ensures that customer needs are
  met by the final result.

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Product Planning
Customer Needs
Product Features
Process Features
Process Control Features
Product Feature Goals
Process Feature Goals
Process Planning
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
10
Setting Aims Understanding the Chain of Effect
inImproving Health Care Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Design Concepts (financing, regulation,
accreditation, education)
Environmental Context
Facilitator of Facilitators
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Health Care Example UPMC

• Aims in redesigning care for patients undergoing
  total joint replacement
• Patient and family education
• Less invasive techniques
• Multimodal anesthesia and pain management
  techniques
• Rapid rehabilitation protocols
• Rapid outcomes feedback (from the patients and
  the providers perspectives)
• Creating a learning environment and culture
• Developing a sense of community, competition and
  teamwork among patients and between patients,
  caregivers and staff
• Promoting a wellness (rather than sickness)
  approach to recovery

DiGioia A, Greenhouse P, Levison T. Patient and
Family-centered Collaborative Care An
Orthopaedic Model. Clinical Orthopaedics and
Related Research. 2007 463 pp 13-19.
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A Case Study From UPMC

• New Designs
• Pre-op testing, teaching
• Coaching meetings with other patients
• Pre-surgery discharge planning
• Strong focus on complete pain management
• Wellness design in orthopedics unit

DiGioia A, Greenhouse P, Levison T. Patient and
Family-centered Collaborative Care An
Orthopaedic Model. Clinical Orthopaedics and
Related Research. 2007 463 pp 13-19.
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Results

• Safe
• Mortality rates 0.1 (0.2 for TKA and 0 for
  THA)
• Infection rates 0.3 (0 for TKA and 1.0 for
  THA)
• Zero dislocations
• SCIP compliance 98 for antibiotics within one
  hour of surgery

DiGioia A, Greenhouse P, Levison T. Patient and
Family-centered Collaborative Care An
Orthopaedic Model. Clinical Orthopaedics and
Related Research. 2007 463 pp 13-19.
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Results

• Effective
• 91 of patients discharged without handheld
  assistance directly to home (national rates
  23-29)
• 99 of patients reported that pain was not an
  impediment to physical therapy, including
  same-day-of-surgery physical therapy

DiGioia A, Greenhouse P, Levison T. Patient and
Family-centered Collaborative Care An
Orthopaedic Model. Clinical Orthopaedics and
Related Research. 2007 463 pp 13-19.
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Results

• Patient-centered
• Press-Ganey mean satisfaction score is 91.4
  (99th national percentile ranking) with 99.7
  positive responses to Would you refer family
  and/or friends?
• Efficient
• Average length of stay
• 2.8 days for TKA (national average is 3.9 days)
• 2.7 days for THA (national average is 5.0 days)
• One MD able to perform 8 joint replacements
  before 200pm

DiGioia A, Greenhouse P, Levison T. Patient and
Family-centered Collaborative Care An
Orthopaedic Model. Clinical Orthopaedics and
Related Research. 2007 463 pp 13-19.
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IHI Example

• The Improvement Map

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Quality Planning

• Heard a need from the field
• Researched the customers and defined needs at
  each level in hospitals
• Met with leaders to define map features (sorts by
  cost to implement, sorts by complexity, links to
  evidence, etc.)
• Talked to customers for trials and defined
  process features (usability trials)
• Designed measures to know how its working

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IHI
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Look This Way
Primary Drivers
Secondary Drivers
AMI Care
Hand Hygiene Bundle
PURPOSE
Central Line Bundle
Pain Control
Shared Decision-Making
CHAOS
CHAOS
CFO Bundle
Boards on Board
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• Builds on the great work of participants in the
  100,000 Lives Campaign and the 5 Million Lives
  Campaign.
• Help us make sense of the many complex and
  competing demands we face.
• Brings together the best knowledge available on
  the key process improvements that will lead to
  exceptional hospital care. 
• Helps hospital leaders set change agendas,
  establish priorities, organize work, and optimize
  resources.
• An open resource, available free of charge to
  anyone, anywhere.
• Launched on 15 September 2009.

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QUALITY PLANNING
QUALITY CONTROL (DURING OPERATIONS)
Sporadic Spike
40
COST OF POOR QUALITY
Original Zone of Quality Control
20
New Zone of Quality Control
Operations
Begin
Chronic Waste (an opportunity for improvement)
QUALITY IMPROVEMENT
0
0
TIME
Juran Trilogy
LESSONS LEARNED
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
28
Quality Control

• Definition The universal managerial process for
  conducting operations to provide stability and
  ensure day-to-day work is maintained in a quality
  way to meet customers needs quality assurance

Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
29
Quality Control Process
Feedback Loop
OK?
Not OK?
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
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Health Care Example
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IHI Example

• Operations Management Team
• Manage day-to-day
• Understand and review the status of each major
  area of IHIs portfolio to ensure work is on
  track with regard to budget (revenue and margin,
  if applicable), results, customer satisfaction,
  and team satisfaction
• Resource utilization
• Match capacity and skills to demand
• Real-time problem solving
• Meets bi-weekly for an hour
• All department leads and major program leads
  attend

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QUALITY PLANNING
QUALITY CONTROL (DURING OPERATIONS)
Sporadic Spike
40
COST OF POOR QUALITY
Original Zone of Quality Control
20
New Zone of Quality Control
Operations
Begin
Chronic Waste (an opportunity for improvement)
QUALITY IMPROVEMENT
0
0
TIME
Juran Trilogy
LESSONS LEARNED
Source Juran J, Godfrey AB, eds. Jurans Quality
Handbook Fifth Edition. New York McGraw-Hill,
1999.
33
Quality Improvement

• Definition The organized creation of beneficial
  change the attainment of unprecedented levels of
  performance

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What are we trying to Accomplish?
When you combine the 3 questions with the
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
the Model for Improvement.
PDSA cycle, you get
A Modelfor Learning and Change
Source The Improvement Guide p. 10
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Repeated Use of the PDSA Cycle for Testing
Changes That Result in Improvement
Spread
DATA
Implementation of Change
Wide-Scale Tests of Change
Hunches Theories Ideas
Sequential building of knowledge under a wide
range of conditions
Follow-up Tests
Very Small Scale Test
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Multiple PDSA Cycle Ramps
Testing and adaptation
Triage
Diagnostic Testing
Fast Track Patients
Capacity/ Demanding
Change Concepts
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Health Care Example
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The 5 Million Lives Campaign

• Campaign Objectives
• Avoid five million incidents of harm over the
  next 24 months
• Enroll more than 4,000 hospitals and their
  communities in this work
• Strengthen the Campaigns national infrastructure
  for change and transform it into a national asset
• Raise the profile of the problem - and hospitals
  proactive response - with a larger, public
  audience

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The Platform

• The six interventions from the 100,000 Lives
  Campaign
• Deploy Rapid Response Teamsat the first sign of
  patient decline
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarctionto prevent deaths from
  heart attack
• Prevent Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevent Central Line Infectionsby implementing a
  series of interdependent, scientifically grounded
  steps
• Prevent Surgical Site Infectionsby reliably
  delivering the correct perioperative antibiotics
  at the proper time
• Prevent Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps

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The Platform

• New interventions targeted at harm
• Prevent Pressure Ulcers... by reliably using
  science-based guidelines for their prevention
• Reduce Methicillin-Resistant Staphylococcus
  Aureus (MRSA) Infectionby reliably implementing
  scientifically proven infection control practices
• Prevent Harm from High-Alert Medications...
  starting with a focus on anticoagulants,
  sedatives, narcotics, and insulin
• Reduce Surgical Complications... by reliably
  implementing all of the changes in care
  recommended by the Surgical Care Improvement
  Project (SCIP)
• Deliver Reliable, Evidence-Based Care for
  Congestive Heart Failureto reduce readmissions.
• Get Boards on Board.Defining and spreading the
  best-known leveraged processes for hospital
  Boards of Directors, so that they can become far
  more effective in accelerating organizational
  progress toward safe care

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The Platform

• plus numerous other interventions that hospitals
  must introduce in order to contribute to meeting
  our aim.

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Results

• 150 New Jersey organizations reduced pressure
  ulcers by 70
• More than 65 Campaign hospitals report going more
  than a year without a ventilator-associated
  pneumonia
• More than 35 report going a year without a
  central line infection
• Looking elsewhereDrops in adverse event rates of
  51-75 in four Safer Patients Initiative
  hospitals across the UK

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IHI Example

• Rapid Improvement Event
• IMPACT Onboarding

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Rapid Improvement Event IMPACT Onboarding
The WASTE BUSTERS
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Rapid Improvement Event Charter
IMPACT Onboarding
x
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Measurements

• Metric Before After
• ? Flow Time 44 Days 1 Day
• ? Touch Time 144 minutes 50 minutes
• ? of Process Steps 30 5
• ? Customer Satisfaction Not Measured (1)
  VOC completed Survey Form created

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Accomplishments

• Created standard work for IMPACT Onboarding
• Sequence Minimized Waste
• Flow Visual Management (Office)
• Reduced Flow and Touch Time
• Eliminated many Non-Value-Added steps
• Conducted face-to-face Voice Of Customer
  interview with Holyoke Hospital VP
• Created customer survey and Standard Work Process
• Developed plan to deploy two new communities
• Constructed a process flow calendar
• Involved support functions (IT, Fin) in future
  state discussions

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People in Action
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Communication Circles
Before After
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Old New
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IHI Example

• Workplace Vitality

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Institute for Healthcare Improvement2008-2010
IHI Strategic Plan
2/13/07
WHO WE ARE  We are a reliable source of energy,
knowledge, and support for a never-ending
campaign to improve health care worldwide.
WHAT WE WILL ACCOMPLISH We will improve the lives
of patients, the health of communities, and the
joy of the health care workforce. We work with
health care providers and others to accelerate
the measurable and continual progress of health
care systems throughout the world toward Safety,
Effectiveness, Patient-Centeredness, Timeliness,
Efficiency, and Equity.
WHAT WE WILL BECOME We will be a recognized and
generous leader, a trustworthy partner, and the
first place to turn for expertise, help, and
encouragement for anyone, anywhere who wants to
change health care fundamentally for the better.
Strategy 1 Motivate Build Will and Optimism
for Change (with an open door for everyone)
Strategy 3 Get Results Drive Broad-Scale
Adoption of Sound Changes (welcoming all who will
join)
Strategy 2 Innovate Invent New Solutions
(working deeply with a few)
Strategy 4 Raise Joy in Work Help Build the
Future Heath Care Workforce (in all that we do)
Triple Aim Sponsor Penny Carver Lead/Driver
Carol Beasley
 
 A. Organize, Lead, and Grow the
Industrys Association for Change IMPACT B.
Develop Strategic Partnerships with Customers Who
Leverage Our Work into Results for Thousands C.
Document, Publish, and Spread New Ideas
Widely   D. Learn from and Assist Leaders of
Change to Get Results in Health Care Settings E.
Adapt and Spread What We Know to Help Save Lives
in the Worlds Resource-Poor Nations

• A. Create New Health Care Models with Far
  Superior Value
• B. Develop, Organize, and Nurture Faculty
• Lead a Few Health Care Organizations to Total
  Transformation
• D. Develop and Use a Uniform Set of System-Wide
  Measures for Acute and Chronic Care

  A. Embed a Professional Education Strategy
into IHI as a Whole B. Develop Change Agents
Through Fellowships C. Collaborate and Partner
to Build Leadership Skills for Transforming
Health Care at All Levels

• Articulate a Vision for Better Health Care
  Systems
• Quantify the Gap Between the Vision and Current
  State
• Demonstrate Success in Closing the Gap
• Be a Public Force for Change
• Establish Strategic Alliances with Other
  Influential Organizations

Getting Results Sponsor Don Goldmann Lead/Driver
Andrea Kabcenell
Excellent Workplace Sponsor Joanne
Healy Lead/Driver Karen Baldoza

• Strategy 5 Stay Vital for the Long Haul
• Achieve Excellence in Loyalty, Financial
  Stability, and Worklife for IHI

A. Continually Improve the Leadership System of
IHI B. Make IHI a Great Place to Work in the
Eyes of Its Employees and Faculty
C. Maintain a Sound Operating Margin and
Strictly Limit Overhead Costs D. Build Loyalty
and Reputation E. Establish Strong Development
Capacity
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Strategic Team

• Aim To make IHI an excellent place to work
• Primary measure Staff satisfaction
• Sponsor Joanne Healy
• Team lead Karen Baldoza
• Team members Steve Brown, Janice Gagnon, Siobhan
  Moran

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Vitality of IHI as a Workplace
Strategic Priority
Drivers
Secondary Drivers

• Strong dissemination strategy
• Vibrant intranet (RNet)

Internal Communications Professional
Development Resource Utilization and
Efficiency Strong, Reliable Management Team
Structure and Function

• Establish and formalize core curriculum and
  opportunities for staff education and training
  (IHI-U)
• Build robust orientation for new employees
• Strong supervisory structure and skilled
  supervisors (someone who cares about every
  employee)
• Robust review (PIP) process

Internal Vitality People Sponsor Joanne Target
80 of staff rate IHI excellent 97 of staff
rate IHI as very good or excellent on staff
surveys

• Active organization project portfolio management
• Match capacity and demand
• Increase efficiency

• Establish management team organizational
  standardized structure
• Finalize standard reporting process and
  template/format (Spider/A3/1-page report)
• Address elephants (honesty, behavior, role of
  leadership teams, 24/7 work mentality)
• Develop oversight and learning system for
  execution projects

v6
Drivers identified from staff satisfaction
surveys, breakfast meetings with senior leaders,
2007 annual staff retreat, Lean RIEs and other
improvement efforts
55
Vitality of IHI as a Workplace The Teams
Strategic Priority
Drivers
Secondary Drivers
Internal Communications Co-Leads Siobhan Moran
Cindy Betti-Sullivan) Professional
Development Co-Leads Steve Brown Angela
Zambeaux Resource Utilization and
Efficiency Co-Leads Janice Gagnon Christina
Gunther-Murphy Strong, Reliable Management
Team Structure and Function Co-Leads Joanne
Healy Karen Baldoza

• Strong dissemination strategy
• Vibrant intranet (RNet)

Team Mike Sweeney, Val Weber, Angela DiGioia,
Katy Dowd, Alan Olasin, Marie Schall, Matt Morse

• Establish and formalize core curriculum and
  opportunities for staff education and training
  (IHI-U)
• Build robust orientation for new employees
• Strong supervisory structure and skilled
  supervisors (someone who cares about every
  employee)
• Robust review (PIP) process

Internal Vitality People Sponsor
Joanne Lead/Driver Karen Target 80 of staff
rate IHI excellent 97 of staff rate IHI as
very good or excellent on staff surveys
Team Janice Gagnon, Jo Ann Endo, Carrie Peck,
Yael Gill, Denise D'Aunno, Christina Lang

• Active organization project portfolio management
• Match capacity and demand
• Increase efficiency

Team Steve Brown, Dan Schummers, Betty Amoah,
Virginia Vance, Jane Roessner, Andy Hackbarth,
Nichole Willy, Bob Lloyd, Rebecca Steinfield,
Julie Buchik Consultants Eugene Litvak, Penny
Carver

• Establish management team organizational
  standardized structure
• Finalize standard reporting process and
  template/format (Spider/A3/1-page report)
• Address elephants (honesty, behavior, role of
  leadership teams, 24/7 work mentality)
• Develop oversight and learning system for
  execution projects

Team Jonathan Small, Pat Rutherford, Joanne
Healy, Andrea Kabcenell, Maureen Bisognano, Penny
Carver, Don Goldmann
v6
Drivers identified from staff satisfaction
surveys, breakfast meetings with senior leaders,
2007 annual staff retreat, Lean RIEs and other
improvement efforts
56
Vitality of IHI as a Workplace The Measures
Strategic Priority
Drivers
Secondary Drivers
Internal Communications Professional
Development Resource Utilization and
Efficiency Strong, Reliable Management Team
Structure and Function

• Strong dissemination strategy
• Vibrant intranet (RNet)

Primary Target 100 of staff say, I know as
much as I want to about whats going on in the
organization or I know who or where to go to get
it.

• Establish and formalize core curriculum and
  opportunities for staff education and training
  (IHI-U)
• Build robust orientation for new employees
• Strong supervisory structure and skilled
  supervisors (someone who cares about every
  employee)
• Robust review (PIP) process

Internal Vitality People Sponsor Joanne Target
80 of staff rate IHI excellent 97 of staff
rate IHI as very good or excellent on staff
surveys
Primary Target 100 of staff say, Someone cares
about me/my work 100 reviews completed per year

• Active organization project portfolio management
• Match capacity and demand
• Increase efficiency

Primary Target Appropriate resources identified
within 1 week of greenlight Team able to begin
actively working on a project within 1 month

• Establish management team organizational
  standardized structure
• Finalize standard reporting process and
  template/format (Spider/A3/1-page report)
• Address elephants (honesty, behavior, role of
  leadership teams, 24/7 work mentality)
• Develop oversight and learning system for
  execution projects

v6
Drivers identified from staff satisfaction
surveys, breakfast meetings with senior leaders,
2007 annual staff retreat, Lean RIEs and other
improvement efforts
57
Results
Q Overall, how do you rate IHI as a place to
work?
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Results
Q My immediate supervisor and I had a
performance and development discussion within the
past 12 months
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Thank You!

• Maureen Bisognano
• Executive Vice President and COO
• Institute for Healthcare Improvement
• 20 University Road, 7th Floor
• Cambridge, MA
• mbisognano_at_ihi.org