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Conference Report: 22nd Annual National Forum on Quality Improvement in Healthcare Print E-mail
The Quarterly 2011

 


Background
The Institute for Healthcare Improvement (IHI) 22nd Annual National Forum on Quality Improvement in Health care was held on 5-8th December 2010 in Orlando, Florida. This event is the peak gathering of clinicians, healthcare executives and health professions involved in healthcare quality improvement in North America. The theme of the conference “Taking Care”, focused on health systems strategies to improve care for patients, families and the health system as a whole.

The forum provided attendees with the opportunity to experience keynote addresses from leaders in healthcare improvement, as well as explore areas of particular interest via workshop areas or tracks. Below is a summary of the key global initiatives within the United States health system for quality care, a brief note on the tracks available, and a reflection on some workshops/ sessions particularly relevant for medical administrators – the challenge of engagement of medical staff in quality and safety.

Keynote addresses in quality and safety
Keynote: Maureen Bisognano, President and CEO of IHI


Maureen Bisognano, President and CEO of IHI, provided the opening keynote address, with an overview of IHI’s achievements, global reach, six aims and 10 new rules to redesign and improve patient carei.

The six aims of the Institute of Healthcare Improvement are:

  • Safe – no needless deaths
  • Effective – no needless pain or suffering
  • Patient Centred – no helplessness in those served or serving
  • Timely – no unwanted waiting
  • Efficient – no waste
  • Equitable – for all

The ten new rules to redesign and improve patient care are:

  1. Care is based on continuous healing relationships
  2. Care is customized according to patient needs and values
  3. The patient is the source of control
  4. Knowledge is shared and information flows freely
  5. Decision making is evidence-based
  6. Safety is a system property
  7. Transparency is necessary
  8. Needs are anticipated
  9. Waste is continuously decreased
  10. Cooperation among clinicians is a priority

IHI is also driving a focus on the “Triple Aim”, simultaneously improving the health of a population, the experience of care and per capita costs (Figure 1). Ms Bisognano also provided a personal insight into her passion for high quality healthcare, sensitively and emotionally expressing the tragedy of her nephew’s death as a result of failures within the healthcare system. This personal reflection reminded the audience that although the healthcare system is large, complex and requires a systems approach, the stories of patients are individual and personal.


Keynote: Secretary Kathleen Sebelius, Secretary for Health and Human Services,

Secretary Sebelius outlined the key healthcare issues facing the Obama Administration, and current strategies to address quality and safetyii

:

  • The Affordable Care Act (which has primarily focused on ensuring a new competitive private insurance market) will also improve the quality of healthcare, and focus on preventative healthcare initiatives (immunisations and cancer screening) in an affordable manner.
  • The National Healthcare Quality Strategy and Plan is being developed, to focus on seamless, coordinated care whilst reducing adverse events.
  • The Centres for Medicare and Medicaid Services (CMS) Innovation Centre has been established with $10 billion to trial and implement innovative strategies to improve care whilst maintaining sustainable costs within the Medicare and Medicaid programs (now lead by Dr Don Berwick, previous CEO of IHI). Such strategies target integrated care, vulnerable populations, patient-centred care for low-income patients, and those with dual eligibility for Medicare and Medicaid.

Keynote: Hon Cory A Booker, Mayor of Newark New Jersey

Hon Cory A Booker, Mayor of Newark, New Jersey, also provided a keynote speech of memorable proportions.iii Hon Booker has reduced shootings and murders by 40% in his city mid-way through his first term in office, in addition to doubling affordable housing production in his city. Obama-like in his oratory, Mayor Brooker regailed the story of his journey through College football, a hunger strike in the early days of politics in response to the high violent crime rates in his jurisdiction, and finally his successes with mentoring programs for recently-released men from correctional facilities to become father-figures and role models to their sons with subsequent significant reductions in recidivism rates. These stories illustrated the significant impact that Mayor Brooker, as an individual, was able to achieve through passionate leadership, thinking laterally, and addressing the root cause of issue. These are all valuable lessons for healthcare leaders sharing the passion to improve the quality of healthcare for patients.

Workshop tracks
There were 84 individual workshops offered during the general conference, with sessions organised into content areas or 'tracks'

  • Hospital care
  • Innovation and spread
  • Leadership and governance
  • Measurement tools, technology and quality processes
  • Office practice and outpatient setting
  • Patient and family centeredness
  • Patient safety
  • Student
  • Quality improvement for vulnerable populations
  • Lessons learned from Virginia Mason’s 10-year quest for zero defects and the perfect patient experience
  • Paediatrics.

In addition, workshops were classified according to their level of learning – fundamental (helpful for the newcomer to quality), masters program (for advanced, cutting-edge improvement) or student program (for health professional students and residents).

Engaging physicians in quality and safety initiatives
The following workshops are some examples of initiatives and strategies relevant for medical administrators.

Mini-course: Dr Gary Kaplan, CEO Virginia Mason Medical Centre

A full-day workshop focused on engaging physicians in transforming care, conducted by Dr Gary Kaplan, CEO Virginia Mason Medical Centre (VMCC), and Dr Jack Silversin, consultant from Amicus who assisted VMMC in its journey to improve patient care.iv

VMMC is a 336 bed not-for-profit hospital with 9 locations, 450 physicians and 5000 employees in Seattle, Washington. The Virginia Mason Production System was established, based on the Toyota Production system philosophies of lean thinking, and adopted throughout the organisation. From 2000 to 2010, VMCC achieved:

  • Hospital of the decade in 2010 from Leapfrog
  • Top 10 hospital in the US (out of 1600)
  • Improved positive financial margins in 2009 to 5.9%
  • Increase in the time nurses spend with patients from 35% to 90%, and
  • Reduced the time it takes for pathology laboratory results by 85%.

The workshop focused on the strategies to engage physicians as part of the implementation of the lean strategies. These included core change-management principles of developing urgency, shared vision and change sponsorship.

Key insights for engaging physicians that were highlighted by Dr Kaplan:

  • Doctors want to see their leaders as an "advocate, protector, communicator, and first among equals - not one millimetre above". Physicians make leaders pay a price for stepping out of advocate/ protector roles, but also noted that there are times when advocacy or protection is appropriate.
  • Engagement with physicians will be difficult if the basic "hygiene" factors are not well addressed (e.g. basic needs to perform their roles, such as computer access, equipment etc).
  • Physicians leaders (who have traditionally thought as physicians, focusing on individual patients) often require shift in mindset to become leaders within the organisation (towards a systems approach)
  • He also noted that working collaboratively with physicians represents an adaptive change for many administrative leaders as well, and a need to move away from language such as "gaining their buy in", and "we’ll roll it out" to a collaborative partnership.

Kaplan also discussed the concept of "compact", or the “give and the get” - reciprocal expectations between doctors and their organisations. These expectations are unstated yet understood, mutually beneficial, and set up and reinforced by society and the organisation. It is essential to establish the current understanding of the 'give and get', and ensure it is aligned with the strategic goals of the organisation.

Workshop: Engaging physicians to reduce clinical variation - Dr Lawrence Shapiro, Dr Lurel Trujillo, Dr Wendi Knapp, Dr Michael van Duren, Palo Alto Medical Foundation

The Palo Alto Medical Foundation (PAMF) Team outlined a Variation Reduction initiative, and the strategies to overcome implementation barriers with physicians. This included:

  • Simple strategies to harvest data on clinical variation
  • Developing skills in talking with specialists about variation reduction
  • Engaging physicians in developing and implementing standards of care.v

Small groups of physician peers were brought together with data comparing episodes of care. The process included:

  • Data was created by assigning all patient costs to the provider who did the initial consults
  • Visual display of live, drillable data (ICD coding of individual patient episodes)
  • The data was explored following the clinician’s curiosity in the data, not judgment on their practice
  • Baseline dataset reviewed, with discussion of proposals for standards (based on national standards)
  • Establishment of a feedback loop, with debriefing, revision and follow up with emails of how things are going after implementation of standards.

Challenges highlighted:

  • How to address the large departments with >50 physicians
  • Vocal opponents – took nearly a year to get a standard protocol developed, and required bringing the vocal opponents to the table and ask them to write the standard
  • Ensure that data is measuring the same thing (i.e. code the data consistently).

Workshop: Disruptive behaviour by physicians, adverse effects on safety – Dr Kevin Steward, Dr Ron Wyatt, IHI Quality improvement Fellows

Dr Kevin Steward, Medical Director of Safety Express at the Department of Health in the UK, and Dr Ron Wyatt, Director of Patient Safety Analysis Centre, US Department of Defense, provided an overview of:

  • Various manifestations of disruptive behaviour
  • The adverse effects of disruptive behaviour on safety, culture and teamwork
  • Effective approaches for dealing with disruptive behaviour.vi

The spectrum of behaviours can include:

  • Passive – inadequate notes, meeting avoidance, and not addressing certain pages
  • Passive-aggressive – derogatory comments, hostile notes, sexual harassment, non-compliance with policies
  • Aggressive – verbal outbursts, assaults, throwing instruments etc.

Dr Steward and Dr Wyatt noted that most doctors do not present problems, but recurrent incidents involving the same individuals are common. Doctors tend to get reported later and treated more leniently, especially the highly valued ones. Of note, there are rarely systems in place for dealing with this.

Effects of disruptive behaviour included patient safety problems, staff turnover, poor team working, complaints and a risk of litigation.

Strategies to manage the behaviour require senior leadership, usual performance development processes and modelling of behaviours.

Discussions and Conclusions
The National Forum provided a valuable opportunity to experience the current state of the quality improvement community in the United States, and learn from proven, successful leaders in patient care. The forum showcased examples such as Virginia Mason Medical Centre’s achievements as Hospital of the Decade, resulting from innovative approaches to quality improvement, safety and reducing waste and costs, as well as providing practical lessons to engage physicians. Due to the breadth of the streams, nearly every interest and professional sub-specialty in the field of quality and safety was provided. Overall, Australian health services, medical administrators and health professionals in general can learn and benefit from participating in conferences and seminars such as the IHI National Forum.


Dr Alison Dwyer
Medical Director, Quality Safety and Risk Management
Austin Health

 

References
i Bisognano, M (2010) Together, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, December 7 2010
ii Sebelius K (2010) Keynote two, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, December 7 2010
iii Booker C A (2010 Keynote four, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, 8 December 2010
iv Kaplan G, Silversin J (2010) Engaging Physicians in Transforming Care, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, December 6 2010
v Shapiro L, Trujillo L, Knapp W, van Duren M (2010) Engaging physicians to reduce clinical variation, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, December 7 2010
vi Steward K, Wyatt R (2010) Disruptive behaviour by physicians, adverse effects on safety, Institute for Healthcare Improvement 22nd Annual National Forum on Quality Improvement in Health Care, December 8 2010





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