Partnership for Patients Content Sequencing January 18, 2012 Christina Gunther-Murphy Director, Hospital Portfolio Operations Institute for Healthcare Improvement

Overview The Partnership for Patients lays out an important and ambitious agenda for hospitals to reduce all-cause harm by 40% and avoidable readmissions b y 20%. In order to achieve these aims, hospitals will need to appropriately sequence their work. There are a variety of ways in which hospitals or those providing technical support to hospitals can sequence the work. Identify the high leverage skills or capabilities that teams need to do all this work and then begin in the areas that will teach teams these high leverage skills. Study data and identify the most problematic areas for the facility; Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates; Start with units with improvement capability or champions; Start in areas where you are likely to see early success in order to increase staff’s desire to continue this work.

Sequencing Methods Identify the high leverage skills or capabilities; Use data to identify problem areas; Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates; Start with units with improvement capability or champions; Start in areas where you are likely to see early success.

High Leverage Skills Method Improvement infrastructure: Teams apply improvement methods in increasingly complex content areas. Reliability and teamwork: Process compliance 95% of the time or higher; good communication; good collaboration across disciplines Rounding and prevention: Meaningful rounding; identify, prevent, and solve safety risks/problems Risk assessment: Beyond developing tools; use of rounding and prevention skills in concert with assessment Monitoring and titration: Get and use data to make decisions; practice appropriate titration and adjustments Work across microsystems: Designing and fixing systems across departments and units

Working Across Microsystems Complexity Working Across Microsystems Monitoring & Titration Risk Assessment Rounding and Prevention Reliability and Teamwork Time Sept’ 10 Sept’ 13

Reliability and Teamwork Rounding and Prevention Risk Assessment Complexity CLABSI SSI CA-UTI VAP VTE PU Falls OB ADE Reliability and Teamwork Rounding and Prevention Risk Assessment Monitoring & Titration Time Sept’ 10 Sept’ 13

Working Across Microsystems Care Transitions Complexity Working Across Microsystems CLABSI SSI CA-UTI VAP VTE PU Falls OB ADE Reliability and Teamwork Rounding and Prevention Risk Assessment Monitoring & Titration Time Sept’ 10 Sept’ 13

Emerging List of Cultural Attributes Passion for excellence Appreciation of the important of culture Over-communication of key messages Positive role-modeling Facile in going from concepts to action Organizational alignment Constructive accountability Highly respectful cross-group teamwork Whole-system view of work Value placed on truth and facts Attention to discipline in approach Continual learning Active engagement of everyone

“Culture eats strategy, tools and methods for lunch!” And we know that… “Culture eats strategy, tools and methods for lunch!” Marc Bard

Organization Process Create aim (what by when = the bar): Decrease SSI rates by 10% over 9 months in orthopedic surgery units. Identify starting content areas (parallel vs. sequential) Create a project list and assignments Develop oversight systems

Work Area Aim Progress Care Transitions CLABSI SSI CA-UTI VAP VTE OB Just started 25% progress 50% progress 100% progress Sustaining CLABSI SSI CA-UTI VAP VTE OB PU Falls ADE

Portfolio of Projects Project Areas of Focus Cardiac Care Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF) Med. Safety High Alert Meds., Med. Reconciliation Med/Surg Unit Spread Pressure ulcers, Med. Rec., High Alert Meds. AMI, CHF, Infection Control Infection Control Methicillin-Resistant Staphylococcus Aureus (MRSA) ICU Safety Rapid Response Teams (RRT), Ventilator-Acquired Pneumonia (VAP), Central Line Infections (CLI) Surgery Safety Surgical Site Infections (SSI), Surgical Care Improvement Project (SCIP)

Portfolio of Projects & Skills Needed Resources and Responsibilities Lead Sponsor Driver Skills Cardiac Care Senior cardiologist Director of cardiac service line Nurse manager Reliability and Flow Improvement DC planning Med. Safety Director of pharmacy COO PharmD Measurement ADE Triggers Improvement MD Engagement Med/Surg Unit Safety VP Nursing Nurse Manager Spread Improvement Infection Control Manager infection control CMO Senior infection control RN Behavioral change Human factors Improvement ICU Safety Med. Director ICU Reliability Cooperation Improvement Surgery Safety High Volume Surgeon Director of surgery RN manager surgery Coordination Cooperation Improvement

Learning and Oversight System Leader: Patient Safety Officer Task Responsible person Frequency Manage spread VP nursing Use weekly RN mgr meeting Manage structural changes Patient safety officer Weekly Review individual teams Sponsors Monthly 1.5 hours Review portfolio CEO and the strategic team Monthly 2 teams 1.5 hrs each. Each team quarterly Overall learning Lead IA, CFO Bi-weekly

Portfolio of Projects Project Areas of Focus Hospital-DC Planning Discharge timing, Anticipating Resources Needed, Connections to Primary Care Hospital- Info Transfer Key Data Project, Connections and Communications Home Health Care Pre-discharge assessment, Building Family Capability HHC and Offices Payment Strategies Offices Immediate Post Discharge Connections, Information Exchange How many have seen this type of portfolio before? 15

Deploy Resources to Projects Discharge Planning Hospitals Information Transfer Project Resources and Responsibilities Sponsor Lead Driver IA skills Discharge Planning COO VP of Nursing Director of Inpatient Services Flow and Queuing; Reliability Information Transfer CIO Director of Community Medicine Community liaison/ informatics specialist Communi-cation; Reliability How many actually think about all these roles when putting together a project? How many distinguish between a lead and a driver? How many have Improvement Advisors or Quality specialists?

Learning and Oversight System-Hospital Only Task Responsible Frequency Manage Structural Changes Hospital Operations Team weekly Review Individual Teams Department Operations varied Review Portfolio in the Hospital CEO and the Strategic Team quarterly Overall Learning Hospital Operations liaison with the Rehospitalization Team Weekly - monthly