Improvement Map: From Here to Excellence Reliable Routes to Exceptional Hospital Care May 20, 2009 Kathy Duncan, IHI Faculty

Institute for Healthcare Improvement IHI is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.

The Campaign: A Recap

100,000 Lives Campaign Objectives (December 2004 – June 2006) Save 100,000 Lives Enroll more than 2,000 hospitals in the initiative Build a reusable national infrastructure for change Raise the profile of the problem - and our proactive response

Six Changes That Save Lives Deployment of Rapid Response Teams…at the first sign of patient decline Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack Prevention of Adverse Drug Events (ADEs)…by implementing medication reconciliation Prevention of Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle” Prevention of Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time and taking several other associated actions Prevention of Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”

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 Campaign’s 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.

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

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) Infection…by 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 Failure…to 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

An International Network of Networks?

Some Returns… Enrollment 4,05100 hospitals (approximately 75%-80% of all US hospital beds) Eight states at 100%; 18 states at 90% or better At least 2,000 hospitals at work on every intervention and 53% committed to Board engagement Nodes in all 50 states (69 in total) and 200 mentor hospitals Outstanding national call attendance ( lines/call), and more than 50,000 downloads of intervention kits Increased action in rural, pediatric, public affinity groups Over 50 million new media impressions Large national learning events (e.g., Fall Harvest, National Network Day)

Rural Hospital Participation Approximately 1,700+ rural facilities are in the Campaign, representing 43% of over 4,000 hospitals enrolled Of the 200+ Mentor Hospitals ─Nearly 60 hospitals are rural ─40+ Hospitals with ≤ 150 beds ─Nine Critical Access Mentors

Where Do We Go From Here? What hospitals value (and need) + What we have learned about managing large-scale improvement + Our knowledge of what is possible + Our urgent need =

Where Do We Go From Here? Aims, prioritization and practical support + Ambitious, value-focused networks + Our knowledge of what is possible + Our urgent need =

Getting Started on the Improvement Map Three new interventions: 1.Prevent Catheter-Associated Urinary Tract Infections 2.Link Quality and Financial Management: Strategies for Engaging the Chief Financial Officer and Provide Value for Patients 3.WHO Surgical Safety Checklist

3 New Interventions Cather Associated UTI Linking Quality and Financial Management WHO Surgical Safety Checklist

Why CA-UTI? Most common hospital acquired infection ─More than 1 million cases annually 12-25% of all hospitalized patients receive a urinary catheter ─Half of these did not have a valid indication Estimated cost per case of CA-UTI range from $500-$3000 Cost to healthcare system up to $450 million annually according to CMS

Preventing CA-UTI 1.Avoid unnecessary catheters 2.Insert using aseptic technique 3.Maintain catheters based on recommended guidelines (daily care) 4.Review catheter necessity daily and remove promptly

Potential for Success Numerous published studies reporting reductions of % ─Use of reminders ─Nurse-driven protocols ─Reduction in duration of catheter days “The duration of catheterization is the most important risk factor for development of infection.” SHEA-IDSA Compendium, October 2008

Link Quality and Financial Management: Getting Started 1.Create a waste reduction portfolio. 2.Assign a finance team member to improvement projects. 3.Know how to convert light green dollars to dark green dollars. 4.Count the savings. 5.Work with the entire Leadership Team to execute flawlessly.

Surgical Safety Is A Serious Public Health Issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications means that at least 1 million deaths and 7 million disabling complications occur each year worldwide

Four Areas Of Focus Infection Prevention – “Clean Surgery” Anesthesia Safety – “Safe Anesthesia” Safe Surgical Teams – “The Operator and Environment” Measurement – “Did we change things?”

National Implementation Test: The Sprint One test. One OR. By April 1.

So what happened? ─The results are in, and we have made great strides in reducing the 17 year gap between research and implementation of a new practice in patient safety. Thank you to the 25 Nodes committed to supporting the Checklist! ─Over 1,000 hospitals have told us that have tested/plan to test the WHO Surgical Safety Checklist, as of the April 1 st deadline. 25 Nodes agreed to encourage the Surgical Safety Checklist - Statewide ─If you would like to commit to the Sprint or have any questions, please

IHI Will Continue Providing….. ─Surgical Safety Checklist Mentor Hospitals to consult with for tips on testing and implementing the Checklist: If you want to apply to become a Surgical Safety Checklist Mentor Hospital, ─Guidelines for making modifications to the WHO Surgical Safety Checklist: ─Recordings of the WHO Surgical Safety Checklist Q Sessions, including the call on March 19, posted to the WHO Surgical Safety Checklist area of the IHI.org website (along with a range of other free tools and resources):

Available Resources Getting-started kits (how-to guides, tips and tricks, bibliographies, measure definitions, alignment grids) National conference calls (recorded) Local learning opportunities (through “nodes”) Thousands of other hospitals in the U.S. and abroad More than 200 mentor hospitals

The Improvement Map A distillation of countless requirements and measurements Sets of high-leverage processes (organized by care setting) for achieving “big dot” aims A sequential guide to performance excellence

Mortality, Harm, Satisfaction, Cost per Case, Equity Patient Care Processes Support Processes Leadership and Management Initiatives AMI Care Processes to Improve End of Life Care High Hazard medications Reliable Lab Processes Boards on Board Time in Patient Care PURPOSE CHAOS Look This Way CHAOS

Customers Will… Browse the Improvement Map Create their own maps by sorting and selecting the processes in the Improvement Map based on their own aims and circumstances Get detailed information about specific processes on their own map, and be linked to more information and resources

“What Would You Like To Do?” Browse the Improvement Map by…… Enter search criteria Sort by Aims: Drop Down Box: Mortality, Harm, Patient Satisfaction……… Sort by Domain: Drop Down Box: Patient Care Processes, Support Processes, Leadership and Management Processes

IHI Improvement Map Reduce Mortality Reduce Harm Reduce Cost per Case Improve Patient Experience Patient Care Processes Support Processes Leadership Processes

Improvement Map Features and Supports: Ideas about how to use the Improvement Map General information on leading improvement: how to set an improvement agenda, how to assess capability, and how to execute Connections to others working on the Improvement Map (network/nodes) Links to programs that offer more support and guidance

Entry Points How-to guides, tools and introductory calls at no cost Virtual membership with unlimited access to Expeditions and conference call series, affinity groups, courses and video-based resources at a lower price point Smaller, ambitious community of facilities pursuing organization-wide change (Leadership Community and Collaboratives)

Kathy D. Duncan