International Forum on Quality & Safety in Healthcare Reducing Cost, Improving Quality: The Life Cycle Model for Sustainability Thursday, April 10, 2014 Lucy A. Savitz, Ph.D., MBA Intermountain Healthcare Katharine Luther, RN Institute for Healthcare Improvement

Key Points  Well done, quality improvement (QI) work is a core capacity for impacting cost and quality.  A learning organization recognizes that QI work is a part of the evidence chain in getting the right care to the right patient at the right time in an efficient manner.  Organizational capacity for change is sustained by strategically directed, collective QI efforts – requiring a critical mass to influence culture.

The Quality Challenge Ensuring consistency in access and quality – but how have we impacted cost? Deming posits that good quality leads to lower costs. This has been demonstrated. The Right Care For The Right Person At The Right Time

Care Delivery Falls Short of Efficiency Potential  Well-documented, massive variation in practices  High rates of inappropriate or unnecessary care  Unacceptable rates of preventable care- associated patient injury & death  A striking inability to do what we know works  Huge amounts of waste, spiraling prices, and limited access

Waste in Healthcare  Reducing waste in health care is key to affordable, high quality health care.  Nearly half of consumed resources represent potentially recoverable waste in U.S. hospitals (44%)

Case for Continuous Improvement Incorporating  Innovation  Disciplined Quality Improvement (QI)  Evaluation Critical to finding new designs and solutions to close the gaps and meet the goals of optimizing:  Patient experience  Health of the population  Controlling cost/reducing waste.

Need for a Healthcare System that Learns We require a sustainable system  That gets the right care to the right person at the right time and then  Captures the results for making improvements.

21 st Century Health Care Information-rich, patient- focused enterprises Information and evidence transform interactions from reactive to proactive (benefits and harms) Evidence is continually refined as a by-product of care delivery Actionable information available – to clinicians AND patients – “just in time”

Challenges to QI Driving Change  Inadequate training in and/or appreciation for scientific process  Lack of expectation for rigor  Missing science of large scale change  Unclear or do not share big picture view

Batalden Rethinking Triple Aim Better Professional Development Better HealthBetter System Performance

Scientific Approach to QI IOM: Selker, H et al., October,  Clear, measurable process & outcomes goals  Basis in evidence  Iterative testing  Appropriate analytic methods  Documented results

QI: Role in Driving Evidence Base Quality Improvement Implementation Science Outcomes Research Qausi- experimental Intervention Studies (Trials) Clinical Effectiveness Program Evaluation Driving the science of change/innovation…

Science of Large-Scale Change McCannon, Berwick, Massoud in JAMA, 298(16): , 2007 Innovation in Health Care  Find or create practices (technologies) that are better than the prevailing ones  Build the evidence base in order to take to scale  Quickly make those improvements ubiquitous  Failure to deploy improved technologies and practices widely and quickly is a form of waste  Charge is to learn about the spread of innovations

Training as a Game Changer  Consider how we allocate training resources to drive rigorous QI  Is the QI training experience an isolated or action oriented, team-based experience?  Are teams held accountable to demonstrate application of training?  Have we trained a critical mass in our organization to create change and support a learning culture?

An Organization’s QI Learning Curve

Building Capacity  Slow beginning is characterized by small number of staff, largely engaged independently in training (reflective learning, hard to sustain)  Steep acceleration is characterized by growing numbers of trained staff, engaging in team-based training (pockets of change, threat of turnover, limited leadership support, & loss of momentum)  Plateau is reached when a critical mass of staff are trained and begin to apply learning as a strategically directed collective (cultural change in the way care is delivered that is sustainable)

From the Bedside to the Balance Sheet: Engaging Front-Line and Finance Staff to Lower Costs and Drive Quality Katharine Luther IHI Lead

Shaping Teams: IHI Integrated Model  Requires collaboration between quality, medicine, finance, patients, and researchers.  Draws on knowledge base and expertise across disciplines for a holistic approach.  “We need each other to make this work.”

Making It Work Examples to Complement Quality Perspective: Finance/economics staff shadowing in clinical settings  Establish a business advisory service with assigned portfolios  Dual reporting relationships Incorporating patient/family point of view. Caveats:  Trust and relationship building are key elements.  It takes the right kind of people. 19

Creating Capacity: Critical Mass Training Within Care Delivery Examples of…  Where it has been done: Intermountain Healthcare, Brent James  Where it is happening: Hopitaux Universitaire de Geneve (HUG) Pierre Chopard

We Need to Know More About  The impact of training…  On the cost and quality impact of individual project changes.  As a lever for routinizing QI into the culture of a clinic, hospital, or system of care.  In generating evidence to promote large- scale change.  For accelerating the spread of evidence- based interventions.

Professional Development Opportunities for Researchers  Academy Health Delivery System Science Fellowship Program is aimed at developing leaders in the field to conduct operationally meaningful research to support Triple Aim activities.  The Health Foundation Improvement Science Development Group is a network of international experts from disciplines within the field, working on the development of improvement science as an international discipline through the sharing of ideas and knowledge. science/improvement-science-development-group/

Your Challenge Moving Forward  Strategically plan and develop your learning journey for continuous improvement to impact cost, quality, and value.  Assess your organizational cultural needs and stage of learning for action planning.  Consider how to sustain past, present, and future culture change driven by training/educational investments.