Collaborative Improvement: A Brief and Recent History Healthcare Learning Collaboratives: Lessons Learned and Future Opportunities Baltimore, MD: November 4 , 2015 November 4, 2015 Donald M. Berwick, MD President Emeritus and Senior Fellow Institute for Healthcare Improvement
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Collaborative Improvement: A Brief and Recent History Healthcare Learning Collaboratives: Lessons Learned and Future Opportunities Baltimore, MD: November.
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Collaborative Improvement: A Brief and Recent History
Healthcare Learning Collaboratives: Lessons Learned and Future Opportunities
Baltimore, MD: November 4 , 2015
November 4, 2015
Donald M. Berwick, MDPresident Emeritus and Senior FellowInstitute for Healthcare Improvement
Model I: Bad Apples
The ProblemQuality
Frequency
Model I: Bad Apples
The Problem
Quality
Frequency
“Reliance on Inspection to Improve”
The Cycle of Fear
Increase Fear
Micromanage Kill theMessenger
Filter theInformation
Some Consequences of Reliance on Inspection
Measurement Gone Wild – Adds massive costs; Distracts from what matters; Objectifies the crucial subjectiveAccountability – Chills dialogue and authentic exchange; Loses upward information flow“Skin in the Game” – Afflicts the disadvantaged; Lacks any evidence baseStandardization – Chills innovation; Disconnects care from individual patientsMarkets – Drives oversupply; Chills exchange 5
“The First Law of Improvement”
Every system is perfectly designed to achieve exactly the
results it gets.Paul Batalden, MD
“Some heades haue taken two head is better then one: But ten heads without wit, I wene as good none.”
- John Heywood, 1546 AD
Paul Batalden, MD
9
“IHI creates membership Organization”
“IHI creates the interpretation of this around conditions”
“IHI organizesactivities”… “produces
stories”
“Pain…Flow…Drugs”
10
Breakthrough Series Collaborative
Pick a topic for improvement
Engage a panel of experts
Harvest “change concepts”
Invite care organizations to enroll teams
Launch a series of learning sessions
Use the learning sessions to teach improvement
Summarize
1. Ideas2. Cycle Times
3. Social Support – Affirmation
“50/50”
“If I don’t discover it,I don’t value it”
“4. Problem level, notmacrounit level. Hospital
as a system”
“The real team is atthe hospital”
“Could do costreduction”
“Reflection asa process”
“Up front: Ask wherein the system there
is a need forimprovement”
“Observe atsystem level”
“Tom Nolan’sphone number”
“Memo to theBoard”
Tom Nolan, PhD
Criteria for Selection16
Clinical importance to patients
Financial importance to organizations
Experts have achieved better performance
Choose cycle times and scale that permitted noticeable improvement within weeks or months
Seek out best practice sites and great ideas for change.
52 Breakthrough Series Collaboratives
Dr. Ken Kizer, Veterans Health Administration19
Vertically Integrated Service Networks (VISNs)20
22 VISNs; total of 134 VA centers
8-Month Results:
Median wait times fell from 48 to 22 days
54% reduction in wait time
3-Year Results:
Wait times fell from >60.4 days to 28.4 days
VISN 2 achieved wait times of 16 days
Dr. John Oldham22
National Primary Care Development
Team (PCDT)
Development Team (NPDT) focus:– Access to primary care– Care for patients with proven coronary heart disease– Access to routine secondary care services.
11 regional PCDT organizations
1000 practices in the UK covered 7 million patients
Reduced waiting times for >32 million patients
The largest improvement program in the world, 2002
Reduction in GP 3rd available appointment - July to September 2000For practices reporting full data and showing improvement in measure over the period
(Represents 45% of practices reporting full data for the period)
0
2
4
6
8
10
12
All practices showing improvement in GP 3rd available appointment measure during the period
Red
ucti
on
in
days t
o 3
rd a
vail
ab
le a
pp
oin
tmen
t -
GP
s
% no of practices achieving GP 3rd Available Appointment within 48hrsThird wave practices
30.0
35.0
40.0
45.0
50.0
55.0
60.0
65.0
70.0
Pe
rce
nta
ge
% no of practices
Wave 3 Collaborative practices Average No. of days - GP 3rd Available Appointment
% Improvement from baseline (April 2000) to September 2001
0
1
2
3
4
No
. o
f d
ays
0
10
20
30
40
50
60
70
80
90
100
%
Average of GP_3rd_Appointment 3.47 3.28 3.06 2.84 2.62 2.23
%Improvement from baseline 0.00 5.48 11.82 18.16 24.49 35.85
Apr-01 May-01 Jun-01 Jul-01 Aug-01 Sep-01
NB : baseline April 01 - 3.47 days
The National Primary Care CollaborativeGP 3rd Available Appointment Trends
First, Second and Third Wave practices
1.5
2
2.5
3
3.5
4
4.5
Avera
ge 3
rd a
vail
ab
le a
pp
oin
tmen
t (d
ays)
First w ave practices 3.3 3.2 2.8 2.9 2.7 2.7 2.3 2.1 2.0 2.1 2.4 2.4 1.8 1.6
Second w ave practices 4.1 3.9 3.7 3.0 3.1 3.1 3.2 3.2 2.6 2.3 1.9
GP Access % Improvement Wave 1 - 50.38% over 14 months of reportingWave 2 - 52.23% over 10 months of reporting Wave 3 - 35.85% over 6 months of reporting
J a n - 0 6 F e b - 0 6 M a r - 0 6 A p r - 0 6 M a y - 0 6 J u n - 0 6 J u l- 0 6M o n t h
Pre
su
re
Ulc
er R
ate
pe
r 1
00
0 P
atie
nt
Da
ys
P r e s s u r e u lc e r r a te p e r 1 0 0 0 In p a t ie n t D a y s L in e a r ( P r e s s u r e u lc e r r a te p e r 1 0 0 0 In p a t ie n t D a y s )
U n f a v o r a b le
F a v o r a b le
N = 5 0
N = 5 0
N = 5 1
N = 5 0
N = 5 0
N = N u m b e r o f R e p o r t in g H o s p it a ls
N = 5 1
N = 5 0
50 hospitals reporting: Overall Rate 1.38
Zero!
Error Reduction at Ascension
Pressure Ulcer
Neonatal Mortality
Birth Trauma
Ventilator-Acquired Pneumonia
Falls with Serious Injury
Bloodstream Infections
Preventable Error Reduction in rate95%
79%
74%
56%
54%
32%
OPQC = Population HealthOhio Perinatal Quality Collaborative
ProgesteronePilot: 23 OB ClinicsSpread: +15-20 OB Clinics
NICU Grads Pilot: 3 NICUsSpread: +3 NICUs
API - 2015
Decreasing Non-Medically Indicated Scheduled Deliveries Prior to 39 Weeks Gestation
31API - 2015
API - 2015 32
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
Q1
Q3
0102030405060708090
100Total Number of Centers (Cumula-
tive)
Cumulative Actual
Num
ber o
f Cen
ters
ImproveCareNow Network
• Industry sponsored research studies – Adalimumab Concomitant Therapy• Methotraxate Trial• PCORI PPRN Phase 1 & 2• Research objectives elicitation & prioritization (CHOP)• PRO collection – PROMIS study• PPRN demo PFA
Funded Research
Inflammatory Bowel Disease Remission Rates:“Improve Care Now” Care Centers
Patient Safety Collaboratives: Today
Modifications for Resource-Poor Settings36
Coaches
Regional meetings
Cell phone technologies
Overcome geographic, financial constraints
Photo: FreeDigitalPhotos.net
“The Breakthrough Series (BTS) structure has proven highly applicable to efforts to improve performance of the more centrally directed, district-based health systems in Africa.
Lack of Internet connectivity necessitated reliance on change agents who pollinated change ideas across sites in the network…
…[the BTS] became a learning system used primarily for innovation of changes that could then be spread. The BTS was also used as a spread mechanism for IHI’s Ghana project on maternal and neonatal mortality…In South Africa, the BTS model was used for innovating and demonstrating effective implementation of HIV care at a District level, and developing change packages that were then spread throughout the national health care system…
- Pierre Barker, 2015
Paul Batalden’s Sketch38
Breakthrough Series Skeptics 39
Doubts about scientific discipline of measurement, inference, results reporting
Doubts about data
Doubts about attribution
Doubts about sustainability: Do these results last?
Lingering Questions40
“Do improvement collaboratives work?”
…“Does parenting work?”
…“Does schooling work?”
Photo: http://www.boas.pro/remco-boas
41
Pawson and Tilley: Realistic Evaluation
“The idea [of collaborative improvement] is better seen as a learning strategy – an action learning strategy – not as an intervention that should be evaluated as a new treatment should be.”
- Paul Batalden, 2015
“The bedrock value within a collaborative is freedom from fear in any form – fear of