Linking Quality to Health Care’s “2nd Curve” From Innovation to Transformation: Delivering and Sustaining Results Institute of Public Administration of Canada Quality Healthcare Network Minto Suites Hotel Ottawa, Ontario 21 January 2011 Martin D. Merry, MD, CM Adjunct Associate Clinical Professor of Health Management and Policy University of New Hampshire
34
Embed
Linking Quality to Health Cares 2nd Curve From Innovation to Transformation: Delivering and Sustaining Results Institute of Public Administration of Canada.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Linking Quality to Health Care’s “2nd Curve”
From Innovation to Transformation: Delivering and Sustaining Results
Institute of Public Administration of CanadaQuality Healthcare Network
Minto Suites HotelOttawa, Ontario21 January 2011
Martin D. Merry, MD, CMAdjunct Associate Clinical Professor of Health Management and Policy
University of New Hampshire
Faculty, American College of Physician ExecutivesFaculty, Center for Healthcare Governance, American Hospital Association
2
An Invitation
“No problem can be solved from the same level of consciousness that created it. We must learn to see the world anew.”
- Albert Einstein
3
1st
2nd
4
1st Curve Founders: “The Four Doctors”
Welch
Halsted
Osler Kelly
5
“The most important event in the history of
American and Canadian medical education”
6
"... for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefitting from the encounter."
1912 : The 'Great Divide'
Harvard Professor L. Henderson
(Harris, Richard. A Sacred Trust. New York, NY: New American Library, 1966)
7
Time
Circa 1910
2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)
(Bifurcation curve: 2011)
First Curve/ 4 sigma
(Craft-Age Culture)
(Craft+Information-Age Culture )
-
Future Performance (Second Curve/
6+ Sigma)
“Crossing the Chasm”
Per
form
ance
8
1st Curve Health Care’s Performance Problem
1st Curve Health Care (Craft Culture)90% OK 100,00095% OK 50,00099% OK 10,000
Sigma Defects per million
1 690,000
2 308,000
3 66,800
4 6,210
5 230
6 3.4
9
10
1st Curve LegacyMedical errors as 5th-8th leading cause of
death in US
44,000 – 98,000 deaths annually
11
May 25, 2004: We learn that Canada, too, is “infected.”
12
The 21st Century/ 2nd Curve Flexner Report?
13
Columns 2 & 3 = 2nd Curve
Regulation Hammurabi
Legal system
State Boards
JCAHO
“Inspection”
Fed/State/Provincial regs
EMTALA, HIPAA, Etc.
LHINs, ECFAA
Medical Science
Hippocrates
Nightingale, 4 doctors
Flexner, Codman, ACS/Hospital
Standardization
M&M conferences
Donabedian,structure process, outcome
Outcomes, Disease
management
Evidence based care, Hospitalists
Management Science
Industrial Revolution
Taylor: “Scientific
Management”
Shewhart
Deming, Juran, Total Quality
Complexity theory
Six Sigma, Safety Mgt, Lean, Appreciative Inquiry, Resilience
Columns 2+3 = 2nd Curve
14
What we MUST understand: The emergence of 2nd Curve Health Care represents a Management, not Clinical paradigm shift. This fact has huge implications for leaders at all levels of the organization.
15
How 2nd Curve Is HappeningEvidence-based medicine
Clinical protocols “Disease-Line” ManagementRapid cycle PDCA Lean Six Sigma IT:EHR, TelehealthClinical Microsystem DesignTeam-based care New models of System-
Community relationshipsCommunity health innovation Strength based change (e.g., Appreciative Inquiry)
Health Care’s beginning ascent of its 2nd Curve:
Re-designing care systems around those served – while restoring the “joy of practice” to caregivers
16
Board of Trustees
• Credentialing• Departmental (Peer)
Review• Surgical Case Review• Blood UR• Drug Usage Review• Pharmacy and
2011: The Structure Hierarchy, Fragmentation, Communication gaps,
Misunderstanding, Power Struggles, etc.
17
Fast Forward: Community Memorial Hospital, Menomonee Falls,
Wisconsin
18
Car
diop
ulm
onar
y C
are
Obstetrics, Gynecology,
Perinatology,Pediatrics,
Neonatology
Management and Coordination of Care
Participation
Leadership Patient/Community
Primary CareInternal Medicine, Medical
Specialties, Family Practice,
Hospitalist, Psychiatry,
Emergency Medicine*
Women & Children
Care
Management
Design
K:\S\wp\7350(953)\misc\janice8.ppt
COMMUNITY MEMORIAL HOSPITALMenomonee Falls,
Hospital
Administration
Hospital Board
Medical Executive Committee
Co
llab
ora
tive
Pra
ctic
eC
redentialing
Performance Improvement
Car
diol
ogy,
Car
diot
hora
cic
Sur
gery
, Pul
mon
olog
y,
Vas
cula
r
Musculoskeletal C
are
Orthopedics, P
odiatry,
Neurosurgery, P
M&
R,
Radiology*
General Surgery, S
urgical
Specialties, A
nesthesia*
Surgical Care
Radiation Oncology, Medical
Oncology, Pathology*Cancer Care
Performance
Improvement Teams /
Clinical
Microsystem
sCaregivers
* Specialties provide care in all service lines
19
20
Patients and Families as Part of the Care Team
21
“Seek first to understand, then to
be understood.”
- Stephen Covey
22
23
1st Curve 2nd Curve Evolved around medical and
hospital practices Disease focus, one patient at a
time Hierarchical, physician
controlled Performance problems
assumed as people-caused “Culture of blame” Fragmentation of care givers
and health care functions, “hand-off” gaps common
Medical records paper, frag-mented, “owned” by caregiver
Complexity frequent errors, harm to patient
Quality is compliance-oriented, 2-4 sigma common
Reactive to “sentinel events”
Designed around patient/ community, population need
Health, prevention focus, patient plus population
Team-based systems outperform hierarchy
Recognition that performance problems 95% systems-based
“Just Culture” Integration of all system
elements, care “seamless” for patients
EHR, “smart cards” owned by patients
Integration of “quality sciences” minimizes error, harm
Quality, value oriented toward 6+ sigma, O preventable harm
Pro-active, Resilience-led
24
25
Senge’s “Five Disciplines”
Personal MasteryMental ModelsTeam LearningShared VisionSystems Thinking
(1st Curve health care, for all of its positives, focused almost solely on “Personal Mastery.” As many have shared at the meeting, all five disciplines are essential to “Learning Organizations.,” and the 2nd Curve.)
26
As John Maynard Keynes once noted . . .
“The hardest thing is not to get people to accept the new ideas, it is to get them to forget the old ones.”
Or, as Max Planck, a pioneering 20th Century physicist once
remarked, “Scientific progress moves forward, one funeral at a
time.”
27
“Command & Control” Pyramid (Taylorism, circa 1900)
Top Management
Obedience
Commands
Hint: Doesn’tWork Anymore
28
The “New Leadership:” Creating Context
“Farmers don’t grow crops; they create conditions under which crops can grow.”
- Stephen Covey
Question: In my leadership role, am I creating a “fertile field” for a) the growth of modern quality/safety practice and b) a fundamentally different form of top-down/bottom up collaboration?
“Realizing that ThedaCare needed change, leaders tried one improvement program after another over the course of many years. Most of the programs offered incrementally better results for a while, until everyone slid back into old habits.” Finally . . Leaders started thinking about breaking down the divisions between caregivers’ specialties, divisions of labor and habits of working to create a unified focus on the patient. Because this would require change in everyone involved, it was clear that hospital units needed a revolution instead of isolated, incremental adjustments.”
32
Today’s Leader
Today’s leader is not someone who knows all the answers…or who makes decisions and gives orders in the old military model of leadership.
Rather, the new leader is someone who can assess a situation, bring people together, build consensus, and discover solutions, building on the talents of everyone involved. The new leader is a facilitator, a communicator, a team builder.
- Diane Dreher, The Tao of Personal Leadership
33
Best of 1st Curve Aviation
2nd Curve
34
There are many ways to ascend Mt. Washington – auto road, cog railway, and many hiking trails. My best
wishes to you Leaders on Ontario Health Care as you ascend your path toward 6 sigma health care!