Hamilton Dr Chan FinalPresentation by HC121105194539

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									Sharpening Leadership Skills
        for Quality


  CCHSE Hamilton Chapter Webinar
               October 28, 2009




       Dr. Ben Chan, MD MPH MPA
    CEO, Ontario Health Quality Council




                                          1
 OHQC Attributes of Quality &
High Performing Health System
•   Effective         • Population health
•   Efficient         • Integrated
•   Equitable         • Appropriately resourced
•   Accessible
•   Safe
•   Patient-centred




                                                  2
Are These Quality Attributes What
 Organizations are Judged By?
• Ontario Hospital Accountability Agreements –
  Volume & Financial Indicators:
   – Current ratio & total margin
   – % of full-time nurses
   – Total (inpatient and day surgery) weighted cases
   – Mental health inpatient days
   – rehabilitation inpatient days
   – Complex Continuing Care resource utilization group-weighted
     patient days
   – Ambulatory care visits (outpatient and emergency department)
   – Emergency visits
   – Other volumes (pre-construction operating plans, protected
     services, critical care)


                                                                    3
Are These Quality Attributes What
 Organizations are Judged By?
• Ontario Hospital Accountability Agreements –
  Monitoring or Developmental Indicators

   – Readmissions to own facility for specified case mix groups
   – Percentage of chronic continuing care patients with new
     ulcers, in restraints, chronic pain, worsening incontinence
   – ED Length of stay by CTAS level
   – Various stroke-related indicators




                                                                   4
       Classic Problems with
      Quality Focus for Leaders
• Board attention to financials vs quality – what is the right
  balance?
• Focus on quantity vs quality
• Challenges in measuring quality
   – Pick narrow slices instead of big picture
   – Validity issues
   – What’s a meaningful target
• Accountability – what happens if miss target?




                                                                 5
How Do We Move from
     Quantity…




                      6
To Quality?




              7
“The currency of leadership is
          attention.”

           Heifetz

                                 8
How Much Time Does the Board
     Spend on Quality?
• Quality focused boards – at least 25% of time on
  quality
• Try Board Agenda audits:
   ITEM              Time spent     % on Q    Q time
   – A-budget 1 hr          0       0%        0
   – B-                     2 hrs   50%       1 hr
   – C-diff                 1 hr    100%      1 hr




                                                       9
       What’s the Board’s
  Definable Vision for Quality?
• Cocktail party test: will people immediately know what
  benefit it will have to them?

• Is it definable, measurable, with a time target for
  completion?

• Does the goal “roll off the tongues” of staff throughout
  the organization?




                                                             10
Definable Visions




         Alcoa
     (Worker Deaths)




                       11
                  Targets
“We’ll increase FOBT rate to 90%ile for Ontario”




                                                   12
                 Target Setting


• Is your thinking:
   – … let’s aim to meet the provincial average?
   or
   – How many defects in what we do can we drive out?
• Consider best ever practice by leading site / institution
  anywhere
• Think beyond “best region in province” stats
• Think of eventual zero defect goal
• Consider decreasing defects by ½ on each QI project
  iteration

                                                              13
    Examples of UK – NHS Goals
• 4 hr maximum ED wait from arrival to admission,
  transfer or discharge.
• Appt with GP within 48 hrs, other primary care
  professional within 24 hrs
• All ambulance trusts to respond to 75% of Category A
  calls within 8 minutes
• 2 wk maximum wait from urgent GP referral to first
  cancer specialist visit
• 3 month maximum wait for revascularisation

  (Time frames from 2004 to March 2005)


                                                         14
   Cynical About
Leadership’s Targets?




                        15
    Typical Cautions About Targets
• Clear strategy to achieve it?
• Fear of setting unrealistic expectations?
• Is it leadership’s vision alone?
• What if factors beyond our control make us miss
  target?
• Create worse cynicism if target missed?
• Unintended consequences of reaching for target?




                                                    16
               Web Discussion

• What is the # 1 “definable vision” for your organization
  (hard target & deadline)?




                                                             17
               Web Discussion

• What is the # 1 “definable vision” for your organization
  (hard target & deadline)?



• Would a random patient / client reading it know exactly
  what benefit the vision would have for him/her?

• Would a random employee exiting your doors know
  about it?



                                                             18
Aim for Strategic Alignment of
          Indicators
• Are your organization’s targets & measures aligned
  with:
   –   Public reporting
   –   Accountability agreements
   –   Accreditation
   –   Major national / provincial QI initiatives




                                                       19
    Lead With
     Quality
    Dashboard

•   Balance quality across different dimensions
•   Balance between quality & financial indicators
•   Focus on big dot indicators at Board level
•   Quality committee of Boards for more detail




                                                     20
                Big Dot Indicators
• BIG DOTS help a board summarize overall quality into
  a single, or small set of indicators
• Important way of managing information overload /
  indicator-itis
• Do your measures adequately capture overall patient
  quality?
      •   Safe
      •   Accessible
      •   Effective (right drugs, tmts, tests, monitoring)
      •   Patient-centred
      •   Efficient (no waste)
      •   Equitable



                                                             21
         Comparison Dashboard
• Examine key indicators compared to other peer
  organizations

• Often reported as rates, case-mix adjusted

• Useful for general priority setting
   – E.g. annual refresh of operating plan




                                                  22
       Improvement Dashboard

• Focus on small # of key aims
• Remove the denominator – track counts - focus on
  harm
• Plot with annotated run chart
• Put a story to the data




                                                     23
      What’s Easier to Understand?

Indicator                    FY2009,   Prov   Target % chg f
                             Q2        Avg           last
                                                     quarter

MRSA rate per 1000 bed       0.8       0.9    0.8    0%
day

C. Difficile rate per 1000   1.19      1.10   1.10   -2%
bed day



                             24
                        # of new hospital acquired infections

                   12




                   10




                   8
# new infections




                   6




                   4

                                                              Ta rge t by De c 09




                   2




                   0
                        Jan    Feb     Mar             A pr     May                 Jun

                                              M onth



                                             25
Alice B., 73 yrs           Ron T., 77 yrs
Stage IV ulcer            Catheter infxn            John M, 68 yrs
                                                     Post-op infxn


    Jan B., 22 yrs                Art B., 83 yrs

   Post-C-section                 Insulin wrong
        infxn                         dose


                                                   Mamie S., 67 yrs
                     Anna B., 76 yrs
                                                      C. difficile
                     Fall in ED, # hip




                                                                      26
  Putting Human Face to Data
         for the Board
• Critical to building will for change
• Respond to people, not just statistics
• Can illustrate key system problems




                                           27
               Pressure Ulcers

• Ms. Etta J. is a 74 yr old woman admitted from home for
  worsening CHF, past stroke and early dementia. She had 4
  admissions to hospital in past 6 weeks. On last admission
  family and home care agreed that she needs placement.
  After 15 days in hospital her doctor declared her to be ALC
  status. At day 22 she developed a large stage IV pressure
  ulcer. The ulcer has been causing her enormous pain
  which has been difficult to control. Her pain medications
  now make her more confused and disrupt bowel habits.
  The family is extremely upset with the hospital at how this
  ulcer could have arisen in the first place.



                                                                28
29
Emerging Ideas for Big Dots for
      Safety & Quality
• Total harm in hospital (#, or % of people harmed)
   – All nosocomial infections
      • C Diff, MRSA, Central line infection, vent assoc’d
         pneumonia, surgical site infection, catheter infxn
   – Falls, new pressure ulcers
   – Med errors, Missed diagnoses
• Mortality (HSMR +/- palliative, or raw counts)
• # / % of people dissatisfied or not received all desired
  elements of experience




                                                              30
Emerging Ideas for Big Dots for
      Safety & Quality
• % of pts getting evidence-based care
   – ACEI/AARB, statin for DM/CAD, b-blkr for CAD, ASA for
     stroke, coumadin for a-fib, door-needle time for stroke, door-
     balloon time for AMI
• % of pts served within target wait time
   – Aggregate across multiple services & urgency categories
• Global functional decline
   – ADLs, cognition score, mood, continence
   – Esp in home care, LTC users of MDS-RAI




                                                                      31
         Internal Accountabilities

•   What is the CEO held accountable for?
•   Consequences for missing quality targets?
•   Interest in CEO remuneration tied to quality in USA
•   How accountable are you to community? Public
    reporting of your performance?




                                                          32
              Chain of Accountability
                            Pt Experience




     Call button                     Smooth     Pain control   Courtesy /
     response        Food           Discharge                   Respect



•   What “drives” the big dot?
•   Who is responsible for improving each driver?
•   What targets need to be set for drivers?
•   What change ideas will you try for each driver?
•   What resources are dedicated by leadership for each driver?


                                                                            33
    Is There “Clear Line of Sight” from
      Boardroom to the Shop Floor?




“We need to increase
% of our patients
                                                   “Radiology will implement
served within target   “We’ll push to drop wait
from 55% to 80% in                                 advanced access
                       times by 20% in ED, 30%     scheduling & test ways to
next 18 months”        in surgery, 50% in          discourage inappropriate
                       diagnostic imaging. We’ll   referrals. Target: go from
                       make sure QI teams get      50% to 75% served within
                       protected time and skills   target time.”
                       training to do it.”



                                                                                34
         QI Skills Development
• Core skills needed throughout workforce



                         Act     Plan


                         Study   Do




                                            35
What Type of QI Capacity Do You
             Have?
• # of experts in QI science
   –   IHI improvement advisor
   –   ASQ or NAHQ certified QI professional
   –   LEAN experts
   –   6 sigma green & black belts
• # of physician champions
• General knowledge of QI throughout workforce




                                                 36
  Future OHQC Partnership in QI
         with LTC Sector
Advancing Quality in Ontario’s Long-term Care Homes
   “Residents First”
• 100 homes (1/6th) in coming year
• Pressure ulcers, falls, incontinence, ED visit
  avoidance, resident experience
• QI team skills development, learning collaboratives,
  improvement facilitators and concurrent leadership
  development stream
• Aligned with public reporting activities & LSAA
• HNHB LHIN one of four early adopter regions


                                                         37
                     Key Points
• Need to focus on quality – not just financials or quantity

• Identify key big dots for quality
   – Aligned with accreditation, QI campaigns, public reporting

• Definable vision – stretch goals – known to all

• Comparison & improvement dashboards – run charts

• Get the QI skills to drive change in your organization



                                                                  38
                   Contact Us

• Email: ben.chan@ohqc.ca

• Website: www.ohqc.ca
  – Download 2009 Report
  – Free quality improvement tools & resources




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