The Model for Improvement - PowerPoint

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					 Creating the Results That
Dashboards, Portfolio Management
         and Execution
      SPSP Networking Event
      Leadership Workstream
         27 August, 2008
Dashboards are a tool for
 improving quality, not
Combining Indicators
  into a Dashboard
                       Instrument Panel
                     or Dashboard Image
        Decision making . . . Dynamic . . . Empowered
• Who uses them?                          Cockpit crew (pilot,
                                          copilot, navigator)
• Who interprets?                         Cockpit crew
• Focus?                                  Present and future
• Utility?                                Real-time monitoring,
                                          predicting the future and
                                          taking action

Adapted from “Report Cards or Instrument Panels: Who Needs What?”
By Eugene Nelson, et al, Journal of Quality Improvement
volume 21, number 4, April, 1995.
        The Instrument Panel or
         Dashboard Metaphor
• Entirely different than report card

• Connotes vitality, timeliness, and clear-cut utility

• Key feature is providing critical, real-time
  information to the user

• Prompts wise decisions and, if needs be, rapid
  midcourse corrections
What Are the Benefits of Developing and
  Using a Dashboard of Indicators?

•   It brings together, in a single management
    report, many of the seemingly disparate
    elements of an organisation’s strategic
•   It helps to reduce information overload, by
    focusing on the “vital few” indicators.
•   It helps to guard against sub-optimisation
    by forcing senior managers to consider all
    the important measures together.
      How Many Measures
Do You Need on Your Dashboard?
      Focus on the Vital Few!

There are many things in life that are interesting
 to know. It is far more important, however, to
work on those things that are essential to quality
 than to spend time working on what is merely

 The challenge, therefore, is to be disciplined
 enough to focus on the essential (or vital few)
things and set aside those things that might be
             interesting but trivial!
Building a

System of
Driving to System Level
Changes: The Portfolio
  A Very Large System Problem

           Medication Safety

Harm from medications alone occurs in over
  25% of all hospitalised patients. Harm to
   outpatients appears to be much higher.
                    Example: Board
                   Medication Safety
                                                               Tier 1:
         Board Medication Safety
                                                              Big Dot

     Hospitals          Rehab            Offices
                                                               Tier 2:

    Med.                                     Patient
                   Self med                 Capability
reconciliation                 Family                          Tier 3:
                                    Correct list
                 Example: Hospital
                 Medication Safety
                                                               Tier 1:
    Hospital Medication Safety
                                                              Big Dot

    Med Surg             ITU              Pharm.
                                                               Tier 2:

    Med.                                       Admix
                 Anti coag.
reconciliation                 Glycemic                        Tier 3:
                                control                       Projects
      IV pumps                         Standardised
                 Example: Service Line
                   Medication Safety
                                            Tier 1:
    Hospital Medication Safety
                                           Big Dot

   Gen Ward 1        Gen Ward   Gen Ward
                        2          3
                                            Tier 2:

reconciliation                              Tier 3:
      IV pumps
A “Project”…

 Source: J. Reinertsen, 2005
Moving a Big Dot!
 6 June, 1944

   Source: J. Reinertsen, 2005
  What is the Difference?

A Project                                 Moving a Big Dot!
            Source: J. Reinertsen, 2005
    The Differences Are….

• Level of ambition
• Commitment: hearts pounding
• Core strategy: staying alive
• Clear measure of daily success:
• Clear overarching goal: Berlin
• People are shooting live ammo!
• “Will, Ideas and Execution”!
Leading the Whole System to Provide
Highly Efficient and Effective Results

                        The Ground Level
                          View (Staff)

 The Big Picture View
             Tier 3:

• Team organisation and capacity matter

• Front-line leadership is critical

• Measures tracked over time and visible

• Senior leaders remove obstacles

• Clear changes important

• Ability to run PDSA cycles
           Tier 2:
• Middle Management key

• What are the “drivers” of the outcomes we want?

• Outcomes tracked over time

• “Connecting the Dots” – Putting the learning

• Continual readjustment of portfolio

• Strong linkage to finance
            Tier 1:
           Big Dot     Issues
• Aims of strategic importance to the system as a whole

• “Big Dot” measure of progress

• Executive, Board and Senior Leader engagement

• Vision and the associated structural changes

• Strong linkage to finance

• Managing the learning, the politics, and the risks
  How Will You Know if …
You are Winning or Losing the
     War or the Battle?

      How Will You Know if …
 All of Your Efforts to Improve
 Quality and Value are Working?
            What Are We Measuring?
IOM Dimension                 Whole System Measures
Safe              • Adverse events
                  • Work days lost
Effective         • Hospital standardised mortality ratio (HSMR)
                  • Unadjusted (raw) mortality
                  • Functional outcomes
                  • Readmission percentage
Patient-Centered • Patient satisfaction
Timely            • 3rd next appointment available
Efficient         • Patient days during the last 6 months of life
                  • Costs per capita
Start to Think About Moving Beyond
          Process Measures
Process Measures               Whole System Outcome
   – AMI care                   Measures
      Time to stent             – Hospital mortality rate
      Beta Blockers on          – Adverse event rate
        arrival                  – Days lost to work
   – Pneumonia care
      Antibiotic timing
   – Immunisation rates
      Influenza vaccination
   – Medication reconciliation

What would a portfolio of projects
look like for safety?

1.   Patient experience
2.   Mortality
3.   Safety/Harm
4.   Timeliness
An Example: Reduce Mortality
                        Tier 1:
  Mortality Reduction
                        Big Dot

                         Tier 2:

                         Tier 3:
Depicting Data to
  Drive Action
                                                      FY 2007 CCHMC QUARTERLY SCORECARD
                                                                                  (Next Update Due 1/31/2006)

HEALTH CARE DELIVERY                                                                                    Goals          FY 2007 Q1   FY 2007 Q2   FY 2007 Q3
                                                                                                FY 07       Term

                                         Indicator                                              Goal        Goal
Wait for 3rd next available appointment for new visits: % divisions <= 10 days (31
divisions currently measured)                                                                    60%        100%          52%
Percent of Patients Delayed (Includes the ED, PICU and PACU)                                    34%            20%       71%
Patient Safety
Adverse drug events (ADE) per 1000 doses - Overall                                                2             1        3.6
Adverse drug events (ADE) per 1000 doses - Preventable                                          0.50            0        0.3
Ventilator Acquired Pneumonia per 1000 ventilator days                                          0.25            0        0.8
Bloodstream infections per 1000 catheter days                                                   0.80            0        1.4
Surgical Site infections per 100 procedure days
(Inpatients only. Includes Class I and Class II infections)
                                                                                                0.50            0        0.5
Clinical Excellence
Codes outside the ICU: Rate per 1000 patient days - Overall                                     0.10           0.10      0.10
Codes outside the ICU: Rate per 1000 patient days - MRT Preventable                               0             0        0.05
Standardized PICU Mortality Ratio
(# actual patient deaths / # of expected deaths.)
                                                                                                0.80           0.80      0.57
Percent of Eligible Patients Receiving Evidence Based Care
(Includes Inpatient and Emergency Department)                                            
                                                                                                 95%        100%          92%
Family Centered Care
Overall Satisfaction Rating: Percent Giving CCHMC a Rating of 10 to a Single Overall
Question (Includes Inpatient, Outpatient, ED, Urgent Care and Home Health Care)      
                                                                                                 60%            80%       59%
Overall Satisfaction Rating: Percent Giving CCHMC a Rating of 0 - 6 to a Single
Overall Question (Includes Inpatient, Outpatient, ED, Urgent Care and Home Health        
                                                                                                  3%            0%       3.5%
Care) Well Being
Turnover Rate (Nursing Only)                                                                    TBD            TBD      14.6%
Accident Rate with Lost Workdays per 100 Employees                                              0.25           0.15      0.05
Staff Satisfaction--TBD                                                                         TBD            TBD       TBD
Reduce Hassles
Touch Time (% time nurse in patient or procedure rooms)                                         TBD            TBD      26.7%
Risk Adjusted Cost per Discharge                                                                  1%
(Inflation adjusted to current quarter dollars. Data are lagged by one quarter)           Decrease
                                                                                                $86,195         TBD    $ 103,479
Last Updated 11/2/2006 by J. LaBare, Division of Health Policy & Clinical
                      Learn from Other Industries
          Technical and       Ambulatory                                                                  Nursing and
          Trade Schools       Health Services         Manufacturing   Hospitals     Construction         Residential Care

          0.1   0.2                                                     1.9                                     2.9
      0               0.4         0.8           1.2           1.6             2.0       2.4        2.6                3.0

                       Cases with Days Away from Work per 100 Full-time Employees per Year

 The incidence rate represents the number of injuries and illnesses per 100
 full-time workers and is calculated as: (N/EH) x 200,000 where:
         • N = number of injuries and illnesses
         • EH = total hours worked by all employees during the calendar year
         • 200,000 = base for 100 equivalent workers (working 40 hours per
         week, 50 weeks per year)

Source: Bureau of Labor Statistics
      Top Leaders Need to be Able to
          Answer Big Questions
• Is access to care getting better?
   – How fast can patients see a doctor?

• Is quality getting better?
   – How does our quality compare to best?

• Is safety getting better?                            Some
   – How do we compare to best?                       “Big Dot”
• Is the value of care getting better?                questions
   – How do our costs compare to best?

• For chronic care patients, are we providing better care at
  lower costs?
        Resources & References

1.   Kaplan, Norton. “The balanced scorecard: translating strategy into
     action.” Harvard Business School Press, 1996.
2.   Lloyd, Quality Health Care: A Guide to Developing and Using
     Indicators. Jones and Bartlett Publishers, 2004.
3.   Lloyd, Martin, Nelson. IHI Whole System Measures Toolkit, Version
     2.0, IHI Boston, 2006.
4.   Nelson, Batalden, Ryer. The clinical improvement action guide.
     JCAHO Press, 1998.
5.   Nelson, Mohr, Batalden, Plume: “Improving Health Care, Part 1: The
     Clinical Value Compass.” The Joint Commission Journal on Quality
     Improvement, 22(4):243-258, April 1996.
6.   Few, Stephen: Information Dashboard Design, the Effective Visual
     Communication of Data. O’Reilly Media Inc. Publishers, 2006.