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Leadership “Machinery”for Transitions-in-Care
at Penn Medicine
University of Pennsylvania Health SystemJune 23, 2010
Lind
American Hospital Association/ Health ForumLeadership Summit
July 22-24, 2010; San Diego, CA
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Who we are
PJ Brennan, MDChief Medical Officer & Senior Vice PresidentUniversity of Pennsylvania Health System
Victoria Rich, PhD, FAAN, RNChief Nursing Executive, University of Pennsylvania Medical CenterAssociate Professor, University of Pennsylvania School of Nursing
Joan Doyle, MBA, MSN, RNExecutive Director, Penn Home Care and Hospice ServicesUniversity of Pennsylvania Health SystemAssistant Dean for Clinical Practice, University of Pennsylvania School of Nursing
Linda May, PhDPrincipalCFAR
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Penn Medicine — Philadelphia, PA
Hospital of the University of Pennsylvania #8 US News & World Report/ Magnet
Pennsylvania Hospital
Penn Presbyterian Medical Center
Home Care & Hospice Services
Good Shepherd Penn Partners
University of PennsylvaniaMedical School
University of PennsylvaniaHealth System
Adult admissions — 77,500
Employees — 12,700
#2 NIH ranking
Faculty — 1,347
Med students — 741
Grad students — 1,079
Residents/ Fellows — 978
Admissions — 18,000Employees — 450
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Transitions in Care — What is UPHS trying toaccomplish?
Hospital StayPreadmission Post-acute CareAdmission Discharge Medical
“Landing”
We’re focused, for now, on the transitionsin and out of the hospital.
Staying out of the hospital or the ED Connecting to a primary care physician Having the right pharmaceuticals Knowing what to do after discharge
From the patient’s perspective, this means:
The aim is to keep patients safe and stableand give them a safe medical “landing.”
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We’ve developed a Transitions model for UPHS —with seven “levers” that make the biggest difference
Educa-tion &red flagmgmt
Links topost-acutefollow-upservices
Primarycarefollowup
Real-timereadmis-sionsfeedbacktoactivelymanagepatients
Screenforpatientsatgreatestrisk
Medmgmtacrossthecontin-uum
UPHS Transitions Model — Seven “Levers”
Interdis-ciplinarycareplanning
But …It’s the leadership“machinery” thatmakes the modelwork.
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Today’s story about leadership machineryhas three parts
The story ofthe CMO/CNOAlliance
The story oflocalleadership
“Acting yourway to newthinking”
The story ofthe TransitionsSteering Group
“Speaking with aunited clinicalvoice”
“Mobilizing otherpeople’senergies —and keeping themoving partsaligned”
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3
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Speaking with a unitedclinical voice1
The story ofthe CMO/CNOAlliance
“Speaking witha unitedclinical voice”
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The CMO/CNO Alliance spans the continuum of care
CMO/CNOAlliance
The CMOs and CNOsbanded together across thecare continuum:
• All three hospitals• Penn’s homecare and hospice
services• Penn’s rehab facilities• Physician practice
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The CMOs and CNOs set clinical direction for UPHS —with Transitions-in-Care as a major element
• Unit clinical leadershipAccountability
• Interdisciplinary roundingCoordination of care
• Reduce hospital-acquiredinfections
• Reduce medication errors
Reduce variations inpractice
• Transition planning
• Medication management
Transitions incare
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to reducemortality and reduce 30-day re-admissions.
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To bring clinical strategy to the frontline, we established“local leadership” on each hospital unit (more on this later)
Physician Leader andNurse Leader are paired atthe hospital unit level — with aProject Manager for Qualitywho brings data and projectmanagement skills.
We call these trios “UBCLs,”for “Unit Based Clinical Leadership.”
Three-Way Partnership Manages Qualityon the Hospital Units
Unit clinical leadershipAccountability
Interdisciplinary roundingCoordination of care
Reduce hospital-acquiredinfections
Reduce medication errors
Reduce unnecessaryvariations in practice
Transition planning Medication management
Transitions in care
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to reduce mortalityand reduce 30-day re-admissions.
1.Post-acute carereferrals
2.Use of hospice3.Med rec on discharge4.Readmission rate for
TCM follow-up program
Transitions in Care — FY’10 Targets
12. Interdisciplinaryrounding
13. Nurse/physiciancollaboration(NDNQI)
14. Patient satisfaction(HCAHPS)
Coordination of Care — FY’10 Targets
5. DVTs & PEs6. BSIs7. Falls with injury8. Pressure ulcers9. VAPs10.SCIP11.UTIs
Reduce Variations in Practice — FY’10 Targets
“Choice within a framework” — we developed targetsand worked with each hospital unit to pick theirs
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Quality outcomes at UPHS are moving in the rightdirection
MORTALITY
REFERRALSTO POST-ACUTE CARE
INFECTIONS
PATIENT& STAFFSATISFACTION
PEERRECOGNITION
LENGTH OF STAY READMISSIONS
P4PIS ONTRACK
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“Focusing attention” — we negotiated a Transitionsmetric in every senior leader’s incentive plan
METRIC: Increase post-discharge referrals tohomecare, hospice, rehab,SNF, infusion, LTAC.
Threshold (3%)
High Performance(10%)
Target (5%)
HP
Hospital 1
Q1 Q2 Q3 Q4
HP
HP
HP HP
Hospital 2
Hospital 3
We picked this metric because itsupports a key element of ourTransitions model — and becausePenn could measure it. We’re setting thestage for a more ambitious“readmissions” metric next year.
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We’re getting out ahead of the budget cycleand negotiating with a united clinical voice
First step — set margins foreach hospital or other entity.Entities are locked in.
Discussion of system-widequality initiatives beforemargins are set.
Entities (separately)submit budgets.
Negotiation — across entitiesand with Finance — occursafter budgets aresubmitted.
CMOs and CNOs submit a jointbudget for system-wide qualityinitiatives they all agreed on.
Negotiation occurs beforebudgets are submitted.
We’re making our job AND theCFO’s job easier.
The old way The new way
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We’re bringing payers to the table
IBC pays Penn to provide the“Transitional Care” (Naylor model)followup program to IBC patients whoare elderly and at risk.
The same advanced practice nursefollows patients before andafter discharge — with assessmentand education about medications,symptom management, and nutrition.The nurse works with other membersof the patient’s healthcare team tocoordinate care.
IBC agreement has beenfinalized. Negotiations withAETNA are underway.
Transitional Care Program Gain-sharing Arrangements
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“Speaking with a united clinical voice” —lessons learned
• One thing led to another. We didn’tstart out with a united voice, but eachexperience showed us a little more aboutwhat joining forces could accomplish.
• “It’s the work, stupid.” To paraphraseJames Carville, we focused on thework.
• The experience of accomplishing realwork turned us into a realleadership team.
A united clinical voice is based on actions, not just words. Theactions create “pull” for speaking with a unitedvoice, which builds over time.
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Mobilizing other people’s energies2
The story ofthe TransitionsSteering Group
“Mobilizing otherpeople’s energies— and keepingthe moving partsaligned”
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The Transitions Steering Group is in theintegration business
TransitionsSteering Group • Sets direction for Transitions-in-Care
• Integrates the moving parts• Opens doors at the system level• Troubleshoots to keep things on track
This multi-disciplinary groupof senior leaders:
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We developed the Transitions model for UPHS —with seven “levers” that make the biggest difference
Educa-tion &red flagmgmt
Links topost-acutefollow-upservices
Primarycarefollowup
Real-timereadmis-sionsfeedbacktoactivelymanagepatients
Screenforpatientsatgreatestrisk
Medmgmtacrossthecontin-uum
UPHS Transitions Model — Seven “Levers”
Interdis-ciplinarycareplanning
In FY10, we focusedon the first four levers
In FY11, we’llconcentrate in additionon the next three
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We’re taking good ideas from elsewhere —AND helping the organization learn from itself
An organization learnsbest when it learnsfrom itself
Pockets of innovation arealready emerging insidealmost every organization —if it knows how to look andlisten
These innovations are thebuilding blocks ofculture change. Yourorganization’s culture is a“renewable resource.”
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Learning from ourselves — three “system-in-the-room”Transitions summits
The summits helpedthe health system …
• Learn from each otherwhat’s already workingat UPHS
• Make commitmentsand momentumtangible
• Create “educatedconsumers” for thechanges to come
Transitions in Care“Pilots” Conference
Transitions in Care“Marketplace”
Transition in Care“Connections”Conference
Three “system-in-the-room”Transitions summitsof 100+ stakeholders each
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We’re mobilizing and shaping “other people’senergies.” Our biggest job is keeping them aligned.
CMO/CNOAlliance acrossthe continuumof care
Unit-basedPharmacists
New HUPTransitionsCollaborative— activeoperational arm
Payers willing tofund follow-upprograms andnegotiate gain-sharingarrangements.
TRANSITIONSIN CARE
for betterpatientoutcomes &reducedreadmissions
Penn MedicineLeadership Forum“action learning”Transitionsprojects
Knowledge BasedCharting is underdevelopmentINTERNAL
EXTERNAL
Bundledpaymentsand ACOsare on thehorizon
Pay-for-performancecontracts
Public reportinginfluencespatient choice
Med Mgmtredesign isfocused onTransitions
CMS reducedpayments forreadmissionsis on thehorizon
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We took advantage of Penn’s flagship leadershipdevelopment program
The purpose of PennMedicine LeadershipForum is to developleadership skills …
… and apply themto a strategicsystem-wideinitiative
Each hospital unit team —with homecare and otherpartners — took up a projectto improve Transitions-in-Care on their unit.
• Innovation
• Strategic orientation
• Execution
• Relationship mgmt
Penn Medicine Leadership Forumis targeted this year to the unit-basedleadership teams — along with homecareand other partners
“Action Learning”
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“Testbeds” — each team tested an aspect of the TransitionsModel. They were all over the place, but look at the energy!
ImproveinternalTransitions
Post-dischargephone calls
Medicationmanagement
Education& red flagmgmt
Links topost-acutefollow-upservices
Primarycarefollowup
Real-timereadmis-sionsfeedback
Screenforpatientsat risk
Med mgmtacross thecontinuum
UPHS Transitions Model — Seven “Levers”
Interdis-ciplinarycareplanning
Patient & familyeducation, withemphasis on selfmanagement
Team-basedDischargePlanners
Screening toolfor post-acutereferrals
New approachesto interdisciplinaryrounding
Real-timereadmissionanalysis andintervention
Discharge“time out”safety check
Follow-upappointmentswith primarycare
House staffawareness ofhomecare &hospice services
Discharge summaryfollows patient topost-acute services
“Opt-out” forhomecarereferral
End-of-lifegoals of care
Transitions Projects for Penn Med Leadership Forum
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Discharge “timeout” safety check(for selected patients)
Hospital StayPreadmission Post-acute Follow-up
Admission Discharge Medical“Landing”
Discharge communication
Risk stratification1
Interdisciplinary rounds
Patient and family education3
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Build eachelement intothe processas far“upstream”as possible— prior toadmissionwhere thatmakes sense.
• Screening tool on admission
• Daily review of real-time readmissions report
• Plan of care looks ahead to post-discharge
• Referral to post-acute care as early as feasible
• Discharge summary to primary careprovider and post-acute services
• Schedule appointment with primary care(selected patients)
• Follow-up phone calls (selected patients)
• Education for post-discharge care andmeds, with emphasis on self management
• Med reconciliation on discharge
To pull it all together, we turned the teams’ work intoan integrated Transitions process for the health system
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Now we’re asking “temporary owners” of each coreelement to figure out the details and carry it forward
TransitionsCollaboratives
Discharge Planners
Workgroup alreadyunderway
Screening tool onadmission
Referral as early asfeasible
Daily review ofrealtime readmissions
The overall Transitionsprocess will build overtime.
Some parts of theprocess will startbefore others.
Not everythingneeds to develop atthe same speed.
“Temporary Owner”to Carry it Forward
Core Element of theTransitions Process
For example …
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“Mobilizing other people’s energies” — lessons learned
• By tapping into other people’senergies and projects, you cancreate results and criticalmass as you go.
• You get change that sticks,because people are creating itthemselves.
• You don’t have to do allthe work yourself.
• Your job is to align what mightotherwise work at cross purposes.
Tapping into other people’s energy and momentumcreates “pull” for the changes you want to make. Otherpeople pull the changes along.
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Local leadership — two casestudies
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The story oflocalleadership
“Acting yourway to newthinking”
Real-time readmissionsfeedback
Unit based clinicalleadership
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Three-way partnership is Penn’s “Swiss Army knife”for managing quality on the hospital units
Three-Way Partnershipon the Hospital Units
This isn’t a project, it’s away of doing things. Youcan bolt differentstrategies onto it.
“
—UPHS CFO ”
We needed amulti-purposesolution on theunits to handlealmost any Qualityproblem.
We call these trios“UBCLs,” for “Unit BasedClinical Leadership.”
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Hospital unit teams take on Transitions —a case study
“Collaborationworks”
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Real-time readmission feedback is at the heartof Penn’s Transitions model
Education& red flagmgmt
Links topost-acutefollow-upservices
Primarycarefollowup
Real-timereadmis-sionsfeedback
Screenforpatientsat risk
Med mgmtacross thecontinuum
UPHS Transitions Model — Seven “Levers”
Interdis-ciplinarycareplanning
Data available intime to takeaction.
Hospital units,discharge planners,and home carework together totroubleshootspecific patientseach day.
Daily Readmissions Report
Readmitted patients (acrossUPHS hospitals), with chief complaint,facility, unit, service, attending.
Detailed history of previousadmissions.
Full report distributed to DischargePlanners, Home Care and others. Hospitalunits see a version with their ownpatients, both “sending” and “receiving.”
UPHS is tracking &trending the data.
Hospital units,discharge plannersand home careare changingclinical practicebased on thefeedback.
Daily Actions Long-termInterventions
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Real-time readmissions feedback — a case study
“Collaborationworks”
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“Act your way to new thinking” — lessons learned
• Collaboration at the local level didn’thappen overnight. One day at a time,we earned new reputations forwhat each other could bring.
• We focused on the work — whichled to new ways of thinking about eachother.
• It’s not just about “educating” eachother. The best way to collaborate wasto work together on a commonproblem — and bring our clinicalexpertise to bear.
Actions create pull for new ways of thinking about each other.It’s easier to “act your way to new thinking” than to thinkyour way to new actions.
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Q&A — We welcome your questions, thoughts,& experiences
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There’s good social sciencebehind what we’re doing4
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It’s not about managing another change project.It’s about changing the way we work.
Early Results thatBuild Momentum —the “Quiet Phase”
SweepingPeople In
Embeddingthe Changes
How do we figureout the changesthat need to happen?
Set a “clear enough”direction?
Do the work thatbuilds momentum?
How do we spreadthe changesacross the system?
Keep things aligned?
Deal with thecomplexity?
How does thisbecome the newnormal?
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Result: Change that sticks and the skills to change again in the future
“Campaign” approach to change
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“Pull” is stronger than “push”
If you create pull,others will do the workof change for you.
New behaviors can’tbe legislated. They begin toshow up when an organizationknows how to create pull forthem.
A Campaign creates“pull” for new behaviors.
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Your organization’s culture is a renewable resource
A useful definition of culture:“The way we do thingsaround here.”
New behaviors are the buildingblocks of an organization’sculture. Each behavior by itselfmay be small, but togetherthey can move theorganization’s culture.
The raw material for aculture change is almostalways already emerging in yourorganization.
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A Campaign is top down AND bottom up
Top down, by itself, lacksthe resilience andcreativity of grass-roots efforts.
Bottom up, by itself, lacksfocus, alignment andthe commitment ofmainstream leaderswho can give resources.
A Campaign taps thecreativity and commitmentof the whole system.
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The leadership skills you’ll need may seemcounterintuitive
Trying to “motivate” or“empower” others
Discovering and freeing upenergy and passion
Pushing people to change Creating pull for the changes
Telling and selling Listening and amplifying
Thinking your way tonew actions
Acting your way tonew thinking
NOT … INSTEAD …
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A few resources — Campaign Approach to Change
Hirschhorn, Larry and Linda May. “The CampaignApproach to Change.” Change, Vol. 32, No. 3,May-June, 2000.
Hirschhorn, Larry, “Campaigning for Change,”Harvard Business Review, July, 2002.
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To be in touch
PJ Brennan, MD
Victoria Rich, PhD, FAAN, RN
Joan Doyle, MBA, MSN, RN
Linda May, PhD
