Upload
vijaybijaj
View
1.427
Download
1
Tags:
Embed Size (px)
Citation preview
Kaiser Permanente’s Large Scale Implementation of Performance Improvement
Lisa Schilling, RN MPH, VP, Healthcare Performance Improvement
WCBF Lean Six Sigma and PI in Healthcare Summit
New Orleans, LA
May 12, 2011
2
Top
dow
n
Red
uce
varia
tion
Learning system
• Economic and social context for change
• Models of workplace learning
• Team performance
• Define organizational needs • Create system view• Plan/ manage improvement
• Align with strategy • ID drivers and portfolios • Build capability to improve
• Engaging the hearts and minds of the front line
• Creating “line of sight” to strategic goals
• Define high performing unit-based teams
Bottom
up
Learning and improvem
ent
High Performing Organizations Build Culture and Capability
Principles What we “do”
© Kaiser Permanente 2010 reproduce by permission only
3
Big Aim
We will be recognized by our members, payers, and employees as the safest, most effective and personal health care delivery system in the country.
Strategy
Dashboard
Targets
© Kaiser Permanente 2010 reproduce by permission only
From Strategy to Execution
4
5
HOW: Mortality & Inpatient Effectiveness Driver
© Kaiser Permanente 2010 reproduce by permission only
6
Quality Goals Timeline – 2011 – 2013
Domain 2011 2012 2013
Population HealthSelf perceived health status data
for 15% of membersSelf perceived health status data
for 20% of membersSelf perceived health status data
for 25% of members
Population Care Management - Chronic Conditions
Medicare Stars Part C 4 StarsHEDIS composite at 90th percentile
All CV, diabetes, and cancer screening metrics at 90th percentile
Behaviorial Health, Musculoskeletal 90%Medication Management 75%
Medicare Stars Part C 4 StarsAll CV, diabetes, and cancer screening
metrics at 90th percentileBehaviorial Health, Musculoskeletal and
respiratory @ 90%Medication Management 75%
Medicare Stars Part C 4 StarsAll CV, diabetes, and cancer screening
metrics at 90th percentileBehaviorial Health, Musculoskeletal and
respiratory @ 90%Medication Management 90%
Inpatient HSMR TJC Composite
Reduce HSMR: Below US Medicare average, crude mortality 10% from 2010
baselineTJC Composite at national 90th percentile
Readmit rate<15% of all cause readmissions
Reduce HSMR: Below US MedicareTBD - May shift to inpatient outcomes
Readmit rate<10% of all cause readmissions
TJC Composite at national 90th percentile
Reduce HSMR: Below US MedicareTJC Composite at national 90th percentile
Patient Safety Never Events
10% less events than 2010 10% less events than 2011 10% less events than 2012
Workplace Safety Per regional targets Per regional targets Per regional targets
Clinical RiskManagement
0 to 5% reduction in lawsuits with a payout from 2010
0 to 5% reduction in lawsuits with a payout from 2011
0 to 5% reduction in lawsuits with a payout from 2012
Service Hospital
Outpatient
HealthPlan
Medicare Stars
At National 75th percentile (final quarter)
75th percentile in local or national in 3 of 8 regions
75th percentile in local or national in 6 of 8 regions
4 Stars on Overall CAHPS
At national 75th percentile (rolling 12 months)
75th percentile in local or national in 5 of 8 regions
75th percentile in local or national 7 of 8 regions
4+ Stars on Overall CAHPS
Above National 75th percentile (rolling 12 months)
8 of 8 Regions at goal
8 of 8 regions at goal
4+ Stars on Overall CAHPS
Equitable CareIdentify interventions to
reduce the gapDecrease the gap by x%
Decrease by x% more over 2012
© Kaiser Permanente 2010 reproduce by permission only
7
Aligning Strategy: Data to Monitor Variation
Range 85% - 95%
Range 94% - 98%
The Joint Commission Index Across Hospitals: Demonstrated Progress in Reducing Variation
8
Our system is based on the attributes of high performing organizations
Best qualityBest service
Most affordableBest place to
work
KP needs to build capability in these six areas in order to achieve breakthrough performance
© Kaiser Permanente 2010 reproduce by permission only
9
Kaiser Permanente’s Performance Improvement System
AIM: Assist regions and facilities in developing, testing and implementing a
KP-wide performance improvement system that builds the capacity to
execute on high priority initiatives in each KP region by 2010.
© Kaiser Permanente 2010 reproduce by permission only
10
page 10
Achieve Breakthrough goals
Manage Local Improvement
Develop Human Resources
Spread and sustainProvide Leadership forLarge system Projects
Provide Day-to-DayLeaders for Micro Systems
Reduce HSMR and Achieve 90th National
Percentile on Joint Commission Index
No Needless Harm
Appropriate Care Setting
Preventable Complications
Preventable Deterioration
Preventable Harm Events
Big Q Targets Primary Drivers Secondary Drivers
Capacity in Alternative Setting
Primary Care Plan-End of Life
Population Based Programs
Trigger Tools (IHI)
Infection Reduction
SCIP (TJC)
Rapid Response
Teams (5 mil)
Escobar Predictive Modeling
(KP)
AMI Bundle (5 mil, TJC)
CHF Bundle(5 mil, TJC)
Pneumonia (TJC)
Medication Reconciliation (5 mil, TJC)
Never Events
Pressure Ulcers (5 mil)
High Alert Meds(5 mil)
Evidence-Based Population Care
Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training
Region/Service Area/Local•Mission critical, high priority initiatives
Expert
Expert
Facility
TPL
TPL
TPL
TPL
TPL
TPL
Ops improvementresource
Expert
Expert
Experts
OperationalLeaders
(Executives)
ChangeAgents
(Middle Managers, Stewards, project leads)
Everyone
(Staff, Supervisors,
UBT lead triad)
Unit Based Teams
SharedKnowledge Continuum of PI Knowledge and Skills
Deep Knowledge
Many People Few People
Quality Goals TimelineDomain 2008 2009 2010
Reduce HSMR X%Reduce HSMR X%Reduce HSMR X%
National 90th percentileThree-quarters of way
between national average and 90th percentile
90th percentile
No Measure less than 75th Percentile
90th percentile
No Measure less than 75th
Percentile
90th percentile
No Measure less than 75th
Percentile
Ambulatory CareHEDIS
ZeroZeroZeroSafety (Never Events)
5% reduction in claims from 2009
5% reduction in claims from 20085% reduction in claims from
2007Clinical Risk Management
TBDLong term goal under development
Proposed: At or above 75% local or National MarketService
TBDTBDTBDResource Stewardship
TBDTBDN/AEquitable Care
Halfway between national average and 90th percentile
InpatientMortality Ratio
TJC Composite Index
1
DRAFT
Execution in KP’s System
Source: IHI 2008
© Kaiser Permanente 2010 reproduce by permission only
11
Lets look at the far left side: Manage local improvement
Moving from a project by project mentality to looking at system level improvement (end to end process with sequencing)
Creating clear lines of accountability and oversight Insure the right portfolio of initiatives to assure ourselves that we are doing enough to move the Big Dot
Reduce HSMR and Achieve 90th National
Percentile on Joint Commission Index
No Needless Harm
Appropriate Care Setting
Preventable Complications
Preventable Deterioration
Preventable Harm Events
Big Q Targets Primary Drivers Secondary Drivers
Capacity in Alternative Setting
Primary Care Plan-End of Life
Population Based Programs
Trigger Tools (IHI)
Infection Reduction
SCIP (TJC)
Rapid Response
Teams (5 mil)
Escobar Predictive Modeling
(KP)
AMI Bundle (5 mil, TJC)
CHF Bundle(5 mil, TJC)
Pneumonia (TJC)
Medication Reconciliation (5 mil, TJC)
Never Events
Pressure Ulcers (5 mil)
High Alert Meds(5 mil)
Evidence-Based Population Care
Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training
Region/Service Area/Local•Mission critical, high priority initiatives
Expert
Expert
Facility
TPL
TPL
TPL
TPL
TPL
TPL
Ops improvementresource
Expert
Expert
© Kaiser Permanente 2010 reproduce by permission only
12
Building Improvement Capability
13
We can build our capacity to improve by developing our skills
Delivering Improvement Advisor through front line skills development program focused on 4 audiences
Using common language for the organization based on MFI, Lean, six sigma
Aligning executive through front line capability by matching infrastructure with new skills
Experts
OperationalLeaders
(Executives)
ChangeAgents
(Middle Managers, Stewards, project leads)
Everyone
(Staff, Supervisors,
UBT lead triad)
Unit Based Teams
SharedKnowledge Continuum of PI Knowledge and Skills
Deep Knowledge
Many People Few People
page 6
Achieve Breakthroughgoals
Manage Local Improvement
Develop Human Resources
Spread and sustainProvide Leadership forLarge system Projects
Provide Day-to-DayLeaders for Micro Systems
Source: API 2006
© Kaiser Permanente 2010 reproduce by permission only
14
Experts Operational
Leaders (Executives)
ChangeAgents
(Middle Managers, Stewards,
project leads)
Everyone
(Staff, Supervisors,
UBT lead triad)
Continuum of PI Knowledge and Skills
Deep Knowledge
Many People Few People
Our approach will be to make sure that each group receives the knowledge and skill sets they need
when they need them and in the
appropriate amounts.
A key operating assumption of
building capacity is that different groups of people will have different levels of
need for PI knowledge and skill.
Content: What Skills Do We Need?
SharedKnowledge
© Kaiser Permanente 2010 reproduce by permission only
15
On-boarding
Dev
elo
p a
nd
Tes
t th
e
Sys
tem
at
a
Fac
ilit
y le
vel
Developing deeper capability to achieve big results over time
Exp
and
Im
pro
vem
ent
sys
tem
to
all
fa
cili
ties
Dee
pen
im
pro
vem
ent
kno
wle
dg
e w
ith
in f
acil
itie
s
September 2008 June 2009 2010 & 2011
Wave 2
Waves of Improvement Institute
Learning and sharing systems regionally and program-wide Improvement Institute
Wave 3Wave 4 & beyond
Implementation ExpansionContinuous
ImprovementComplete
We are here
Level of Project
Difficulty
• All Regions• 500 IA’s• 15 internal faculty
Mentors• 3,000+ Operations
Managers• 20,000+ Front line staff• IHI Forum and courses
• 7 regions• 300 Improvement
Advisors • 35 UBTC’s• 1,250 Operations
managers• 8,000 Front line staff• IHI Forum and courses
• 5 regions• 65 Improvement Advisors• 300 operations managers• 3,500 Front line staff• IHI Forum
© Kaiser Permanente 2010 reproduce by permission only
16
17
KP’s Improvement Model has Four Phases
•Process map•Baseline data•Charter project•Create portfolio•Data collectionplan
•Training•Policy & procedures•Feedback loops•Error proofing•Control charts•Spread plan
•Standardize and simplify•Reduce waste•6S•Reduce defects•Apply evidence-based practices
AssessDevelop/ Identify Change
Test Implement/Control
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in improvement?
Source: API© 2006
18
Case Study: Improving CHF Readmission Rates
Problem statement:
CHF 30 day readmission rates at 16% want to decrease as much as possible while improving health outcomes
Where would you start? What would you measure? Whom would you involve?
19
Where we started
20
Where? KP-SCAL w/CMI
How? •Coordinated concurrent medication reconciliation by Home Health RN, PharmD, and Patient in the patients home.
•Improved identification of Heart Failure patients in the Hospital
•Increased reliability of Home Health visit within 48 hours
•Increased reliability of Out-patient Heart Failure Clinic follow up in one week
•Implemented readmission diagnostic tool to identify system gaps
Results •Reduced 30-day re-hospitalization rate to 9% (and 90 day readmission to 20%).•Improved the reliability of the Transitions Care Program component bundle measures from 61%-95%•$ value estimated at $1,800,000
Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08
Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08
Case Study: Readmission Reduction CHF
At South Bay, it takes a village to manage our heart failure patients, with the help of our local, regional and national leadership teams and the strength of our administrative infrastructure, we have been able to make an improvement with 3 key components: real time medication reconciliation at the home health visit, home health visits in a timely manner and the use of the diagnostic readmission tool. Joan Fredella, Pharm. D., Clinical Pharmacist
30 Day readmission rates-HF reason
(12 month roll up)
1.0
3.0
5.0
7.0
9.0
Sept Oct Nov Dec Jan Feb Mar April
SCAL Regional SouthBay
SBAY 30 day HF readmission rates declining!Pre Work
StartedPDSA cycles
started
BEST inRegion!
% p
ts.
Rea
dm
itte
d f
or
HF
in 3
0 d
ays
TCP Pilot Started
PharmacistRole restructuredTo focus on HF
Gap AnalysisComplete
RIMPre-workstarted
•Kick Off Mtg•PDSAs Started:
1. ConcurrentMed Rev
2. Pt ID/HH ref.
ReliableDesignWkshopPt. ID
21
How we know we are better: Organizational Capability Tool
Performance Improvement Initiative Assessment Score Card
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Leadership
Learning
Systems & Process
Measurement
Capacity & Sustainment
Culture & Communication
Results Performance Goal
0.0
1.0
2.0
3.0
4.0
5.0
Leadership
Learning
Systems & Process
Measurement
Capacity & Sustainment
Culture & Communication
2009Q4 Target
January 2008 December 2009
Regions and Medical Centers are more capable of achieving better performance
© Kaiser Permanente 2010 reproduce by permission only
22
“The future of healthcare is ours to imagine.”
-Institute for Healthcare Improvement
Change your thoughts and you change your world.
-Peale