the more i know, the less i sleep

2© 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

Member of the World Economic Forum Global Agenda Council60 countries, 170+ occasions.


65 senior healthcare leaders from 30 countries

VektisMr. Herman BennemaGeneral Director

Discovery HealthDr Jonny BroombergCEO

All-Party Parliamentary Group on Global HealthLord Nigel CrispCo-Chair

Fundaçâo Antonio PrudenteMr. Irlau Machado FilhoCEO

MonitorDr David BehanCEO

Hospital Sirio LibanesDr. Paulo ChapchapStrategy Director

Médica SurMr. Antonio CrosswellCEO

Institute Gustave RoussyMr. Charles GuepratteDeputy CEO

Institute for HealthcareImprovement (IHI)Ms. Maureen BisognanoPresident and CEO

Karolinska University HospitalDr. Soki ChoiProject Leader of “Nya Karolinska”

Salford Royal Hospitals Foundation TrustSir David Dalton CEO

National VoicesMr Jeremy HughesChair

Swiss Medical GroupMr. Miguel Carlos BlancoCEO

Queensland DoH, Health Services DivisionDr. Michael ClearyDeputy Director-General

West/North West Hospitals GroupMr. Noel DalyChairman

Virginia Mason Medical CentreDr. Andrew JacobsMedical Director

Buurtzorg NetherlandsMr Jos de BlokDirector

South Metropolitan Health ServiceProf. Robyn CollinsAdj. Associate Professor

Alberta Ministry of HealthMs. Janet DavidsonDeputy Minister

Wiener Krankenanstalt-enverbundProf. Dr. med. Udo JanßenCFOHealth and Social

Care Northern IrelandMr. John ComptonCEO

Centers for Medicare & Medicaid Services (CMS)Ms. Julie Boughn, Former Deputy Director, Center for Medicaid and CHIP Services Former CIO

Nuffield TrustMr Nigel EdwardsCEO

Keiju Healthcare SystemsDr. Masahiro KannoCEO

MenzisMr. Roger van BoxtelCEO

Unfallkrankenhaus BerlinProf. Dr. Med. Axel Ekkernkamp, CEO

Royal Liverpool and Broadgreen Uni. Hosp. Mr. Aidan KehoeCEO

Memorial Sloan KetteringDr. Murray BrennanVP, International Programmes

Access Health ConnecticutKevin CounihanCEO

The Society for Family HealthSir Bright Ekweremadu Managing Director

NHS EnglandMr. Tim KelseyNational Director for patients and information


65 senior healthcare leaders from 30 countries

AchmeaMr. Roelof KontermanCEO

United Family HealthcareMs. Roberta LipsonChairwoman

UCL Hospitals NHS FTSir Robert NaylorCEO

The Investment Fund for Healthcare in AfricaMr. Onno SchellekensManaging Director

Faculty Hospital BrnoDr. Roman KrausCEO

NHS Leadership AcademyMs. Karen LynasDeputy Managing Director

Singapore Health ServicesProf. Ivy Ng Group CEO

Apollo HospitalsLt. Gen. Dr. M. SinghDirector Medical Services

Foundation Hospital St JosephMr. Jean-Patrick Lajonchere, CEO

Health and Social Care Board Northern Ireland Pamela McCreedy Director

NHS EnglandSir David NicholsonFormer CEO

KPJ Healthcare BerhadSiti Sa’diah Sheikh BakirCorporate Advisor

Hygeia GroupMs. Fola LaoyeChairwoman

The EconomistMs. Anne McElvoyEditor Department of

HealthMs Una O’BrienPermanent Secretary

St Joseph’s Healthcare, HamiltonDr. Kevin SmithPresident and CEO

Yonsei Univ. Health System - Severance University HospitalDr. Chul LeePresident and CEO

Health Service JournalMr. Alastair McClellanEditor The Royal Marsden

NHS Foundation TrustMs Cally PalmerCEO

Geisinger Health SystemDr. Glenn SteelePresident and CEO

Myong-Ji Hospital M. Wang-Jun LeeCEO and Chairman

EspriaMr. Marco MeerdinkCEO

Narayana HealthDr. Ashutosh RaghuvanshiVice Chair, Group CEO

National VoicesMr. Jeremy TaylorCEO

Peking UniversityProf. Ling LiProfessor

Life Healthcare South AfricaMr. Andre Meyer, CEO

Public Health Foundation of IndiaProf. K. Srinath ReddyPresident

Ministry of HealthProf. Josef VymazalFirst Deputy Minister

Department of Health of the Canton Zurich Mr. Hansjörg Lehmann Head of Health Planning and Control

HumanitasMr. Luciano Ravera CEO

Assuta Medical CentresMr. Pinhas TsruyaCEO

CZMr. Wim van der MeerenCEO

Birmingham University Hospitals NHS FTDame Julie MooreCEO

NSW Ministry of HealthMr. Ken WhelanDeputy Director General


10 characteristics of clinical and operational excellence

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Enduring Values

Shared purpose

Consistent and stable leadership

Deep engagement with clinical staff

Strong focus on front-line

Set culture, hold professionals to account

Align individual, team and organisational objectives

Information transparency – internal and external

Curiosity about high performance

Authentic partnership


In-depth interviews with leading providers and regulators

■ The Mayo Clinic, USA

■ Fortis Hospitals, India

■ Jordan Specialty Hospital

■ Helios Kliniken, Germany

■ Sick Kids, Canada

■ Salford Royal Foundation Trust, UK

...followed by four round-table discussions with more of the world’s leading organisations

■ University Hospital Birmingham, UK

■ King's College Hospital, UK

■ Changi General Hospital, Singapore

■ Intermountain Healthcare, USA

■ The General Medical Council UK

A global perspective on clinical governance – we brought together 43 global healthcare leaders from 12 countries

LausanneBoston

SydneyAmsterdam


A mix of anxiety, curiosity and desire is required to provide great quality care

This work is extremely timely given a number of high-profile failures around the world

It is also necessary – healthcare is still too much like an old-fashioned, individual craft-based system

If the aviation industry adopted the same random quality control systems we simply wouldn’t fly

Regulation is necessary but never sufficient

Global standards for healthcare?

Big data offers new possibilities

We identified the four building blocks of a ‘high-reliability’ organisation:

A culture devoted to quality1

Responsibility and accountability2

Optimising and standardising processes3

Measurement4


■ Methodically measuring care outcomes

■ Understanding the key drivers of these outcomes

■ Understanding how to make these outcomes best in class

■ Systematically preventing avoidable harm to patients

Base error rate of each step

No. of steps

1 0.05 0.01 0.001 0.00015 0.33 0.05 0.005 0.002

25 0.72 0.22 0.02 0.003

50 0.92 0.39 0.05 0.005

100 0.99 0.63 0.1 0.01

“More hand-offs, more errors”

What did our interviewees mean by ‘in control’?

Even at seemingly low error rates per step, processes with multiple steps have unacceptably high error rates.

Source: System changes to improve patient safety, Nolan, T W., British Medical Journal, 320, 771-3, 2000

“Being in control ”“Being in control ”


The journey towards a high-reliability organisation

0 No real Board oversight of quality; outcomes are not uniformly measured; responsibility is poorly-defined

1 Attention to quality is becoming more systemic; progress depends on systems, not individuals; measurement of outcomes is common but not standard

2 Key outcomes routinely reported; blame-free learning approach; a culture intolerant of breaking basic rules; clear individual responsibility & accountability

3 Probably only required in the most high-risk environments: ICU, theatres, A&E

PHASE:


Mary Jo Haddad, Former President and CEO, SickKids Hospital, Toronto

A zero tolerance for complacency is crucial..... We have created an open, transparent, trusting culture, and if something goes

wrong we delve into it, report on it,learn from it, and share these

lessons.

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The four building blocks of a ‘high-reliability’ organisation in practice:


Building block 1: a culture devoted to quality

Continuous measurement and a clear sense of accountability are intrinsic values throughout the organisation

Much of this isn’t very sexy. It is the small stuff that matters the most, and it is sometimes hard to get everyone to focus on that.

Ralf Kuhlen,Chief Medical Officer, Helios Kliniken, Germany

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Leaders may have to confront entrenched attitudes among professionals and question their own assumptions over safety and behaviour

Leadership has to demonstrate an aversion to being average, and must empathise with patients, families and professionals following

incidents where patients have been harmed

The Board must reverse its traditional deference to professionals, and take an active role in defining and measuring quality and safety

The ‘concrete floor’ is the separation between clinical and managerial perspectives in most health care providers – financial and operational on one hand, clinical value for the patient on the other

Beneath it, the clinicians work away delivering their services, driven primarily by professional

specializations, which are in turn driven by sophisticated technologies. Above it, senior managers advocate and negotiate with one

another, and manage the non-clinical operations when they are not, of course,

engaged in one of their perpetual – and often fruitless – reorganizations.

Mintzberg (1998)

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Progressing through the stages – penetrating the concrete floor


Building block 2: responsibility and accountability

Clear responsibility for outcomes so the Board can identify who is accountable (managers and professionals) and measure performance

Even if you would know what to measure, you lie awake thinking about what to do with this data. You can’t just throw it back at your doctors; you have to make it live for them and be actionable

David Rosser, Medical Director,University Hospital Birmingham, UK

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A streamlined upward flow of the most important measures, with appropriate levels of detail for each audience

Measures are not developed from the top down and quality governance is not done from the sidelines - those at the front line know what is most

important to track. Make the clinical service lines accountable

Without a clear vision of how to use them, even the best metrics are of little value

Strategy Capability and culture Processes and structure Measurement

1a Does quality drive the Trust’s strategy?

2a Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda?

3a Are there clear roles and accountabilities for quality governance?

4a Is appropriate quality information being analyzed and challenged?

1b Is the Board sufficiently aware of potential risks to quality?

2b Does the Board promote a quality-focused culture throughout the Trust?

3b Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?

4b Is the board assured of the robustness of information relating to quality?

3c Does the Board actively engage patients, staff and other key stakeholders on quality

4c Is the information on quality being used effectively?

1a 2a

1b 2b

3a

3b

4a

4b

3c 4c

In the UK, the Quality Governance Framework tests the ‘robustness’ of quality governance in providers

Monitor – the UK economic regulator


A mixture of announced and unannounced inspections,

focusing on 5 domains:

The role of the CQC

The Care Quality Commission – the UK quality regulator

■ Setting standards of quality and safety

■ Monitoring, inspecting and reporting publicly on performance

■ In-depth investigations looking at care across the whole system.

Safe People are protected from abuse and avoidable harm

Effective Care achieves good outcomes, promotes a good quality of life & is based on best evidence available

Caring Staff involve and treat people with compassion, kindness, dignity and respect

Responsive Services are organised so that they meet people’s needs

Well-led Leadership and governance ensure the delivery of high-quality person-centred care, support learning and innovation & promote an open and fair culture

The Care Quality Commission – the UK quality regulator


Building block 3: optimising and standardising processes

Measurement, roles and culture should all be aligned with standard pathways and operating procedures

Guidelines are typically forgotten half of the time, so we made these automated pathways the default way of doing things.

Brent JamesChief Quality Officer, Intermountain Healthcare, USA

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This high degree of standardisation reduces complexity and variation, improves cooperation and communication – and thereby improves quality

Front-line professionals are responsible for confirming that guidelines are followed; they have the capability and will to intervene when they fear

this is not happening.

For patients with acute respiratory distress syndrome:

...guideline variances dropped from 59% to 6% within just 4 mths

...patient survival increased from 9.5% to 44%

...physicians’ time commitments fell by about half

...the total cost of care decreased by 25%

This approach has since been extended to cover the vast majority of the care within Intermountain’s system, with similar success.

Intermountain Healthcare – saving lives, reducing costs

Intermountain Healthcare introduced standard workflow guidelines, and measured outcomes. They made dramatic and continuous improvements:


Building block 4: measurement

The world’s leading healthcare organizations share an obsession with measurement: state-of-the-art dashboards, process and outcome measures, many of which in real time.

KPMG and University Hospitals Birmingham have developed the International Hospital Benchmark

Robust international comparison at both the whole-hospital and diagnosis level:

Quality and safety

Productivity and efficiency

Financial performance

We aim to religiously and relentlessly measure and re-measure.

Mike Harper, Executive Dean of Clinical Practice,Mayo Clinic

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They also seek to benchmark themselves internationally, to learn from best practice around the world.

Maternity & Neonatal – Deliveries AustraliaEnglandGermanyNetherlandsUSA

Qua

lity

& s

afe

ty

Productivity & efficiency

Regulation is much too important to leave to the regulators.

Niall Dickson,Chief Executive and Registrar, General Medical Council, UK

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System governance

Many healthcare leaders see tension between a wealth of external requests for measurement – which they often feel measure the wrong things – and their own internal drive for excellence

The most important measures – for both internal and external use – are those that capture the overall outcomes of care. Once hospitals are able to reliably measure and report these outcomes, there is no need to report a plethora of process and intermediate measures.

KPMG International – ‘The more I know, the less I sleep’

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In order to become high-reliability organizations, providers need to align these external and internal tasks

This will reduce complexity and increase transparency

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Embrace the four building blocks: culture, accountability, standardisation and measurement

Measure the outcomes that matter to patients and the processes that contribute to that

Make individuals accountable for clinical and financial outcomes

Align measurement processes with care pathways

Create a culture intolerant of complacency, committed to excellence and learning

Adopt the right IT to optimise measurement – but don’t let a lack of IT infrastructure be an excuse

Focus external reporting on important patient outcomes, not detailed protocols

Continually seek ways to risk-adjust measurements for better benchmarking

Provide independent assurance over the reliability of quality measures

Adopt certification as the most appropriate way to assure safety, not public reporting of negative outcomes

10 practical steps towards being a high-reliability organisation

The first in our ‘What Works’

series..

Creating new value with patients, carers and communities

For more information, visit kpmg.com/healthcare

http://www.kpmg.com/healthcare

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The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavour to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation.

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