WELCOMEAn Introduction to IHI

Penny CarverSenior Vice President

Carnegie Foundation

Knowledge Alliance Working Meeting

January 20, 2010

IHI Mission

The Institute for Healthcare Improvement is a not-for-profit organization driving the improvement of health by advancing the quality and value of health care.

Why We Exist

“Between the health care we have and the care we could have lies

not just a gap, but a chasm.” - Institute of Medicine, Crossing the Quality Chasm, 2001

Defects….for example…• 45% of needed care is not received• 22% of chronically ill adults report a “serious error”

in their care• 74% of chronically ill adults say the system needs

“fundamental change” or “complete rebuilding”• Case-mix adjusted hospital death rates vary 400%• Resource use in the last six months of life varies

>500% among 77 top-rated US hospitals• Per capita annual health care costs:

─ US: ~$6000─ Sweden: ~$2800

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Variation in Practice

Hysterectomy by age 70

Prostatectomy by age 85

Mainhospital

Mainehospital

Iowahospital

Iowahospital

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Mainehospital

Mainehospital

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International Comparison of Spending on Health, 1980–2005

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* PPP=Purchasing Power Parity.Data: OECD Health Data 2007, Version 10/2007.

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 20088

Is there an achievement gap in education?

Our Blueprint: the IOM’s Six Aims

• Safe – no needless deaths• Effective – no needless pain or suffering• Patient-Centered – no helplessness in those

served or serving• Timely – no unwanted waiting• Efficient – no waste• Equitable – for all

We Do This By…

• Building the will for change• Cultivate promising improvement

ideas• Putting those ideas into action

through effective execution

“Improvement of any system requires will, ideas and execution.”

- Tom Nolan, PhD

WHO WE ARE We are a reliable source of energy, knowledge, and support for a never-ending campaign to improve health and health care worldwide.

A. Discover health care processes and systems that will deliver better outcomes and lower costs

B. Demonstrate the efficacy of new models and codify content in preparation for spread

A. Ensure that young health professionals are prepared for effective participation in improvement

B. Ensure that executives, boards, and relevant public officials are prepared to support improvement

C. Develop and nurture a cadre of improvement leaders

A. Continually improve IHI’s leadership system and plan for succession

B. Make IHI the best place to work in the eyes of its employees and faculty

C. Maintain a sound operating margin, continually reduce overhead costs

D. Raise funds reliably to help support unfunded community benefits

A. Publicize widely the case for improvement, promising designs and impressive results

B. Publish widely in peer-reviewed journals

C. Ally with influential organizations that share our aims to amplify our effectiveness

D. Influence the national health policy debate

Institute for Healthcare Improvement2010 IHI Strategic Plan

Strategy #1: Motivate

Stimulate the desire and optimism for change

Strategy #3: Get Results

Ensure wide adoption of sound changes

Strategy #2: Innovate

Create, find and test new models of care

Strategy #4: Raise Joy in Work

Help build a better health care workforce

Strategy #5: Stay Vital for the Long Haul

Sustain IHI’s viability

A. Convene and manage vibrant networks, communities and partnerships to deploy proven changes rapidly

B. Disseminate health care improvement ideas and methods through world-class learning events

C. Create and expand a world-class web presence to propel the spread and adoption of improvements at very low cost

WHAT WE WILL ACCOMPLISHIn the US and abroad, we will improve the lives of patients, the health of communities, and the joy of the health care workforce, and reduce health care costs. We work with health care providers and others to accelerate the measurable and continual progress of health care systems throughout

the world toward Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity.

WHAT WE WILL BECOMEWe will be a recognized and generous leader, a trustworthy partner, and the first place to turn for expertise, help, and

encouragement for anyone, anywhere who wants to change health care fundamentally for the better.

How We Change the World

The Technical Approach

The First Law of Improvement

“Every System Is Perfectly Designed to Achieve Exactly the

Results It Gets”(Therefore, although not all change is

improvement, all improvement Is change)

Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Repeated Use of the Cycles

Changes that Result in

Improvement

HunchesTheories

Ideas

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DS

DATA

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Multiple PDSA Cycle RampsTes

ting

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adap

tatio

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Triage Diagnostic Testing

Fast TrackPatients

Capacity/Demanding

Change Concepts

A P

S D

A PS D

A P

S D

D S

P A

A P

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A PS D

A P

S D

D S

P A

A P

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A PS D

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D S

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Applying the Model for Improvement to Education

The Social System

Breakthrough Series Collaboratives

The Breakthrough Series

Select Topic

Expert Group

Change Concepts

Participants

LS 1 LS 2 LS 3

E-mail

Phone

Assessments

Supports

Printed Reports

Visits

Documents

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National

Congress

Prework

Degree of belief that the changes will

result in improvement

High

Prototype Pilot Spread

Successful changes

Changes still need further testing. There is a risk of moving to spread

Unsuccessful proposed changes

Low

Moder-ate

Where is the Project?

An IHI program funded by The Robert Wood Johnson Foundation to improve patient outcomes dramatically by pursuing perfection in all of the major care processes. Pursuing perfection means striving to:

• Deliver all indicated services at the right time;• Avoid services that are not helpful to the patient or

reasonably cost effective;• Avoid safety hazards and errors that harm patients

and employees; and• Respect patients’ unique needs and preferences.  

January 2001-April 2006

Pursuing Perfection

Unnecessary Hospital Deaths: Developing a Learning System

• Do people die unnecessarily every single day in our hospitals?

• In order for us to understand this, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.

• New model: - What can we learn from the deaths? - Was perfect care given?

• You need to get a clearer understanding of local conditions that contribute to mortality.

IHI Approach to Mortality Reduction

ICU Admission No ICU AdmissionComfort Care 86/3175

3%(0-14%)

402/317513%

(0-40%)

Non Comfort Care 1161/317537%

(10-72%)

1526/317548%

(18-76%)

• Box 3 Changes (ICU)─Ventilator Bundle─Central Line Bundle─Multidisciplinary Rounds/Shared Goal Sheet─Glycemic Control─Sepsis Bundle and detection─Appropriate tidal volume for ARDS/Acute

Lung Injury patients - very early work for us

Areas of Improvement That We are Focusing On

Areas of Improvement That We are Focusing On

• Box 4 Changes (non-ICU)─ Rapid Response Team ─ Improved communication

SBARShift handoffs

─ Early Warning System─ Multidisciplinary Rounds outside the ICU─ Glycemic Control outside of ICU─ Crew Resource Management Training

The “100,000 Lives Campaign”

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The Campaign “Planks” -- Six Changes That Save Lives

• Deployment of Rapid Response Teams• Delivery of Reliable, Evidence-Based Care

for Acute Myocardial Infarction • Medication Reconciliation• Prevention of Central Line Infections• Prevention of Surgical Site Infections• Prevention of Ventilator-Associated

Pneumonias

Six Additional Planks

• Prevent Pressure Ulcers• Reduce Methicillin-Resistant Staphylococcus

Aureus (MRSA) Infection• Prevent Harm from High-Alert Medications• Reduce Surgical Complications (the Surgical

Care Improvement Project (SCIP)) • Deliver Reliable, Evidence-Based Care for

Congestive Heart Failure• Get Boards on Board

IHI Programs

• The Improvement Map• WIHI• STAAR• Safer Patients Network• Scottish Patient Safety

Programme (SPSP)

• Triple Aim• How Do They Do That?• R&D• The IHI Open School

• Builds on the great work of participants in the 100,000 Lives Campaign and the 5 Million Lives Campaign.

• “Help us make sense of the many complex and competing demands we face.”

• Brings together the best knowledge available on the key process improvements that will lead to exceptional hospital care. 

• Helps hospital leaders set change agendas, establish priorities, organize work, and optimize resources.

• An open resource, available free of charge to anyone, anywhere.

• Launched on September 15, 2009.

Safer Patients Initiative An IHI Program Funded by The Health Foundation

• The 100,000 Lives Campaign was built around 6 interventions

• The Safer Patients Initiative combined 5 of the “Campaign 6” plus 10 other change elements

• Phase 1: Four acute hospital trusts – Wales, Northern Ireland, England, and Scotland

Safer Patients Initiative Multiple “Centers of Gravity”

• The SPI change package addresses five clinical areas:

- Medicines management

- Infection prevention and control

- Peri-operative care

- Critical care

- Care on general wards• All supported by an organisational wide effort to bring

about a change in culture working at all levels but with a key role for senior leaders

Safer Patients Initiative

.Improve healthcare safety on an organisation-wide basis by reducing:

1. Mortality by 15%

2. Adverse events by 30%

Leadership System for Safety

Care of Critically Ill Patients

Perioperative Care Management

Care of General Ward Patients

Medicines Management

Primary Drivers

Ventilator Associated Pneumonia (Reduce to 0 or 300 Days Between)Central Line Bloodstream Infections(Reduce to 0 or 300 Days Between)Blood sugars within Range (80% or >)

Crash Call Rates(Reduce by 30%)MRSA Bloodstream Infections(Reduce by 50%)

Secondary Drivers

Anticoagulant Adverse Drug Events(Reduce by 50%)

Surgical Site Infections - clean(Reduce by 50%)

Safety as a Strategic PrioritySustainable InfrastructureEngaged and Committed Leadership

Safer Patients Initiative 2

Driver Diagram

The “Triple Aim”

• Improve Individual Experience

• Improve Population Health

• Control Inflation of Per Capita Costs

The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these three aims separate. Society on the other hand

needs these three aims optimized (given appropriate weightings on the components) simultaneously.

--- (Tom Nolan, PhD)

How Do They Do ThatLow-Cost, High-Quality Care

• July 21, 2009: Meeting in Washington, DC with Don Berwick, Elliott Fisher, Atul Gawande and Mark McClellan

• Involving health care leaders from a select group of high-performing regions of the U.S. to share their experiences

• Sponsored by the Institute for Healthcare Improvement, The Dartmouth Institute for Health Policy and Clinical Practice, the Harvard School of Public Health, and the Engelberg Center for Health Care Reform at The Brookings Institution

Much has been learnedPrice-adjusted per-capita Medicare spending 2006

$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)

Not Populated

Hope

90-Day Project Topics November 2009-Janurary 2010

Hospital Projects• Waste Reduction Tool• Financial Implications for Hospitals of Reduce Readmissions• Learning from Specialty Care and ED Use Prototyping• Work Place Safety Program Development• Other Hospital Waste and Cost Reduction Projects as needed

Triple Aim Projects• Triple Aim in a Region• Improvement at a Country Level• Connecting and Activating Community Health Care and Other Resources• Socially Complex Patients

“Advance health care improvement and patient safety competencies in the next generation of health

professionals worldwide.”

The IHI Open School Mission

The IHI Open School

Progress

• Registration─ Over 20,000 students registered on IHI.org

─ Over 6,000 faculty and deans registered on IHI.org

• Online courses ─ Over 20,000 courses completed (50% students, 50% professionals)

─ Available: 6 Quality Improvement, 3 Patient Safety, 1 Leadership

• Online Resources─ Over 30,000 downloads of case studies, glossaries, exercises, activities

─ Over 58,000 downloads of audio and video recordings

• Online Community─ YouTube, Facebook, Blog, Twitter

IHI Open School Chapters

173Chapters

173 Chapters on 185 campuses119 US Chapters in 40 states54 International Chapters in 24 countries

Experiential Learning

• Projects initiated by students─WHO Surgical Checklist Student Project

• Projects initiated by faculty─Beverly Hospital Chapter

• Projects initiated by the IHI Open School team─Shadowing students of another health profession

So Where Will IHI Lead?

• To meet the challenge of moving the “big dots”

• To create new, more effective designs

• To ensure deep results and broad reach

• To restore joy and confident capability

IHI Staff

IHI Values

Cooperation and Boundarylessness Our culture is team-oriented, and we all learn from and teach each other. We are an organization without walls that welcomes members of our team who are not based in Boston to be fully included in and informed about our day-to-day work.

Patient and Health Care Focus We focus our energies primarily on content areas that will improve the lives of patients.

Speed and AgilityWe anticipate customer needs and develop solutions that address those needs quickly and efficiently.

Customer FocusWe anticipate customer needs and develop programs that address those needs quickly and efficiently. We will know we have succeeded when customers can measure results and value from our interactions.

IHI Values

Valuing VolunteersWe will continually delight the faculty and associates with whom we work.

Honesty and TransparencyWe will be honest and open about our successes and failures, and will thereby be worthy of trust.

OrderlinessWe will continuously improve our leadership and management by developing innovative processes and eliminating waste.

Celebration and ThankfulnessWe celebrate our work and thank publicly and privately those that bring about our successes.