Maureen Bisognano, President and CEO, Institute for Healthcare Improvement, gives an international perspective on leading for better healthcare at The King's Fund Second Annual NHS leadership and Management Summit.

1. An International Perspective:
Leading for Better Healthcare
2nd Annual NHS Leadership and Management Summit
23 May 2012
The King’s Fund
Maureen Bisognano
President and CEO
IHI

2. The Problem
• In the US, we spend over $2.7 trillion per
year on health care
• Over 75% is spend on chronic disease
management
• And all of our chronic diseases are getting
worse

3. The Problem
• In the UK and across other countries in Europe, the
same 70% of health care budgets are going to chronic
disease care
• Diabetes, cardiac disease, and obesity are expected to
increase by 50% by 2035
• The “burden of the illness” in these diseases is 24/7 and
requires a new way to look at the “burden of the
treatment,” including designs and costs

4. Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.

5. Not Just an American Problem

7. Health Care Spenders and Costs
The top 1% of spenders
accounts for 21.8% of the
costs
The next 4% account for
28.2% of the costs
The bottom 50% account
for just 3% of the costs
Spenders Costs
Source: AHRQ – “The Concentration and Persistence in the Level of Health Expenditures over
Time: Estimates for the U.S. Population, 2008-2009”
http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.shtml

8. Courtesy of the Institute for Healthcare Improvement, April 2009

9. Courtesy of the Institute for Healthcare Improvement, April 2009

10. Michael Porter’s Thinking
• Disutility of a primary care model with an
incredibly diverse patient mix
• Challenges of managing excellent clinical
care with the latest evidence in the face of
heterogeneity
• Chaos of daily life for clinicians

11. Joanne Lynn’s Thinking
• “Bridges to Health Model”
─Splits populations into 8 segments
1. Healthy
2. Maternal-infant health
3. Acutely ill, likely to return to health
4. Chronic conditions with normal daily function
5. Serious relatively stable disability
6. Short decline to death
7. Repeated exacerbations, organ system failure
8. Multi-factor frailty, with or without dementia
Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and
Kambic, Robert T., Using Population Segmentation to Provide Better Health
Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2,
pp. 185-208, June 2007.

12. Where Are We?
Optimizing the
Current Model
Technical Leadership:
• Problem solving through
expertise
Viability
Transforming the
Organization
Adaptive Leadership
• New beliefs & behaviors
• New relationships
Patient • New customers
Inflection
Point
Clinical Model Episodic Care  Coordinated Care  Population Directed Care
Adaptive
Challenge Business Model Fee for Service  Bundled Payment/Capitation  Disruptive Innovation?
Technical Infrastructure Segmented  Integrated  Cloud
Leadership
Models Adapted from The Second Curve, Ian
Morrison 1996

13. Build widespread improvement capability
− Leadership
− Middle management
− Front-line teams
− Integrated clinical teams
− Engaged, empowered, and enthusiastic staff
Work on Safety
− Reduce medical errors and harm
Thriving −
−
Eliminate “never events”
Work on preventable admissions
on the and readmissions
First Curve Engage members/patients and families
− Ensure access
− Design for continuous care
− Improve patient engagement and
satisfaction
Improve efficiency
− Reduce artificial variation (LOS, use rates,
readmissions, etc.)
− Eliminate “flow faults”
− Set a goal of reducing waste by 1-3% of operating
expense budget for I year, year on year

15. Henry Ford Health System
Total Harm-Associated Costs 2009*
Harm Issue Total Associated Costs
Pressure Ulcer stage 2 or higher $10,624,410
Coded Procedural Complication ICD9 (998-999.99) $7,670,520
UTI using coded data and AHRQ definition. $5,662,895
Glucose below 40 $3,846,375
Coded Acute Renal failure $2,665,680
Coded DVT/PE in both medical and surgical patients $2,365,470
No Pulse Blue Alert $1,535,808
Coded Medication issue $1,216,078
Clostridium difficile infection $824,544
Reported Fall with injury $696,527
Bloodstream Infections using NHSN criteria $640,000
Coded Pneumothorax using AHRQ definition $340,260
SSI using NHSN criteria $280,000
VAP using NHSN criteria $190,352
*Henry Ford Hospital Only

16. What Improvement Skills are Needed for Each Role?
Everyone Change
Agents
Operational
(Middle
Leaders Experts
(Staff, (Executives)
Managers,
Supervisors, Stewards,
UBT lead project leads)
triad)
• Analysis,
prioritization of
portfolios
• Setting direction and big
goals • Deep statistical
process control
• Execution leadership
• Deep improvement
• Portfolio selection and
• Setting goals and methods
• Setting goals and measures management
measures • Leadership team
• Identifying problems • Managing oversight of
• Identifying advisory re portfolio
• Mapping process improvement
problems selection, process
• Sequencing tests of change • Being a champion and
• Mapping process • Effective plans for
• Simple understanding sponsor
• Testing change implementation and
variation • Understanding variation spread
• Simple waste to lead
reduction • Implementation and spread
• Simple waste reduction • Managing
• Simple implementation and
standardization • Simple standardization spread
• Team behaviors
16

17. Wave III focuses on full deployment and execution and IV on expansion
and continuous improvement
Waves of Improvement Institute
February 2008 September 2008 June 2009
• 7 regions*
Deepen improvement knowledge
• 150 Improvement Advisors
Expand Improvement system to
• 5 regions (medical center, regional,
national)
Develop and Test the System
• 80 Improvement Advisors
(Medical Center) • 12 Faculty Mentors (KP)
• 3 Regions • 11 Faculty Mentors (KP) • 1000+ Operations
• 6 Improvement Advisors • 4 Regional mentor students managers
(Medical Center) • 300 operations managers • 10,000 Front line RIM+
at a Facility level
within facilities
• 3 Faculty Mentors • 3,500 Front line RIM+ staff staff
(internal and external) • Middle manager PSU • Middle manager PSU
all facilities
• Front line staff RIM • Reliable design • Reliable design
• Middle managers PSU
• Reliable design
Learning and sharing systems regionally and program-wide Improvement Institute
Level of Project
Difficulty Continuous
Complete On-boarding Implementation Expansion Improvement
We are here
17

18. Leadership and capability
− Build innovation capability and set aims
− Analyze key areas for design (population
segments, geographic areas)
− Identifying “light green potential” & translating
to “dark green dollars”
Work on spread
Thriving − Ensure best practices and results
everywhere
on the
Second New partnerships
Curve − Payer “deep dive” such as
“marketplace collaboratives”
− Build on ABCD or community
organizing skills
New designs
− Coordinated care for frail, older population
− Triple Aim designs for the sickest
− The “year of care” for the well 50%

19. Organizations Learning from Patients
The Old Way
• Ryhov Hospital in Jönköping had traditional hemodialysis
and peritoneal dialysis center.
• But in 2005, a patient, Christian, asked about doing it
himself.

20. The New Way
• Christian taught a 73-yr-old woman how to do
it…
• …and they started to teach others how to do it.

21. The New Way
• Now they aim to have 75% of patients to be on
self-dialysis
• They currently have 60% of patients

22. Lessons to Date
• From Christian (patient):
─“I have a new definition of health.”
─“I want to live a full life. I have more energy
and am complete.”
─“I learned and I taught the person next to me,
and next to her. The oldest patient on self-
dialysis is 83 years old.”
─“Of course the care is safer in my hands.”

23. Lessons to Date
• From Anette (nurse leader):
─ Surprised at design differences between patients,
family, and staff
─ Managing at 1/2 – 1/3 less cost per patient
─ Evidence of better outcomes, lower costs, far fewer
complications and infections
─ “We brought in the county’s employment, helped the
patients make or update the CVs, and trained them
for a new career.”

25. Update
• Now calculated costs at 50% of costs in
other hemo-dialysis units
• Complications dramatically reduced and
subsequent expensive care avoided
• Measuring success by “number of patients
working”

26. Jonkoping Visit, October 2011

27. PFCC

28. Tony DiGioia
Dr. Anthony M. DiGioia III, orthopedic
surgeon and developer of the patient- and
family-centered care program for UPMC, in
his office at Magee-Womens Hospital in
Oakland.

29. Wellness
Focus

30. Results
• Safe:
─Mortality rate: 0%
─Infection rates: 0.3% (0.2% for TKA and 0.7%
for THA)
─Zero dislocations
─SCIP compliance: 98% for antibiotics within one
hour of surgery
DiGioia A, Greenhouse P, Levison T. “Patient and Family-
centered Collaborative Care: An Orthopaedic Model”.
Clinical Orthopaedics and Related Research. 2007: 463; pp:
13-19.

31. Results
• Effective:
─95% of patients discharged without handheld
assistance directly to home (national rates:
23-29%)
─99% of patients reported that pain was not an
impediment to physical therapy, including
same-day-of-surgery physical therapy
DiGioia A, Greenhouse P, Levison T. “Patient and Family-
centered Collaborative Care: An Orthopaedic Model”.
Clinical Orthopaedics and Related Research. 2007: 463; pp:
13-19.

32. Results
• Patient-centered:
─ Press-Ganey mean satisfaction score is 91.4% (99th
national percentile ranking) with 99.7% positive
responses to “Would you refer family and/or friends?”
• Efficient:
─ Average length of stay:
 2.8 days for TKA (national average is 3.9 days)
 2.7 days for THA (national average is 5.0 days)
─ One MD able to perform 8 joint replacements before
2:00pm
DiGioia A, Greenhouse P, Levison T. “Patient and Family-
centered Collaborative Care: An Orthopaedic Model”.
Clinical Orthopaedics and Related Research. 2007: 463; pp:
13-19.

33. Study Tour in Denmark

34. Leadership
− Redesigning the workplace to optimize
teamwork
− Engage the community (ABCD and
organizing)
Thriving
on the Optimize health and care skills with the community
− Shared decision making
Third Curve − Move from “What’s the matter?” to
“What matters to you?”
− Real goal-setting
Innovate for technology integration
− Optimize the use of technology, the
patients’ perspective and use of data, and
other technologies

35. Health of a
Population
Experience of Per Capita
Care Cost

36. IHI’s Partners/Activation Mechanisms:
Memphis / Shelby County, TN
• Memphis Activation Mechanism:
─ A virtual faith-based network.
• Focus of Activation mechanism – Project Goals:
1. Reduce untreated and unmanaged hypertension
among low-income African American men
2. Reduce health risk and incidence of uncontrolled
chronic disease for vulnerable women in Memphis

37. Activating Memphis’
Congregational Health Network (CHN)
• Scaling up the reach to young women:
─ Beginning with 30 existing CHN members in Year 1 and scaling
up engagement to over 2,000 designated health volunteers in
approx. 300 churches over 3 years.
 Reaching over 8,000 women across the community with information and
skills for self-care and health improvement through family and community
networks.
• Scaling up the reach to men:
─ Onsite screening for hypertension and other health risks will be
carried out at approx. 400 congregations over the first two years
(150 in Year 1 and 250 in Year 2).
 Paired with additional outreach in Year 3 through male church members’
connections to other community groups, including workplaces, neighborhood
associations, and social groups, these efforts are expected to reach approx.
over 2,700 individuals with previously undiagnosed or untreated
hypertension who can be brought into community-based
treatment.

38. Malawi Progress
• Population ~13 million
• Maternal mortality: ~350/100,000
(USA <10/100,000)
• Neonatal Mortality: ~30/1000 ( in
the US ~4/1000)
3 Districts
• Aim: Reduce maternal and
neonatal mortality by 30%
in three Districts (pop 3
million) by February 2012.
• 5-year RCT to test health
facility (QI), and
community interventions
(women’s groups)
Partners: Women and Children First, Inst Child
Health UCL, IHI. Funders: The Health
Foundation.

39. Focus of our Interventions
3 Delays model
• Delay in deciding to seek
care
• Delay in reaching the Women Groups & Task
facility Forces
• Delay in receiving timely QI intervention
and appropriate care
PLAN
SMALL TEST
ACT CYCLES THAT DO
TAP LOCAL
KNOWLEGE
STUDY

40. Focus on Demand, Supply and Linkages
Referral &
Access
Increasing
Demand Quality
services

41. Malawi: Results Over 4 Years
Infrastructure for change
• Established new NGO – MaiKhanda
• Community structures: 650 Women’s groups
• Facility structures: 55 QI teams formed (13 hospitals, 42
health centers)
• Linkage structures: 707 safe motherhood task forces
RCT evaluation results show:
• 22% reduction in NMR for combined FI and CI
intervention (no effect for either intervention
alone)
• 16% reduction in perinatal mortality for CI alone,
no effect of FI alone
• No reduction of MMR over secular trends

42. Southcentral Foundation
Anchorage, Alaska
• “Nuka” – Alaskan word for
strong, giant structures
and living things.
─ Also the name for the
health care model that
transformed the system
from health care
transactions for patients to
a healthy system with the
population

43. Some Programs (Relationships)
 Elder Program
• Healthy Elders through supportive gathering, activities, sharing, caring -
relationships
 Pathway Home
• Recovering youth through development of community, healthy relationships,
personal and group responsibility
 RAISE
• Youth internships emphasizing team, group, learning, responsibility, skills –
within SCF Nuka System of Care (relationships)
 Dena-A-Coy
• Residential treatment for pregnant women to return to healthy relationship
with self, family, pregnancy, newborn infant.

44. Some Programs (Relationships)
 Nutaqsiivik
• Two year partnering in intensive personal relationship between SCF staff and
new mothers with infants
 Quyana Clubhouse
• Long term personal relationships with individuals with limited cognitive
capabilities and mental health challenges to support healthy living
 Primary Care
• Complete rethinking of what our roles are – everyone – in the integrated care
team environment where trusting, accountable, long-term, personal
relationships are the core service delivered – with full same-day access – and
the whole person and family are supported.

45. Why listen to our story
 Evidenced-based generational change reducing family violence
 50% drop in Urgent Care and ER utilization
 53% drop in Hospital Admissions
 65% drop in specialist utilization
 20% drop in primary care utilization
 75-90%ile on most HEDIS outcomes and quality
 Childhood immunization rate of 93%
 Over 50% of Diabetics with HbA1c below 7%
 Employee Turnover rate less than 12% annualized (very low)
 Customer and staff overall satisfaction over 90%
 In an urban Alaska Native community with huge challenges
 Sustained for over a decade and continually improving
 Very long list of external recognitions – Baldrige Award now

46. Per Capita Expenditures
Copyright © 2011 Southcentral Foundation. All Rights Reserved.

47. Looking Ahead
• New definitions of “organization”
• New ways to lead multigenerational work
forces
• New methods and a new culture of
engaging patients and families in designs
• New learning networks for all of us