Creating the Future Through a Focus on Quality 2.16.10 Chris Schieffer

This message is part of Creating the Future

This message is part of Creating the Future

This message is part of Creating the Future

Agenda The Mayo Clinic Quality Construct Mayo Clinic’s Value Equation Applying Lean Six Sigma in healthcare Current major initiatives at Mayo Clinic

William Worrall Mayo (Father)

Select case studies in our application of Lean Six Sigma Quality as a business strategy Creating “Mayo Quality Fellows” Spreading best practice Tracking measures of strategic objectives

This message is part of Creating the Future

PRIORITIES

VISION

Mayo Clinic Strategic Plan Primary Value: The needs of the patient come first Mission: Mayo Clinic will provide the best care to every patient every day through integrated clinical practice, education, and research Vision: Mayo Clinic will be the premier patient-centered academic medical organization

Quality

Integration

Quality Individualized

Satisfy Our Patients

EXECUTION

• Achieve the highest levels of patient service and satisfaction • Demonstrate Mayo Clinic as the choice destination medical center

Medicine

Science of Health Care Delivery

Achieve Mission-Advancing Financial Performance • Achieve operating margin target • Achieve sufficient and stable sources of funding for Research and Education

Improve and Demonstrate Quality, Safety, Service, and Value • Achieve the highest levels of quality care and safety • Develop high-value care models targeted to specific patient populations

Attract, Develop, and Retain the Best People • Improve staff satisfaction, training, retention, and recognition • Increase diversity of all staff 5 11/12/07

• Strengthen leadership development • Establish a culture of innovation and discovery This message is part of Creating the Future

Mayo Clinic Quality Construct I

III

The best care for every patient every day… Culture

• Roles and expectations • Transparency • Leadership training–CALD III • Champions training • Safety competency/training • Business Case • Teamwork/Communications • Rapid Response Teams • Social Capital

II • • • •

IV

Engineering

Enterprise Accountability • Warfarin, SII, VAP-II, Pressure Ulcers, PQRI, Insulin, Surgery + Opioids, Semi-urgent Results, Rfos Department Accountability • Medication Reconciliation, Universal Protocol, Hand Hygiene, Sentinel Events, Teamwork

V

Execution

• Active visible leadership • Frontline empowerment • Process owners • Common scorecard and targets • Horizontal infrastructure • Adverse event oversight group • 100-day discipline • Business case

Infrastructure Quality Academy Quality Data Management System Health Sciences Research AHRQ patient safety indicator analysis

• • • •

Convergence of Electronic Systems Enterprise Learning System – Socrates Develop Mayo Value Management System Simulation 31 January 2008

Adapted from Bisognano, Plsek. 10 More Powerful Ideas for Improving Patient Care. This message is part of Creating the Future Chicago: Health Administration Press & Institute for Healthcare Improvement; 2006.

Value Creation System The best care for every patient every day… Quality Construct

n a l PExecution Culture Engineering l a •Managed Diffusion n o •Reorganize for Value •Single High Value i t Practice a •Value Metrics r •Roles and expectations e •PQRI p •Standardization •Front-line empowerment O •Grow Social Capital •Simulation 0 1 •Residency Programs 0 2 : T F Infrastructure A R Leverage Enterprise Information Management • Refine Value D Creation System •• Utilize Mayo Expert (ELS) Numerator Intensive • 30 day readmissions • Chronic disease/care mgmt • Mortality • HAI • Hand-offs (Joint Commission)

Denominator Intensive • 2 Service line lean efforts • Capture cost of poor quality (1%)

• Expand Quality Academy • Spread Specialty Councils

• Coordinate Improvement Assets This message is part of Creating the Future

Creating Greater Value for Our Patients

Quality

Goal: increasing(Outcomes value + Safety + Service)

(Outcomes + Safety + Service)

Value =

Cost

(For a span of care)

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Supporting Improvement Projects

This message is part of Creating the Future

This message is part of Creating the Future

This message is part of Creating the Future

Quality Academy …not a tradeoff

IRR 217%

Cost avoidance

NPV > $17M

↑ Capacity

Define

Measure Analyze

FTE redeployed Improve

Control

Diffusion

“100 Days” This message is part of Creating the Future

Launching Improvement Projects

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Project  Charter

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Project Prioritization

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2x2 Matrix Bubble Plot of Priority Score by Feasibility Score Sized by Staffing-Project ID Project 36 34 32

Priority Score

30 28 26 24 22 20 18 16 10 Circle Size

11

12

13

14

15

16 17 Feasibility Score

18

19

20

21

Bubble plot produced using JMP Statistical Analysis and Visualization software

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22

Status Reports

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Financial

Schedule

Scope

Owner

PM

n/a

Green

Green

B Asplin, D Brown, S Peters

J Thompson, C Berardinelli

JC Collaborative on Hand-offs

1/12/10

Status: Green Issues/challenges: • Top risks: Large scope, resources

Comments: • Goal: improve communication • ED ←→ ICUs, ICUs ←→ general care units • Kano analysis complete, Moving into design • In scope: ED, MICU, Dom 6D • Measures: reduce missing requirements by 50%,

reduce Sentinel/adverse events by XX%, improve sender/receiver sat by XX% This message is part of Creating the Future

Active Enterprise Priority Projects1 JC Collaborative on Hand-offs (12/9/09) ▼

IDOV

Identify/Define

30 Day Readmissions (12/9/09) ▼ Healthcare Assoc. Infections (12/9/09) ▼ Mortality (12/9/09) ▼ Chronic Disease/Care Mgmt Strategies ▼

DMAIC

Define

Blood Utilization ▼ PQRI (12/9/09) ▼

PMBOK

Initiating

Develop

Optimize

Verify

Implement

Portfolio Tracking…

Measure Analyze

Improve

MIDAS+ (Jan 2008)2 ▼ Mortality Review Spread ▼

Planning Executing

Key: Project Name (date charter approved) ▼

Monitoring

Control

Diffusion

Critical Tests, Critical Results + Semi Urgent Results (2/27/07) ▼

Controlling

Closing

1 MCR Component Only 2 Project launched Jan 2008 w/o charter

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Dashboards

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Sample of Improvement Projects

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Acute Myocardial Infarction (AMI) Mayo Clinic Quality Team

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Acute Myocardial Infarction (AMI) Charge: • Within 100 days, achieve and sustain performance at ≥95% on AMI core measure set using “all or none”* methodology * all patients eligible for at least 1 of the 8 measures must receive the care specified

• Promote collaboration and integration across Mayo Clinic sites

Results: • Achieved overall system-wide average performance of 97% early* * ~ 1 ½ months before end of 100 day period This message is part of Creating the Future

Heart Failure Team Mayo Clinic Quality Team

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Heart Failure Charge: • The team was chartered to improve compliance to core measures for heart failure care to 95% or greater • Mayo Clinic’s performance is reported publicly to the Centers for Medicare and Medicaid Services and to Joint Commission on Accreditation Healthcare Organizations

Results : • Through effective teamwork, outstanding leadership and dedication, the team implemented changes to achieve high performance for our patients This message is part of Creating the Future

Institutional Review Board (IRB) Mayo Clinic Quality Team

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Institutional Review Board (IRB) Charge: •

BPO Project to improve cycle time for reviewing key IRB applications. Project Goal: Turnaround time (from submission of application to dispatch of minute excerpt) of new full-Board Protocols and full-Board Modifications to be no more than 21 days.

Results:

• Improved compliance against goal from 25% at baseline to 70% at end of project

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Pneumonia

Mayo Clinic Quality Team

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Pneumonia Charge: Goal: To improve care processes for pneumonia to a 95% or better reliability on the 7 process measures using the all or none measurement methodology

Results: • Improved all or none score for pneumonia care measures 4Q2005: All or none score = 55% May 1, 2006: Project start date 3Q2006: All or none score = 83% 4Q2006: All or none score = 75%* This message is part of Creating the Future

Surgical Site Infection (SSI) Mayo Clinic Quality Team

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Surgical Site Infection (SSI) Charge: • Goal: To improve compliance with CMS guidelines for preoperative administration of prophylactic antibiotics to 95% or better Results: Surgical patients receive prophylactic antibiotics within 60 minutes prior to incision Surgical patients receive prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure) Prophylactic antibiotics are discontinued within 24 hours after documented surgery end time (48 hours if CABG or Other Cardiac Surgery)

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Ventilator Associated Pneumonia (VAP) Mayo Clinic Quality Team

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Ventilator Associated Pneumonia Charge: 15% of Ventilated Patients Develop VAP • Ventilated Patient Mortality – 32%

• •

Patient with VAP Mortality – 46% VAP Attributable Cost $40,000/patient

120

Results

100

80

60

40

20

0 MCJ

MCA

MCR Baseline

Actual

MHS

Mayo Clinic

Goal

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Ventilator Bundle Head of bed elevation Sedation vacation DVT prophylaxis PUD prophylaxis

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Change in Adherence to Ventilator Bundle vs Change in VAP

P e rc e n t In c re a s e in a d h e re n c e

120 100 80 60 40 20 0 0

20

40

60

80

100

Resar et al, Joint Commission Journal on Quality and Patient Safety May 2005

Change In VAP Rate This message is part of Creating the Future

Warfarin

Mayo Clinic Quality Team

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Warfarin Charge: • Reduce iatrogenic harm by narrowing the proportion of Warfarin inpatients that experience INR > 5, have an unsafe discharge plan

Results (annualized): Annual # of Mayo Inpatients w/ INR > 5

Annual # of Mayo Inpatients w/ Discharge Plan Unsafe # of Inpatients with D/C Plan Unsafe (Before QI) # of Inpatients with D/C Plan Unsafe (After QI)

# of Inpatients w/ INR > 5 Before QI # of Inpatients w/ INR > 5 After QI

¹ ¹ ¹

100 50

¹

50% improvement ² 412

MCR (7500)

150

MCJ (3000)

58% improvement ²

84

45% improvement ²

45

51

MCA (3200)

46% improvement ²

28

647

MC (18700)

64% improvement ²

273 0

100

200

300

400

# of patients

500

600

700

1000 500

MHS (5000) Site (annual # of warfarin pts)

Site (annual # of warfarin pts)

MHS (5000)

¹

50% improvement ² 3900

MCR (7500)

1275

¹

MCJ (3000)

2151

81% improvement ²

420

MCA (3200)

1184 1152

MC (18700)

67% improvement ²

3% improvement ² 8235

3347 0

2000

4000

59% improvement ² 6000

8000

10000

# of patients

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CP1261910-6

Mayo Clinic Vision

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Quality As a Business Strategy (2009 economic crisis hits home)

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Timeless values, changing times We are firmly committed to our primary value The needs of the patient come first

We need to be willing to change everything else

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What Are We Doing? Overall Strategy Reducing expenses, improving revenue • Task Force led by Mike Harper, M.D.

Transforming our practice

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What are we doing? Rochester Transformational Activities Hospital Census Management Manage Patient Mix/Access New Models for Internal Consults Surgical Care Redesign and Coding Critical Care of the Future Staff to Workload – Outpatient Transcription Services Redesign Manage to Reimbursement This message is part of Creating the Future

Transforming our Practice Manage to Reimbursement Practice redesign initiatives under way in CV Surgery and Ortho Value stream mapping to identify and eliminate unnecessary steps Goal to preserve and enhance quality, safety and service while reducing costs by 20% Care processes and roles will change This message is part of Creating the Future

Current Environment Factors making the case for change Economic environment • Requires immediate response from Mayo

Health care reform Demographic growth of patients of Medicare age Finances and operational implications

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2009 Plan – Improving Value Effective process change increases quality and decreases cost 2009 Priority projects focused on denominator of value equation (cost over time) Lean Process Redesign of Clinical Service Lines • Identifying two clinical areas for initial focus, using Quality

Academy

Teaching leaders to lead change • Quality Academy This message is part of Creating the Future

2009 Plan – Improving Value Top MCR projects and initiatives – “fast track” efforts with the highest potential for immediate financial return Hospital Census Control Patient Mix/Access New Internal Consult Models Surgical Care Redesign & Documentation/Coding improvement Critical Care Delivery

Cost I & II: Reduce Medicare Gap Inpatient Warfarin Management Employee and Community Health International Office This message is part of Creating the Future

Short-Term Plans to Create Greater Value Achieve capacity, volume and productivity targets: each week, each month • SOPs, OPVs, Surgical Patients, Procedures, etc.

Achieve expense and cash management goals • • • • • •

Planning for 2010 budget Restrained PCC and AH staff growth; some reductions Defer salary increase for voting/consulting staff Defer capital projects by 50% Travel expense reduction Reduced remodeling and deferrable maintenance

Realize short-term gains from MCR initiatives

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Mid-Term Plans to Create Greater Value Major transformational initiatives Contingency planning Fast-tracked transformational initiatives New pilots for new care management models Lean process improvement

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Long-Term Plans to Create Greater Value Destination Strategy 2020 Strategy Support Enterprise Focus on wellness vs. sick care: The New Paradigm

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Further Embedding QI  Methodologies into Our DNA

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Quality Fellows program Purpose: to provide a fellowship program to learn, develop and apply new knowledge for continuous improvement Audience: Physicians, Nurses, allied health & administrative professionals Outcome: Increased knowledge, skills and tools needed to design, improve, implement and evaluate sustainable quality improvement

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CP1000000-55

Quality Fellows Program Tiered program • • • •

Bronze Silver Gold Diamond

Knowledge & application to improvement projects Teaching & publication

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This message is part of Creating the Future

Quality Fellows Program Pathways Core Mayo Required Level

Bronze Silver Gold Diamond

101

Electives ASQ Certification (optional)

CQIA Green Belt Black Belt Master Black Belt

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This message is part of Creating the Future

MQF Functions & Roles Matrix Position

Employees & Students

Nurse, Resident / Fellow

Consultant, Nurse, Supervisor / Manager

Level

Awareness

Bronze

Bronze

Silver

Gold / Diamond

Function

Participate in QI Teams

Improve the process

Sustain Improvements

Lead & Do Projects

Apply, Lead & Teach Improvement framework

Role (s)

QI team member

QI team member

QI team member / Team Leader

Project Champion or Process Owners

Group Facilitator

Responsibilities

Suggest process improvements, Assist with implementation of process improvements, Foster team work, seek to understand all key stakeholders' needs

Select, Initiate & Prioritize Quality improvements projects and related Charters, Assist with implementation of process improvements, guide project teams, Foster team work, seek to understand all key stakeholders' needs, close QI projects

Select, Initiate & Prioritize Quality improvements projects and related Charters, Assist with implementation of process improvements, guide project teams, Foster team work, seek to understand all key stakeholders' needs, close QI project

Knowledgeable in core QI methods. Commission teams/ projects to impact the Mayo Value Equation. Support, coordinate & monitor QI teams. Conducts project review. Receives support/guidance from QI expert.

Collaboration / Coordination

Collaboration / Coordination

Critical Skill

Problem Consciousness

Problem Solving

Supervisor / Manager, Administrator / Department Chair

QI Advisor / Analyst

Facilitate team , Use QI framework, develop communication / display tools, ensure data integrity, resolve team conflict, ensure process documentation, create / maintain project documentation

QI tool knowledge

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This message is part of Creating the Future

Quality Review Board In 2000, the 24 Member Boards of the American Board of Medical Specialties (ABMS) agreed to evolve their recertification programs to one of continuous professional development – ABMS Maintenance of Certification ® (ABMS MOC®) ABMS MOC assures that the physician is committed to lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing measurement of six core competencies: Patient Care, Medical Knowledge, Interpersonal and Communication Skill, Professionalism, Systems-based Practice, and Practice-based Learning and Improvement This message is part of Creating the Future

This message is part of Creating the Future

Specific Project Examples Surgery + Opioids = Narcan Reduce by 50% the number of adverse respiratory events requiring administration of Narcan related to Opioid-based medication administered intravenously following surgery.

VTE Spread Attempt rapid spread of proven concepts in DVT prophylaxis and implement a new system to improve ongoing use of appropriate DVT-P in hospitalized patients.

MRSA Reduction Pilot (for 6 months*) the addition of a de-colonization protocol for MRSA carriers admitted to 2 ICUs at St Mary’s hospital and to observe the change in HA-MRSA infections that result.

ICU Sepsis Management Process Simulation Use a systems engineering approach to develop a fully scalable simulation model of severe sepsis and septic shock management in the ICU.

Manage to Reimbursement Reduce cost/case by 20% for selected bypass & valve procedures by 1/1/10, resulting in annual cost savings of $10M in 2010.

Wipe out C.Diff Introduce cleaning patient rooms with bleach in an identified high risk Clostridium difficile infection (CDI) incidence patient care unit to reduce transmission.

SBAR Implement an effective means of structured communication through developed toolkits and educational resources that promote compliance with the 2009 National Patient Safety Goal

Hospital-Based Inpatient Psychiatry Services Improve core measures of Admission Screening, Discharge and Multiple Antipsychotic Medications at Mayo Psychiatry and Psychology Treatment Center (MPPTC) in adherence to the Hospital Based Inpatient Psychiatric Services (HBIPS) data set as defined by Joint Commission.

Staffing to workload Improve Mayo Clinic’s ability to staff to workload in the outpatient practice with the goal to optimize staffing resources.

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Safety Focus: Communication

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Universal Protocol Primary Goal: Zero sentinel events due to failed elements of universal protocol.

2004-6: 8.25 events/year (MCR) 2007: 14 events (MCR, MCA & MCF) 2008: 3 events (MCR, MCA, MCF & MHS) Most issues are currently experienced in non-surgical suite environments This message is part of Creating the Future

Daily events: ~50%

Researchers found that farmers who named their cows Betsy or Gertrude or Daisy improved their overall milk yield by almost 68 gallons annually.“ Just as people respond better to the personal touch, cows also feel happier and more relaxed if they are given a bit more one-to-one attention," Catherine Douglas of the university's School of Agriculture, Food and Rural Development said in a news release.Dairy farmer: "We love our cows ... and every one of them has a name. Researchers questioned 516 dairy farmers in the United Kingdom. "By placing more importance on the individual, such as calling a cow by her name or interacting with the animal more as it grows up, we can not only improve the animal's welfare and her perception of humans, but also increase milk production.“Study out of Newcastle University in northeast England, published online Wednesday in the academic journal Anthrozoos. This message is part of Creating the Future

B teams + A system Always beat A teams + B system

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Quality vs. Productivity Low error rate

Quality

(error rate) High error rate

Hotels Hotels

Airlines Airlines

Telecommunications Telecommunications

Computers Computers Retail Retail banking banking U.S. U.S. Postal Postal Service Service Auto Auto manufacturing manufacturing

Food Food services services

Health Health services services

Low

High

Productivity/efficiency

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Clinical Advisory Board 2005 National Meetings for Member Executives

Spreading Best Practices (Diffusion)

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Why? Increase the utilization of successful changes Impact a larger number of patients Reduce redundancy and “re-invention” Increase efficiency, momentum, knowledge Enhance quality and safety of care

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Some Key Theories of Spread Agenda setting and change agents, Attributes of an innovation, Adopter categories, communicationEverett Rogers Content, context, community- John Seely Brown Tipping point, key messengers- Malcolm Gladwell Stages of Change - James Prochaska Social Marketing- Philip Kotler Motivators for behavior change, incentives, support for adopters- Albert Bandura Modified from Qualis Health, Overview of the Spread Model, Sharon Eloranta, MD

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Past approaches: 2006 – 2008 Measures based – give each site a numeric target and

expect them to achieve; any sharing would be based on local sites seeking out best practices from others with better scores (Top 5 Safety Initiatives)

Enterprise teams – organizing groups with representatives

from each site to work collectively to develop and implement a common set of best practices (pneumonia, AMI, SSI, warfarin, etc)

Alpha/Beta –

one site will develop “best practice” with a defined expectation that other sites will follow implementation (VAP II, mortality review)

Grass roots – sharing of efforts either formally or informally

with the hope that others will adopt (plus one, specimen labeling) This message is part of Creating the Future

Key Elements of Spreading Leading Practices

Establish Leading Practices •Process Owner •Define expectations •Provide supporting evidence

Approval Process •Define approval authority •Provide feedback loops •Timely review

Implementation •Staff education •Hardwire practice into standard process •Aligned incentive

Monitoring •Ability to track compliance •Hold staff accountable •Continuously review results and modify practice

Communication and Change Management Principles This message is part of Creating the Future

Establish Leading Practices Prioritize targeted practices for improvement Identify spread model as a part of the chartering process Define what is meant by leading practice (i.e. advisory, guideline or standard) Articulate expectations and value of proposed practice to our patients (i.e. why should I do this?) • What is expected outcome and cost over time? • Identify value of care to our patients This message is part of Creating the Future

Establish Leading Practices Clearly define the expected practice • Identify common measures and how data is collected • Provide description, protocols, orders sets, consults, etc

Summarize supporting evidence (e.g. national guidelines, internal research, expert opinions, etc.

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Approval Process Clearly identify the “process owner” and use the ARCIVD model to articulate roles Acknowledge there will be different approval groups at various levels based on: • Enterprise, site and department • Global, service line or local dept/division practice

Publish minority opinions so it is clear what perspectives have been considered Allow for a feedback loop so those with concerns regarding the practice have a venue to be heard This message is part of Creating the Future

Implementation Making “the right thing to do, the easy thing to do” Educate staff regarding evidence supporting the practice and expectations; acknowledge varying compliance based on specific patient needs (Intermountain Health experience shows 5 – 15 % variance)

Building the practice into the clinical work flow using standard order sets, clinical worksheets, templated notes, etc Aligning incentives with expectations This message is part of Creating the Future

Monitoring Further develop measures, outcomes and patient tracking systems (i.e. Midas, EDT and GDMS) Utilize these systems to monitor compliance and results of leading practices Identify organizational structure that is responsible for monitoring data and holding practitioners accountable Establish monthly review and improvement discussions This message is part of Creating the Future

Potential 2010 Goals Deliver world-class, outstanding, trusted and affordable care (“highest value care”) Transform Mayo Clinic’s healthcare delivery system while influencing the national health care system Execute a proactive business strategy to deliver medical care, to generate medical knowledge, to manage that knowledge and deliver what we know to new people, groups and places Create the medical workforce of the future This message is part of Creating the Future

The glory of medicine is that it is constantly moving forward, that there is always more to learn. The ills of today do not cloud the horizon of tomorrow but act as a spur to greater effort. Dr. William J. Mayo This message is part of Creating the Future

This message is part of Creating the Future