Original Article
Transformational Quality in Kaiser Permanente Northern California Carmen Adams, DNSc, RNC; Roxanne O’Brien, PhD, MSN; Elizabeth Scruth, PhD, RN, MPH, CCNS, CCRN The evolving nature of health care related to optimizing the quality of patient care while increasing efficiencies presents an opportunity to redesign roles within hospital quality departments to meet these upcoming challenges. Specifically, passage of the Patient Protection and Affordable Care Act and creation of Accountable Care Organizations will require hospitals to carefully monitor patient care outcomes as well as continually seek to improve their processes. An approach used by the Kaiser Permanente Northern California Regional Quality and Regulatory Services Department assisted the 21 hospitals of Kaiser Permanente Northern California to improve quality-of-care outcomes, establish effective assessment teams, and create infrastructure for sustainability. Leadership by a centralized internal consulting group used a model that weighs risk and opportunity against cost and outcomes to support strategic planning as projects and initiatives developed, rather than after they were initiated. This model can assist other organizations in maximizing cost-efficient and -effective performance improvement approaches to clinical and operational excellence. Key words: organizational structure, performance improvement, quality, sepsis, strategic planning
A
n opportunity exists to redesign roles within hospital quality departments to meet upcoming challenges related to payment systems based on quality-of-care goals and passage of the Patient Protection and Affordable Care Act.1 A structure for this redesign uses a model that weighs risk and opportunity against cost and outcomes. Adaptation of principles from the Reinertsen model at the Kaiser Permanente Northern California (KPNC) Regional level assisted the 21 hospitals of KPNC to improve quality-ofcare outcomes.2 The KPNC Regional approach is manifested in the work of the Quality Consulting Group (QCG), which offers design, support, and leadership for transforming existing approaches to improving care to achieve enhanced, sustainable health care outcomes. Transformational quality is defined by the authors as an approach that offers flexibility and content expertise to better align with organizational strategic goals and allows an expeditious response to the evolving health care environment. PURPOSE The purpose of this article is to describe the approach used by the Quality and Regulatory Services Department of KPNC to proactively plan and execute costAuthor Affiliation: Quality and Regulatory Services, Kaiser Permanente Northern California, Oakland. Correspondence: Roxanne O’Brien, PhD, MSN, Quality and Regulatory Services, Kaiser Permanente Northern California, 1950 Franklin St, 14th Floor, Oakland, CA 94612 (Roxanne.L.O’[email protected]; [email protected]). The authors declare no conflicts of interest. Q Manage Health Care Vol. 24, No. 1, pp. 4–8 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000015 4
January–March 2015 r Volume 24 r Number 1
effective, cost-efficient, and sustainable performance improvement initiatives. BUSINESS MODEL The QCG was designed to include quality professionals with unique expertise and knowledge in clinical, administrative, and operational strategies to drive performance improvement in the 21 hospitals of KPNC. In contrast to other approaches of internal project management or performance improvement, the QCG provides medical centers with a clinically focused team that work with hospital-based collaboratives to provide support and guidance to accelerate the work to improve patient care. Three of the QCG members refined their performance improvement skills by attending a yearlong program in performance improvement at the Institute for Healthcare Improvement (IHI), graduating as improvement advisors (IAs). Other QCG members trained as IAs through the KPNC internal performance improvement training process. Strong clinical backgrounds, knowledge of the current literature, and expertise in performance improvement allow the QCG to complement the skills of frontline staff and be accepted by them as part of the process of improvement. QCG members facilitate the formation of multidisciplinary, collaborative teams. This reflects the foundational philosophy of the QCG that the development of ideas for performance improvement belongs to frontline staff who has a vested interest in making changes to improve patient care. QCG members work in small and large collaborative teams to conduct regulatory risk assessments, research clinical and administrative information essential for decision making, and define roles and responsibilities of team members. Technological tools, as well as face-to-face meetings, support the collaborative team work. This unique approach offers the flexibility and content expertise to meet the regulatory demands of www.qmhcjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
January–March 2015 r Volume 24 r Number 1
today and health care reform in the future. These requirements challenge institutions to try innovative and new ways to keep patient care quality high while conserving resources. Centralization of expertise has allowed strategic planning to occur as projects and initiatives are envisioned, rather than after activities have been initiated. This strategy has increased communication, eliminated rework, and enhanced efficient implementation of performance improvement initiatives. The QCG is nested within a larger quality division with oversight to ensure successful accreditation, licensing, and quality outcomes for all hospitals in KPNC. This approach has been successful through a combination of deployment to hospitals, development of infrastructures (linkage to data teams, coordinated reporting, identified point of contact for information technology consultation), and multidisciplinary collaboration to provide expert knowledge. The QCG approach consists of a strategic leader whose role is to communicate with senior leaders, subject matter experts, and QCG members. The role of each QCG member is to lead several hospitals in developing and sustaining improvement projects. QCG members meet weekly to discuss challenges and successful practices. The members strategize ways to ensure that initiatives stay on target to meet the Regional goal of enhancing efficiency. When the clinical improvement target is identified and senior leader support is confirmed, the QCG member will immediately identify hospital-based key stakeholders, contact them personally, and travel to the local site. The QCG member will tour the targeted unit and, after introductions, talk to frontline staff, observe practice, and outline next steps. These steps include drafting a group charter with a nurse manager and a physician champion for team review; assisting with identification of team members; inventory of clinical equipment if applicable to the project; review unit culture surveys; and identification of the unit staffing structure and governance. The measurement strategy also begins at the first visit, with exploration of manual and technological tools for data collection. As the work matures, the teams analyze data, discuss barriers and opportunities, and identify actions to address issues. A unique facet of the QCG work is this commitment to ongoing support to reach identified goals. Activities that support the spread of successful practice include planning collaborative calls, analyzing data from across the region, holding educational sessions, and developing reports that are shared among all hospital teams and Regional leadership. Organizations facing similar challenges to maximize resources and exceed required standards of care demanded by health care reform can modify the QCG model depending on financial resources, clinical improvement priorities, and skill level of the proposed consultants. Both individual hospitals and hospital systems can modify the QCG approach for specific needs by investing in intensive performance improvement training for 1 or more consultants, redefining performance improvement projects to focus on development and sus-
www.qmhcjournal.com
5
tainability rather than as a project to accomplish, and by committing to developing infrastructure rather than quick fixes. The job description for the QCG consultant and the strategic leader is written broadly to include the following elements: (a) strong clinical background, (b) performance improvement knowledge, (c) facilitation skills to enable the change process, (d) expert communication and listening skills, (e) ability to engage in courageous conversations with stakeholders, (f) knowledge of design strategies to ensure initiatives are positioned for sustainability, and (g) ability to articulate understanding of how practice change contributes to the global patient care quality of the organization and infrastructure development. Consideration should be given to maximizing the role of the strategic leader to function in both the consultant and leader roles.
APPLYING THE BUSINESS MODEL TO HEALTH CARE The current economy tests the resilience of organizations. The essence of resilience is the ability to cope positively with stress and adversity, specifically as it relates to the economic environment and constant variability in health care.3 Reinertsen enumerates principles for challenging existing belief systems regarding achieving flow in organizations.2(p1) Organizations need to acknowledge the high variability present in their industry and determine how to manage that variability. They must address dysfunctional beliefs that hold back creative solutions to problems and inhibit change. Reinertsen suggests that taking risks testing new and more effective approaches to managing challenges in organizations risks failure.2(p50) However, according to Reinertsen’s principle of Optimum Failure Rate, these failures inform the organization of the economics of the situation.2(p92) The ability to tolerate imperfect decisions and even allow for failure is essential. Delaying decisions in the quest for perfection may sacrifice the opportunity to be creative and transformative in approaches to performance improvement. The result is that those same failures may be repeated. Only new failures yield information. The Reinertsen model describes specialists as a rare commodity, typically used as a scarce resource.2(p82) Multiple variables need to be taken into account when making a decision to change an operational approach to measuring quality, including capital and human resources. Using appropriate consultants (Reinertsen’s Big Guns principle) to assist in making the right decisions will produce faster results and ultimately be less expensive.2(p155) Utilization of specialized consultants lessens the attendant risk of moving faster. Centralization, using the Intervention principle, results in improved patient throughput and flow time through the organization.2(p79) Limiting the use of specialists can deter or delay the testing of new and more effective approaches to reducing variation and improving outcomes.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
6
January–March 2015 r Volume 24 r Number 1
In 2004, a strategic partnership was formed between the IHI and the Kaiser Permanente organization to accelerate improvement on a large scale. On the basis of concepts from the IHI model for improvement (including collaboratives, team charters, the Plan-DoStudy-Act cycle, and development of a measurement strategy), the QCG has demonstrated that taking risks can yield important gains for both local entities and the organization as a whole. The IHI encourages transformative efforts to enhance patient outcomes while containing costs and capitalizing on current market share.4 Several elements of Reinertsen’s model complement the IHI model for improvement. The first of these is a focus on efficiency. Reinertsen posits that a good first step to enhancing efficiency is to encourage early involvement of specialists (Big Guns principle).2(p155) This is consistent with IHI’s approach of using subject matter experts to design projects and the Lean Six Sigma principle of reducing defects by first analyzing the process.4(p7) Reinertsen encourages organizations to focus on improving variation that enhances economic value, which is consistent with the IHI teaching that standardization will improve cost and Lean’s dictum to reduce waste. Reinertsen states that one approach to creating maximum value for minimum cost is to sequence activities using the principle of Tailored Routing, which is consistent with the process mapping described by the IHI and value stream mapping taught by Lean Six Sigma.2(p199) Using the Reinertsen principles as a foundation, the QCG acts as a critical response team, able to constantly weigh risk and opportunity against cost and outcomes yet provide resiliency and efficiency to address challenges in meeting quality-of-care outcomes. A misconception in many organizations is that centralized resources decrease reaction time. In reality, centralized resources have greater flexibility to meet multiple demands and can result in faster response times (Resource Centralization principle).2(p206) These principles and IHI performance improvement tools give the QCG hands-on skills for bringing teams together to work on accelerating improvement, reduce failures in care, improve the health care economic environment, and improve patient safety. REDUCING MORTALITY ASSOCIATED WITH SEPSIS The aim of the Sepsis Initiative is to use the QGC model to reduce mortality associated with sepsis. A focused review of 950 medical records in 19 KPNC hospitals revealed unacceptable mortality rates from sepsis (∼25%). On the basis of this analysis, the formation of the Sepsis Initiative in 2008 aligned KPNC hospital quality programs to reduce hospital mortality and morbidity by focusing on evidence-based care and teamwork and supporting a safe culture. The Sepsis Initiative was supported by a combination of outside funding along with in-kind funding from Kaiser Permanente. The goal was to develop and implement a comprehensive program at all KPNC hospitals to identify and treat septic patients
www.qmhcjournal.com
to achieve a 25% reduction in risk-adjusted sepsis mortality. Reinertsen’s concepts of taking risks to mobilize resources to implement the Sepsis Initiative supported positive economic outcomes secondary to decreasing the sepsis mortality rate and increasing identification of sepsis upon presentation to the emergency department. To coordinate efforts to reach the goals, the QCG formed a KPNC Region-wide Steering Committee whose role was to oversee the process of implementation of the Sepsis Initiative. The QCG members adopted the roles of both as mentors to unit-based work teams and as Sepsis Faculty, assisting with oversight and ongoing development of the initiative. Unit-based work teams at the medical centers consist of frontline staff and allied health care professionals. A physician and a nurse on each unit (selected by the teams or having volunteered) share leadership of the teams. The unit-based teams influence the adaptation of staff practice to sepsis protocols. They perform medical record review, data analyses, and restructuring of the performance improvement processes when necessary. The QCG members work actively on-site, mentoring and building strategy with the teams. They review patient records when there is deviation from the protocol and analyze those data. The QCG members supported development of a Web-based data submission tool at the KPNC Regional level, which has significantly improved data collection. Unit-based teams focus on 3 objectives: increasing identification of sepsis, instituting reliable treatment measures (protocols and bundle development), and data monitoring to follow progress. Research by Rivers et al5 was used to develop the protocol for treating patients presenting to the emergency department with sepsis and subsequently admitted to the intensive care unit. The QCG members assessed in planning staff training needs, developed performance metrics, and designed implementation tools. A Sepsis “Playbook,” developed by QCG members and available to all staff members, describes the clinical protocol, outcome metrics, and how to interpret data. Large-scale conferences, or Sepsis Summits, are sponsored by the QCG and KPNC leaders to ensure ongoing communication and discussion of successes and barriers and build the collaborative culture. Improvement advisors, defined as staff who work exclusively in performance improvement, work with QCG members to address issues immediately at the hospital level. Badge cards showing treatment protocols were made for staff. A paging system, called a Sepsis Alert, pages nurse managers to prepare for the admission of a septic patient. The QCG members guide the discussion of changes to metrics and protocols using monthly Sepsis Faculty calls. A monthly Sepsis Scorecard is sent to each hospital to demonstrate the progress of achievement toward the defined metrics. Collaborative calls with the unit leaders and IAs highlight best practices and discussion of barriers and successes in the pursuit of reducing mortality in each hospital. Continuing education
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
January–March 2015 r Volume 24 r Number 1
www.qmhcjournal.com
7
Table. Sepsis Regional Supports Timeline 2008
2009
2010-2011
Steering Committee formed
Sepsis Faculty meet twice a month
Steering Committee ends
Completed baseline data analysis
Monthly Regional Collaborative calls Sepsis Faculty meeting semimonthly start
KPNC senior leaders launch Sepsis Initiative Two pilot sites engaged Playbook for Mortality Summit developed Mortality Summit held Mailbox available for submission of questions, issues, barriers
Monthly IA Collaborative calls start Monthly Sepsis Scorecard available Monthly Sepsis Newsletter available Sepsis Web site available Annual Sepsis Summit held Annual training begins using a “train the trainer” model
Web-based data entry available Semiannual MD/IA meetings start Monthly regional collaborative calls hosted by medical center Monthly newsletter ongoing Annual Regional training ends 2011 Ongoing
2012-2013 Regional Collaborative calls held quarterly Physician/IA meetings held annually IA Collaborative calls end Sepsis Newsletter published quarterly Web site ongoing Annual Sepsis Summit and local training ongoing Ongoing
Abbreviations: IA, improvement advisor; KPNC, Kaiser Permanente Northern California.
takes place through the Sepsis Summits, Web-based meetings, simulation workshops, and medical center visits for localized education. Feedback is gathered during these collaborative meetings that provide ideas for further development of refinement to the protocols. The unit-based teams have appreciated that there is always a contact person available, and the continuous streams of metrics to tell them how they are performing. A timeline showing Regional support is displayed in the Table.
PERFORMANCE IMPROVEMENT METRICS Figures 1 and 2 demonstrate success in meeting the objectives, showing results from early, baseline data collection from 2006 to 2013. Figure 1 demonstrates that sepsis mortality ratio has shown a dramatic decrease. Sepsis mortality is calculated using the denominator of all patients with a diagnosis of sepsis and the numerator reflects those patients in the denominator who have expired. This is not a capture of observed to expected mortality since there is no way to predict expected mortality for a population that was not previously tracked. Figure 2 shows that the diagnosis of sepsis per 1000 admissions continues to climb.
Figure 1. Sepsis mortality ratio.
SUMMARY AND APPLICATION TO OTHER ORGANIZATIONS The QCG model facilitates the development of transformative quality by providing an infrastructure for building multidisciplinary collaborative teams, mentoring those teams and acting as change agents, maintaining a presence in the hospitals, and facilitating communication among sites. Using this infrastructure to sustain changes in daily practice to improve patient care can be adopted at the regional and local hospital levels. The number of QCG members will expand and reduce on the basis of project prioritization. Support from senior leadership for the QCG model is essential for practice change strategy as well as a key element in the sustainability of those changes. QCG members guide their teams to establish charters, set realistic goals, create measurement strategies, and start with manageable steps. The framework allows QCG mentors to build relationships with the teams through hands-on attention, data analysis, and sharing of challenges and successes from multiple sites. The underpinning of sustainability for performance improvement involves the establishment of an infrastructure such as the one described earlier.
Figure 2. Sepsis diagnoses per 1000 admissions.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
8
January–March 2015 r Volume 24 r Number 1
Most people are familiar with project management that is associated with a “launch and leave” mind-set. Performance improvement efforts, however, require ongoing nurturing and attention. The successful outcomes of the sepsis mortality-reduction practice change at KPNC demonstrate the power of the QCG model. Health care organizations will face challenges and successes in the future. The QCG model may be used by other complex health care organizations in maximizing the expertise and potential of people within the organization. Cost-effective and -efficient models for organizational and clinical performance improvement initiatives need to be explored to determine how to set the stage for achieving success in the face of an uncertain future health care state.
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REFERENCES 1. Department of Health and Human Services. 42 CFR Part 425 Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With the Medicare Sharing Savings Program and the Innovation Center; Proposed Rule and Notice. Fed Regis. 2011;76(67, pt 11):1950-1952. 2. Reinertsen D. The Principles of Product Development Flow: Second Generation Lean Product Development. Redondo Beach, CA: Celeritas; 2009. 3. Atkinson P, Martin C, Rankin J. Resilience revisited. J Psychiatr Ment Health Nurs. 2009;16(2):137-145. 4. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Boston, MA: Institute for Healthcare Improvement; 2003. 5. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Transformational Quality in Kaiser Permanente Northern California Carmen Adams, DNSc, RNC; Roxanne O’Brien, PhD, MSN; Elizabeth Scruth, PhD, RN, MPH, CCNS, CCRN The evolving nature of health care related to optimizing the quality of patient care while increasing efficiencies presents an opportunity to redesign roles within hospital quality departments to meet these upcoming challenges. Specifically, passage of the Patient Protection and Affordable Care Act and creation of Accountable Care Organizations will require hospitals to carefully monitor patient care outcomes as well as continually seek to improve their processes. An approach used by the Kaiser Permanente Northern California Regional Quality and Regulatory Services Department assisted the 21 hospitals of Kaiser Permanente Northern California to improve quality-of-care outcomes, establish effective assessment teams, and create infrastructure for sustainability. Leadership by a centralized internal consulting group used a model that weighs risk and opportunity against cost and outcomes to support strategic planning as projects and initiatives developed, rather than after they were initiated. This model can assist other organizations in maximizing cost-efficient and -effective performance improvement approaches to clinical and operational excellence. Key words: organizational structure, performance improvement, quality, sepsis, strategic planning
A
n opportunity exists to redesign roles within hospital quality departments to meet upcoming challenges related to payment systems based on quality-of-care goals and passage of the Patient Protection and Affordable Care Act.1 A structure for this redesign uses a model that weighs risk and opportunity against cost and outcomes. Adaptation of principles from the Reinertsen model at the Kaiser Permanente Northern California (KPNC) Regional level assisted the 21 hospitals of KPNC to improve quality-ofcare outcomes.2 The KPNC Regional approach is manifested in the work of the Quality Consulting Group (QCG), which offers design, support, and leadership for transforming existing approaches to improving care to achieve enhanced, sustainable health care outcomes. Transformational quality is defined by the authors as an approach that offers flexibility and content expertise to better align with organizational strategic goals and allows an expeditious response to the evolving health care environment. PURPOSE The purpose of this article is to describe the approach used by the Quality and Regulatory Services Department of KPNC to proactively plan and execute costAuthor Affiliation: Quality and Regulatory Services, Kaiser Permanente Northern California, Oakland. Correspondence: Roxanne O’Brien, PhD, MSN, Quality and Regulatory Services, Kaiser Permanente Northern California, 1950 Franklin St, 14th Floor, Oakland, CA 94612 (Roxanne.L.O’[email protected]; [email protected]). The authors declare no conflicts of interest. Q Manage Health Care Vol. 24, No. 1, pp. 4–8 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000015 4
January–March 2015 r Volume 24 r Number 1
effective, cost-efficient, and sustainable performance improvement initiatives. BUSINESS MODEL The QCG was designed to include quality professionals with unique expertise and knowledge in clinical, administrative, and operational strategies to drive performance improvement in the 21 hospitals of KPNC. In contrast to other approaches of internal project management or performance improvement, the QCG provides medical centers with a clinically focused team that work with hospital-based collaboratives to provide support and guidance to accelerate the work to improve patient care. Three of the QCG members refined their performance improvement skills by attending a yearlong program in performance improvement at the Institute for Healthcare Improvement (IHI), graduating as improvement advisors (IAs). Other QCG members trained as IAs through the KPNC internal performance improvement training process. Strong clinical backgrounds, knowledge of the current literature, and expertise in performance improvement allow the QCG to complement the skills of frontline staff and be accepted by them as part of the process of improvement. QCG members facilitate the formation of multidisciplinary, collaborative teams. This reflects the foundational philosophy of the QCG that the development of ideas for performance improvement belongs to frontline staff who has a vested interest in making changes to improve patient care. QCG members work in small and large collaborative teams to conduct regulatory risk assessments, research clinical and administrative information essential for decision making, and define roles and responsibilities of team members. Technological tools, as well as face-to-face meetings, support the collaborative team work. This unique approach offers the flexibility and content expertise to meet the regulatory demands of www.qmhcjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
January–March 2015 r Volume 24 r Number 1
today and health care reform in the future. These requirements challenge institutions to try innovative and new ways to keep patient care quality high while conserving resources. Centralization of expertise has allowed strategic planning to occur as projects and initiatives are envisioned, rather than after activities have been initiated. This strategy has increased communication, eliminated rework, and enhanced efficient implementation of performance improvement initiatives. The QCG is nested within a larger quality division with oversight to ensure successful accreditation, licensing, and quality outcomes for all hospitals in KPNC. This approach has been successful through a combination of deployment to hospitals, development of infrastructures (linkage to data teams, coordinated reporting, identified point of contact for information technology consultation), and multidisciplinary collaboration to provide expert knowledge. The QCG approach consists of a strategic leader whose role is to communicate with senior leaders, subject matter experts, and QCG members. The role of each QCG member is to lead several hospitals in developing and sustaining improvement projects. QCG members meet weekly to discuss challenges and successful practices. The members strategize ways to ensure that initiatives stay on target to meet the Regional goal of enhancing efficiency. When the clinical improvement target is identified and senior leader support is confirmed, the QCG member will immediately identify hospital-based key stakeholders, contact them personally, and travel to the local site. The QCG member will tour the targeted unit and, after introductions, talk to frontline staff, observe practice, and outline next steps. These steps include drafting a group charter with a nurse manager and a physician champion for team review; assisting with identification of team members; inventory of clinical equipment if applicable to the project; review unit culture surveys; and identification of the unit staffing structure and governance. The measurement strategy also begins at the first visit, with exploration of manual and technological tools for data collection. As the work matures, the teams analyze data, discuss barriers and opportunities, and identify actions to address issues. A unique facet of the QCG work is this commitment to ongoing support to reach identified goals. Activities that support the spread of successful practice include planning collaborative calls, analyzing data from across the region, holding educational sessions, and developing reports that are shared among all hospital teams and Regional leadership. Organizations facing similar challenges to maximize resources and exceed required standards of care demanded by health care reform can modify the QCG model depending on financial resources, clinical improvement priorities, and skill level of the proposed consultants. Both individual hospitals and hospital systems can modify the QCG approach for specific needs by investing in intensive performance improvement training for 1 or more consultants, redefining performance improvement projects to focus on development and sus-
www.qmhcjournal.com
5
tainability rather than as a project to accomplish, and by committing to developing infrastructure rather than quick fixes. The job description for the QCG consultant and the strategic leader is written broadly to include the following elements: (a) strong clinical background, (b) performance improvement knowledge, (c) facilitation skills to enable the change process, (d) expert communication and listening skills, (e) ability to engage in courageous conversations with stakeholders, (f) knowledge of design strategies to ensure initiatives are positioned for sustainability, and (g) ability to articulate understanding of how practice change contributes to the global patient care quality of the organization and infrastructure development. Consideration should be given to maximizing the role of the strategic leader to function in both the consultant and leader roles.
APPLYING THE BUSINESS MODEL TO HEALTH CARE The current economy tests the resilience of organizations. The essence of resilience is the ability to cope positively with stress and adversity, specifically as it relates to the economic environment and constant variability in health care.3 Reinertsen enumerates principles for challenging existing belief systems regarding achieving flow in organizations.2(p1) Organizations need to acknowledge the high variability present in their industry and determine how to manage that variability. They must address dysfunctional beliefs that hold back creative solutions to problems and inhibit change. Reinertsen suggests that taking risks testing new and more effective approaches to managing challenges in organizations risks failure.2(p50) However, according to Reinertsen’s principle of Optimum Failure Rate, these failures inform the organization of the economics of the situation.2(p92) The ability to tolerate imperfect decisions and even allow for failure is essential. Delaying decisions in the quest for perfection may sacrifice the opportunity to be creative and transformative in approaches to performance improvement. The result is that those same failures may be repeated. Only new failures yield information. The Reinertsen model describes specialists as a rare commodity, typically used as a scarce resource.2(p82) Multiple variables need to be taken into account when making a decision to change an operational approach to measuring quality, including capital and human resources. Using appropriate consultants (Reinertsen’s Big Guns principle) to assist in making the right decisions will produce faster results and ultimately be less expensive.2(p155) Utilization of specialized consultants lessens the attendant risk of moving faster. Centralization, using the Intervention principle, results in improved patient throughput and flow time through the organization.2(p79) Limiting the use of specialists can deter or delay the testing of new and more effective approaches to reducing variation and improving outcomes.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
6
January–March 2015 r Volume 24 r Number 1
In 2004, a strategic partnership was formed between the IHI and the Kaiser Permanente organization to accelerate improvement on a large scale. On the basis of concepts from the IHI model for improvement (including collaboratives, team charters, the Plan-DoStudy-Act cycle, and development of a measurement strategy), the QCG has demonstrated that taking risks can yield important gains for both local entities and the organization as a whole. The IHI encourages transformative efforts to enhance patient outcomes while containing costs and capitalizing on current market share.4 Several elements of Reinertsen’s model complement the IHI model for improvement. The first of these is a focus on efficiency. Reinertsen posits that a good first step to enhancing efficiency is to encourage early involvement of specialists (Big Guns principle).2(p155) This is consistent with IHI’s approach of using subject matter experts to design projects and the Lean Six Sigma principle of reducing defects by first analyzing the process.4(p7) Reinertsen encourages organizations to focus on improving variation that enhances economic value, which is consistent with the IHI teaching that standardization will improve cost and Lean’s dictum to reduce waste. Reinertsen states that one approach to creating maximum value for minimum cost is to sequence activities using the principle of Tailored Routing, which is consistent with the process mapping described by the IHI and value stream mapping taught by Lean Six Sigma.2(p199) Using the Reinertsen principles as a foundation, the QCG acts as a critical response team, able to constantly weigh risk and opportunity against cost and outcomes yet provide resiliency and efficiency to address challenges in meeting quality-of-care outcomes. A misconception in many organizations is that centralized resources decrease reaction time. In reality, centralized resources have greater flexibility to meet multiple demands and can result in faster response times (Resource Centralization principle).2(p206) These principles and IHI performance improvement tools give the QCG hands-on skills for bringing teams together to work on accelerating improvement, reduce failures in care, improve the health care economic environment, and improve patient safety. REDUCING MORTALITY ASSOCIATED WITH SEPSIS The aim of the Sepsis Initiative is to use the QGC model to reduce mortality associated with sepsis. A focused review of 950 medical records in 19 KPNC hospitals revealed unacceptable mortality rates from sepsis (∼25%). On the basis of this analysis, the formation of the Sepsis Initiative in 2008 aligned KPNC hospital quality programs to reduce hospital mortality and morbidity by focusing on evidence-based care and teamwork and supporting a safe culture. The Sepsis Initiative was supported by a combination of outside funding along with in-kind funding from Kaiser Permanente. The goal was to develop and implement a comprehensive program at all KPNC hospitals to identify and treat septic patients
www.qmhcjournal.com
to achieve a 25% reduction in risk-adjusted sepsis mortality. Reinertsen’s concepts of taking risks to mobilize resources to implement the Sepsis Initiative supported positive economic outcomes secondary to decreasing the sepsis mortality rate and increasing identification of sepsis upon presentation to the emergency department. To coordinate efforts to reach the goals, the QCG formed a KPNC Region-wide Steering Committee whose role was to oversee the process of implementation of the Sepsis Initiative. The QCG members adopted the roles of both as mentors to unit-based work teams and as Sepsis Faculty, assisting with oversight and ongoing development of the initiative. Unit-based work teams at the medical centers consist of frontline staff and allied health care professionals. A physician and a nurse on each unit (selected by the teams or having volunteered) share leadership of the teams. The unit-based teams influence the adaptation of staff practice to sepsis protocols. They perform medical record review, data analyses, and restructuring of the performance improvement processes when necessary. The QCG members work actively on-site, mentoring and building strategy with the teams. They review patient records when there is deviation from the protocol and analyze those data. The QCG members supported development of a Web-based data submission tool at the KPNC Regional level, which has significantly improved data collection. Unit-based teams focus on 3 objectives: increasing identification of sepsis, instituting reliable treatment measures (protocols and bundle development), and data monitoring to follow progress. Research by Rivers et al5 was used to develop the protocol for treating patients presenting to the emergency department with sepsis and subsequently admitted to the intensive care unit. The QCG members assessed in planning staff training needs, developed performance metrics, and designed implementation tools. A Sepsis “Playbook,” developed by QCG members and available to all staff members, describes the clinical protocol, outcome metrics, and how to interpret data. Large-scale conferences, or Sepsis Summits, are sponsored by the QCG and KPNC leaders to ensure ongoing communication and discussion of successes and barriers and build the collaborative culture. Improvement advisors, defined as staff who work exclusively in performance improvement, work with QCG members to address issues immediately at the hospital level. Badge cards showing treatment protocols were made for staff. A paging system, called a Sepsis Alert, pages nurse managers to prepare for the admission of a septic patient. The QCG members guide the discussion of changes to metrics and protocols using monthly Sepsis Faculty calls. A monthly Sepsis Scorecard is sent to each hospital to demonstrate the progress of achievement toward the defined metrics. Collaborative calls with the unit leaders and IAs highlight best practices and discussion of barriers and successes in the pursuit of reducing mortality in each hospital. Continuing education
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
January–March 2015 r Volume 24 r Number 1
www.qmhcjournal.com
7
Table. Sepsis Regional Supports Timeline 2008
2009
2010-2011
Steering Committee formed
Sepsis Faculty meet twice a month
Steering Committee ends
Completed baseline data analysis
Monthly Regional Collaborative calls Sepsis Faculty meeting semimonthly start
KPNC senior leaders launch Sepsis Initiative Two pilot sites engaged Playbook for Mortality Summit developed Mortality Summit held Mailbox available for submission of questions, issues, barriers
Monthly IA Collaborative calls start Monthly Sepsis Scorecard available Monthly Sepsis Newsletter available Sepsis Web site available Annual Sepsis Summit held Annual training begins using a “train the trainer” model
Web-based data entry available Semiannual MD/IA meetings start Monthly regional collaborative calls hosted by medical center Monthly newsletter ongoing Annual Regional training ends 2011 Ongoing
2012-2013 Regional Collaborative calls held quarterly Physician/IA meetings held annually IA Collaborative calls end Sepsis Newsletter published quarterly Web site ongoing Annual Sepsis Summit and local training ongoing Ongoing
Abbreviations: IA, improvement advisor; KPNC, Kaiser Permanente Northern California.
takes place through the Sepsis Summits, Web-based meetings, simulation workshops, and medical center visits for localized education. Feedback is gathered during these collaborative meetings that provide ideas for further development of refinement to the protocols. The unit-based teams have appreciated that there is always a contact person available, and the continuous streams of metrics to tell them how they are performing. A timeline showing Regional support is displayed in the Table.
PERFORMANCE IMPROVEMENT METRICS Figures 1 and 2 demonstrate success in meeting the objectives, showing results from early, baseline data collection from 2006 to 2013. Figure 1 demonstrates that sepsis mortality ratio has shown a dramatic decrease. Sepsis mortality is calculated using the denominator of all patients with a diagnosis of sepsis and the numerator reflects those patients in the denominator who have expired. This is not a capture of observed to expected mortality since there is no way to predict expected mortality for a population that was not previously tracked. Figure 2 shows that the diagnosis of sepsis per 1000 admissions continues to climb.
Figure 1. Sepsis mortality ratio.
SUMMARY AND APPLICATION TO OTHER ORGANIZATIONS The QCG model facilitates the development of transformative quality by providing an infrastructure for building multidisciplinary collaborative teams, mentoring those teams and acting as change agents, maintaining a presence in the hospitals, and facilitating communication among sites. Using this infrastructure to sustain changes in daily practice to improve patient care can be adopted at the regional and local hospital levels. The number of QCG members will expand and reduce on the basis of project prioritization. Support from senior leadership for the QCG model is essential for practice change strategy as well as a key element in the sustainability of those changes. QCG members guide their teams to establish charters, set realistic goals, create measurement strategies, and start with manageable steps. The framework allows QCG mentors to build relationships with the teams through hands-on attention, data analysis, and sharing of challenges and successes from multiple sites. The underpinning of sustainability for performance improvement involves the establishment of an infrastructure such as the one described earlier.
Figure 2. Sepsis diagnoses per 1000 admissions.
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Most people are familiar with project management that is associated with a “launch and leave” mind-set. Performance improvement efforts, however, require ongoing nurturing and attention. The successful outcomes of the sepsis mortality-reduction practice change at KPNC demonstrate the power of the QCG model. Health care organizations will face challenges and successes in the future. The QCG model may be used by other complex health care organizations in maximizing the expertise and potential of people within the organization. Cost-effective and -efficient models for organizational and clinical performance improvement initiatives need to be explored to determine how to set the stage for achieving success in the face of an uncertain future health care state.
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