“Leading p Value Improveme

This PPT and other resources fromThis PPT and other resources from

http://homepage.mac.com/johnovr/FileShar

John Øvretveit,

11/9/2009 

Director of Research, Professor, Karolinska Medical 

Management Centre Sweden and Professor of Health Management, Faculty of Medicine, Bergen University
Outline

• Key g messa es• What is “Value Improvement?” • Why do it?PART 2:• Quality waste• Solutions• Savings or lossesPART 3• Leading Value Improvement

11/9/2009 
Overview

• October 2008 - $6,500Tr - 2 weeks • US GDP $15T US GDP $15Tr

• UK citizen debt $2,200 per year – on the loan intere• Recession hits healthcare

11/9/2009 
Economy conscious

• Budget cuts – how to protect quality?• US 

– how to kee

p gy makin

g mone

y

?

Reduce any costs & wasteQuestion any spending

What does spending on quality contribute to bottom line?What is essential for doin

g business vs discretionar

y

?

Is QA/QI diverting time and money from direct clinical care?

Message:

= quality needs to get “economy-conscious”= focus on Value Improvements

11/9/2009
The new world : 

quality accountability – for imp

• Is QI like the bank robbers? Is QI like the bank robbers?• Complicated schemes we do not understa• Q lit i d t f lli th di Quality industry fuelling the spending

• Patchy evidence of effectiveness and pay-

• Emperor’s clothes? Credibility crisis?• More evidence, less trusting More evidence, less trusting – measureme

measureme

costing

11/9/2009 
Review of evidence Review of evidence

(Øvretveit Øvretveit 2

D i i lit Does 

improv

i

n

g quality save mo

Q1 Cost no of poor q alit ? Q1 Cost now of poor

q

ualit

y

?

Q2 Spend cost? Q2 Spend cost?Q3 When do we save? (TTPO:1yr 

11/9/2009
What is “improving quality

1 Clinical change – antibiotics before surgery

– Implementation strategy to get this change Implementation strategy to get this change

2 Process improvement3 Systems and structure changes to reduce latent c4 Regulatory and large scale programmes

(eg i di ) n cators

)

11/9/2009
Under-developed “evaluation techn

evaluation techn

• Good for evaluating treatments and discrete cha

clinical practice clinical practice

• Not good for evaluating 

– Strategies to ensure these changes– Sy g stems or structure changes for better SQ– Regulatory or large scale changes

• Controls or experimental designs difficult Controls or experimental designs difficult• Other methods – tomorrows seminar 11/9/2009 
Key Messages: from review of evi

Key Messages: from review of evi

Does improving quality save money?1. Sometimes2. Mostly we don’t know3. Of h d d Often t

he spen

der 

does not save 

– someone el 

4. Saving waste is not releasing cash – 2 steps ne

5. Ch fi i t d di Change financ

ing 

to rewar

d spending 

–

5 year

6. Now – choose improvements which return on 

investment

7. Use research, experience, implementability-as

to choose wisel

y

8. Do simple costings before, during and after Q
Patient: 84 y y( ) ear old obstructive airways (COPD) a

disease 

Stable at home on meds, yp fiercely independent

Supported with regular visits to GP by son and h

cleaner

11/9/2009 
Health care experience

Friday 10am fall breaks hip• 14.00 admitted• 17.00 orthopaedic ward

– Change of medication

Sat Sun - no opsMonday – surgeon informed lateTuesday am operationFriday - isolated due to MRSA developing on on arm wound1 week later Discharged with no information to PHC2 weeks later Readmitted with weig ,p ht loss, pneumonia and wound inf11/9/2009 
In y , pf f our service, hands up for one of t

1) None of this could happen2) One or two of these quality problems may ha3) Many of these happen4) Much more – that’s not half of it...

11/9/2009
Cost to healthcare system =

€4470. 

• PHC treatment after discharge €870 (income)

– (avoidable) but could not manage patient acuity (3 nu

time, ambulance))

• E dii mergency rea

d

m

iss

ion 

€3 600 (i ) 3,600 (income

)

– (avoidable) and aggressive treatment for pneumonia a

Other actual or potential costs• Family travel and time-off work (€2,800)• After 4 day wait with fractured hip, lucky no complicatio

surgery (near miss of €2100)

• Death 17 weeks later due to.... 
84 year old experience, over 6 

11/9/2009 
Evidence and experience I will 

• Quality economics research, projects in Sweden an

work with IHI 1999-2009

• 2009: 2 systematic reviews of research, and book 
5 Practical messages for lea

5 Practical messages for lea

1) Support the few. 

–

...if their improvement will return the investment if their improvement will return the investment

– Not starting projects is an option. Hero leader and context

2) Ensure 

1 clinicians involved and accountable for results, 2 measurement, 3 reporti

skilled project leader (getting this may need external facilitation)

3) Estimate: Cost Spend Sa e? : Cost, Spend, Sa

ve?

4) Value improvements unite parties who need to w5) All leaders gi e same message 5) All leaders gi

v

e same message

focusing on Value improving using proven methods – formal and informal 
Hands up

• I am a manager• I am a leader• Only followers can answer thatManaging : making best use of resources

Printer waiting for ink, not using a nurses skills whe

K i th t d i it Knowing the waste and removing it

Leading : inspiring and focusing Leading value improvement: 

uniting effort and motivating to make changes which sav

improve patient care
What is a What is a “value improvem

value improvem

• Examples:

– “Read back” now used consistently to confirm messag

and understood

– Patient Path a redesign sing less clinician time & f

Patient Pathway redesign using less clinician time & f

A change which saves money and suffe

...caused by poor organisation or lack of support to provide

– (g y suffering avoidable by better organisation)
Why do it?

• Someone told us to. Looks bad if we don

the CEO government the CEO, government

• Reducing suffering got lost in the comple• Organise better, to treat better• We can take control of our organisationRe-awakens values about what is important about our service. In a more realistic way - for complex and financially pressured ..where our professional competence with the patient is not eno

a competent system and evidence of returns a competent system and evidence of returns
Some Ingredients 

Sustained motivation Sustained motivation

• Values concern: what is important and what we v

red i ff i ducing suffering – of di f 

ften disappears from every

• Facts: 

• f l h b f d li bl from elsewhere about safety and quality problems

– local data continually showing the problems & progress in our s

• Belief in a solution Belief in a solution

– for a better service, achievable and financially realistic,

• Belief in a journey Belief in a journey

– which we can all share which will get us to the solution, despite 

weather, detours and tough terrain.
PART 2

• Problem poor quality - and costs• Solutions – and the “spend costs”• Business case - savings or losses 

–The business case is local – “context sp

• I li i mp cations – practi l df 

ical and for resea

11/9/2009
The problem – which adverse event 

common i h it l? in your 

hospit

al?

• Pressure ulcers• Hospital acquired infection (HAI)• W i rong s

ite surgery

• Adverse dru

g () event 

(ADE

)

• Patient fallsAnswer – diff b h i l b differs 

between 

hosp

ita

ls 

but not 

site surgery

11/9/2009
1) Cost of poor quality – one 

• 16 pediatric patients with an SSI vs 16 matched 

patients, similar operation, no SSI

•

LOS 10.6 days longer

• $27 288 extra cost for each patient with a preven

“data analysis strengthened and focused our effort

future SSIs”
Evidence of avoidable wa

• 100k hospital acquired infections 

(5k die

) in En

€1.4bn Costs (UK Hoc rprt 2000)

•

€330 di i t d 330m medi

c

ines re

turne

d t h i f di 

to p

harmac

ies 

for dis

year UK (BMJ 2002)

• 40% f di ti 40% o

f medications unnecessary (R d USA t 

(Ran

d USA s

t

u

• 25% of radiological tests not necessary (UK Roy

of Radiologists) of Radiologists)

• 25% of hospital days and clinical procedures ina•

€415b / “ t d t d d d i ffi i t 

415b

n

/yr 

“was

t

e

d on ou

tmo

d

e

d an

d

ineffi

c

ien

t 

procedures in the US” Juran study

the cost of poor quality care will likely exceed $1 trilliothe cost of poor quality care will likely exceed $1 trillio
Poor quality and safety typ

For patients• Over-use (no medical benefit)

– Tests and antibiotics

• Under-use of effective treatments

– 79% of eligible heart attack survivors fail to receive beta blocker– anticoagulant to prevent thrombi

• Miss-use (esp miss diagnosis 10%-15%)•

U de n r-coo d o r

dinati

o

n

– 500 GPs - 70% reported late discharge summaries “often” or 

reporting it “compromised clinical care” and 68% “compromi”

. One summary arrived 11 years late One summary arrived 11 years late

For Organisations Under, over, and miss-use of QS interv
The “in-between” problem

• Communication and transfers between shifts

professions, services.

– Bolton hospital: 250 communications hand-off b

personnel to discharge one patient with complex 
Solutions – do they work and do t

more than the problem?

1)Effectiveness evidence – AHRQ 2001 “Nike • Timely antibiotics before surgery• Barrier precautions before central line cathet

Barrier precautions before central line cathet

But2) little evidence of effective implementation method

Eg training p pp p , computer support, feedback, supervisi

3)little evidence of spend cost• Wh d k ? What do we know?
Operation cancellations and dela

ys in 

(Øvretveit 2000)

• Cost of waste of 98 cancellations every three 

€50 000? 300 000 or 900 000? 50,000?, 300,000 or 900,000?

Evidence Cost = 

€320,000 annually

•

S

pend 1 

year = 

€ 98,000.

• Saving = 

€ 62,000 for Yr 1, 

€160,000 for fut

reduction sustained at no cost reduction sustained at no cost

11/9/2009
VHA - reported experien

Falls resulting in fractures av

$30,000 

• 30% over 65 with a fall-related fracture die

“An investment of $25,000 in a fall prevention progra

$115,000 in savings in fracture care”

Nosocomial infections cost a minimum of $5,000 per “An investment of $1,000 in hand hygiene yielded $60

avoided care costs” 

Calculation details not given

(Source: Bagian reports from VHA (in AHRQ 2008) 
Summary so far

• Widespread quality and safety problem• High financial cost• Some evidence of effective solutions Some evidence of effective solutions• Effectiveness locally depends on implementa

– And infrastructure supports for quality (previous 

investment) 

• Solution “spend cost” – little research, local • Save money Save money – some evidence some evidence

11/9/2009
Your experience – note

1) I have been involved in a quality or safety i2) We know how much the improvement cost 3) We know we saved money We know we saved money4) We know someone else saved money from • How do we make or save money from impr

How do we make or save money from impr

11/9/2009
Point 1) Increasing income is fast

getti hf d i i

n

g cas

h

from re

duc

i

n

g wa

What we learned from reducing OPs cancellations & • Paper savings are not cash savings: the “show me t

issue

• Saving time and materials does not bring cash imm• May save on next years purchasing or use fewer sta

May save on next years purchasing or use fewer sta

• Quicker cash from increasing throughput

– But purchaser ceilings & other bottlenecks
Point 2: Payment disincentives for im

• Glaucoma care reimbursement 300€• Hospital cost to provide it 1 800 Hospital cost to provide it

1,800

€

• But Surgery income 2,270€• P tl reven

t g

laucoma = l 1500 oose 1500

€ D th oe surgery= gai 227

n

“The current deficit on glaucoma care in the eye hospitals is in

through the through the profits made with cataract surgery profits made with cataract surgery

”
The Mary case: Financing system dis

• Discharge early with no information Discharge early with no information• Triple incentive for poor quality

– Save on early discharge (lower LOS, DRG based fixed i

– Paid for readmission

– Save on costs of time to give info to PHC and cost of sy– No finance to invest in improvement

• Paid to treat illness caused by healthcare or poor co

–

E

g readmissions due to 

p yg oor treatment or earl

y dischar

g

e

– BUT DRG based payment does not reward infection or A–

No 

q y ualit

y measures

– AND P4P never events systems are penalising a few 
Implications - Practical

• 5 yr Measure quality and include in financing 5 yr Measure quality and include in financing• 5 yr Change financing system• 2 yr Agree cost and savings sharing for improveme• 1yr Select improvements which save or make mone

current system

• Focus on Value im

p g p 

rovement = chan

ges which im

p

or save or make money
Implications - practical

• Ch hi h i b id i h 

Choose whi

c

h

improvements 

by consider

ing t

he 

case as well

• Ch h li i i d d 

Choose t

hose cli

n

i

c

ians an

d managers want, an

d 

purchasers and providers can agree on

• U h hl h Use researc

h to 

h

e

lp c

hoose - gi i di i 

ives 

i

ndicat

ion o

– Problems likely in your service – but you need local – Effective solutions – but it you need to assess your i

capability for each

– P ibl i Possible sav

ings – b t it d t d th b i 

b

u

t it you nee

d

to 

do the 

bus

iness 

payment system, and increasing income is faster thafrom reducing waste

– Cats end
PART3 : Leading change

H d an s up

• Our change is faster and more ef

than I expected

• Limited progress is my fault Limited progress is my fault – we 

we 

work harder to make the change

11/9/2009 
Good news from research Good news from research

• Research found slow change is typical• It might not be you but your surroundings w

It might not be you, but your surroundings, w

constrains change

–

Change and innovation depends less on your leadership 

hange and innovation depends less on your leadership 

implementation strategy, than whether you have “a supp

• History and culture of experimentation in your organ

failure allowe

d

• Change management expertise for advice• Higher levels allow time to design and test changes Higher levels allow time to design and test changes• Incentives

11/9/2009 
Why John did not grow up in Norw

Ø i

John’s Dad: I like

and I couldn’t chan

Mrs Øvretveit:

I could not grow

roses thereall the year round all the year round

Y h ou can change

the soil 

but not the climate 

11/9/2009 
Roses year round Roses year round – what does it ta

what does it ta

Seed Gardener/planting & nurture Clim

Your change?

Change idea + Co

+ Implementation actions

Your change?

11/9/2009 

g

Evidence + Implementation + Env
Collective multi Collective multi-level leadership n

level leadership n

• Leaders at higher levels 

– Create conditions which help or hinder.. lower level leaders to make value improvement lower level leaders to make value improvement

Example Johns Hopkins ICU safety programme56. What leading improvement is really like

11/9/2009 
Original initiative at Johns H

• Recovering from burns at th

Hopkins Children's Center, 

•

Josie, 18-month-old

• Staff missed warning signs o

dehydration

– cardiac arrest cardiac arrest

• Ms. Sorrel King - not reveng

to prevent this again to prevent this again

• “Apologize. Tell the truth. A

steps to fi h bl ” fix the problem.

”
Response

• Josie's nurses, Drs Paidas and McKee with Second Sunday after Josie's death, • Dr George Dover head of the Center visited Dr. George Dover head of the Center, visited"This is my hospital. This happened on my wa

my responsibilit I'll t t th b tt f it 

ibility. I'll get to the bottom of it,

“A committee will review, as required, what h

recommend ways to correct any problems...

the hospital will not cover anything up”

9:30 and 10 every Friday morning talk with S
Case Review

• Aft th k i After three weeks in recovery - wei ht l d

ight loss, severe d

intense thirst and lethargy.

• Warningg f y signs of severe dehydration not acted on 

– shortcomings in communication, between the surgeo

team, between doctors and nurses.

• Agency nurse Agency nurse - more assertive in alerting physician

more assertive in alerting physician

• After doctors removed Josie's central line - should h

another intravenous line.

• Resuscitation efforts after arrest hindered without oCaregivers should have listened more closely to Sorrel Caregivers should have listened more closely to Sorrel

repeatedly expressed worries "Nobody p, knows a child better than the parents," 
Local clinical champion

• Af l l l S l D P P After 

lega

l sett

lement, 

Sorre

l met 

Dr 

Peter 

P

Anesthesiologist & critical care specialis

• When medical student at Hopkins, father die

error made at a Connecticut hospital

•

Lymphoma misdiagnosed as another cancer 

• Did not receive proper treatment. 

• Died at home in pain, weighing only 38kg.

"Sorrel and I both felt this very strong commitm

patients deserve more...

...We felt like kindred spirits, that we were on a 

together."
Other local leaders

•

Dr. Charles Paidas -

pediatric surgeon in Jo

part of the safety initiative. 

• “There are certain people in this world that 

mentors, that sp g ark enthusiasm, new energi

people," "And Sorrel's that kind of person.

There s' magic that magic that s' going to come out of this

going to come out of this

"And I don't think anyone here would disagre

because of the family because of the family. "
2002 Josie King Patient Safety Pro

• Funded in part by Sorrel Funded in part by Sorrel s’ $50 000 contribution $50,000 contribution, 

• Two teams at the Children's Center: find safety problems and devise ways to preve

Pronovost introduced Sorrel at a pediatric grand rounds. • Auditorium packed with doctors, nurses, pharmacists, & the hospital president, D"Doctors and nurses make mistakes, and lives are being lost. These human errors nee

solution. You are the only ones that can solve this problem,"

Role of hospital leaders 

"This is my hospital. This happened on my watch. This is my responsibility. I'll get to • Understood punishing individuals would not remedy the system causes

Death review – “we are not looking for someone to blame...• We are looking for deficiencies in the hospital's system that has allowed failures t

with these tragic results”

William Brody, p p y resident Johns Hopkins University echoed this • "We really need to redesign the whole system from the inside out," - "This is a rev
Supported the evolving program at 

• Pl d d i d il 8 Planne

d an

d carr

i

e

d out a pilot 

8 step program

improve safety in 2 surgical ICUs

• S d t t f JH Sprea

d

to res

t of JH

• One step – find staff safety concerns. 

• I ICU di ti i t f til t In ICU: medication errors 

in 

transfers, ventila

tor c

communications. 

• And reducin

g f

 catheter related blood stream infecti

• CDC guidelines not followed – esp residents no

barrier precautions

• Intervention: Checklist, correction by nurses, f

data.

• 96% drop, no CR-BSI in 9m
VHA leaders

• VHA ICU improvement programme led by P• Used Hop pp kins approach to reduce Ventilato

CR BSIs

• VAP down by 50% (7.5 to 5.3/1000 pvds) VAP down by 50% (7.5 to 5.3/1000 pvds)

• State leaders
Michigan Hospital Association (

Keystone p g ro ramme

• Nearly all ICUs participated Nearly all ICUs participated – apply CR BS

apply CR BS

• Overall CR BI rate per 1000 catheter days a• 3 h di f ll f 2 0 3 months Median fell from 2.7 to 0• 18 months mean 7.7 to 1.4 • Cost of each $12k-$54k• Pronovost et al 2006 NEJM Pronovost et al 2006 NEJM
National leaders

•

Established NNIS measurement and staff fo

based infection control (National Nosocomi

Infections Surveillance System)

• AHR

Qf g p g funded Michigan 

pro

gramme

• Federal-level context factor hindering impl

enforcement of patient privacy regulations benforcement of patient privacy regulations b

authority.

• The reaction of individuals and organisatio

The reaction of individuals and organisatio

different levels then influenced change to th

context factor context factor.
Conclusions

• Leaders ST: instinctive symbolic action from • Create context of y s stems, culture, resource

procedures

• Passion, persistence and procedures Passion, persistence and procedures
“3Ps” of the science and politic

improvement 

• “1P”=People

–The core project team & associate–th l e p ayers, –and the psychology power and po

and the psychology, power and po

change.

Principle 1: involve the right people in the r

a structure and process for implementati

11/9/2009
“2P”: Principles

• Invol th i ht l i th i ht (

lve the right people in the right way (

creation)

• Ai il t d t Aims, miles

tones an

d ou

tcomes. 

• Define the actions 

– to reach each of the milestones and agree w

what in practice, and when

• Start small test and spread Start small, test and spread• Communicate 

• wh t d t b d d h t th th 70 h

a

t nee

ds 

to 

be 

done an

d w

hy, 

to the other 70

service who are affected by the change.

• Feedback presented visually and continu

Feedback presented visually and continu

• Reviews and adjustments: 
“3P”: Process - the steps and 

1. F th t t F th j t t Form the structure: Form the core project te

aims, milestone and outcomes are agreed a

understood, 

2.Agree the measures, tasks and actions: Pro

assesses help g ers and hinders to the chang

same time as they define the detailed actioothers need to carry out to achieve the cha

3.A f db k i f i Arrange ways to get feedback information

4.Start the actions

5.R i ev ew progress

6.Adjust the actions

7.Senior management review and decisions a

Senior management review and decisions a

actions till the next review 

11/9/2009
Summary

• We all have personal experience of the cost of p• Evidence that the p p roblem is widespread• Some preventable and evidence of effective sol• S id f i Some evidence of savings

• Your local business case 

– needs to estimate your implementation capability – Take account of py y py ayment system and time till pay-b

• Focus on Value improvement• U i k h ld k i h 

Unite stakeholders to work with current system 
What leading improvement is re

.
Implications – for you?

• Any surprises?• Have you done costings? • Do you now need to? Do you now need to?• What needs to change?• What you you need to know more about?

11/9/2009
Where to find out more

Øvretveit, J (2009) Does improving quality save money? Health Foundation, LØv etve t retveit, J ( 009) ead g ev de ce o ed va ue p ove e t ea t ca 

J

(

2009) Leadin

g evide

nce informed value im

p

rove

m

e

n

t in health ca

Press, Chichester, UK

Others case experiences reported onHealth foundation: http://www.health.org.uk/current_work/IHI: htt

p gp ://www.ihi.or

g/ihi/to

pics

AHRQ innovations exchange: 

http://www.innovations.ahrq.gov/index.aspx

11/9/2009
Your experience making improv

• What have you seen a leader do which affect

What have you seen

a leader do which affect

improvement change?

• Wh l l d d i 

What can on

ly 

lea

ders 

do to get 

improvemen

• Wh

y don’t more do it?

11/9/2009
.

•DETA S IL
.

•

.

–

.

•

.

–

.

11/9/2009
Hopkins known for clinical resea

centre of excellence.

• Environment conducive to trying different patient safety practices. •

Pronovos

t and other colleagues influenced the hospital to provide d

infrastructure supports 

• Helped their test and development of ICU safety practices, and then 

throughout the hospital. throughout the hospital.

• eg if physicians did not follow every step on the checklist, the nurse

supported to intervene by higher management.

• Through conferences and other media (which are ‘supportive con- 

Pronovos

t spread h id d id d the ideas an

d evidence, 

• Influenced VHA and the Michigan Hospital Association (MHA) to 

programme. 

• MHA and Michigan state created some context factors which influ

MHA and Michigan state created some context factors which influ

implementation. 

• One federal-level context factor hindering implementation - enforc

privacy regulations by a federal authority.

• Th ti f i di id l d The reaction of

i

ndi

vidua

ls an

d organi ti sa ons at diff t l l th 

t differen

t

leve

ls the

change to this national context factor.
Local context factors 

Found in the research to be important to getti

change were: 

• characteristics of the unit and of the hospita• leadership,

• knowledge, 

• culture, 

• communication, and 

• pre-existing performance 

(Pronovost e(Pronovost e
Typically

‘environmental features’ are: financial, polit

regulatory, profession-related, and change r

For the chosen improvement, • a leader and their implementation team may 

a leader and their implementation team may 

research into a similar change 

• which has investigated context or barriers t

which has investigated context or barriers t

implementation. 

C i t ti i t f t Can give a starting point for an assessment. 

Failing this, it is possible to use general theor

environmental factors supporting change wrelevant. 
Environment for improvem

Everything which is not the change, impleme

outcome’. 

• Many aspects play no role in helping or hin

implementation but some are critical.

• The context factors important for impleme• a computer physician order entry system (C

likely to be different to those for 

• proph lactic antibiotics before s rger to r

prophylactic antibiotics before s

urgery to r

surgical infection. 
Different context factor

Infl ence implementation in different a s These can Infl

uence implementation in different 

ways. These can 

into background, necessary, and direct context facto

Background condition 

• helpful for implementation action and generally supportive 

improvement 

• (e.g. good safety culture, adequate staff- ing, posters askin

if the staff member washed their hands [the absence of thincrease risk of harm]). 

• These conditions reduce ‘latent failure’ factors.

Necessary but not sufficient context factor for implem

• Implementation far less likely without this factor• e.g. hand washing facili- ties and alcohol rubs available (a 

may also be a direct influence).

Direct influence: • on implementation actions, or on the change intend

• e.g. disciplinary action for failure to follow hand hygiene p

(individual/behaviour change level), or accreditation standprocedure for this.
Conclusions

1. This was new or surprising for me This was new or surprising, for me...2. Th f l id f k he most useful idea for my work was...3. What I would like to find out more abou11/9/2009