WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care

Date: July 24, 2014

Featuring:

• Kedar Mate, MD, Vice President, Institute for Healthcare Improvement
• David Williams, PhD, Improvement Advisor and Founder, TrueSimple
• Jonathan R. Studnek, PhD, NRP, Quality Improvement Manager, Mecklenburg EMS Agency (North Carolina)
• Kevin Rooney, MBChB, FRCA, FFICM, Consultant in Anaesthesia and Intensive Care Medicine; Professor of Care Improvement, University of the West of Scotland

When it comes to reliability, it’s hard to beat the track record of paramedics and EMTs. Whether it’s speed, knowing just what to do in the event of an accident, serious injury, gun violence, or heart attack, or the amazingly calm and reassuring way  emergency responders go about their work, there are plenty of reasons to heap praise on this group of individuals. This also includes how patients are cared for during that ambulance ride to the hospital emergency department.

 

Could our opinion of EMTs get even higher? Maybe so, now that emergency medical services (EMS) are becoming part of fully integrated health care systems and paramedics are being trained and equipped to initiate even more life-saving and beneficial treatments in the field. Our guides — Kedar Mate, David Williams, Johnathan Studnek, and Kevin Rooney — have a compelling story to tell about dramatic changes underway with EMS, not just in the US but globally. The very use of the term “prehospital” reflects new strategies and capabilities to respond more effectively to patients suffering heart attacks, strokes, and traumatic injuries.This is the evolution we explore on this WIHI.

WIHI: New Roles, New Routes for Managing Populations

Date: June 19, 2014

Featuring:

• Trissa Torres, MD, MSPH, FACPM, Senior Vice President, Institute for Healthcare Improvement
• D. Clay Ackerly II, MD, MSc, Associate Medical Director, Population Health and Continuing Care, Partners Healthcare; Assistant Chief Medical Officer, Non-Acute Services, Massachusetts General Hospital
• L. Gordon Moore, MD, Chief Medical Officer, Treo Solutions (a wholly owned subsidiary of 3M)
• Jennie Chin Hansen, CEO, American Geriatrics Society

If you’re wondering why health care quality and clinical leaders have been talking a lot more with their counterparts in finance or IT, look no further than the latest value-based contract they’ve likely just entered into with a payer. Within a hospital, these leaders may be putting their heads together to figure out how to deliver better care and better value for whole populations of patients. How might their data systems, for instance, help them better understand the utilization patterns and needs of everyone they see with Type 2 Diabetes? Or, within an accountable care organization (ACO) comprising a major hospital system, several physician practices, and a skilled nursing facility, how can the representative senior teams guide operations to reflect new, shared responsibilities and forge new ways to work together?

It’s early going with these new types of arrangements, and no one has it all figured out. But as organizations from across the continuum of care get up to speed, they’re eager to share what they’re learning. On this WIHI, host Madge Kaplan welcomes IHI Senior Vice President Dr. Trissa Torres, a long-standing medical director, who has many years of experience from her work in Michigan developing greater collaboration between health care delivery organizations and surrounding communities to improve population health. At IHI, she is currently helping to frame the skill sets all leaders need to accelerate this type of change on a broader scale.

This WIHI also taps into the on-the-ground experience of Dr. Clay Ackerly, whose title at Partners Healthcare, Associate Medical Director of Population Health and Continuing Care, speaks to the new responsibilities he has and that are in store for leaders like him. Dr. L. Gordon Moore, with years of experience helping to redesign primary care, is now working with office practices to enlarge this vision to encompass population health.

Rounding out the WIHI panel is the CEO of the American Geriatrics Society, Jennie Chin Hansen, whose pioneering work in San Francisco helped lay the groundwork for the comprehensive and integrated national program known as PACE. She understands well the needs of older patients, an increasing number of whom now receive their health care in hospitals, clinics, and community settings that are operating under shared savings agreements with Medicare.

You will hear some good ideas to carry forward, including your own ideas and experiences which the panelists are very eager to hear about. You might also want to try out a population management assessment tool that IHI has developed.

WIHI: Making the Work of QI Less Draining and More Sustaining

Date: June 5, 2014

Featuring:

• Chris Hayes, MD, MSc, Med, FRCPC, Harkness Fellow in Health Care Policy and Practice (IHI); Medical Officer, Canadian Patient Safety Institute
• Uma R. Kotagal, MBBS, MSc, Senior Vice President for Quality, Safety, and Transformation, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
• Julie A. Holt, RN, MSN, CENP, Vice President, Patient Services, Cincinnati Children’s Hospital Medical Center

If a systems approach is our best shot at improving the safety and quality of health care, a systems approach might also help address the added time and complexity that’s often a feature of improvement work itself. There are growing signs that even the most dedicated improvement champions and clinicians are overwhelmed by what’s required to meet new standards, regulations, and reporting requirements; and, even more troubling, frontline staff are starting to resent and question the value of new quality initiatives and expectations. Add to this physician burnout, which has been a festering problem in the US since the 1990s, and the time is ripe for some solutions.

 

How can organizations be mindful of the burden constant change places on frontline staff? What is "maximally adoptable improvement" and how can improvers better understand it? We explored all of these issues and this WIHI. 

WIHI: The Patient-Centered Medical Home: Early Results, Tough Scrutiny

Produced in collaboration with the Journal of the American Medical Association (JAMA)

Date: May 22, 2014

Featuring:

• Mark Friedberg, MD, MPP, Natural Scientist, Professor, Pardee RAND Graduate School
• Christine A. Sinsky, MD, Medical Associates Clinic and Health Plans (Dubuque, Iowa); Director, American Board of Internal Medicine
• Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement
• Richard Baron, MD, President and CEO, American Board of Internal Medicine, ABIM Foundation

The patient-centered medical home (PCMH) is getting a hard look this year. In a study published in JAMA in February 2014, the largest of its kind, researchers followed 32 primary care practices certified as PCMHs over a three-year period, and were unable to find any impact on overall health care costs or patients’ utilization of health care services, including emergency departments.

To put it mildly, this was not welcomed news by the health care improvement community — especially those who are looking to PCMHs as one jewel in the crown of a redesigned primary care system that offers patients more integrated, coordinated, cost-effective care. Headlines such as “Medical Homes Haven’t Saved Money or Substantially Improved Care” and “Medical Homes May Not Be The Answer” suggested just the opposite.
 
This is not the entire story. The state of Minnesota recently issued a report on its success with PCMHs. And, where focused work is underway elsewhere, the uptake of process improvements is encouraging. But the study in JAMA has functioned as a sort of wake-up call, which many experts, including champions of PCMHs, believe is timely and beneficial. On this WIHI, we pulled together some of these experts for an intensive look at the early results and critical next steps for the patient-centered medical home.

WIHI: Partnering with Patients for Safety: The Next Phase of Work and Commitment

Date: May 8, 2014

Featuring:

• • Tejal K. Gandhi, MD, MPH, CPPS, President, National Patient Safety Foundation and Lucian Leape Institute
  • Susan Edgman-Levitan, PA, Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital
  • Maureen Bisognano, President and CEO, Institute for Healthcare Improvement
  • Linda K. Kenney, Executive Director and President of MITSS (Medically Induced Trauma Support Services, Inc.)

Health care is at a tipping point with respect to patient engagement – from something that’s “nice to do” (or even “the right thing to do”) to something that’s absolutely necessary. Research and experience are making it clear that no health care organization can operate in a reliably safe way without the involvement of patients and families. And without their involvement, any organization’s safety agenda is bound to encounter diminishing returns. Patients and family members offer extra eyes and ears to events unfolding around them, and have crucial knowledge about and perspectives on what kinds of changes will help them the most.

To frame what a vision of patient engagement needs to encompass, and what an across-the-board implementation of that vision needs to embrace, The National Patient Safety Foundation’s Lucian Leape Institute (LLI) has just published a comprehensive report that lays it all out: Safety Is Personal: Partnering with Patients and Families for the Safest Care. The contents of the report and just how to make it actionable are the focus of this WIHI.

WIHI: Transforming Tensions and Tempers on Health Care Teams

Date: April 24, 2014

Featuring:

• Neil Baker, MD, Principal, Neil Baker Consulting and Coaching
• Nan Cochran, MD, President, American Academy on Communication in Health Care (AACH); Associate Professor of Medicine, Geisel School of Medicine and Dartmouth Institute for Health Policy and Clinical Practice
• Calvin Chou, MD, PhD, FAACH, Professor of Clinical Medicine, UCSF; Vice President for External Education, AAC

The last thing a patient needs to experience at a hospital or a clinic is tensions between staff members. Yet, we've all been there and seen and heard things that make us wonder “who isn’t getting along with whom” or, worse, are we getting the best care when we can tell providers are just barely disguising their frustrations with one another? It's a fair question, especially since health care is being redesigned at all levels to be more of a team effort. Doesn't that mean that the team has to be cohesive and everyone needs to get along?

 

For this WIHI, we brought together the expert group that spoke to a packed room about managing conflict on health care teams at IHI’s 25th Annual National Forum in December 2013. Neil Baker, a longtime IHI faculty member, has spent the past 30 years helping organizations and professionals deal with "people issues" that jeopardize patient safety and stall improvement work. Nan Cochran, the president of the American Academy on Communication in Healthcare, trains around conflict management and negotiation, and Calvin Chou focused on teaching medical students and residents humanistic clinical skills that are critical to communicating more effectively with patients.

 

Listen and learn about the skills that can help health care teams understand and appreciate their differences and avoid the pitfalls and conflicts that cause disruption and harm for patients.

WIHI: Reclaiming Empathy — Best Practices for Engaging with Patients

Date: April 10, 2014

Featuring:

• Helen Riess, MD, Director, Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital
• Stacie Pallotta, MPH, Senior Director, Office of Patient Experience, Cleveland Clinic

• Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement

Empathy is not the same thing as sympathy. In the first instance, we feel seen and truly heard; sympathy tends to maintain a distance between two people, often deliberately so. One of the best explanations of the distinction, and why empathy can be so much more powerful, is an online video narrated by human vulnerability expert Dr. Brené Brown. And then there’s the Cleveland Clinic’s video about empathy, directed at health professionals. This moving reminder of the stories behind the faces of patients that pass through health care every day has been viewed on YouTube over a million times.

Why the seemingly sudden need to draw the attention of doctors and nurses to the humanness of the patients before them? Is it because, as some fear, empathy is becoming harder and harder for health professionals to feel and express in the course their jobs? Could be, but there’s nothing inexorable about the loss of empathy in health care today. And, as we learned on this WIHI, there are effective ways to help today’s busy and often overwhelmed caregivers reconnect with their own feelings and the feelings of others, namely their patients.

At the Cleveland Clinic, Stacie Pallotta is part of a team that’s looking at empathy as one important part of an overall strategy to improve patient experience. Dr. Helen Riess, who specializes in the neuroscience of emotions and has given a TEDx talk on the power of empathy, is turning her findings into “empathy education” for health professionals. She’s also found that if students’ empathy towards patients tends to erode over the course of their medical training, as evidence suggests, new research shows that additional training can either disrupt or reverse this process. 

We hope you'll listen to this vibrant discussion on what caregivers can do to reconnect their emotions to the patients they care for.

WIHI: Bright Spots for Patients with Complex Needs

Date: March 27, 2014

Featuring:

• John W. Whittington, MD, Lead Faculty, Triple Aim Initiative, Institute for Healthcare Improvement
• Crispin Kontz, Manager, Support and Clinical Systems, Alberta Health Services (Edmonton, Canada)
• Catherine Craig, MPA, MSW, Independent Consultant, Community Health Transformation, Care Coordination
• Ann Lindsay, MD, Co-Director, Stanford Coordinated Care, Stanford Hospitals and Clinics

When Atul Gawande wrote in The New Yorker about high utilizers of the health care system in Camden, New Jersey – “hot spotters,” he called them – he attached faces and stories to the very real human drama and challenge of meeting the needs of some of the most complex patients among us. Since that article was published in 2011, interventions and initiatives to better support, care for, and partner with populations with costly and life-draining multiple illnesses and problems have grown in number and effectiveness. We touch base with some of the people spearheading this work on this WIHI.
 
Dr. John Whittington and a team here at IHI have been working with close to 140 organizations around the world for several years now on transforming how health care and communities engage with people with complex needs. Dr. Whittington has been relentless in harvesting the learning from this work. He has often collaborated with Catherine Craig, who brings deep experience about raising the health and the expectations of especially disenfranchised communities. Crispin Kontz has some fresh results and progress to share with us from Alberta Health Services in Canada. Dr. Ann Lindsay told us about a truly innovative new clinic she co-directs that’s been designed explicitly for individuals with chronic health problems and illnesses. Care coordination is its middle name. Imagine what we might learn from this model! Imagine, also, what can come from community coalitions, data sharing, co-designing with patients, greater use of community health workers, and more. 
 
In the US, 5% of the population contributes to 50% of all health care costs. Most of us can recite this statistic as though it were immutable. But it need not be. Listen to our four outstanding experts about improving the health and the lives of complex populations.

WIHI: How High? How Low? Shared Decision Making Amidst Shifting (Hypertension) Guidelines

Produced in collaboration with the Journal of the American Medical Association (JAMA)

Date: March 13, 2014

Featuring:

• Craig W. Robbins, MD, MPH, Medical Director, Center for Clinical Information Services, Kaiser Permanente Care Management Institute
• Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement
• Peter Basch, MD, FACP, Medical Director, Ambulatory EHR and Health IT Policy, Medstar Health
• Eric Peterson, MD, MPH, Director, Duke Clinical Research Institute; Professor of Medicine, Division of Cardiology, Duke University Medical Center

 

Hypertension is a hot issue, especially in the US, where an expert committee recently recommended that the available evidence does not support initiating treatment (largely medication) for people 60 years or older until their blood pressure climbs to 150 over 90. The decades-long consensus had been to initiate treatment at 140 over 90, which is still the recommendation for adults younger than 60. The reasons for this change are possibly as complicated as the guideline process itself, but one of the chief concerns of the majority on the Eighth Joint National Committee (“JNC 8”) is the risk associated with aggressive treatment of hypertension in older adults.
 
So, can we talk about this? We invite you to listen to this special WIHI produced in collaboration with the Journal of the American Medical Association. The discussion was constructive and forward-looking.

 
Some experts take exception to the committee’s findings and the process itself. Our guests are going to take all that into consideration, but, with your help, we’ll focus primarily on the best ways to approach changing and often-debated guidelines when working with patients to achieve optimal health. (The new guidelines for determining who should be put on statins to lower cholesterol are another case in point.)

WIHI: Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

Date: February 27, 2014

Featuring:  

• Laurie Herndon, MSN, GNP-BC, Director of Clinical Quality, Massachusetts Senior Care Foundation
• David Gifford, MD, MPH, Senior Vice President, Quality and Regulatory Affairs, American Health Care Association
• Annette Crawford, Administrator, Stafford Healthcare at Ridgemont
• Marie Schall, Director, Institute for Healthcare Improvement

In the world of health care improvement, and in society at large, talking about skilled nursing facilities (SNFs) and long-term can be a tough subject. When a loved one moves in to a nursing home, they’re usually quite elderly, and it's often the last move they'll make of this kind before dying. So, whether because of this association or because other sectors of health care tend to get more attention, the hard work that’s going on to ensure that all types of SNFs, and nursing homes, deliver high-quality and patient-centered care, has been somewhat obscured. We’d like to help change this by zeroing in on one aspect of the work.
 
This WIHI looks at new developments with better coordination and communication between SNFs, local hospitals, and various community stakeholders, to reduce unnecessary transfers of patients to acute care settings. These avoidable admissions or readmissions can come from short-term-stay SNFs or long-term ones, from assisted living residences or rehab facilities.
 
Unpacking what’s behind unnecessary transfers and what better, safer, actions might be taken has been the focus of IHI’s STAAR initiative and is captured in one of a series of STAAR How-to Guides: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations.

 

Our guide on the learning and momentum everyone can build upon from STAAR was IHI’s own Marie Schall, who’s also the first to point to the rich activity and resources available from Laurie Herndon and the widely recognized INTERACT program.
 
Another huge resource is the American Health Care Association, which is mobilizing SNFs across the US to do their part to reduce readmissions within 30 days by 15% by 2015. David Gifford also spoke to these efforts.
 
And, then there’s the amazing example of Kitsap County in the state of Washington, where Annette Crawford’s SNF has played a leading role building a new kind of coalition across the continuum of care to ensure that patients get the right care in the most appropriate setting.