WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: No Excuses, No Slack! The Latest from the Front Lines on Hand Hygiene

Date: March 7, 2013

Featuring:

• Gene H. Burke, MD, Vice President and Executive Medical Director for Clinical Effectiveness, Sentara Healthcare
• Michael Howell, MD, Director of Healthcare Delivery Science, Director of Critical Care Quality, Beth Israel Deaconess Medical Center
• Lisa L. Maragakis, MD, MPH, FSHEA, Director of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital
• Scott A. Miller, MD, FACP, Vice President, Medical Affairs, Sentara Leigh Hospital
• Tom Talbot, MD, MPH, Chief Hospital Epidemiologist, Vanderbilt University Medical Center

One of the cornerstones of infection prevention in any health care setting, including when someone is being cared for at  home, is good hand hygiene. Much of the attention in recent years has focused on hospitals and their rates of hand hygiene compliance among staff. And rightly so. Among the biggest contributors to hospital-acquired infections are, inadvertently, health professionals themselves... and others who come in contact with patients.

The good news is that awareness of the necessity of strict hand hygiene compliance has never been greater… not just in the US, but in acute care settings globally. And this awareness has been coupled with practices that are being adhered to more reliably than ever before. But not everywhere, all the time; organizations that can tout rates as high as 95% are still the exception, not the rule, and good performers continue to face challenges closing the gap.

WIHI host Madge Kaplan gathered infection prevention leaders and clinicians from four organizations whose recent innovations with hand hygiene at their facilities represent what could be the best bet yet that 100% compliance is achievable. Sentara, Johns Hopkins, Vanderbilt, and Beth Israel Deaconess Medical Center all have fresh approaches that rely on new kinds of auditing tools to discern what really works; better surveillance, monitoring, and measuring; reengineering; constant education; and a laser-like focus on behavior and culture change.  

What’s working in your organization? How are you getting your hand hygiene compliance rates to move upward? Compare and contrast your methods with those of our guests on this WIHI.

WIHI: Clinicians and Financial Staff Can Improve Quality and Lower Costs, Part 2

Date: February 21, 2013

Featuring:

• Norman E. Dascher, Jr., FACHE, CEO of Acute Care – Troy and Vice President, St. Peter’s Health Partners, Northeast Health (Troy, New York)
• Lucy A. Savitz, PhD, MBA, Senior Scientist, Institute for Healthcare Delivery Research, Intermountain Healthcare
• Katharine Luther, RN, MPM, Vice President, Hospital Portfolio Planning and Administration, Institute for Healthcare Improvement (IHI)
• Catherine Abbott, RN, MSN, Administrator, Performance Improvement, Hackensack University Medical Center (Hackensack, New Jersey)

 

Here’s the rub about reducing health care costs to improve your hospital’s bottom line: The “old” solutions of cutting back on staff and services are shortsighted at best. The best solutions require delivering better care and getting rid of wasteful practices. Even getting bigger to achieve efficiencies and economies of scale won’t help in the long run; the new world pays for value over volume. And value involves care coordination that follows patients wherever they go, including after they leave your hospital.

How to survive, and thrive, in this brave new world? This WIHI is the second installment of a focus this month on cost reduction strategies that marry the best ideas from quality improvement with sharpened-pencil, financial and business acumen. The discussion focuses on the work of two organizations — Northeast Health and Hackensack University Medical Center — and unpack how they, and some 58 other organizations that were part of IHI’s Impacting Cost + Quality initiative, are on track to save $43 million.

Can your hospital leadership commit to reducing costs at least two percent over the next five years, while maintaining or improving quality? If you can’t make that commitment today, what would get you on the path to making it? WIHI host Madge Kaplan, with the help of IHI’s Kathy Luther and three dynamic hospital leaders and experts — Norm Dascher, Lucy Savitz, and Cathy Abbott — promise you a bold and bottom-line discussion.

The following materials may also be of interest:

• Leaders challenged to reduce cost, deliver more. Healthcare Executive. Jan/Feb2012
• Eliminating Waste Without Hurting Quality. HFMA Leadership Magazine, May 2012
• IHI Innovation white paper series: Hospital Inpatient Waste Identification Tool
• IHI Innovation white paper series: Increasing Efficiency and Enhancing Value in Health Care

WIHI: Employers and Employees Can Improve Quality and Lower Costs: Stories from the Front Lines, Part 1

Date: February 7, 2013

Featuring:

• Trissa Torres, MD, MSPH, Senior Vice President, Institute for Healthcare Improvement
• Xavier Sevilla, MD, MBA, FAAP, Vice President of Clinical Quality for Physician Services, Catholic Health Initiatives
• Lindsay A. Martin, MSPH, Executive Director and Improvement Advisor, Institute for Healthcare Improvement
• Randy Van Straten, Vice President Business Health, Bellin Health; Executive Director Bellin Run

US employers have had a lot to say about health care costs the past several years. Large and small companies alike have openly complained about the apparently inexorable rise in health care spending, skyrocketing insurance rates, and the degree to which both trends have threatened bottom lines, restrained wages, and eroded benefits for employees.

Some of the most vocal businesses have been determined to remedy the situation by exercising their purchasing clout to get better deals from insurers and by shifting more costs and co-pays onto the workforce. The most enlightened have also ramped up their wellness programs. But these “solutions” are short-term at best, and efforts to encourage employees to get to the gym and adopt healthier lifestyles are proving insufficient. So, what to do instead?

This WIHI discusses what promises to be the next wave of employer engagement in improving health and controlling health care costs in the US. This involves taking a deeper dive into the underlying, often chronic health conditions affecting today’s employees. And, in a growing number of cases, partnering and learning from health care delivery organizations working on the very same issues — heavy health care utilization and high costs — with their own staff.

WIHI host Madge Kaplan welcomes IHI’s Trissa Torres and Lindsay Martin, who have the big picture of these exciting new developments. Also joining the discussion are leaders from Bellin Health Care Systems, Catholic Health Initiatives, and other places that are “walking the talk” with their own employees. Among other things, these providers are redesigning systems to deliver better care and better value to the community and all those paying the bills: employers, public and private insurers, and patients themselves.

WIHI: A Partnership to Reduce Deaths from Sepsis

Date: January 24, 2013​

Featuring:

• John D’Angelo, MD, FACEP, Chairman, Department of Emergency Medicine, Glen Cove Hospital, North Shore-Long Island Jewish Health System
• Martin E. Doerfler, MD, Vice President, Evidence Based Clinical Practice, North Shore-Long Island Jewish Health System
• Darlene Parmentier, RN, MSN, MBA, Assistant Director of Critial Care and Telemetry, Glen Cove Hospital, North Shore-Long Island Jewish Health System
• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement
• Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement

Developing an infection can be complicated enough, but when the body's immune system reacts by going into overdrive in the form of sepsis, every second counts. The diagnosis needs to be swift and, if sepsis is confirmed, interventions in the form of fluids and antibiotics must be administered immediately. Because the global death rate from sepsis remains painfully high — tens of millions each year — stepped-up efforts to reduce mortality have been underway on a global scale for at least the past decade. And there is progress to report on multiple continents where many health care organizations have been working hard on sepsis, often as part of international initiatives such as the Surviving Sepsis Campaign and in concert with professional societies such as the Society of Critical Care Medicine.

In the US, where 25 percent of the 750,000 people who develop sepsis each year die, North Shore–Long Island Jewish (NSLIJ) Health System has reduced its sepsis mortality rate significantly. North Shore–LIJ is now in the midst of a strategic partnership with IHI to maintain and further these gains, and key learning has begun to emerge. WIHI host Madge Kaplan explores this progress on reducing deaths from sepsis with three clinical leads from North Shore–LIJ and two improvement leaders from IHI. Early detection and intervention are key, but in order to execute best practices reliably, changing the culture and engaging the leadership of the organization have proven essential. At North Shore–LIJ, focusing on the emergency department has also been foundational to testing best practices and spreading them to the rest of the hospital system.

Don't miss this very important discussion about a critical problem that everyone in acute care needs to be aware of and working on. Patients and families are getting engaged too.

WIHI: Navigating New Care Teams with Nurse Practitioners

Date: January 10, 2013

Featuring:

• Susan B. Hassmiller, PhD, RN, FAAN, Senior Advisor for Nursing, Robert Wood Johnson Foundation
• Daryl Lynch, MD, Vice Chair Ambulatory Medicine, Children’s Mercy Hospitals and Clinics (Kansas City); Director, Division of Adolescent Medicine
• Cathy Rick, RN, PhD, FAAN, FACHE, Chief Officer, Office of Nursing Services, US Department of Veteran Affairs (VA)
• Patricia Gerrity, PhD, RN, FAAN, Director, Eleventh Street Family Health Services of Drexel University; Associate Dean for Community Programs, Drexel University College of Nursing and Health Professions

As we roll into 2013, the health care improvement community has a lot on its plate. Just for starters: reducing avoidable hospital readmissions, building community coalitions to improve population health, building active partnerships with patients and families, achieving meaningful use of electronic health records, and redesigning primary care. Each entails massive changes in thinking and strategy in order to achieve the larger aim of moving health care from a volume-based to a value-based system, focused on helping everyone lead healthier lives. 

So what does the health care workforce have to do with meeting these challenges? Plenty. Caregivers must increasingly see themselves as change agents, and leaders must tap the strengths and talents of all their clinical staff in new and innovative ways.

WIHI host Madge Kaplan is pleased to kick off the new year with a discussion of how nurse practitioners or advanced practice nurses are being deployed and woven into new, interdisciplinary, team-based delivery designs. Our guides are four individuals who are engaged in both pioneering and common-sense solutions to patient needs in ways that match the right caregivers with the right patients and the right needs.

At the Robert Wood Johnson Foundation, Susan Hassmiller has a bird’s eye view of where and how nurses across the US are contributing at the top of their education and training; Cathy Rick, at the VA, is overseeing the implementation of a new national strategic plan to better align nursing services with new systems of care for some six million veterans who use the VHA; Patricia Gerrity directs a nurse-managed community health center in North Philadelphia; and, in addressing the health needs of teenagers, physician Daryl Lynch has created deep and effective collaborations with nurse practitioners.

There are challenges to getting the care team right, and disagreements over roles and functions. But as you’ll learn from this WIHI, there’s also a new spirit of forging ahead given the growing emphasis on primary care in a rapidly reforming health care system.

WIHI: Reality Knocks with Reducing (Hospital) Readmissions

Date: November 15, 2012

Featuring:

• Patricia Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement; Co-Principal Investigator, STate Action on Avoidable Rehospitalizations (STAAR)
• Elizabeth H. Bradley, PhD, Professor of Public Health (Health Policy and Management), Yale School of Public Health; Faculty Director, Yale Global Health Initiative
• Leora Horwitz, MD, MHS, Assistant Professor, Internal Medicine, Yale University School of Medicine

Of all the improvement issues facing health care, reducing avoidable hospital readmissions may well be the one that finally breaks down traditional silos — and allows promising changes to realize their full impact. Why? In order to prevent patients from bouncing back into the hospital, front-line staff must create robust care coordination strategies across multiple health care settings, as well as the home and the community — taking a fundamentally broader view of the patient journey and the reforms needed.

However, doing the right thing ​— keeping patients out of the hospital — often hurts a hospital’s bottom line. So far, anyway. In the US, the Centers for Medicare & Medicaid Services (CMS) has now imposed fines on some 2,200 hospitals for higher-than-average readmission rates, as part of new federal policy. This latest move won’t make the financial piece any easier, but it does put hospitals on notice that there’s “nowhere to run, nowhere to hide.” If you want to reduce readmissions, you have no choice but to fundamentally redesign what you’re doing now.

What are the most promising ideas and strategies to look to and build upon? This WIHI convenes some important leaders and thinkers on reducing readmissions and care coordination that, between them, have a comprehensive view of what’s working, what’s challenging, and where we go from here. Elizabeth Bradley and Leora Horwitz are among the co-authors of an article in the Journal of the American College of Cardiology published in August 2012 that examines the all-too-persistent gap between best intentions and uneven execution of known best practices. Drs. Bradley and Horwitz discuss the study findings and what can be done to help health care organizations follow through on their own robust policies. In her role as Co-Principal Investigator of IHI’s STAAR initiative, Pat Rutherford has been deeply involved with hospital leaders and officials in three states that have taken to heart the challenge of reducing readmissions, with results to show for it. Pat Rutherford also carefully tracks the work of multiple initiatives in the US, including Project BOOST, Project RED, and Hospital to Home (also known as H2H).

WIHI host Madge Kaplan welcomes Dr. Bradley, Dr. Horwitz, and Pat Rutherford to the show, to share their crucial and timely insights and learning. These improvement leaders are keenly aware of the ways in which policy and reimbursement changes surrounding readmissions are giving hospitals that want to do the right thing a jolt.

WIHI: OpenNotes: Doctors and Patients Are on the Same Page

Date: November 1, 2012

Featuring:

• Tom Delbanco, MD, Richard and Florence Koplow–James Tullis Professor of General Medicine and Primary Care, Harvard Medical School
• Robert D. Harrington, MD, Professor of Medicine, University of Washington; Medical Director, Harborview Medical Center HIV clinic; Associate Section Chief of Infectious Diseases, Harborview Medical Center
• Richard Martin, MD, FAAFP, Department Director of Community Practice Service Lines (CPSL), Scranton and Monroe Counties; Director of Care Continuum, Geisinger Health System
• Michael Meltsner, AB, JD, Matthews Distinguished University Professor of Law, Northeastern University School of Law, Boston, MA

Some changes in medicine are easier to contemplate than others. For a long time the notion that patients should be able to view what doctors write about them, following a visit, was unthinkable. It was a kind of “patient don’t ask, doctor don’t tell” policy. However, the growth of electronic health records, increased pressure for transparency, and the need to improve communication and understanding between patients and providers in every way possible are all tugging at information once considered off limits.

Despite the fear that “physician notes” have a tendency to be brief, even glib, and might unintentionally insult or alarm the reader, some health systems, like Dartmouth Hitchcock, have been successfully offering patients easier access to these notes, along with the entire electronic health record, for several years. [See the December 2009 WIHI: OpenNotes and the Electronic Medical Record.]

Still many more health systems have been on the fence, waiting for evidence that there’s value in doing so — and that the benefits outweigh the risks. Now that evidence seems to have arrived, and this WIHI digs into the experience of more than 13,000 patients and 100 primary care doctors who were part of a pilot study.

The findings appear in the October 2, 2012, issue of the Annals of Internal Medicine, reporting on a one-year experiment with what have come to be called “open notes” at three major health care organizations: Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System in Pennsylvania, and Harborview Medical Center in the state of Washington.

WIHI host Madge Kaplan welcomes lead author of the study, Dr. Tom Delbanco, one of the key innovators behind OpenNotes and their trial use at BIDMC, and two clinicians who helped lead the pilots at Geisinger and Harborview. By making notes accessible to patients in their own practices, both these clinicians came to better understand shared decision making and the ways in which transparency, rather than offend, increases trust. Michael Meltsner shares what mattered to him when he faced serious illness. A distinguished law professor, Meltsner’s “A Patient’s View of OpenNotes” also appears in Annals, and captures the brave new world of patient expectations and the need to level the playing field.

WIHI: Gaining Ground: Quality Improvement and US Medical Residency

Date: October 25, 2012

Featuring:

• Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement (IHI)
• Kedar Mate, MD, Assistant Professor, Department of Medicine, Weill Cornell
  Medical College; Clinical Lead for Research and Development, IHI
• James Moses, MD, MPH, Pediatric Director of Quality and Safety, Boston Medical Center; Academic Advisor, IHI Open School for Health Professions

Residency training in the US has long had the reputation of a rite of passage — a period when grueling hours on busy hospital floors are spent converting four years of medical school, and some clinical exposure, into real-time accountability for real patients who have sometimes serious and life-threatening medical conditions.

However, a changing health care system now demands that residents develop the skills not just to diagnose and treat patients who are ill, but to protect them from harm and to reduce their chances of being readmitted. Residents need to know about managing chronic conditions and how to help patients lead healthier lives.

These new goals present newly-minted MDs, and those who train them, with new challenges — among them, the need to work in teams and communicate with everyone, including patients and families, more effectively; the need to sleep after long hours on the job and to honor the requirement to take the time (and time off) to do so; the need to engage in effective handoffs to other providers and to help coordinate care across multiple health care settings.

It’s a tall order for the nation’s complex system of training doctors, and aligning what happens in residency programs with the ambitions of quality improvement is at an early stage. Why is this the case? What can be done to accelerate reforms? Where are promising new models starting to emerge?

This WIHI takes up these questions and more, with three outstanding guests who are directly helping to hasten the transformation of residency training in the US.

Drs. Don Goldmann, Kedar Mate, and James Moses are working with multiple organizations, including the Accreditation Council for Graduate Medical Education (ACGME), to better identify what’s needed, including building greater capacity among faculty in residency programs to teach and model improvement skills. Dr. Goldmann has a strong understanding of the structural barriers that must be addressed to make this possible. Dr. Mate has a unique and important view on the intersection between residency training and the growing field of hospital medicine, as well as innovations emerging from primary care practices on their way to becoming patient-centered medical homes. Dr. Moses has been instrumental in shaping the offerings of the IHI Open School for Health Professions to ensure they’re relevant and accessible to today’s residents.

Read the IHI 90-Day R&D Project report related to this topic. 

WIHI: Navigating the Elections with a Clear-Eyed View

Date: October 12, 2012

Featuring:

• Donald M. Berwick, MD, MPP, Former President and CEO, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare & Medicaid Services
• Chris Jennings, President, Jennings Policy Strategies (Washington, DC); Former Senior Health Care Advisor (Domestic Policy & National Economic Councils) to President Bill Clinton
  
  

We’re just weeks out from the November elections in the US and, depending on the outcome, health care reforms championed by the Obama administration will either continue unabated or possibly face some serious challenges — from a new President or a differently configured Congress. In the midst of this uncertainty, numerous individuals are keeping a close eye on the national policies and initiatives that have done the most of late to accelerate new payment schemes and the redesign of health care delivery, as well as expand insurance coverage.

IHI has two programs this fall to help you navigate this election cycle with a clarity of purpose that health care improvement requires more than ever in these tumultuous times: a WIHI with Dr. Don Berwick and Chris Jennings on October 12 and, on November 8, Out of the Blocks, an in-person, one-day conference in Washington, DC, featuring post-election analysis from Sen. Tom Daschle and Sen. Bill Frist, IHI President and CEO Maureen Bisognano, Virginia Mason CEO Gary Kaplan, and moderated by Don Berwick and NBC’s Nancy Snyderman, MD.

Because health care reform has become such a political flash point, it’s sometimes hard to find the “through line” for the improvement community in particular and the country as a whole. But Don Berwick says this is precisely what needs to happen. In this WIHI, he explains what “continuity of purpose” might entail in order to stay focused on a robust agenda that includes much greater attention to improving care across the continuum, reducing costs, and helping people and communities lead healthier lives. You can also count on Chris Jennings to summon his 25 years of experience as a health policy strategist to provide the freshest and most sanguine ways to think about reinventing health care in the US, even when political winds can, and often do, change directions.

Madge Kaplan hosts this special pre-election WIHI... Whether you’re steeped in forming an accountable care organization or patient-centered medical home, innovating to improve the patient experience, hard at work on reducing avoidable readmissions, or engaged in any combination of these efforts and more.

WIHI: Pioneering ACOs: What Do We Know So Far?

Date: September 27, 2012

Featuring:

• Elliott Fisher, MD, MPH, Director, Center for Population Health, Dartmouth Institute for Health Policy and Clinical Practice
• Palmer “Pal” Evans, MD, former Senior Vice President & Chief Medical Officer, Tucson Medical Center (TMC)
• John Friend, Vice President Business Development & Associate General Counsel, TMC Healthcare; Executive Director, Arizona Connected Care, LLC
  
  

One of the best-kept secrets about US health care this election season is the degree to which change and transformation are coming, no matter what happens in November. You won’t hear “global payment” or Medicare Shared Savings Program mentioned as often as “individual mandate” in the current political debate, but ask anyone leading a health care organization today which issue keeps them up at night, and it’s definitely payment reform. In general terms, the entire system is shifting from paying for volume – lots of procedures – to paying for value, or how well patients are cared for over time and across the continuum.

Accountable care organizations (ACOs) are one critical new reflection of this migration, and they’re being encouraged by public and private payers alike. What do we know about the more than 200 ACOs that have formed in the US thus far? It’s still early in the process, but some smart people are keeping a close eye on ACOs, and we’re going to be talking with a few of them on WIHI.

As Director of Population Health and Policy at the Dartmouth Institute for Health Policy and Clinical Practice, Dr. Elliott Fisher is leading a major study of the factors enabling ACOs to get up and running and to successfully implement new forms of care delivery. WIHI host Madge Kaplan welcomes Dr. Fisher to the show to share what he and his team of evaluators have learned thus far. He’ll be joined by leaders from Tucson Medical Center, one of the nation’s earliest adopters of the ACO concept. Dr. Palmer “Pal” Evans and John Friend from Arizona Connected Care both say that one of the biggest hurdles for newly forming ACOs is to let go of the notion that hospitals can and should run the show. That’s not where the future is headed, both say, and they’re learning this in spades in Arizona. They’re also learning how to build will and buy-in from mostly independent physicians, a situation that’s typical of most US hospitals.

There are plenty of uncertainties ahead, but Elliott Fisher, Pal Evans, and John Friend agree that ACOs or something similar are likely to be a feature of reform for the forseeable future. They share their perspectives and answer questions on WIHI.

For some background on Tucson Medical Center’s entrance into the ACO experiment, please take a look at these Commonwealth Fund case studies published earlier this year.