WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: Conversations as Cornerstones of End-of-Life Wishes

Date: August 30, 2012​

Featuring:

• Ellen Goodman, co-founder, The Conversation Project; Pulitzer-Prize winning columnist and author
• Larry Weber, Chairman, W2 Group; Author, Everywhere: Comprehensive Digital Business Strategy for the Social Media Era
• Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement

We have lots of meaningful conversations in the course of our lives, but topping the list has to be talking with family members and loved ones about our own — or their — wishes for care at the end of life. Despite the inevitability of death, for many of us this is the last conversation we either want to have or know how to have; it can be especially difficult to initiate. And yet, without these discussions, we or our loved ones run the risk of running headlong into a medical crisis and getting care we don’t want, and not getting the care we do.
 
Back in January, WIHI offered listeners a preview of a ground-breaking, grass-roots initiative aimed at changing this state of affairs. The Conversation Project — whose goal is that everyone’s end-of-life wishes will be expressed and respected — launched in August 2012 in collaboration with IHI, and some of its key founders and creators are back in the WIHI studio on August 30 to explain what the effort is all about and how you can participate.

From the get-go, Ellen Goodman’s vision has been that end-of-life conversations need to become normalized — and that the best place to have the conversation is at the kitchen table, not in the ICU. To support its public campaign, The Conversation Project has created a website that will act as ground zero for collecting and spreading stories, sharing tips and templates to help people get started, and facilitating the networking that’s crucial when trying to bring about cultural change. The latest social media tools (Facebook, Twitter, and YouTube) will be available to extend the reach and impact of what everyone is learning along the way. 
 
IHI’s Martha Hayward joins Ellen Goodman on WIHI to discuss how The Conversation Project can accelerate efforts to make health care more patient- and family-centered — and not just pertaining to end-of-life care, but with a myriad of health issues. WIHI host Madge Kaplan also welcomes Larry Weber from W2 Group, whose knowledge of social media and its potential to unleash social change has been a critical component of the development of The Conversation Project.

WIHI: Minimally Disruptive Medicine

Date: August 9, 2012

Featuring:

• Victor Montori, MD, MSc, Director, Mayo Clinic Healthcare Delivery Research Program; Professor of Medicine, Mayo Clinic.
• Nilay Shah, PhD, Assistant Professor of Health Services Research, Mayo Clinic

Please note:

• Dr. Montori will be offering a Special Interest Keynote on Minimally Disruptive Medicine on December 11, 2012, at IHI’s National Forum.

One of the most common phrases used to describe patients who are not taking their prescribed medications or following up on the recommendations of their health care providers is “non-compliant.” What if we viewed the behavior as an act of civil disobedience instead?

This provocative notion definitely got the attention of health professionals in the audience at IHI’s 13th Annual Summit on Improving Patient Care in the Office Practice and the Community (March 18-20, 2012). It’s the thinking of Dr. Victor Montori, a diabetologist and researcher at Mayo Clinic whose keynote remarks at the gathering were, in part, intended to shake up common and sometimes negative assumptions about patients with chronic diseases who don’t seem to be holding up their half of the bargain. Dr. Montori invites all of us to consider the work of being a chronically ill patient, and the burden of increased expectations to follow regimens that don’t easily fit into a patient’s daily life, social circumstances, preferences, and more.

What’s the alternative? Dr. Montori and colleagues call it “minimally disruptive medicine,” and WIHI invites you to learn more about this change of mindset and approach to chronic disease and what it can look like in practice. Host Madge Kaplan and Dr. Montori are joined by Nilay Shah, a health services researcher at Mayo Clinic. Both Drs. Shah and Montori argue that with the growth of patient-centered medical homes and numerous other initiatives that assume a greater role for patients and family members in managing chronic conditions, it’s a critical moment to examine what added workload this implies. The two argue that some of the burden on patients can be reduced if approaches to care are married with efforts to reduce unnecessary and costly over-treatment.

Think of it this way, says Dr. Montori: So-called “non-compliance” is actually an alarm system for a health care system that’s failing patients. The goal needs to be shifting and sharing responsibility for chronic disease with patients and families — not shifting the burden.

To learn a bit more about minimally disruptive medicine, check out the story of Susan and John. 

WIHI: Triple Perspectives on Triple Aim in a Region

Date: July 26, 2012

Featuring:

• Craig Brammer, Director, Beacon Communities, Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services
• Shelley B. Hirshberg, MHSA, Executive Director, P2 Collaboration of Western New York; Project Director, Western New York Aligning Forces for Quality(AF4Q), Robert Wood Johnson Foundation
• Carol Beasley, MPPM, Executive Director of Strategic Projects, Institute for Healthcare Improvement
• Katherine Browne, MBA, MHA, Chief Operating Officer, National Program Director, Aligning Forces for Quality, Robert Wood Johnson Foundation
  
  

There’s a lot of interest in the Triple Aim in the US, Canada, and several European countries. And it’s no wonder. Ever since IHI conceived of the framework of the simultaneous pursuit of better health, better health care, and lower per capita costs, a whole array of strategies have opened up for health care improvers. Some of the most interesting and groundbreaking strategies have built as much on insights from outside health care as within.

And, just imagine if the various communities making headway with the Triple Aim started to think regionally? Well, many are and that’s the evolution this WIHI focuses on, tapping into three related but unique endeavors: IHI’s Triple Aim Initiative (with special focus on recent regional work), the Beacon Community Program (a project of the Office of the National Coordinator for Health Information Technology), and the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q).

These three efforts combined have already impacted nearly 200 communities, to the point where many now realize that thinking regionally is the logical next step. Among other things, a regional focus forces an examination of cross-cutting social issues that affect more than a single community — issues such as unemployment, education, transportation, and crime. One community’s solutions to the needs of an aging population, people with chronic conditions, and individuals with complex social problems might benefit the community next door. Further, a regional outlook necessitates building even broader coalitions, drawing on the expertise of health systems operating in multiple locations, state and municipal leaders, public health experts, urban planners, economic developers, and more.  

Our guides for the July 26 WIHI are Craig Brammer, Katherine Browne, Carol Beasley, and Shelley Hirschberg. The AF4Q effort alone has some 270 partners and a portfolio of projects, including health information technology, that point to what’s possible when one starts to act regionally as well as locally. We’ll be identifying other emerging regional “movers and shakers” as well.

WIHI: Essential Skills for Health Care Reformers and Improvers: Holding Tension and Learning Habits of the Heart

Date: June 20, 2012

Featuring:

• Parker J. Palmer, Founder and Senior Partner, Center for Courage and Renewal; Author, Healing the Heart of Democracy
• Jeffrey D. Selberg, MHA, Executive Vice President and Chief Operating Officer, Institute for Healthcare Improvement

The health care improvement community has often benefited from the work and perspective of other industries. Taking a systems approach to improving quality and safety in health care owes much to the concepts and work that turned the tide on risks and defects and waste in aviation and manufacturing.

The quality improvement movement has also benefited from the wisdom of “outsiders” — individuals asked to look in at what health care improvement is trying to achieve and to tell us what we may be missing or what they see that we don't, because we’re just too close to the problems and the day-to-day solutions. Parker Palmer is just such a person, and he’s visited with the improvement community before; in 1997 he delivered a moving keynote at IHI’s National Forum about the challenges of being a dedicated health care professional.

On the eve of the Supreme Court issuing its decision on the Affordable Care Act, and with new policies and payment schemes and community-focus reshaping the very core of what it means to be an effective health care leader, WIHI thought this would be a perfect moment to invite Parker Palmer to speak with us again. IHI Executive Vice President and COO, Jeff Selberg, who knows Dr. Palmer’s ideas and writings well, helps lead the discussion, along with WIHI host, Madge Kaplan.

When one is committed to change, there are good days and bad, and successes can easily be followed by disappointments and setbacks. The challenge becomes how to hold the entire picture in a sort of “creative tension,” to avoid retreating from the public square, and to retain one’s openness and curiosity when things don’t go as hoped or planned. Parker Palmer is very aware of the tremendous pressures and challenges all health care leaders and professionals now face to forge a new kind of contract with payers and patients alike. It’s an exciting time, and a difficult one.

WIHI: Situational Awareness and Patient Safety

Date: June 7, 2012

Featuring:

• Stephen Muething, MD, Vice President for Safety, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
• Anne Lyren, MD, Co-Leader, OCHSPS National Children’s Network; Strategic Advisor for Quality and Safety, Rainbow Babies & Children’s Hospital
• Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement

It may seem obvious that anticipating problems makes a whole lot more sense than dealing with things after the fact. Especially if the problems could have been prevented. When it comes to patient care, this can of course mean the difference between life and death but, more often, the lack of attention to complexities that could arise leads to a lot of unnecessary complications and suffering and costs. But what exactly do the systems look like that focus ahead of time on risky situations and high-risk patients with the same degree of science and scrutiny as we’ve come to associate with studying failures, after the fact? Indeed, what if the entire emphasis shifted to doing everything possible to predict problems as a means of preventing failures in the first place? WIHI explored the road to becoming a “high reliability organization” with the Joint Commission’s Dr. Mark Chassin on the March 8, 2012, program, and we’re now returning to the issue based on the groundbreaking work going on at Cincinnati Children’s Hospital Medical Center.

We’re going to zero in on “situational awareness” and our guide will be Dr. Stephen Muething, who enjoys a well-deserved reputation for making the principles and practices understandable and within reach. To prepare for the WIHI, we invite you to check out the resources at the James M. Anderson Center for Health Systems Excellence at CCHMC. Dr. Muething will be joined by Dr. Anne Lyren, who’s part of a children’s hospital network in Ohio and nationally, committed to sharing data and best practices. Dr. Lyren will explain the critical role that daily huddles play with getting everyone on the same page and capable of responding to problems and crises as they’re developing, in real time. IHI’s Carol Haraden has been leading patient safety improvement initiatives all across the globe and, despite the progress, she’s the first to admit how much work still lies ahead. That’s one of the reasons Carol Haraden is so excited about the work at CCHMC, and in Ohio, where leaders have decided safety on any given day is not only job number one, it’s the product of the vigilance and preparation from the day before... and the day before that.

What does your organization’s commitment to high reliability and situational awareness look like?

 

WIHI: Testing,Testing! Is This Procedure Necessary?

Date: May 17, 2012

Featuring:

• Daniel B. Wolfson, Executive Vice President and COO, ABIM Foundation
• Steven Pearson, MD, MSc, FRCP, President, Institute for Clinical and Economic Review – Institute for Technology Assessment
• Amanda Kost, MD, Acting Assistant Professor, University of Washington Department of Family Medicine
• Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement
• Karen Boudreau, MD, FAAFP, Chief Medical Officer, Boston Medical Center, HealthNet Plan; Former Senior Vice President, Institute for Healthcare Improvement and Medical Director for IHI Continuum Portfolio

Of all the sources of excessive health care spending, none may be higher on the list than the habit of ordering lots of expensive tests and procedures. This appetite for the best of what high-tech medicine can offer – whether warranted or not – is a big factor behind estimates that up to a third of health care spending in the US is wasteful and unnecessary. But everyone also has a story of someone, maybe themselves, helped by a diagnostic procedure. There’s no question that one person’s unnecessary test is another person’s lifesaver. So, how do we get closer to more appropriate use? And is there a more active role that physicians can play?

The ABIM Foundation is betting there is a way to bring the ordering of tests and procedures into better balance AND that doctors are key to making this happen. This is the premise behind the ABIM Foundation’s new campaign, Choosing Wisely. Nine medical societies are on board (with eight more joining in the fall), and they’ve each identified five procedures that tend to be overused and that should trigger discussions to ensure that they’re really needed and of value. The American Academy of Family Physicians, for example, has a list that begins with thinking twice before immediately ordering imaging for low back pain.

WIHI host Madge Kaplan has assembled a great group of experts: The ABIM Foundation’s Daniel Wolfson will explain the campaign. Karen Boudreau will help us think through the role of family practitioners, while Steven Pearson will contribute some of the latest and sharpest thinking about evidence-based medicine and comparative effectiveness. Amanda Kost got to put on her “choosing wisely” shoes a bit ahead of the game by being part of the National Physician Alliance’s Promoting Good Stewardship in Medicine project. She’ll provide some key frontline learning on best practices that can help wean doctors and patients alike from reaching for the most expensive solution, first. Finally, IHI’s Don Goldmann, will discuss how Choosing Wisely aligns with other national initiatives and why it’s crucial that the medical profession take a leading role with health care reform.

Whether or not you’re directly in the role of ordering tests or procedures, we invite you to consider that we all have a part in making health care more effective and affordable – in other words, of true value to patients.

WIHI: "Pursuing the Triple Aim" Book Discussion with the Authors and Innovators

Date: May 3, 2012

Featuring:

• Maureen Bisognano, President and CEO, Institute for Healthcare Improvement, Co-author, Pursuing the Triple Aim
• Charles Kenney, Writer and Journalist, Co-author, Pursuing the Triple Aim
• Alide Chase, Senior Vice President, Medicare Clinical Operations and Population Care, Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals
• Anthony M. DiGioia, MD, Renaissance Orthopaedics; Medical Director, Bone and Joint Center, Magee-Womens Hospital and PFCC Partners – Innovation Center of UPMC
• George E. Kerwin, FACHE, President and Chief Executive Officer, Bellin Health
• Patricia A. McDonald, Vice President, Technology and Manufacturing Group and Director of Product Health Enhancement Organization, Intel Corporation
• Diane K. Miller, MBA, Vice President, Virginia Mason Medical Center, Executive Director, Virginia Mason Institute
• Rebecca Ramsay, RN, MPH, Director, Care Support Manager, CareOregon
• Brian H. Rank, MD, Medical Director, HealthPartners Medical Group, HealthPartners, Inc.
• Marci Sindell, Chief External Affairs Officer, Atrius Health and Harvard Vanguard
  
  

It isn’t always easy to tell the story of improving health care in the US. An awful lot of the answers and promising solutions fly under the radar screen and get drowned out by politics and policy debates. That’s why Maureen Bisognano and Charlie Kenney decided to move about the country this past year and capture just a small sample of the innovation underway that promises to move health reform forward… even as national debates rage on.

What the organizations featured in Maureen and Charlie’s new book, Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs, share in common is this clear-eyed view that the status quo is not sustainable and that new models to simultaneously improve health, improve health care, and reduce per capita costs aren’t just needed, they’re needed urgently.

The organizations whose stories you can read about in the new book and that you’ll hear about on WIHI are currently in the trenches and represent a leading spear of change, tackling some of the hardest issues ever for health care. All the people associated with the work are eager to share whatever they can with as many as they can. WIHI host Madge Kaplan pulls together the program’s first ever audio “book party” with enough time to hear from all the contributors and also ask questions and engage in discussion. 

A special note to improvers in other countries and around the globe: many of you have been part of IHI’s Triple Aim prototyping initiative for the past several years or have crafted initiatives of your own. Work outside the US is also critical and vital to everyone’s learning and everyone is encouraged to participate in this WIHI discussion.

WIHI: You Can't Improve What You Can't Evaluate

Date: April 19, 2012

Featuring:

• Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement
• Dale Webb, PhD, Director of Evaluation and Strategy, The Health Foundation, UK
• Mary Dixon-Woods, BA, DipStat, MSc, DPhil, Professor of Medical Sociology, University of Leicester, UK
• Gareth Parry, PhD, Senior Scientist, Institute for Healthcare Improvement

WIHI doesn’t need to travel all the way to Paris, France, to focus on challenges with the design and evaluation of improvement initiatives. But, four leading experts in this area are going to be sharing some of the latest thinking on this topic at the 17th annual International Forum on Quality and Safety in Healthcare in Paris.

WIHI host Madge Kaplan talks with these four presenters after their panel to share their observations with the WIHI audience. Here’s just a sample of what Don Goldmann, Dale Webb, Mary Dixon-Woods, and Gareth Parry want to cover: 

• Despite best intentions and commitment, improvement initiatives don’t always yield hoped-for results. Why does this happen?
• It seems so obvious, yet it turns out to be much harder to spread successes in one setting to another even if, on the surface at least, the settings seem pretty similar. What can help this adaptation?
• Everything seems to be running smoothly, but then problems with the design of the work are discovered late in the process. How can problems and design flaws be detected sooner?
• Everyone is very excited about the results of some improvement work, but when it comes times to write it all up, there’s confusion and disagreement about which mechanisms are actually responsible for the changes. How can this be avoided?

One underlying theme is the need to integrate what one hopes to learn from an improvement initiative right from the start, and to build into the process a robust learning and evaluation system for every step of the way. These aren’t just abstract notions; you’ll hear from the WIHI guests about recent situations they’ve been part of or witnessed where “learning the hard way” has given rise to much better and clearer-eyed processes for the future.

Here are some other things the guests promise to discuss:

• Developing a theory of change at the outset
• Matching expectations to the intervention
• Aspirational vs. evaluative goals
• The conspiracy of enthusiasm
• The importance of independent evaluation

The theme of this year’s International Forum is “Solutions for Tough Times,” and improvers in the US and globally face many challenges. Getting the nuts and bolts and the design right for improvement work couldn’t be more important and relevant.

WIHI: Going, Going, Green! Embedding Environmental Health and Sustainability into Health Care Delivery

Date: April 5, 2012

Featuring:

• Gary Cohen, President and Co-Founder, Health Care Without Harm
• John Messervy, AIA, Director of Capital and Facility Planning, Partners HealthCare, Inc.
• Amy Collins, MD, Emergency Physician, MetroWest Medical Center; Chair, Go Green Committee, MetroWest

How green is your hospital? Green, as you know, has become shorthand for everything from recycling to the use of safer products to shrinking one's carbon footprint to preventing pollutants from spewing into the air. There are any number of urgent reasons for the health care sector to be examining its green practices. One of them is just the sheer amount of resources hospitals consume: in the US, that’s tons and tons of water and 836 trillion BTU of energy annually. These same hospitals dispose of 6,600 tons of waste per day. Fortunately, we can all now point to visible efforts at most hospitals to “think and act” a lot greener. But even these well-intentioned efforts have a tendency to stall or lose steam, too often dependent on staff volunteers and lacking a bigger, bolder vision that cuts across the entire organization and how it's run.

Aiming to build on existing progress and to make a giant leap forward on the environmental front, three organizations are now joining forces to launch what’s being dubbed the Healthier Hospitals Initiative. The new effort is anchored by some large hospital systems in the US whose green practices are already exemplary and demonstrate the wisdom behind linking environmental stewardship to efforts to improve safety and reduce health care costs. The Healthier Hospitals Initiative hopes to enlist some 1,000 hospitals in the broad-based campaign, focused on an agenda that includes increased use of safer materials and products for patients and staff alike; reduction of energy consumption and waste; and adoption of policies to ensure sustainability.

WIHI host Madge Kaplan welcomes three guests to the program. Gary Cohen is the co-founder and president of Healthcare Without Harm and Practice Greenhealth, whose work has helped lay the groundwork for this larger initiative. Dr. Amy Collins, who leads a number of efforts at MetroWest Medical Center in Framingham, Massachusetts, is helping MetroWest garner a number of environmental excellence awards. John Messervy founded the Partners Sustainability Initiative in 2008, and he has tremendous knowledge of the environmental engineering changes possible throughout a large hospital system.

WIHI: What Can You Learn in 90 Days? IHI’s Innovation Process

​Date: March 22, 2012

Featuring:

• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement
• Lindsay Martin, MPH, Executive Director for Innovation, Research & Development, Institute for Healthcare Improvement
• Bela Patel, MD, Assistant Dean of Healthcare Quality and Division Director for Critical Care Medicine, The University of Texas Health Science Center

Where do new ideas for how to improve health care come from? Sometimes they start with a hunch or an expressed need from health care providers; sometimes they’re unearthed by deciding to make a dramatic reduction in mortality in a resource-poor setting or by drawing a line in the sand on the wasteful practices of fee-for-service medicine.

Whatever the motivation or source — whether a hunch or a need or a challenge — even the best-sounding new improvement ideas need careful vetting and scrutiny and, if appropriate, a well-designed test to determine if an innovative approach to better patient care can make a difference in an actual health care setting. Not every new idea flourishes, but chances are it’ll die on the vine without an effective and efficient way to determine its potential contribution. This, in a nutshell, is the rationale behind IHI’s 90-Day Research and Development Process.  

Now in its sixth year — and its 23rd 90-day wave of putting innovative ideas through a disciplined, evaluation pipeline — IHI’s R&D process has had its share of wins: improvement “bundles,” the Global Trigger Tool, the optimal elements of best stroke care, the early thinking and widely disseminated framework of the Triple Aim, and much more.

How is it possible to conduct R&D on a “shoestring”? What are the core components, the resources, and the steps necessary for an effective 90-day process? What kinds of innovations has IHI put to the test, which ones generated valuable learning, and, most importantly, what kinds of fresh approaches could your organization use to generate, evaluate, and — when viable — turn into effective improvement processes?  

WIHI host Madge Kaplan welcomes two people who have helped shape and nurture IHI’s 90-day R&D process since its inception: Andrea Kabcenell and Lindsay Martin. They couldn’t be more passionate about the process and possibilities and necessity of R&D, and they share the nuts and bolts and the vision that could become part of your agenda, too. Rounding out the program is Dr. Bela Patel of The University of Texas Health Science Center and Memorial Hermann Hospital in Houston, Texas. Dr. Patel is in the process of jumpstarting R&D work based on what she recently learned at IHI’s Innovation College.