WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: Highly Reliable Hospitals: The Work Ahead

Date: March 8, 2012

Featuring:

• Maureen Bisognano, President and CEO, Institute for Healthcare Improvement
• Mark R. Chassin, MD, FACP, MPP, MPH, President, The Joint Commission and the Joint Commission for Transforming Healthcare

How many patient safety goals does it take to get the US health care system to function as safely and as reliably as it should? And, looked at through the lens of the Joint Commission’s program for hospitals, can 15 broad goals covering patient identification, medication safety, infection prevention, surgical error prevention, communication, and prevention of patient suicide add up to the safe and effective care that must become a hallmark of health care delivery and that patients deserve? The answer is, “Of course not.” Everyone, including the Joint Commission, knows that health care organizations today can’t possibly meet the Joint Commission’s goals, or any other benchmarks, unless they’re embedded in huge culture changes that comprise strong leadership, good communication skills, multidisciplinary teamwork, an engaged frontline staff, and an informed governing board. That's among the reasons why progress still remains far too slow at most of the nation’s hospitals, even if pockets of excellence are becoming more numerous.

For Dr. Mark Chassin, who heads the Joint Commission, the concept that he believes can and should become a game changer is “high reliability.” That means safe and effective processes that can be executed and sustained over long periods of time. Writing in the April 2011 issue of Health Affairs, Dr. Chassin states, “What has eluded us thus far…is maintaining consistently high levels of safety and quality over time and across all health care services and settings. The pockets of excellence coexist…with enormously variable performance across the delivery system. Along with some progress, we are experiencing an epidemic of serious and preventable adverse events.”

Dr. Chassin argues that one place to start on the path to high reliability is to conduct an honest self-assessment of an organization’s readiness. WIHI host Madge Kaplan welcomes Dr. Chassin to the program to dig deeper into the subjects of excellence and reliability. He’s joined by IHI’s Maureen Bisognano, a long-time champion of high reliability. Ms. Bisognano knows that the success of any initiative to improve safety and quality reliably, and over time, depends on creating and sustaining a culture of safety, from the board to the executive to the front lines. This culture is needed across the entire continuum of care, especially at crucial intersections where patients are most at risk. Ms. Bisognano also believes that a culture of safety must be accompanied by a culture of innovation that supports and encourages professionals to test out new ideas and harvest proven methods from wherever they are found.

WIHI: The Patient Will See You Now: New Technology for New Collaborations

Date: February 23, 2012

Featuring:

• John Moore, MD, PhD Candidate, MIT Media Lab – New Media Medicine
• David Judge, MD, Project Leader, CIMIT Ambulatory Practice of the Future; Instructor in Medicine, Harvard Medical School

New technologies by themselves cannot create more robust patient-provider partnerships. But, with a lot of ingenuity and thoughtful design, and a commitment to creating tools that help put patients more in charge of their health, technology can be a game changer. That’s the guiding principle behind some fascinating work under development at the MIT Media Lab, and that’s where this WIHI takes place for its first ever “live on location” broadcast.

If you’ve never heard of NewMediaMedicine, you’re in for a treat. Using a conceptual and software platform called CollaboRhythm, researchers are designing and testing tools that offer patients real-time data about their own chronic health conditions that can then be easily conveyed to a health care provider, enabling coaching and communication practically on the spot. It might sound glib to refer to primary care as a shared environment that can be tapped on an “as-needed basis,” thanks to a couple of smart phones, but in the health care world that NewMediaMedicine envisions, the best primary care will be transformed into something less like a single office visit and more like a daily engagement with one’s health goals, with expert advice available when necessary.

Joining WIHI host Madge Kaplan are two people who can explain it all. Dr. John Moore is a physician and technologist overseeing multiple projects at the Media Lab and in true “open source” fashion is eager to share what he and his colleagues are up to. Dr. David Judge’s work is closely aligned, thanks to the Ambulatory Practice of the Future at Massachusetts General Hospital, which opened its doors in July 2010. Dr. Judge talks about what it’s really like to offer a model of “continuous, customized, iterative, and well-informed care” in the environments most convenient for patients.

This special “on location” WIHI is taking place on the heels of the Media Lab’s third annual Health and Wellness Innovation sprint that took place at the end of January 2012. In addition to what’s in the testing phase now, find out what teams of students, health professionals, and innovators are imagining next.

WIHI: The Social Imperative to Demonstrate That Better Care = Lower Costs

Date: February 9, 2012

Featuring:

• Donald Berwick, MD, MPP, Former Administrator, Centers for Medicare & Medicaid Services; Former President and CEO, Institute for Healthcare Improvement (IHI)

• Gerard M. Shea, Assistant to the President for External Affairs, American Federation of Labor and Congress of Industrial Organizations (AFL-CIO)

Imagine this. You’re driving or walking or maybe even bicycling by your local hospital and you notice a big sign over the entrance that you’ve never seen before. Here’s what it says: “This hospital saved 5 Million Dollars in 2011 by improving patient care and reducing unnecessary procedures. We have returned the money to local employers, local unions, and the state.”

Sound preposterous? Hopefully not, because this is the kind of bold commitment and public declaration that Don Berwick and Gerry Shea would like everyone in health care to start thinking about, seriously. It’s just that urgent, they say, and they’ll explain why.

WIHI host Madge Kaplan welcomes Berwick and Shea to the program, fresh off Dr. Berwick’s 18 months implementing change at the Centers for Medicare & Medicaid Services (CMS), and building on Gerry Shea’s extensive knowledge of quality improvement and the promise of better care and lower health care costs for working Americans.

The problem is, we’re nowhere near there yet, especially where costs are concerned, and both Berwick and Shea believe one of the reasons is that there’s still too much of a disconnect between what better use of health care services and improvement initiatives can achieve, and what health care payers (Medicare and Medicaid, employers, individuals, etc.) are able to reap in return. As Berwick puts it, “Payers aren’t seeing it yet,” and this means that anyone footing the bill, and that’s pretty much all of us, continues to be squeezed in ways that society can’t afford.

So, what can dedicated legions of health professionals, already deeply immersed in improvement work, do differently or better? Berwick started to lay this out on December 7, 2011, at IHI’s National Forum. Berwick and Shea both say that one area ripe for review is the conceptual and often actual way in which health care organizations separate their quality and “lean” strategies, when these should be one and the same. Implementing greater efficiencies has everything to do with safety and better care, the two say. Getting this right would speed things up and generate greater savings. The question then becomes, where should the money go?

WIHI: Have You Had "The Conversation"? Helping Loved Ones Discuss End-of-Life Preferences

Date: January 26, 2012

Featuring:

• Ellen Goodman, Columnist, Author, founding member of The Conversation Project
• Ira Byock, MD, Professor, Dartmouth Medical School; Director of Palliative Medicine, Dartmouth-Hitchcock Medical Center
• Bernard “Bud” Hammes, PhD, Director, Medical Humanities and Respecting Choices®, Gundersen Health System
• Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement

Most of us, if asked, say we care a great deal about will happen to us when we’re at the end of our lives. And yet, because we’d also rather focus on just about anything but death and dying, especially if we’re young and healthy or aging well, we’re all vulnerable to what can transpire by default: spending our last few days in an ICU, even if that’s at odds with our needs and preferences. The reasons for this disconnect are complex but often stem from the fact that individual and family decisions come late, are hashed out during a crisis, and in the very setting — a hospital — that promises high-tech and high-intervention cures for just about everything. 
 
This scenario is slowly starting to change. There are now numerous efforts, some medically-based and many more that are grassroots, successfully promoting alternative perspectives and practices so that people who’d prefer to die at home can do so, and benefit from pain management and comfort over costly and heroic measures. But when you get right down to it, “dying well” is quite personal and, as such, needs to start in a personal place: by having a conversation with the people you’re closest to about how you want to die and how they, surviving friends and family members, can feel okay carrying out your wishes. Equally important: initiating or being open to that conversation, perhaps several conversations, when the circumstances aren’t so fraught and there’s time to digest and reflect and integrate the information.
 
All of this and more are what’s behind a new initiative getting underway in 2012 called The Conversation Project (TCP), which will be discussed on the January 26 WIHI. In collaboration with IHI, award-winning columnist and founding member Ellen Goodman and the project’s team members seek to create a cultural movement with one basic goal: to help every American say what they want at the end of life so that family members and medical providers have the guidance they need to respect those preferences. To get there, TCP wants to normalize discussions that can at times feel “too big to broach” by encouraging loved ones to talk to one another when circumstances aren’t so charged — when everyone is healthy — and the environment is more conducive to a good exchange. Around the kitchen table, for instance, rather than the hospital bed.  
 
To launch a national campaign to bring about this change, Ellen Goodman and members of TCP have turned to many, many experts on death and dying, palliative care, and successful partnerships with patients and families, including two outspoken champions of change on the clinical and community side: Dartmouth’s Ira Byock and Gundersen Health System’s Bud Hammes. With IHI’s Martha Hayward also on board, WIHI host Madge Kaplan invites you to get an early look at a unique initiative in the making from the architects themselves. Increasingly, that’s going to become all of us —­having “The Conversation” and telling others how it went and what we learned in the process. It’s hoped that many will benefit, including health professionals who often find themselves at a loss for words, brought up short by their training, and caught in the cross hairs of their own and others’ conflicting emotions and wishes.

WIHI: Removing Barriers to Care with Medical-Legal Partnerships

Date: January 12, 2012

Featuring:

• Barry Zuckerman, MD, Chair, Department of Pediatrics, Boston University School of Medicine; Founder, National Center for Medical-Legal Partnership
• Robert Kahn, MD, MPH, Associate Professor of Pediatrics and Director, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center
• Carol Beasley, MPPM, Director of Strategic Projects, Institute for Healthcare Improvement

Let’s face it. If someone mentions the words “medical” and “legal” in the same sentence, the next thing we imagine we’ll hear about is a lawsuit. Picture this instead: empowered, proactive social workers, collaborating with health care providers, lawyers, and legal experts, to ensure that the health of indigent patients isn’t undermined by unsafe housing, lack of food, or lack of access to benefits and entitlements. Some people refer to this type of outreach as “preventive law” because it’s directly related to preventive health measures we now recognize are crucial to help people head off disease or better manage chronic conditions.

Doctors and nurses on the front lines have understood for years the role that social conditions play in improving or worsening health. Also, what happens when problems brewing at home, such as domestic abuse, don’t rise to the surface during a routine medical visit? Fifteen years ago, Dr. Barry Zuckerman founded a program at Boston Medical Center to address a swarm of issues affecting the health of low-income children. Six years ago, this initiative became the National Center for Medical–Legal Partnership, focusing on anyone, at any age, in need of the combined power of medical and legal intervention. The effort and the framing caught on and there are now over 200 programs like Zuckerman’s across the US, one of them in Cincinnati. 

WIHI host Madge Kaplan welcomes Dr. Zuckerman and Dr. Robert Kahn of Cincinnati Children’s Hospital Medical Center to explain and explore the ingredients of an effective medical-legal partnership and how the efforts to date are making a difference in patients’ health and their lives. At Cincinnati Children’s, key prompts to get at social determinants of health are built right into the electronic health record. This helps screen for health-undermining circumstances — for instance, a landlord’s lack of attention to a faulty refrigerator — that might benefit from legal attention. This is just the type of thing Carol Beasley is keeping an eye on as she continues to help spearhead the work of the IHI Triple Aim initiative. When the goals are improving the experience of care, improving the health of populations, and reducing per capita costs, it’s increasingly essential to form coalitions and partnerships that integrate legal and social service expertise with health care expertise.

WIHI: Heard at the Forum: New Ideas and Learning from IHI's 23rd Annual National Forum

Date: December 15, 2011

Featuring:

• • Jeffrey D. Selberg, MHA, Executive Vice President and Chief Operating Officer, Institute for Healthcare Improvement (IHI)

 

• 2011-2012 IHI Fellows

 

 

Every December, nearly half the people who attend IHI’s National Forum in Orlando, Florida, do so for the very first time. They join with the “regulars” and the “veteran” conference-goers and immerse themselves in intense learning and networking over four packed days. By the time it all winds up, everyone is eager to return to colleagues back home to share new ideas and initiate new improvement strategies. Some of IHI’s best informants wind up being our fellows, most of whom have never attended the Forum before. At the Forum, they fan out to cover as much ground as possible so that they can spread the learning among themselves and beyond.

That’s the spirit behind WIHI’s December 15 program, “Heard at the Forum.” The 2011-2012 IHI Fellows and IHI’s Executive Vice President and COO Jeff Selberg join WIHI host Madge Kaplan to talk about what they learned from IHI’s 23rd Annual National Forum: stand-out results; new improvement strategies; new ideas about leadership; the growth of the quality improvement movement internationally; the necessary and new role patients are taking on in designing better care; new thinking about navigating the complexities of the health care environment in the US; the opportunities embedded in health care reform; and more.

This rich round-up from the Forum will be beneficial for the entire improvement community, whether or not you attened this year’s event. WIHI participants who have their own favorite conference stories, session “take-aways,” and memorable quotes from the keynotes, also add to the discussion for everyone’s benefit.

WIHI: Night Talks and Nocturnists: New Interventions for the Hospital at Night

Date: December 1, 2011 

Featuring:

• David Gozzard, FRCP, FRCPath, MBA, Consultant in Quality Improvement, North Wales, UK; Former Consultant Haematologist
• Christine White, MD, MAT, Assistant Professor, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center
• Win Whitcomb, MD, MHM, Medical Director of Healthcare Quality, Baystate Health

 
Although most hospitals are open for business 24/7, patients are well aware that days, nights, weekends, and holidays are not created equally in hospitals. There’s a history of assigning fewer medical and nursing staff during these times, creating a host of challenges for improvement leaders seeking to ensure safe and reliable care regardless of what the clock says. And there are real consequences: a study published in JAMA in 2008 found that patients who had heart attacks in the hospital at night and on weekends were less likely to survive than if they’d arrested during “normal business hours.”

Innovative solutions to close this gap in care are cropping up in several corners. In the US, the growing number of and reliance on hospitalists is giving rise to a particular type of hospitalist, known as a “nocturnist,” who specializes in after-hours care. In the UK, attention to patient safety as well as work hours for medical staff have spawned an increasingly widespread practice of interdisciplinary “night teams.” And, many hospitals are focusing on night times and weekends as part of their overall efforts to improve handoffs between nursing shifts and medical residents, who, in the US, now have shifts of their own they must adhere to in order to comply with ACGME regulations.

So, the road to ensuring that patients get the same kind of care, no matter the time of day or night, is definitely still under development. Guests Drs. David Gozzard, Christine White, and Win Whitcomb join WIHI host Madge Kaplan to share how they are contributing to the solutions for providing reliable, high-quality care.

WIHI: Health Literacy: New Skills for Health Professionals

Date: November 17, 2011

Featuring:

• Helen Osborne, MEd, OTR/L, President, Health Literacy Consulting; Author, Health Literacy from A to Z
• Gail A. Nielsen, BSHCA, Director, Learning and Innovation, Center for Clinical Transformation, Iowa Health System; Faculty, Institute for Healthcare Improvement
• Lisa M. Stevens, MSHSA, Director of Clinical Quality, Crusader Community Health

 

In its 2004 report, "Health Literacy: A Prescription to End Confusion," the Institute of Medicine defined health literacy as “the degree to which individuals have the capacity to obtain, process, communicate, and understand basic health information and services needed to make appropriate health decisions.” Seven years later, the field of health literacy has exploded into something far beyond this most basic description. There are legions of health literacy advocates and initiatives; innovative, creative, and culturally attuned resources; a much greater emphasis on empowerment and engagement rather than mere compliance; and a far greater understanding — helped along by research — of the health consequences of low health literacy.

We wouldn’t be able to recount such progress without the hard work of champions like Helen Osborne, who has just released the second edition of Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. Helen discusses how this latest edition can serve as the backbone for any health care organization’s efforts to communicate and engage more effectively with patients of diverse backgrounds and health care fluency.

WIHI host Madge Kaplan also welcomes to the program former IHI Fellow and Iowa patient safety leader, Gail Nielsen, who has been working hard on health literacy for years, with a special emphasis on improving patient/provider partnerships, shared decision making, and care coordination. Together with Lisa Stevens, a quality expert from Illinois focused on cultural competency, Helen and Gail discuss where and how health literacy efforts stand to benefit from health care reform and what it’s going to take to close communication gaps that still remain for millions of Americans.

WIHI: Organizing for Health: A Story from South Carolina

Date: November 3, 2011

Featuring:

• Rick Foster, MD, Senior Vice President of Quality and Patient Safety, South Carolina Hospital Association
• Kate B. Hilton, Director, Organizing for Health; Principal in Practice for Leading Change at the Hauser Center for Nonprofit Organizations at Harvard University
• Landis Landon, President, Immaculate Merchant Services; Resident, Columbia, South Carolina

In August 2011, a very different sort of town hall meeting was held in Columbia, South Carolina. About 90 people who shared the zip code 29203 sat down to talk about the health issues they faced. The list was long: lack of dental care, colon cancer, breast cancer, diabetes, heart disease, stroke, mental illness, low birth weight babies, and more.

Any one of these issues is worthy of attention; indeed, in most parts of the US, you can find initiatives trying to either prevent or reduce the burden of specific diseases that affect specific individuals. But what if the approach was more comprehensive and more widespread — and, most importantly, engineered by the community itself? What if hundreds of people from across the community — representing businesses and insurance companies and local hospitals and municipal offices and professional schools — all decided to band together to turn things around? 

That’s what the people decided in Columbia, South Carolina. WIHI host Madge Kaplan talks with some of the key leaders behind the effort — Rick Foster, Kate Hilton, and Landis Landon — who describe their groundbreaking mobilization.

Some of the concepts and goals underpinning the Healthy South Carolina campaign are quite familiar, such as increasing access to primary care and the community’s commitment to wellness. But what sets this initiative apart is the strategy they’re using to make any goal a reality. It starts with training some 300 leaders by the end of 2011. They’ll play several roles, but will focus in part on fanning out across Columbia, SC, to help individuals and neighborhoods develop wellness programs and policies. There will also be a major emphasis on improving everyone’s health literacy and communication skills. And every part of the community’s health care delivery system is pledging, along with insurers, to engage in serious discussions about how to improve access to primary care, reduce reliance on emergency departments for non-urgent problems, and reduce costs.

Yes, it’s just the beginning stages and yes, it’s just one community. And no one knows whether this multi-year effort will succeed. Still, at a time when new models of better health, better health care, at reduced per capita costs, are badly needed, Healthy South Carolina is an initiative to root for, learn from, and watch.

 

WIHI: Safety Net Hospitals: Untold Stories of Quality Transformation

Date: October 20, 2011

Featuring:

• Bruce Siegel, MD, MPH, President and Chief Executive Officer, National Association of Public Hospitals and Health Systems (NAPH)
• Linda Cumming, PhD, Vice President for Research at the National Association of Public Hospitals and Health Systems (NAPH) and Director of the National Public Health and Hospital Institute (NPHHI), NAPH’s research affiliate
• Steven R. Counsell, MD, Chief of Geriatrics and Medical Director for Senior Care, Wishard Health Services, Indianapolis; Professor, Indiana University School of Medicine; Director, Indiana University Geriatrics
• Caroline M. Jacobs, MPH, MSEd, Chief Patient Safety Officer/Senior Vice President, Patient Safety, Accreditation and Regulatory Services, New York City Health and Hospitals Corporation

 

The usual way safety net hospitals wind up in the news in the US is when — faced with insufficient reimbursements and other reductions in funding — survival is questionable. The story angle becomes one of fiscal woes exacerbating and undermining the efforts of dedicated providers to deliver good care to mostly uninsured and underserved communities.

This situation and the necessity to address it remain quite real. But it often obscures another picture that's emerging in this critical sector of US health care: the ways in which safety net and public hospitals are innovating their way to greater stability. Even with financial constraints, they are improving care for patients, becoming leaders in quality and safety, and acting as mentors to other health care organizations interested in population health.

Denver Health, Contra Costa Health Services, Cambridge Health Alliance, and Stony Brook University Medical Center are just some of the names of places with visionary leaders and bold initiatives underway — so much so that they're gaining the attention of national policy leaders in search of new models of care to achieve health reform.

WIHI host Madge Kaplan speaks with Bruce Siegel and Linda Cummings of the National Association of Public Hospitals and Health Systems, who describe a comprehensive agenda for change that’s underway to support the ambitions of their members. In addition, Caroline Jacobs of the New York City Health and Hospitals Corporation and Steve Counsell of the Indiana University School of Medicine and Wishard Health Services provide some rich examples of what’s being achieved at their hospitals on the front lines of care.

The focus of this WIHI is especially timely as all of health care gears up to engage with greater numbers of low-income patients gaining insurance under health care reform. Who better to turn to for decades of experience but public and safety net hospitals?