WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: The How and Why of Deprescribing

Date: September 13, 2018

Featuring:

• Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, Executive Director, Peter Lamy Center on Drug Therapy and Aging; Professor, University of Maryland School of Pharmacy 
• Florian Daragjati, PharmD, BCPS, Director, Ascension Center of Excellence for Antimicrobial Stewardship and Infection Prevention
• Lynn Deguzman, PharmD, BCGP, Regional Clinical Operations Manager, Kaiser Permanente
• Leslie J. Pelton, MPA, Senior Director, Institute for Healthcare Improvement
• Leanne Phillips, PharmD, BCPS, Clinical Pharmacy Coordinator, St. Vincent’s East, Ascension

The ground is shifting for prescription medication in the US and Canada, and in other countries, too. There’s much talk and publicity about weaning people off drugs, or what is referred to as “deprescribing”: a process that entails taking patients off some of their medications or tapering down the dosages.

The underlying reasons for deprescribing include concerns about polypharmacy, especially the impact on older and frail adults; antibiotic resistance caused by inappropriate and excessive use; and the ongoing opioid epidemic connected to years of overprescribing highly addictive medicines for pain.

A growing number of health care organizations are working with IHI on how to safely implement deprescribing. Learn about their experiences and the future of this work on the September 13 episode of WIHI, The How and Why of Deprescribing,

WIHI: Connecting Patient Experience to Strategic Aims

Date: August 9, 2018

 

Featuring:

• Barbara Balik, RN, EdD, Co-Founder, Aefina Partners, and Senior Faculty, Institute for Healthcare Improvement (IHI)
• Kris White, MBA, RN, Co-Founder, Aefina Partners, and Faculty, IHI
• Helen Macfie, PharmD, FABC, Chief Transformation Officer, MemorialCare

 

Most hospitals are understandably preoccupied with patient experience scores. High-performing organizations worry when their scores plateau, and those with mediocre scores wonder why their attention to better "customer service" hasn't improved the numbers. Up and down the rankings, there's discussion about patients as unreliable informants, flawed survey instruments, low survey response rates, and institutions being judged unfairly by these scores.

 

A decade into publicly reported patient experience data for US hospitals (most notably with HCAHPS​), experts say that health systems are working on patient experience too much in isolation, separate from other organizational strategic aims. If you're tired of the same old discussion about patient experience scores, we hope you'll listen the new ideas and best practices presented on the August 9 WIHI: Connecting Patient Experience to Culture and Strategic Aims.

 

WIHI: How to Build Better Behavioral Health in the Emergency Department

Scott Zeller, MD, Vice President of Acute Psychiatry, Vituity

Robin Henderson, PsyD, Chief Executive, Behavioral Health, Providence Medical Group Oregon and Clinical Liaison, Well Being Trust

Vera Feuer, MD, Director of Pediatric Emergency Psychiatry, Northwell Health

Mara Laderman, MPH, Director for Innovation, Institute for Healthcare Improvement (IHI)​

 

​For all that emergency departments (EDs) do to stabilize individuals and save lives, they’ve never been the ideal place for patients whose crises are related to behavioral health. EDs are designed to address the most urgent, sometimes life-threatening problems, and then discharge or transfer patients to the appropriate next level of care. If a psychiatric or addiction-related admission is needed, however, there may not be any beds. This often leads to boarding patients in the ED or adjacent hallways for hours, sometimes days. ​

 

In the US, many blame an underfunded mental health system for the shortage of inpatient beds and an inadequate supply of outpatient services that might help patients avoid going to the hospital altogether. Emergency department staff aren't any happier with the status quo. They have begun to look at how EDs might improve the overall care experience for behavioral health patients and contribute to continuity of care.

 

Promising new practices are being tested in nine hospitals participating in Integrating Behavioral Health in the Emergency Department and Upstream​, an initiative led by IHI in partnership with Well Being Trust​. Improvements these hospital EDs are testing include creating new lines of communication and care coordination, including post-discharge follow-up, with community-based services; standardizing and streamlining processes from intake to discharge for a range of mental health and substance abuse issues; working with both patients and their family members on self-management skills; and educating ED staff on behaviors consistent with a trauma-informed and empathetic culture.

 

We dicsussed these tests and innovations on the July 12 episode of WIHI: How to Build a Better Behavioral Health in the Emergency Department

WIHI: Addiction Treatment Demystified: Proven, Practical Steps for Complex Care.​​

• Corey Waller, MD, MS, FACEP, DFASAM, Addiction, Pain, Emergency Medicine Specialist; Managing Partner, Complex Care Consulting, LLC; Chair, Legislative Advocacy Committee for the American Society of Addiction Medicine (ASAM)
• Catherine Mather, MA, Director, Institute for Healthcare Improvement (IHI)

 

About 5 percent of patients in the US are individuals with complex needs. Many show up at hospital emergency departments with a combination of physical, socioeconomic, and behavioral health issues — only to return, again and again, sometimes in worse condition, because the current system isn't set up to address a multitude of problems. The burgeoning field of "complex care" is trying to break the cycle with new interventions and stronger connections to supportive services.  .

But addiction, a common thread among the complex patient population, is often dealt with differently. While the recent opioid epidemic has forced health care providers to change some of their prescription practices and to become more knowledgeable about substance use disorders in general, patients themselves are still typically 'referred out' for treatment — to a much less integrated and accessible system, already stretched to its limits.​

What could the health care system offer that it's not offering now? We explored that and more on the June 21 episode of WIHI: Addiction Treatment Demystified: Proven, Practical Steps for Complex Care.​​

WIHI: Strategic Pathways to Population Health

• Saranya Loehrer, MD, MPH, Head of the North America Region, Institute for Healthcare Improvement (IHI)
• Christina Lundquist, BA, MHS, Vice President of Operations, Rainbow Babies and Children's Hospital and MacDonald Women's Hospital at University Hospitals (UH) Health System
• Lora Council, MD, MPH, Senior Medical Director for Primary Care, Cambridge Health Alliance ​

 

Health systems face numerous challenges in their efforts to improve population health. Among them, multiple entry points, such as initiating better care management for all patients with chronic asthma, widespread depression screening, or working with the community to address food insecurity. Each initiative is valuable yet, taken together, don't necessarily add up to a comprehensive population health strategy. Is there a logic to what to do first, then second, and so on? How do you know you're on the right track?

 

There are no simple answers, but there has been enough experience with population health in the US and elsewhere that several groups, including IHI, have come up with four portfolios of work to help organizations become more strategic about their efforts. With the help of new resources​, we discussed these four "pathways" and with two health systems that are deeply engaged in improving population health on the June 7 episode of WIHI: Strategic Pathways to Population Health.

WIHI: Giving Patients and Families the Tools to be Health Care Improvers

Amar Shah, Consultant Forensic Psychiatrist & Chief Quality Officer, East London NHS Foundation Trust

​Lindsey Bourne, Director of Education, PFCCpartners

Barbara Grey, Director SLaM Partners & Quality Improvement (QI), South London and Maudsley NHS Foundation Trust

Sarah Davenport, Service User Consultant, South London and Maudsley NHS Foundation Trust

​Gabrielle Richards, Head of Inclusion, Recovery, Occupational Therapy, and Allied Health Professionals, South London and Maudsley NHS Foundation Trust​

 

Patients and families are playing a greater role in health care quality improvement. Over the last decade participation has grown to include serving on Patient and Family Advisory Committees, or PFACs; regularly meeting with hospital board safety and quality committees; joining co-design and co-production initiatives; and speaking or leading sessions at QI conferences.

 Along the way, there's been some exposure to QI principles and methods, but now some organizations believe it's essential for patients and families to have training in basic improvement to enhance their influence and involvement. On the May 17 episode of WIHI, Giving Patients and Families the Tools to Be Health Care Improvers, we discussed getting improvement basics into the hands of patients and their families with East London NHS Foundation Trust and South London and Maudsley Trust and how "service users" have become involved in nearly half the improvement projects happening at their organizations.

WIHI: How to Make Change Happen: An Introduction to IHI's Psychology of Change Framework ​

Date: May 10, 2018

Featuring:

• Michael Rose, MD, Anesthesiologist, Vice President of Surgical Services & Chairperson of Community Board of Trustees, McLeod Regional Medical Center
• ​Kate B. Hilton, JD, MTS, Faculty, Institute for Healthcare Improvement; Senior Consultant, ReThink Health​
• Alex Anderson, Research Associate, Institute for Healthcare Improvement

For the past 30 years, the Institute for Healthcare Improvement (IHI)​ has worked with organizations around the world to improve health and health care using an approach to quality improvement that's grounded in W. Edwards Deming's System of Profound Knowledge. Dedicated improvers know that, to achieve results, we need to consistently apply systems thinking, an understanding of variation, and theories of knowledge.

So, what often stands in the way of adopting and spreading meaningful improvements? Breaking news: People are resistant to change.

Deming himself stressed the importance of psychology — or the adaptive, human side of change — in his System of Profound Knowledge. But health care improvers still have a lot of work to do to sharpen our thinking, vocabulary, and tools in this challenging domain.

That's why the IHI Innovation Team has been researching and testing "psychology of change" ideas and methods to promote and accelerate successful, scalable, and sustainable improvement work. Kate Hilton and Alex Anderson described how they are working with organizations to implement the IHI Psychology of Change Framework, and Dr. Michael Rose discussed implementing many of these methods to spread the use and adoption of a surgical safety checklist at McLeod Regional Health Center in Florence, South Carolina on this episode WIHI: How to Make Change Happen: An Introduction to IHI's Psychology of Change Framework. 

WIHI: Pursuing Health Equity in North Carolina

Date: April 19, 2018

 

Featuring:

Julie Kennedy Oehlert, DNP, RN, Chief Experience Officer, Vidant Health

Jermaine McNair, Executive Director, NC CIVIL

Jafet Arrieta, MD, MMS, Director, Institute for Healthcare Improvement (IHI)

Meghan Hassinger Welch, MBA, Senior Project Manager, IHI

 

Eight health systems are working with IHI to broaden their impact on health equity as part of the two-year Pursuing Equity initiative​. These systems are working to elevate health equity to a strategic priority, confront institutional racism, and improve the livelihood and health of their patients, employees, and surrounding communities.

Vidant Health​, based in Greenville, North Carolina, is a 1,447-bed health system serving more than one million patients each year from 29 eastern North Carolina counties. This part of the state is largely rural, poor, and home to a racially diverse population. Vidant's health equity priorities are centered on improving the health and wellbeing of their patients and — as the largest employer in Greenville — some 12,000 employees, many of whom live in nearby cities and towns.

Vidant's efforts to improve equity also benefit from a strong partnership with NC CIVIL​, a nonprofit grass roots community development organization in Greenville. Jermaine McNair, its Executive Director, will discuss their focus on strengthening economic, social, political, and legal processes in the community and how working with Vidant Health is helping on all these fronts on this episode of WIHI, Pursuing Equity in North Carolina.

WIHI: Sustaining and Strengthening Safety Huddles

Date: April 5, 2018

Featuring:

• James L. Reinertsen, MD, The Reinertsen Group
• Ronette Wiley, RN, BS, MHSA, CPPS, Executive Vice President, COO, Bassett Medical Center
• Helen Mackie, MB, ChB, FRCP, Consultant Gastroenterologist, University Hairmyres Hospital, NHS Lanarkshire; National Clinical Advisor for "Realistic Medicine," Scottish Government

The safety huddle​ has become an important way for hospitals to surface safety concerns affecting patients and the workforce. The best huddles are multidisciplinary, highly structured, brief (15 minutes or less), take place early in the morning and focus on incidents from the day before and risks to safety in the day ahead. Is the safety huddle effective? Have organizations grown lax with the process over time?

Some participants have observed that, over time, safety huddles tend to become "just another meeting" or "another box to check off." Dr. James Reinertsen, who has spent decades coaching clinical leaders and staff about safety, says too many huddles allow department leads to report "no safety issues today." That's impossible, says Reinertsen. Every department has safety risks; it's a matter of being proactive and looking for them.

On this episode of WIHI, Sustaining and Strengthening the Safety Huddle, we discussed two strong examples of safety huddle programs at two different health systems: Ronette Wiley shared the story of the turnaround with the safety huddle​ and the tools they use​ at Bassett Medical Center in upstate New York, and Dr. Helen Mackie educated us about the safety huddle at Hairmyres Hospital in Scotland where issues are flagged daily in a rigorous process known as The Onion​. 

WIHI: Mobility Matters for Age-Friendly Care

Date: March 22, 2018

Featuring:

• ​Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine (Geriatrics) and Professor, Institution for Social and Policy Studies; Section Chief, Geriatrics (co-chair)
• Marie Cleary-Fishman, BSN, MS, MBA, CPHQ, CPPS, CHCQM, Vice President, Clinical Quality, Health Research & Educational Trust (AHA)
• J. Michelle Moccia, DNP, ANP-BC, CCRN, Program Director, Senior Emergency Center, St. Mary Mercy Hospital (Trinity Health)
• Belinda Dokic, CPht, BA, MBA, Quality Performance Improvement Leader, St. Mary Mercy Hospital (Trinity Health) 

Preventing injuries from falls, especially among the elderly, has been a flagship issue for health care quality improvement and patient safety for nearly two decades. The complications that can follow broken bones at an advanced age, most notably a broken hip, can literally be deadly. This reality, numerous programs, and reporting requirements have kept falls prevention front and center across the health care continuum.

Now a new initiative wants to emphasize the physical and mental health benefits of mobility, and encourage greater mobility for older patients in conjunction with falls prevention, as part of a broadening vision of "age-friendly" care​. We explored what this looks like in practice, starting with the hospital setting, on the March 22 episode of WIHI: Mobility Matters for Age-Friendly Care.