WIHI - A Podcast from the Institute for Healthcare Improvement

WIHI: Harnessing Improvement to Reduce Diagnostic Errors and Delays

Date: December 1, 2015

Featuring:

• Mark Graber, MD, FACP, President, Society to Improve Diagnosis In Medicine; Senior Fellow, RTI International
• Thomas Gallagher, MD, FACP, Professor and Associate Chair, Department of Medicine; Director, Hospital Medicine and Center for Scholarship in Patient Care Quality and Safety, University of Washington
• Kedar Mate, MD, Senior Vice President, Institute for Healthcare Improvement (IHI)
• Jennifer Lenoci-Edwards, RN, MPH, CPPS, Director, Patient Safety, IHI

In September 2015, the Institute of Medicine issued a landmark report on diagnostic errors in the US, and the news wasn’t good: one in 20 adults suffers a diagnostic error every year. The report offers a two-part definition of diagnostic error: “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” And it shines a light on the multiple factors that cause diagnostic errors – ranging from cognitive failures on the part of diagnosing physicians, to system failures for tracking and managing test results, to lack of teamwork and communication.
 
So, how do you take such a formidable analysis and “wake-up call” about patient safety and turn it into opportunity? How do you determine the nature and extent of diagnostic errors in your organization? What are the best improvement approaches to bring about real solutions? These are the big questions featured on this episode of WIHI.

WIHI: Medicare Reimbursement and Meaningful Conversations about End-of-Life Care

Date: November 19, 2015

Featuring:

• Kate Lally, MD, FACP, Director of Palliative Care, Care New England; Hospice Medical Director, VNA of Care New England; Clinical Assistant Professor of Medicine, Alpert Medical School of Brown University
• Harriet Warshaw, Executive Director, The Conversation Project
• Holly Oh, MD, Chief Medical Officer, The Dimock Center
• Jocelyn Moore, Managing Director, The Glover Park Group

On October 30, the US Centers for Medicare & Medicaid Services (CMS) announced that, starting January 1, CMS will reimburse physicians and other practitioners for talking with any Medicare recipient about their health care preferences at the end of life – also known as advance care planning. Caught up in a political maelstrom several years ago, CMS has now caught up with a growing desire of patients and loved ones to express, and have health care respect, their wishes. Talking with a trusted provider, before one is faced with a terminal illness, can be an important part of the process.

The good news is that more people today appreciate the need to articulate their preferences regarding end-of-life care. We know this from surveys and our own experiences, and because multiple initiatives, including Respecting Choices and The Conversation Project (TCP), have tapped into a groundswell of interest in tools and resources to conduct discussions about end-of-life care wherever they can occur… around the kitchen table, at family gatherings, at community centers, and in the workplace. The next frontier is for health care to reliably “receive, record, and respect” everyone’s stated wishes.

Will the new CMS payment options make advance care discussions more likely and encourage health professionals to gain the necessary skills? That’s certainly the hope, and we sorted through the latest developments on this WIHI.

WIHI: Accelerating Improvement: The Enduring Value of Collaboratives

Date: November 12, 2015

Featuring:

• Bruce Spurlock, MD, President and CEO, Cynosure Health Solutions
• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement (IHI)
• Kedar Mate, MD, Senior Vice President, IHI
• Jane Brock, MD, MSPH, Medical Director, Telligen; Clinical Director, Quality Innovation Network - Quality Improvement Organizations National Coordinating Center

One of the hallmarks of the health care improvement movement has been the way in which diverse organizations and teams come together to gain the knowledge, skills, and confidence needed to implement change. The most celebrated of these models over the past few decades has been the “collaborative” – as simple a concept as it is radical. Simple because it’s essentially a gathering of health care practitioners and leaders willing to move beyond their own walls in order to learn with and from others facing similar patient care challenges, in pursuit of the shared goal of accelerating improvement. Radical because to take this step requires a commitment to set an ambitious, shared aim; learn together and take action locally; measure progress toward the stated goal; and share learning, in the strong belief that everyone, everywhere deserves the highest quality care…not just the people who receive treatment at your hospital or your clinic.
 
So, how has health care improved over the years, thanks to the steady work of collaboratives and the shared vision of better care for all that drives participants to this day? As the language and the ideas evolve with the times (are “learning networks” the next generation?) and the fundamentals of collaborative work take hold among patient and family improvers, students, and community coalitions focused on creating better health as well as best care, what’s next for collaboratives? How would you revise and refine this mode of working together to accelerate change?

WIHI: How Health Care Organizations Can Create Equity in the Community

Date: October 29, 2015

Featuring:

• Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health & Equity and Chief Wellness and Diversity Officer, Henry Ford Health System
• John Whittington, MD, Lead Faculty, IHI Triple Aim; Senior Fellow, Institute for Healthcare Improvement
• Sandra Bailey, Vice President for Care Transitions, Methodist Le Bonheur Healthcare
• Joy Sharp, Manager, Community Navigators, Methodist Le Bonheur Healthcare
• Mara Laderman, MSPH, Senior Research Associate, IHI

Health and health care improvement communities in the US are focusing on equity and racial disparities in some important new ways. Frustrated by the slow progress of closing gaps (despite decades of research and documentation of the problems), many are forging ahead to create more equitable access to care and better outcomes wherever and whenever they can. The new learning is coming from the “doing,” often making use of existing data that already tell a powerful story of persistent inequities (e.g., in cancer diagnosis and treatment, heart disease, and diabetes care) and highlight where there are opportunities to intervene.
 
On this episode of WIHI, we explored the opportunities health systems have to reduce inequities by virtue of their role as employers and purchasers, as well as their overall stature in the community. Health systems can promote equity with better hiring practices; by using a diverse pool of contractors and suppliers for goods and services; by offering living wages; and by engaging in initiatives in low-income — and often adjacent — neighborhoods. There are also many ways to use the influence and the resources of a health system to develop more community-friendly spaces and places for outdoor activities and physical exercise.

These aren’t just pie-in-the-sky ideas. They’re being spearheaded by organizations such as Methodist Le Bonheur Healthcare in Memphis and the Henry Ford Health System in Detroit. There are numerous other examples — but still, not nearly enough.

WIHI: Relationships Count: Community Health Workers and Team-Based Care

Date: October 15, 2015

Featuring:

• Durrell J. Fox, BS, Community Health Worker & Health Equity, Public Health Consultant
• Kevin Barnett, DrPH, MCP, Senior Investigator, Public Health Institute
• Shreya Kangovi, MD, MS, Founding Executive Director, Penn Center for Community Health Workers; Assistant Professor of Medicine, University of Pennsylvania
• Heidi Behforouz, MD, Founding Executive Director, AnansiHealth; Associate Professor of Medicine, Harvard Medical School

Of all the people who can make a difference in the lives of patients these days, one group that’s rising in importance is community health workers, or CHWs. CHWs are increasingly being utilized by community health centers, office practices, and hospitals to bridge gaps for patients between health care, home, and the community. Since many CHWs come from the same neighborhoods as the patients themselves, there’s a lot of mutual trust right off the bat. This is true whether a CHW is helping a patient manage a chronic illness, develop healthier behaviors, or act on information from a medical appointment that might otherwise be misunderstood or forgotten.

For community health workers and the patients and populations they serve, the questions are many. What are the particular skills and training needed to be an effective CHW? How can CHWs gain greater professional recognition? Largely grant-funded now, how can the work of CHWs become part of standard reimbursement? Where is research underway on the best deployment of CHWs and the contribution they can make to population health? What can be learned from the use of CHWs in other countries?

The growing interest in CHWs is sparking some important discussions and the development of innovative programs. We explored both on this WIHI.

WIHI: Getting Right Care, Right!

Date: October 1, 2015

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Featuring: 

• ​Shannon Brownlee, MS, Senior Vice President, Lown Institute; Visiting Scientist, Harvard T.H. Chan School of Public Health
• Jim Conway, MS, Adjunct Faculty, Harvard T.H. Chan School of Public Health; Member, IOM Committee on Optimizing Scheduling in Health Care
• Kedar Mate, MD, Senior Vice President, IHI
• Aaron Stupple, MD, Hospitalist, Department of Medicine, Beth Israel Deaconess Medical Center
   

There’s growing awareness of the need to curb health care’s overuse of interventions that lack a strong evidence base, unnecessarily subject patients to potential harm, and are more expensive than equally effective, cheaper alternatives. Initiatives like Choosing Wisely and Costs of Care have done a great job sounding the proverbial alarm about particular treatments and procedures doctors have grown too accustomed to prescribing automatically; antibiotics, certain screenings, and imaging tests often top the list. Costs of Care has put the spotlight on the financial harm of overtreatment on individual patients themselves, many of whom are now shouldering a larger and larger share of the health care bill. 

Against this backdrop, a new initiative called the RightCare Alliance encourages providers to take action to eliminate practices and procedures of little benefit to patients. They’re currently crowdsourcing a number of ways care providers across the US can engage in more thoughtful interactions with patients that can result in better treatment decisions. The most-favored suggestions will get top billing during RightCare Action Week, October 18-24. We explored those suggestions and more on this WIHI. 

WIHI: What Students in the Health Professions Can Do for You... and Improvement

​Date: ​September 17, 2015

Featuring:

• James Moses, MD, MPH, Medical Director of Quality Improvement (QI), Boston Medical Center; Academic Advisor, IHI Open School
• Justin Slade, Fourth Year Medical Student, Boston University School of Medicine; Senior Student Advisor, Former President, IHI Open School Chapter
• Jessica Perlo, MPH, Senior Community Manager, IHI Open School
• Rebekah Bally, MPH, CPH, Former Learning Coordinator, PSU and OHSU IHI Open School Chapter

When you imagine the legions of quality improvers around the globe working hard to transform health and health care, does your picture include students? If it doesn’t, it definitely should.

 

Right now, thanks to the IHI Open School and other initiatives, there are thousands of students in the health professions – and health professionals themselves – actively engaged in gaining the knowledge and skills to improve health and health care delivery and to build bridges between the classroom and the community. And, what’s important to underscore is that medical students, nursing students, pharmacy students and others in training, are often now the instigators for improvement initiatives within a hospital or a community clinic…initiatives that are as insightful and potentially impactful as other improvement work underway.

 

Learn more about the IHI Open School, the tools, and the networks that students are using to make a difference in health and health care: 

• The ​IHI Open School
• The Open School Change Agent Network, which supports students and health professionals leading improvement projects
• The Open School Quality Improvement Practicum​, the foundation behind teams' successful quality improvement campaigns

WIHI: Saving Lives by Design: Lessons for All from Ghana's Project Fives Alive!

Date: July 23, 2015

 

Featuring: 

• L. Nneka Mobisson-Etuk, MD, MBA, MPH, Executive Director of African Operations, Institute for Healthcare Improvement
• Sodzi Sodzi-Tettey, MD, MPH, Director, Project Fives Alive!, Senior Technical Director, Africa Region, IHI
• Pierre Barker, MD, Senior Vice President, Institute for Healthcare Improvement
• Nana A.Y. Twum-Danso, MD, MPH, Founder & CEO, MAZA; Former Senior Program Manager, Gates Foundation; Former Director, Project Fives Alive!
• Kavita Singh Ongechi, PhD, Research Assistant Professor, Gillings School of Public Health, University of North Carolina at Chapel Hill

 

One of the biggest ongoing challenges facing health and health care quality improvers is moving from small-scale successes to large-scale ones. This turns out to be far more complicated than originally thought, no matter what aspect of improvement you’re working on. That’s why it’s incredibly inspiring to learn from initiatives that are cracking the code — moving beyond barriers one deliberate step at a time, to impact the health and health care of thousands and potentially millions for the first time.

 

One such initiative has been unfolding in the African nation of Ghana since 2008, where there’s now an amazing story to tell about reductions in mortality in children under five years of age in 134 or 80 percent of the nation’s public-sector hospitals. Important lessons learned from this initiative, known as Project Fives Alive!, have been captured in a recently published practical guide. On this WIHI, we assembled an outstanding panel to talk and walk us through the critical aspect of adaptive design that has made Project Fives Alive! so successful.

WIHI: The Echo Effect of Project ECHO's Access to Specialty Care

Date: July 9, 2015

 

Featuring: 

• Sanjeev Arora, MD, FACP, FACG, Director, Project ECHO (Extension for Community Healthcare Outcomes), Department of Internal Medicine, UNM School of Medicine
• Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement

There’s telemedicine, and then there’s Project ECHO. Founder and director, Dr. Sanjeev Arora, makes the distinction so we don’t miss what’s groundbreaking about Project ECHO’s approach. While telemedicine focuses on bridging geographic divides that can separate patients from needed specialists, Project ECHO is on a mission to bridge divides within the provider community itself that prevent medical expertise from being shared and distributed more widely.

 

With Project ECHO, primary care doctors and others working in underserved, isolated, or small community settings use videoconferencing to advance their skills and ability to handle complex cases because of what they learn from specialists some distance away. The goal is both simple and profound: a “democratization of knowledge” so that patients anywhere can receive the best care from the doctor or health care practitioner they have easiest access to, not the one they don’t. 

 

What began in 2003 as a process for improving access to treatment for people in New Mexico suffering from Hepatitis C, now offers support and learning for 30 different diseases and conditions, impacting patients in some 22 states. A lot of observers believe Project ECHO’s approach to expanding access to specialty care is disruptive in the best sense. That’s why this WIHI took a good, hard look at what difference this effort is making to patients and providers alike.

 

WIHI: The IHI Triple Aim: Lessons from the First Seven Years

Date: June 25, 2015

Featuring:

• John Whittington, MD, Lead Faculty, IHI Triple Aim; Senior Fellow, IHI
• Trissa Torres, MD, MSPH, FACPM, Senior Vice President, IHI
• Kevin Nolan, MA, Associates in Process Improvement; Senior Fellow, IHI
• Ninon Lewis, MS, Executive Director, Triple Aim for Populations, IHI

It’s never been easy to define an overall strategy for the transformation of US health care. And that may explain why the Triple Aim has been so resonant with so many. In part it’s the simplicity of a three-part framework to achieve better care, better health, at lower per capita costs. It’s also the goals themselves. The idea of simultaneously improving the care of individual patients, improving the health of larger populations, and bringing health care costs down, first conceived by the Institute for Healthcare Improvement (IHI) in 2008, now defines the pursuits of health care systems and communities in many parts of the world, but especially here in the US.

 

Fast forward to June 2015 and Milbank Quarterly​ has just published the first major harvesting of lessons learned over the past seven years of work on the Triple Aim, drawing on IHI’s engagement with some 141 organizations across a wide array of settings. We brought the article authors into our WIHI studio to discuss their analysis.