In this session, Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement (IHI), shares the latest tools to engage patients and families in the care system. Many are calling person-centred care/patient engagement ‘the next blockbuster drug’ because of its powerful potential to produce the best outcomes while learning best practices.
See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources
3. Patient Engagement
The New Blockbuster Drug
Large body of scientific literature on clinical inertia and
failure to intensify treatment, especially in diabetes and
hypertension management
Label patients who can‟t or don‟t manage all as “non
compliant”
No research of de-intensification of
unnecessary, ineffective treatment
4. Patient Engagement
Moving from “what‟s the matter?” medicine
to “what matters to you?” medicine
– Susan Edgman-Levitan and Michael Barry
The patient is the team captain; the
clinicians are the team‟s coaches
– Fred Southwick
5. How can we make
this move to “What
matters to you?”
6. Exercise
Read “Return of the Hero”
Discuss with your colleagues at your tables.
Talk about and make a plan to visit a patient person,
without any medical equipment, and learn who they are
and what they hope for.
7. Patient Engagement Has the Potential to:
Improve health outcomes
Expand our definition of “the health care
workforce”
Lower costs
Improve patient satisfaction
10. Serious Safety Event Rate: One View
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EventRate
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NumberofEvents
Rolling 12-month Serious Safety Events expressed per 10,000 adjusted patient days
SSER August 2008: 0.41
Average Days between events: 14 days (CY08 Sept YTD)
19 days (CY07)
37 days (CY06)
Safety Behavior Training Begins
Employee Training Ends
Medical Staff Training Ends
11. John L.
4/27/2008
HAI
Baby C.
4/13/2008
Delay in Tx
Ralph H.
3/12/2008
Fall
Harold C.
8/5/2008
Fall
George P.
5/07/2008
Fall
Roberta A.
10/13/2008
Fall
Tom D.
1/29/08
Delay in Tx
Tammy F.
1/17/2008
Post Procedure Death
Jaunita D.
8/25/2008
Fall Baby D.
8/1/2008
Wrong Pt. Procedure
Donald C.
6/26/2008
Delay in Tx
James A.
9/06/2008
Delay in Dx
Frank H.
6/03/2008
Delay in Tx
Joe E.
9/23/2008
Wrong Site Surgery
Johnny R.
9/08/2008
Delay in Dx.
Another View of the Same Data
for the Last 3 Months
Herman D.
3/17/2008
Retained Foreign Obj.
Mark G.
8/17/2008
Fall
John G.
1/03/2008
Delay in Tx
Nick S.
1/4/2008
Delay in Dx
14. An Alarming Disconnect
70 percent of Americans want to die at home…but 70
percent die in institutional settings1
80 percent of Californians want to speak to a doctor
about end-of-life wishes…but only 7 percent have done
so2
82 percent of Californians say it‟s important to put their
wishes in writing…but only 23 percent have done so2
1CDC. Worktable 309: deaths by place of death, age, race, and sex: United States, 2005.
2California HealthCare Foundation. Final chapter: Californians‟ attitudes and experiences with death and dying.
CHCF, 2012.
15. Two Complementary Initiatives
Everyone‟s end-of-life wishes
will be expressed and
respected
Every one has a story to tell
The conversations are
personal, not medical
The power of storytelling
Develop a culture of shared
decision making with patients
Improve processes to reliably
prompt, store, and
access end-of-life care wishes
http://theconversationproject.org/
http://www.ihi.org/offerings/Initiatives/C
onversationProject/Pages/Conversation
Ready.aspx
16. The Conversation Project
A grassroots movement to encourage everyone to have
conversations about end-of-life wishes with loved ones
“at the kitchen table”
Bringing about change “from the outside in”
Leveraging media, including social media, to bring
messages and tools to all
Targeting specific geographic regions and segments of
the population
17. Early Enthusiasm
Over 86,000 visits to website
(theconversationproject.org)
Over 43,000 downloads of
the Conversation Starter Kit
(also available in Spanish)
18. Conversation Ready
IHI initiative: 10 Pioneer organizations committed to
being “conversation ready” within one year
Requires a new perspective – moving beyond the
current “rescue culture” of US health care
Leveraging the lessons of exemplar organizations such
as Gundersen-Lutheran in La Crosse, WI, and Dana-
Farber Cancer Institute in Boston, MA
21. Lean Visits at ThedaCare
“Encircle Health”
– Anticipate and structures to meet all needs in
one visit
– Lab designed to get results to patient record
within 15 minutes
– Patients leave with one plan, all results
22. Collaborative Care at ThedaCare
• Collaborative
rounding on your
admission
• Evidence-based
care
• The nurse as
manager of care
• Electronic Records
• Design of physical
space
24. Work of being a chronic patient
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitoring, appraisal
25. 5000
Hours
Source: Asch DA, et al. “Automated Hovering in Health Care – Watching Over the
5000 Hours.” New England Journal of Medicine. July 2012: 367(1).
27. Diabetes Visit Cards
Developed in England by the Design Council to
improve the effectiveness of chronic care visits
at physicians‟ offices
The patient sorts the cards to select issues that
form the agenda for the visit
Satisfaction is improved and patients report
more control of their disease
33. Dose
Better Health Greater Cleveland:
– In-person educational sessions for the community led by respected
clinicians; and digital education for clinicians, medical students, and
residents
Texas Medical Association:
– County medical societies promoting Choosing WiselyTM
recommendations to
47,000 physicians and medical students
– State-wide patient campaign
– Collaborative to share best practices for implementation
American Society of Echocardiology, MA Medical Society, and
American Society of Nuclear Cardiology
– Apps to allow for easy search for criteria
– Websites for patients and clinicians to use in shared decision making
35. Purpose of ImproveCareNow
Transform health, care and costs for all children
and adolescents with Crohn’s and ulcerative colitis
sustainable collaborative chronic care network,
enabling patients, families, clinicians and
researchers to work together in a learning health
care system
accelerate innovation, discovery and the
application of new knowledge
37. How do you create network–based
production for health?
1. Focus on outcome
2. Build community
3. Effective use of technology
4. Learning system
System science, QI, qualitative
research, clinical research
39. Place
Source: Landro L. “Hospitals Try House Calls to Cut Costs, Admissions.” The Wall Street Journal. Feb. 4, 2013. Available at:
http://online.wsj.com/article/SB10001424127887324610504578278102547802848.html
40. Place – New Health Communities
NORCs (Naturally Occurring Retirement
Communities)
– Strong trend in the US for better elder
communities combines with a trend toward
self care and decreased confidence in the
unquestioned authority of the medical system
41. Place – Schools (site visit)
NHS Tayside and Perth & Kinross Council:
– Developing improvement methods by working across
a wider community campus model
– Designing a „strategic coalition‟ across the public
sector, the voluntary sector and communities.
– Almondbank House: outcome-focused improvements
which have been delivered in partnership with
traditionally hard-to-reach families
42. Tempo
Moving from “2 per year” to “2 per week”
“A year of care”
Technology and MIT‟s “15 minutes a
quarter”
43. Dose, Place, and Tempo: Self-Dialysis
The Old Way
Ryhov Hospital in Jönköping had traditional hemodialysis
and peritoneal dialysis center.
But in 2005, a patient, Christian, asked about doing it
himself.
44. The New Way
Christian taught a 73-yr-old woman how to do it…
…and they started to teach others how to do it.
45. The New Way
Now they aim to have 75% of patients to be on
self-dialysis
They currently have 60% of patients
46. Lessons to Date
From Christian (patient):
– “I have a new definition of health.”
– “I want to live a full life. I have more energy and am
complete.”
– “I learned and I taught the person next to me, and
next to her. The oldest patient on self-dialysis is 83
years old.”
– “Of course the care is safer in my hands.”
47. Lessons to Date
From Anette (nurse leader):
– Surprised at design differences between
patients, family, and staff
– Managing at 1/2 – 1/3 less cost per patient
– Evidence of better outcomes, lower costs, far fewer
complications and infections
– “We brought in the county‟s employment, helped the
patients make or update the CVs, and trained them
for a new career.”
49. Update
Now calculated costs at 50% of costs in other
hemo-dialysis units
Complications dramatically reduced and
subsequent expensive care avoided
Measuring success by “number of patients
working”
51. In 3 Years, Our Model of Care Will Be:
Assisted
HD
Home HD
Self care
on HD
We believe that a culture of
Sharing the care on
Haemodialysis is the foundation
for Self care on dialysis units.
• We plan to initiate shared
haemodialysis care in dialysis
centres across Yorkshire and
Humber.
• We will to this by –
– Setting up a course to teach
dialysis nurses how to support
patient to learn aspects of their
own dialysis.
– Supporting willing patients to
learn as much of their own
dialysis as they wish to.
52. Exercise
At your tables, brainstorm 5 things patients and
families can do for themselves…
…to get better outcomes
…to get better self-efficacy
…to lower health care costs
Use data and stories equally to build willCan we take the trend line out?
Kinds of patient work according to the normalization process theory approach we are using to understand patient work (see more on this theory at http://normalizationprocess.org – we are currently conducting patient interviews and review of consultations to further understand this domain and develop a psychometrically sound measure of treatment burden.
This slide shows the impact on the rate of remission among the first 15 teams to join the network. This is an annotated control chart showing, on the Y-axis, the % of patients in remission. Time is on the X-axis. The various interventions are noted on the slide. These data are from last August when the rate of remission reached about 73%. We are now up to about 77%.How are they doing it – sharing. Sharing data, know how and knowledge