1. Patient Engagement: The New Blockbuster Drug 2013 NHS Scotland Event 11 June to 12 June, 2013 Glasgow Maureen Bisognano President and CEO

2. The New Blockbuster Drug 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 cant or dont manage all as non compliant No research of de-intensification of unnecessary, ineffective treatment 4. Patient Engagement Moving from whats 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 teams 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 8. Lesson: Will-building Will-building at the Senior Level Colones rounds Walk of shame OBriens breakfast meeting Transparency Sharp end knowledge 9. Will-building Ginnys Story: http://www.youtube.com/watch?v= s5x1f3_NJX8 10. Serious Safety Event Rate: One View 0.00 0.25 0.50 0.75 1.00 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 EventRate 0 1 2 3 4 5 6 7 8 9 10 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 12. Patient and Family Engagement 13. An Alarming Disconnect 70 percent of Americans want to die at homebut 70 percent die in institutional settings1 80 percent of Californians want to speak to a doctor about end-of-life wishesbut only 7 percent have done so2 82 percent of Californians say its important to put their wishes in writingbut 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. 14. Two Complementary Initiatives Everyones 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 15. 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 16. Early Enthusiasm Over 86,000 visits to website (theconversationproject.org) Over 43,000 downloads of the Conversation Starter Kit (also available in Spanish) 17. 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 18. Patient Engagement Redesigned processes in acute care New ways to think about teamwork 19. 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 20. Collaborative Care at ThedaCare Collaborative rounding on your admission Evidence-based care The nurse as manager of care Electronic Records Design of physical space 21. Minimally disruptive medicine Health care delivery designed to reduce the burden of treatment on patients while pursuing patient goals 22. Work of being a chronic patient Sense-making work Organizing work and enrolling others Doing the work Reflection, monitoring, appraisal 23. 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). 24. Medication Choice Cards Other Cards Low Blood Sugar (hypoglycemia) Blood Sugar (A1c Reduction) Side Effects Daily Routine Daily Sugar Testing 25. 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 26. Diabetes Visit Cards 27. Redesigning Care with Patients Think: Dose Place Tempo 28. 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 29. 44 Pediatric GI Centers 30. Purpose of ImproveCareNow Transform health, care and costs for all children and adolescents with Crohns 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 31. 30% 40% 50% 60% 70% 80% 90% 04/01/2007n=132 05/01/2007n=184 06/01/2007n=255 07/01/2007n=298 08/01/2007n=353 09/01/2007n=383 10/01/2007n=411 11/01/2007n=436 12/01/2007n=459 01/01/2008n=488 02/01/2008n=495 03/01/2008n=513 04/01/2008n=516 05/01/2008n=526 06/01/2008n=522 07/01/2008n=541 08/01/2008n=570 09/01/2008n=595 10/01/2008n=631 11/01/2008n=657 12/01/2008n=718 01/01/2009n=772 02/01/2009n=785 03/01/2009n=797 04/01/2009n=821 05/01/2009n=840 06/01/2009n=891 07/01/2009n=920 08/01/2009n=945 09/01/2009n=961 10/01/2009n=970 11/01/2009n=978 12/01/2009n=996 01/01/2010n=1009 02/01/2010n=1002 03/01/2010n=1025 04/01/2010n=1041 05/01/2010n=1050 06/01/2010n=1068 07/01/2010n=1090 08/01/2010n=1126 09/01/2010n=1153 10/01/2010n=1187 11/01/2010n=1613 12/01/2010n=1687 01/01/2011n=1728 02/01/2011n=1791 03/01/2011n=1857 04/01/2011n=1963 05/01/2011n=2019 06/01/2011n=2137 07/01/2011n=2168 08/01/2011n=2239 09/01/2011n=2269 10/01/2011n=2328 11/01/2011n=2360 12/01/2011n=2427 01/01/2012n=2490 02/01/2012n=2537 03/01/2012n=2566 04/01/2012n=2587 05/01/2012n=2612 06/01/2012n=2769 07/01/2012n=2759 08/01/2012n=2849 09/01/2012n=2808 % of Patients in Remission 18 care centers with > 75% of patients in registry 32. How do you create networkbased 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 33. Place George Halvorsons 4 sites of care: Hospital beds Face-to-face Home Electronic 34. 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 35. 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 36. 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 37. Tempo Moving from 2 per year to 2 per week A year of care Technology and MITs 15 minutes a quarter 38. Dose, Place, and Tempo: Self-Dialysis The Old Way Ryhov Hospital in Jnkping had traditional hemodialysis and peritoneal dialysis center. But in 2005, a patient, Christian, asked about doing it himself. 39. The New Way Christian taught a 73-yr-old woman how to do it and they started to teach others how to do it. 40. The New Way Now they aim to have 75% of patients to be on self-dialysis They currently have 60% of patients 41. 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. 42. 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 countys employment, helped the patients make or update the CVs, and trained them for a new career. 43. 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 44. Jonkoping Visit, October 2011 45. 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. 46. 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 47. Thank You! Maureen Bisognano President and CEO Institute for Healthcare Improvement 20 University Road, 7th Floor Cambridge, MA mbisognano@ihi.org