Clinical leadership on the unit and at the top— a “Swiss Army knife”
for sustained performance
University of Pennsylvania Health SystemSeptember 19, 2008
University HealthSystem Consortium2008 Quality and Safety Fall Forum
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Who We Are
Victoria Rich, PhD, FAAN, RNChief Nursing Executive, University of Pennsylvania Medical CenterAsst. Dean for Clinical Practice, University of Pennsylvania School of Nursing
PJ Brennan, MDChief Medical Officer & Senior Vice PresidentUniversity of Pennsylvania Health System
Kendal Williams, MDDirector, Center for Evidence-based Practice, UPHSService Chief, Penn Presbyterian Medical Center
Elizabeth Riley-Wasserman, PhDSenior Vice President, Human Resources & Organization DevelopmentMercy Health System(Formerly Chief Learning Officer, University of Pennsylvania Health System)
Linda May, PhDPrincipalCenter for Applied Research (CFAR)
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Today’s talk
First the basics
What it looks and feels like on the units
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How we’re getting there — and what we’re doingto sustain the gains
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A “campaign” approach to change4
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A new take on accountability
From “thou shalt” to developing theeveryday work practices —large and small — that make itpossible for people to takeresponsibility, up and down theorganization.
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And a new take on innovation
Helping the organization learn fromitself — and look for places wherepockets of innovation are alreadybeginning to emerge.
The leader’s job is to be opportunistically strategic— to develop the radar to recognize those opportunitiesand build on them.
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It’s not the “Unit Clinical Leadership” model,it’s the approach
If you leave today saying, “This modeldoesn’t apply to us,” or “Penn has moremoney than we do,”
— then we haven’t done a good jobcommunicating what this talk isabout.
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First the basics1
We were here last year to talkabout how we developed theUnit Clinical Leadership model— those slides are in yourpacket.
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Blueprint for Quality and Patient Safety — theframework for clinical strategy at UPHS
Unit clinical leadership4. Accountability
Interdisciplinary rounding3. Coordination ofcare
Reduce hospital-acquiredinfections
Reduce medication errors
2. Reduce variationsin practice
Transition planning
Medication management1. Transitions in care
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to prevent thepreventable — reduce QIII/QIV mortality andreduce 30-day re-admissions.
The CMOs and CNOs from across UPHS’ three hospitalsand the homecare agency have banded together todevelop the Blueprint for Quality and Patient Safety.
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We needed a “Swiss Army knife” — no morewhack a mole
The institution was tired ofplaying “whack a mole.” Everyyear we’d develop three or fournew initiatives — but thenanother problem would comealong.
We needed a multi-purposestructure on the units tohandle almost any problem.
This isn’t a project, it’s a way ofdoing things. You can boltdifferent strategies onto it.
“—UPHS Chief Financial Officer”
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What does our “Swiss Army knife” look like?
The Unit Clinical Leadershipmodel is the partnership of aPhysician Leader and NurseLeader at the unit level — with adedicated Quality Coordinatoras the essential third member ofthe team.
Three-Way Partnership at the Core of theUnit Clinical Leadership Model
Physician Leader
QualityCoordinator
Nurse Leader
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We started modestly at first, so the teams couldlearn to work with each other
Four Core Activities inthe Pilot Year
Raising the Bar in FY’09
Weekly operationsmeeting to review metrics &plan ahead
Interdisciplinaryrounding
Orienting house staff
Two improvementprojects aimed at healthsystem objectives like reducinghospital-acquired infections.
Plus a more extensive set ofimprovement targets
All these (and sustain thegains)
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It takes the whole unit — ratios and leverage
Provides leveragefor the nursing role
10 patients perCertified NursingAssistant
1:10 CNA Ratio
Allows the unit tofocus on qualityagenda
5 patients per RN
1:5 RN Ratio
Staff and patienteducation makethe other rolesmore effective
Handles the “airtraffic control” thatfrees the nurseleader to partnerwith physicianleader and freesthe nurses to focuson patient care
Provides strategicview and continuityon off-shift andweekends
At least .5 FTE perunit
One per unit.Rotationalassignment.
One per unit on offshift. Units shareon weekends.
Clinical NurseSpecialist/Educator
Charge Nursewithout Patient
Care Duties
Assist NurseManager on Off
Shift andWeekends
What
Why
Unit leadership alone won’t make the difference. The model includesthe staffing infrastructure to succeed.
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The Unit Clinical Leadership teams are showingresults already — here are the headlines
The strongestfinancial case can bemade for BSIs.
98 fewer BSIs in FY’08,for a cost savings of$1,881,404.
Bloodstream infections aregoing down.
Urinary-tract infections aregoing down.
Medication reconciliationaccuracy is improving at bothadmission & discharge.
Additional projects aimed atreducing variations in practiceare also showing results.
A return on investment is also expected in lives saved, fewerreadmissions, regulatory compliance, patient satisfaction,and interdisciplinary collaboration and communication.
On the 13 pilot units:
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And next year’s targets are even higher
• Unit clinical leadership4. Accountability
• Interdisciplinary rounding3. Coordination of care
• Reduce hospital-acquiredinfections
• Reduce medication errors
2. Reduce unnecessaryvariations in practice
• Transition planning• Medication management
1. Transitions in care
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to prevent thepreventable — reduce QIII/QIV mortality andreduce 30-day re-admissions.
• HUP only: 25% reduction in preventablereadmits for CHF, Diabetes &Anticoagulation for patients from HCHS
• Increase appropriate use of hospice
• Core measures — heart failure dischargeinstructions
• Unplanned readmission to ICU
Selected Units
• Increase use of homecare
• Med reconciliation on admission
All Units
Transitions in Care — FY’09 Targets
• “Staff worked together” (PressGaney)
• Likelihood of recommendation(HCAHPS)
• Anticipated discharge by patient(Patient Progression)
All Units
Coordination of Care — FY’09 Targets
• Ventilator-associated pneumonia• SCIP (Surgical Care Improvement Program)• Process improvements for high risk patient
populations• HUP only: Anticoagulation med errors (applies to
HUP pharmacy, but goals are unit specific)
Selected Units
• Reduce CR bloodstream infections• Reduce urinary tract infections• Time to admin of STAT antibiotics• Decrease rate of DVTs & PEs• Decrease falls with injury• Decrease pressure ulcers• Adherence to hand hygiene
All Units
Reduce Variations in Practice — FY’09 Targets
• Timely launch of UnitClinical Leadership team
Selected Units
All Units
Accountability — FY’09 Targets
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UPHS has committed to thirteen more units inFY’09 — with more over time, if results sustain
Q4: Apr-JuneQ3: Jan-MarQ2: Oct-DecQ1: Jul-Sep
FY’09 — 13 new units
(26 cumulative by end of fiscal year)
Fully up and running: 4 Cathcart 7 Cathcart 4 Preston 5 Preston
Fully up and running: 5 South 5 East MICU
Fully up and running: Founders 10 Silver 10 Rhoads 1 Rhoads 3 Ravdin 6 Dulles 6
Founders 5 Silver 7 Rhoads 5 MICU SICU CCU ICN
FY’11
Evaluate remaining: ORs ICN Inpatient psych
ACE CCU SICU 3 East 3 South 4 East
Evaluate remaining: ORs
Founders 11 Silver 9 Silver 12 Rhoads 4 Ravdin 9
FY’10
5 Cathcart 6 Cathcart 7 Scheidt CCU ICCU ED L&D
PAH
4 SouthPPMC
Founders 12 Founders 14 Silver 11 Rhoads 6 Rhoads 7
HUP
FY’08
— 13 unitsHospital
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What it looks and feels likeon the units
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On the ground at 4 South,Penn Presbyterian MedicalCenter
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On the ground at Founders 14,Hospital of the University ofPennsylvania
Founders 14 UTI Infection Data
1838
128 129 170 129 92 94 80 47 84.0 47 80 42
0
200
400
600
800
1000
1200
1400
1600
1800
2000
FY07
Jul-0
7
Aug-0
7
Sep-0
7
Oct-0
7
Nov-0
7
Dec-0
7
Jan-
08
Feb-
08
Mar
-08
Apr-0
8
May
-08
Jun-
08
Dev
ice
Day
s
0
5
10
15
20
25
30
35
40
45
Infe
cti
on
s
Device Days Infections
Founders 14 BSI Infection Data
2966
153 177 204 226 217 225 179 199 262 211 206 163
0
500
1000
1500
2000
2500
3000
3500
FY07Ju
l-07
Aug-07
Sep-07Oct-
07
Nov-07
Dec-07
Jan-0
8
Feb-08
Mar-08
Apr-08
May-08
Jun-0
8
Dev
ice
Day
s
0
2
4
6
8
10
12
Infe
cti
on
s
Device Days Infections
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How we’re getting there —and what we’re doing tosustain the gains
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Operational Infrastructure — Quality, Finance, Med Records, …
Governance Committees
Entity Leadership
Chairs & Chiefs
Unit Staff at the Bedside
Unit Clinical Leadership Teams
We’re w
ork
ing a
t m
ult
iple
leve
ls
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We’ve stuck together as a CMO/CNO alliance …
Unit Clinical Leadership
Transitions in Care
Medication Management
Quality Redesign
Our alliance is getting stronger and stronger — and we’redoing it through the work we’re taking on:
Unit Clinical Leadership is the foundation that makes theothers possible.
It’s taken some hard conversations among ourselves, butwe’ve stuck together through that as well.
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We’ve sneaked up on the institution …
Looked for natural affinities and career goals
Uncovered physicians already playing the role
Asked the nurses who they wanted
Put “medical quarterbacks” on surgical floors
Focused on hospitalists where that makes sense
But we tried things like this:
For example, no one believed we’d be able to recruitenough physicians for the Unit Clinical Leadership teams.
We’re going for the tipping point where momentum andexpectations begin to feed on themselves.
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We’ve focused on the everyday infrastructure ofaccountability …
CMOs & CNOs meet together (monthly)to strategize and keep things on track
Ongoing communication with theUPHS community embedded intoexisting committees and venues.
The ordinary, everyday work practices — some big, some small— that make it possible for people to take responsibility:
Teams meet (monthly) one-on-one with theirCMO/CNO pair, for coaching and troubleshooting
Reallocated an FTE to establish aproject manager for the overall program.Engaging the Clinical Directors
and Medical Directors to takeon the coaching role over time
Clinical tools and resources forimprovement targets — BSIs, UTIs,DVT/PE, falls, pressure ulcers,surgical infections.
Reporting the teams’ metricsacross the health system
Regular links to existinggovernance committees
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We’re tapping into larger efforts and otherpeople’s energy …
Knowledge-based Charting(electronic medical record)
Unit-based pharmacists
“Unit Clinical Leadership meetsTransitions in Care”Two more hospitals seeking
Magnet recognition
Appetite to decentralize aspectsof the Quality function
UPHS looking for leadershipdevelopment programs
IBC looking to supporttransitions programs, to keepreadmissions down
Patient Progression
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We’re helping the organization learn from itself …
Build psycho-social interventions into the continuum of care
Contact with the follow-up program while still in the hospital — toestablish the relationship (especially important when followup is by phone)
Hyper-vigilance during the first fewdays. And everyone has a call-back number.
Identifycandidatepatients asearly aspossible,including pre-admissions andED.
Interdisciplinary (electronic) plan of care follows patient afterdischarge (taps into UPHS efforts to implement knowledge-based charting)
Manage medications along the continuum (taps intoUPHS efforts to establish unit-based pharmacists)
Bi-directional followup — Patient has ways tobe in touch, program has ways to check in.
Connect patient with anaccountable providerwithin two weeks
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7
6
9
1
5
10
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Tap into inpatient “platforms” — e.g., Unit Clinical Leadership teams, CRM/SWdischarge planning — to plan for follow-up from the beginning
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Hospital StayPreadmission Follow-up Program
Admission Discharge Medical“Landing”
Actively involve the patient in care planning. Link patienteducation before, during, and after hospitalization
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We “discovered” theseprinciples — by looking atwhat people are already doingto improve transitions(early pilots, fragments,pieces and parts).
And we drew thosepeople into ouralliance.
Design Principles for Transitions in Care
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We’ve trusted ourselves and the organizationto figure it out …
We don’t know what thefinal product will look like.
We’re relying on theorganization toexperiment and learnfrom itself — and we’retrying to build thatcapacity into theculture.
Culture eats processmaps for lunch.“
”— UPHS Chief NurseExecutive
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We’re creating “educated consumers” …
Conferences for 100+ stakeholders
Transitions in CareConference — To learnwhat’s available and givefeedback to thetransitions programs
Interdisciplinary RoundingSummit — To learn from units atvarious stages of implementinginterdisciplinary rounding, and todevelop a system-wide set of designspecifications
Transitions in Care“Marketplace” — To matchspecific hospital units withspecific transitions programs
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We’re offering “scarce goods” to attract people …
Offered Six Sigma Green Belt and Black Beltcertificates. On site, can use educational benefits.
Not a required “program,” but an opportunity to develop acompetency
The credential has attracted three cohorts to the training sofar — with a waiting list for the next class
And it has created a pipeline for the Quality Coordinator job.
So we:
For example, it’s a tight market for the kinds of QualityCoordinators we need to recruit.
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We’re building a new alliance with the financialside of the house …
The 7:00 am breakfast meeting withthe health system CFO
We don’t want Finance to set themargins for the hospitals withoutinput from the Quality strategyfirst. And we want to do that at asystem level.
Can we count on you?
“
”— UPHS CMO & CLO
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We’re getting out ahead of the budget cycle …
The old way This year
First step: set margins foreach entity; entities arelocked in.
Discussion of system-wide qualityinitiatives before margins are set.
Across entities
With the financial side of thehouse (two big planning retreats)
Entities (separately)submit budgets.
Negotiation occurs afterbudgets are submitted.
CMOs and CNOs banded together tosubmit a joint budget for system-widequality initiatives they all agreed on.
Negotiation occurred before budgetswere submitted:
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We’re reframing the negotiations across the separatehospitals and with Finance …
A “Two Goods” Framework for Problem Solving
System-wide qualityinitiatives to improvepatient outcomes
Fiscal accountability —Individual hospitals areresponsible for their own bottomline
Both are clearly “good,” but theycan appear to be in conflict — howcan an individual hospital fund system-widequality initiatives if it also has to meet itsbottom line?
But what if system-wide quality initiatives can actuallyincrease revenues for the separate hospitals?
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We’re making the case that Quality can improvethe bottom line …
Quality initiatives not only improve patient care, but give UPHS an advantage in themarketplace and help us attract faculty with a reputation for translational research.
IBC pay-for-performancecontract — $13M at stake forUPHS over next five years
MS DRG changes — $4Madditional opportunity for UPHS inMedicare re-imbursement, if newMS DRGs are captured correctly
Clinical risk reduction means fewer claimsand less money tied up in reserves
Sharp declines in length of stayconstrain the functions that hospitals onceprovided
Present-on-admissionindicators — unless wedocument it, UPHS “owns” thefinancial responsibility
Nationwide pressure to managehealthcare costs & utilization
Public reporting of patientsatisfaction scores, hospitalinfections, etc., influencespatients’ choice
Attracting faculty who dotranslational researchdepends on the quality andaccessibility of an institution’sclinical data
Gain-sharingcontracts withinsurers, asreadmissions fall.
Quality, Public Policy and Revenue are beginning to Intersect
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We’re knitting with hard wire — aligning financialincentives across the system …
CPUP Departments
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I. Transitions in CareAll Units
1 Increase use of homecare X2 Med reconciliation X X X X X X
Selected Units3 HUP only: 25% reduction in preventable readmits for
CHF, Diabetes & Anticoag. for patients from HCHS
4 Increase appropriate use of hospice X5 Core measures — heart failure discharge instructions
6 Unplanned readmission to ICU X X
II. Reduce Unnecessary Variations in PracticeAll Units
7 CR BSI X X X8 UTI9 Time to admin of STAT antibiotics X X
10 Decrease rate of DVTs & PEs X X X X X X X X11 Decrease falls with injury X X X12 Decrease pressure ulcers X X13 Adherence to hand hygiene X X X X X X X X X X X
Selected Units14 VAP X X X15 SCIP (Surgical Care Improvement Program) X X X X16 Process improvement for high risk pt. populations17 HUP only: Med errors (applies to HUP Pharmacy, but
goals are unit specific) (NEED PHARM INPUT)
III. Coordination of Care All Units
18 "Staff worked together" (Press Ganey)19 Likelihood of recommendation (HCAHPS)20 Anticipated discharge by patient (Patient Progression)
IV. AccountabilitySelected Units
21 Timely launch of Unit Clinical Leadership team
Quality Targets for Hospital Units - FY'09
We negotiated withChairs and other UPHSleaders to align theiryear-end bonustargets to supportquality on the units.
We asked them to focuson what they cando, at their level, tosupport the unit targets.
The “X’s” in the Chairsworksheet indicateconnections that arepotentially mostrelevant.
Alignment Worksheet — How Can the Chairs SupportQuality on the Units?
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What’s next?
In July and August, empty beds caught us bysurprise. Partly because of fewer BSIs and VAPs,we’re seeing reduced days and a lower census.
We’re committed for the long haul.
We plan to step up conversations with ourpayers; we’re looking for gain-sharingarrangements that take account of how we’ve beenable to keep our patients healthy.
Breaking News — The Dilemma of Success
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The “campaign” approach tochange
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There’s good social sciencebehind what we’re doing
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To change behavior, you change the everyday workpractices. They’re the building blocks of culture.
New workpracticescreate newbehavior — whatpeople actually do,on the ground. System of Supports,
Large and SmallThese work practicesare the buildingblocks of culture.Each by itself may besmall, but togetherthey can move theorganization’sculture.
To change work practices, you haveto put in place the supports andinfrastructures that attract people to the newpractices and make them easier, not harder.
Data
Tools
Scheduling
Coaching, peerlearning
Funding
Aligned financialincentives
“You are Here”
We’re beeninterveninghere,
in order tomake adifferencehere.
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An organization can learn from itself how to makethe changes it needs to make
Pockets of innovation arealready emerging insidealmost every organization— if it learns how tolook.
The future’s alreadyhere — in bits andpieces.
The raw material for culture change is alreadypresent in your organization — in pieces and parts. Yourorganization’s culture is a renewable resource.
“”
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“Pull” is stronger than “push.” And you can createpull for the changes you want to create.
Tapping into other people’senergy & momentum
Piggybacking on what peopleare already committed todoing
Drawing on the urgencyof deadlines andwindows of opportunity
Creating an infrastructure oftools and supports thatmake it easier, not harder
Attaching tosomething “bigger”
Creates pull for thechanges you’re trying tocreate
Establishing a “scarce good”
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The leadership skills you’ll need may seemcounterintuitive
Trying to “motivate” or“empower” others
Discovering and freeing upenergy and passion
Pushing people to change Creating pull for the changes
Telling and selling Listening and amplifying
Thinking your way tonew actions
Acting your way tonew thinking
Not … Instead …
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Figure/ground — your leadership developmentdollar at work
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Resources — Campaign Approach to Change
Hirschhorn, Larry and Linda May. “The CampaignApproach to Change.” Change, Vol. 32, No. 3, May-June, 2000.
Hirschhorn, Larry, “Campaigning for Change,” HarvardBusiness Review, July, 2002
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We welcome your thoughts,questions, and experiences …
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To be in touch
Victoria Rich, PhD, FAAN, RN
PJ Brennan, MD
Kendal Williams, MD
Elizabeth Riley-Wasserman, PhD
Linda May, PhD
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University of Pennsylvania Health System
Hospital of the University of Pennsylvania
Pennsylvania Hospital
Penn Presbyterian Medical Center
Penn Home Care and Hospice Services
Good Shepherd Penn Partners
Penn Medicine at Radner
Penn Medicine at Cherry Hill
Penn Medicine at Rittenhouse
Clinical Practices of the University of Pennsylvania
Clinical Care Associates
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