IHI National Forum and some people who have ‘cracked it’

Wow, so I’ve just been to the 25th IHI National forum.

It kind of hits you – this is not just an organisation or a conference, it really is a movement. Four of Orlando’s hotels convene on the World Marriott for an array that boggles the mind (and eyes at times).

The forum has a few main strands:

  1. Keynote speeches sweep optimism through the camp like a tropical storm. Maureen Bisognano explained and then challenged us to ‘flip healthcare’ while blind mountaineer Erik Weihenmayer took us through what it takes to make the impossible possible, an emotional yet incredible journey of vision (yes vision), tenacity and teamwork. Checkout http://nobarriersusa.org/
  2. Offsite visits enable delegates to experience out of the box learning. Go to EA sports to find out how a games company maintains real innovation at it’s core. Understand how to engage the real customers at legoland, or gain transferable knowledge on safety from stuntmen at Universal studios.
  3. The scientific symposium brings the best of the science of improvement, translational research
  4. Learning labs and minicourses go through everything from learning lean methodology and toyota production system from Virginia Mason to patient centered care to personal mastery of transformational leadership
  5. 100’s of storyboard posters explain everything from enabling a patient safety culture to staff designing (and trial running!) their new A&E to student QI projects on improving a single process.
  6. Legs ache at the multiple receptions. Surely the free drinks is a ploy to socially lubricate and get the business cards flowing

Here an example of a workshop session I found particularly relevant from ALASKA SOUTHCENTRAL FOUNDATION

Now, just to whet your appetite – have a look at the following outcomes. Healthcare transformation with positive outcomes IS possible in the world we live in…but it takes a shift in culture, system design and priorities.

  • Evidenced-based generational change reducing family violence
  • 50% drop in Urgent Care and ER utilization
  • 53% drop in Hospital Admissions
  • 65% drop in specialist utilization
  • 20% drop in primary care utilization
  • 75-90%ile on most HEDIS outcomes and quality
  • Childhood immunization rate of 93%
  • Diabetes with 50% of HbA1c below 7%
  • Employee Turnover rate less than 12% annualized
  • Customer and staff overall satisfaction over 90%
  • In an urban Alaska Native community with huge challenges

What did these guys build on to get these figures? Clearly hard work but hard work is not enough. Patients and families really are placed at the center of this system. Integrated care teams  and a holistic view of the system is pervasive. Primary care and a proactive approach is the backbone. Smart use of data and measurement of outcomes ( not merely process or activity) at every level. A positive culture that coaches and optimizes not only performance but relationships. Outcome not income, person not disease, population not process, service not practice   The core elements

  • Defining the purpose –“RELATIONSHIP*” over time
  • Understanding complexity science – principles, data modelling
  • Moving from product to service as the fundamental base of entire system
  • Optimized primary care with redefined entire system on that ‘new’ backbone/platform
  • Customer driven design – reallocation of power and control at every level
  • Optimizing messy human relationships

The execution of the conference is a study in itself. IHI ‘blue shirts’ man all areas from 6am with a customer attitude most hotels aspire to. The same guys on the billboards are showing delegates around Nothing is left to chance from attire to information. Aching feet and many hours later the 25th anniversary party is a welcome opportunity to let off steam. There is a very real sense of innovation and ‘can do attitude’ here which starts to penetrate the years of constraint and pessimism. They don’t wait for someone else to find out if something works but in doing so themselves data, measurement and outcomes are key. At the start of the IHI, the small group of pioneers discussed how long IHI may need to be in place. “Until the end of the grant” said one, “5 years another”. Paul Batalden suggested 25. Eyebrows were raised. Like most things he appeared to be spot on. While much has Much has been achieved, these guys are now going global so I think I’m pretty safe to say we should be planning for another 25.  If you really want to do change for the better, you have to stick at it.


Relationships between customer-owner (patient) , family and provider must be fostered and supported

Emphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness)

Locations convenient for customer-owners with minimal stops to get all their needs addressed

Access optimized and waiting times limited

Together with the customer-owner  (patient) as an active partner

Intentional whole-system design to maximize coordination and minimize duplication

Outcome and process measures continuously evaluated and improved

Not complicated but simple and easy to use

Services financially sustainable and viable

Hub of the system is the family

Interests of customer-owners drive the system to determine what we do and how we do it

Population-based systems and services

Services and systems build on the strengths of Alaska Native cultures



Without measurement how do you know we have improved? Quite simply, we don’t.

Measurement seems to be one of those topics that gets people unstuck but the reality is we often over complicate it.

Measurement for improvement differs from that of research and this may be part of the issue.

Here’s a simple comparison

Measurement for Research Measurement for Learning and Process Improvement
Purpose To discover new knowledge To bring new knowledge into daily practice
Tests One large “blind” test Many sequential, observable tests
Biases Control for as many biases as possible Stabilize the biases from test to test
Data Gather as much data as possible, “just in case” Gather “just enough” data to learn and complete another cycle
Duration Can take long periods of time to obtain results “Small tests of significant changes” accelerates the rate of improvement

Our aim should be to get a balanced ‘family’ of measures that allows us to see the different facets of an improvement. These should fall into three categories and enable us to produce a ‘dashboard’ to track improvement.
1. Outcome – what will actually define the success

2. Process – help us understand if we are moving in the right direction

3. Balancing – help us see unexpected effects of our project on the ‘ system; around us or visa versa

Typically in healthcare we focus on one type of process measure – activity. This is a scant, paltry and of itself completely inadequate measure of improvement.

Effective measurement has certain characteristics. These include:

Applicable: Sounds obvious? We must still be able to justify why a measure is required and is of importance to our ultimate aim.

Available: Many measures are available, but may need collaboration, networking or a system for collection. For small projects however its worth using what is already there. What is your plan for each measure – responsibility, process?

Accurate: Clearly we will not be able to read into the results if there is wide variance in the measurement accuracy

Automated (ideally): Using precious time to collect and collect will hamper the effort so streamlining these steps with informatics should always be our goal. However, don’t wait until there is an IT solution to start improving we are aiming for usefulness not perfection. For large data, sampling is an effective way of

Chronological: An absolute of quality improvement are measures over time. Minimally this should be monthly, any longer and our time to improvement will become too tenuous to perform robust analytics. The shorter the time frame from collection to collation the more effective our learning system will be e.g. a 1 week lag time versus a 6 week lag time will effectively mean a improvement project can run at six times the speed and mean changes will be connected to measures – greatly improving our ability to monitor effectiveness.

Transparent: Enabling, especially frontline staff, to see the data easily will engender the collective effort. Why should data be covered up anyway?

A typical project should have 3-10 measures. Large scale system wide changes may require more. Such system wide measures should seek to address the 6 attributes of healthcare quality, namely: safe, effective, patient-centered, timely, efficient, and equitable

Next week > presentation of data: From traffic lights to meaningful graphical analysis


What’s so special about this IHI place anyway?

So I’m at the Institute for Health Improvement…Your next question may well be – “what’s so special about this ‘IHI’ place anyway?”

I would describe the IHI as a cross between a movement and an improvement organisation. They are an innovator, a partner, a trusted conveyor of experts and a driver of results.


IHI is a ‘not-for-profit organisation’ started 25 years ago by previous CEO Dr. Don Berwick who had gathered a small group of like-minded people. His first project was to think outside the box and sent quality hungry CEOs to learn principles from non-health care companies with a track record of quality improvement. Today the 5 key areas on the portfolio in order of foundational principles are:

  1. Improvement capability
  2. Patient Safety
  3. Patient and family centered care
  4. Cost, Quality and Value
  5. Triple Aim for Populations: Cost, Quality and Patient Experience

How do they go about this? They aim to reach specific groups at specific levels.

  1. 100’s of people: Innovation with strategic partnerships at the frontline (free)
  2. 1000’s of people: Bespoke training programs in improvement, safety, flow, etc. (costs)
  3. 10,000’s of people: Forums and large scale events (costs)
  4. 100,000’s of people: Online training at the Open School (free)

Clinicians who visit IHI describe it like their ‘batteries have been recharged’. Okay, so it’s not a busy clinical setting with patients braying at the doors. However, there’s something about this place that’s inspirational and transferable.

The first thing you realize when you walk in is the quite literal complete transparency. It’s open plan with glass pods and meeting rooms. Even Maureen Bisognano, CEO, shares an office and welcomes staff to swing by. People don’t see boundaries here and it affects the level of thinking. The finances of the whole organisation are shared each month at the weekly staff meeting. Fellows are invited to observe senior meetings. The walls are covered with the mission, strategy, projects, outcomes, charts. When it comes to taking the learning away, content resources from programs are made permanently available. Turns out that transparency brings about trust, belongingly and a sense of respect.

Despite a significant number of the 150 employees spread across the country, there’s a real sense of one team. I put this down to the fact that working for IHI is not merely a job – its call to action and requires complete sign up to the vision “to improve the health and healthcare worldwide”. Personal guidance is explicit but in no way command and control. Amongst other things, being an IHI ‘citizen’ means being prepared to ‘say sorry’. The IHI forum is the largest quality conference globally attracting nearly 6000 delegates. Except the hire of the hotel, it’s all managed in house by about 60 people. That’s a pretty good ratio and testimony to IHI’s focus on investing in people to build both internal capacity and capability.

While there’s very little bravado there’s a sense of relentless optimism but certainly not naivety. Is it easy managing collaboratives and programs of diverse health care individuals, hospitals and systems across the globe? Usually not. Spreading initiatives across whole countries is of course hard work but the difference with so many health care settings is that these people believe they have the will power, the strategy and the tools to enable and manage change for the better – even through others. As an improvement organisation, both learning and it’s application is in the DNA, and is applied at every opportunity as the oil to an engine.

Finally, being at IHI is infectious. Gene therapy aside, it gets inside of you. That may explain how IHI so effortlessly maintains huge networks, develops strategic partnerships with prestigious organizations and are able to draw on such an array of world class specialists.

The good news – there’s no ‘secret ingredient’ here, so let’s be bold and commit to improvement from the inside out.



Week Two – The Driver Diagram

Last week we looked briefly at the Model for Improvement. Question (1) is all about defining your AIM – what by when.

A Driver Diagram is a helpful way of moving theory to action and describing the key concepts required to achieve the aim. The big buckets are the ‘PRIMARY DRIVERS’ (or main areas of consideration). SECONDARY DRIVERS break each primary driverone down into specific areas to work on and from these we can list our CHANGE CONCEPTS.

Essentially a driver diagram tells us everything inour system that we need to work on to reach our aim. This is crucial on considering that ‘every system is perfectly designed to achieve the results it gets’

The driver diagram helps link the concepts of our project, define our measures (especially helpful for process measures) and the key areas to apply the PDSA cycles – sometimes termed ‘PDSA RAMPS’.

For example: AIM – lose 10kg weight in 4 months (in order to compete in the Olympics of course)

ImageThe drivers may then help in identifying project measures….


Now for a clinical example on reducing infant mortality…