So in the US we have ACOs, we have about 500 of them, these are actually integrated systems
now that include hospitals, primary care, GPs, especially doctors, all in one and that
group gets paid by the federal government to care for populations of patients. Thedacare
ACO in 2013 was the highest quality performer. This performance has continued through 2014
now, the lowest cost and highest quality performer in the ACO programme in the US.
There are 20,000 Medicare beneficiaries in this programme, so we’re really looking
at population health of 20,000 people. The platform is still fee for service so there’s
shared savings related to the platform we’re able to accomplish shared savings every year.
In the first year of this programme the Thedacare organisation actually reduced the total cost
of care by 4.6% for 20,000 people. So you can imagine in the US since we’re the most
costly country in the world, if we could actually start reducing the total cost of care for
our patients over 65 by 4½% a year we could start to get on top of our cost problem.
So if you’re the lowest cost highest quality ACO how did you actually accomplish that?
And it was accomplished by this nationally recognised management system using principles
and practices from guess what, industry. And what it shows is that we were able to reduce
the growth and per capita health spending, year over year, and at the same time able
to improve quality to the benchmark in the US.
The framework of what we’re talking about here with this method actually is this house
and I want to talk through this with you. So what we start with with the executive teams
of these hospitals is to say, “What really matters to your patients? Because I know you
have to report a lot of metrics frankly to the government so do we but most of those
things are useless from the standpoint of patients. So let’s talk about what really
matters to patients”. And at the children’s hospital of Eastern Ontario what really matters
to patients is how long the kids wait for things. Now they’ve established an incredible
goal of reducing the number of days kids wait for service by 50,000 days. That is something
that every single staff member in that hospital can get their arms around. Everybody knows
that waiting is a problem. So guess what we’re going to do, we’re going to take this method
that we’re learning and we’re going to re-design our care processes to get that wait
time down.
Here’s Western Sussex True North metrics, hospital standardised mortality rate because,
you know what, if I come to your hospital the one thing I don’t want you to do is
kill me. So isn’t that the one thing we should focus on? Are we actually making mistakes
that are killing patients? So how can I impact hospital standardised mortality ratio at Western
Sussex? Well guess what, we should maybe work on ventilator associated pneumonias in the
ICU. On the medicine ward maybe what we should do is try to keep people from falling out
of bed and hitting their head and dying.
So one of the things we do with the senior executive teams is we ask them how many strategic
initiatives do you have going on at any given time in your hospital? My teacher many years
ago said, “You can have three to five things” and we went from 150 things at our hospital
to four things, it took us 15 months to get there. This is part of the over-burden of
your staff by the way, because guess what, you’re not doing the work, the staff’s
doing the work. One of the things that we’ve learned in this method is that we have to
start with the underlying principles of the method, because what happens usually is that
we start with the tools because the tools are really cool. We’ve got spaghetti diagrams,
and tag time and kaizen and wow it’s really cool stuff. But the reality is if we start
with the tools we never sustain anything. So we need to start with the principles of
the methodology. And so we’re going to see tools and artefacts and behaviour on top of
the iceberg but what really underpins all of that stuff that we see as we go out and
look at organisations that are really improving quickly?
And so what we’re recommending to folks is we start with these principles which then
actually get us to the behaviours that are required to build the systems that are necessary
to deliver the results. So there’s a sequence here that most organisations are missing.
And we start with these principles, what are these principles? Well creating value for
the patient. That’s the number one principle. That means we’re going to focus on improving
the quality and lowering the cost of our health care delivery to the patient. Front and centre,
that’s it. Constancy and purpose. Not 57 True North metrics, five. Not 222 strategic
initiatives. Three to five. And we’re going to think about the components as a system.
So these are the principles, this is what we start with, this is why we do what we do.
That’s the idea. And the aligned principles are what the executive leadership needs to
stay focused on.
The enabled principles are the cultural transformation activities that are going to be the underpinning
of the overall improved performance. So we’re going to lead with humility, you know that
that means? It means that me as CEO I don’t have all the answers. In fact the people at
the frontline have the answers. So how do we push the decision making down to them?
Because the way it works right now is most people that have a problem they sent it to
the manager and say, “Here’s a problem go fix it for me”. Well what if we had a
system in which the people that actually identified the problem on the frontline solved the problem?
Wow that would be unique. Now we have to have the principle of respect every individual
as part of our principle based approach here or we won't have that happen. And what we
mean by respect is that we respect everyone who is doing the work on the frontline to
identify and solve problems. The problem doesn’t have to been solved by us.
These are the improved principles so this is what most people focus on. We’re going
to do kaizen, we’re going to do PDSA, but the reality is the enable and align principles
are really the underpinning of the cultural change.
Here’s the align principles and here is the different roles and responsibilities for
everyone. So at the leadership level the leaders are not solving problems, they’re developing
a vision, they’re setting targets, they’re communicating what those targets are. The
middle management is organising and allocating resources, so that the frontline can identify
meaningful goals and improve care.
Same thing on the enable. The idea is that the leaders are energising and motivating
and embracing both success and failure. The middle management is empowering the authority,
that means giving up authority to the frontline who are going to find opportunities to improve
care.
And finally on the improve piece, the leaders are looking for, asking questions, supporting
new models of care delivery. They’re not building new models of care delivery, that
happens on the frontline. I was trained at the greatest university in the world, as we
all were, by the greatest professor in the world, as we all were, to be all knowing,
in charge, autocratic, buck stops here, impatient and blaming.
Now we get into this new world where if we’re actually going to build a different culture
one that has people identifying and solving problems every day, I have to be mentor, facilitator,
teacher, coach, learner, the question is now what do we do next? And that’s up to you.
But we know that we’ve got a method here that is way better than anything else we’ve
been doing in the last 50 years in this business. So I think there’s a burning platform to
move forward.
I appreciate your attention and I think we’re going to have some questions.