Featured Speaker Peter Pronovost Presents "From Healing in the Hospital to Healthy at Home"

Featured Speaker Peter Pronovost Presents "From Healing in the Hospital to Healthy at Home"



Joe thank you for your visionary leadership you're CEO of a publicly-traded amazingly successful company you're founded this spectacular movement but mostly Joe of what I admire is your humanism you see words matter they matter deeply because they create how we feel those feelings generate the stories that we tell and those stories drive how we behave in the world and Joe I think you must be the only CEO that uses the word love and it's real I know a brother and and you mean it but these words are so so powerful words like Jamie said where he was told it's not your fault words like I'm sorry sometimes silence as the most potent word that we have the word Patient Safety gets a lot of attention the word movement hasn't been dissected much and there's a science behind creating a movement and no doubt this is a social movement the author Charles Duhigg has these three items checklist for social movements clear behaviors you can think of as a checklist a small group with really tight social connections and then looser connections with many many other teams an example how social movements spread Rosa Parks the one of the leaders of the civil rights movement wasn't the first to refuse to give up her seat on a bus indeed there were hundreds for years before her but she had been trained by a charismatic Reverend Martin Luther King in a simple behavior a checklist of nonviolent protest and when Rosa ever gave up her seat she was a social gadfly in about 40 different social groups and everyone loved her and she connected them and each of those social groups had really clear activities were tight and so in Rosa was arrested it ignited a revolution because each of those did their own work to organize the protests in this case the boycotts and they spread all throughout Alabama in the country Jo what you've created here is a social movement our 17 apps are those behaviors these 35 chapters are those those nodes in those 17 countries but the magic is those small little micro learnings that are created in the hospitals where the work gets done and many of you have asked why isn't this spreading why aren't people doing it and I'm gonna go back to what's been a theme here the stories you see you we have all used stories externally saying how do they get attention how do they motivate change what we haven't dissected is turning internal and look at the stories that we tell ourselves stories about whether we're powerful or powerless stories about whether others are competitors or collaborators you see stories define what we do you change the story and you change everything stories like JFK I want a man on the moon so we're going to dissect the stories that are hindering people from joining this social movement because we know the mechanics those three things are immutable but the reason it's not spreading is internal and deeper and something very human but I'd like you to either write or reflect on the words I will because I know Joe is a outcomes driven CEO this conference isn't about hearing stories it's about action it's about saving lives so at the end I hope and through that days we'll have time to question what's your I will statement that's going to come out of this now I'd like to explore these mindsets of what are holding us back and if I were to say what's the greatest safety movement are the opportunity in the world it's changing the narrative from success is healing in hospital to being healthy at home because we know 40% of hospital admissions should never happen in the first place at least we could reduce that there's good science on that so yes we need to manage what they ate with what's going on in the hospital but we need to explore what narratives are holding this movement back from spreading and my friends I'll put forth there's three narratives that are holding us back and I like to share my own journey on trying to understand and reframe those narratives the first narrative and it's the most fundamental is we still accept harm as inevitable rather than preventable we say we don't but we've been hearing the same darn stories for 20 years and we know hospitals can go years without infections if we really believed it was preventable we want to accept these stories my own journey on this began in 2001 on a snowy night in a dark corner of our pediatric ICU where Josie King was taken off of life support and died in her mother's arms she was burned and ready to go home though was healing but a catheter infection and then unrecognized sepsis sacrificed her her mother came to me because she was worried that he was this was going to happen to her other daughters and said could you tell me this won't happen again I wanted to give her the executive spiel of all the great stuff we're doing but I couldn't I looked at her and said I can't our rates of infection are sky-high we don't have any science-based programs but I will give you an answer you see at the time myself and every other clinician still in this training just accepted that sometimes when you care for sick people little girls will die and she did we accepted it as the cost of care we accepted harm as inevitable so we did some things at the time that were heretical we declared a goal zero infections like this my colleagues thought I was off my rocker and perhaps I was we made a checklist of best practices we encouraged doctors and nurses to work together to make sure that checklist was used we investigated every infection as a defect to change that culture and that narrative and we had accountability for those infection rates the rates not just plummeted but now just a year ago we published that this program and a lot of other work was spread state-by-state across the country and now these catheter infections are down 85 percent from when to urge human – now like a remarkable success story and to put this into context when this work started central line infections one small item of your 17 checklist killed more people than breast or prostate cancer and we just accepted it so we have the ability to cure public health problems of that scale and so we got curious and said why did this social movement take off when so many others floundered and it took off I want to explore on three levels on the national level it took off because of three simple things number one we had a valid way of measuring infections that was epidemiological sound I'll put forth to you that infections and they're not perfect are the only harm that we have a valid measure for sadly twenty years after we've been doing this I don't think we have a valid measures of any other harms doesn't mean we don't stop the work or we're not counting but shame on us and shame on policymakers – it was publicly reported and that itself didn't do it but the great journalism work who called out stories of hospitals whose rates are ten times the national average to hold them to account for what they did drove most of the behavior and three we had science to guide us we had evidence from which we could make a checklist we then went into 200 hospitals we published it recently to say what separated zero hospitals from non zero hospitals because it wasn't just the checklist zero hospitals my friends all did for simple things their leaders declared a goal of zero infections if I walked into that hospital and asked the CEO what's your goal and they said huh you know my ICU cot guaranteed they weren't zero second thing they did is they created an enabling infrastructure what that means is they provided project management they provided training they provided data and feedback and they provided checklist tools to make it easy for clinicians three they engaged frontline clinicians and connected them in peer learning communities and forth they transparently reported results and had clear clear accountability if you had infections someone asked why but we went deeper we partnered with some of our anthropologists and I said something deeper happened at the individual level and we want to find out why so we interviewed hundreds of clinicians and what we found we knew we were speaking them was profound you could see in their eyes what they believed in their hearts they started telling a new story when we started they all said these infections are inevitable and I'm just a and fill in the blank I'm a nurse I'm an attending I'm a resident I'm a tech and I'm powerless and they got to zero when they told a new narrative so we got curious and said okay well if we could find what leads to that narrative we have the most powerful force for change in the world and as we looked we realized there's quite a robust social science literature that tells us how to create new narratives it's called believing and belonging I have a TEDx talk if anyone's interested in this specific thing to pieces the believing piece is the leaders of that organization committed to zero and believe that their people can do it so they believed in it themselves and if you want an example of the power of belief I'm a runner so I like this take the story of Roger Bannister breaking the four-minute mile for 2,000 years since the first alípio scientists said it is impossible to break the four-minute mile you will die trying well Bannister as a medical student go tribe broke it in 1954 and he didn't die and you may know that story but what's often not known is the next year this 2,000 year record 12 more people broke in the year after 156 people broke it and now high school kids are breaking it in the last New York Marathon a guy ran a four-minute mile for the whole 26 marathon right unbelievable and what changed not evolution not blood doping not new sneakers the stories they tell Bannister freed all of us to break that four-minute impossibility and Joe that's the legacy of this movement the second piece that they did was they belonged to peer learning groups it wasn't economic incentives it was belonging to a learning community I'll give you an example of learning communities how many of you have seen Mary Poppins the movie or the players you all probably know a very prominent feature in the play as these birds chirping when she's dropping down from the sky when she's skipping when she's fainting and that's because that's what London was like in the late 1940s because at London was fill of two types of melodious songbirds the red robins and the blue boobies and they thrived because they pecked through the tops of the milk containers that were left on people's Stoops they sucked the fat out and they were plump very well nourished birds but then the milk companies changed the containers from cardboard and steepled to aluminum and flat and it required a few of both birds are required the birds to learn a new technique they had to learn to protect their beacon and those both birds are equally smart and a few of both birds learned the new technique but the red Robins are extinct now in downtown London and the boobies thrive and the difference is the Robins were solitary birds they had their stoop or their corner we call it our department our specialty our hospital our con tree and that wisdom never was shared the blue boobies are flocking birds they fly in a V they fly strong and proud together and that wisdom quickly disseminated through those organizations and we need to be much more like those blue boobies if we're going to solve this problem the second narrative I like to share with you is that we say health care is a system but it is the furthest furthest thing from a system rustle a cough the great system theorist said as a system is a set of parts interacting to achieve the goals we have all the parts matter of fact the parts are all in this room they're not aligned around a goal and they certainly don't interact the way they need to but there's lessons we could learn and many of you are students of high reliability organizing what these organizations that truly work as a system they organized around the needs of those they serve in our case our patients we don't really do that I'll give you an example I was working with a clinic that treats sickle cell patients because I was looking at what were causing hospital readmissions remember we don't get him in the first place and by far the number one cause five times more than anything else was patients with sickle cell when I dug into it I found well the clinic had patients but if someone was on narcotics they kicked him out of the clinic because it didn't fit their efficiency of their clinic well if any of you have know about sickle cell there's a lot of pain there most are many are on narcotics and you couldn't think of a more destructive way to manage than to kick people out of your clinic but they weren't working as a system they weren't organizing around patients needs second characteristic of these systems is everybody's job is to improve value everybody's not just the doctors not just the nurse everybody's I learned this when I visited an aircraft carrier to study this and I was standing talking to the Admiral and there was a gentleman sweeping the deck next to me and as you made know on the power hierarchy that gentleman is way below the admiral way way below maybe as a high school education but on the safety hierarchy they're equal because if there's a debris on that deck or a hammer plane comes down they all blow up it's no difference than the power hierarchy between the environmental service worker who cleans the hospital and the CEO low education big power gradient but safety equal because we get c-diff for mrs a if we don't clean it well I asked that gentleman what job he does and I was blown away he stood up tall and proud look me in the eye and said sir I help planes takeoff and land safely to serve the mission of the United States said whoa it's a guy connected to his purpose I left there and walked into a hospital and walked to a stand EVs worker what job do you do and what answer did I get not standing up tall and proud sheep lessly looking away almost shameful saying I clean the rooms they didn't say no you're not an EVs worker you're an infection Preventionist right what infection prevention specialist I asked the person in a call center what job do you do I answer the phones so no no you're a healer you connect people to needed care that prevents cancers and prevents harm and we haven't managed healthcare as a system third thing these organizations do is they hardwire the upstream and downstream connections so that makes sure the system those parts actually do interconnect we have a huge problem with readmissions nationally it's about 6% of patients leave the hospital with an appointment scheduled like what are you thinking is going to happen right or we send people who come to the emergency room and we send them out without any appointment for follow-up just hopefully they're gonna get there because our mindset isn't as a system I'm just a part and finally they create management systems for accountability I look at this brilliant work of 17 checklist and apps but what I haven't seen yet is a management system where we're not playing whack-a-mole at everyone but there's a board level of zero harm there's work teams in every one of these in others there's transparent reporting and accountability and that's all integrated in a disciplined management system towards zero harm third narrative and it's a new one for this group and some may say what the heck you're talking about this is that improving value is everybody's responsibility and by value just so we're clear it's quality plus patient experience over the annual total cost of care Y value and why is this important for our journey well right now though healthcare does miracles every day and there's no doubt that we do the vast majority of the time medical error we say is the third leading cause of death the reality is we don't know how many people died needlessly shame on us because we don't have good measurement systems the estimates in the u.s. very twenty fold but that said its enormous and if you add misdiagnosis if you add failure to give evidence-based therapy if you give failure to and control blood pressure or treat diabetes it is by far the leading cause of death medicine today has one third of patients leaving their healthcare interactions saying I wasn't respected I wasn't listened to I don't know what to do when I leave or cancer patients waiting weeks to get a report back and my friends when you have cancer or you're worried about your health time is suffering that's harm a third of every dollar we spend in the u.s. a trillion dollars collectively goes for therapies that don't get patients well or is wasted on these things at an individual level that's $10,000 per household that's equal to the median net worth of the people in urban LA or Cleveland or Baltimore so not getting this right isn't just health care it's the future of the American dream because if you look at states like Massachusetts that expanded access and I believe we need to expand acts their healthcare budget went up but it came at the expense of every other social good Parks and Recreation stem preschool education care for the elderly so we have to balance and get this waste out of the system and right now every payer of healthcare the federal government state government employers and us as individuals our health care expenses are going up more than our revenue in hospitals expenses now or at 7 percent their revenues are 4% going up and their margins are the lowest they've ever been 1.5 percent and 25 percent of them have negative margins and guess what budgets are getting cut from this all the things that drive safety nurse staffing ratios your infection prevention staff your safety staff so we have to start thinking about how do we start telling a new narrative that value is my responsibility that these keeping people healthy at home is part of what we all need to begin to do well as you know I'm a bit of a checklist fanatic and so I made a checklist for optimizing value and when I started doing this what I was astounded of is that when you add the waste of every defect on this checklist and the harm to patients it is mind-blowing it is far larger than a way ever dreamed of but what we've played is whack-a-mole trying to tackle each one of these individual things so let's look at this value checklist and say there's defects and harm and we fail to help people stay well right now most large employers 15% of their employees get an annual well in this exam we know that leads to less harm better outcomes maybe half are fewer get their cancer screenings that they're supposed to or get the immunizations they supposed to and well up to 70 to 80% of us don't have healthy habits we don't eat well we don't exercise enough we don't reduce stress we don't connect with our colleagues how well do we help people get well for every disease every chronic disease there's defects at every pathway let's take diabetes for example 40% of diabetics are undiagnosed about half get the right therapy 1/3 have their blood pressure their LDL and their and their a 1c controlled and they have outrageous degrees of healthcare utilization indeed about 40% of their admissions wouldn't need to be there if we manage these things but whose job is it not mine and then finally how well are we managing an acute condition the defects are is care coordinated with primary care because that's good care that keeps people out of the hospital the reality is to date we don't connect those wires is what we're recommending appropriate and almost every procedure that's been looked at thirty percent of them aren't needed 30 percent if you go to cancer centers of excellence you see the same thing 30 25 to 30 percent of the cancer diagnosis these change or the treatment change is the site of service optimal about 40 percent of what we do in a high expense health care setting like a hospital could be done in an alternative setting but we don't do that and increasingly in the home we can now give close to ICU level care in the home it's much more patient-centered it's safer it's much lower expense but we're not driving that and within that site of service are we directing care to a high value provider because the reality is amongst our provider tribe there is four to eight fold variation depending on which cardiologist you go to which hospital you go to for care but all that stuff is largely invisible in my new role at u-h I have responsibility for the ACO and for value in the delivery system and importantly for the employee health plan and we're trying to change that new narrative across a whole large system and clinicians are resonating it because they get this concept of defects and checklist and for my providers at hospitals or the health systems I would encourage you to use your employee plan as the Learning Lab for optimizing value we talked about unaligned financial incentives health systems with a cell sense ensure employee plan are the only natural experiment where every incentives aligned you're at full risk for the cost of those people in this case they're only in network care is within this health system we control the Wellness and the ACO plans and we control the incentives we give to the physicians to give good care so why aren't we using those to see if we could really eliminate the defects that we have in our health systems so I'm asking us to broaden our narrative not that our journeys anywhere near done but to start thinking more broadly in this concept of value and could we commit to eliminate these defects in value because the economics of hospital financing are not looking so pretty and I feared we're going to see safety budgets cut unless we're really driving the valley that's going to fund some of these needed infrastructures to keep us moving forward now this big change that we're talking about is scary and we talked about the narratives that we tell not externally not the stories to get intention but us owning it what stories are we telling ourselves and after spending 25 or nearly 30 years studying safety and quality I've learned that the secret of quality is that word that this meeting was opened up with and that's love but by love I don't mean a 50-year marriage oh for sure there is love and loving moments in that marriage by love I mean what the psychologist Barbara Frederickson talks about in her book love 2.0 it's a fascinating book where she studies the biology of love and looks at what makes oxytocin spike is your oxy toes is the cuddle hormone that goes up on your hug or when you nurse and what she found is that love is micro moments of connection between two or more people micro moments I feel warm towards you you feel warm towards me and we create energy so love is listening to a colleague who just made an error love is putting a hand on a worried patient love is respectfully smiling and that homeless person asking you for money love is saying to that EVs worker thank you for preventing infections you see my friends this big journey that we're embarking on and it is a big journey is made up of thousands of small steps and every one of those is only made possible and facilitated by micro moments and we could choose to go make micro moments right now so I challenge you to say what is your I will statement because we've been telling the same stories of harm for far too long and I'm tired of hearing more CLABSI stories right and we hear them over over and again they should be zero and the question isn't to judge our colleagues it's to understand why haven't they told that new narrative and how do we begin to create those new narratives by believing they can get to zero and connect creating communities like this where they belong to groups that they learn from each other you see that question that Sorrell King asked me and haunts me every day is Josie less likely to die I think she and every other patient in this room is asking each of us and we we deserve to give them an answer so thank you [Applause]

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