I’m delighted to be with you all today, and
I’m excited to talk about a topic that’s really near to my heart. It’s something that I’ve been working on for
several years and have come to believe that we can’t ever transform healthcare unless
we unleash the patient’s power in not only helping us to design healthcare, but to help
us deliver healthcare to the patients in a different way. We face some pretty substantial challenges,
I think, as we all know, in terms of financial constraints and the increasing burden of chronic
disease around the world. I’ve been more convinced that the IHI, the
Institute for Healthcare Improvement’s, idea of the triple aim or the quadruple aim is
where we need to go, so let’s focus on how we could improve the experience of care, how
we can work to improve the health of the population, how we can lower our per-capita cost and do
so with a joy in the workforce. As I say on my slide here, it’s not going
to be moving more faster. We need new ways to think, and that’s going
to require us, I think, to think about how do we flip our thinking? A few years ago, I was reading in the New
York Times an article about a teacher who decided to flip his classroom. He noticed that when he was teaching during
the day, he would get up and give a lecture, used slides or overheads, gave the lecture
and then gave the students homework. They would then go home and struggle by themselves
while they were trying to figure out how to incorporate what he taught into their daily
life. Then he was also an athletic coach and after
school, he’d go and coach. He realized when he was coaching that he addressed
that in a completely different way. What he would do then when he was coaching
is he would bring all the athletes together and they would train together. He would observe where their strengths and
their weaknesses where, but before they came to practice each day, he would give them videos
to watch at home. Rather than giving them the videos during
the lecture, as he did in the classroom, what he did was he gave them the learnings at home
before coming together. Then he could actually get to watch them practice. He said, “I don’t understand why I teach one
way and coach the other,” so he decided to flip the classroom and he gave all the students
videos to watch at home or at school if they didn’t have equipment at home. Then when they got together in the classroom,
they worked together with him. He got to see how each child was absorbing
information, where the barriers were. What he found is that when he flipped this
way of teaching, more like his coaching, that the results flipped in every grade. Failure rates dropped. Graduation rates rose. Class attendance rose. I guess what was most important to me is that
it helped him identify what he called the silent failers, the kids who were struggling,
but he never saw it when he teaching the old way. He certainly did when he flipped his method
of teaching. He said that his idea was that we needed to
move from being the sage on the stage to the guide on the side. When I read that line, I said, “That’s exactly
what we need in health care.” Our ability to sit and write prescriptions
or give patients recommendations one way only isn’t doing it. We’re seeing our health rates in the United
States drop even as our costs rise. I think we have a great potential when we
move to being the guide on the side. It, in truth, will help us to get to the triple
aim, improving health, much better experiences of care … And I mean in that way, everything
from safety to patient centeredness, access, efficiency and effectiveness and equity and
decreasing per-capita cost. I also read an article some years ago by Susan
Edgman-Levitan and Michael Barry. Again, one line in that article transformed
the way I think about my work. In this article, they said, “We can’t only
ask, ‘What’s the matter?’ We also have to ask, ‘What matters to you?'” I started doing that. I started going out to the field. I started meeting patients. I started recommending to clinicians, “Don’t
just say, ‘What’s the matter?’ Ask, ‘What matters to you?'” I can tell you it transforms the interaction
between a person who’s sick in the health care system or a person who’s well and wants
to stay well. I would hope that you’d take as your first
homework assignment this idea that we need to also ask, “What matters to you?” This idea has now spread worldwide. Countries around the world are running, “What
matters to you day?”, on June 6th every year with tens of millions of tweets and staff
saying that although they were a little fearful in the beginning, they found that they could
answer the question, “What matters to you?” They could guide people to better health and
care. They could help us move from a focus on disease
to a focus on health ease. I think that’s what’s so exciting for me. I was also teaching with Susan Dentzer some
years ago, and we were talking about the power of patient engagement as a blockbuster drug. You may have seen this research, where patients
in a coordinated care setting were engaged in the design of their care plans and carrying
out their everyday life through a perspective of engagement. You can see the results are dramatic. Clinical care teams reduced overall mortality. I love this line. “Imagine what the headlines would be if a
new cardiac drug proved this kind of effectiveness. It would be malpractice not to use it.” That’s how I feel about patient engagement. We have that much of an obligation. Here are a few examples of patients who I
went and asked, “What matters to you?” This is Trevor Torres. He’s a young man with diabetes. Although I’m not going to show you the link
to his video, I would encourage you when you get the slides after our session today … Again,
your second homework is to just watch this very brief video of Trevor talking about his
diabetes. He talks about the fact that he’s got so many
chronic diseases and yet how empowered he feels when he’s able to engage in his own
care. He says as an example that his clinicians
told him, “Well, there are two ways to think about giving yourself insulin. You can either take the same dose every day
and adjust your diet or if you know you’re going to be eating something different, then
you can adjust your dose.” Trevor’s reaction was, “Well, why don’t I
just create an algorithm that deals with both variables?” It was so empowering for me to spend time
with Trevor talking about his diabetes. I said to him first, “Trevor, how do you define
health?” He said, “It’s the energy to do all I need.” He said, “I’m just starting college. My life is hectic. I feel like my focus should be on my school,
on my grades, on making new friends. If my health is predictable and I can control
my health and energy, I can thrive.” That’s what health means to him. Then I said to him, “What do you need from
health care?” He said, “I hope for no surprises. I hope I can predict my days and manage my
health in a very positive way.” He said, “Straight answers. I don’t need your sympathy. I need your information.” He said, “I need advice and easy access.” He said that he’d love to be able to just
email his team and get a quick response back, which is how he deals with everything else
in the rest of his life, but then he told me that he, “Would cut the old people some
slack.” I think he was talking to me. He said that, “He doesn’t feel like all of
his clinicians have the technology fully engaged to get the kind of care he needs.” He said his dream is a strong bond with a
doctor and a care team, which was interesting because I’m so used to people saying, “I want
a relationship with my doctor.” Trevor says that young people like him, and
certainly him, have a strong need to have much more frequent interactions with their
clinicians. They love the idea of a care team. I’ve asked a lot of people since I met Trevor,
“Have you called to make an appointment with your clinician, your physician lately? If so, how long does it take?” People will tell me all over the country. “Well, I called to make an appointment and
I’ve got one in October,” or, “I’ve got one in February to see a dermatologist.” Trevor’s idea of a dream health care system
is that if he’s at school and he’s concerned that he can text his team and get an answer
very quickly. He said, “I’d love FaceTime visits. I’d love not to have to go to the office. I feel like that would be an amazing way for
me to get my care.” He is one of the healthiest people I know. He always says, “I think I’m really healthy,
and I have great sense of self efficacy because I always think, ‘Boy, I did this and I had
diabetes at the same time.'” It’s a different thing when you start looking
at patient engagement. I’m going to turn it over to Sarah for a poll
question, our first poll question. Yeah, thanks Maureen. Based off of the story that Maureen just shared,
we’d like to know what percent of your young patients are like Trevor, those who prefer
to manage their own health and care. The options are 0-25%, 26%-50%, 51%-75% and
76%-100%. We’ll just leave the poll open for a moment
here. I also want to take this time to remind you
to submit your questions. We’re excited to have the question and answer
session at the end of Maureen’s presentation today. We’re just leaving the poll open for just
one more moment. Thank you. We’re seeing these numbers come pouring in. We’re going to go ahead and close the poll
and share the results with you. It looks like 19% of our attendees reported
0-25%, 26% reported 26%-50%, 36% reported 51%-75% and 19% reported 76%-100%. What do you think about that, Maureen? I think that’s going to change pretty quickly. I am seeing this in my daily work that more
and more people, when they find their voice like Trevor has, are really excited and they’re
finding better health and care when they are engaged in their own health. I would predict that we’re going to see a
change in that pretty quickly. I wanted to go on by asking you do you know
what this number is? 5,000 hours. This number is the number of waking hours
in a year when people with a chronic disease like Trevor are taking care of themselves. When you think about it, should we optimize
the health care system? Should we optimize health by working on the
5,000 hours or should we work on the two 15-minute visits? I think we’ll get much more when we start
to think about patient engagement through the 5,000 hours lens. When you think about it, the cost of diabetes
is incredibly expensive in human terms, in disability terms, in dollar terms and in hospital
utilization. We can work with patients like Trevor and
make dramatic improvements toward the triple aim. A second story I wanted to tell you about
is changing the balance of power. This is a story, again, of a young man in
Ryhov in Sweden. I was making my way through an academic medical
center in Jönköping, Sweden, and I found a place that looked very different than any
other place I had ever visited in a hospital. I said, “What is this?” They said, “This is the patient self dialysis
wing.” I know patients do their own hemodialysis
and their own peritoneal dialysis, but I had never seen the wing of an academic medical
center totally designed and run by patients giving themselves their own care. I asked, “How did this happen?”, and they
said, “We’re very innovative here. We’ve been working with IHI for a long time.” I said, “No, how did this really happen that
a CEO decided to build a wing for patients to care for themselves?” I met Christian Farman. He was a young mechanic in Saab Avionics when
he came down with glomerulonephritis and was admitted for dialysis. He was a mechanic, so after a few weeks, he
had figured it all out when he was being dialyzed. He asked his nurse to teach him how to do
his own dialysis, so she did. Then the 73-year-old woman in the next bed
said she wanted to learn. Pretty soon, many of the patients … Of course,
not all, but many of the patients in the unit were asking and curious about taking on their
own care. Now they have a dialysis unit where up to
70% of the patients are doing their own dialysis. There will always be patients who are too
sick or have some kind of a constraint or they don’t want to do their own dialysis,
but the vast majority of patients do. I met with Anette, the nurse leader, and I
asked her, “How did you come to this idea?” She said that running a PDSA, with many patients,
gradually the number of patients began to grow who wanted and were capably doing their
own dialysis.” She said that she realized, though, that if
she kept co-mingling the patients who were getting care with the patients who were doing
care that she could never really optimize health and decreased social isolation and
she could never realize the cost savings. She went to the CEO and said, “I’ve calculated
that if we can build a separate building, I can work on decreasing supplies and staffing
for that level. I can decrease cost and improve the health
and care of those patients.” He realized that she was doing something very
profound in patient engagement and they built the building. What was really exciting was that … She
was telling me that as she was designing it one day, she heard a knock on the door. It was Christian, and he said, “What are you
doing?” “I’m designing the new building.” He said, “What does it look like?” She said, “It’s going to be nice and warm
and comfortable.” He said, “It’s a hospital, damn it. I don’t want it to be warm and comfortable.” I’ll show you in a minute what he designed. It’s an amazing place. If you ever get to Sweden, I would encourage
you to visit it. I asked her, “What’s your job now if you’re
not doing care?” She looked through the number of patients
in the unit and realized they were physically strong, socially connected, happy, but they
weren’t working. Her job when she admits a patient is she helps
them update their CV and she brings in the county employment bureau once a month. She said that almost everybody now is working. This is what the unit looks like. It’s not a warm, comfortable place. It’s a place where people come into to exercise. Some of these patients come in an hour before
their procedure and exercise or, as the man in the lower right is, he’s exercising while
he’s dialyzing. I’ve been to dialysis units from Vancouver
to New Zealand and I’ve never seen one like this, where the patients are happy, healthy
and taking care of themselves in a way that demonstrates the power of patients in their
own care. What they’re seeing now is that their costs
are dramatically reduced. Their complications are reduced. They measure their success, as I said, in
the number of patients working. When I first met Christian, I said to him,
“Christian, what matters to you?” He said, “I want to work.” When I saw him a few years later, I said to
him, “Did you go back to Saab?” He said no, and I thought, “Oh, it’s a failure.” He said, “No, I’m an RN. I decided I’m in the hospital all the time,
I’ll go to nursing school.” He’s the head nurse on the ENT unit. I said to him, “What matters to you now?” He said, “I want to get married.” I did get invited to his wedding. I asked him again, “What matters to you?” He said, “I want to have a baby.” This is Wilmer, his son. He said, “I know I never would have had this
baby if I wasn’t taking care of myself.” It’s not just improvements in the health care
system. The power of patient engagement is profound
on a patient’s personal life. I told this story to a nephrologist in Texas,
Richard Gibney. He asked Annette and Christian to come to
Waco, so the patient and the nurse went to Waco to teach the nephrologist how to do patient
self dialysis. Richard Gibney’s results are just the same. He’s seeing dramatic reductions in mortality
and complications. In his population, which is largely Hispanic,
he had to translate most everything into Spanish. When I talked to Richard last, he told me
that he had several patients who were completely blind who were doing their own dialysis and
one patient who’s paralyzed on one side, who’s doing his own dialysis. A lot of times I think we underestimate the
assets and focus on the deficits of our patients, and Richard has proven that that’s not so. When you trust patients, the results are amazing. In Philadelphia, Ed Jones, a nephrologist,
is one of the early pioneers of doing patient self dialysis. He calls it in-center self care. Again, dramatic results with a population
that’s largely African American. They’re coming in and doing their own care
and producing much better clinical outcomes at a much lower cost. A group of patients that I met with at the
IHI forum were so excited about this, they created an app. They said, “We need to be involved in the
decision about what kind of dialysis. Not only where we have it.” There’s an app you can get on your iPhone
for free called, “My Dialysis, My Choice,” and it walks patients through lifestyle values
and options when they find out that they may need dialysis. It asks them questions like, “Do you have
a dog? Would you rather sleep at night or dialyze
at night? Is there someone at home with you should you
need help? Are you afraid of needles?” Once they go through and fill out the app,
it gives them a recommendation about peritoneal versus hemodialysis in center versus at home,
daily versus nocturnal and what these patients are saying is that when they go in and have
these conversations with their clinicians, they are feeling like they are co-designing
their care and they feel like they’re getting better results. Again, if we start to think about this idea
of flipping from, “I’ll take care of you,” to, “How do I work with you,” we’re seeing
dramatic improvements in results all across the triple aim and enjoying work. Another example is I visited this Centering
Pregnancy model at Boston Medical Center. Boston Medical Center is a hospital here in
Boston. The population is largely underserved, often
under insured and a nurse, midwife there was frustrated that she was running all day, taking
care of pregnant women and she felt like she never really had a complete visit before. When she put her hand on the door handle,
the patient would say, “I have one more question,” and then she would have to say to the next
patient, “I’m late. Later. I’m sorry.” She felt like she never did a great job with
the entire population of patients. But then one day, as she was driving home,
she said, “I’m doing the same thing for every person. Why don’t I do it together?” She gave an opportunity for women who found
out they were pregnant, if they wanted to get their care separately, they could. If they wanted to join a centering model,
she tested it and she brought in usually 10 to 12 women in the same stage of pregnancy,
who come in to their visits together. Usually, as you know, if you’ve had a baby,
you get appointment, you’re by yourself and then after that appointment, you make another
one for a month and then another month and then every two weeks and the like. With this, when you find out we sign up for
the model, you get 10 2-hour appointments throughout the course of your pregnancy and
you come in with all the other women on your team. It’s an amazing thing to sit in on these visits. What I found is that the model is flipped. They don’t go to a registration area, they
don’t sit in the waiting room, they go to a little conference room. As they come in, they’re learning about exercise,
they’re learning about resilience, they’re learning from each other. Each one has a separate couple of minutes
with one of the … either the nurse or the midwife or the obstetrician at the back of
the room but most of the visit is they are together. I met a young woman who I followed, whose
name is Nora. She was 24 weeks pregnant with her first baby
and her husband was still back in Nigeria. She was hoping that he was going to be here
for her birth. What I loved about the flipped model is she
comes in, she takes her own vital signs, she weighs herself, she enters all the data on
her record and then she shares it with the physician and the midwife. Then, in the meantime, they’re chattering,
they’re eating healthy food, they’re talking about their life circumstances, they’re all
talking about what matters to you. When I asked Nora what matters to her, she
said, “I am so afraid of labor.” She said, “I’m terrible with pain. I always have been. I’m scared. I really don’t think I could make it.” What I was interested in was the midwife and
the physician did not automatically talk to her directly. They said, “Two of you have had babies before. Why don’t you tell Nora what it’s like?” The first woman said, “Nora, I’m going to
tell you it is the worst pain of your life. I’m not going to lie. It’s horrible. I went running into the emergency room screaming,
‘Epidural, epidural.’ Once they give you the epidural, then I was
fine and then I had my baby and I’m going to do the exact same thing this time.” The second woman said, “She’s right. It is the worst pain you will ever experience
but,” she said, “I didn’t want an epidural, so I asked the midwife to teach me what other
options I had.” She said to the midwife, “Can I show Nora?” “The midwife asked all of us, there were 12
patients, the midwife, the obstetrician and me, and she said, ‘Put out your hand and she
put ice cubes into all of our hands.’ And then she said, ‘Just look at your hand
for a minute,’ and everybody’s looking and as the ice cubes started to freeze up our
hands, you could see people reacting to the pain and dumping the ice cubes back into the
cup.” “Then, the midwife said, ‘I’m going to teach
you something.’ She said something although I was a doula
for many years early in my career, she taught me something I didn’t learn. She said, ‘Okay, first of all, relax your
hair,’ and everybody started laughing. She said, ‘No really, relax your hair and
then relax your jaw.’ And then, she said, ‘All your pain and your
stress will go to your jaw and I’m hoping that you’re all relaxing your hair and your
jaw now.’ Then, she said, ‘This is how I want you to
breath.’ After just a few minutes, she said, ‘Put out
your hand,’ and she put the ice cubes back into our hand and in every case, all of us
in the room, the ice completely melted.'” Then Nora said, “I can have my baby.” That taught me the power of not telling someone
how to think about their care but how we can engage people. The centering model is very powerful with
these women. It’s really positive and people are engaging
in it in a very great way. What they find is that when they go to the
pediatrician and they’re all by themselves with their baby and the one doctor, they say,
“No. We want centering pediatrics now.” But the results are wonderful experiences
for the women. Look at this, reducing the risk of pre-term
birth by 33% especially for Hispanic and African-American populations in nearly twice the number of
centering participants are breastfeeding successfully and longer. Again, the triple aim when we work with people
and empower them rather than feeling like with take care of them. Another example from England, is again, a
link that I will give you and I hope you get through, so that you’ll go and watch this
again, very brief video. This was a young fellow of IHI. He was one of my fellows for a few years,
who, when he went back to Sheffield, England, was struggling with length of stay and looking
at how can we improve the discharge process and he remembered this idea of flipping and
he said, “What if we flip the discharge process and rather than doing occupational training
and rather than doing physical therapy in the hospital and then discharging someone
to a home that we don’t know what it’s like, why don’t we, as soon as the patient is clinically
stable, discharge them to home and have our home health people go and admit them and assess
them to get them ready for their care at home.” They started trying it and they found that
the flip discharge process works really well. As soon as someone’s clinically stable, they
bring the patient home, OT and PT, visiting nurses are there in their home, they do an
assessment and they train. What they found, again, is that when the patient
was in a scared or sick position while they were in hospital, as soon as they got home,
they were in a powerful position and they were doing things that they couldn’t do while
they were in the hospital but naturally in their home environment, they were finding
the will, the power, the comfort to go ahead and make themselves well again. I was in Oslo in Norway and I was visiting
a home healthcare organization and a hospital system. I said, “Bring me to the place that you are
proudest of and they brought me to the reablement unit. Now, all over the world, people talk about
reablement. I’ve not yet found anybody in the United States
who knows what that word means but it’s a very different approach to enabling someone
to get back to health. With reablement, it’s an interprofessional
team led by an occupational therapist and they have physiotherapists, nurses, social
workers and also pharmacists, behavioral therapists and others are on the team, but when a patient
encounters a serious health challenge, the reablement team sits with them and the first
thing they say is, “What matters to you?” They assess the needs of the patients, the
interests, the resources. They look at the assets and the limitations
and create a plan of care. I met with so many people and the care that
they go under reablement was very different from the care for the same diagnosis that
they would’ve received in the United States. One example was Jarle. Jarle was a 70-year-old man with a number
of chronic diseases and he had had a major stroke and had severe limitations in his mobility
on one side. He was confused at first and really depressed. They asked him in reablement, “What matters
to you, Jarle?” And he said, “I want to live alone.” He said, “My adult life had been happiest
when I’m alone. I don’t want you to put me in a place where
I’m living with other people. I will do anything to live alone.” Well, I was thinking about how would we design
care for Jarle in the United States and typically, what I’m seeing is occupational therapy, 45
minutes a day, 5 days a week or physical therapy, the like. It stretches out over a long period of time. With reablement, it’s extremely intensive
but for a very brief period of time. Jarle went through OTPT behavioral therapy
pharmaceutical processing, deep prescribing and optimizing working with all these clinicians
very intensely, like eight or eight and a half hours a day for five weeks. When I was with Jarle, he is indeed living
alone. I went with him to his apt and was walking
down the hallway with him, he uses a walker because he still needs that for long walks
and we were walking to the door of his apartment and when we got there, he was fumbling for
his keys in his pocket and I said, “Oh Jarle, can I get the door?” The reablement person put her hand on my arm
and pulled me away and said, “No. Jarle will get the door.” When we got in, I said, “Oh Jarle, can I make
you some coffee?” And she said, “No. Jarle will make you some coffee,” and then
she kindly told me that not everybody’s qualified to work on a reablement team, so I had indeed
been fired because my normal instinct I had to do for and not guide people to reablement. I learned amazing lessons by being with Jarle
and many other patients there in Norway. In doing so, I realized that when we feel
like our job is caring for people instead of with people, that we actually limit their
recovery and often times, they don’t get to what matters to them. The third of the videos I want you to watch
tonight, again is a very brief limited video from England using technology to empower people. In this video, you’ll see three patients. One is a young patient, a young boy with diabetes
who’s very, very brittle. He’s got a number of health problems other
than his diabetes but has been hospitalized dozens of times in the last year. His clinicians actually feared that he wasn’t
going to live. The second patient is this elderly gentleman
you see in the picture who has asbestosis from working in the shipyards and the third
is a young, single mother who’s trying to learn to breastfeed. What they found is each one of them expressed
5,000 hours. Each one of them expressed that living with
different chronic diseases every day of their life and that the interactions with the health
system were so far apart, so brief and so focused on telling, that they weren’t getting
better. The health system developed a new technology. They call it Flo, F-L-O, short for Florence
Nightingale. But what it is, is it’s a way for the patient
to optimize the 5,000 hours. You see, in each case, the technology interacts
with them. In the case of the young boy with diabetes,
every morning at a certain time, “Flo,” his phone rings and Flo says, “What’s your blood
sugar and tell me what’s going on,” and he types in. With this man with asbestosis, he weighs himself,
he takes his oxygen level, he takes his blood pressure and he puts those in. In each case, in the woman with the breastfeeding,
the same. The more frequent, daily interactions with
technology is empowering them to take good care of themselves. If any of the indicators are amiss, then a
person is notified by Flo, the technology and there’s an immediate connection with a
human. But those 5,000 hours are so optimized. I think if you take a look at this video,
you’ll get some amazing ideas about the potential of technology to optimize the 5,000 hours. My challenge is how do we think about flipping
the balance of care from the hospital to the community. The balance of delivery, “How do we think
of moving from individual providers to care teams,” as Trevor asks. “How do we think about the balance of power,”
as Christian asked. The balance of cost from treatment to going
upstream in prevention and the emphasis from volume to value and from healthcare to health. We’ve got another poll question that Sarah’s
going to lead us to that. Thanks Maureen. In this next poll question, we’d like to know
what is impeding you at the organizational level from more fully including patient input
into the care that you provide? The options are leadership, daily, immediate
operational challenges, resources such as labor and money, IT documenting and workflow
systems and then performance measures focused elsewhere. Thank you. We’re seeing those votes coming in. We’ll leave the poll open for just another
moment and yet, again, encourage you to submit your questions. We’ve had a lot of great ones coming in and
we are getting close to the Q&A session, so we do want you to make sure to get those in
before we reach that time. Okay? Just a few more moments here. Okay, we’re going to go ahead and close that
poll and share the results. It looks like 18% reported leadership, 32%
reported the daily, immediate operational challenges, 15% reported resources, 14% said
IT documenting or workflow systems and 20% said performance measures focused elsewhere. Do you think that lines up with what you would
expect Maureen? Yeah. It’s a pretty even split, isn’t it? I think it shows that the challenges we have
are pretty acute but in all of these cases, I hope that you notice that for the centering
pregnancy model, for the patient self-dialysis model, for Trevor, that it started with one
clinician and one patient running one PDSA cycle and then gradually grew to proving that
it works for a greater population. I think that idea of really focusing on looking
at how do we deal with the challenges by taking one step at a time, that then gives us the
proof that we need in order to change policy and to recommend changes in resource allocation. It does prove to leaders as it did in Sweden
that making a change like that can produce a profound and important effect on the triple
aim and increased joy in work. It does bring me to my final area for our
conversation today and that is the importance of curiosity. When I first became the CEO of hospital, I
was 34 years old. I was young and I believed that my job was
to hire the most intelligent people. I would say the smartest but I know my Boston
accent will get in the way. I thought my job was to hire the people with
the greatest IQ and that that was how we were going to provide great care. As soon as I started making rounds and talking
to staff, talking to patients, I realized that EQ, emotional quotient or empathy was
just as important. I’ve come, in my later career to realize how
critically important CQ is, curiosity quotient. I think some people are naturally curious
but I do believe you can build your CQ and I believe it’s absolutely necessary in today’s
world to build your CQ. The way I do it, just as an example is whenever
I’m in a new healthcare organization, whether it’s an outpatient clinic or a hospital, anything,
what I’ll do is I’ll say the question that I shared before, I’ll say, “Take me to the
place your proudest of,” because I have been in places where I never would’ve known to
ask to go there. I’ve learned amazing things when people will
take you to a dementia unit and you learn that they’ve been able to go for 861 days
without a restraint in a 30 bed dementia unit by putting book case covers over the doors,
so that people weren’t constantly seeing doors opening up and getting out of bed. It’s PDSAs and improvement every day that
gets us there, but the other thing CQ does is it will help innovation and as I said,
I am a big believer that we need models of care today more than we ever have. I’d ask you to think about how do you in your
organization build innovation in? Do you have an innovation lab or at IHI, at
Institute for Healthcare Improvement, ihi.org, you can tap into the innovative models that
people all around the world are building and sharing. But we need new ways to design processes differently
like you’ve heard me say today and we also need new ways of harvesting. Going out and finding the best ways to think. When I go into a new hospital, when I haven’t
been in before, I ask four questions and they tell me everything I need to know about quality
in that place. The first is, do you know how good you are? What do you look at? Who gets to look at the data? How often? Do you know what patients think? Do you know what staff think? What is it that leaders look at on a daily
or weekly or monthly basis that tells them the answer to that question, do you know how
good you are. The second question is do you know where your
variation exists because most people look at averages and they don’t know where their
exemplars or their poor performers are and that gap between best and worst is hugely
energizing because you know how to close that gap within your organization. The third with I ask is do you know where
you stand relative to the best? If you don’t have a harvesting function, if
you don’t have somebody whose job it is to get out and look, then you’ll always be satisfied
with what you’re doing internally and the world is changing so quickly that getting
out and harvesting, I think, is a critical function for us today. I would even recommend a Chief Harvesting
Officer, somebody whose job it is to spend a part of their week every reading and getting
out to find best models. Then, the last question is, do you know your
rate of improvement over time? Because most people over estimate it and I
think that’s very energizing as well. The second challenge that we’ve got is spread. If you find that you’re doing it really well,
how do you assure the uptake of that new model everywhere? I think it’s not moral for us, as healthcare
leaders, to see a best practice at one place and to tolerate variation in another in our
systems. I think spread is a critical leadership function
of the day. The last thing I want to discuss is a critical
leadership function. The last is exnovation. I don’t know if you know what that is, but
exnovation is getting rid of all of the stuff in our lives that adds no value. In health care, we’re terrible exnovators. If you walk onto a nursing unit, you’ll find
policies and procedures and cupboards full of old supplies. We diffuse new guidelines, but we never undiffuse
the old ones. We prescribe new meds, but we never deprescribe
medications. It’s a huge step forward when we learn the
skills of exnovation and really take away things like unnecessary meetings, unnecessary
reports, unnecessary supplies and equipment and put the energy back where it needs to
be, which is improvement and innovation. I’ll turn to our next poll question. Yeah, thanks Maureen. In this last poll question from Maureen, we’d
like to know do you have a CEO, a chief exnovation officer, at your organization? Your options are yes and no. We’ll leave this poll open for just a moment. We have had several questions coming in asking
whether the slides will be available after the fact, and they definitely will. We will be emailing a link to the slides as
well as a recording of this webinar shortly after the webinar concludes today. Just leaving this poll for just one more moment. We’re going to go ahead and close that and
share the results. It looks like a whopping 92% said, no, they
do not have a chief exnovation officer. Does that line up with what you would imagine,
Maureen? Yes, but I think it’s something we can change
and begin to work on. Great. You can keep moving through your slides here. We’ll wrap up with a few extra questions before
we jump into the Q&A. I just wanted everybody to have my contact
information. I’m delighted that we’ll be sharing with you. Do your homework and watch those videos because
they’re very powerful. Feel free to share those widely as you go
along. Perfect. We do just have a few wrap-up questions before
we jump into the Q&A. While today’s topic was an educational webinar
focused on the power that patients have in their own care, we do often have attendees
who want to know more about Health Catalyst products and professional services. If you’d like someone from Health Catalyst
to contact you to learn more, please answer this poll question. Thank you. We are seeing your responses coming in. We’ll just leave the poll open for one more
moment. This is also a great last chance for you to
submit any lingering questions that you haven’t typed in yet. Okay, perfect. I’m going to go ahead and close this one. Then Maureen, if you could just take us over
to the next slide. Before we move into the questions and answers,
we have a few giveaways for complementary Healthcare Analytics Summit registrations. This is an annual event with more than a thousand
provider and payer attendees. It’s going to be occurring September 11th
to 13th in Salt Lake City, Utah, this year. It will feature brilliant keynote speakers
from the health care industry and beyond. You can see on this slide just a handful of
the speakers that we will be having. If you’ll go to the next slide for me, Maureen. If you know that you are able to attend and
are interested in being considered for complementary passes for a team of three to attend the Healthcare
Analytics Summit, please answer this poll question. Great, we are seeing your responses pouring
in. We’ll leave this open for just one more moment. We’re going to go ahead and close that poll. Then if you’ll move one more slide for me,
Maureen. Okay. Then lastly, if you know you can attend the
Healthcare Analytics Summit and you’d like to be considered for a complementary individual
registration, please respond to this poll question for us. Wonderful. We’ll give you just one more moment here before
we jump into the Q&A. We’re going to go ahead and close that. Maureen, if you’ll just click one more slide
over for us. Okay, we’re ready to jump into the Q&A. We’ve had some really great questions coming
in. The first one that we’re going to answer here
or pose to you, Maureen, is from Carolyn. She asks, “What is some scripting you would
use to engage patients over the phone when you’re cold calling patients to get them engaged? These are people who have complex chronic
conditions.” That’s a great question. I love that. I think I’d start with something very simple
like, “Tell me about your day today.” Something that would engage them in thinking
about how to answer the question, not from a clinical perspective. I think we’ve trained patients so well to
try and focus on the clinical needs and yet the rest of the determinants are so powerful
and so impactful on people’s health. I’d start with something simple like that. Okay, so then we’re moving onto our next question,
which comes from Anita. She asks, “What is the adoption rate for the
self dialysis that you’ve seen?” It’s very high when it’s introduced. In the Swedish one, as I said, they’re up
to 70%. They’re seeing great progress in Philadelphia
and Texas. When a leadership team comes together, the
nephrologist, the dialysis nurses begin to engage in it, the uptake is great. However, the uptake is terrible in trying
to get other centers to pick it up. I’m working with Richard Gibney now. He’s got a group of about 12 neurologists
from around the country. Everybody’s interested, but all of the barriers
that we talked about before, leadership and some of those other barriers … People perceive
barriers sometimes where there are very important barriers and sometimes where there aren’t
any. What we’re finding is that the uptake in spread
across the nation is very slow. It’s something for all of us to consider. We’ve got hundreds of people on the phone
today who can think about, “Is there something we could do individually or together to help
the spread of patient self dialysis and some of these other things?” Great. That’s very interesting. Our next question comes from Teresa, who asks,
“With a system like Kaiser Permanente in California, if you were advising them to create a patient
engagement center, what would your first question be to the decision makers?” What took you so long, I guess. No, I think Kaiser Permanente’s actually a
great example of really listening to what matters to patients. The idea of a center is a wonderful idea. I would say probably take a look at the most
frequent … The social causes of illness or the most frequent barriers that people
are encountering and get people together in a room to come and talk about those. I’ve had incredibly positive experiences in
my work with Kaiser Permanente because they are so wonderful and gracious about having
me open every single leadership meeting with interviewing a patient or more than one patient. The learnings from every single one of those
interviews has profoundly changed the way care’s happened. The notion of getting a center together, beautiful. Our next question comes from Jennifer, who
asks, “How does a consultant approach providers to consider this approach in health care?” A consultant … You mean somebody who doesn’t
work within the organization I guess? I’ll answer it that way, but Jennifer if you
can type in any clarification, that would be helpful. The way that I typically do it when I’ve been
working with organizational leadership is I will interview a patient from that setting
and then I will tell the story of that patient like the story of Trevor or the story of Nora. When you’re telling that story, they’ll begin
to see the 5,000 hours. They’ll begin the places where the health
care system enhances that person’s life and the barriers that are inadvertently built
up by the structures of that system. Then I’ll extrapolate and say, “How many other
Noras are there?” Extrapolate from the story to the total population. Then talk about the human cost like with a
young person with diabetes, what’s the likelihood that they might become blind or suffer some
other human complications over the course of their next 10 years or life? Then look at the financial costs. When you create that arc of story to extrapolation
to human cost to financial cost, I think it’s pretty easy to engage a whole team of leaders
around a table in thinking about the potential for change. Wonderful. The next question comes from Doug, who asks,
“We’re utilizing simulation centers more and more to train docs and other health care workers. Are you aware of the use of simulation training
for patients and their health care home team for any chronic disease management?” That’s a great idea. I have seen a couple of places outside the
US and some in the US, where they’re looking at prehab and they’re doing a bit of simulation
in the prehab. A patient who’s coming in for a procedure,
as an example, going through a simulated experience like learning how to walk with a walker if
they’re going to have a joint replacement that requires such. In some other countries, I think they do it
better in that prehab includes everything from learning to cook in a simulation center,
learning to walk with crutches or a walker. I think it’s a great idea and I think we should
build them all over the United States. I love that idea, Doug. Thank you. The next question comes from Ronessa, who
asks, “How do these models affect the billing process?” That’s a great question, Ronessa. I think what we’re seeing in some cases, particularly
where organizations are working in part by value-based purchasing or ACO reimbursement
models. It’s all good and I think as I look at the
future of health care, we’re moving in that direction anyway, so for that population,
it’s a great way to start to get people to think about care across the continuum, not
only care in the hospital. We do have some constraints with moving from
the old model of, “We’ll pay you for a medication or we’ll pay you for the procedure,” to thinking
about, “We’ll pay you for health.” That’s what Richard Gibney is trying to do
is actually start to think about going to insurers and payers and saying, “If I can
produce better health at a lower cost, let me work on a new model for reimbursement for
our dialysis as an example.” That’s been a challenging one I will say. Some of the other ones, like the centering
model, they get paid for visits anyway, so most of those patients are on Medicaid in
Massachusetts and working with the payers, it’s been both a positive for the payers and
for the clinicians as well. The next question comes from Leah, who says
that she thinks that a challenge that’s missing is the ability of the consumer to own directing
their own care when cognitive or physical issues or present or that support is lacking? Is there evidence of addressing those challenges? I will say it’s a wonderful challenge I think
that we need to deal with. I will say that one of the founders of IHI,
Paul Batalden, has been working on a new model called co-production. He’s looking at many different … He’s got
some great publications already on this idea of co-production. What I’m seeing is that patients with cognitive
challenges or a lack of support, as you say, are in a very different place. They might need some different kinds of support. The dementia unit that I mentioned in Singapore,
as an example, is looking at people’s assets and then they’re running PDSA cycles to deal
with the patients with dementia. It’s a different way to look at it. If you don’t have support, it’s a very big
challenge, but we’re seeing much more innovation in terms of home care. I recently spent a day in Northern Ireland
in a recovery college as an example. Recovery college is a different way to think
about patients with mental stress, mental illness, addictions. When a patient is diagnosed with any one of
those in different parts of the UK, rather than automatically be put on a waiting list
to get into see a psychiatrist or admitted, they are given a brochure to enroll in the
recovery college. The brochure is amazing. There are courses on how to build resilience,
on how to improve your diet, on how to improve your cognitive thinking and your memory, how
to deal with intimate partner violence. Many different courses and all of the courses
are taught by people who have lived experience with that. The day I spent there with the faculty and
with the students was just amazing. I think we shouldn’t underestimate the power
of working with these patients as well. Maureen, we’re almost at the top of the hour. Do you have any flexibility to stay over a
little bit? We do have about five questions left. Sure, I do. Okay, perfect. Our next question looks like it comes from
Nick, who says, “What do you see as the roles for medical specialty associations and academies
in impacting patient engagement and implementing some of the strategies that you discussed
today?” I’m hoping that the specialty associations
will do a deep dive into where they can be most helpful and actually push. I think some of the specialty organizations
are still resistant to, as an example, opening their thoughts to patient engagement. I think they should be the drivers. They’re the ones who know best what the specialty
organizations have to contribute and how best they can empower patients to take up some
of their own care. Our next question is really more of a comment,
but we will share it with you, from Roberta. She just says she’d like to thank you, Maureen,
that you’re wonderful and inspire her every day, your words are the best and that this
presentation has contributed to her improving her work and her job. We just thought we’d share that with you. Thank you so much. I appreciate that. Moving onto our next question. It comes from Wendolyn, who asks, “How do
you see CMS reimbursement and VBP aligning with patient-centered care?” Great question. I got a chance to work with John Berwick when
he was there in thinking through some of these ideas. I think that’s when he was there leading CMS
was the prompt for CMMI, for the Center for Medicare and Medicaid Innovation. I do think that even now there are some ideas
floating around there thinking about can they change the models of payment? If they can, and I do hope they will, we can
see an acceleration of spread. Typically, what’s happened is CMS has responded
to the demonstration that these models work. That’s why I’m encouraging all of us to be
creating these models to demonstrate that it works on the whole and then when we can
share with CMS that this model does produce better outcomes, better health and lower costs,
then I see them changing payment models for us. Our next question comes from Elizabeth, who
says, “I work for a large hospital system. We have a lot of independent practitioners
and doctors that drive our work in outcomes. How do we get them onboard?” I would say start with the innovators. You may have learned from the Everett Rogers
Diffusion of Innovation Curve, but what Rogers’ work taught me is go to the innovators and
the early adopters. Just find a few, a doctor and a nurse who
work together particularly well and say, “Could you test something for me for a day or a week?” Then extrapolate those lessons and begin to
share. I think it’s that slow internal testing that
demonstrates the power of the effect on a population inside an organization. If you try and make a presentation at a medical
staff meeting, you’ll have everybody in the room from the innovators to the late adopters
and it’s really much harder to build momentum for change. Our next question comes from Carrie, who asks,
“Did any of the sites that you mentioned in your stories receive human-centered design
or co-design training before testing out their different models?” I think many of them did not, but they have
now gone to human-centered design. I’m starting to see this idea of human-centered
design pop up much more frequently as I work across the country. It’s a wonderful tool and a way to think about
getting the voice of the patient. In most of these cases, it started with a
kind of pioneering patient or groups of patients and a group of clinicians who really had high
curiosity quotient and were open to driving these tests. Human-centered design is certainly going to
add to that. Then this is going to be the last question
we have for you today. It comes from Anita. She asks, “When you do check ins with the
patient, is it better to ask more of the numerical-scale questions, such as rate your pain, or more
of the context-based questions, such as how do you describe your pain in comparison to
labor pain, things like that?” It’s a great question, Anita, because I was
just sitting with a patient who was near the end of his life. The hospice nurse came in and she said, “Can
you rate your pain in your right leg on a scale of one to nine? Can you rate your pain on the left leg?” She went through all that because she needed
to enter it into the computer, into the electronic record. Then afterward, she closed the computer and
turned around to him and said a question that I have often said myself, “Tell me about your
best day in the last couple of months.” The transformative conversation was so helpful
both to her in understanding what he needed and to him in really describing what mattered
to him. I guess regretfully we have to do both, but
always ending with the question of, “Tell me about your best day,” or, “Tell me what
matters most,” is I think the way to go. Thank you so much, Maureen, for joining us
today and for everyone who has joined us as well.