The more I know, the less I sleep

“The more I know, the less I sleep”

Dr Mark Britnell Chairman and Partner KPMG’s Global Health Practice

@markbritnell

Member of the World Economic Forum Global Agenda Council 60 countries, 170+ occasions.

© 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

1

65 senior healthcare leaders from 30 countries Vektis Mr. Herman Bennema General Director

Discovery Health Dr Jonny Broomberg CEO

All-Party Parliamentary Group on Global Health Lord Nigel Crisp Co-Chair

Fundaçâo Antonio Prudente Mr. Irlau Machado Filho CEO

Monitor Dr David Behan CEO

Hospital Sirio Libanes Dr. Paulo Chapchap Strategy Director

Médica Sur Mr. Antonio Crosswell CEO

Institute Gustave Roussy Mr. Charles Guepratte Deputy CEO

Institute for Healthcare Improvement (IHI) Ms. Maureen Bisognano President and CEO

Karolinska University Hospital Dr. Soki Choi Project Leader of “Nya Karolinska”

Salford Royal Hospitals Foundation Trust Sir David Dalton CEO

National Voices Mr Jeremy Hughes Chair

West/North West Hospitals Group Mr. Noel Daly Chairman

Virginia Mason Medical Centre Dr. Andrew Jacobs Medical Director

Alberta Ministry of Health Ms. Janet Davidson Deputy Minister

Wiener Krankenanstalt-enverbund Prof. Dr. med. Udo Janßen CFO

Nuffield Trust Mr Nigel Edwards CEO

Keiju Healthcare Systems Dr. Masahiro Kanno CEO

Unfallkrankenhaus Berlin Prof. Dr. Med. Axel Ekkernkamp, CEO

Royal Liverpool and Broadgreen Uni. Hosp. Mr. Aidan Kehoe CEO

The Society for Family Health Sir Bright Ekweremadu Managing Director

NHS England Mr. Tim Kelsey National Director for patients and information

Swiss Medical Group Mr. Miguel Carlos Blanco CEO Buurtzorg Netherlands Mr Jos de Blok Director Health and Social Care Northern Ireland Mr. John Compton CEO

Queensland DoH, Health Services Division Dr. Michael Cleary Deputy Director-General South Metropolitan Health Service Prof. Robyn Collins Adj. Associate Professor

Menzis Mr. Roger van Boxtel CEO

Centers for Medicare & Medicaid Services (CMS) Ms. Julie Boughn, Former Deputy Director, Center for Medicaid and CHIP Services Former CIO

Memorial Sloan Kettering Dr. Murray Brennan VP, International Programmes

Access Health Connecticut Kevin Counihan CEO


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65 senior healthcare leaders from 30 countries Achmea Mr. Roelof Konterman CEO

Faculty Hospital Brno Dr. Roman Kraus CEO Foundation Hospital St Joseph Mr. Jean-Patrick Lajonchere, CEO

Hygeia Group Ms. Fola Laoye Chairwoman Yonsei Univ. Health System - Severance University Hospital Dr. Chul Lee President and CEO Myong-Ji Hospital M. Wang-Jun Lee CEO and Chairman Department of Health of the Canton Zurich Mr. Hansjörg Lehmann Head of Health Planning and Control Peking University Prof. Ling Li Professor

United Family Healthcare Ms. Roberta Lipson Chairwoman NHS Leadership Academy Ms. Karen Lynas Deputy Managing Director Health and Social Care Board Northern Ireland Pamela McCreedy Director The Economist Ms. Anne McElvoy Editor Health Service Journal Mr. Alastair McClellan Editor Espria Mr. Marco Meerdink CEO CZ Mr. Wim van der Meeren CEO Life Healthcare South Africa Mr. Andre Meyer, CEO

Birmingham University Hospitals NHS FT Dame Julie Moore CEO

UCL Hospitals NHS FT Sir Robert Naylor CEO

Singapore Health Services Prof. Ivy Ng Group CEO NHS England Sir David Nicholson Former CEO Department of Health Ms Una O’Brien Permanent Secretary

The Royal Marsden NHS Foundation Trust Ms Cally Palmer CEO Narayana Health Dr. Ashutosh Raghuvanshi Vice Chair, Group CEO

Humanitas Mr. Luciano Ravera CEO Public Health Foundation of India Prof. K. Srinath Reddy President

The Investment Fund for Healthcare in Africa Mr. Onno Schellekens Managing Director Apollo Hospitals Lt. Gen. Dr. M. Singh Director Medical Services KPJ Healthcare Berhad Siti Sa’diah Sheikh Bakir Corporate Advisor St Joseph’s Healthcare, Hamilton Dr. Kevin Smith President and CEO Geisinger Health System Dr. Glenn Steele President and CEO National Voices Mr. Jeremy Taylor CEO Assuta Medical Centres Mr. Pinhas Tsruya CEO Ministry of Health Prof. Josef Vymazal First Deputy Minister NSW Ministry of Health Mr. Ken Whelan Deputy Director General


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10 characteristics of clinical and operational excellence

1 2 3 4 5

6 7 8 9 10

Enduring Values Shared purpose Consistent and stable leadership Deep engagement with clinical staff Strong focus on front-line Set culture, hold professionals to account

Align individual, team and organisational objectives Information transparency – internal and external Curiosity about high performance Authentic partnership


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A global perspective on clinical governance – we brought together 43 global healthcare leaders from 12 countries In-depth interviews with leading providers and regulators ■ ■ ■ ■ ■ ■

The Mayo Clinic, USA Fortis Hospitals, India Jordan Specialty Hospital Helios Kliniken, Germany Sick Kids, Canada Salford Royal Foundation Trust, UK

■ ■ ■ ■ ■

University Hospital Birmingham, UK King's College Hospital, UK Changi General Hospital, Singapore Intermountain Healthcare, USA The General Medical Council UK

...followed by four round-table discussions with more of the world’s leading organisations

Boston:

Lausanne:

Amsterdam: Sydney:


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A mix of anxiety, curiosity and desire is required to provide great quality care This work is extremely timely given a number of high-profile failures around the world It is also necessary – healthcare is still too much like an old-fashioned, individual craft-based system If the aviation industry adopted the same random quality control systems we simply wouldn’t fly

Regulation is necessary but never sufficient

Global standards for healthcare?

Big data offers new possibilities © 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

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We identified the four building blocks of a ‘high-reliability’ organisation:

1

2 3 4

A culture devoted to quality Responsibility and accountability

Optimising and standardising processes Measurement

“Being in control ” What did our interviewees mean by ‘in control’? ■ Methodically measuring care outcomes ■ Understanding the key drivers of these outcomes ■ Understanding how to make these outcomes best in class ■ Systematically preventing avoidable harm to patients

“More hand-offs, more errors” Base error rate of each step No. of steps 1 5

0.05 0.33

0.01 0.05

0.001 0.005

0.0001 0.002

25

0.72

0.22

0.02

0.003

50

0.92

0.39

0.05

0.005

100

0.99

0.63

0.1

0.01

Even at seemingly low error rates per step, processes with multiple steps have unacceptably high error rates. Source: System changes to improve patient safety, Nolan, T W., British Medical Journal, 320,

© 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk 771-3, 2000 van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

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The journey towards a high-reliability organisation

PHASE:

0

No real Board oversight of quality; outcomes are not uniformly measured; responsibility is poorly-defined

1 2 3

Attention to quality is becoming more systemic; progress depends on systems, not individuals; measurement of outcomes is common but not standard Key outcomes routinely reported; blame-free learning approach; a culture intolerant of breaking basic rules; clear individual responsibility & accountability Probably only required in the most high-risk environments: ICU, theatres, A&E


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The four building blocks of a ‘high-reliability’ organisation in practice:

“

A zero tolerance for complacency is crucial. .... We have created an open, transparent, trusting culture, and if something goes wrong we delve into it, report on it, learn from it, and share these lessons.

”

Mary Jo Haddad, President and CEO, SickKids Hospital, Toronto


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Building block 1: a culture devoted to quality

“

Much of this isn’t very sexy. It is the small stuff that matters the most, and it is sometimes hard to get everyone to focus on that.

”

Ralf Kuhlen, Chief Medical Officer, Helios Kliniken, Germany

Continuous measurement and a clear sense of accountability are intrinsic values throughout the organisation

Leaders may have to confront entrenched attitudes among professionals and question their own assumptions over safety and behaviour The Board must reverse its traditional deference to professionals, and take an active role in defining and measuring quality and safety

Leadership has to demonstrate an aversion to being average, and must empathise with patients, families and professionals following incidents where patients have been harmed © 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

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Progressing through the stages – penetrating the concrete floor The ‘concrete floor’ is the separation between clinical and managerial perspectives in most health care providers – financial and operational on one hand, clinical value for the patient on the other

“

Beneath it, the clinicians work away delivering their services, driven primarily by professional specializations, which are in turn driven by sophisticated technologies. Above it, senior managers advocate and negotiate with one another, and manage the non-clinical operations when they are not, of course, engaged in one of their perpetual – and often fruitless – reorganizations.

”

Mintzberg (1998)

Building block 2: responsibility and accountability Without a clear vision of how to use them, even the best metrics are of little value Clear responsibility for outcomes so the Board can identify who is accountable (managers and professionals) and measure performance

A streamlined upward flow of the most important measures, with appropriate levels of detail for each audience

Measures are not developed from the top down and quality governance is not done from the sidelines - those at the front line know what is most important to track. Make the clinical service lines accountable

“

Even if you would know what to measure, you lie awake thinking about what to do with this data. You can’t just throw it back at your doctors; you have to make it live for them and be actionable

”

David Rosser, Medical Director, Birmingham, UK © 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij vanUniversity KPMG Europe LLP enHospital lid van het KPMG-netwerk van zelfstandige ondernemingen die verbonden zijn aan KPMG International Cooperative (‘KPMG International’), een Zwitserse entiteit. Alle rechten voorbehouden. Gedrukt in Nederland. De naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

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Monitor – the UK economic regulator In the UK, the Quality Governance Framework tests the ‘robustness’ of quality governance in providers Strategy

Capability and culture

Processes and structure

Measurement

1a Does quality drive the Trust’s strategy?

3a Are there clear roles 2a Does the Board have the 3a necessary leadership, skills and accountabilities for and knowledge to ensure quality governance? delivery of the quality agenda?

4a Is appropriate 4a quality information being analyzed and challenged?

1b Is the 1b Board sufficiently aware of potential risks to quality?

2b Does the Board promote a quality-focused culture throughout the Trust?

3b Are there clearly 3b defined, well understood processes for escalating and resolving issues and managing performance?

4b Is the board 4b assured of the robustness of information relating to quality?

3c 3c Does the Board actively engage patients, staff and other key stakeholders on quality

4c 4c Is the information on quality being used effectively?

The Care Quality Commission – the UK quality regulator

The role of the CQC ■ Setting standards of quality and safety ■ Monitoring, inspecting and reporting publicly on performance ■ In-depth investigations looking at care across the whole system.

A mixture of announced and unannounced inspections, focusing on 5 domains: Safe

Effective Caring

Responsive

People are protected from abuse and avoidable harm Care achieves good outcomes, promotes a good quality of life & is based on best evidence available

Staff involve and treat people with compassion, kindness, dignity and respect Services are organised so that they meet people’s needs

Leadership and governance ensure the delivery of high-quality person-centred care, support learning © 2013 KPMG Advisory N.V., ingeschreven bij het handelsregister in Nederland onder nummer 33263682, is een dochtermaatschappij van KPMG Europe LLP en lid van het KPMG-netwerk van zelfstandige ondernemingen dieand verbonden zijn aan KPMG International Cooperative (‘KPMG een Zwitserse Alle rechten voorbehouden. Gedrukt in Nederland. De innovation & promote an International’), open and fair entiteit. culture

Well-led

naam KPMG, het logo en ‘cutting through complexity’ zijn geregistreerde merken van KPMG International.

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Building block 3: optimising and standardising processes

“

Guidelines are typically forgotten half of the time, so we made these automated pathways the default way of doing things.

”

Brent James Chief Quality Officer, Intermountain Healthcare, USA

Measurement, roles and culture should all be aligned with standard pathways and operating procedures

This high degree of standardisation reduces complexity and variation, improves cooperation and communication – and thereby improves quality

Front-line professionals are responsible for confirming that guidelines are followed; they have the capability and will to intervene when they fear this is not happening.


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Intermountain Healthcare – saving lives, reducing costs Intermountain Healthcare introduced standard workflow guidelines, and measured outcomes. They made dramatic and continuous improvements: For patients with acute respiratory distress syndrome: ...guideline variances dropped from 59% to 6% within just 4 mths ...patient survival increased from 9.5% to 44% ...physicians’ time commitments fell by about half ...the total cost of care decreased by 25%

This approach has since been extended to cover the vast majority of the care within Intermountain’s system, with similar success.

Building block 4: measurement The world’s leading healthcare organizations share an obsession with measurement: state-of-the-art dashboards, process and outcome measures, many of which in real time. We aim to religiously and relentlessly measure and re-measure.

“

”

Mike Harper, Executive Dean of Clinical Practice, Mayo Clinic

They also seek to benchmark themselves internationally, to learn from best practice around the world.

Robust international comparison at both the whole-hospital and diagnosis level: Quality and safety Productivity and efficiency Financial performance

Maternity & Neonatal – Deliveries

Quality & safety

KPMG and University Hospitals Birmingham have developed the International Hospital Benchmark

Australia England Germany Netherlands USA

Productivity & efficiency


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System governance Many healthcare leaders see tension between a wealth of external requests for measurement – which they often feel measure the wrong things – and their own internal drive for excellence

“

”

Regulation is much too important to leave to the regulators.

Niall Dickson, Chief Executive and Registrar, General Medical Council, UK

In order to become high-reliability organizations, providers need to align these external and internal tasks This will reduce complexity and increase transparency

“

The most important measures – for both internal and external use – are those that capture the overall outcomes of care. Once hospitals are able to reliably measure and report these outcomes, there is no need to report a plethora of process and intermediate measures.

”

KPMG International – ‘The more I know, the less I sleep’

10 practical steps towards being a high-reliability organisation 1 2 3 4 5 6 7

8 9 10

Embrace the four building blocks: culture, accountability, standardisation and measurement Measure the outcomes that matter to patients and the processes that contribute to that Make individuals accountable for clinical and financial outcomes

Align measurement processes with care pathways Create a culture intolerant of complacency, committed to excellence and learning Adopt the right IT to optimise measurement – but don’t let a lack of IT infrastructure be an excuse

Focus external reporting on important patient outcomes, not detailed protocols Continually seek ways to risk-adjust measurements for better benchmarking Provide independent assurance over the reliability of quality measures

Adopt certification as the most appropriate way to assure safety, not public reporting of negative outcomes

The first in our ‘What Works’ series.. Creating new value with patients, carers and communities

This document is CONFIDENTIAL and its circulation and use are RESTRICTED. © 2013 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. Printed in the United Kingdom. The KPMG name, logo and ‘cutting through complexity’ are registered trademarks or trademarks of KPMG International Cooperative (KPMG International).

The more I know, the less I sleep

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