Profiles in Improvement: Pete Knox, IHI Senior Fellow

Pete KnoxPeter J. Knox, Executive Vice President, Bellin Health, has been associated with Bellin Health for 30 years and currently he is responsible for population health strategies, accountable care strategies, learning and innovation for the system, execution of system strategy, employer strategies, and physician networks. Bellin has been on the leading edge of quality and achievement of performance results for many years. In addition to his role at Bellin, Mr. Knox pursues his passion for helping organizations achieve strategic results as CEO of his consulting company. He is a Senior Fellow at the Institute for Healthcare Improvement and author of two books, The Business of Healthcare and Destination Results, which wil be published in summer 2011.
Q: What is your background in health care?
I started out working for the City of Green Bay, Wisconsin, in the human resources department. Back in the late 1970s, I joined Bellin Health in Green Bay, an integrated delivery network with multiple facilities, including a hospital, about 120 primary care physicians, a group of partner specialists, and a physician hospital organization. I’ve been at Bellin for 30 years, in a variety of positions that really run the gamut of the organization.
I got involved in what was called our “total quality management” initiative in the mid-1980s — so Bellin was involved very early in that work, for health care. Many members of our board of directors were CEOs outside of health care, so their companies were involved in total quality management, and they said to us, “You should be applying this in your health care organization.”
We studied and read about concepts from other industries — at the time, mostly manufacturing. There was very little being written on quality in health care. We would take what we learned from examples and instruction in other industries and constantly try to bring that back and apply it to Bellin.
Q: How did you get to know and start working with IHI?
While I was leading Bellin’s total quality management efforts in the late 1980s we got involved with the Quality Management Network, which was led by the National Demonstration Project  [the predecessor to IHI] and was focused on implementing quality management principles in health care. I think there were about 40 organizations from around the country that joined this network; you had to apply and be accepted. So, we had early connections to IHI and stayed involved through the years, as we continued to evolve, to forge our own path.
In the early 1990s a group from Bellin went on a study mission to Japan. We had been learning a lot about the principles and concepts of quality improvement, and training our managers in these, but it was still a lot of project orientation, versus a full integration into the fabric of the organization. On the trip to Japan we learned about aligning mission, vision, and strategic planning — the whole concept of aligning the entire organization around the strategies of the organization, and how companies in Japan then deployed that throughout their work force.
Q: How did your role at Bellin and the organization’s improvement work evolve over time?
We reorganized Bellin in the early 1990s around service lines across the hospital continuum, and I took on all of our business operations. I was responsible for finance, IT, and marketing; all business functions supporting the operations of the core business. During this time, as I was still leading our quality improvement efforts, I developed a framework that I called “alignment and deployment.” It was my early thinking about a systemic approach to organizational performance across a balanced set of performance metrics — advancing strategic performance.
In the late 1990s I became chief operating officer of the hospital, and also started writing my first book, The Business of Healthcare. Through the book I introduced a broad business model framework to achieve strategic results called the “high-performance healthcare model.” The model defines what it takes to run a good health care business and produce exceptional strategic results. I’ve continued to evolve this model over the years.
The high-performance model consists of six dynamic and synergistic dimensions:
  1. Customer and strategic alignment: This alignment sets the foundation specifications for the production system design
  2. Production system design: Design concepts and principles are applied to efficiently deliver value to customers
  3. Measurement system design: Measurement overlays the production system to provide knowledge and insight into what is working well and what needs improvement
  4. Performance improvement design: The concepts of rhythm and discipline in improvement and innovation are introduced
  5. Sales/marketing and communication alignment: Compelling stories are communicated internally and externally
  6. Cultural alignment: A passionate and aligned culture is needed
By 2000, Bellin had acquired a number of primary care physician practices, and, like a lot of organizations growing in this way, we faced challenges — we needed to determine how the practices would become a part of a system that created value for patients and customers. We were losing money, there was no structure, physicians were unhappy and wondering why they had joined the health system. I was asked to lead the efforts to bring some structure and organization to the physician practice group. We applied the high-performance healthcare model as a business framework to the medical group. To essentially turn around a poorly functioning organization, we changed our approach. We set up a whole different way of thinking about the business; we created governing structures that invited physicians to help us run the business and think about how to create and evolve to a high-performing medical group. Most of those structures are still in place today, and the medical group is now, I believe, one of the better performing medical groups in the country.
In 2005 I became executive vice president for what Bellin calls “regional clinical sales and services.” I’m responsible now for pretty much all the work we do outside the hospital: the medical group, physician practices, employer strategies, population health strategies,  the physician hospital organization, and the clinically integrated network. Our work in population health is focused on improving the health in segments of the population. So, I have responsibility for trying to advance the organization in the world outside the hospital — the heart of our Triple Aim work.
In the spring of 2010, Bellin CEO George Kerwin approached me about working with IHI and it has evolved into a one-year working fellowship at IHI. I spend three-quarters of my time at IHI, and one week a month at Bellin.
Q: What is the focus of your work at IHI?
I’m helping the internal working group focused on IHI’s programs with acute care hospitals — to help lay the foundation and strategy for IHI’s ongoing work in this area.
I’m also involved in two IHI 90-Day R&D projects, both in areas of strong interest for me. One project involves children’s health and is based on work we’re doing at Bellin with school districts. I’m trying to advance a vision of creating an international network of organizations — schools, think tanks, health plans, health care providers — who are all invested in improving children’s health across the age spectrum: from prenatal through adolescence. There’s a lot of good work out there, but it tends to be in pockets. I think there’s an opportunity for IHI to link a lot of that work together, to develop partnerships among these groups and build a network to create best practices and methods for improving the health of children.
The other IHI R&D project I’m contributing to involves production system design. It also builds on a project I’m working on at Bellin, with colleague and former IHI Fellow, Jacquelyn Hunt. We’re developing a concept for production system design within health care that we call a “connected personal experience across the continuum.” I’m excited about this work. The work focuses on both depth and breadth in production system design. Breadth is the broad continuum and building an intelligent system to support the health and life goals of the individual; depth considers the contribution of each microsystem to the continuum. We use an eleven-step “quality in daily work” concept.
I’m also lead faculty for IHI’s Impacting Cost + Quality initiative. This initiative has a lot of potential, based on the two specific aims for the program. The first aim is focused on expense reduction: organizations that participate will reduce expenses by one percent, for whatever scope of work they define. The second aim is broader in its intent, more ambitious: IHI will help participating organizations build a framework for sustainable improvement over time. The feedback from participating members is really strong, so we’re off to a great start.
Q: Is there a common thread that goes through all of the work you’ve done?
My passion is in helping organizations become better at achieving strategic results and executing their strategies. I’m very interested in advancing the thinking about performance — within health care and outside of it — because I’ve found that industries of any kind, across the board, are struggling with the same issues. Health care is not all that different when it comes to the reasons we’re failing and the structure or framework that might help us be more successful. The application of a strong business model is not industry specific.
Q: What are you most excited about for your time here at IHI?
I’m most excited about learning. I certainly want to add value, but there’s a lot to learn, right there in front of me. IHI is an amazing organization, with extremely talented people, relationships, and connections around the world. It’s taking on issues and problems the health care world is facing and coming up with solutions, ways to help health care organizations improve. I’ve learned a lot already — about myself as well as the content knowledge.
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