M14, set 1 goran henriks, carlo favaretti - lloyd provost

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Integrating quality and safety thinking into the whole healthcare system

Carlo Favaretti, Azienda Provinciale per i Servizi Sanitari, ItalyGöran Henriks, Jönköping County Council, SwedenLloyd Provost, Institute for Healthcare Improvement, USA

International Forum on Quality and Safety in Health Care

April 20 2007 Barcelona

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Questions we try to answer today?– How can management strength be developed by

system thinking?– How can integration and coordination of improvement

efforts support transformational change of a system?– How does quality and safety work depend on good

integration of learning, science and practice

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Questions in the beginning• What is the purpose of our existence?• How do you ensure that it´s the patient

perspective that are in front of your development work?

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Results (for the Health Care Sytem that you work in)

• Avergage per capita health expeditures• Hospital beds per 1,000 inhabitants• Employee turnover rate• Overall patient satisfaction score• Hospital (or system) mortality rate• Total number of infections in hospital• Number of patient harmed• Percent re-admissions• Average Waiting time for appointment• Infancy mortality rate (first year of life),• Mammographic screening adhesion rate, • Anti-influenza vaccination rate (people over 65),

Last Quarter´s result

This years target

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System: Definitions

• “A system is a network of interdependent components that work together to try to accomplish the aim of the system “

W. Edwards Deming, The New Economics, 1993 • “A system is an whole which cannot be divided into independent

parts” Russell Ackoff, Better management for a Changing World

• System: an interdependent group of items, people, or processes working together toward a common purpose. Associates in Process Improvement, Quality as a Business Strategy, 1987

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Deming’s view of Production as a System (1950, 1994)

Designand

RedesignConsumerresearchSuppliers of

Raw MaterialsReceipt and

test of Materials

Consumers

Distribution

Test of processes,machines, methods,

costs

Production, assembly, finishing, inspection

A

B

C

D

E

F

G

Stage 0:Generation of ideas

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Deming’s view of the Organization as a System (1950, 1994)

Designand

Redesign

ConsumerresearchSuppliers of

Raw Materials Receipt andtest of

Materials

Consumers

Distribution


costs


A

B

C

D

E

F


Management Lens (leadership level)

Micro-system Lens (team level)

Improvement Science Lens

Three Perspectives of the Health Care System

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Lev

el o

f Det

ail

Low

High

Choice of Detail when Describing a System

5-9

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System Principles• We can think of all work as a process • A system is an interdependent group of items,

people, and processes with a common aim• Every system is perfectly designed to achieve the

results it achieves• If each part of a system, considered separately, is

made to operate as efficiently as possible, then the system as a whole will not operate as effectively as possible.

• Improvement of a system requires change, but not every change is an improvement

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Designand

Redesign



Materials

Consumers

Distribution


costs


A

B

C

D

E

F


Management Lens

Micro-system Lens



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• Do we have a quality strategy?• If so, what could we do to make it more

likely we would execute our strategy successfully?

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Designand

Redesign



Materials

Consumers

Distribution


costs


A

B

C

D

E

F

Stage 0: Generation of ideas

Management Lens (leadership level)




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1. The context

2. The EFQM Excellence Model

3. Enabler improvement

4. Measuring results

5. Innovation and learning

Overview:

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1. 7,400 employees (around 4,000 healthcare professionals)

2. 390 general practitioners and 79 community paediatricians (indipendente contractors)

3. 2 hub hospitals, 11 healthcare districts (with 5 more spoke hospitals) and many outpatients facilities (more then 2,600 ordinary booking lists + clinical priorities lists)

4. Agreements with outpatients clinics, private hospitals and 52 nursing homes

5. budget 2005: 879 millions euros, in balance

The Autonomous Province of Trento

Trust’s figures

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Inhabitants 495,000

Population density 76.3 per sqm

Per capita GDP 23,000 euros

Unemployement rate (%) 3.4 %

Tourist day stays per year 28 million


(+ 20% of the average national figure)

(Italy = 9.2 %)

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Birth rate 10.5 x 1,000

Life expectancy M = 76 yrs F = 83

yrs

Crude mortality rate 9.3 x 1,000

Infant mortality rate 2.0 x 1,000

Population > 65 yrs 18.0 %

Population > 75 yrs 8.7 %


Italy

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• Health promotion

• Preventive medicine

• Primary and hospital care

• Rehabilitation

• Psychiatric care

Trust’s Mission


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1. The context





Overview:

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Governance EFQMmodel

APSSapproach

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Systems and processes y which trusts lead, direct and control their functions in order to achieve organizational objectives, stafety and quality of services and in which they relate to patients, the wider community and partner organizations. (Governing the NHS: a guide for NHS Boards, 2003)

“Integrated governance arrangements representing best practice are in place in all healthcare organizations and across all healthcare communities and clinical networks” (Standards for Better Health - Integrated Governance Handbook, Department of Health, 2006)

Integrated governance is a co-ordinating principle....It does not seek to replace or supersede clinical or financial governance – or any other governance domain. Rather re-energises their vital importance and the inter-dipendence and inter-connection between them. (Integrated Governance Handbook, Department of Health, 2006)

INTEGRATED GOVERNANCE

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Integration risk assessment with the initial objective setting process

Developing an appropriate schem for reporting progress against objectives

Aligning the various governance systems so that they complement each other without overlap

Developing an effective assurance framework (The voice of NHS management:

The developement of integrated governance, 2004)

STEPS TO ITEGRATED GOVERNANCE

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Bringing togheter various strands of governance(clinica, financial, human resources, patients and staff safety, information, technological, etc.): transitional position moving beyond the handling of organizational issues in silos

Promoting a new quality frameworkbased on interrelationship of quality strands

balancing needs and expectations of competing elements (national v local, quality v cost, information v sharing individual rights, past and future demands etc) and stakeholders expectations

(Integrated Governance Handbook, Department of Health, 2006)

THE CHALLENGE....

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The EFQM Excellence Model

Leadership Processes Customer Results

Key Performance

Results

People Results

Society Results

Partnerships & Resources

Policy and Strategy

People

INNOVATION AND LEARNING

ENABLERS RESULTS

Each element is important …

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ENABLERS RESULTS

… but the undelying network is also crucial … !

Leadership

People

Policy and Strategy

Partnerships & Resources

Processes

People Results

Customer Results

Society Results

Key Performance

Results


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ENABLERS RESULTS


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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Punteggio totale

Leadership

Policy and strategy

People

Partnership and resources

Processes

Clients risults

People results

Society results

Key performance results

2001 self assessment

2003 selfassessment

2005 self assessment

PS Prize 2005

EFQM corporate self assessments

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La gestione del Livello: ASSISTENZA COLLETTIVA

La gestione del Livello: ASSISTENZA DISTRETTUALE

La gestione del Livello: ASSISTENZA OSPEDALIERA

Le ATTIVITÀ TRASVERSALI ai Livelli di assistenza

Il processo chiave: LA GESTIONE DEI

LIIVELLI DI ASSISTENZA

L’ORGANIZZAZIONE AZIENDALE

LA PIANIFICAZIONE DELLE ATTIVITÀ

ILCONTROLLO DELLE ATTIVITÀ E IL RIESAME DELLA DIREZIONE

LA COMUNICAZIONE CON LE PARTI INTERESSATE

LA RICERCA E L’INNOVAZIONE

Key process:LA GESTIONE DI

POLITICHE E STRATEGIE

L’ACQUISIZIONE DEL PERSONALE

LA FORMAZIONE DI BASE

L’ORGANIZZAZIONE DEL LAVORO

L’AMMINISTRAZIONE DEL PERSONALE

LA GESTIONE DEGLI INCARICHI

LA FORMAZIONE CONTINUA

LA GESTIONE DEGLI OBIETTIVI

LA SICUREZZA DEI LAVORATORI

Il processo chiave:LA GESTIONE DEL PERSONALE

LA GESTIONE DEGLI IMMOBILI

LA GESTIONE FINANZIARIA

LA GESTIONE DELLE ATTREZZ. SANITARIE

LA GESTIONE DEI MATERIALI

LA GESTIONE DEI SERVIZI DI SUPPORTO

LA GESTIONE DEL SISTEMA

INFORMATIVO

Il processo chiave:LA GESTIONE DELLE

RISORSE E DELLE ALLEANZE

Il processo chiave: LA GESTIONE DELLA LEADERSHIP

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1. The context





Overview:

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8. Services and care domains integration

ENABLER IMPROVEMENT Continuous enablers improvement to develop integrated governance:

2. Aligning reporting mechanisms1. Strategic planning

3. Budgeting process4. Managing of demand and supply

5. Health technology assessment

7. Continuos Education and staff evaluation6. Risk management

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1. Health promotion within health promoting settings

2. Continuous quality improvement

3. Coherent managerial action

STRATEGIC DIRECTIONS:

Enabler improvement - 1STRATEGIC PLANNING

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TO DEVELOPHEALHCARE

DELIVERY PROCESSES

1. Adopting of a comphrensive health care approach2. Delivering health care effective, appropriate and safe services3. Evaluating the impact of health care technologies4. Measuring healthy outcomes of performed activities

TO DEVOP TECHNICAL ADMINISTRATIVE

PROCESSES

1. Semplifing stake holders’ life 2. Favouring omogeneous behaviours3. Decentrating decisional levels4. Measuring organization outcomes of performed activities

TO DEVELOP ALLPROCESSES

1. Connecting the parts of the system 2. Analyzing needs and defining priorities 3. Promoting autonomy of the stake holders 4. Benchmarking of activities and results

Key actions for the ongoing development of the plan

Enabler improvement -2STRATEGIC PLANNING

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INTERNAL CONTROL EXTERNALCONTROL

SHARED CONTROL

WITH CITIZIENS

COMPULSORYMECHANISMS

• audit committee• ordinary financial

monitoring • administrative

procedures control• evaluation committee

• autonomous province of Trento general and specific objects

• Autonomous province of Trento authorisation on health care facilities

• Institutional accreditation of the Autonomous Province of Trento

• Corte dei conti control controllo• Certification by Istituto Superiore di Sanità on public

hygiene laboratory

• Complaint cycle

VOLUNTARYMECHANISMS

• self assessment• clinical audit and organizational audit• project management

office (PMO)

• certifications: EFQM, ISO, OHSAS• professional accreditations (i.e. JCI, scientific

societies)• “Safe hospital” campaing in collaboration with CittadinanzAttiva

• civic audit with CittadinanzAttiva

• local audit experiences with volunteer associations (i.e. Multidimensional Assessment Unit)

Stake holders reporting and accountability

Enabler improvement - 2REPORTING MECHANISMS

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- Activities and resources- Clinical and organizational processes- Actors: heads of department and staff, doctors,

nurses and other professionals- Routines and innovation

BUDGETING = YEARLY ACTIVITY PROGRAM

The budget is the tool for integrating the most important processes:

Enabler improvement – 3aBUDGETING PROCESS

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ACTIVITIES to performand available RESOURCES

SECTORALPLANS

OPERATIONALBUDGET

• Patients safety• Workers safety• Education• Building• Devices• Informatics• Human resources• Goods and services

Budget sheets:- APSS- central directorates-hospital and districts and structural dipartments-operational unit and services

BALANCESHEETS

• “Activity plan”• “Yearly and multi-years

provisional balance sheet”• “CEO report on yearly and multi-years provisional balance”

PROJECTSPORTFOLIO

Main corporate projects (informatics, building, Autonomous Province of Trento objectives, riorganizations, ecc.)

Enabler improvement – 3bBUDGETING PROCESS

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• Segmenting and scheduling outpatients access to services according to their clinical needs. The system, succesfully established involving general practitioners and specialists, is in place for all disciplines. Have been set omogenous waiting groups of 3, 10 or 40 days according to the clinical urgency for more then 70 different services

• Incresing of supply in critical areas

• Monitoring of booked services (centralised call center/web site booking system for outpatients services)

• Appropriatness improvement initiatives

• Clinical pathways in the management of some chronic and neoplastic conditions

• Strenghtening of health care services at district level

• Telemedicine

Enabler improvement – 4MANAGING OF DEMAND AND SUPPLY

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Enabler improvement – 5TECHNOLOGY ASSESSMENT

elementi principali attività

Services(ambulatory care tariff nomenclator, day surgery services, home care nursingservices, ….);

Pattern of care(clinical pathways, guide lines implementation…);

Investments planHealth equipments and devices

Support systems(horizon scanning, informative dipartimental systems, PACS ...)

Applied research (projects such as six-sicc, etc)

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• Observatory for monitoring and prevention of healthcare civil liablity risks

• Guidelines on information and patient informed consensus; spreading and implementation of clinical address papers (guidelines, prcedures, clinical pathways,..);

• Trust surveys to analyse risk related to structural aspects and devices;• “Trust committee on patients safety” and subsequent yearly sectoral plans;• strategie comuni di comportamento among all the different trust committee

omitati involved by risk management activities

• Improvement of documental system;

• Continuous Education;

• Organizational experimentations (es. distribuzione dei farmaci in reparto).

Enabler improvement – 6RISK MANAGEMENT

Performed activites

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Report on personal clinical activities

and credit of CME

EFQM personalassessment

Annualbudget results

Disciplinary actions

EVA

LUA

TIO

N

LeadershipPolicy and StrategyPeoplePartnerships & ResourcesProcesses

consistent with EFQM enablers:

Enabler improvement - 7CONTINUOS EDUCATION AND STAFF EVALUATIONC

EO

reap

poin

tsor

mov

es d

own

The EFQM assessment schemeis coherent

with the professional jobdescription

framework for clinicians evaluation

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Enabler improvement – 9SERVICE AND CARE DOMAINS INTEGRATION

• Partnership agreement with nursing homes (providing assisted living services)

• Shared disease management pathways among hospitals, primary care, rehabilitation centres and nursing homes

• Agreement with local councils and subsequent activities for Integration of health and social care for targeted patients groups at community level

• Education and health promotion intiatives involving trust preventive services, local goverment institutions, schools and no profit organizations

• Partnership with: accredited private health providers (ambulatory services, hospitals and nursing homes) and citiziens and patients associations

• Personalized integrated home care services

• Broad public health and socio-cultural development projects and activities involving the trust and other local community stakeholder

TOWARDS A BETTER INTEGRATION...

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1. The context





Overview:

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1. performance results

2. stakeholders satisfaction

3. Integrating clinical governace: dashboard information

4. Clinical indicators and ability to drill down the information

Continuous improvement in measuring results:MEASURING RESULTS

...“The goal in creating performance mnagement systems must be to provide the board with relevati and meaningful information that can be quickly assimilated and understood”...(Integrated Governance Handbook, Department of Health, 2006)

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CONSUMO

0

200

400

600

800

1000

1200

2002 2003 2004 2005

DDD/

1000

/die

APSSmedia Italiaregione miglioreregione peggiore

SPESA LORDA PRO-CAPITE

0

50

100

150

200

250

300

2000 2001 2002 2003 2004 2005

APSSmedia Italiaregione miglioreregione peggiore

Measuring results - 1a:PERFORMANCE RESULTS

PHARMACEUTICAL CONSUMPTION

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Pazienti valutati dalle UVM

0

1000

2000

3000

4000

2001* 2002 2003 2004 2005

MULTIDIMENSIONAL ASSESSMENT UNIT (MAU)

Assessment results (2005)

Nursing homes eligible patients 1.837

Residential beds eligible patients 142

Integrated home care – Integrated home care palliative care

962

Other (planned home care, etc) 141

*since 07-01-2001

Patients evaluated during 2005 = 3.082

Measuring results – 1b:PERFORMANCE RESULTS

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ENVIRONMENTAL WASTE/MANAGEMENT

Measuring results – 1c:PERFORMANCE RESULTS

0

20.000

40.000

60.000

80.000

100.000

gen-

99lug

-99

gen-

00

lug-0

0ge

n-01

lug-0

1

gen-

02lug

-02

gen-

03

lug-0

3ge

n-04

lug-0

4

gen-

05lug

-05

Monthly hospital wastes in Kilograms

Monthly hospital stay days

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• “Waiting lists management should consider clinical priority indications, not only first come first served principle”

2002: 93.8% agrees (quite or strongly agrees) 2006*: 85.4% agrees (quite or strongly agrees)

*Clinical priority system based on Omogeneous Waiting Groups in place everywhere since 2004 (neary 42,000 services with clinical priority delivered)

Survey by phone interview in 2002 and 2006 (1,500 people sample):

Measuring results – 2a:STAKEHOLDERS SATISFACTION

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Measuring results – 2bSTAKEHOLDERS SATISFACTION

INTEGRATED SURVEYS: opinions of employees and citizens on Trust’s health services are concordant but employees believe that citizens are too critical

CITIZENS CLINICIANScitizen opinion as CONSIDERED by

clinicians

satisfied 88 % 89 % 33 %

unsatisfied 12 % 11 % 67 %

Example: opinions on quality of Trust’s health services:

Barcelona April 20*from Claims Report 2005

District care

Measuring results – 2cSTAKEHOLDERS SATISFACTION

CLAIMS

2001 2002 2003 2004 2005

WRITTEN CLAIMS COLLECTED 1,243 1,441 1,306 1,161 1,115

Hospital care public health care

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STAFF SATISFACTION

surveys:2003 (150 questionnaires )2004 (250 questionnaires)2005 (600 questionnaires)

people: • Physicians leaders • Nursing leaders• “Quality network”

trend:↑↑ improvement↑↑ satisfied↓↓ deeply unsatisfied

Measuring results – 2dSTAKEHOLDERS SATISFACTION

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OMOGENEOUS WAITING GROUPS VISITS:

sampling audit on 1,360 service prescriptions (2005)X-Ray and others imaging exams

107 = agreement

163 = disagreement

295 = agreement

191 = disagreement

26 = agreement

85 = disagreement

X-Ray

Ultrasonography

CT Scan

MRI

72 %

61 %

40 %

23 %

28 %

39 %

77 %

60 %

Measuring results – 3aINTEGRATION CLINICAL GOVERNANCE: DASHBOARD INFORMATION

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ASSISTENZA OSPEDALIERA:International Quality Indicatori Project (IQIP)

Patients in the ED with a LOS > 6 hours

0

5

10

15

APSS Europe USA

Each ward or health care delivery unit has chosen at least one clinical indicator used also for

the budgeting process

* Il grafico mostra l’andamento del tempo che i pazienti trascorrono in pronto soccorso per le procedure assistenziali (IQIP indicators)

Measuring results – 3bINTEGRATION CLINICAL GOVERNANCE: DASHBOARD INFORMATION

CLINICAL INDICATORS

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1. The context





Overview:

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• COMMITMENT• COHERENCE• CONCRETENESS• PATIENCE


Four words seem to describe the present status of the Trust development:

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• Innovation management approach based on health technology assessment

• Continuos needs assessment, communication and information flow inside the organization linking clinical and administrative areas in the decision making process

• Strong committment of the trust to create and promote learning opportunities for the staff

• Project Management techniques for breakthrough and short term hard technology innovation

• Central guidance, committees, working groups and educational activites to manage long term organizational innovation and service delivery

• Clear and immediate work linkage with the local government • Partnership with university research institutes and private companies

to devolop hard and “soft” (organizational) technologies

• Incentive and rewarding systems in place linked to performance

Were underpinned by the following issues:INNOVATION AND LEARNING

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ENABLERS

RESULTS


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• Improve the alignment fo clinical and corporate governance in the development of the organization bringing closer links with the performance agenda.

• Strenghten the way in which patients, staff and the public are involved in the planning and delivery of quality services

• Further spread evidence based practice and minimise the risks associated with the delivery of care

• Further develop information systems to support the audit and analysis of clinical outcomes and care

Next steps are to:


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Designand

Redesign



Materials

Consumers

Distribution


costs


A

B

C

D

E

F


Management Lens




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We are here to increase value for our inhabitants…

We believe all improvement must start with the purpose…

Our mission.. people and patients should get the care they need when they need it

Source:Budget 2007, The County Council of Jönköping

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Sweden

Jönköping

Europe

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Sum index

Diff

i SEK

1751501251007550

2000

1500

1000

500

0

-500

-1000

0

Scatterplot of Diff in SEKvs Sum index

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Sum index

Diff

i SEK

1751501251007550

2000

1500

1000

500

0

-500

-1000

0Västerbotten

Norrbotten

Västra GötalandHalland

Skåne

Östergötland

Gotland

JönköpingKronoberg

Blekinge

Gävleborg

VästernorrlandDalarna

Kalmar

Jämtland

Värmland

Örebro

Västmanland

Uppsala

Sörmland

Stockholm

Scatterplot of Diff in SEK vs Sum index

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What knowledge can healthcare integrate from other high performing industries?

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Här ska du sedan skriva in din rubrik...

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General Competencies for all employees8 000 training programs

• Patient care• Medical knowledge• Practice based learning and improvement• Professionalism• Interpersonal communication Skills• System based practice

ACGME

Re-examination is done based on above competencies

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• It´s essential to have a basic understanding of how a given system works. If you don´t understand the way things work and you try to change them, it won´t be sustainable change…And to create a high performing organization, you have to have high performing small systems within it

» Paul Batalden

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Betterpatient (population)

outcome

Bettersystem

performance

Betterprofessionaldevelopment

Everyone

Creating a sustainable situation for the continual improvement of health care

Source:Batalden,Henriks

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Important concepts• Design• Processanalyze• Primary and secondary drivers• PDSA• Benchmarking• 5p:s• Creativity• Communication

Appreciation of a System

Theory of Knowledge

Psychology

UnderstandingVariation Source: Deming

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Raise high barrier breaking goals

Strong support To local improvement

Develop the person behind Professional role

Spread and developsustainability

Develop leaders for systemic projects

Develop leadershipFor the microsystems

Execution

Information&

Information Technology

Staff

Patients•

Performance

Leadership•

Lessons from P2 G Henriks

Ref: Henriks, Nolan

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Mesosystem

Microsystem

Macrosystem

FrontlineNursingUnits

Nursing Divisions

Nursing Services

Example

System Levels

Source: Henriks, Bojestig, Jonkoping CC Sweden

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Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

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Purpose

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Andel kariesfria 19-åringar i % åren 1990 - 2005

0

5

10

15

20

25

30

35

40

1990 1991 1992 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Riket 23 % 2002

Amount of 19 year old persons without any kaires at all

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Rate of Influensavaccination to inhabitants 65 years of age and older in

Jönköping County, Sweden

70

686659

52

3945

0

10

20

30

40

50

60

70

80

90

100

1999 2000 2001 2002 2003 2004 2005

Year

Perc

ent

2001 starting to plan the innovation

2002 - Vaccination for free- Vaccination registry- Education in vaccination for 250 nurses and 30 physicians- TV-commercials and advertises in the locale press- Goal=60%

2003Same activities as the year before Goal=68%

2004Same activities as the tw o previous years but the TV-commercial is changed a bit.Goal=75%

2005Same activities as the previous years. This is no longer a project it is a standardGoal=75%

Jönköping’s newspaper11/9, 2006

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HSMR Reducerat, sjukhusvårdtillfällen samt endast verifierade överföringar

0,50

0,60

0,70

0,80

0,90

1,00

1,10

1,20

1,30

1,40

1,50

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Sjukhusmortalitet Jönköpings läns landsting 2002 - 2005

UCL=0,025902

LCL=0,013649

CEN=0,019775

0,00%

0,50%

1,00%

1,50%

2,00%

2,50%

3,00%

Proc

ent a

v vå

rdtil

lfälle

nHospital Mortality in Jönköping County Council 2002 – 2005

Per

cent

age

of C

are

occa

sion

s

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• Monthly report of system measuresEarly warning system

Adversed Drug Events, ADE Patient Satisfaction Mortality at hospitals, over age 65

Access Cost per inhabitant Cost per care event

System Measures

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• How do we define our gaps?

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GuidelinesGuidelines Routine careRoutine care

• A Gap between optimal treatment of cardiac infarction according to guidelines and what is really performed in the clinical activity

• Big variation between hospitals

• The hospital´s treatment traditions have a tendency to be stable over time

• Evidence based methods for quality development is needed

ACE-inhibitor (%) at discharge after AMI

0

10

20

30

40

50

60

0 10 20 30 40 50 60 Activity index in 1999

Act

ivity

inde

x in

200

0

• Big variation within hospitals

Control Chart: Coronary angiography 1999

Sigma level: 2

121110987654321

,8

,6

,4

,2

0,0

Coronar angiography

UCL

Center = ,29

LCL

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Searching for Improvement ideas

- Brainstorming - Litterateur searching - Site visits

- Learning from other teams

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Conduct Cardiac Tests

Conduct Nuclear

Medicine Tests

Conduct Nevrsophysiology

Tests

Provide Consulting Services

Provide Education

Receive ReferralCommunication

Conduct Tests

Referring Clients

University Students

Preparing Measurement

Reports

SchedulingPatients

Handle Telephone and

Fax Communication

Maintain Equipment

Calibrate Equipment

Coordinate SWEDAC

Audits

Handle Complaints

Conduct Research

Conduct Planning

Develop Budgets

Coordinate IT Support

Attend Professional

Society Meetings

Work with Equipment Suppliers

Learning From Clients

Design and Redesign

Conduct Internal Audit

Meeting

Conduct Unit Staff Meeting

Conduct Team Meeiings

Meeting with Referring ClientsCoordinate

Changes in Work with Our

Unions

Research New Techology

Improving the System

Provide Emergency

Support

Scheudling Staff

Scheduling

Prepare Reports

Develop and Update

Protocols

Conduct Meetingss

Clinical l Physiology Mainstay

Referring Professionals

Identify Opportunities to Colloborate

Clinical Physiology Role StatementHealthcare professionals in Jonkoping County Council need access to information and knowledge that enables them to properly diagnosis causes of disease and to ensure that appropriate treatment is given to the patient. The Clinical Physiology department matches this need by providing cardiac, nuclear medicine, neurophysiology tests, consulting and education.

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Entry,Assignment Orientation

InitialWork-up,

Plan for care

Disenrollment

Biological

Functional

Expectations

Costs

Biological

Functional

Satisfaction

Costs

Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system

Satisfaction of need, monitoring, assessment of outputs

A “Generic” Clinical Microsystem Model

Acute care

Chronic care

Preventive care

Palliative care

Ref:Gene Nelson

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Variation

.

tid

Efter-frågan

Kapacitet

“Ryggsäck”

Outnyttjad kapacitet kan inte sparas

Ref: Strindhall, HenriksMurray

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• How do we identify waste and links that do not work?

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Planning•StrategicObjectives•ImprovementEfforts•Resources

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Inpatients

400500600700800900

Anta

l Beläggning

60708090

100110

%

Lengt of stay

22,5

33,5

44,5

55,5

daga

r Watingtime

020406080

100120140

daga

r

Number of deths

01020304050

anta

l

Staff satisfaction

707580859095

100

%

Patientsatisfaction

77,5

88,5

99,510

%

Percentage of deths

0,002,004,006,008,00

ande

l

Contact with coordinator

050

100150200

Anta

l

Readmissions within 14 days

02468

1012

%

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0

5

10

15

20

Number of Falls reported at Kristinedal nursery home (ward 3 and 4)

• Education for assistant nurses and nurses

• Risk analysis of falling for all patients in the unit

• Meetings in the Team planning individual steps for each risk patient

• Systematic drug survey for all risk patients to prevent falling

• Information to patients/ relatives around risks for falling

• Clear of indoors environment• Continuous measuring• Notice board• Purchase of technical facilities

Changes done:

Business Case: Fall prevention

One broken hip: Cost for health care: 10 – 12 000 dollarsCost in all for the society: 35 000 dollars

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NowPatient enrolled

Pr. ulcer develops?

Treatment of pr. ulcer

Patient dicharged

Yes

No

Value Assessment

53 000 episods of care/year

At 8 % of episodes pressure ulcer develops

Treatment of pressure ulcers costs 7.6 million dollars

NewPat enrolled

Pr. Ulcer develops?

Treatment of pr. ulcer

Patient discharged

Yes

No

Value assessment

53 000 episodes of care/year

Assume that half of the pressure ulcers can be prevented

4 million dollars

Risk?Preventive treatment

Assessment acc. to Norton

YesNo

ALL patients are assessed 572 000 dollars

8 % of patients has a risk acc. to assess-ment

572 000dollars

Total cost

7.6 million dollars

Total cost

5 million dollars

Business Case: Pressure Ulcer

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Primary Care

Speciality Care

AccessDiagnosis, treatment and

Decision Support

Support Self

Management

Delivery system designDefine Ongoing

Relationship

Participate in

Jonkoping

Executive

Meeting

Design and

redesign the

system

Conduct

Business

Planning

Conduct

Council

Business

Meeting Obtain

Feedback

Conduct

Research

Customers

Patients

Nursing Homes

Participate in

County Council

Assembly

County Council

Learning how to better

serve our Patients

HR IT Transportation Economy

Maintain

Buildings &

SecurityClinical

Physiology

Public

Relations

Systems View of County Council of Jonkoping

Governance for

Spread of

Change

Provide

nursing

Care

Ear, nose,

throat

diseases

Surgical

diseases

Women

Provide

Pediatric

care

Provide

Psychiatric

care

Provide

care for

Medical

diseases

Neuromus

cular

Manage

Infection

controll

Ophtal-

mology

Derma-

tology

Telephone

triage

Drop in visits

Scheduling

appointments

Conduct

Home

care visits

Provide

Palliativ

care

Provide

E-learning

Conduct

Surgical

care

Provide

care in ER

Conduct

Ambulance

care

Provide

care for In

patients

Provide

care for

Out

patients

Provide

Intensiv

care

Provide

Group

visits

Conduct

evaluation

Planning for

follow up

Conduct Social

planning

Provide

radiology

Provide

labratory

Provide Diagnoses support

Attending

professional

meeting

Information

system

Manage drop in

visits

Support IT

information

systems

Get every one on the bus

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Dashboard

Dep. of medicine, Värnamo hospitalForest and Garden, Huskvarna AB

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• How do we integrate improvement work as an everyday work?

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Simple rules• We protect the patients and ourselves• It is the system’s result that counts• We share the results from our development and improvement work with

others• Health care emanates from the patient’s value, need and whishes• Either solve the problem or take responsibility for the handing over to next

step• Feedback to the step before• Work with guidelines

Ref: The County Council of Jönköping, 2002Bojestig, Henriks

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The system for care

Lean

Co

nsum

ption

User f

riend

ly an

d

orien

ted

Teamness

Everybody are involved and improve

the processes in the system

Change at all levels

CARESYSTEM

Ref: The county council of Jönköping, 2005, Bardon, Bojestig, Henriks

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Designand

Redesign



Materials

Consumers

Distribution


costs


A

B

C

D

E

F


Management Lens

Micro-system Lens Improvement Science Lens


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Improvement of Healthcare• Improvement of health care systems requires learning:

– Learning from research– Learning from quality improvement – Learning from daily management and practice

• Effective integration of these learning opportunities can accelerate the rate of improvement

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Workshop

• Work in small groups• Discuss a recent improvement in health care in one of

your organizations.• Where did the knowledge to make this improvement

come from?– Clinical research – Quality improvement – Clinical practice

• Discuss additional examples of improvements as time permits.

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Evaluating Quality of Evidence

I. At least one systematic review of multiple well-designed Randomized Control Trials (RCT).

II. At least one properly designed RCT of appropriate sizeIII. Well-designed trials without randomization (single group, time

series or matched case-control studies)IV. Well-designed non-experimental, based on clinical evidence,

descriptive studies or reports of expert committeesV. Opinions of respected authorities, based on clinical evidence,

descriptive studies or reports of expert committees

Source: Sackett DL. Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone 1997

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Dr. W. Edwards Deming stressed the importance of studying four areas to become more effective in leading improvement:• Appreciation of a system• Understanding variation• Theory of knowledge• Psychology

Deming called the interplay of these four areas “Profound Knowledge”

The Science of Improvement

Source : Improvement Guide, Introduction, p xxiv-xxvi

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Clinical Research

• Study of a drug, biologic, or device in human subjects • Encompasses

– translational research (study of laboratory findings in humans)– clinical trials of preventive and therapeutic strategies– epidemiology, behavioral research, and health services and

outcomes research. • Results in treatments (and drugs) that directly improve health care.

Harold Varmus, MDwww.najbr.org/public/research_definitions

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Campbell et atBMJ 2000;321:694–6

Clinical Research

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Characteristics of Clinical Research

• Focus is new knowledge• Emphasis on linear cause-effect relationships• Each study is a single learning cycle• Attention to control of bias to sharpen comparison

– Selection– Confounding– Measurement– Chance

• Methods to ensure uniform application of study design across study participants

• Goal is generalizability; principles or theory that goes beyond specific settings and patients

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Health Care Quality Improvement (QI)

A broad range of activities of varying degrees of complexity and methodological and statistical rigor through which health care providers develop, implement, and assess small-scale interventions and identify those that work well and implement them more broadly in order to improve clinical practice*

* The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PhD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October, 2004

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Characteristics of Health Care QI– Contextual factors (background variables or confounders in research)

are a major focus– The initial intervention (changes to the system) are adapted and modified

as study progresses– Measuring over time (improvement is temporal)– Graphical analysis and presentation (SPC)– Involvement of local expertise in conducting project– Multiple experimental cycles for quick feedback and learning– Multi-factor experiments to learn from complex systems with non-linear

and dynamic cause and effect relationships– Building reliability of the interventions can be a major part of the effort– Sustainability is a consideration from the beginning of the project– Design and execution led by the “Science of Improvement”

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Source: Improvement Guide, p 10

Framework, or Roadmap, for Quality Improvement Projects

Other Frameworks Exist:• DMAIC (from 6 Sigma)• Focus PDCA• 7-step Problem Solving• QI Story

PDSA – The Continuous Scientific Method

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Repeated Use of the PDSA Cycle

Theories Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP ADATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

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Evaluating Progress in QI Projects:Annotated Time Series

Medication Errors per Day

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

Jun-

98

Jul-9

8

Aug

-98

Sep

-98

Oct

-98

Nov

-98

Dec

-98

Jan-

99

Feb-

99

Mar

-99

Apr

-99

May

-99

Jun-

99

Jul-9

9

Month

Aver

age

ME/

D

ME's/PD Goal Baseline

100% IV Protocol

Test IV Protocol

Formulary changes

Floor mixing eliminatedSingle concentrations on units

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Some Challenges in Quality Improvement Projects

1. Description of the system is imprecise2. The need to serve as both advocate and investigator3. The use of external resources can hamper the ability to

sustain the improvement4. Building new knowledge is insufficient5. Replication is difficult6. Publishing QI studies

Nolan and Nolan Chapter 13, http://symptomresearch.nih.gov

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Improvement vs. ResearchContrast of Complementary Methods

ImprovementAim: Improve practice of health careMethods:• Test observable• Stable bias • Just enough data• Adaptation of the changes• Many sequential tests • Assess by degree of belief

Clinical ResearchAim: Create New clinical knowledgeMethods:• Test blinded• Eliminate bias (e.g. case mix)• Just in case data• Fixed hypotheses• One fixed test• Assess by statistical significance

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Clinical Practice vs. Research and Quality Improvement

• Clinical practice is designed to take care of a specific patient's medical needs

• Clinical practice includes adaptation and innovation. • Clinical practice provides a daily opportunity for learning

that can lead to improvement

The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PhD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October, 2004

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Improvement in Daily Practice

• Ongoing patient feedback systems • Daily and weekly performance measurement• Work toward standardization• Daily huddles to optimize communication• Use of QI tools with individual patients (control charts, experimental

design)• Formal learning from special causes• Daily PDSA’s • Philosophy of “stopping the line” and addressing problems as they

occur

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Control Chart for Osteoporosis Patient

Neck of Femur BMD

0.4000.4500.5000.5500.6000.6500.7000.7500.800

1 2 3 4 5 6 7 8 9 10 11 12 12

Jan-93

Feb-93

Feb-94

Feb-95

Jan-96

May-97

May-98

Dec-00

Oct-03

May-05

Mar-06

May-07

g/cm2

CL = .61UCL = .75LCL = .47

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Patient with Insomnia: Experimental Variables

Response Variables Measure

Length of Sleep Time woke up – time laid down (luminous clock)

Quality of Sleep Visual Analog Scale (0-10)0–Totally worthless, 10–Couldn’t have been better

Factors Low Level High Level

Food & Drink Yes after 9pm None after 8pm

Yoga None 20 min exercise before bed

Bedtime After 11pm Before 10pm

Rise Time Stay in bed until 6am Get up within 1 hr. of waking up

Jesper Olsson, et al, Quality Management in Health Care Volume 14, Issue 4, Oct-Dec, 2005

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Integrating Learning from Research, Improvement, and Practice

Continuous, enduringimprovement in care

PragmaticScience

Rigorous researchand evaluation

Local learningand improvement

Improvement in Daily Work

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Workshop

• Medication Errors are a common safety problem in today’s health care system.

• Discuss in your group how the three learning approaches can be leveraged to solve this problem:– Clinical research – Quality improvement – Clinical practice

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Special Report: The Ethics of Using QI Methods to Improve Health Care Quality and

Safety, July-August 2006/Hastings Center Report

Research on QI

Research

QI /Research on QI

Clinical &

Managerial

Innovation and Adaptation

Quality Improvement

QI

Research

Note: Figures not drawn to scale

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Superior Cancer Survival in Children Compared to Adults: A Superior System of Cancer Care?Joseph V. Simone, M.D.* and Jane Lyons, M.B.A.

“It is instructive to learn that the cure rate for childhood acute lymphoblastic leukemia rose from about 40% in the early-1970’s to about 70% in the mid-1990’s without a single new frontline therapeutic agent.

In leukemia and other cancers, improvements came largely from trial-and-error adjustments of therapeutic dosages and schedules made possible by the large pool of patients participating in clinical trials. This was true for other childhood cancers as well.”

www.iom.edu 6/2003

http://www.iom.edu/

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Methods for learning

• Clinical research methods and quality improvement methods are different ways to apply the scientific method– Good research involves elements of QI– Good QI involves attention to research methods

• Ongoing improvement is also an important component of clinical practice

• More careful integration of these approaches will accelerate improvements in health care

M14, set 1 goran henriks, carlo favaretti - lloyd provost

Health & Medicine

Transcript of M14, set 1 goran henriks, carlo favaretti - lloyd provost