13 januari 2005Mats Brommels, Helsingfors universitet och Karolinska Institutet Vårdprogram – en god gammal idé Neuropediatriska föreningens vidareutbildng.

13 januari 2005 Mats Brommels, Helsingfors universitet och Karolinska Institutet

Vårdprogram – en god gammal idé

Neuropediatriska föreningens vidareutbildng 13-14 jan 2005

• Historien: Berg- och dalbana med platåfas?

• Idén i en tredje nytappning

• Utmaningen: praxispåverkan

• Genombrottet: integrerat informationsstöd?

13 januari 2005 Mats Brommels, Helsingfors universitet och Karolinska Institutet

Recycling

• Att återanvända är inte bara tillåtet utan rentav lovvärt (okänd tänkare)

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

From care programmes to clinical protocols and evidence-

based guidelines -1

• The 1970’s and 1980’s:– Decision support (algorithms)– Blueprints for collaboration (”chains of care”,

seamless care) – Diabetes, stroke, heart failure, cancer treatment

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

From care programmes to clinical protocols and evidence-

based guidelines -2

• The 1990’s:– Disease management and managed care

(reducing practice variation and restricting resource utilisation)

– Evidence-based medicine

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

From care programmes to clinical protocols and evidence-

based guidelines -3

• The first millenium decade:– ”Management by guidelines”– Clinical management improving the quality and

efficiency of care

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Medical managementThe Leadership Task

• To align goals and create co-ordination

• To secure an efficient use of resources and a high quality outcome

• To create conditions for innovation and renewal

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Management economics

Input Process Output

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Medical management:An economic appraisal model

Objective Process Output Outcome Benefit Services Health gain QoL

Efficacy – effectivenessInput Productivity

Efficiency

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Efficient resource utilisation (1)

• Strategic level:– Aim: Best possible medical outcome, i.e. health

gain– Diagnostic work-up and treatment according to

scientific evidence and best practice– Evidence based choice of an effective clinical

strategy

• Operative level:– ...

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Efficient resource utilisation (2)

• Operative level:– Aim: Optimal utilisation of resources and the

best possible quality (process view)– Minimisation of costs and complications in the

implementation of an effective clinical strategy – Control by the use of clinical care protocols

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Management control: ”Evolutionary stages”

• Budget control – ”management by budgets”

• ”Frame budgets” – decentralised cost responsibility

• Management by objectives

• ”Management by results” – profit centres

• Activity-based management – ”management by guidelines”

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Political decision-makers

Management

Input Output

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Political decisionmakers

Management

Input Output

Budget

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Total costs

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Political decisionmakers

Management

Input Output

Budget - FRAME OBJECTIVES

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Total costs

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Political decisionmakers

Management

Input Output

Budget Services provided

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Income

./. Expenditure

Profit/loss

Total costs

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Political decisionmakers

Management

Input Output

Budget Services provided

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Activities

+Visits

+Admissions

+Hospital days

+Examinations

+ICU days …..

Total costs Care process

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Input factors

1st order: Material resources – specified according to cost item

2nd order: Knowledge and competence

3rd order: Common goals based on shared values

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Activity-based costing

• Process description of the clinical care (cf. quality and process management)– Care process: diagnostic, therapeutic, care,

rehabilitation and follow-up interventions in sequential order described in a flow diagram

• Basic concepts

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

ABC in radiology -1

• The radiological process: activities– Time scheduling and registration– Radiological procedure– Assisting procedure (moving patients,

preparations etc.)– Film developing– Radiologist’s statement– Clinical conference

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

ABC in radiology -2

• ”Standardised activities” (fixed cost driver)– Product development– Quality assurance– Teaching and research

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

ABC in radiology -3

• Resources (resource pools)– Radiologists– Radiology technicians– Secretaries– Auxillary personnel– Materials– Facilities– Equipment

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

ABC in radiology -4

• Activity drivers– Number of patients and procedures

• Cost drivers– Staff time (in minutes)– Materials consumed– Length of procedure (in minutes)

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

ABC in radiology -5

Conventional costing ABC

Overhead 318,000 (57 %) 75,000 (16 %)

Material and support 40,400 110,600

Rooms and equipm 93,800 136,600

Auxillary staff 58,000 150,600

Radiologists 52,400 83,500

Fluoroscopy Unit cost + 35 %

Ultrasonography Unit cost - 8 %

Plain radiography Unit cost + 7 %

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Activity-based management (ABM)

• Process description of medical care (as defined by diagnosis and interventions)

• Activities: – Diagnostic and therapeutic interventions– Paramedical and administrative support services

• Activities define resources deployed by medical decisions

• Resource management: changes in “activity mix” based on the availability of resources

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Changing professional practiceKnowledge-based interventions

• Self-directed, problem or action oriented learning

• Focus on problems from the practice• ”Academic detailing”: expert feedback and

advice• Efficiency requirement (Adult learning theory, experience from continuous

medical education)

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Obstacles to change

• ”Comfort zone”

• Internal factors– Lack of knowledge, dissidence, missing skills,

uncertainty about effects

• External factors– Conflict with assumed patient benefit, lack of

resources, organisational barriers

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Change of practice – a learning perspective

• Sense of problem perceived need for change

• Follow-up and reflection– data on own practice – comparisons – Expert feed-back (academic detailing)

• Removal of barriers to change

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Evidence from systematic reviews – change strategies

Strategy # of reviews

# of studies

Conclusions

Trad education 13 3-37 Mixed effects

Interactive small groups

4 2-6 Mostly effective

Educational outreach

8 2-8 Effective for prescr/prevent

Feedback 16 3-37 Mixed effects

Reminders 14 4-68 Mostly effective

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Evidence from systematic reviews – change strategies

Strategy # of reviews

# of studies

Conclusions

Computerised decision support

5 11-98 Mostly effective for prescr/prevent

Subst of tasks & multiprof coll

11 2-22 Mostly effective

TQM/CQI 1 55 Limited effects

Financial interventions

6 3-89 Fundholding & budgets effective

Combined 16 2-39 More eff than single int

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Conclusions(Grol & Grimshaw 2003)

• Interactive and continuous education– Feedback on performance

– Local consensus

– Personal and group learning plans

• Built into daily practice• Clinical decision-support and reminders• Adjusting the organisation, care proceses,

resources, leadership and political environment

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Knowledge management – the traditional way

• Building knowledge repositories

• Establishing employee networks and ”communities of practice”

• Encouraging information sharing

• Marginally successful(Davenport & Glaser, HBR July 2002)

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Knowledge management in specialist organisations

• Integrate specialised knowledge into the jobs of the highly skilled workers

• Embed the knowledge into the technology that is used in practice– Examples: physician order-entry and

prescription systems

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

Partners HealthCare, Boston

• Support from opinion leaders

• Correct and up-to-date knowledge base

• Focus on truly critical work processes

• Final decision by the experts

• Culture of measurement

• Highly qualified informatics support