Barcelona April 20 Integrating quality and safety thinking into the whole healthcare system Carlo Favaretti, Azienda Provinciale per i Servizi Sanitari, Italy Göran Henriks, Jönköping County Council, Sweden Lloyd Provost, Institute for Healthcare Improvement, USA International Forum on Quality and Safety in Health Care April 20 2007 Barcelona
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Barcelona April 20
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
Barcelona April 20
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
Test of processes,machines, methods,
costs
Production, assembly, finishing, inspection
A
B
C
D
E
F
Stage 0:Generation of ideas
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
Barcelona April 20
Deming’s view of the Organization as a System (1950, 1994)
Designand
Redesign
ConsumerresearchSuppliers of
Raw Materials Receipt andtest of
Materials
Consumers
Distribution
Test of processes,machines, methods,
costs
Production, assembly, finishing, inspection
A
B
C
D
E
F
Stage 0:Generation of ideas
Management Lens
Micro-system Lens
Improvement Science Lens
Three Perspectives of the Health Care System
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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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Deming’s view of the Organization as a System (1950, 1994)
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
The Autonomous Province of Trento
(+ 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 %
The Autonomous Province of Trento
Italy
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• Health promotion
• Preventive medicine
• Primary and hospital care
• Rehabilitation
• Psychiatric care
Trust’s Mission
The Autonomous Province of Trento
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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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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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INNOVATION AND LEARNING
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
The EFQM Excellence Model
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INNOVATION AND LEARNING
ENABLERS RESULTS
The EFQM Excellence Model
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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
Barcelona April 20
1. The context
2. The EFQM Excellence Model
3. Enabler improvement
4. Measuring results
5. Innovation and learning
Overview:
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8. Services and care domains integration
ENABLER IMPROVEMENT Continuous enablers improvement to develop integrated governance:
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
Barcelona April 20
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
Barcelona April 20
- 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
Barcelona April 20
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
Barcelona April 20
• 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
Barcelona April 20
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)
Barcelona April 20
• 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
Barcelona April 20
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
Barcelona April 20
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
2. The EFQM Excellence Model
3. Enabler improvement
4. Measuring results
5. Innovation and learning
Overview:
Barcelona April 20
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)
Barcelona April 20
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
Barcelona April 20
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
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
Barcelona April 20
1. The context
2. The EFQM Excellence Model
3. Enabler improvement
4. Measuring results
5. Innovation and learning
Overview:
Barcelona April 20
1. The context
2. The EFQM Excellence Model
3. Enabler improvement
4. Measuring results
5. Innovation and learning
Overview:
Barcelona April 20
• COMMITMENT• COHERENCE• CONCRETENESS• PATIENCE
INNOVATION AND LEARNING
Four words seem to describe the present status of the Trust development:
Barcelona April 20
• 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
Barcelona April 20
INNOVATION AND LEARNING
ENABLERS
RESULTS
INNOVATION AND LEARNING
Barcelona April 20
• 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:
INNOVATION AND LEARNING
Barcelona April 20
Deming’s view of the Organization as a System (1950, 1994)
Designand
Redesign
ConsumerresearchSuppliers of
Raw Materials Receipt andtest of
Materials
Consumers
Distribution
Test of processes,machines, methods,
costs
Production, assembly, finishing, inspection
A
B
C
D
E
F
Stage 0:Generation of ideas
Management Lens
Micro-system Lens (team level)
Improvement Science Lens
Three Perspectives of the Health Care System
Barcelona April 20
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
Barcelona April 20
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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Barcelona April 20
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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
Barcelona April 20
Betterpatient (population)
outcome
Bettersystem
performance
Betterprofessionaldevelopment
Everyone
Creating a sustainable situation for the continual improvement of health care
Source:Batalden,Henriks
Barcelona April 20
Important concepts• Design• Processanalyze• Primary and secondary drivers• PDSA• Benchmarking• 5p:s• Creativity• Communication
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
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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Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
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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
Barcelona April 20
Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
Barcelona April 20
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
Barcelona April 20
Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
Barcelona April 20
Variation
.
tid
Efter-frågan
Kapacitet
“Ryggsäck”
Outnyttjad kapacitet kan inte sparas
Ref: Strindhall, HenriksMurray
Barcelona April 20
• How do we identify waste and links that do not work?
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
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
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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
Barcelona April 20
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
Barcelona April 20
Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
Barcelona April 20
Deming’s view of the Organization as a System (1950, 1994)
Designand
Redesign
ConsumerresearchSuppliers of
Raw Materials Receipt andtest of
Materials
Consumers
Distribution
Test of processes,machines, methods,
costs
Production, assembly, finishing, inspection
A
B
C
D
E
F
Stage 0:Generation of ideas
Management Lens
Micro-system Lens Improvement Science Lens
Three Perspectives of the Health Care System
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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
Barcelona April 20
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
Barcelona April 20
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”
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
Integrating Learning from Research, Improvement, and Practice
Continuous, enduringimprovement in care
PragmaticScience
Rigorous researchand evaluation
Local learningand improvement
Improvement in Daily Work
Barcelona April 20
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
Barcelona April 20
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
Barcelona April 20
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.”
• 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