The more I know, the less I sleep: Global perspectives on clinical governance

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  • 1. The more I know, the less I sleep Global perspectives on clinical governance kpmg.com/healthcare KPMG INTERNATIONAL
  • 2. The governance challenge     High-profile incidents are putting the spotlight on care quality. Healthcare is still too much a craft and needs a healthy influx of standardization and other normal industry operating principles, along with common industry standards of inspection, reporting and improvement. Enormous burden of registration with very little to show for it in terms of transparency or assurance of safety. Cost reduction is on the agenda as never before – how to save costs without hampering quality, or even through enhancing quality. © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 1
  • 3. Part 1: Clinical and corporate governance: delivering quality reliably    Governance is the critical glue that brings together delivery and assurance Four building blocks towards a ‘high reliability’ organization: 1. A culture devoted to quality 2. Responsibility and accountability 3. Optimizing and standardizing processes 4. Measurement Four-stage journey towards high reliability; most organizations have not gone beyond stage 2 © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 2
  • 4. Developing clinical and corporate governance Part 1: Clinical and corporate governance: delivering quality reliably Part 2: System governance: assuring quality About the report:  Studied national and regional industry best practices.  Conducted 20 interviews with C-level practitioners in the US, UK, India, Germany, Australia, Canada and Singapore.  Held round table discussions in Sydney, Amsterdam, Lausanne and Boston, to test, validate and further develop the findings. © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 3
  • 5. Delivering quality reliably  Doctors are typically responsible for clinical excellence and Boards have no influence over quality  What does ‘in control’ mean according to the interviewees? - Methodically measuring care outcomes - Understanding the key drivers of these outcomes - Understanding how to make these outcomes best of class - Systematically preventing avoidable harm to patients “ “ We score on the top of most lists. But are we ‘in control’ yet? No…we can do better. Mike Harper, Executive Dean of Clinical Practice, The Mayo Clinic © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 4
  • 6. Four building block towards a ‘high reliability’ healthcare organization ‘High reliability’ organizations: The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value. © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 5
  • 7. Building block 1: A culture devoted to quality Build trust and respect for each other’s roles Take a constructive approach to errors rather than blaming people Zero tolerance to any breaches of safety, with an aversion to being average Board members should not defer to professionals Penetrate the ‘concrete floor’ separating clinicians and management “ “      Being satisfied with average can lead one to slowly start to accept the most appalling levels of quality Malcolm Lowe-Lauri, KPMG in Australia © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 6
  • 8. Building block 2: Responsibility and accountability      Clarify responsibility for outcomes and reporting structures Patient pathways should have identifiable owners and teams The Board should set the tone by making outcomes the key objective Internal audit monitors and works to improve governance processes Front line staff know what is most important, so measures should be developed bottom-up “ A zero tolerance for complacency is crucial… We have created an open, transparent, trusting culture, and if something goes wrong we delve into it, report on it, learn from it and share these lessons. Mary Jo Haddad, President and CEO, SickKids Hospital, Toronto “ © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 7
  • 9. Building block 3: Optimizing and standardizing processes  There is deep resistance towards standardization in healthcare  Standard operating procedures provide a foundation for clinicians to apply finer clinical analysis  Align measurement, roles and culture, and introduce standard pathways and operating procedures  Apply evidence-based, user-friendly processes, with scrutiny and double checks “ “ Guidelines are typically forgotten half of the time, so we made standardization the automatic, default way of doing things around here. Dr. Brent James, Chief Quality Officer, Intermountain Healthcare, US © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 8
  • 10. Building block 4: Measurement  Measurements must relate to patient outcomes such as prevention practices, readmissions, length-of-stay and satisfaction  Data should be fed back to the owners of clinical pathways to enable continuous improvement  Over-measurement can cause data overload  International benchmarking should raises standard  IT is vital – but lack of IT infrastructure is no excuse for lack of measurement “ “ We constantly face the issue of limited documentation, yet we work around that, and obtain data through different methods. We measure to improve, to be better than the rest. Dr. Panigrahi, Head of Medical Operations, Fortis Healthcare, India © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 9
  • 11. Towards a ‘high reliability’ organization Phase 0: Unrestrained individual autonomy of professionals Phase 1: Constrained individual autonomy Phase 2: Constrained collective autonomy (teams) Phase 3: Teams with strong situational awareness Most healthcare organizations are in stages 0 or 1 © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 10
  • 12. Part 2: System governance: assuring quality Many healthcare leaders perceive a disconnect between the internal drive for excellence and external requests for measurement and assurance, viewing the latter as unnecessary Rise in reporting has not stemmed crises Continued tension between internal and external reporting Measurements should be simpler and more relevant Reliability of reports should be verified Safety needs to be assured through certification “ Regulation is much too important to leave to the regulators “      Niall Dickson, Chief Executive and Registrar, General Medical Council, UK © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 11
  • 13. The tension between internal and external reporting  The number of required measures is expanding rapidly  Many regulatory measures are considered irrelevant, wasting time and resources  Measures are often too detailed and low-level, and do not paint a picture of the overall value of care “ “ When Boards or regulators have too limited a focus on measures, the whole dashboard may be green while the house is on fire Neil Thomas, Audit Partner, KPMG in the UK © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 12
  • 14. Making measurements simpler and more relevant  The key measures should capture overall care outcomes that matter most to patients  Hospitals should measure ‘primary endpoints,’ such as a stroke patient’s status 90 days after the onset of a stroke  Measures should be linked to internal improvement efforts  Hospitals are still trying to define and measure key outcomes “ “ Ideally, internationally standardized measures would work best...we could compare outcomes, and really bring medicine forward Ralf Kuhlen, Chief Medical Officer, Helios Kliniken, Germany © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 13
  • 15. Assuring the reliability of reports  Most publicly reported outcome data is still unreliable.  Data is often not gathered in a standardized manner, with no segregation between recording and reporting.  Unsophisticated systems used for recording and reporting.  Data may be massaged to improve scores. © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 14
  • 16. Assuring the reliability of reports According to the leaders interviewed:  Regulators need to audit reports along the same lines as financial internal/external audits  All providers must publish figures that are independently checked  Providers must balance the need for data reliability with available resources © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 15
  • 17. Assuring safety  A prime objective is avoiding catastrophic or sentinel events  Measuring and benchmarking a potentially huge number of rare and unanticipated events is difficult  Measuring care ‘bundles’ is also a challenge, due to the large number of processes  Certification is arguably the most effective way to reassure the public that care is safe Keys to creating a safe organization: 1. Measure the right processes and safety outcome measures at the right level 2. Align these measures with clear responsibilities and accountabilities for safety 3. Combine zero tolerance with an openness to learning 4. Make processes secure, and owned by staff with appropriate authority © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 16
  • 18. Conclusion: Characteristics of a high reliability healthcare system  Achieving and measuring outcomes and safety is systematic  Teams – not individuals – should be responsible for quality, with standardized processes  Internal and external measurements and reporting converge around what is best for the patient  Common international standards for care – and for auditing © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 17
  • 19. Conclusion: 10 actions towards high reliability 1 Embrace the 4 building blocks: measurement; responsibility and accountability; culture; process optimization and standardization 2 Measure outcomes that matter most to patients 3 Give individuals responsibility for clinical and financial outcomes 4 Align measurement with care pathways and lines of reporting 5 Zero tolerance to complacency 6 Adopt appropriate IT to optimize measurement and processes 7 External reporting should be simpler and cover important patient outcomes 8 Risk-adjust measurements, to enable better benchmarking 9 Provide independent assurance via internal and external audits 10 Certification is often the most appropriate way to assure safety © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 18
  • 20. How KPMG can help you Global network of 3200 healthcare professionals combined with our Healthcare Center of Excellence, working with KPMG member firm clients to:    Perform clinical governance risk assessment/gap analyses, to identify areas for improvement Design and implement systems and processes for collecting and processing information Help ensure that reports and data are subject to robust internal controls, including appropriate segregation of duties in preparation and reporting of data We help clients produce objective, quality reports that:     Contain information relevant to all stakeholders Give a true view of care quality, including unfavorable data Are based on routine-based measurement of relevant data Are externally audited, to the same standards as financial reports © 2013 KPMG International Cooperative ("KPMG International"), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. 19
  • 21. To view the full report, please visit kpmg.com/healthcare 20
  • 22. kpmg.com/socialmedia © 2013 KPMG International Cooperative (“KPMG International”), a Swiss entity. Member firms of the KPMG network of independent firms are affiliated with KPMG International. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. All rights reserved. The KPMG name, logo and “cutting through complexity” are registered trademarks or trademarks of KPMG International. The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavour to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation. The views and opinions expressed herein are those of the interviewees and do not necessarily represent the views and opinions of KPMG International or any KPMG member firm