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

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International Forum on Quality & Safety in Health Care, Barcelona 2007: Minicourse di Goran Henriks, Carlo Favaretti e Lloyd Provost su "Integrating quality and safety thinking into the whole healthcare system

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  • Review definitions…many
  • Should I put stage 0 in ? Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • Change title
  • Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • Introduce Carlo’s slides (slide 10) Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • To introduce perspective from Goran Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • Other terminologies associated with the study of systems include:   Inputs - information, materials, or other forces imported from the environment into the system.   Throughput - the transformation through interaction of the components of the system of inputs into other forms that will be returned to the environment as products, services, and by-products.   Outputs - items, information, materials, and other forces exported from the system to the environment. The organizational system is designed to create specific products and services (as defined in its purpose), but may also produce by-products such as pollution or scrap.   Feedback - information on the outputs of a system or the effects of the output on the environment that is returned to the system.    
  • Not biochemistry, anatomy, physiology, other basic sciences
  • So the point of clinical research is to generate evidence that can be used to guide clinical decisions.
  • 2
  • M14, set 1 goran henriks, carlo favaretti - lloyd provost

    1. 1. Integrating quality and safety thinking into the whole healthcare system Carlo Favaretti, Azienda Provinciale per i Servizi Sanitari, Italy Göran Henriks, J önköping County Council , Sweden Lloyd Provost, Institute for Healthcare Improvement, USA International Forum on Quality and Safety in Health Care April 20 2007 Barcelona
    2. 2. Questions we try to answer today? <ul><ul><li>How can management strength be developed by system thinking? </li></ul></ul><ul><ul><li>How can integration and coordination of improvement efforts support transformational change of a system? </li></ul></ul><ul><ul><li>How does quality and safety work depend on good integration of learning, science and practice </li></ul></ul>
    3. 3. Questions in the beginning <ul><li>What is the purpose of our existence? </li></ul><ul><li>How do you ensure that it´s the patient perspective that are in front of your development work? </li></ul>
    4. 4. Results (for the Health Care Sytem that you work in) <ul><li>Avergage per capita health expeditures </li></ul><ul><li>Hospital beds per 1,000 inhabitants </li></ul><ul><li>Employee turnover rate </li></ul><ul><li>Overall patient satisfaction score </li></ul><ul><li>Hospital (or system) mortality rate </li></ul><ul><li>Total number of infections in hospital </li></ul><ul><li>Number of patient harmed </li></ul><ul><li>Percent re-admissions </li></ul><ul><li>Average Waiting time for appointment </li></ul><ul><li>Infancy mortality rate (first year of life), </li></ul><ul><li>Mammographic screening adhesion rate, </li></ul><ul><li>Anti-influenza vaccination rate (people over 65), </li></ul><ul><li>  </li></ul>Last Quarter´s result This years target
    5. 5. System : Definitions <ul><li>“ A system is a network of interdependent components that work together to try to accomplish the aim of the system “ </li></ul><ul><li> W. Edwards Deming, The New Economics, 1993 </li></ul><ul><li>“ A system is an whole which cannot be divided into independent parts” </li></ul><ul><li> Russell Ackoff, Better management for a Changing World </li></ul><ul><li>System: an interdependent group of items, people, or processes working together toward a common purpose. </li></ul><ul><li> Associates in Process Improvement, Quality as a Business Strategy , 1987 </li></ul>
    6. 6. Deming’s view of Production as a System (1950, 1994) Stage 0: Generation of ideas Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F G
    7. 7. Deming’s view of the Organization as a System (1950, 1994) Stage 0: Generation of ideas Management Lens (leadership level) Micro-system Lens (team level) Improvement Science Lens Three Perspectives of the Health Care System Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F
    8. 8. Choice of Detail when Describing a System 5-9 Level of Detail Low High
    9. 9. System Principles <ul><li>We can think of all work as a process </li></ul><ul><li>A system is an interdependent group of items, people, and processes with a common aim </li></ul><ul><li>Every system is perfectly designed to achieve the results it achieves </li></ul><ul><li>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. </li></ul><ul><li>Improvement of a system requires change, but not every change is an improvement </li></ul>
    10. 10. Deming’s view of the Organization as a System (1950, 1994) Stage 0: Generation of ideas Management Lens Micro-system Lens Improvement Science Lens Three Perspectives of the Health Care System Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F
    11. 11. <ul><li>Do we have a quality strategy? </li></ul><ul><li>If so, what could we do to make it more likely we would execute our strategy successfully? </li></ul>
    12. 12. Deming’s view of the Organization as a System (1950, 1994) Stage 0: Generation of ideas Management Lens (leadership level) Micro-system Lens (team level) Improvement Science Lens Three Perspectives of the Health Care System Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F
    13. 13. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    14. 14. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    15. 15. <ul><li>7,400 employees (around 4,000 healthcare professionals) </li></ul><ul><li>390 general practitioners and 79 community paediatricians (indipendente contractors) </li></ul><ul><li>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) </li></ul><ul><li>Agreements with outpatients clinics, private hospitals and 52 nursing homes </li></ul><ul><li>budget 2005: 879 millions euros, in balance </li></ul>The Autonomous Province of Trento Trust’s figures
    16. 16. 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 %)
    17. 17. 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
    18. 18. <ul><li>Health promotion </li></ul><ul><li>Preventive medicine </li></ul><ul><li>Primary and hospital care </li></ul><ul><li>Rehabilitation </li></ul><ul><li>Psychiatric care </li></ul>Trust’s Mission The Autonomous Province of Trento
    19. 19. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    20. 20. Governance EFQM model APSS approach
    21. 21. 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
    22. 22. <ul><li>Integration risk assessment with the initial objective setting process </li></ul><ul><li>Developing an appropriate schem for reporting progress against objectives </li></ul><ul><li>Aligning the various governance systems so that they complement each other without overlap </li></ul><ul><li>Developing an effective assurance framework </li></ul>(The voice of NHS management: The developement of integrated governance, 2004) STEPS TO ITEGRATED GOVERNANCE
    23. 23. 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 framework based 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....
    24. 24. 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 …
    25. 25. 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
    26. 26. INNOVATION AND LEARNING ENABLERS RESULTS The EFQM Excellence Model
    27. 27. EFQM corporate self assessments
    28. 28. La gestione del Livello: ASSISTENZA COLLETTIVA La gestione del Livello: ASSISTENZA DISTRETTUALE La gestione del Livello: ASSISTENZA OSPEDALIERA Le ATTIVIT À TRASVERSALI ai Livelli di assistenza Il processo chiave: LA GESTIONE DEI LIIVELLI DI ASSISTENZA 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 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
    29. 29. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    30. 30. <ul><li>Services and care domains integration </li></ul>ENABLER IMPROVEMENT Continuous enablers improvement to develop integrated governance: 2. Aligning reporting mechanisms 1. Strategic planning 3. Budgeting process <ul><li>Managing of demand and supply </li></ul>5. Health technology assessment 7. Continuos Education and staff evaluation <ul><li>Risk management </li></ul>
    31. 31. <ul><li>Health promotion within health promoting settings </li></ul><ul><li>Continuous quality improvement </li></ul><ul><li>Coherent managerial action </li></ul>STRATEGIC DIRECTIONS: Enabler improvement - 1 STRATEGIC PLANNING
    32. 32. Key actions for the ongoing development of the plan Enabler improvement -2 STRATEGIC PLANNING <ul><li>Connecting the parts of the system </li></ul><ul><li>Analyzing needs and defining priorities </li></ul><ul><li>Promoting autonomy of the stake holders </li></ul><ul><li>Benchmarking of activities and results </li></ul>TO DEVELOP ALL PROCESSES <ul><li>Semplifing stake holders’ life </li></ul><ul><li>Favouring omogeneous behaviours </li></ul><ul><li>Decentrating decisional levels </li></ul><ul><li>Measuring organization outcomes of performed activities </li></ul>TO DEVOP TECHNICAL ADMINISTRATIVE PROCESSES <ul><li>Adopting of a comphrensive health care approach </li></ul><ul><li>Delivering health care effective, appropriate and safe services </li></ul><ul><li>Evaluating the impact of health care technologies </li></ul><ul><li>Measuring healthy outcomes of performed activities </li></ul>TO DEVELOP HEALHCARE DELIVERY PROCESSES
    33. 33. Stake holders reporting and accountability Enabler improvement - 2 REPORTING MECHANISMS <ul><li>civic audit with CittadinanzAttiva </li></ul><ul><li>local audit experiences with volunteer associations (i.e. Multidimensional Assessment Unit) </li></ul><ul><li>certifications: EFQM, ISO, OHSAS </li></ul><ul><li>professional accreditations (i.e. JCI, scientific societies) </li></ul><ul><li>“ Safe hospital” </li></ul><ul><li>campaing in collaboration with CittadinanzAttiva </li></ul><ul><li>self assessment </li></ul><ul><li>clinical audit and </li></ul><ul><li>organizational audit </li></ul><ul><li>project management office (PMO) </li></ul>VOLUNTARY MECHANISMS <ul><li>Complaint cycle </li></ul><ul><li>autonomous province of Trento general and specific objects </li></ul><ul><li>Autonomous province of Trento authorisation on health care facilities </li></ul><ul><li>Institutional accreditation of the Autonomous Province of Trento </li></ul><ul><li>Corte dei conti control controllo </li></ul><ul><li>Certification by Istituto Superiore di Sanità on public hygiene laboratory </li></ul><ul><li>audit committee </li></ul><ul><li>ordinary financial monitoring </li></ul><ul><li>administrative procedures control </li></ul><ul><li>evaluation committee </li></ul>COMPULSORY MECHANISMS SHARED CONTROL WITH CITIZIENS EXTERNAL CONTROL INTERNAL CONTROL
    34. 34. <ul><li>Activities and resources </li></ul><ul><li>Clinical and organizational processes </li></ul><ul><li>Actors: heads of department and staff, doctors, nurses and other professionals </li></ul><ul><li>Routines and innovation </li></ul>BUDGETING = YEARLY ACTIVITY PROGRAM The budget is the tool for integrating the most important processes : Enabler improvement – 3a BUDGETING PROCESS
    35. 35. ACTIVITIES to perform and available RESOURCES SECTORAL PLANS OPERATIONAL BUDGET <ul><li>Patients safety </li></ul><ul><li>Workers safety </li></ul><ul><li>Education </li></ul><ul><li>Building </li></ul><ul><li>Devices </li></ul><ul><li>Informatics </li></ul><ul><li>Human resources </li></ul><ul><li>Goods and services </li></ul><ul><li>Budget sheets: </li></ul><ul><li>APSS </li></ul><ul><li>central directorates </li></ul><ul><li>hospital and districts </li></ul><ul><li>and structural dipartments </li></ul><ul><li>operational unit and </li></ul><ul><li>services </li></ul>BALANCE SHEETS <ul><li>“ Activity plan” </li></ul><ul><li>“ Yearly and multi-years provisional balance </li></ul><ul><li>sheet” </li></ul><ul><li>“ CEO report on yearly </li></ul><ul><li>and multi-years </li></ul><ul><li>provisional balance” </li></ul>PROJECTS PORTFOLIO Main corporate projects (informatics, building, Autonomous Province of Trento objectives, riorganizations, ecc.) Enabler improvement – 3b BUDGETING PROCESS
    36. 36. <ul><li>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 </li></ul><ul><li>Incresing of supply in critical areas </li></ul><ul><li>Monitoring of booked services (centralised call center/web site booking system for outpatients services) </li></ul><ul><li>Appropriatness improvement initiatives </li></ul><ul><li>Clinical pathways in the management of some chronic and neoplastic conditions </li></ul><ul><li>Strenghtening of health care services at district level </li></ul><ul><li>Telemedicine </li></ul>Enabler improvement – 4 MANAGING OF DEMAND AND SUPPLY
    37. 37. Enabler improvement – 5 TECHNOLOGY ASSESSMENT attività elementi principali Health equipments and devices Investments plan (ambulatory care tariff nomenclator, day surgery services, home care nursing services, ….); Services (clinical pathways, guide lines implementation…); Pattern of care (projects such as six-sicc, etc) Applied research (horizon scanning, informative dipartimental systems, PACS ...) Support systems
    38. 38. <ul><li>Observatory for monitoring and prevention of healthcare civil liablity risks </li></ul><ul><li>Guidelines on information and patient informed consensus; spreading and implementation of clinical address papers (guidelines, prcedures, clinical pathways,..); </li></ul><ul><li>Trust surveys to analyse risk related to structural aspects and devices; </li></ul><ul><li>“ Trust committee on patients safety” and subsequent yearly sectoral plans; </li></ul><ul><li>strategie comuni di comportamento among all the different trust committee omitati involved by risk management activities </li></ul><ul><li>Improvement of documental system; </li></ul><ul><li>Continuous Education; </li></ul><ul><li>Organizational experimentations (es. distribuzione dei farmaci in reparto). </li></ul>Enabler improvement – 6 RISK MANAGEMENT Performed activites
    39. 39. Report on personal clinical activities and credit of CME EFQM personal assessment Annual budget results Disciplinary actions EVALUATION Leadership Policy and Strategy People Partnerships & Resources Processes consistent with EFQM enablers: Enabler improvement - 7 CONTINUOS EDUCATION AND STAFF EVALUATION CEO reappoints or moves down The EFQM assessment scheme is coherent with the professional job description framework for clinicians evaluation
    40. 40. Enabler improvement – 9 SERVICE AND CARE DOMAINS INTEGRATION <ul><li>Partnership agreement with nursing homes (providing assisted living services) </li></ul><ul><li>Shared disease management pathways among hospitals, primary care, rehabilitation centres and nursing homes </li></ul><ul><li>Agreement with local councils and subsequent activities for Integration of health and social care for targeted patients groups at community level </li></ul><ul><li>Education and health promotion intiatives involving trust preventive services, local goverment institutions, schools and no profit organizations </li></ul><ul><li>Partnership with: accredited private health providers (ambulatory services, hospitals and nursing homes) and citiziens and patients associations </li></ul><ul><li>Personalized integrated home care services </li></ul><ul><li>Broad public health and socio-cultural development projects and activities involving the trust and other local community stakeholder </li></ul>TOWARDS A BETTER INTEGRATION...
    41. 41. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    42. 42. <ul><li>performance results </li></ul><ul><li>stakeholders satisfaction </li></ul><ul><li>Integrating clinical governace: dashboard information </li></ul><ul><li>Clinical indicators and ability to drill down the information </li></ul>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)
    43. 43. Measuring results - 1a: PERFORMANCE RESULTS PHARMACEUTICAL CONSUMPTION
    44. 44. MULTIDIMENSIONAL ASSESSMENT UNIT (MAU) *since 07-01-2001 Patients evaluated during 2005 = 3.082 Measuring results – 1b: PERFORMANCE RESULTS Assessment results (2005) 141 Other (planned home care, etc) 962 Integrated home care – Integrated home care palliative care 142 Residential beds eligible patients 1.837 Nursing homes eligible patients
    45. 45. ENVIRONMENTAL WASTE/MANAGEMENT Measuring results – 1c: PERFORMANCE RESULTS Monthly hospital wastes in Kilograms Monthly hospital stay days
    46. 46. <ul><li>“ Waiting lists management should consider clinical priority indications, not only first come first served principle” </li></ul><ul><li> </li></ul><ul><li>2002 : 93.8 % agrees (quite or strongly agrees) </li></ul><ul><li>2006*: 85.4% agrees (quite or strongly agrees) </li></ul><ul><li>* Clinical priority system based on Omogeneous Waiting Groups in place everywhere since 2004 (neary 42,000 services with clinical priority delivered) </li></ul>Survey by phone interview in 2002 and 2006 (1,500 people sample): Measuring results – 2a: STAKEHOLDERS SATISFACTION
    47. 47. Measuring results – 2b STAKEHOLDERS SATISFACTION INTEGRATED SURVEYS: opinions of employees and citizens on Trust’s health services are concordant but employees believe that citizens are too critical Example: opinions on quality of Trust’s health services: 67 % 11 % 12 % unsatisfied 33 % 89 % 88 % satisfied citizen opinion as CONSIDERED by clinicians CLINICIANS CITIZENS
    48. 48. *from Claims Report 2005 District care Measuring results – 2c STAKEHOLDERS SATISFACTION Hospital care public health care 1,115 1,161 1,306 1,441 1,243 WRITTEN CLAIMS COLLECTED 2005 2004 2003 2002 2001 CLAIMS
    49. 49. STAFF SATISFACTION Measuring results – 2d STAKEHOLDERS SATISFACTION ↑↑ improvement ↑↑ satisfied ↓↓ deeply unsatisfied trend: 2003 (150 questionnaires ) 2004 (250 questionnaires) 2005 (600 questionnaires) surveys: <ul><li>Physicians leaders </li></ul><ul><li>Nursing leaders </li></ul><ul><li>“ Quality network” </li></ul>people:
    50. 50. OMOGENEOUS WAITING GROUPS VISITS: sampling audit on 1,360 service prescriptions (2005) X-Ray and others imaging exams X-Ray Ultrasonography CT Scan MRI 72 % 61 % 40 % 23 % 28 % 39 % 77 % 60 % Measuring results – 3a INTEGRATION CLINICAL GOVERNANCE: DASHBOARD INFORMATION
    51. 51. ASSISTENZA OSPEDALIERA: International Quality Indicatori Project (IQIP) <ul><li>Each ward or health care delivery unit has chosen at least one clinical indicator used also for the budgeting process </li></ul>* Il grafico mostra l’andamento del tempo che i pazienti trascorrono in pronto soccorso per le procedure assistenziali (IQIP indicators) Measuring results – 3b INTEGRATION CLINICAL GOVERNANCE: DASHBOARD INFORMATION CLINICAL INDICATORS
    52. 52. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    53. 53. <ul><li>The context </li></ul><ul><li>The EFQM Excellence Model </li></ul><ul><li>Enabler improvement </li></ul><ul><li>Measuring results </li></ul><ul><li>Innovation and learning </li></ul>Overview:
    54. 54. <ul><li>COMMITMENT </li></ul><ul><li>COHERENCE </li></ul><ul><li>CONCRETENESS </li></ul><ul><li>PATIENCE </li></ul>INNOVATION AND LEARNING Four words seem to describe the present status of the Trust development:
    55. 55. <ul><li>Innovation management approach based on health technology assessment </li></ul><ul><li>Continuos needs assessment, communication and information flow inside the organization linking clinical and administrative areas in the decision making process </li></ul><ul><li>Strong committment of the trust to create and promote learning opportunities for the staff </li></ul><ul><li>Project Management techniques for breakthrough and short term hard technology innovation </li></ul><ul><li>Central guidance, committees, working groups and educational activites to manage long term organizational innovation and service delivery </li></ul><ul><li>Clear and immediate work linkage with the local government </li></ul><ul><li>Partnership with university research institutes and private companies to devolop hard and “soft” (organizational) technologies </li></ul><ul><li>Incentive and rewarding systems in place linked to performance </li></ul>Were underpinned by the following issues: INNOVATION AND LEARNING
    56. 56. INNOVATION AND LEARNING ENABLERS RESULTS INNOVATION AND LEARNING
    57. 57. <ul><li>Improve the alignment fo clinical and corporate governance in the development of the organization bringing closer links with the performance agenda. </li></ul><ul><li>Strenghten the way in which patients, staff and the public are involved in the planning and delivery of quality services </li></ul><ul><li>Further spread evidence based practice and minimise the risks associated with the delivery of care </li></ul><ul><li>Further develop information systems to support the audit and analysis of clinical outcomes and care </li></ul>Next steps are to: INNOVATION AND LEARNING
    58. 58. Deming’s view of the Organization as a System (1950, 1994) Stage 0: Generation of ideas Management Lens Micro-system Lens (team level) Improvement Science Lens Three Perspectives of the Health Care System Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F
    59. 59. 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
    60. 60. Sweden Jönköping Europe
    61. 61. S u m i n d e x D i f f i SEK 1 7 5 1 5 0 1 2 5 1 0 0 7 5 5 0 2 0 0 0 1 5 0 0 1 0 0 0 5 0 0 0 - 5 0 0 - 1 0 0 0 0 S c a t t e r p l o t o f D i f f in SEK v s S u m i n d e x
    62. 62. S u m i n d e x D i f f i SEK 1 7 5 1 5 0 1 2 5 1 0 0 7 5 5 0 2 0 0 0 1 5 0 0 1 0 0 0 5 0 0 0 - 5 0 0 - 1 0 0 0 0 V ä s t e r b o t t e n N o r r b o t t e n V ä s t r a G ö t a l a n d H a l l a n d S k å n e Ö s t e r g ö t l a n d G o t l a n d J ö n k ö p i n g K r o n o b e r g B l e k i n g e G ä v l e b o r g V ä s t e r n o r r l a n d D a l a r n a K a l m a r J ä m t l a n d V ä r m l a n d Ö r e b r o V ä s t m a n l a n d U p p s a l a S ö r m l a n d S t o c k h o l m S c a t t e r p l o t o f D i f f in SEK v s S um i n d e x
    63. 63. What knowledge can healthcare integrate from other high performing industries?
    64. 64. Här ska du sedan skriva in din rubrik...
    65. 67. General Competencies for all employees 8 000 training programs <ul><li>Patient care </li></ul><ul><li>Medical knowledge </li></ul><ul><li>Practice based learning and improvement </li></ul><ul><li>Professionalism </li></ul><ul><li>Interpersonal communication Skills </li></ul><ul><li>System based practice </li></ul>ACGME Re-examination is done based on above competencies
    66. 68. <ul><li>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 </li></ul><ul><ul><ul><ul><ul><li>Paul Batalden </li></ul></ul></ul></ul></ul>
    67. 69. Better patient (population) outcome Better system performance Better professional development Creating a sustainable situation for the continual improvement of health care Source:Batalden,Henriks Everyone
    68. 70. Important concepts <ul><li>Design </li></ul><ul><li>Processanalyze </li></ul><ul><li>Primary and secondary drivers </li></ul><ul><li>PDSA </li></ul><ul><li>Benchmarking </li></ul><ul><li>5p:s </li></ul><ul><li>Creativity </li></ul><ul><li>Communication </li></ul>Appreciation of a System Theory of Knowledge Psychology Understanding Variation Source: Deming
    69. 71. Raise high barrier breaking goals Strong support To local improvement Develop the person behind Professional role Spread and develop sustainability Develop leaders for systemic projects Develop leadership For the microsystems Execution Lessons from P2 G Henriks Ref: Henriks, Nolan Information & Information Technology Staff <ul><li>Patients </li></ul><ul><li>Performance </li></ul><ul><li>Leadership </li></ul>
    70. 72. Frontline Nursing Units Nursing Divisions Nursing Services Example System Levels Source: Henriks, Bojestig, Jonkoping CC Sweden Mesosystem Microsystem Macrosystem
    71. 73. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    72. 74. Purpose
    73. 75. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    74. 76. Riket 23 % 2002 Amount of 19 year old persons without any kaires at all
    75. 77. Jönköping’s newspaper11/9, 2006
    76. 80. Hospital Mortality in Jönköping County Council 2002 – 2005 Percentage of Care occasions
    77. 81. <ul><li>Monthly report of system measures </li></ul>Early warning system Adversed Drug Events, ADE Patient Satisfaction Mortality at hospitals, over age 65 Access Cost per inhabitant Cost per care event System Measures
    78. 82. <ul><li>How do we define our gaps? </li></ul>
    79. 83. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    80. 84. <ul><li>A Gap between optimal treatment of cardiac infarction according to guidelines and what is really performed in the clinical activity </li></ul><ul><li>Big variation between hospitals </li></ul><ul><li>The hospital´s treatment traditions have a tendency to be stable over time </li></ul><ul><li>Evidence based methods for quality development is needed </li></ul><ul><li>Big variation within hospitals </li></ul>Guidelines Routine care ACE-inhibitor (%) at discharge after AMI Control Chart: Coronary angiography 1999 Sigma level: 2 12 11 10 9 8 7 6 5 4 3 2 1 ,8 ,6 ,4 ,2 0,0 Coronar angiography UCL Center = ,29 LCL
    81. 85. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    82. 86. Searching for Improvement ideas - Brainstorming - Litterateur searching - Site visits - Learning from other teams
    83. 88. Entry, Assignment Orientation Initial Work-up, Plan for care Disenrollment 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 Ref:Gene Nelson Biological Functional Expectations Costs Biological Functional Satisfaction Costs Acute care Chronic care Preventive care Palliative care
    84. 89. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    85. 90. Variation <ul><li>. </li></ul>Outnyttjad kapacitet kan inte sparas Ref: Strindhall, Henriks Murray tid Efter- frågan Kapacitet “ Ryggsäck”
    86. 91. <ul><li>How do we identify waste and links </li></ul><ul><ul><li>that do not work? </li></ul></ul>
    87. 92. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    88. 93. <ul><li>Planning </li></ul><ul><li>Strategic </li></ul><ul><li>Objectives </li></ul><ul><li>Improvement </li></ul><ul><li>Efforts </li></ul><ul><li>Resources </li></ul>
    89. 95. Number of Falls reported at Kristinedal nursery home (ward 3 and 4) <ul><li>Education for assistant nurses and nurses </li></ul><ul><li>Risk analysis of falling for all patients in the unit </li></ul><ul><li>Meetings in the Team planning individual steps for each risk patient </li></ul><ul><li>Systematic drug survey for all risk patients to prevent falling </li></ul><ul><li>Information to patients/ relatives around risks for falling </li></ul><ul><li>Clear of indoors environment </li></ul><ul><li>Continuous measuring </li></ul><ul><li>Notice board </li></ul><ul><li>Purchase of technical facilities </li></ul>Changes done: Business Case: Fall prevention One broken hip: Cost for health care: 10 – 12 000 dollars Cost in all for the society: 35 000 dollars
    90. 96. Now New Pat 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 Yes No ALL patients are assessed 572 000 dollars 8 % of patients has a risk acc. to assess-ment 572 000 dollars Total cost 7.6 million dollars Total cost 5 million dollars Business Case: Pressure Ulcer Patient 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
    91. 97. Primary Care Speciality Care Access Diagnosis, treatment and Decision Support Support Self Management Delivery system design Define 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 & Security Clinical 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
    92. 98. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    93. 99. Dashboard Dep. of medicine, Värnamo hospital Forest and Garden, Huskvarna AB
    94. 100. <ul><li>How do we integrate improvement work as an everyday work? </li></ul>
    95. 101. Simple rules <ul><li>We protect the patients and ourselves </li></ul><ul><li>It is the system’s result that counts </li></ul><ul><li>We share the results from our development and improvement work with others </li></ul><ul><li>Health care emanates from the patient’s value, need and whishes </li></ul><ul><li>Either solve the problem or take responsibility for the handing over to next step </li></ul><ul><li>Feedback to the step before </li></ul><ul><li>Work with guidelines </li></ul>Ref: The County Council of Jönköping, 2002 Bojestig, Henriks
    96. 102. The system for care Lean Consumption User friendly and oriented 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
    97. 103. Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger
    98. 104. Deming’s view of the Organization as a System (1950, 1994) Stage 0: Generation of ideas Management Lens Micro-system Lens Improvement Science Lens Three Perspectives of the Health Care System Design and Redesign Consumer research Suppliers of Raw Materials Receipt and test of Materials Consumers Distribution Test of processes, machines, methods, costs Production, assembly, finishing, inspection A B C D E F
    99. 105. Improvement of Healthcare <ul><li>Improvement of health care systems requires learning: </li></ul><ul><ul><li>Learning from research </li></ul></ul><ul><ul><li>Learning from quality improvement </li></ul></ul><ul><ul><li>Learning from daily management and practice </li></ul></ul><ul><li>Effective integration of these learning opportunities can accelerate the rate of improvement </li></ul>
    100. 106. Workshop <ul><li>Work in small groups </li></ul><ul><li>Discuss a recent improvement in health care in one of your organizations. </li></ul><ul><li>Where did the knowledge to make this improvement come from? </li></ul><ul><ul><li>Clinical research </li></ul></ul><ul><ul><li>Quality improvement </li></ul></ul><ul><ul><li>Clinical practice </li></ul></ul><ul><li>Discuss additional examples of improvements as time permits. </li></ul>
    101. 107. Evaluating Quality of Evidence <ul><li>I. At least one systematic review of multiple well-designed Randomized Control Trials (RCT). </li></ul><ul><li>II. At least one properly designed RCT of appropriate size </li></ul><ul><li>III. Well-designed trials without randomization (single group, time series or matched case-control studies) </li></ul><ul><li>IV. Well-designed non-experimental, based on clinical evidence, descriptive studies or reports of expert committees </li></ul><ul><li>V. Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees </li></ul>Source: Sackett DL. Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone 1997
    102. 108. <ul><li>Dr. W. Edwards Deming stressed the importance of studying four areas to become more effective in leading improvement: </li></ul><ul><ul><li>Appreciation of a system </li></ul></ul><ul><ul><li>Understanding variation </li></ul></ul><ul><ul><li>Theory of knowledge </li></ul></ul><ul><ul><li>Psychology </li></ul></ul><ul><li>Deming called the interplay of these </li></ul><ul><li>four areas “Profound Knowledge” </li></ul>The Science of Improvement Source : Improvement Guide , Introduction, p xxiv-xxvi
    103. 109. Clinical Research <ul><li>Study of a drug, biologic, or device in human subjects </li></ul><ul><li>Encompasses </li></ul><ul><ul><li>translational research (study of laboratory findings in humans) </li></ul></ul><ul><ul><li>clinical trials of preventive and therapeutic strategies </li></ul></ul><ul><ul><li>epidemiology, behavioral research, and health services and outcomes research. </li></ul></ul><ul><li>Results in treatments (and drugs) that directly improve health care. </li></ul>Harold Varmus, MD www.najbr.org/public/research_definitions
    104. 110. Campbell et at BMJ 2000;321:694–6 Clinical Research
    105. 111. Characteristics of Clinical Research <ul><li>Focus is new knowledge </li></ul><ul><li>Emphasis on linear cause-effect relationships </li></ul><ul><li>Each study is a single learning cycle </li></ul><ul><li>Attention to control of bias to sharpen comparison </li></ul><ul><ul><li>Selection </li></ul></ul><ul><ul><li>Confounding </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Chance </li></ul></ul><ul><li>Methods to ensure uniform application of study design across study participants </li></ul><ul><li>Goal is generalizability; principles or theory that goes beyond specific settings and patients </li></ul>
    106. 112. 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
    107. 113. Characteristics of Health Care QI <ul><ul><li>Contextual factors (background variables or confounders in research) are a major focus </li></ul></ul><ul><ul><li>The initial intervention (changes to the system) are adapted and modified as study progresses </li></ul></ul><ul><ul><li>Measuring over time (improvement is temporal) </li></ul></ul><ul><ul><li>Graphical analysis and presentation (SPC) </li></ul></ul><ul><ul><li>Involvement of local expertise in conducting project </li></ul></ul><ul><ul><li>Multiple experimental cycles for quick feedback and learning </li></ul></ul><ul><ul><li>Multi-factor experiments to learn from complex systems with non-linear and dynamic cause and effect relationships </li></ul></ul><ul><ul><li>Building reliability of the interventions can be a major part of the effort </li></ul></ul><ul><ul><li>Sustainability is a consideration from the beginning of the project </li></ul></ul><ul><ul><li>Design and execution led by the “Science of Improvement” </li></ul></ul>
    108. 114. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Source: Improvement Guide , p 10 Framework, or Roadmap, for Quality Improvement Projects <ul><li>Other Frameworks </li></ul><ul><li>Exist: </li></ul><ul><li>DMAIC (from 6 Sigma) </li></ul><ul><li>Focus PDCA </li></ul><ul><li>7-step Problem Solving </li></ul><ul><li>QI Story </li></ul>PDSA – The Continuous Scientific Method Act Plan Study Do
    109. 115. Repeated Use of the PDSA Cycle Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change A P S D A P S D A P S D D S P A What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement
    110. 116. Evaluating Progress in QI Projects: Annotated Time Series
    111. 117. Some Challenges in Quality Improvement Projects <ul><li>Description of the system is imprecise </li></ul><ul><li>The need to serve as both advocate and investigator </li></ul><ul><li>The use of external resources can hamper the ability to sustain the improvement </li></ul><ul><li>Building new knowledge is insufficient </li></ul><ul><li>Replication is difficult </li></ul><ul><li>Publishing QI studies </li></ul>Nolan and Nolan Chapter 13, http://symptomresearch.nih.gov
    112. 118. Improvement vs. Research Contrast of Complementary Methods <ul><li>Improvement </li></ul><ul><li>Aim: Improve practice of health care </li></ul><ul><li>Methods: </li></ul><ul><li>Test observable </li></ul><ul><li>Stable bias </li></ul><ul><li>Just enough data </li></ul><ul><li>Adaptation of the changes </li></ul><ul><li>Many sequential tests </li></ul><ul><li>Assess by degree of belief </li></ul><ul><li>Clinical Research </li></ul><ul><li>Aim: Create New clinical knowledge </li></ul><ul><li>Methods: </li></ul><ul><li>Test blinded </li></ul><ul><li>Eliminate bias (e.g. case mix) </li></ul><ul><li>Just in case data </li></ul><ul><li>Fixed hypotheses </li></ul><ul><li>One fixed test </li></ul><ul><li>Assess by statistical significance </li></ul>
    113. 119. Clinical Practice vs. Research and Quality Improvement <ul><li>Clinical practice is designed to take care of a specific patient's medical needs </li></ul><ul><li>Clinical practice includes adaptation and innovation. </li></ul><ul><li>Clinical practice provides a daily opportunity for learning that can lead to improvement </li></ul>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
    114. 120. Improvement in Daily Practice <ul><li>Ongoing patient feedback systems </li></ul><ul><li>Daily and weekly performance measurement </li></ul><ul><li>Work toward standardization </li></ul><ul><li>Daily huddles to optimize communication </li></ul><ul><li>Use of QI tools with individual patients (control charts, experimental design) </li></ul><ul><li>Formal learning from special causes </li></ul><ul><li>Daily PDSA’s </li></ul><ul><li>Philosophy of “stopping the line” and addressing problems as they occur </li></ul>
    115. 121. Control Chart for Osteoporosis Patient
    116. 122. Patient with Insomnia: Experimental Variables Jesper Olsson, et al, Quality Management in Health Care Volume 14, Issue 4, Oct-Dec, 2005 Measure Response Variables Get up within 1 hr. of waking up Stay in bed until 6am Rise Time Before 10pm After 11pm Bedtime 20 min exercise before bed None Yoga None after 8pm Yes after 9pm Food & Drink High Level Low Level Factors Visual Analog Scale (0-10) 0–Totally worthless, 10–Couldn’t have been better Quality of Sleep Time woke up – time laid down (luminous clock) Length of Sleep
    117. 123. Integrating Learning from Research, Improvement, and Practice Continuous, enduring improvement in care Pragmatic Science Rigorous research and evaluation Local learning and improvement Improvement in Daily Work
    118. 124. Workshop <ul><li>Medication Errors are a common safety problem in today’s health care system. </li></ul><ul><li>Discuss in your group how the three learning approaches can be leveraged to solve this problem: </li></ul><ul><ul><li>Clinical research </li></ul></ul><ul><ul><li>Quality improvement </li></ul></ul><ul><ul><li>Clinical practice </li></ul></ul>
    119. 125. 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
    120. 126. 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
    121. 127. Methods for learning <ul><li>Clinical research methods and quality improvement methods are different ways to apply the scientific method </li></ul><ul><ul><li>Good research involves elements of QI </li></ul></ul><ul><ul><li>Good QI involves attention to research methods </li></ul></ul><ul><li>Ongoing improvement is also an important component of clinical practice </li></ul><ul><li>More careful integration of these approaches will accelerate improvements in health care </li></ul>

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