This document discusses redesigning clinical processes using quality improvement principles. It argues that relying solely on clinical judgement leads to inappropriate and variable care. Quality improvement uses evidence-based protocols and process management techniques to standardize care delivery while still allowing flexibility for individual patients. This approach aims to eliminate waste and improve outcomes by reducing unwarranted variation. The document provides examples of analyzing variation in length of stay and comorbidities for heart failure patients to identify opportunities for process improvement.

1. CLINICAL REDESIGN
Looking back to see the future

2. ▪What is redesign all about?
▪Why do it?
▪What has it got to offer?

5. A FUNDAMENTAL ASSUMPTION OF
MEDICAL DECISION MAKING
▪ “Our minds are interpreters of evidence. We can accurately
convert all forms of evidence into conclusions, which in turns
determines our actions”
▪ “Therefore, no one has to tell us what to do. Just give us the
evidence and we will work it out. Besides there are lots of other
factors to be considered. That can only be done with clinical
judgement.”
▪ Dr David Eddy

6. LEAVE CLINICIANS TO SORT IT OUT?

7. THE FUNDAMENTAL ASSUMPTION IS WRONG
Poor evidence for most practices
The inherent complexity of modern medicine , versus the limitations
of the human mind
Lead to
High variations in beliefs
Well documented, massive variations in practices
High rate of inappropriate care
Unacceptable rates of preventable patient injury
Wasted resources on a large scale
Dr David Eddy

8. PROCESS MANAGEMENT DESIGNS
Do they work for medicine?

9. SCIENTIFIC MANAGEMENT
Developed by Frederick Taylor Approx 1911
Defined mass production
Based on the idea of process, management led design
uneducated workers, cogs in a machine
Very successful

10. TAYLORISM CONTINUED
Hardly a competent workman can be found who does not devote a considerable
part of time to studying just how slow he can work and still convince his employer
that he is going at a good pace…Under our system a worker is told just what to do
and how he is to do it
It is only through the enforced standardisation of methods, enforced adoption of
best implements and working conditions, and enforced cooperation that this faster
work can be assured. The duty of enforcing the adoption of standards and of
enforcing this cooperation rests with management alone. Any of those who after
proper teaching can not or will not work in accordance with the new methods
must be discharged by management
Frederick Taylor The Principles of Scientific Management 1911

11. SCIENTIFIC MANAGEMENT
Scientific Management fails in the face of
Complexity

12. THE CRAFT OF MEDICINE
An individual doctor
placing patients health needs above any other goal,
drawing on extensive clinical knowledge gained
through formal education and experience
Can
Craft
A unique diagnostic and treatment plan customized
for an individual patient

13. THE CRAFT OF ADMINISTRATION
Under the craft of medicine the role of the
organisation is to create an environment within
which individual, independent medical
professionals can interact with their patients
without undue distractions that could harm care
So we see the development of business solutions to
solve business problems and financial measures to
manage facilities

14. OPPOSING IDEALS
Administrative management versus clinical management

15. QUALITY IMPROVEMENT AND PROCESS
MANAGEMENT
1911
Frederick Taylor
1931
Walter Shewhart
Economic Control of
Manufactured Product
1939
Statistical Method from the
Viewpoint of Quality Control
1951
W. Edwards Deming Elementary Principles of the
Statistical Control of Quality

16. W.EDWARDS DEMING
Organize everything around value added (front line) work
processes
Quality Improvement is the science of process management

17. SHEWHART/DEMING PDSA CYCLE

18. Taylor Top Down
Deming Bottom Up
Hardly a competent
worker can be found
Almost all failures come
from underlying
processes
Empower
Learning
Teams (fundamental
knowledge)
Integrated Tools built into
workflow
Critize/Control
Judgement playing God
Heroic Individuals
Unfunded mandates
assumes unlimited time
and attention
Motivate incentivize
(payment)
Make it easy to do right

19. QUALITY IMPROVEMENT AND PROCESS
MANAGEMENT
1911
Frederick Taylor
1931
Walter Shewhart
Economic Control of
Manufactured Product
1939
Statistical Method from the
Viewpoint of Quality Control
1951
W. Edwards Deming Elementary Principles of the
Statistical Control of Quality
1990
Womack Jim
The Machine that changed the
World (Lean)

20. LEAN OR PULL THROUGH PRODUCTION
Standardisation processes with
Smart cogs that
Adapt to individual needs
Mass customisation
Efficient processes that can deal with complexity

21. PROTOCOLS CAN IMPROVE CARE
Shared baselines (lean production)
A multidisciplinary team of health care professionals
• Select a high priority care process
• Generate an evidence based “best practice” guideline
• Blend the guideline into the flow of clinical work
• Staffing
• Training
• Supplies
• Physical building
• Education
• Measurement

22. PROTOCOLS CONTINUED
Use guidelines as a shared baseline with clinicians
free to vary based on individual patient needs
Measure and learn from and (over time) eliminate
variation from professionals; retain variation arising
from patients

23. PRACTICAL LIMITATIONS ON PROTOCOL
USE
When abstract guidelines hit real patient care,
experience clearly shows
No protocol fits every patient
More importantly
No protocol perfectly fits any patient

24. HEALTHCARE IS CHANGING
From
Craft Based Practice
• Individuals, working alone,
• Handcrafting a customized solution for each patient
• Based on a vast personal knowledge gained from training and experience
To
Professional based practice
• Groups of peers, treating similar patients in a shared setting
• Plan coordinated care delivery processes
• Which are adaptable to specific patient needs

25. WHAT ARE THE BENEFITS?
1.It produces better outcomes for our patients
2.It eliminates waste, reduces costs and increases available
resources for patient care
3.It puts healthcare professionals in control of care delivery
4.It is the foundations for useful electronic data collection

26. WE ARE ALL READY DOING THIS AREN’T WE
Insufficient evidence for most treatment choices
Expert opinion is essentially random
Practice guidelines don’t change practice
Most guidelines lack sufficient evidence to actually guide
practice
Most guidelines have no validation data

27. IMPROVING QUALITY
Eliminate inappropriate variation
(process steps)
Document continuous improvement
(outcomes)

28. An example of how we are examining variation as part of process redesign
Distribution of LOS - DRG F62
F62A
F62B
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44
LOS (days)
MIN
MAX RANGE
MEDIAN MEAN
CASES
OUTLIERS
DAYS
OVERSTAYED
F62A
1
44
43 days
6
8.7
128
8
263
F62B
1
40
39 days
3
3.7
227
7
145

29. Heart Failure
50%
75%
75%
60
25%
Distribution of days of stay - F62B
25% 50%
Frequency
0
0
5
20
10
Frequency
40
15
20
Distribution of days of stay - F62A
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46
0
los
•
•
•
•
25% of patients stay between 1-3 days.
25% of patients stay between 3-6 days
25% of patients stay between 6-11 days
25% of patients stay between 11-44 days
2
4
6
8
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
LOS (days)
•
•
•
•
25% of patients stay between 3-5 days
25% of patients stay between 5-40 days
25% of patients stay 1 day.
25% of patients stay between 1-3 days

30. Heart Failure
First
Second
Third
Fourth
Total
32
32
32
32
128
58 (5.2%)
131 (11.8%)
256 (23.1%)
664 (59.9%)
1109
80.0
80.2
76.1
79.4
78.9
46.9%
59.4%
50.0%
59.4%
53.9%
1-3
3-6
6-11
11-44
1-44
One
22
22
24
22
90 (70.3%)
Two
9
8
7
8
32 (25%)
Three
1
2
1
2
6 (4.7%)
Total Separations
Total Bed Days
Mean Age
Male %
Variation in LOS
Admissions
in 12 months
25% of patients accounted for 59.9% of bed days. If all 32 of the cases in the fourth quartile could
be reduced to 11 days stay (the maximum of the third quartile – effectively making 11 days the
maximum LOS for DRG F62A) a total of 312 bed days could be saved within this DRG^.
Multiple admissions for same patients during the 2012/13 period:
• 70.3% = single admission
• 25.0% = two admissions
• 4.7% = three admissions
The number of prior admissions remained equal within all quartiles, meaning there is no association
between multiple admissions and longer LOS. ^(Current 664 days minus (32 cases * 11 days = 352 days) = 312 bed days saved)

31. Heart Failure
First
Comorbidities
Third
Fourth
Total
32
Total Separations
Second
32
32
32
128
32 (100%)
32 (100%)
32 (100%)
32 (100%)
128 (100%)
Heart
30 (93.8%)
32 (100%)
32 (100%)
32 (100%)
126 (98.4%)
Hypertension
16 (50%)
17 (53.1%)
8 (25.0%)
10 (31.3%)
51 (39.8%)
Diabetes Type 1
-
1 (3.1%)
-
-
1 (0.8%)
Diabetes Type 2
14 (43.8%)
21 (65.6%)
18 (56.3%)
14 (43.8%)
67 (52.3%)
Renal
2 (14.3%)
9 (42.9%)
9 (50.0%)
5 (35.7%)
25 (37.3%)
Diabetic Neuropathy
7 (50.0%)
9 (42.9%)
14 (77.8%)
7 (50.0%)
37 (55.2%)
Ophthalmology
1 (7.1%)
7 (33.3%)
2 (11.1%)
4 (28.6%)
14 (20.9%)
Diabetic Ulcers
-
-
4 (22.2%)
1 (7.1%)
5 (7.5%)
Diabetic Hypoglycaemia
3 (21.4%)
2 (9.5%)
3 (16.7%)
-
8 (11.9%)
Lactic Acidosis
-
-
1 (5.6%)
-
1 (1.5%)
Peripheral Angiopathy
2 (14.3%)
2 (9.5%)
3 (16.7%)
1 (7.1%)
8 (11.9%)
Multiple micro-vascular complications
-
4 (19.0%)
9 (50.0%)
4 (28.6%)
17 (25.4%)
Other Diabetic Complications
1 (7.1%)
2 (9.5%)
4 (22.2%)
7 (50.0%)
14 (20.9%)
The number of co-morbidities did not change significantly between quartiles for F62A, with all patients
experiencing at least one co-morbidity.

32. T a il a n a ly s is
. . . a s s u m e s th a t, if s e r io u s fa ilu r e s a r e
in s p e c te d a n d e lim in a te d , w h a t r e m a in s
is s o m e h o w e x c e lle n t . . .

33. r
a
F o c u s o n th e T a il
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b e tte r
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w o rs e
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`a c c e p ta b le ' q u a lity
`u n a c c e p ta b le ' q u a lity

34. T r a d itio n a l Q u a lity A s s u r a n c e
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35. Q u a lity Im p r o v e m e n t
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A f
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36. Better has no Limits

37. Questions