health care management and epidemiology or epidemiolgy …objectives of the session by the end of...

PROFESSIONAL PRACTICE PROFESSIONAL PRACTICE PARADIGMS IN PARADIGMS IN

EPIDEMIOLGY & EPIDEMIOLGY & QUALITY PERFORMANCE QUALITY PERFORMANCE

IN HEALTH CAREIN HEALTH CARE

Haroutune K. ArmenianHaroutune K. Armenian

OBJECTIVES OF THE SESSIONOBJECTIVES OF THE SESSION

By the end of this session you should be able to:By the end of this session you should be able to:

1. Explain what is a profession and discuss 1. Explain what is a profession and discuss whether epidemiology is a professionwhether epidemiology is a profession

2. Explain why Epidemiology can be used to 2. Explain why Epidemiology can be used to improve management in health care?improve management in health care?

3. Give examples of how Epidemiology can be 3. Give examples of how Epidemiology can be used for effective management.used for effective management.

ProfessionProfession

WebsterWebster: : ““ A A callingcalling requiring requiring specialized specialized knowledgeknowledge and often long and intensive and often long and intensive academic preparationacademic preparation””..

John RacyJohn Racy: : ““ A A socially sanctionedsocially sanctioned activity activity whose primary object is the whose primary object is the wellwell--being of being of othersothers above the above the professionalprofessional’’s personal s personal gaingain””. .

Key wordsKey words

CallingCallingSpecialized knowledgeSpecialized knowledgeAcademic preparationAcademic preparationSocially sanctionedSocially sanctionedWellWell--being of othersbeing of others> (above) personal gain> (above) personal gain

ProfessionProfessionMore than a jobMore than a job an identityan identity

Examples:Examples:PhysiciansPhysicians DentistsDentistsPharmacistsPharmacists NursesNursesEngineersEngineers etc.etc.

Public Health As a ProfessionPublic Health As a ProfessionAll of the aboveAll of the above+ mission+ mission-- Identity Identity –– lacks (organization)lacks (organization)

Public Health as a ProfessionPublic Health as a ProfessionResources for Professional Resources for Professional

PracticePracticePeoplePeopleInformationInformationGoodsGoods

Activities in Professional PracticeActivities in Professional PracticeGenerateGenerateProcessProcess ResourcesResourcesDistributeDistribute

Professional PracticeProfessional Practice

People Information Goods

Generate

Process

Distribute

Invariables in Public HealthInvariables in Public Health

Interdisciplinary Interdisciplinary (Renaissance man)(Renaissance man)

Force of change Force of change (Agent of change)(Agent of change)

Rewards are long termRewards are long term(Long incubation)(Long incubation)

Primary social concernPrimary social concern(Part of social fabric)(Part of social fabric)

(continued)(continued)

Invariables in Public HealthInvariables in Public HealthScientific baseScientific base

(Rational decision)(Rational decision)Institutional practiceInstitutional practice

(Organizational)(Organizational)Personal characteristicsPersonal characteristics

Team playerTeam playerHumilityHumilityPerseverance Perseverance IntegrityIntegrity

Continuums of Public HealthContinuums of Public Health

Bureaucracy Bureaucracy -- ActivismActivismScientificScientific -- Social RolesSocial RolesAtomistic Atomistic -- EcologicalEcologicalShort RangeShort Range -- Long RangeLong RangeNarrow Narrow -- MultifocalMultifocalDisciplinaryDisciplinary IntegrativeIntegrativeCategoricalCategorical -- ComprehensiveComprehensive

PARADIGMSPARADIGMS OF OF PUBLIC HEALTHPUBLIC HEALTH

Why Paradigms in Education?Why Paradigms in Education?

Professional vs. liberal arts and research Professional vs. liberal arts and research based models of educationbased models of educationNot just the ability to perform tasks but a Not just the ability to perform tasks but a professional who is investigating professional who is investigating problems, solving them, and developing problems, solving them, and developing programs that address the needs of the programs that address the needs of the public. Such a professional needs some public. Such a professional needs some models to work with.models to work with.

A Paradigm isA Paradigm is

ExampleExampleModelModelPatternPatternStandardStandardArchetypeArchetypeExemplarExemplarPrototypePrototype

Examples of Paradigms in Examples of Paradigms in Public HealthPublic Health

Problem SolvingProblem Solving––An overarching An overarching paradigmparadigmProblem investigationProblem investigation--Several modelsSeveral models

EpidemiologicEpidemiologicSystems AnalysisSystems AnalysisBiologicalBiological--environmental etc.environmental etc.

Project and Program DevelopmentProject and Program DevelopmentEvaluation and AssessmentEvaluation and Assessment

Competency Based Educational Competency Based Educational PlanningPlanning

CompetencyCompetency: The ability to : The ability to perform an integrative task.perform an integrative task.

Competency 1Competency 2Competency 3Competency 4Competency 5Competency 6

Skills

Knowledge

Attitude

CompetencyTasks/Performance

Competency 7

PARADIGM = MODEL (THEORY)

PARADIGM = METHOD (THEORY)

1, 2, 3…

1, 2, 3…

1, 2, 3…

PARADIGMS OF PUBLIC HEALTHPARADIGMS OF PUBLIC HEALTH

Problem solving paradigmProblem solving paradigm1.1. Problem DefinitionProblem Definition2.2. Measurement IssuesMeasurement Issues3.3. Assessment of Risks {Biologic, Behavioral, Assessment of Risks {Biologic, Behavioral,

Environmental factors}Environmental factors}4.4. Prevention/Intervention StrategiesPrevention/Intervention Strategies5.5. Ascertainment of resources {Policy & Priority Ascertainment of resources {Policy & Priority

Setting, Weighing competing alternatives}Setting, Weighing competing alternatives}6.6. Implementation/EvaluationImplementation/Evaluation


Program DevelopmentProgram Development

PlanningPlanningProgrammingProgrammingImplementingImplementingMonitoringMonitoringEvaluatingEvaluating


Systems Analysis ParadigmSystems Analysis Paradigm

1.1. StructureStructure2.2. ProcessProcess3.3. Outcome {Outputs}Outcome {Outputs}

Marco Polo describes a bridge, stone by stone.Marco Polo describes a bridge, stone by stone. ““But which is the stone that supports the But which is the stone that supports the

bridge?bridge?”” Kubai Khan asks.Kubai Khan asks. ““The bridge is not supported by one stone The bridge is not supported by one stone

or another,or another,”” Marco answers, Marco answers, ““but by the line of but by the line of the arch that they formthe arch that they form””..

Kubai Khan remains silent, reflecting. Kubai Khan remains silent, reflecting. Then he adds: Then he adds: ““Why do you speak to me of the Why do you speak to me of the stones? It is only the arch that matters to mestones? It is only the arch that matters to me””..

Polo answers: Polo answers: ““Without stones there is no Without stones there is no archarch””..

Invisible Cities by Italo CalvinoInvisible Cities by Italo Calvino

Epidemiological ParadigmsEpidemiological ParadigmsProcess of Generating InformationProcess of Generating Information

a. Clinical & biological dataa. Clinical & biological datab. Descriptive studiesb. Descriptive studiesc. Analytic methodsc. Analytic methodsd. Experimental modelsd. Experimental models

Process of InferenceProcess of Inference•• BiasBias•• ConfoundingConfounding•• Causality Causality -- significancesignificance

STEPS IN THE EPIDEMIOLOGIC STEPS IN THE EPIDEMIOLOGIC PROBLEM INVESTIGATION:PROBLEM INVESTIGATION:

1. Define clearly (delineate) the problem1. Define clearly (delineate) the problem--the outcome of the outcome of interest.interest.

2. List the various possible determinants of this 2. List the various possible determinants of this problem.problem.

3. Establish a process of monitoring this problem or 3. Establish a process of monitoring this problem or outcome (the outliers).outcome (the outliers).

4. Identify the possible determinants of the problem by 4. Identify the possible determinants of the problem by one of two approaches:one of two approaches:

a. Comparing persons with the outcome to those a. Comparing persons with the outcome to those without the outcome or problem.without the outcome or problem.

b. Assessing the occurrence of the outcome in b. Assessing the occurrence of the outcome in subgroups with different characteristics.subgroups with different characteristics.

STEPS IN THE EPIDEMIOLOGIC STEPS IN THE EPIDEMIOLOGIC PROBLEM INVESTIGATION:PROBLEM INVESTIGATION:

5. Measure determinants independently 5. Measure determinants independently from the assessment of outcome status.from the assessment of outcome status.

6. Always consider alternative explanations 6. Always consider alternative explanations to the problem including the interaction of to the problem including the interaction of more than one determinant in producing more than one determinant in producing the outcome of concern.the outcome of concern.

7. Assess the information value of the 7. Assess the information value of the observation.observation.

EPIDEMIOLGY AS AN INFORMATION EPIDEMIOLGY AS AN INFORMATION SCIENCESCIENCE

DATADATA--INFORMATION FOR DECISION MAKINGINFORMATION FOR DECISION MAKING

ETIOLOGYETIOLOGY

EVALUATIONEVALUATIONEFFICACYEFFICACYEFFECTIVENESSEFFECTIVENESS

EFFICIENCYEFFICIENCY

PROGRAM DEVELOPMENT PROGRAM DEVELOPMENT CONTINUUM:CONTINUUM:

PLANNINGPLANNING

PROGRAMMINGPROGRAMMING

IMPLEMENTINGIMPLEMENTING

MONITORINGMONITORING

EVALUATIONEVALUATION

IS EPIDEMIOLGY RELEVANT TO ALL IS EPIDEMIOLGY RELEVANT TO ALL FIVE STAGES?FIVE STAGES?

PLANNINGPLANNING

PROGRAMMINGPROGRAMMING

IMPLEMENTINGIMPLEMENTING

MONITORINGMONITORING

EVALUATIONEVALUATION

Management Competencies in Management Competencies in Health Care:Health Care:

1.1. Policy analysis and strategic Policy analysis and strategic planning.planning.

2.2. Assessing organizational structure Assessing organizational structure and performance.and performance.

3.3. Assessment, assurance and Assessment, assurance and improvement of quality.improvement of quality.

4.4. Cost/benefitCost/benefit--effectiveness and effectiveness and decision analysis.decision analysis.

5.5. Political analysis.Political analysis.

Management Competencies in Management Competencies in Health Care:Health Care:

6.6. Developing and managing a budget.Developing and managing a budget.7.7. Monitoring program performance.Monitoring program performance.8.8. Managing personnel.Managing personnel.9.9. Communicating information.Communicating information.10.10. Coordinating and catalyzing team Coordinating and catalyzing team

activity.activity.11.11. Dispute resolution, negotiation, and Dispute resolution, negotiation, and

conflict management.conflict management.

What are some What are some principles for quality principles for quality

management in management in industry?industry?

THE DEMING ROUTE TO QUALITY AND THE DEMING ROUTE TO QUALITY AND PRODUCTIVITY 1PRODUCTIVITY 1

-- The need for constancy and The need for constancy and consistency of purposeconsistency of purpose

-- Adopting a philosophy that higher Adopting a philosophy that higher quality costs less not morequality costs less not more

-- Eliminating the need for inspection Eliminating the need for inspection by building quality into the product in by building quality into the product in the first placethe first place

-- Continuous improvement of the Continuous improvement of the system of production and servicesystem of production and service

THE DEMING ROUTE TO QUALITY AND THE DEMING ROUTE TO QUALITY AND PRODUCTIVITY 2PRODUCTIVITY 2

-- Driving out fear to encourage Driving out fear to encourage effectiveness and pride of effectiveness and pride of workmanship.workmanship.

-- Instituting management by leadership Instituting management by leadership rather than by directives.rather than by directives.

-- Developing a vigorous program of Developing a vigorous program of education and selfeducation and self--improvement.improvement.

-- Making transformation everybodyMaking transformation everybody’’s job.s job.

MALCOLM BALDRIDGE NATIONAL QUALITY MALCOLM BALDRIDGE NATIONAL QUALITY AWARD. HEALTH CARE PILOT CRITERIA 1995AWARD. HEALTH CARE PILOT CRITERIA 1995 ((US Department of Commerce. Technology US Department of Commerce. Technology Administration.GaithersburgAdministration.Gaithersburg,,

Core values and concepts that include:Core values and concepts that include:--PatientPatient--focused quality and value.focused quality and value.--Leadership.Leadership.--Continuous improvement &organizational learning.Continuous improvement &organizational learning.--Employee/health care staff participation and Employee/health care staff participation and development.development.--Management by fact.Management by fact.--Results orientation.Results orientation.--Community health and public responsibilities. Community health and public responsibilities. -- Partnership development.Partnership development.--Design development.Design development.--LongLong--range view of the future.range view of the future.--Fast response.Fast response.

Differences in Concepts of Differences in Concepts of Quality:Quality:

INDUSTRIAL VS. HEALTH CARE MODELS:INDUSTRIAL VS. HEALTH CARE MODELS:

Health care has a more complex set of Health care has a more complex set of responsibilities toward the individual responsibilities toward the individual and society. (Donabedian) and society. (Donabedian) --1.1. Need to act on behalf of the patients Need to act on behalf of the patients and consumersand consumers2. Importance of engaging individual 2. Importance of engaging individual consumers and society in the consumers and society in the management process.management process.

Differences in Concepts of Quality:Differences in Concepts of Quality:

INDUSTRIAL VS. HEALTH CARE MODELS:INDUSTRIAL VS. HEALTH CARE MODELS:3. Responsibility for social welfare in addition 3. Responsibility for social welfare in addition to individual welfare.to individual welfare.4. Improvements in quality cost more 4. Improvements in quality cost more (diminishing returns in health following further (diminishing returns in health following further increases in care).increases in care).5. Tremendous variability that health care 5. Tremendous variability that health care professionals have to deal with. No professionals have to deal with. No standardized solutions. Uncertainty is standardized solutions. Uncertainty is pervasive.pervasive.

THE CHALLENGE FOR THE CHALLENGE FOR EPIDEMIOLOGY IN QUALITY OF EPIDEMIOLOGY IN QUALITY OF

CARECARE1. Identify the problems 1. Identify the problems -- define define -- monitormonitor2. Use of appropriate measurement instruments.2. Use of appropriate measurement instruments.3. Investigate using the comparative method. Try 3. Investigate using the comparative method. Try

to measure from within the system.to measure from within the system.4. Look for alternative explanations 4. Look for alternative explanations -- confounding confounding

and interaction.and interaction.5. Process of inferences.5. Process of inferences.6. Communicate and explain.6. Communicate and explain.

HOW CAN EPIDEMIOLOGY HOW CAN EPIDEMIOLOGY ASSIST IN ACHIEVING ASSIST IN ACHIEVING

BETTER PERFORMANCE BETTER PERFORMANCE IN MANAGEMENT IN MANAGEMENT

FUNCTIONS?FUNCTIONS?

ATTRIBUTES IN EPIDEMIOLOGY IN ATTRIBUTES IN EPIDEMIOLOGY IN MANAGEMENTMANAGEMENT

-- Epidemiology is an information science.Epidemiology is an information science.-- Epidemiology generates data that is used for Epidemiology generates data that is used for

decision making.decision making.-- Epidemiology provides a structured approach Epidemiology provides a structured approach

for making inferences and decisions.for making inferences and decisions.-- Continuous reassessment of existing Continuous reassessment of existing

knowledge and solutions (Continuous Quality knowledge and solutions (Continuous Quality Improvement).Improvement).

-- A philosophy as well as an approach in A philosophy as well as an approach in affecting health care organizations towards affecting health care organizations towards improved quality.improved quality.

ATTRIBUTES IN EPIDEMIOLOGY IN MANAGEMENTATTRIBUTES IN EPIDEMIOLOGY IN MANAGEMENT

STEPS IN THE EPIDEMIOLOGIC PROBLEM STEPS IN THE EPIDEMIOLOGIC PROBLEM INVESTIGATION: INVESTIGATION:

1.1. Define clearly (delineate) the problemDefine clearly (delineate) the problem--the outcome of the outcome of interest.interest.

2.2. List the various possible determinants of this List the various possible determinants of this problem.problem.

3.3. Establish a process of monitoring this problem or Establish a process of monitoring this problem or outcome (the outliers).outcome (the outliers).

4.4. Identify the possible determinants of the problem by Identify the possible determinants of the problem by one of two approaches:one of two approaches:

a. Comparing persons with the outcome to those a. Comparing persons with the outcome to those without the outcome or problem.without the outcome or problem.b. Assessing the occurrence of the outcome in b. Assessing the occurrence of the outcome in subgroups with different characteristics.subgroups with different characteristics.

STEPS IN THE EPIDEMIOLOGIC PROBLEM STEPS IN THE EPIDEMIOLOGIC PROBLEM INVESTIGATION:INVESTIGATION:

5. Measure determinants independently 5. Measure determinants independently from the assessment of outcome status.from the assessment of outcome status.6. Always consider alternative 6. Always consider alternative explanations to the problem including explanations to the problem including the interaction of more than one the interaction of more than one determinant in producing the outcome of determinant in producing the outcome of concern.concern.7. Assess the information value of the 7. Assess the information value of the observation.observation.

DISCIPLINE OF OPERATION AND THOUGHTDISCIPLINE OF OPERATION AND THOUGHT

Attributes that epidemiology provides and that Attributes that epidemiology provides and that are important for effective management of are important for effective management of

health services:health services:1.1. Information systems for continuous Information systems for continuous

surveillance and monitoring of outcomes.surveillance and monitoring of outcomes.

2.2. Well tested methods of investigation of Well tested methods of investigation of health problems.health problems.

3.3. A process of inferences in making decisions A process of inferences in making decisions from the available data information.from the available data information.

4.4. A rigorous method of assessing the A rigorous method of assessing the validity and reliability of data.validity and reliability of data.

5.5. Well defined ideology and goals Well defined ideology and goals directed at prevention of health directed at prevention of health problems that is consistent across time, problems that is consistent across time, and place.and place.

6.6. A continuous reassessment of A continuous reassessment of knowledge. There are no fixed answers knowledge. There are no fixed answers in epidemiology. Truth is constantly in epidemiology. Truth is constantly rediscovered.rediscovered.

Challenges for Epidemiology and Challenges for Epidemiology and Health Services ManagementHealth Services Management--11

Two concerns: Outcome (quality) and CostTwo concerns: Outcome (quality) and CostValue = Outcome / CostValue = Outcome / CostWhat can be done to increase the value of What can be done to increase the value of health care?health care?

Manpower trainingManpower trainingNew systems of assessmentNew systems of assessmentIntegration of epidemiology in managementIntegration of epidemiology in management


Manpower trainingManpower trainingA new cadre of epidemiologistsA new cadre of epidemiologistsTranslating epidemiologic findings Translating epidemiologic findings on efficacyon efficacyEpidemiology to a broader group of Epidemiology to a broader group of professionalsprofessionals


New systems of assessmentNew systems of assessmentMatching treatment to the patient Matching treatment to the patient –– placeboplaceboIncorporate case based and other methods as Incorporate case based and other methods as part of information systems for decision part of information systems for decision makingmaking

Integration of epidemiology in Integration of epidemiology in managementmanagement

OBJECTIVES OF THE SESSIONOBJECTIVES OF THE SESSION

By the end of this session you should be able to:By the end of this session you should be able to:

1. Explain what is a profession and discuss 1. Explain what is a profession and discuss whether epidemiology is a professionwhether epidemiology is a profession

2. Explain why Epidemiology can be used to 2. Explain why Epidemiology can be used to improve management in health care?improve management in health care?

3. Give examples of how Epidemiology can be 3. Give examples of how Epidemiology can be used for effective management.used for effective management.

health care management and epidemiology or epidemiolgy …objectives of the session by the end of...

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