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CLINICAL REDESIGN Looking back to see the future

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Page 1: Simon Foster

CLINICAL REDESIGN Looking back to see the future

Page 2: Simon Foster

▪What is redesign all about?

▪Why do it?

▪What has it got to offer?

Page 3: Simon Foster
Page 4: Simon Foster
Page 5: Simon Foster

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

Page 6: Simon Foster

LEAVE CLINICIANS TO SORT IT OUT?

Page 7: Simon Foster

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

Page 8: Simon Foster

PROCESS MANAGEMENT DESIGNS

Do they work for medicine?

Page 9: Simon Foster

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

Page 10: Simon Foster

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

Page 11: Simon Foster

SCIENTIFIC MANAGEMENT

Scientific Management fails in the face of

Complexity

Page 12: Simon Foster

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

Page 13: Simon Foster

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

Page 14: Simon Foster

OPPOSING IDEALS

Administrative management versus clinical management

Page 15: Simon Foster

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

Page 16: Simon Foster

W.EDWARDS DEMING

Organize everything around value added (front line) work processes

Quality Improvement is the science of process management

Page 17: Simon Foster

SHEWHART/DEMING PDSA CYCLE

Page 18: Simon Foster

Taylor Top Down Deming Bottom Up Hardly a competent worker can be found

Almost all failures come from underlying processes

Critize/Control Empower

Judgement playing God Learning

Heroic Individuals Teams (fundamental knowledge)

Unfunded mandates assumes unlimited time and attention

Integrated Tools built into workflow

Motivate incentivize (payment)

Make it easy to do right

Page 19: Simon Foster

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)

Page 20: Simon Foster

LEAN OR PULL THROUGH PRODUCTION

Standardisation processes with

Smart cogs that

Adapt to individual needs

Mass customisation

Efficient processes that can deal with complexity

Page 21: Simon Foster

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

Page 22: Simon Foster

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

Page 23: Simon Foster

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

Page 24: Simon Foster

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

Page 25: Simon Foster

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

Page 26: Simon Foster

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

Page 27: Simon Foster

IMPROVING QUALITY

Eliminate inappropriate variation

(process steps)

Document continuous improvement (outcomes)

Page 28: Simon Foster

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

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)

F62B

F62A

Distribution of LOS - DRG F62

An example of how we are examining variation as part of process redesign

Page 29: Simon Foster

75%

05

10

15

20

Fre

qu

en

cy

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46

los

Distribution of days of stay - F62A25% 50%

• 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

Heart Failure

020

40

60

Fre

qu

en

cy

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

LOS (days)

Distribution of days of stay - F62B25% 50%

75%

• 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

Page 30: Simon Foster

First Second Third Fourth Total

Total Separations 32 32 32 32 128

Total Bed Days 58 (5.2%) 131 (11.8%) 256 (23.1%) 664 (59.9%) 1109

Mean Age 80.0 80.2 76.1 79.4 78.9

Male % 46.9% 59.4% 50.0% 59.4% 53.9%

Variation in LOS 1-3 3-6 6-11 11-44 1-44

Admissions

in 12 months

One 22 22 24 22 90 (70.3%)

Two 9 8 7 8 32 (25%)

Three 1 2 1 2 6 (4.7%)

Heart Failure

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)

Page 31: Simon Foster

First Second Third Fourth Total

Total Separations 32 32 32 32 128

Comorbidities 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%)

Heart Failure

The number of co-morbidities did not change significantly between quartiles for F62A, with all patients

experiencing at least one co-morbidity.

Page 32: Simon Foster

T a i l a n a l y s i s

. . . a s s u m e s t h a t , i f s e r i o u s f a i l u r e s a r e

i n s p e c t e d a n d e l i m i n a t e d , w h a t r e m a i n s

i s s o m e h o w e x c e l l e n t . . .

Page 33: Simon Foster

F o c u s o n t h e T a i l

b e t t e r w o r s e

Q u a l i t y

Q A t h r e s h o l d ( s t a n d a r d )

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` a c c e p t a b l e ' q u a l i t y ` u n a c c e p t a b l e ' q u a l i t y

Page 34: Simon Foster

T r a d i t i o n a l Q u a l i t y A s s u r a n c e

w o r s eb e t t e r

w o r s eb e t t e r

Q u a l i t y

Q u a l i t y

t h r e s h o l d

B e f o r e

A f t e r

Page 35: Simon Foster

Q u a l i t y I m p r o v e m e n t

w o r s eb e t t e r

w o r s eb e t t e r

Q u a l i t y

Q u a l i t y

B e f o r eA f t e r

Page 36: Simon Foster

Better has no Limits

Page 37: Simon Foster

Questions