EDUCATING OUR HEALTH CARE

WORKFORCE FOR IMPROVEMENT

Quality improvement, measurable and immeasurable;

challenges for the generalist

Friday 13th November 2015

Harvey Newnham

Clinical Program Director of Emergency &Acute Medicine

Director of General Medicine

Alfred Health

h.newnham@alfred.org.au

Synopsis

•Making a difference

•Complex decision making in a team

framework

•What our clinicians need to know.

IHI Boston version of hedgehog principle June 2015

Why work in GenMed?

Maureen Bisognano IHI

Reality Check

Reality Check 2

• Do you know how good you are?

• Do you know where you stand relative to

the best?

• Do you know where your variation exists?

• Do you know your rate of improvement

over time?

Maureen Bisognano IHI

$1 INVESTED

$5 RETURN

BENEFITS

• Reduced variation

in care

• Quality & Safety

• Empowerment

• Accountability

• Interdisciplinary

care

• Sustainable care

• Reduced costs

*V = A(O+S) W V=Value

A=Appropriateness

O=Outcomes

S=Service

W=Waste

*VMMC Value equation Gary Kaplan

To Patient To Organisation

Making a difference

•Clinical competence and skills

•Education of trainees

•Research

•Improve your job/the system

Making a difference – clinicians viewpoint

• Better clinical care than ever before

• Personalised approach

• Heart and soul

• Time and extensive clinical and research

effort

• Intricate balance of evidence, experience,

skill

• Better care = Try harder than anyone else

Clinician’s dilemma when something goes

wrong

• Grief, shame, angst, denial

• Soul searching

• Pray for forgiveness

• Challenge to professional competence

• Loss of confidence

• Unsustainable: Have to try harder, study

more

Doomed to fail

If

Quality arises from personal

competence;

Then,

Errors represent professional

incompetence.

Brent James, IMIHCDR

Factors affecting decisions

• Professional interests

• Financial interests

• Clinician preferences and personal tastes

• Desire to have something to offer (Rule of Rescue)

• Love for the work

• Wishful thinking

• Selective memory

• Legal considerations

• Patient preference and pressure from family

David Eddy

Evidence Our

minds Conclusions Actions

Limited, complex Huge range of uncertainty Massive variation,

Inappropriate care

5-7 factors are the maximum we can handle simultaneously

Collapsing under the quality assurance and

performance burden

1. Societal expectations of

transparency and guaranteed

quality

2. Measuring because we can (too

many targets)

3. Consequences:

a) tampering

b) compliance fatigue (sucking the

oxygen),

c) focus mainly on yesterday’s problems

d) drives system design away from

clinical stream QI,

e) temptation for gaming

f) staff dissatisfaction.

Balancing rock, near Moab, Utah people

Death by a thousand cuts

Guaranteed ongoing cost reduction

pressures

Options:

a) be reactive and scrimp, save and cut

wherever those above choose to apply

pressure,

or

b) Proactively understand our processes

and improve quality and patient

outcomes with cost reductions as a

consequence rather than the primary

goal.

Which approach is likely to engage

physicians and nurses and improve patient

satisfaction? Cleveland fine art museum

3 ways to achieve a number

1. Improve the system (achieve the number in a way that truly

makes things better)

2. Sub-optimize the system (achieve the number for one part of

the system at the expense of other, unmeasured, perhaps more

important, aspects of the system)

3. Cheat (fraud)

W. Edwards Deming

Variation in health care

• Variation in practice is like a fog – makes it

difficult to see what is/isn’t working.

• Best route to optimize the best care model is to

control the variables in care delivery.

Brent James, Maureen Bisognano

Quality waste

Cost of rework arising from not providing best care

first time.

• errors, complications, readmissions

1.We are paid for quality waste….so far!

2.Failure to identify errors is wasteful of both cost

and opportunities to improve quality.

Suboptimisation “Work-arounds are quality waste”

It would be good if

she gets the MRI

before discharge

She can only

get the MRI as

an inpatient if I

make it urgent

I’ll ring the

radiologist to ask for

an urgent MRI

MRI is

booked for

tomorrow

5pm

Patient spends

extra night as

inpatient

MRI shows non-

urgent problem

requiring neuro

opinion

I’ll keep

her in for

neuro

opinion

Radiologist

slowed down by

discussion and

rescheduling

Patient spends

extra night as

inpatient. Neuro

referrals fall

further behind

Delay for MRIs

increase further

Bed-block forces

employment of agency

staff to open beds and

blows budget so we

can’t afford new MRI My patient needs an

MRI

Efficiency waste

Processes A and B produce

equivalent quality but A costs less

than B

Challenges to improving efficiency:

• practitioner autonomy, work practices,

awards, poor culture, poor

measurement, misaligned incentives

Physician autonomy

Is like a Limber pine on the edge of Bryce Canyon

Eddy: “The complexity of modern medicine exceeds the capacity of the unaided human

mind”

Healing professions are changing

From craft-based practice:

• Individual physicians working alone or apprenticed regs/HMOs

• Handcraft a customized solution for each patient

• Based on a core ethical commitment to the patient and

• Vast personal knowledge gained from training and experience

To profession-based practice:

• Groups of peers, treating similar patients in a shared setting

• Plan coordinated care delivery processes

• Which individual clinicians adapt to specific patient needs

• Evidence suggests:

• Less complex (fewer mistakes, less conflict and reduced delay)

• Better patient outcomes

• Less expensive (can staff, train, supply and organise to care processes)

Brent James IIHCDR

Protocols can improve care

Shared baselines: A multidisciplinary team of health professionals

1. Select a high priority care process

2. Generate an evidence-based “best practice” guideline

3. Blend the guideline into the flow of clinical work • Staffing

• Training

• Supplies

• Physical layout

• Educational materials

• Measurement/information flow

4. Use the guideline as a shared baseline, with clinicians free to vary based on individual patient needs

5. Measure, learn from, and (over time) eliminate variation arising from professionals: retain variation arising from patients

Medical Training

misses the work context

Adapted from Harold Jarche, NHS IQ video 2014

KNOWLEDGE

IN PRACTICE

Fundamental

knowledge of

teamwork &

processes

of care

What we TEACH

them in medical

school

What doctors

THINK they

know

What doctors

actually USE

QUALITY

IMPROVEMENT

(QI) How to

discover

best practice

What doctors NEED to know to

discover and deliver best care

3D Health Care Course Discover, Design, Deliver better health care

TOPICS

• History of medicine and physician autonomy

• Cost of healthcare

• Variation in health care

• Measuring quality

• History of QI/QI meets health care

• QI principles

• Value in healthcare: improving quality improves outcomes and reduces costs

• Disruptive Innovation and the Job To Be Done

• Health system governance

• Staff engagement

• Organisational culture

• Understanding and measuring costs

• Human factors in healthcare

• Work/life balance

• The Just Culture/performance management

SKILLS

• Mentored project work

• QI Project management techniques

• Statistics and SPC charts for clinician

managers

• Excel workshops

• Teamwork techniques

• Meetings with meaning

• Leadership and change management

• Interviewer/interviewee effectiveness

• Stepping up to a leadership role

• Design principles

• Educating health workers

• Media skills

• Business case preparation/presentation

• Presentation skills

A course for current or aspiring health care leaders, professionals,

managers and educators (all in the same room)

Professional

Development,

Cleveland

Clinic

2014, Fall courses!

Cleveland

Clinic

Where might you start?

• Read (both measurabes and immeasurables)

• Count

• Write

• Local courses

• Monash, Masters of Health Service Management

• Deakin, Master of Clinical Leadership

• Online

• Institute for Health Improvement

• NHS

• Big trips

• Intermountain Institute of Health Care Delivery

• Harvard Macy courses

Recommended

reading to get

started

The best way to change culture of

an organisation is:

one project at a time.

Missed opportunities!

We have amazing staff – let’s spend a little

time training them in improvement skills

Change

“Look for the opportunity to change. I am not

saying you should take on every new thing

that comes along. But be willing to recognize

the inadequacies in what we do and to seek

out solutions.”

Atul Gawande

Innovation

“The best innovations happen

within the tightest constraints.”

Clayton Christensen, Harvard Business School

GenMed Workshop Werribee Mansion May 6-8 2016

Conclusions

1. GenMed is complex and can only be done well by a

highly effective interdisciplinary team working in a well

organised health care delivery system.

2. Patients deserve models of care that minimise error.

3. Medical autonomy is killing our patients

4. If it’s not fun, it’s not improvement work.

5. Start next Tuesday

Fur seals on the Big

Sur, highway 1,

California between

Carmel and Hearst

Castle