Improving Healthcare Service today and tomorrow Paul Batalden, MD - - PowerPoint PPT Presentation

Improving Healthcare Service— today and tomorrow

Paul Batalden, MD

The Dartmouth Institute for Health Policy and Clinical Practice Jönköping Academy May 11, 2018

Sometimes

Sometimes if you move carefully through the forest, breathing like the ones in the old stories, who could cross a shimmering bed of dry leaves without a sound, you come to a place whose only task is to trouble you with tiny but frightening requests, conceived out of nowhere but in this place beginning to lead everywhere. Requests to stop what you are doing right now, and to stop what you are becoming while you do it, questions that can make

• r unmake

a life, questions that have patiently waited for you, David Whyte

What might we learn & adapt from those who used an enterprise-wide approach to quality?

• W. Edwards Deming

1900-1993

System of ‘Profound Knowledge’

• System
• Variation
• Psychology
• Theory of Knowledge

Walter Shewhart 1891-1967 C.I. Lewis 1883-1964

• Subject
• Discipline
• Values

Professional knowledge

Traditional Improvement of Healthcare Service

Improvement knowledge

• System
• Variation
• Psychology
• Theory of knowledge

Continual Improvement of Healthcare Service

+

Joseph M. Juran 1904-2008

Basic “Tools” for QC Circles

• 1. Cause-and-effect diagram
• 2. Check sheet
• 3. Control charts
• 4. Histogram
• 5. Pareto chart
• 6. Scatter diagram
• 7. Stratification

Kaoru Ishikawa 1915-1989

Sakichi Toyoda 1867-1930

• 1. Be contributive to the development and welfare of the country by

working together, regardless of position, in faithfully fulfilling your duties.

• 2. Be at the vanguard of the times through endless creativity,

inquisitiveness and pursuit of improvement.

• 3. Be practical and avoid frivolity.
• 4. Be kind and generous; strive to create a warm, homelike

atmosphere.

• 5. Be reverent, and show gratitude for things great and small in

thought and deed.

Eji Toyoda 1913-2013 Kiichiro Toyoda 1894-1952 Taiichi Ohno 1912-1990

Some of what attracted us to Toyota

“Customer Quality” “Gemba” “Toyota Suggestion System” “Muda”

• 1. Overproduction
• 2. Waiting
• 3. Transporting
• 4. Inappropriate/Too costly Processing
• 5. Unnecessary Inventory
• 6. Unnecessary / Excess Motion
• 7. Defects

“QC Circles”

Enterprise-wide quality awards

Japanese Deming Prize (1951)

A. Establishment of business

• bjectives and strategies and top

management’s leadership B. Suitable utilization and implementation of TQM C. Effect of TQM

US Malcolm Baldrige Prize (1988)

1. Leadership 2. Strategy 3. Customers 4. Measurement, analysis, and knowledge management 5. Workforce 6. Operations 7. Results

Every system is perfectly designed to get the results it gets

Production as a system

W.E. Deming

• Mt. Hakone

“Production as a system”

A system capable of continual improvement

How we improve what we make Why we make what we make How we make what we make

Healthcare Professional

Other Practitioners Clinical Support Administrative Support Information Technology

Need, aim Healthcare Services

Testing a change for improvement

Generalizable, science-informed practice

Particular setting, context Measurable performance change, improvement

+ à

1 2 3

4

5

Find a process to improve Organize a knowledgeable team Clarify current process Understand the variation Select an initial change to test Plan a change Do it Study what happened Act to hold the gain, move on Define Measure Analyze Improve Control

Biology Function Satisfaction Cost

Value Compass

General Competencies of the ACGME (1999)

• 1. Patient care
• 2. Medical knowledge
• 3. Practice-based learning & improvement
• 4. Professionalism
• 5. Interpersonal skill & communication
• 6. System-based practice

David Leach

Linda Cronenwett

Quality & Safety Education for Nurses (2007)

• 1. Patient-centered care
• 2. Teamwork & collaboration
• 3. Evidence-based practice
• 4. Quality improvement
• 5. Safety
• 6. Informatics

ABMS Maintenance of Certification Standards (2015)

Part I Professionalism and Professional Standing Part II Lifelong Learning and Self-Assessment Part III Assessment of Knowledge, Judgment, and Skills Part IV Improvement in Medical Practice

Paul Miles

Old Question:

What might we learn from those who regard never-ending improvement as an “enterprise-wide” effort?

New Question:

How might we improve the value of the contribution that healthcare service makes to better health?

Victor Fuchs 1924-

Making a service is fundamentally different from making goods, products. All service...at some level...is produced by professionals and those who receive the benefit.

1968

Harvey Garn, et al; Elinor & Vincent Ostrom, others: Elinor Ostrom 1933-2012 Nobel Laureate 2009

The coproduction of public services is an economical way of providing service, solving community challenges.

Community and society Co-execution Co-planning Civil discourse Healthcare system

Co-produced high value healthcare service Good health for all

Patients Professionals

• M. Batalden, et al

The interdependent work of users and professionals to design, create, develop, deliver, assess and improve the relationships and actions that contribute to the health of individuals and populations through mutual respect and partnership that notices and invites each participant’s unique strengths and expertise. The coproduction of healthcare services

Relationship.............................................Activity

A healthcare service:

Knowledge, skill Habit, Vulnerability

Civil discourse (I) Co-planning (II) Co-execution (III)

Professional

Co-producing good services

System(s) What might they do, contribute, invite, offer? What might they do, contribute, invite, offer? What might systems do, contribute, invite, offer? What might this mean?

Patient/Client/TIFKAP

Courtesy: Gautham Suresh

Patients Professionals

Chartering a project for learning/improvement--1

• Team Members:
• Project Title:
• Organization Name:
• Sponsor Name(s):
• What are we trying to accomplish, and how does that link

coproduction to organizational strategy?Aim statement (How

good? For whom? By when? 1-2 sentences); Reason for the effort (Defines WHY; 4-5 sentences). How did you arrive at the aim statement listed above? Did you engage patients and families in developing your aim? How does the reason for the effort link explicitly to the

• rganizational strategy and the priorities of senior leaders? Expected
• utcomes/benefits and what we will learn about co-production (Defines

WHAT specifically, still not HOW; 3-4 sentences)

• How do we know that a change is an improvement and that

coproduction was a significant variable? (Identify outcome,

process, and balancing measures; 4-5 sentences)

• What changes can we make that will illustrate coproduction

methods and lead to improvement? (Initial changes, barriers, key

stakeholders; 4-5 sentences) REFERENCE TO A DRIVER DIAGRAM

• Which stakeholders will you involve in this effort, and how?

Stakeholder; Activity/extent of involvement

• Team Members:
• Project Title:
• Organization Name:
• Sponsor Name(s):
• What are we trying to accomplish? Aim statement (How

good? For whom? By when? 1-2 sentences):; Reason for the effort (Defines WHY; 4-5 sentences) ; Expected outcomes/benefits (Defines WHAT specifically, still not HOW; 3-4 sentences)

• How do we know that a change is an improvement?

(Identify outcome, process, and balancing measures; 4-5 sentences)

• What changes can we make that will lead to

improvement?(Initial changes, barriers, key stakeholders; 4-5

sentences) REFERENCE TO A DRIVER DIAGRAM

1.What are we trying to accomplish and how does that link coproduction to org. strategy?

• Aim statement is clear and answers how good, by when, and for whom
• Aim explicitly links project to organizational strategic goals
• Aim was developed together with patients and families
• Problem to be addressed clearly justifies the need for improvement
• Identifies aspect of care that will be improved and subsystems that will be affected
• The impact (+/-) on customers and their lived reality is clear
• Supportive background info is provided
• Specific objectives and numerical goals are clearly defined
• Project can be completed within the time frame
• Addresses anticipated products, tools & deliverables that will be used in the process
• 2. How do we know that a change is an improvement and that coproduction was a significant variable?
• An appropriate family of measures is identified (1 outcome, 2-3 process, 1 balancing)
• Measures identified are directly related to the project description, objectives, goals
• Each measure is appropriately operationally defined
• Data collection on metrics is reasonable and practical given scope of project
• Measures reflect lived experience of TIFKAPs and quality of coproduction experience
• Measures reflect effective coproduction process & result
• 3. What changes can we make that will illustrate coproduction methods and that will lead to improvement?
• Initial changes to be tested are clear & well-defined
• Spec. strategy/methods (ie, driver diagram) used in selecting change is identified & explained
• Changes reflect a rigorous analysis of lived reality of TIFKAPs
• Changes reflect a clear understanding of the current state of the service offered
• Project constraints/barriers are defined incl. how they will be addressed
• Identifies key stakeholders & explains their role in the process

1 5 2 3 4 6 B B B B A A A A A Pt Prof

Flow of ”as is” current state

Key:

Pt input

Prof input Numbered (named) Step

Pt

• utcome

Prof

• utcome

PB March 29, 2018

Testing a change for improvement

Generalizable, science-informed practice

Particular setting, context Measurable performance change, improvement

+ à

Present

Particular setting, context

à

Measurable performance change, improvement

Generalizable, science-informed practice Patient aim +

X

Future

5

Jönköping Academy

Professional Education Primary Healthcare Service Health System Leaders Research

Network Founders Illustrative Communities

• f Practice

Developmental Work Tests in Practice Collated insights, test results

International Coproduction Health Network (ICoHN)

The Dartmouth Institute

Batalden

www.icohn.org

• 3. Empathy w/ TIFKAPs
• lived reality
• assets
• burdens & mgmnt
• capabilities &

interest

• personae
• anticipating enablers

& barriers

• pt/fam engagement
• 6. Radical collaboration
• relevant science, current

state, & lived reality

• shared aim
• options/resources/value

architecture

• metrics of success/ failure
• pt/fam engagement
• 7. Science-informed rapid prototyping
• service construction
• testing
• modification
• pt/fam engagement
• 8. So what
• stabilization/FMEA
• generalizable lessons
• pt/fam engagement
• 9. Now, then what
• path for this dyad
• implications
• system value architecture/facilitation
• improve context receptivity
• technologic enablers
• 1. Strategy
• sr. leader

short list

• must do
• 2. Real work, real people, real connections
• in/out locus
• charter
• front line/microsystem
• people
• 4. Current state assessment
• “as is” process
• process variability made visible
• frequent failures noted
• cycle times
• descriptive data
• internal scan
• external scan
• pt/fam engagement
• modified patient journey mapping
• 5. Science-informed practice
• literature-int/ext validity
• local experience
• measurement
• illness/treatment burden
• coproduction capability/possibility

3/24/2018

Current ICoHN (ICoHN-related) work

• Coproduction infrastructure

development

• Development of measures of coproduction process

and result

• Evaluation of development / scale-up
• Digital habitat development
• Annual gathering
• Coproduction toolkit development
• Projects/exemplars/illustrative work
• Community of practice—Health System Leaders
• Business model development for value creation
• Community of practice—Palliative care learning

network development

• Housing development & coproduction of health
• Education/professional development
• Community of practice—Graduate medical

education

• Community of practice—Researcher development:

PhD students, Post-doctoral fellows, Faculty development

• Undergraduate health professional development
• Post-graduate health professional development
• Coproduction & collegiate learning
• Organization/systems/policy
• Integration of health and social services
• Center for the coproduction of human service
• Extended registry “Information commons”
• Learning health system network development

Spring, 2018

Old Question:

What might we learn from those who regard never-ending improvement as an “enterprise-wide” effort?

New Question:

How might we improve the value of the contribution that healthcare service makes to better health?

Øystein Fjeldstad

• Univ. Oslo

Value “chain”—standardized sequential processes to meet a commonly occurring need. Value “shop”—customized response to particular need. Value “network”—flexibly configured roles, resources to adapt to present & emerging needs.

We need systems with architectural designs that fit the nature of the work.

Value models

Value shop: Customized solutions to unique problems

Fever of unknown

• rigin

Value network: Facilitating relationships between people with problems and solutions coming from diverse resources

Transition facilitator/navigator for patient at high risk for readmission

Value chain: Linked processes that provide reliable solutions to standard problems

Algorithmic management of chest pain in the ED

Maren Batalden

Single patient PPt-Nurse Standardized Service Pts doing their own dialysis in community Pts doing their own dialysis in community ffacilitator NETWORK Leader

Elements common to value creating service systems

• shop--this system mode refers to the ability of a system to meet a particular, often changing, unclear need,

such as people who are experiencing a new fever of unknown origin. It usually involves the construction of a customized response after some mode of diagnosis, understanding, classification of the need.

• chain--this system mode refers to the ability of a system to meet a commonly occurring need, such as

people with community acquired pneumonia. It usually involves the work of a series of linked processes, which occur sequentially.

• network-- this system mode refers to the ability of a system to meet a variety of needs with the help of a

community of resources, often including individuals struggling with similar challenges and problems, such as a group of people who may share a common diagnosis or treatment pathway.

• facilitation--this work--done by an individual, group of individuals, or technical processes—helps a

person in need by matching need with an appropriate mode of meeting that need.

• NETWORK-- this refers to the interconnected elements above which are in some relationship with each
• ther and the relevant population.
• leadership--this work involves the interaction & development of the elements above, their

improvement and their accountability for best value approaches to meeting need(s).

Actor-oriented learning network(s)

• 1. Aligning participants around a common goal
• 2. Standards, processes, policies and infrastructure to enable

multiactor collaboration

• 3. A commons where information, knowledge, resources and

know-how to achieve that goal are created and shared.

Some implications

• 1. Education of professionals and the public
• 2. Healthcare system redesign
• 3. Redesign outside and at the edges of the healthcare system
• 4. Measurement of good healthcare service

Sometimes

Sometimes if you move carefully through the forest, breathing like the ones in the old stories, who could cross a shimmering bed of dry leaves without a sound, you come to a place whose only task is to trouble you with tiny but frightening requests, conceived out of nowhere but in this place beginning to lead everywhere. Requests to stop what you are doing right now, and to stop what you are becoming while you do it, questions that can make

• r unmake

a life, questions that have patiently waited for you, questions that have no right to go away. David Whyte

Ernest Rutherford 1871-1937

13 Nobel Prizes in one decade!

Reginald Revans 1907-2003

Rutherford: “We don’t want to hear what you think you know…we want to know what you are trying to figure out.”

In 1993, we were teaching together in Manchester, UK and he said…

Meditation is old and honorable, so why should I not sit, every morning of my life, on the hillside, looking into the shining world? Because, proper ly attended to, delight, as well as havoc, is sug-

• gestion. Can one be passionate about the just, the

ideal, the sublime, and the holy, and yet commit to no labor in its cause? I don’t think so. All summations have a beginning, all effect has a story, all kindness begins with the sown seed. Thought buds toward radiance. The gospel of light is the crossroads of—indolence, or action. Be ignited, or be gone.

What I Have Learned So Far

Mary Oliver

Given my belief that ‘one cannot be passionate about the just, the ideal, the sublime, and the holy, and yet commit to no labor in its cause’… what am I trying to figure out now?

1. How to prepare, enable pt/prof support for healthcare service coproduction? 2. When to use service/product logic when designing and testing change? 3. What relationships & actions make up the coproduction of healthcare service? 4. How does knowledge, skill, habit and willingness to be vulnerable bring the relationships and actions of coproduced healthcare service together? 5. How to lead, develop value NETWORKS (of chains, shops and facilitated networks)? 6. How to transition from hierarchies to NETWORKS?

What are you trying to figure out?