Batalden Kalmar 071025

Toward a good conversation: What assumptions might be underneath the development of a regional system for evidence-based patient care and health professional development?: 

Toward a good conversation: What assumptions might be underneath the development of a regional system for evidence-based patient care and health professional development? Paul Batalden, MD Boel Andersson-Gäre, MD, PhD The Dartmouth Institute for Health Policy and Clinical Practice October 25, 2007

Assumptions: 

Assumptions Outcome measurement and generalizable scientific evidence can inform changes in patient care and professional formation and development. Health professionals and patients are part of the same system…and meet in the clinical microsystems, and microsystems are not the same as multidisciplinary teams. Good professional development and good patient care go together. Making health care safer involves making it more reliable…and that requires rehearsal and experience-based learning. Leadership means connecting these things and making them happen.

What are your assumptions about the development of a regional cooperative system for evidence-based patient care and health professional development?: 

What are your assumptions about the development of a regional cooperative system for evidence-based patient care and health professional development? Have a discussion with your colleagues and we’ll check back in 15 minutes.

Agenda: 

Agenda Some fundamentals about QI My reactions to your questions Suggestions for the path forward

1. Outcome measurement and generalizable scientific evidence can inform changes in patient care and professional formation and development.: 

1. Outcome measurement and generalizable scientific evidence can inform changes in patient care and professional formation and development. Generalizable Scientific Evidence + Particular Context Measured Performance Improvement

Slide6: 

Generalizable Scientific Evidence + Particular Context Measured Performance Improvement Control for context, RCTs Be pre-occupied re: context, identity, habit, etc. Preserve time order, create new, balanced measures Right plan? Execution: strategy, operations, human resources

Slide7: 

Knowledge systems in the science of improvement Generalizable Scientific Evidence + Particular Context Measured Performance Improvement

2. Health professionals and patients are part of the same system…and meet in the clinical microsystems, and microsystems are not the same as multidisciplinary teams.: 

2. Health professionals and patients are part of the same system…and meet in the clinical microsystems, and microsystems are not the same as multidisciplinary teams.

Slide9: 

Entry, Assignment Orientation Initial Work-up, Plan for care Disenrollment Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system Satisfaction of need, monitoring, assessment of outputs A “Generic” Clinical Microsystem model

Slide10: 

DHMC Big Picture: Micro, Meso, Macro for AMI Care Qm1 + Qm2 + Qm3 + Qm4 = QHS ©2005, Trustees of Dartmouth College, Nelson, January IHI – Whole System Metrics

Microsystem  Team: 

Microsystem  Team Providers + beneficiaries People + Information, Technology, Purpose in relationship People, Work in a setting

So, why focus on the “clinical microsystem?”: 

So, why focus on the “clinical microsystem?” Basic “building block” of health care as a system Unit of clinical policy-in-use Locus of most workplace “motivators” and many “hygiene” factors Most variables relevant to patient satisfaction controlled here Where “good value” and “safe” care is made Where most health professional “formation” occurs after initial preparation

3. Good professional development and good patient care go together.: 

3. Good professional development and good patient care go together. Clinical care professionals develop practical wisdom (phronesis) by meeting particular patients with particular needs. Recent Dartmouth Health Care Atlas data suggests medical specialists-in-training adopt the “quality signature” of the training region/setting.

“quality improvement”: 

“quality improvement” The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, educators – to make changes that will lead to better patient outcome, better system performance, and better professional development.

What does “quality improvement of health care” mean?: 

What does “quality improvement of health care” mean? Better patient / population outcome Better system performance Better professional development

Helpful knowledge: 

Helpful knowledge Better patient / population outcome Better system performance Better professional development Everyone balanced measures? benchmark? theoretic limit? trends? failure(s)? trend data? standards? benchmark? theoretic limit? cost? joy, pride in work? learning? certification / re-certification? new skills development? satisfaction? hiring? orientation? supervision? recognition?

QI is not: 

QI is not A set of methods and tools. A new language for distracting activities in the midst of otherwise busy, meaningful lives. Measurement unattached to the phenomena it reflects . Measurement without reflection. A new name for insulting the professional desire for mastery.

4. Making health care safer involves making it more reliable…and that requires rehearsal and experience-based learning.: 

4. Making health care safer involves making it more reliable…and that requires rehearsal and experience-based learning.

Slide19: 

No system beyond this point 10-2 10-3 10-4 10-5 10-6 Civil Aviation Nuclear Industry Railways (France) Chartered Flight Himalaya mountaineering Road Safety Chemical Industry (total) Fatal risk Medical risk (total) Blood transfusion Anesthesiology ASA1 Cardiac Surgery Patient ASA 3-5 No limit on discretion Microlight or helicopters spreading activity Excessive autonomy of actors Craftmanship attitude Ego-centered safety protections, vertical conflicts Loss of visibility of risk, freezing actions Increasing safety margins Becoming team player Agreeing to become « equivalent actors » Accepting the residual risk Accepting that changes can be destructive Very unsafe Ultra safe René Amalberti’s Model The Institute for Healthcare Improvement, 2004

Slide20: 

Excessive autonomy of actors No system beyond this point 10-2 10-3 10-4 10-5 10-6 Civil Aviation Nuclear Industry Railways (France) Chartered Flight Himalaya mountaineering Road Safety Chemical Industry (total) Fatal risk Medical risk (total) Blood transfusion Anesthesiology ASA1 Cardiac Surgery Patient ASA 3-5 No limit on discretion Microlight or helicopters spreading activity Craftsmanship attitude Ego-centered safety protections, vertical conflicts Loss of visibility of risk, freezing actions Increasing safety margins Becoming team player Agreeing to become « equivalent actors » Accepting the residual risk Accepting that changes can be destructive Very unsafe Ultra safe Matching system design with professional development

Slide21: 

Concrete experience Observations and reflections Formation of abstract concepts and generalizations Testing implications of concepts in new situations “Lewinian” Experiential Learning Model Notice Make sense Implications for setting, context Anticipate requisite assessment David Kolb

Questions from prior September, 2007 retreat (bold=priorities): 

Questions from prior September, 2007 retreat (bold=priorities) How do we create awareness of the need for change? What results do we expect from the improvement work? What resources do we need in order to succeed in the improvement work? How and where do we start the improvement work? How do we work with the logistics of health care from a patient perspective? How can we increase our organizational learning? How do we create long-term thinking and engagement? How do we design IT systems which support new and better methods of working? What things do we need to stop doing in our work?

1. How do we create awareness of the need for change?: 

1. How do we create awareness of the need for change?

Getting specific about SE Sweden: 

Getting specific about SE Sweden

Using the open comparisons…: 

Using the open comparisons…

4. How and where do we start the improvement work?: 

4. How and where do we start the improvement work?

Starting: 

Starting Start close in… Start with what you teach Start with the care you give Start with what you do…as you demonstrate how you do what you do and improve what you do…

Slide28: 

START CLOSE IN Start close in, don’t take the second step or the third, start with the first thing close in, the step you don’t want to take. Start with the ground you know, the pale ground beneath your feet, your own way of starting the conversation. Start with your own question, give up on other people’s questions, don’t let them smother something simple. To find another’s voice, follow your own voice, wait until that voice becomes a private ear listening to another.

Slide29: 

Start right now take a small step you can call your own don’t follow someone else’s heroics, be humble and focused, start close in, don’t mistake that other for your own. Start close in, don’t take the second step or the third, start with the first thing close in, the step you don’t want to take. David Whyte

Starting: 

Starting Start close in… Start with what you teach Start with the care you give Start with what you do…as you demonstrate how you do what you do and how you improve what you do…

Mapping the opportunity in health professional development / education: 

Mapping the opportunity in health professional development / education Who are the learners and what are they being taught? Who are the faculty? What do people take pride and joy about? Current connections in the usual path of study (#1 above) to local / regional patient / population outcomes? Current connections in the usual path of study (#1 above) to local / regional system performance? Relevant recent statements of intention / policy that could enable learning about improvement of health care quality, safety and how that might be so? Relevant life-long development process in actual practice

Mapping the opportunity in health professional work: 

Mapping the opportunity in health professional work Who are the various professionals and what is their usual path of life/work in the organization? Who are the supervisors? What do people take pride and joy about? Current connections in the usual path of work (#1 above) to local / regional patient / population outcomes? Current connections in the usual path of work (#1 above) to local / regional system performance? Current connections in the usual path of work (#1 above) to professional formation / development? Relevant recent statements of intention / policy that could enable learning about improvement of health care quality, safety and how that might be so? Relevant life-long development process in actual practice?

Improvement is about working on work, using the following knowledge and skill domains…: 

Improvement is about working on work, using the following knowledge and skill domains… 1. Health care / professional education as process, system. 2. Variation & measurement. 3. Customer / Beneficiary knowledge. 4. Leading, following and making changes in health care / professional education. 5. Collaboration. 6. Social context & accountability. 7. Developing new locally useful knowledge. 8. Professional subject matter.

Start with the small, front line systems of work: 

Start with the small, front line systems of work www.clinicalmicrosystem.org “Quality by Design” “Practice-based Learning & Improvement”

7. How do we create long-term thinking and engagement?: 

7. How do we create long-term thinking and engagement?

Long-term thinking…: 

Long-term thinking… Have good conversation with one another about the improvements / changes you have been testing… Work on “real” work (what you usually do) Achieve “real” change (measure) Joy in work, learning (celebrate)

As this effort moves forward, and based on what you know helps you take in something successfully, what should we be sure to include as part of the “path forward?”: 

As this effort moves forward, and based on what you know helps you take in something successfully, what should we be sure to include as part of the “path forward?” Identify the several relevant suggestions at your table and be prepared to share the top three suggestions from your table

The opportunity: 

The opportunity All counties’ care systems have a commitment to ongoing improvement, change. Östergötland, Jönköping & Kalmar commitment to multidisciplinary professional formation. Swedish disease registry and open comparison systems availability. Regional commitment to leadership learning and development for the one million people who depend on you for their health. Dartmouth models, experiences & faculty resources for inviting linking health professional development and patient care improvement.