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

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

System of ‘Profound Knowledge’ • System • Variation • Psychology • Theory of Knowledge W. Edwards Deming 1900-1993 C.I. Lewis Walter Shewhart 1883-1964 1891-1967

Professional Improvement knowledge knowledge • Subject • System • Discipline • Variation • Values • Psychology • Theory of knowledge + Traditional Continual Improvement of Improvement of Healthcare Service 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

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 Sakichi Toyoda thought and deed. 1867-1930 Kiichiro Toyoda Taiichi Ohno Eji Toyoda 1894-1952 1912-1990 1913-2013

Some of what attracted us to Toyota “Customer Quality” “QC Circles” “Muda” “Gemba” 1. Overproduction 2. Waiting 3. Transporting 4. Inappropriate/Too costly Processing 5. Unnecessary Inventory “Toyota Suggestion System” 6. Unnecessary / Excess Motion 7. Defects

Enterprise-wide quality awards US Malcolm Baldrige Prize (1988) 1. Leadership Japanese Deming Prize (1951) 2. Strategy 3. Customers A. Establishment of business objectives and strategies and top 4. Measurement, analysis, and management’s leadership knowledge management B. Suitable utilization and 5. Workforce implementation of TQM 6. Operations C. Effect of TQM 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”

How we improve Why we make what we make what we make A system capable of continual improvement How we make what we make

Need, aim Other Information Practitioners Technology Healthcare Healthcare Professional Services Administrative Support Clinical Support

Testing a change for improvement 4 5 Generalizable, Measurable + Particular à science-informed performance change, setting, context improvement practice 1 2 3

F ind a process to improve O rganize a knowledgeable team C larify current process U nderstand the variation S elect an initial change to test P lan a change D o it S tudy what happened D efine A ct to hold the gain, move on M easure A nalyze I mprove C ontrol

Value Compass Function Biology Satisfaction Cost

General Competencies of the ACGME (1999) 1. Patient care David Leach 2. Medical knowledge 3. Practice-based learning & improvement 4. Professionalism 5. Interpersonal skill & communication 6. System-based practice

Quality & Safety Education for Nurses (2007) 1. Patient-centered care 2. Teamwork & collaboration 3. Evidence-based practice 4. Quality improvement Linda Cronenwett 5. Safety 6. Informatics

ABMS Maintenance of Certification Standards (2015) Paul Miles 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

Old Question: New Question: What might we learn How might we from those who improve the value of regard never-ending the contribution that improvement as an healthcare service “enterprise-wide” makes to better effort? health?

Victor Fuchs 1968 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.

Elinor Ostrom 1933-2012 Nobel Laureate 2009 Harvey Garn, et al; Elinor & Vincent Ostrom, others: The coproduction of public services is an economical way of providing service, solving community challenges.

Community and society Healthcare system Co-execution Patients Professionals Co-planning Civil discourse Co-produced high value healthcare service Good health for all M. Batalden, et al

The coproduction of healthcare services 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.

A healthcare service: Knowledge, skill Relationship ............................................. Activity Habit, Vulnerability

Co-producing good services System(s) What might this mean? Patient/Client/TIFKAP Professional Co-execution (III) What might they Co-planning What might they do, contribute, (II) do, contribute, invite, offer? invite, offer? Civil discourse (I) What might systems do, contribute, invite, offer?

Patients Professionals Courtesy: Gautham Suresh

Chartering a project for learning/improvement--1 • Team Members : • Team Members : • Project Title: • Project Title: • Organization Name: • Organization Name: • Sponsor Name(s): • Sponsor Name(s): • What are we trying to accomplish, and how does that link • What are we trying to accomplish? Aim statement (How coproduction to organizational strategy? Aim statement (How good? For whom? By when? 1-2 sentences):; Reason for the effort good? For whom? By when? 1-2 sentences); Reason for the effort (Defines WHY; 4-5 sentences) ; Expected outcomes/benefits (Defines WHY; 4-5 sentences). How did you arrive at the aim statement (Defines WHAT specifically, still not HOW; 3-4 sentences) listed above? Did you engage patients and families in developing your aim? How does the reason for the effort link explicitly to the organizational strategy and the priorities of senior leaders? Expected • How do we know that a change is an improvement? outcomes/benefits and what we will learn about co-production (Defines (Identify outcome, process, and balancing measures; 4-5 WHAT specifically, still not HOW; 3-4 sentences) 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 lead to improvement ? (Initial changes, barriers, key stakeholders; 4-5 • What changes can we make that will illustrate coproduction sentences) REFERENCE TO A DRIVER DIAGRAM 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