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@neel_shah System Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP

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Page 1: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

@neel_shah

System Complexity and the Challenge of Too Much Medicine

Neel Shah, MD, MPP

Page 2: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Cap

abili

ty

Too Little

Too Much

Time

Page 3: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

United States Cesarean Deliveries, 1970-2010

Page 4: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

United States Cesarean Delivery Rate (%)

0

5

10

15

20

25

30

35

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Healthy People 2000: 15% CD Rate

Electronic fetal monitoring saturates market

Trial of labor after cesarean promoted

Page 5: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

United States Cesarean Delivery Rate (%)

0

5

10

15

20

25

30

35

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Healthy People 2000: 15% CD Rate

Electronic fetal monitoring saturates market

Trial of labor after cesarean promoted

Page 6: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 7: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 8: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Why is the facility a woman delivers at her biggest risk factor for major surgery?

How can we help hospitals improve?

How can we help patients choose better hospitals?

Page 9: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 10: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

73.2% emphasize their choice of OB/midwife over hospital

Page 11: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

66.5% expect their OB/midwife will deliver their baby

Page 12: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

55.1% do not believe their choice of hospital will impact their chance of CD

Page 13: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

74.9% understand that quality of care varies across hospitals—few value existing metrics

Page 14: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

C‐sectionRate

MaternalBirth

TraumaRate

NeonatalBirth

TraumaRate

ObstetricInfectionRate

GeneralHospitalQuality

Somewhat/VeryImportant

Notimportant/Don'tKnow

Page 15: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

What makes Hospital A different from Hospital B?

Management

Page 16: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 17: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 18: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 19: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 20: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 21: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

• Clinical Protocols• Productivity Incentives

• Backup Coverage Policies

WORKLOAD

Pressure Builds for a Delivery DecisionThree system factors that influence the decision between Vaginal vs. Cesarean Delivery

PRESSURETANK

CAPACITY

Cesarean Delivery

• Delivery Volume/LDR Bed Ratio

• Nurse Staffing Model

• Shift Length

• Hiring Practices• Talent Developmentand Retention

• Employee Satisfaction• Performance and Consequence Management

Vaginal Delivery

MOTIVATION

2 hrs.Of Clinical Attention

RELEASEVALVE

20 hrs.Of Clinical Attention

Page 22: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Key:

24.6%

TeachingNo Midwifery

27.7%

No TeachingNo Midwifery

23.5%

No TeachingMidwifery

11.7%

No TeachingMidwifery

32.6%

TeachingNo Midwifery 16.1%

No TeachingMidwifery

20.7%

TeachingMidwifery

27.9%

TeachingMidwifery

500‐2,500 births per year

2,500‐5,500 births per year

5,500‐11,000 births per year

21.6%

TeachingMidwifery

Page 23: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Patient Level ModelINPUTSINPUTS

Patient Covariates:• Age at admission• Age squared• Race (16.4% missing)• Interaction of age & race• Payer (3.3% missing)• MS-DRG

Hospital Covariates:• Teaching Status• Total Deliveries (2013-

2014)• NICU Level

Hospital Management:• Capacity• Workload• Motivation

OUTPUTSC-section Rates / Length of Stay / Adverse Outcomes

Page 24: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Structure Process Outcome

(management)(design)

Page 25: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 26: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 27: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 28: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much
Page 29: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Room Demand vs. Cesarean Rate

10%

20%

30%

40%

Ces

area

n R

ate

300 450150

Annual Deliveries per Labor & Delivery Room

Page 30: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

What improved knowledge, skills, and/or toolsto managers need to run better labor and delivery units?

Case scheduling strategies

Nurse workload measurement

Dynamic bed management

Page 31: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

Next Steps: Management Intervention

Stakeholder Consultation

Rapid‐cycle intervention testing and feedback

TEST

Prototype

Expert Consultation

Page 32: System Complexity and the Challenge of Too Much Medicine - Neel Shah.pdfSystem Complexity and the Challenge of Too Much Medicine Neel Shah, MD, MPP. Capability Too Little Too Much

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