vårdprogram – en god gammal idé neuropediatriska föreningens vidareutbildng 13-14 jan 2005

13 januari 2005 Mats Brommels, Helsingfors universitet och Karolinska Institutet

Vårdprogram – en god gammal idé

Neuropediatriska föreningens vidareutbildng 13-14 jan 2005

• Historien: Berg- och dalbana med platåfas?

• Idén i en tredje nytappning

• Utmaningen: praxispåverkan

• Genombrottet: integrerat informationsstöd?

13 januari 2005 Mats Brommels, Helsingfors universitet och Karolinska Institutet

Recycling

• Att återanvända är inte bara tillåtet utan rentav lovvärt (okänd tänkare)

13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet

From care programmes to clinical protocols and evidence-

based guidelines -1

• The 1970’s and 1980’s:– Decision support (algorithms)– Blueprints for collaboration (”chains of care”,

seamless care) – Diabetes, stroke, heart failure, cancer treatment



based guidelines -2

• The 1990’s:– Disease management and managed care

(reducing practice variation and restricting resource utilisation)

– Evidence-based medicine



based guidelines -3

• The first millenium decade:– ”Management by guidelines”– Clinical management improving the quality and

efficiency of care


Medical managementThe Leadership Task

• To align goals and create co-ordination

• To secure an efficient use of resources and a high quality outcome

• To create conditions for innovation and renewal


Management economics

Input Process Output


Medical management:An economic appraisal model

Objective Process Output Outcome Benefit Services Health gain QoL

Efficacy – effectivenessInput Productivity

Efficiency


Efficient resource utilisation (1)

• Strategic level:– Aim: Best possible medical outcome, i.e. health

gain– Diagnostic work-up and treatment according to

scientific evidence and best practice– Evidence based choice of an effective clinical

strategy

• Operative level:– ...


Efficient resource utilisation (2)

• Operative level:– Aim: Optimal utilisation of resources and the

best possible quality (process view)– Minimisation of costs and complications in the

implementation of an effective clinical strategy – Control by the use of clinical care protocols


Management control: ”Evolutionary stages”

• Budget control – ”management by budgets”

• ”Frame budgets” – decentralised cost responsibility

• Management by objectives

• ”Management by results” – profit centres

• Activity-based management – ”management by guidelines”


Political decision-makers

Management

Input Output


Political decisionmakers

Management

Input Output

Budget

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Total costs



Management

Input Output

Budget - FRAME OBJECTIVES

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Total costs



Management

Input Output

Budget Services provided

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Income

./. Expenditure

Profit/loss

Total costs



Management

Input Output

Budget Services provided

Cost items

-Personnel

-Material

-External services

-Capital charges

-Overhead

Activities

+Visits

+Admissions

+Hospital days

+Examinations

+ICU days …..

Total costs Care process


Input factors

1st order: Material resources – specified according to cost item

2nd order: Knowledge and competence

3rd order: Common goals based on shared values


Activity-based costing

• Process description of the clinical care (cf. quality and process management)– Care process: diagnostic, therapeutic, care,

rehabilitation and follow-up interventions in sequential order described in a flow diagram

• Basic concepts


ABC in radiology -1

• The radiological process: activities– Time scheduling and registration– Radiological procedure– Assisting procedure (moving patients,

preparations etc.)– Film developing– Radiologist’s statement– Clinical conference


ABC in radiology -2

• ”Standardised activities” (fixed cost driver)– Product development– Quality assurance– Teaching and research


ABC in radiology -3

• Resources (resource pools)– Radiologists– Radiology technicians– Secretaries– Auxillary personnel– Materials– Facilities– Equipment


ABC in radiology -4

• Activity drivers– Number of patients and procedures

• Cost drivers– Staff time (in minutes)– Materials consumed– Length of procedure (in minutes)


ABC in radiology -5

Conventional costing ABC

Overhead 318,000 (57 %) 75,000 (16 %)

Material and support 40,400 110,600

Rooms and equipm 93,800 136,600

Auxillary staff 58,000 150,600

Radiologists 52,400 83,500

Fluoroscopy Unit cost + 35 %

Ultrasonography Unit cost - 8 %

Plain radiography Unit cost + 7 %


Activity-based management (ABM)

• Process description of medical care (as defined by diagnosis and interventions)

• Activities: – Diagnostic and therapeutic interventions– Paramedical and administrative support services

• Activities define resources deployed by medical decisions

• Resource management: changes in “activity mix” based on the availability of resources


Changing professional practiceKnowledge-based interventions

• Self-directed, problem or action oriented learning

• Focus on problems from the practice• ”Academic detailing”: expert feedback and

advice• Efficiency requirement (Adult learning theory, experience from continuous

medical education)


Obstacles to change

• ”Comfort zone”

• Internal factors– Lack of knowledge, dissidence, missing skills,

uncertainty about effects

• External factors– Conflict with assumed patient benefit, lack of

resources, organisational barriers


Change of practice – a learning perspective

• Sense of problem perceived need for change

• Follow-up and reflection– data on own practice – comparisons – Expert feed-back (academic detailing)

• Removal of barriers to change


Evidence from systematic reviews – change strategies

Strategy # of reviews

# of studies

Conclusions

Trad education 13 3-37 Mixed effects

Interactive small groups

4 2-6 Mostly effective

Educational outreach

8 2-8 Effective for prescr/prevent

Feedback 16 3-37 Mixed effects

Reminders 14 4-68 Mostly effective


Evidence from systematic reviews – change strategies

Strategy # of reviews

# of studies

Conclusions

Computerised decision support

5 11-98 Mostly effective for prescr/prevent

Subst of tasks & multiprof coll

11 2-22 Mostly effective

TQM/CQI 1 55 Limited effects

Financial interventions

6 3-89 Fundholding & budgets effective

Combined 16 2-39 More eff than single int


Conclusions(Grol & Grimshaw 2003)

• Interactive and continuous education– Feedback on performance

– Local consensus

– Personal and group learning plans

• Built into daily practice• Clinical decision-support and reminders• Adjusting the organisation, care proceses,

resources, leadership and political environment


Knowledge management – the traditional way

• Building knowledge repositories

• Establishing employee networks and ”communities of practice”

• Encouraging information sharing

• Marginally successful(Davenport & Glaser, HBR July 2002)


Knowledge management in specialist organisations

• Integrate specialised knowledge into the jobs of the highly skilled workers

• Embed the knowledge into the technology that is used in practice– Examples: physician order-entry and

prescription systems


Partners HealthCare, Boston

• Support from opinion leaders

• Correct and up-to-date knowledge base

• Focus on truly critical work processes

• Final decision by the experts

• Culture of measurement

• Highly qualified informatics support

vårdprogram – en god gammal idé neuropediatriska föreningens vidareutbildng 13-14 jan 2005

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