Vårdprogram – en god gammal idé Neuropediatriska föreningens vidareutbildng 13-14 jan 2005
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Transcript of 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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
From care programmes to clinical protocols and evidence-
based guidelines -2
• The 1990’s:– Disease management and managed care
(reducing practice variation and restricting resource utilisation)
– Evidence-based medicine
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
From care programmes to clinical protocols and evidence-
based guidelines -3
• The first millenium decade:– ”Management by guidelines”– Clinical management improving the quality and
efficiency of care
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Management economics
Input Process Output
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Medical management:An economic appraisal model
Objective Process Output Outcome Benefit Services Health gain QoL
Efficacy – effectivenessInput Productivity
Efficiency
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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:– ...
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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”
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Political decision-makers
Management
Input Output
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Political decisionmakers
Management
Input Output
Budget
Cost items
-Personnel
-Material
-External services
-Capital charges
-Overhead
Total costs
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Political decisionmakers
Management
Input Output
Budget - FRAME OBJECTIVES
Cost items
-Personnel
-Material
-External services
-Capital charges
-Overhead
Total costs
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Political decisionmakers
Management
Input Output
Budget Services provided
Cost items
-Personnel
-Material
-External services
-Capital charges
-Overhead
Income
./. Expenditure
Profit/loss
Total costs
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Political decisionmakers
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
Input factors
1st order: Material resources – specified according to cost item
2nd order: Knowledge and competence
3rd order: Common goals based on shared values
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
ABC in radiology -2
• ”Standardised activities” (fixed cost driver)– Product development– Quality assurance– Teaching and research
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
ABC in radiology -3
• Resources (resource pools)– Radiologists– Radiology technicians– Secretaries– Auxillary personnel– Materials– Facilities– Equipment
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
ABC in radiology -4
• Activity drivers– Number of patients and procedures
• Cost drivers– Staff time (in minutes)– Materials consumed– Length of procedure (in minutes)
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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 %
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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)
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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)
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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
13 January 2005 Mats Brommels, University of Helsinki and Karolinska Institutet
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