Australian Institute of Health Innovation

1. Australian Institute of Health Innovation Creating Value and Joy in the Clinical Microsystem Julie K. Johnson, MSPH, PhD Associate Professor and Deputy Director Centre for Clinical Governance Research Australian Institute of Health Innovation University of New South Wales Sydney, Australia 29 August 2013

2. Overview of Today’s Session • How do we define value in healthcare? • Value models and the implications for our work • Creating value and joy in the clinical microsystem

3. Value in Healthcare “Achieving high value for patients must become the overarching goal of healthcare delivery” “Rigorous, disciplined measurement and improvement of value is the best way to drive system progress” • Porter, M. N ENGL J MED 363:26. 23 Dec 2010

4. What is value in healthcare? • Hint: it’s not just about cutting costs and improving productivity • Value is defined as the health outcomes achieved per dollar spent • Value should always be defined around the patient’s needs Porter, M. N ENGL J MED 363:26. 23 Dec 2010

5. How do we measure value? • How do we assess whether value is improving over time?

6. A story about creating value and joy in healthcare • Christian Farman • diagnosed with renal failure at age 25 • An athletic man in good shape • “It was a big shock for me to get into dialysis.” • Farman received a kidney transplant, but in 2005 he was back on dialysis in the Ryhov County Hospital hemodialysis clinic in Jönköping, Sweden • He researched self dialysis and became convinced that if he could manage his own treatment, the side effects would disappear • He spoke with Britt-Mari Banck, a nurse in the clinic. Farman said to her, “You have to help me treat myself – I need to have control in my life.”    • Source: IHI Annual Report 2012, ihi.org

7. A story about creating value and joy in healthcare • Britt-Mari showed Farman how to use the dialysis machine, read and interpret lab results, and document his care in his chart • Within five weeks, Farman was managing his dialysis independently. The side effects decreased. • Others wanted to learn to manage their own treatment . . .

8. A story about creating value and joy in healthcare • Infection rates fell • “We were a community, and we didn’t feel we were sick anymore, because the treatment was so good” • Today, nearly 60 percent of the hospital’s dialysis patients are managing their own treatments. The hospital aims to increase that number to 75 percent. • Banck says, “It’s a very joyful thing.”

9. Value Models • Value Chain • Delineates a process • Providing effective treatment • Value Shop • Creates solutions to problems • Making the diagnosis • Value Network • Facilitates connections • Linking patients, healthcare professionals, processes, and the care giving environment • Nelson, et al, Value by Design, 2011 • Stabell and Fjeldstad, Strategic Management Journal, 1998

10. Value Models

11. Value is defined differently in each model • Value chains • The process works reliably every time • Professionals prepared to adhere to the process • Produce the service in a timely way (efficiency) • Value (solution) shop • Intensive application of customised knowledge • Value network • Creating and facilitating networks • Christenson et al, The Innovator’s Prescription, 2009

12. How is value illustrated in Christian’s story? • Christian’s story, and Rhyhov Hospital’s story, illustrates a “value network” • What is important in this model? • How would you measure value? • What would you improve?

13. Value models applied to healthcare • The delivery of healthcare is often organisedas a “shop” • Our current methods of improvement rely on redesigning the process or the “chain” • Perhaps the most potential for improvement is to focus on the “network”

14. Lingering questions • How do we design for value? • How do we evaluate value? • Is their a link between value and joy in work?

15. What brings us joy? • Study of 41 primary care teams from 37 academic health centres participating in a chronic care improvement collaborative • Collaborative team members asked to describe experiences caring for people with chronic illness and the effect of the improvement collaborative on teams and teamwork • 1145 narrative entries submitted • Members of teams that achieved highest performance on Collaborative indicators demonstrated an enthusiasm resulting from the work, environment, and interactions which we termed “Joy in Work” • Team members from teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures” • Johnson et al, Joys and Challenges in Improving Chronic Illness Care. Jgen Intern Med. Vol 25 (Suppl 4), 2010.

16. Joy in Work • Our data suggest • Improving specific clinical measures is meaningful for both the healthcare professional and the patient A patient that we have been calling weekly to titrate insulin came today with perfect sugars. She was happy and so were we. We called the nurses in to look at her logbook! It takes a village to take care of a patient. [Physician]

17. Joy in Work • Improved communication among team members and the recognition of non-physician team members contributing to the care of the patient also contribute to joy in work I am responsible for scheduling our diabetic patients for our Chronic Disease Management Visit Clinic... this is such an important task and a lot of our success hinges upon what I do. [Administrative Staff]

18. What next? • There are certain experiences that increase professional satisfaction and bring joy in work • The stories our healthcare professionals tell provide a platform for thinking about design and redesign or care • How do we feed these stories back into the improvement process to further enhance professional satisfaction and continue to improve outcomes for our patients?

19. Link Between Value and Joy • Improvement in value requires • measuring what is important to the patient, • teamwork • Sharing accountability for performance • Cooperation among providers • All hard to achieve when we work in departmental silos . . .

20. Clinical Microsystem • Small group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients • The clinical purpose defines the essential parts of the microsystem • Core team of healthcare professionals and support staff • Defined population of patients they care for • Information & information technology • Care processes • Equipment, environment • Processes, activities specific to accomplishing the aim

21. Community, Market, Social Policy System Self-care System Macro Organization System Individual caregiver & patient System Clinical Microsystem Systems within Systems . . .

22. Where Can You Find a Microsystem? • Everywhere! • A community based general practice • A cardiac surgery team • A dialysis clinic . . .

23. Microsystems are everywhere; however, some function better than others

24. What Are The Characteristics of High Performing Microsystems? • Leadership • Organizational Support • Staff Focus • Education and Training • Interdependence • Patient Focus • Community and Market Focus • Performance Results • Process Improvement • Information and Information Technology

25. Why is This Important? • The overwhelming amount of the daily work of providing care within a microsystem • The organisational boundaries of the microsystem reflect the appropriate level for measuring and improving value

26. Intersection of Value and Joy in the Clinical Microsystem • How do we design for, and evaluate, value and joy? • Value should always be defined around the patient’s needs • Patients, carers, and family members will have unique insights into the patient experience – we need to ask them • We need to elicit the stories, assumptions, and beliefs that people have about their illness, treatment of their illness, and living with their illness • We can’t create value without first creating a partnership

27. Thank you • J.johnson@unsw.edu.au