Vårdprogram – en god gammal idé Neuropediatriska föreningens vidareutbildng 13-14 jan 2005

1. Vårdprogram – en god gammal idéNeuropediatriska föreningens vidareutbildng 13-14 jan 2005 • Historien: Berg- och dalbana med platåfas? • Idén i en tredje nytappning • Utmaningen: praxispåverkan • Genombrottet: integrerat informationsstöd? Mats Brommels, Helsingfors universitet och Karolinska Institutet

2. Recycling • Att återanvända är inte bara tillåtet utan rentav lovvärt (okänd tänkare) Mats Brommels, Helsingfors universitet och Karolinska Institutet

3. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

4. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

5. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

6. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

7. Management economics Input Process Output Mats Brommels, University of Helsinki and Karolinska Institutet

8. Medical management:An economic appraisal model Objective Process Output Outcome Benefit Services Health gain QoL Efficacy – effectiveness Input Productivity Efficiency Mats Brommels, University of Helsinki and Karolinska Institutet

9. 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: • ... Mats Brommels, University of Helsinki and Karolinska Institutet

10. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

11. 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” Mats Brommels, University of Helsinki and Karolinska Institutet

12. Mats Brommels, University of Helsinki and Karolinska Institutet

13. Mats Brommels, University of Helsinki and Karolinska Institutet

14. Mats Brommels, University of Helsinki and Karolinska Institutet

15. Mats Brommels, University of Helsinki and Karolinska Institutet

16. Mats Brommels, University of Helsinki and Karolinska Institutet

17. Input factors 1st order: Material resources – specified according to cost item 2nd order: Knowledge and competence 3rd order: Common goals based on shared values Mats Brommels, University of Helsinki and Karolinska Institutet

18. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

19. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

20. ABC in radiology -2 • ”Standardised activities” (fixed cost driver) • Product development • Quality assurance • Teaching and research Mats Brommels, University of Helsinki and Karolinska Institutet

21. ABC in radiology -3 • Resources (resource pools) • Radiologists • Radiology technicians • Secretaries • Auxillary personnel • Materials • Facilities • Equipment Mats Brommels, University of Helsinki and Karolinska Institutet

22. ABC in radiology -4 • Activity drivers • Number of patients and procedures • Cost drivers • Staff time (in minutes) • Materials consumed • Length of procedure (in minutes) Mats Brommels, University of Helsinki and Karolinska Institutet

23. ABC in radiology -5 Mats Brommels, University of Helsinki and Karolinska Institutet

24. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

25. 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) Mats Brommels, University of Helsinki and Karolinska Institutet

26. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

27. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

28. Evidence from systematic reviews – change strategies Mats Brommels, University of Helsinki and Karolinska Institutet

29. Evidence from systematic reviews – change strategies Mats Brommels, University of Helsinki and Karolinska Institutet

30. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

31. 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) Mats Brommels, University of Helsinki and Karolinska Institutet

32. 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 Mats Brommels, University of Helsinki and Karolinska Institutet

33. 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 Mats Brommels, University of Helsinki and Karolinska Institutet