Transcript Clinical Management: Concepts and Models for Analysis

Vårdprogram –
en god gammal idé
Neuropediatriska föreningens
vidareutbildng 13-14 jan 2005
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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 januari 2005
Mats Brommels, Helsingfors
universitet och Karolinska Institutet
From care programmes to
clinical protocols and evidencebased 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 evidencebased 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 evidencebased 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 management
The 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
13 January 2005
Process
Mats Brommels, University of
Helsinki and Karolinska Institutet
Output
Medical management:
An economic appraisal model
Objective
Process Output
Services
Input
13 January 2005
Outcome
Health gain
QoL
Efficacy – effectiveness
Productivity
Efficiency
Mats Brommels, University of
Helsinki and Karolinska Institutet
Benefit
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
13 January 2005
Output
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)
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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 practice
Knowledge-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
13
# of
studies
3-37
Conclusions
Interactive
small groups
Educational
outreach
4
2-6
Mostly effective
8
2-8
Effective for
prescr/prevent
Feedback
16
3-37
Mixed effects
Reminders
14
4-68
Mostly effective
Trad education
13 January 2005
Mats Brommels, University of
Helsinki and Karolinska Institutet
Mixed effects
Evidence from systematic
reviews – change strategies
Strategy
Computerised
decision support
Subst of tasks &
multiprof coll
TQM/CQI
Financial
interventions
Combined
13 January 2005
# of
reviews
5
11
# of
Conclusions
studies
11-98 Mostly effective for
prescr/prevent
2-22
Mostly effective
1
6
55
3-89
16
2-39
Limited effects
Fundholding & budgets
effective
More eff than single int
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
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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
13 January 2005
Mats Brommels, University of
Helsinki and Karolinska Institutet