This is going to be a big year - healthcare needs more change and innovation than ever! So one of my resolutions is to do more regular blogging. I will likely move to shorter blogs about news stories of interest, with a plan to distill them down to points which will be relevant to those interested in promoting innovative thinking and action in healthcare.
I'm going to start with two new stories that are more related than one might think - one on healthcare value, the other on snow removal.
How Measuring Outcomes Drives Innovation
I just read Michael Porter's latest NEJM essay entitled, "What is Value in Healthcare?". The key points are:
1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume. In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".
2. Measuring real outcomes is critical (what really happens to the person, not simply their lab values or process followed). For example, for a diabetic - real outcomes are whether someone loses their sight, needs to go on dialysis or has a heart attack (not what their HbA1C value is and how often it is checked). He defines these in an "Outcome Measures Hierarchy" that involves three tiers: Tier 1 (Degree of Recovery), Tier 2 (Time to Recovery) and Tier 3 (Sustainability of Recovery). This spectrum is what we really care about and encompasses both short and long-term outcomes, as well as "cycle time" (how quickly one gets to recovery).
3. The main purpose of measuring actual outcomes is to enable "innovations in care". He describes how measuring, reporting and comparing these actual outcomes are what allows us to think and act in innovative ways.
Dr. Thomas Lee follows up on Porter's essay with his own complementary one: "Putting the Value Framework to Work". He says, "When measurement is oriented toward what happened to patients instead of what services were performed, interesting challenges and opportunities arise." For example, he notes that their typical PCP reports included data on number of office visits and RVUs, but not on the number of ER visits and hospital re-admissions, nor on the cycle times for how quickly discharged patients are seen in follow up clinic. Dr. Lee also notes that "just the collection of such data requires organizational change and the weakening of walls between our silos", (which I assume he means is a good thing!). He notes that his system (Partners) is currently working on creating "value dashboards" for issues such as stroke, diabetes and colon cancer. They will identify "pause points" in patients care and define what should be routine at those points via checklists. That is basically what we have been developing with our Process Checklist System (we call them "Pathways") - for things like new diagnoses of Hematuria, Afib and Cancer - so I am a big can of that concept!
Paying plows by inch, not hour, can save a city’s snow budget (link to story)
The second story which caught my attention was an NPR interview I heard with the Mayor of small town in Massachusetts... and how they saved time and money by creating a value based system for snow removal. Apparently, the typical reimbursement mechanism for snow removal has been to pay for the amount of time to remove snow ("hourly rate"). Thus the incentive for truckers has been to go slow so they can charge more. The Mayor of Quincy changed the incentive to paying by the inch. The result is that they saved money AND the snow was removed more quickly! Yep - just common sense, and something that I'd like to see more of in the healthcare system as well!!!
Showing posts with label Checklists. Show all posts
Showing posts with label Checklists. Show all posts
Sunday, January 02, 2011
Monday, February 22, 2010
Checklists: Moving from Procedures to Clinical Care Workflow
I am a big fan of the Checklist philosophy (see past post reviewing this), as espoused by docs like Atul Gawande and Peter Provonost. And I like to combine that with the writings of Dr. Richard Bohmer (Designing Care) who talks about "Islands of Standardization" that stand out in a sea of unstructured medical thinking (those areas where docs need to take in a lot of info and make a decision). In other words, we should use checklists for those areas of clinical care that should be standardized... and be careful not to overuse them in places where the care cannot be as structured.
For example, as part of the Szollosi Healthcare Innovation Program , we have studied some "inflection points" in healthcare (i.e. A new and important finding that can have a large impact). Whereas traditional checklists focus on procedures, we have started adopting the concept to parts of the clinical care process. To help understand this, it's important to understand that the clinical care process has three basic phases:
1. The Initial Diagnosis Phase: : An "unstructured" time where the doctor takes in all history, physical exam, and test elements and decides on a "final diagnosis". To date, we have explored (in order of increasing complexity): Hematuria, Atrial fibrillation, and Cancer.
2. The "Workup" Phase: Once one of these "Diagnoses" has been decided by the physician, there is usually an "island of standardization" that often involves further testing and a consult to a specialist. For Atrial fibrillation, it involves getting a stress ECHO and a Holter monitor, and then seeing a Cardiologist after those tests are completed. We therefore created a "Checklist" within an EMR message that allows the doctor to send a note to our Care Coordination team. The doctor needs to choose the message type (called "PATHWAY - Atrial Fibrillation"), answer one question within the message (which helps decide how acute the problem is), and then send it to a coordinator who follows the directions of the message (e.g. set up the tests, and then the consult).
3. The Management Plan Phase: This is another unstructured time where the PCP or specialist reviews all the information and decides on the treatment plan. But note, depending on certain issues, it is possible to make this part somewhat standardized as well.
4. The Stable Follow-Up Phase: This is a very structured time where the patient is stable on their treatment plan and just needs routine follow-up care, such as checking some blood tests and vital signs every 6 months. This can often be done by an NP or even an RN, and the doctor is only notified if a patient's findings veer off course. This area is particularly ripe for Checklists.
In other words, we do not want to try and create checklists for the unstructured thinking part of the physician's job- that part is critical and is very hard to replicate or standardize- but the time it takes is relatively small. Unfortunately, physicians instead waste their valuable time on trying to remember the exact protocol for the workup phase, and helping their patients complete them as quickly as possible and make sure they do so in the right order. THAT is where a checklist helps, and even better if we can hand it off to a "lower level" person on our team! As the saying goes, make sure each team member is working to the top of their ability and licensure!
__________
Since we are on the topic of using Checklists appropriately... you should read this new article from HealthLeaders magazine: "Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems". Three great quotes from this article point to how we need to be careful in further understanding how to be successful with Checklists:
However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.
"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box." (Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins)
The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."
UPDATES
Medical Personnel Taking a Page Out of the Pilot Handbook
Dec, 2009: Medical personnel who used procedural checklists modeled after preflight checklists used by pilots were more likely to report safety-related incidents and feel empowered to address safety issues, according to an online report in the December 21, 2009 Archives of Surgery (PDF). After preoperative checklists were introduced to certain medical teams, their use rose from 75 percent in 2003 to 100 percent in 2007, the study found. The introduction of checklist-based programs, known in the aviation industry as "crew resource management programs," or CRMs, was accompanied by an increase in self-initiated reports of safety breaches among medical staff, from 709 per quarter in 2002 to 1,481 per quarter in 2008 among teams using the checklists.
For example, as part of the Szollosi Healthcare Innovation Program , we have studied some "inflection points" in healthcare (i.e. A new and important finding that can have a large impact). Whereas traditional checklists focus on procedures, we have started adopting the concept to parts of the clinical care process. To help understand this, it's important to understand that the clinical care process has three basic phases:
1. The Initial Diagnosis Phase: : An "unstructured" time where the doctor takes in all history, physical exam, and test elements and decides on a "final diagnosis". To date, we have explored (in order of increasing complexity): Hematuria, Atrial fibrillation, and Cancer.
2. The "Workup" Phase: Once one of these "Diagnoses" has been decided by the physician, there is usually an "island of standardization" that often involves further testing and a consult to a specialist. For Atrial fibrillation, it involves getting a stress ECHO and a Holter monitor, and then seeing a Cardiologist after those tests are completed. We therefore created a "Checklist" within an EMR message that allows the doctor to send a note to our Care Coordination team. The doctor needs to choose the message type (called "PATHWAY - Atrial Fibrillation"), answer one question within the message (which helps decide how acute the problem is), and then send it to a coordinator who follows the directions of the message (e.g. set up the tests, and then the consult).
3. The Management Plan Phase: This is another unstructured time where the PCP or specialist reviews all the information and decides on the treatment plan. But note, depending on certain issues, it is possible to make this part somewhat standardized as well.
4. The Stable Follow-Up Phase: This is a very structured time where the patient is stable on their treatment plan and just needs routine follow-up care, such as checking some blood tests and vital signs every 6 months. This can often be done by an NP or even an RN, and the doctor is only notified if a patient's findings veer off course. This area is particularly ripe for Checklists.
In other words, we do not want to try and create checklists for the unstructured thinking part of the physician's job- that part is critical and is very hard to replicate or standardize- but the time it takes is relatively small. Unfortunately, physicians instead waste their valuable time on trying to remember the exact protocol for the workup phase, and helping their patients complete them as quickly as possible and make sure they do so in the right order. THAT is where a checklist helps, and even better if we can hand it off to a "lower level" person on our team! As the saying goes, make sure each team member is working to the top of their ability and licensure!
__________
Since we are on the topic of using Checklists appropriately... you should read this new article from HealthLeaders magazine: "Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems". Three great quotes from this article point to how we need to be careful in further understanding how to be successful with Checklists:
However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.
"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box." (Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins)
The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."
UPDATES
Medical Personnel Taking a Page Out of the Pilot Handbook
Dec, 2009: Medical personnel who used procedural checklists modeled after preflight checklists used by pilots were more likely to report safety-related incidents and feel empowered to address safety issues, according to an online report in the December 21, 2009 Archives of Surgery (PDF). After preoperative checklists were introduced to certain medical teams, their use rose from 75 percent in 2003 to 100 percent in 2007, the study found. The introduction of checklist-based programs, known in the aviation industry as "crew resource management programs," or CRMs, was accompanied by an increase in self-initiated reports of safety breaches among medical staff, from 709 per quarter in 2002 to 1,481 per quarter in 2008 among teams using the checklists.
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