Evidence Based Management: The Role of Guidelines

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Evidence Based Management The Role of Guidelines
QI

• Escola Nacional de Saude Publica Sergio Arouca
• Fundacao Oswaldo Cruz
• Rio de Janeiro, RJ
• June 2004

Arnold D. Kaluzny, Ph.D. Professor of Health
Policy and Administration
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An Expert on Health Care Evaluates His Own Case
Who is this man?
1919 - 2000
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An Expert Evaluates His Own Care
Things wont improve until something is done
about the design of the system
The problem stems for a bit of myopia mixed
with ignoranceTheres lip service to quality and
goodness knows, propaganda, but real commitment
is in short supply
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An Expert Evaluates His Own Care
I think commercialization of care is a big
mistake. Health care is a sacred mission.It is a
moral enterprise and a scientific enterprise but
not fundamentally a commercial. We are not
selling a product. We dont have a consumer who
understands everything and makes rational
choices..
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The problem is the system and the system belongs
to management. Edward Deming
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What is Quality?
degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge IOM, 1990
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Health Care Quality The Challenge
In practice, the knowledge base for both
efficacy and effectiveness of many health
services is weak, our understanding of the link
between the process and outcomes of care and of
the relative importance of the science and art of
care is incomplete. (but getting
better) Kathy Lohr
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Improving Quality The Challenge
The efficacy of fewer than 20 of all customary
medical practices have been demonstrated with a
randomized clinical trial Berwick, 1989
80-90 of treatments have not been adequately
evaluated in controlled studies it is difficult
to overstate the importance of this issue. In a
field with uncertainty and doubt, the difference
between when in doubt, do it and when in
doubt, stop could easily swing 100 billion a
year. Eddy, 1993
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The IOMs Six Aims for Improving
Quality(Provided Focus)

• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable
• IOMs Committee on the Quality of Health Care
• in America, Crossing the Quality Chasm, 2001

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Approaches to Quality Management
Guidelines
CQI
JCAHO
Quality
TQM
EBM
Outcomes
HEDIS
Benchmarking
Breakthrough Improvement
Process
Structure
Academic Detailing
Disease Management
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How are we doing????
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What is EBM??

• The conscientious, explicit judicious use of
  current best evidence in making decisions about
  the care of patients
• Integrates individual clinical experience with
  best available available evidence from systematic
  research
• Uses the best evidence available in consultation
  with the patient to decide upon the option which
  best suits the patient

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Clinical Guidelines The NCI Experience(not
impressive)

• CHOP-NCI program designed to permit physicians
• who saw the majority of cancer patients to
  develop patient management guidelines for
  selected cancer sites
• Follow-up revealed that except for physicians
  most active in the the CHOP committee there was
  no diffusion to other physician or change in
  community practice patterns
• Ford et. al. JCO,1987

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Successful Guidelines Based on

• Evidence based formulated by key physicians
• Guidelines disseminated to all affected providers
  for critique
• Implementation includes direct feedback on
  physician performance and system performance
• Accountability for performance
• Peer pressure does not require financial
  reward/penalty
• Smith and Hillner, JCO,2001

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Further research needed

• Assess how guidelines are enacted in
  organizations beyond treatment eg prevention
• Ways to improve compliance of providers not
  committed to change
• Ways to improve accountability
• Smith and Hillner,JCO,2001

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Quality Improvement

• The challenges and opportunities of continuous
  quality improvement

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Professional Vs Managerial

• TQM OR TWT
• where
• TQM - Total Quality Control
• OR - Operations Research
• TWT - Total Waste of Time

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Total Quality Management

• An organized systematic approach to continuous
  improvement designed to focus on satisfying
  customer expectations, identifying problems,
  building commitment among personnel and promoting
  open decision making.

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TQM/CQI as a Managerial Innovation?

• Any program, product or technique which
  represents a significant departure from the state
  of the art of management at the time it first
  appears and which affects the nature, location,
  quality or quantity of information that is
  available in the decision making process
  John Kimberly

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ComponentsQuality Improvement

• Find and implement the best
• Find fault find solutions
• Process operators use measurement tools to
  eliminate inappropriate variation and to document
  continuous improvement
• A process is a series of linked steps designed to
  cause some set of outcomes to occur

James, Frontiers in Health Services Management1
993
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From small q to big Q

• Traditional view (q)
• Limited to operations
• Concern of specialists
• Based on meeting standards
• Tactical
• Stagnant concept

• Contemporary view (Q)
• Organization-wide
• Concern of everyone
• Based on meeting stakeholder needs
• Strategic
• Dynamic concept

James Dean, Kenan-Flagler School of Business
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Removal of Extrasystemic Cause
System Maintenance Will Prevent This
System Average
Level of Undesirable Attribute
Onset of Extrasystemic Cause
Time
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Gain is Quality With System Improvement
Old System Average System Average After Change
Level of Undesirable Attribute
Change to the System
Time
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The Quality Improvement Process
Diagnose the Process 1. Understand the
process 2. Identify the customers 3. Identify the
requirements 4. Analyze the problem 5. Identify
the root causes
Select a Process 1. Identify the problem 2.
Identify the departments 3. Define the problem 4.
Describe the problem 5. Identify the team 6.
Charter the team
Improve the Process 1. Select a solution 2.
Design the solution 3. Test the solution 4.
Address resistance 5. Implement the solution
Monitor the Process 1. Monitor performance 2.
Improve the process
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Features of CQI

• Customer is not just the patient or community
  ...but the many users of work processes including
  other health providers

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Features of CQI

• Identification / reduction of variation in work
  performance by inter-disciplinary teams requiring
  continuous and relentless improvement in total
  work process

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Features of CQI

• All personnel required to have a clear
  understanding of the work process and its
  relationship to the larger system

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Features of CQI

• Changes are based on the needs and desires of
  patients, clients and health professionals
  involved in the entire work process...not simply
  the prevailing values of providers

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Quality Control Methods

• Force Field Analysis
• Control Chart
• Run Chart
• Pareto Chart
• Check Lists
• Cause and Effect Diagrams
• Flow Diagrams

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Group Process Techniques

• Brainstorming
• Consensus
• Nominal Group
• Multiple Voting
• Rank Ordering

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Adopting CQI

• Inherent Contradictions
• Barriers

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Inherent Contradictions

• Participatory, decentralized yet managed
  top down
• Paradigm shifting yet
• adopting one unit at a time
• Requires low threat and job security yet
  organizations are under siege
• Adoption depends on results yet
• outcomes depend on adoption

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CORPORATE CULTURE

• Basic pattern of shared beliefs, behaviors, and
  assumptions acquired over time by members of the
  organization.

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PROFESSIONAL VS CQIAREAS OF CONFLICT

• PROFESSIONAL
• Individual responsibility
• Professional leadership
• Autonomy

• CQI
• Collective/Partici-pative
• Managerial/Partic-ipative
• Accountability/organizational

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Physician-Management Perspectives

• Organizational purpose
• Interpersonal skills
• Work orientation
• Leadership style
• Ethnic

Patient health 11 task collegial individual
welfare
Organizational survival 1N process /
design hierarchical utilitarian / collective
welfare
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IMPROVEImproving Prevention through
Organization, Vision and Empowerment

• Description CQI initiation in 44 primary care
  clinics( 22 intervention/22 control) to increase
  compliance with prevention guidelines
• Findings
• Rate of increase 6 in intervention clinics
• Great variation among clinics
• Eg., clinic could be high on mammography and low
  on all others such as smoking, PSA,colo-rectal
• Solberg,Kottke Brekke, 2006

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IMPROVEImproving Prevention through
Organization, Vision and Empowerment

• Lessons Learned
• High priority commitment to change
• Improving prevention not high
• Organization ability to manage change
• Keep it simple
• Substantive Change content
• Ability to make a difference
• Effective development implementation
• Inertia
• Time
• Reasonable but not too long

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The Role of Management To fix it !!)
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The Bottom Line is The Inevitability of
Re-engineering

• Within health care, some of our processes
  are so bad that we could spend the rest of our
  professional careers trying to continuously
  improve them. We need to throw them out and
  begin with a clean sheet of paper and make sure
  we understand what the elements of each of these
  processes are. We need to REDESIGN them to be
  effective in the long run.
• (Ellen
  Gaucher, 1994)

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WHAT IS ORGANIZATIONAL DESIGN?

• Organizational design is the arrangement of (and
  the process of arranging) activities, roles, or
  positions in the organization in order to
  coordinate effectively the interdependencies that
  exist and to improve the effectiveness of the
  organization.

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The Problem

• I was thinking of installing one of those
  openers over the weekend. The directions say,
  Make certain garage door is square and straight
  and that the garage floor is level. Directions
  always read like that. Is everything in your
  house straight, square, and level? If my house
  was straight, square, and level, I would never
  have to fix anything. What we all need is
  directions that tell us what to do when
  everything is crooked, off-center, and all
  screwed up.
• Andy Rooney

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WHY IS DESIGN IMPORTANT?

• Design provides a map reflecting past power
  struggles (clue for future events)
• Design provides basis for setting realistic
  limits within which a manager operates
• Design factors are important in affecting
  indicators of performance

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Implications for Quality!!

• Changing the process of care at the individual
  level is not the only nor necessarily the best
  means of improving quality of care. To the
  extent that structural characteristics (design)
  determine the quality of care, efforts to improve
  care in the long run through changing the
  structure of care (design) my prove to be more
  cost effective than short-run, quality assurance
  programs.
• Palmer Reilly,79

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LEVELS OF DESIGN
INDIVIDUAL POSITION Managers
WORK GROUPS Task Forces
CLUSTER OF WORK GROUPS Medical Staff Organization
TOTAL ORGANIZATION Hospitals
NETWORK OF ORGANIZATIONS Organizations Providing
Services for Geriatric Patients
SYSTEMS A System of Health Services
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LIMITS OF DESIGN

• Little agreement on what constitutes
  effectiveness
• Systemic study of design in health service
  organizations (a recent and limited phenomena)
• Inability to encompass technical, sociological,
  political, psychological factors involved in
  design and generate creative design solutions

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SYMPTOMS OF AN INAPPROPRIATEORGANIZATIONAL DESIGN

• Motivation or morale may be depressed
• Decision making may be delayed or of poor quality
• Conflict or lack of coordination
• Unable to respond rapidly/ innovatively to
  changing circumstances

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A FUNCTIONAL DESIGNNursing Home or Chronic Care
Facility
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FUNCTIONAL DESIGNAdvantage
Disadvantage

• Promotes skill specialization
• Uses resources full-time
• Enhances career advancement
• Facilitates sup/sub communication (share
  expertise)
• May raise intrinsic work satisfaction
• Consistent with high centralization/formalization

• Too rigid in turbulent environment
• Emphasizes routine tasks (short-term horizon)
• Foster parochial perspectives
• Reduces communication between departments
• Obscures accountability
• Stimulate interdepartmental conflict competition

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A DIVISIONAL DESIGNAn Academic Medical Center
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PURPOSEFUL/DIVISIONAL DESIGN

• Advantages
• Integrates clinical/support services
• Fosters outcomes perspectives
• Insures accountability
• Departmental cohesiveness
• MD control/autonomy
• Training of top management

• Disadvantages
• Inefficient use of skills
• Limits career advance of specialists
• Limits specialists exposure to other specialists
• Difficult performance evaluation
• Sub-optimization

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PRODUCT LINE/MATRIX DESIGN
Women's Care
Oncology
Cardiology
Rehabilitation
Product lines
Substance abuse
Long-term care
Health promotion
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NCI Division of Cancer Prevention
Peter Greenwald Director Leslie Ford Carolyn
Clifford Co-Acting Deputy Directors Leslie Ford
Assoc. Dir. for Clinical Research
Office of Preventative Oncology Douglas Weed,
Chief
FOUNDATIONS OF PREVENTION RESEARCH GROUPS
Community Oncology and Prevention Trials Lori
Minasian Chief
Chemopreventive Agent Development James
Crowell Acting Chief
Basic Prevention Science Peter Greenwald Acting
Chief
Early Detection John Gohagan Chief
Nutritional Science John Milner Acting Chief
Cancer Biomarkers Sudhir Srivastava Chief
Biometry Philip Prorok Chief
Coordinating Unit
ORGAN SYSTEM RESEARCH GROUPS Breast and
Gynecologic Cancer Karen
Johnson Chief Prostate and Urologic
Cancer Carolyn Clifford
Acting Chief Lung and Upper Aerodigestive
Cancer Eva Szabo Acting
Chief Gastrointestinal and Other Cancer
Ernest Hawk Chief
PROJECT TEAMS
October 10, 2000
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WHEN IS MATRIX ORGANIZATION APPROPRIATE?

• When the organization has more than one goal
• In a complex environment
• Where there are complex, innovative technologies
• When a variety of specialized and scarce human
  skills are required

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MATRIX DESIGN Advantage
Disadvantage

• May be temporary or permanent
• Makes specialized/functional knowledge available
  to all projects (maintain reservoir)
• Forces communication
• Legitimizes multi-source of power
• Can adopt to end changes
• High consensus decisions

• Difficult to introduce without supportive climate
• Increase role ambiguities (stress)
• Rewards political skills vs. technical skills
• Groupitis
• Prone to collapse during efficiency push

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A PARALLEL DESIGN
Board of Trustees (B1)
President (P1)
Functional Structure
Parallel Structure
Example Problems
Vice Presidents
Investigate need for new technology
A3
M3
M4
Examine incidence of drug loss
Middle Managers
A3
A4
Develop public relations strategy for a new
program
Firstline Managers
A2
M2
Develop continuing education programs for
physician managers
Service Providers
B1
P1
F1
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PARALLEL DESIGN Advantage
Disadvantage

• Good for problem solving under high uncertainty
• Flexible
• Improves inter-departmental relationships
• Leadership drawn from many levels

• Confusion who is running the organization
• May take over too much decision making
• Too many meeting/extra cost
• Loss of control by management

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ADDENDUM
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Strategies for Improved QualityOutcomes
Academic Detailing

• A constellation of principles and techniques
  that focus on physician behavioral change,
  including the use of market research to develop
  an understanding of motivational patterns of
  physician use, sociometric identification of key
  decision makers and use of basic learning
  techniques
• (Soumerai and
  Avorn, 1990)

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Clinical Practice Guidelines

• Systematically developed statements to assist
  practitioner and patient decisions about
  appropriate health care for specific clinical
  circumstances
• Most important attribute.. validity.. regarding
• Health and cost outcomes
• Strength of relationship between clinical
  recommendation and scientific evidence

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What are report cards?

• A summary of statistics (rate, ratio, frequency)
  that
• provides interpretation
• compares multiple organizations
• is publicly available
• is independently validated

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Report Cards are derived from measure sets

• Examples of Hospital Measure Sets
• Joint Commission on the Accreditation of Health
  Care Organizations (JCAHO) ORYX
• Quality Improvement Organizations (PROs)
• Agency for Healthcare Research and Quality
  (AHRQ) Healthcare Cost and Utilization Project
  (HCUP) Quality Indicators

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Quality Improvement Organizations Quality
Indicators

• Clinical Topics AMI, Breast Cancer,Diabetes,
• Heart Failure, Pneumonia and Stroke
• Indicators
• AMI- eg.,early adm asprin,beta blocker (medical
  records)
• Breast Cancer-Biennial mammography (Medicare
  claims)
• Diabetes-eg., Biennial retinal exam,lipid profile
  (Medicare claims)
• Pneumonia-eg., influenza vaccinations, approp.
  Antibiotics (medical record)

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Report Cards--No Escape???everyone is using (or
planning to use) them

• Medicare Choice
• Federal Employees Benefit Health Plans
• Purchasers/Employers
• State governments
• state health data agencies
• Medicaid Managed Care
• state insurance regulators/payers
• nursing home and home health regulators

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Public Reporting--A balancing act.
Patient Privacy
Timeliness
Proprietary Concerns
Clinical Information
Accuracy
Relevance
Administrative data
Fairness
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Resources

• Agency for Healthcare Research and Quality
  www.ahrq.gov
• Health Care Financing Administration
  www.hcfa.gov
• Joint Commission on the Accreditation of
  Healthcare Organizationswebsites www.jcaho.com
• American Association of Health Plans
  www.aahp.org
• National Committee for Quality Assurance
  www.ncqa.org

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JCAHO Selected Programs

• Compliance with Standards
• ORYX Integrates outcomes data with other
  performance measurements
• Began 1987------Launched 7/1/02
• Core Outcome Measures eg.,AMI, Heart Failure
• Staffing Effectiveness Standards-links clinical
  outcomes to specific staffing indicators

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JCAHO Staffing Effectiveness

• Clinical Service Indicators
• Adverse Drug Events
• Injuries to Patients
• Length of Stay
• Patient Complaints
• Patient Falls
• Pneumonia
• Postoperative Infections
• Skin Breakdown
• Urinary Infections

• Human Resource Indicators
• Overtime
• Nursing care hours / patient day
• Staff Satisfaction
• Staff Turnover Rates
• Staff Vacancy Rates
• Sick Time