Post on 01-Oct-2020
Doctor in the Cockpit
Diffusion of aviation innovations in hospitals
Dirk F. de Korne, PhD MSc Deputy Director, Health Innovation
Assistant Professor, Health Services Management & Organisation
Singapore Healthcare Management Congress, 19 August 2013
How safe are hospitals? (James 2000)
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Nr. encounters per death
To
tal n
um
be
r o
f d
ea
ths
an
n.
REGULATED DANGEROUS (>1/1000)
ULTRA-SAFE (<1/100K)
American
Hospitals
Mountain
Climbing
Bungee Jumping
Car
Driving
Chemical
Factories
Private Charters
Corporate Airlines
European Railways
Nuclear
plants
(Amalberti et al. Ann Intern Med 2005:756-64)
> In U.S. hospitals 44,000 - 98,000 annual deaths due to
preventable iatrogenic harm (IOM, 1999)
> 20-30% of hospitalized patients experience harm (Classen et al.
2011)
> 30% of U.S. health care expenditures are unnecessary or
wasted (IOM 2010; ibid. 2012)
> In Dutch hospitals annually 1,735 - 1,960 annual deaths due to
preventable iatrogenic harm
… and about 30,000 patients got serious iatrogenic harm (2.3%).
(De Bruijne et al., 2007)
What do we know about patient safety?
Human factors (knowledge, behaviour, skills): 56%
Organisational factors: 14%
Technical factors: 4%
Main causes adverse event hospitals (De Bruine et al.,
2007)
Tenerife, 27 March 1977
Latente failures
Latent failures
Active and latent failures
Organizational
Factors
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Plane collision
Failed or absent
defenses
Active failures
Accidental causal chain
(“Swiss cheese model”, Reason 1990)
System dynamics model for safety conditions
(“feedback loops”, Bouloiz et al 2013)
• Decrease of hierarchie co-efficient in the cockpit and
importance of team work
• Recognize personal limitations
• Disclosure of (near) incidents
• Standardization and checklists
>>> System & Culture Change
What has aviation learned since Tenerife?
• Innovation = ‘an idea, practice or objective perceived as
new by an individual, a group, or an organisation’
• Diffusion = ‘the process in which an innovation is
communicated, through certain channels over time,
among the members of a social system’
Diffusion of innovations (Rogers 1995)
Medical innovations diffuse slowly (Balas & Boren 2000)
• From research trial to clinical practice: 17 years
Spread and sustainability of innovations in health
services organisations (Greenhalgh et al. 2005)
Framework for analysis (Greenhalgh et al. 2005, adapted)
Quality
dimension(s)
Quality issue Type(s) of industry
with comparable
experience
Model
Efficient
Accessible
Patient centered
Safe
Process orientation Manufacturing,
Aviation
Process
Reengineering
Safe Safe design of operating
areas
Offshore, Aviation Marking
Safe Awareness of risks and
unsafe conditions
Aviation Crew Resource
Management
Efficient
Effective
Accessible
Patient centered
Costs of non compliance Manufacturing Quality Costing
Efficient
Effective
Accessible
Patient centered
Process orientation Manufacturing,
Automobile Industry
Value Chain
Efficient
Effective
Performance assessment Printing Benchmarking
Learning from quality experiences in other sectors
Patient
Traveller
Taxi
service
Planning
system
Critical
check
points
Time
out
Crew
Resource
Managem
ent
Black
box
Diffusing Aviation Innovations in Hospitals
Corporate philosofie (‘why?’): Fear reduction
Marking
de Korne et al. JCJ 2010:339-47
Application philosophy KLM planning
reservation
seat on plane
=
reservation of
consult
or
reservation of
surgery
Rotterdam Eye Hospital, Netherlands
Fear Reduction
Rotterdam Eye Hospital - Figures
• 145,000 outpatient visits (510 p/day)
• 14,000 surgeries (50 p/day)
• 4 OR’s + 2 Daysurgery OR’s
• 9 beds
• 93 % daycase
• 50 % outside of Rotterdam
• 26,000 emergency visits (70 p/day )(7/24)
• 25 outpatient rooms
• 400 employees
• 30 ophthalmologists + 20 residents
• care, teaching & research
World Association of Eye Hospitals
> choose organizations your doctors esteem
> exchange of staff members
> make the nurse your consultant
> stimulate implementation in professional organization
> benchmark results
Learning from peers in your own sector
Singapore National Eye Centre
Singapore National Eye Centre - Figures
• 280,000 outpatient visits
• 36,000 surgeries
• 9 OR’s
• 0 beds
• 98% daycase
• 30 outpatient rooms
• 560 employees
• 64 ophthalmologists + 20 residents
• care, teaching & research: SERI
• national centre, part of SingHealth
Safety Improvement: Risk Analysis & Management
26-9-2013 The Rotterdam Eye Hospital 29
Effects of a ‘Time Out’ before surgery
Developments in (Near) Wrong Side Surgeries
0
2
4
6
8
10
1996
1998
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Nu
mb
er o
f (N
ear)
Wro
ng
Sid
e S
urg
erie
s
5000
7000
9000
11000
13000
15000
Nu
mb
er o
f S
urg
erie
s
Wrong Side
Sentinel
Events
Reported
Near Wrong
Side Events
Number of
Surgeries
Introduct
ion Time
Out
Procedure
Extra
Pre-Op
Checks
de Korne et al. JCJ 2010:339-47
Crew > Team Resource Management
Safety audits of processes and (team) activities and feedback by aviation experts
Classroom training sessions and lectures on safety awareness and human factors by aviation experts
Video recording of (team) activities and feedback by aviation experts (black box)
Flight simulator session Boeing 737-800 with feedback on team
Team Resource
Management
Seduction
26-9-2013 Het Oogziekenhuis Rotterdam 36
Pilot and physician
Eye Care Air
“The modern-day flight attendant is
more like a safety professional,
almost a different profession from
that what it was in the 1950s and
1960s when American stewardesses
were celebrated icons of American
womanhood”
SIA stewardess Ms Ong
Teng Teng (37) was inspired
by the way nurses cared for
her son Lukas when he had
to undergo surgery as a baby
“When I was flying, I was
happy for myself (..) now I am
satisfied when I can nurse a
patient back to health.”
26-9-2013 The Rotterdam Eye Hospital 42 26-9-2013 Het Oogziekenhuis Rotterdam 42 26-9-2013 The Rotterdam Eye Hospital 42
Flight Data
Recorder
start
Team training improves safety culture
Advances in Health Care
Management 2013;14:95-117.
26-9-2013 Het Oogziekenhuis Rotterdam 48
Launch of tower top section in action
Safe system design
Safe design Safe system design
Are the surgical instruments positioned
correctly?
6,1
10,7
36,1
52,1 53,8
0
10
20
30
40
50
60
sep-08 mar-09 mar-09 oct-09 jan-11
not marked not marked marked marked marked
% o
f su
rgic
al cases
p<0.001
de Korne et al. BMJ Qual Saf 2012:746-52
Risk management is related to context
Appendicitis surgery,
Izi, Nigeria
System approach: pilot vs. doctor selection
Pre-screening on non-technical skills
Checklist Professional Profile
- Resilience - Dominance
- Stress tolerance - Assertiveness
- Impulse control - Openness
- Ambition - Need for variation
- Accurary - Teamwork
- Perseverance - Altruism
- Autonomy - Empathy
- Persuasiveness
COMPASS
Control & coordination
Slalom
Orientation
Multi-task management
Mathematics
Short term memory
Computerized Pilot Aptitude Screening System
0
1
2
3
4
5
6
7
CONTROL SLALOM MEMORY MATH ORIENT TASKMNGR
OOGZH
NL
Preliminary scores: n=97 physicians vs. n=715 pilots
Preliminary CPP results (N_physicians=98;
N_KLMpilots=715; N_Emiratespilots=2,133)
n=97 physicians)
Preliminary CPP results (N_surgeons=98;
N_KLMpilots=715; N_Emiratespilots=2,133)
System approach: patient in the lead
11-item post-retinal surgery discharge checklist
DOMAIN ITEM
A. Physical safety 1. Posture advice
2. Eye protection
3. Activities of daily living (ADL)
B. Medication safety 4. Prescription checked
5. Eye drops administering
6. Medication reconciliation
C. Post-op hospital contact 7. Emergency
8. Complaints
9. Follow-up visit
10. Helpdesk
D. Patient peer community 11. Retina patient forum
Patient peer community
Post-op hospital contact
Medication safety
Physical safety
Non checked post-surgical information
items
AV=10.8% AV=10.8%
Vankan et al. submitted
System approach: standardisation and spread
Intensive collaboration
of ophthalmic departments
in Dutch hospitals
in order to improve the
quality of ophthalmic
care
by sharing knowledge
Integrated Eye Care Network:
12 hospitals, > 70 ophthalmologists
> 70 ophthalmologists
> 200 opticians & optometrists
12 hospitals
> 100 general practitioners
3 rehabilitation institutes
Currently moving to…
The I-bus
Comparable ‘right-siting’ questions in Singapore
Stable chronic eye patients (glaucoma, diabetic retinopathy)
[‘integrated care delivery value chain’]
Specialist Outpatient Clinic Primary Care Clinic
Ophthalmologist Non-Ophthalmologist
Centralized Decentralized
Many possible barriers for ‘right-siting’ (Venketasubramanian et al. 2008)
Patient: emotional attachment to specialist; greater confidence
in specialist; fear that is will be difficult to return, increased
cost if referred back post-discharge; proximity; etc.
Specialist: reduced confidence in non-specialist; income
generated by seeing patients; etc.
Non-specialist: feeling uncomfortable managing ‘complicated’
cases; lack of time; etc.
Health system factors: gap between primary care and hospital
care; reimbursement not aligned with care pathway; lack of
supporting ‘chain’ EMR; etc.
System dynamics modeling
Patients WithSpecialist
Outpatient Clinic
new patientsattrition soc
population PREVALENCE RATEOF EYE CONDITION
population witheye condition
potentialpatients
ENROLLMENTRATE
ATTRITIONRATE SOC
Ophthalmologistshiring
ophthalmologistattrition
ophthalmologist
ATTRITION RATEOPHTHALMOLOGISTS
AVERAGE VISIT PERPATIENTS PER YEAR
total soc visitper year
average workloadper ophthalmologists
desiredophthalmologist
Patients WithPrimary Eye Care
Clinics
referral to pec
indicated referralrate
potential referralto pec
FRACT ELIGIBLEFOR REFERRAL TO
PEC
attrition pec
ATTRITIONRATE PEC
INITIALREFERRAL RATE
TOTAL COSTPEC
averagecost pec
AVERAGE COSTPER PATIENT SOC
effect of cost onreferral
NonOphthalmologistshiring non
ophthalmologistsattrition non
ophthalmologists
AVERAGE VISITPER PATIENT PEC
total visit perprimary eye care
clinic
average workloadnon ophthalmologists
desired nonophthalmologists
REFERENCEWORKLOAD NON
OPHTHALMOLOGISTS
effect of averageworkload on referral to
pec
referral tosoc
ATTRITION RATE NONOPHTHALMOLOGISTS
indicated fracteligible for referral to
soc
clinicaloutcome
effect of clinicaloutcome on referral
rate of adherence to diagnosisand treatment protocals by non
opthalmologists
REFERENCEQUALITY OF CARE
INITIAL CLINICALOUTCOME
REFERENCE FRACTELIGIBLE FOR
REFERRAL TO SOC
effect of workloadon attrition soc
effect of workloadon attrition pec
REFERENCEWORKLOAD
OPHTHALMOLOGISTS
effect of pec onenrollment
Integrated Eye Care Model
ophthalmologist gap
TIME TO HIREOPHTHALMOLOGIST
non ophthalmologistsgapTIME TO HIRE NON
OPHTHALMOLOGISTS
attractiveness of primaryeye care clinics to referred
patients
waitingtime
quality oftraining
thoroughness ofdiagnosis and
treatment
effect offcompensation ofophthalmologists
compensation ofophthalmologists
consultation time perpatient
effect of quality of care onattrition of non
ophthalmologists
SEED and SiDRP DATA
HOSPITAL ADMIN DATA
PEC and HOSPITAL ADMIN DATA
Example: existing data from SiDRP study
4. Report and
recommendation to
Clinicians
2. Image transmitted to SAILOR
Tele-Ophthalmology
3. Image grading
L
1. Image capture sites • Polyclinics
• Optometrists
• General Practitioners
Pilot service to GPs, private healthcare
groups, optometrists in Singapore and
overseas
Conclusions: diffusion of innovations
• Methods not copied, but adapted to fit the local context
• ‘Open innovation’ and ‘co-creation’: use industry experts
and collaboration to ‘seduce’ hospital professionals
• Integration of ‘clinical’ – ‘admin’ – ‘research’ perspectives
in professional organisation (‘user system’)
• Systems approach request systems expertise
‘Divided house’
However,
patient value =
health results / dollar =
integration
Spread and sustainability of innovations in health
services organisations (Greenhalgh et al. 2005)
Look forward!
Thank you!
Dirk de Korne
E dirk.de.korne@snec.com.sg
T +65 6322 7497