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

Flight crew and nursing team

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

Crew Resource Management

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