The Ringerike Pilot Hospital Model - plus.rjl.se · comments on a flipchart 24. ... Pneumonia...

Special Advisor and Project Leader Tone Reneflot Thoresen

Senior Advisor Aleidis Skard Brandrud

The Ringerike Pilot Hospital Model: Helping the patients and the organization to

understand and manage

the processes of the patients journey

that flow through and between microsystems

1

Vestre Viken Hospitals Area

27 square kilometer

450 000 inhabitants

Ringerike Hospital

2

Vestre Viken Health Trust (is a unit of four hospitals)

Kongsberg Ringerike

Bærum Drammen

9 500 employees

3

Sogn og fjordane

Buskerud

Oppland

Til Valdres

Ringerike sykehus

Hallingdal sjukestugu

Buskerud

Oppland

RV 7

E 16

Hardangervidda

RV 7

Hemsedal

Norefjell

Geilo

Nordmark

Randsfjorden

Jevnaker

E 16 Oslo

Tyrifjorden

Ringerike hospital1000 employes75 000 inhabitants20 000 tourist a day

Hallingdal local health center120 km north of Ringerike

Ringerike HospitalHönefoss

4

The nomination

• May the 7th 2009 Ringerike Hospital was nominated as a National Pilot Hospital,

together with four other Norwegian hospitals.

5

The National Pilot Hospital ProjectThe five Pilot hospitals were funded and followed up by The Norwegian Ministry of Health and Care Services for two years to:

•guide the project according to the basic values of equal rights•mingle the Pilot hospitals for mutual learning,

•foster the Pilots hospitals’ influence on the national health care development.

6

Ringerike Pilot Hospital Aim

Transform the healthcare system to give the patients and the providers personal control over their situation, by providing

information, communication and education, and coordinate and integrate the care across silos.

CEO

7

A review of > 70 studies indicates that it is important to patients to achieve personal control

8

1999 Patient focused redesign

2003 Horizontal mesosystem development

with organizational adjustments

2004 Electronic mesosystem guidelines

2005 Balanced clinical monitoring

system development

2009 Transitional care system

development

The processbehind thenomination….no quick fix!

2010 Web-based patient

information system

1996 Strategy: Integrated multidisciplinary care

within and between microsystems9

THE BACKGROUND

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Lege

r

Pleie

Info

prø

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Stand

ard

Pårør

ende

Org

aniser

ing

Forut

sigb

arhe

t

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BOX 2 Continual improvement system

Success factor I: INFORMATION1. Provide continual and reliable information about best practice2. Provide continual and reliable information about current practice3. Benchmark systems and outcomes to others

Success factor II: ENGAGEMENT 4. Anchor the improvement work to the leadership at all stages5. Focus on and engage the patient and family in all stages of the improvement work6. Anchor the changes to the professional environment7. Engage the staff in all stages of the improvement work

Success factor III: INFRASTRUCTURE 8. Base the infrastructure on improvement knowledge9. Multidisciplinary improvement teams tailored to the topic 10. Develop a learning system tailored to the different target groups11. Develop a system to facillitate the improvement work12. Develop a follow-up system to secure sustainability

(Brandrud AS, Schreiner, A Hjortdahl P, Helljesen GS, Nyen B & Nelson EG. BMJ Qual Saf 2011).

A continual improvement system is needed

11

Aleidis Skard Brandrud 12


The BTS Model for Improvement

Act Plan

Study Do

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

(“Focus PDSA”: Langley, Nolan & Nolan 1994)


The BTS Model for Improvement

Act Plan

Study Do

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

(“Focus PDSA”: Langley, Nolan & Nolan 1994)

“Every system is perfectly designed to get exactly the results it gets”

(Paul Batalden)

“Improving healthcare means improvingsystems of care applying quality

improvement methodology”(Don Berwick, Institute for Healthcare Improvement)

The theoretical framework

Batalden & Stoltz 1993 Langley, Nolan & Nolan 1994

Continual improvement The model of improvementThe embedded

systems of healthcare

Nelson, Batalden & Godfrey 2007

Meso-system

Macro-system

Geopol.marketsystem

Self-caresystem

Ind. careg.& patientsystem

Micro-system

12

Everybody's taskis to contribute

to make this chain of

meetings as good

as possible



meetings as good

as possible

13

CEO

Healthcare is a complex

system

Most Norwegian hospitals are trying to make the care safer by building siloes to

provide more evidence based medicine, and to make the

organization look simpler and easier to manage from

a top-down perspective

14

One consequence of organizing the care in silos

• Healthcare is a complex (adaptive) system

• The complexity that is cleared away from the top of the organization by organizing the care in siloes,

… is still there…

• It is only pushed down and into the mesosystems.

• The microsystems are struggling with some complexity challenges….still are the most complex parts only visible in the mesosystems, where the patient and their families are travelling (alone).

15

The microsystems are trapped in silos

CEO

Team 1

Team 4

Team 7

Team 9

Team 12

Team 11

Team 13

OutpatientClinic

AdmissionDetection Treatment DischargePrimary

care nursePrimary care

physician

Team 14

Team 15

Team 16

Team 3

Team 17

Team 19

Team 20

Team 22

Team 26Team 2

Team 5

Team 6Team 8 Team

21Team 10

Team 23

Team 24

Team 25

A chain of microsystems is the patients mesosystem

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We need to know to what extend the microsystems are interacting

CEO

Studying adverse events

An analysis of 1158 patient complaints to the CEO of a Norwegian University Hospital from 1995 - 2001

4 %

35 %

5 %

24 %

32 %

35% Predictability32% Treatment/care24% Respect and dignity5 % Costs4 % Facilities


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“Always an other nurse or physician (asking the same questions). Conflicting information and conflicting performance.Inaccessibility, broken appointments, unpredictable waiting times, poor continuity/no follow up.

Poor communication and coordination of the care between settings. Adverse health consequences upon discharge because of poor discharge planning”

20

The National Patient Experience Study (2006)

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LegerP leie

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Pasienterfaringer somatiske avd. Ringerike sykehus, PasOpp 2006

Pred

ictab

ility

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The national study is only providing silo organized information about patient satisfaction

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We need to know the patient’s experiences with the mesosystem, or else we don’t know exactly what processes we need to improve

23

Data collection in focus group meetings from patients in a particular mesosystem

The critical Incident Technique (CIT)

(Gremler 2004, Brandrud et al 2011)

• Inviting patients and family from a specific mesosystem

• 2-3 focus group meetings

• We let the story telling move uninterrupted around the table

• The researcher is observing, not interviewing, but summarizes the comments on a flipchart

24

Kvantitativ studie av gyn-pasienters utsagnThen we make a questionnaire out of the respondents comments, and send it to a sample of about 200-

300 patients from the same mesosystem

25

Kvantitativ undersøkelse av de ansattes perspektiv på de samme pasienterfaringene

The same questionnaire is given to the staff, asking them to answer

what they THINK is the most common patient experiences in

that particular mesosystem

26

Comparing the patients’ and the providers’ priority of problems

Prior. pas Diff Prior ansatte Spørsmål1 -26 27 46. Tilbud - snakke ut m. jordmor om sykd.sit. eller annet sæ.viktig for deg?6 -16 22 54. Fikk du info om normale og unormale reaksjoner på sykdommen din?7 -24 32 25. Info selv kunne gjøre v tilbakefall eller ekstra skj. etter kom hjem?8 -24 32 44. Fikk du snakke med den legen som opererte deg etter operasjonen? 11 -16 27 24. Fikk du informasjon om hvilke plager du kunne regne med fremover?14 -47 61 48. I hvilken grad ble du vist rundt i avdelingen?16 -19 35 64. I hvilken grad fikk du snakke med legen før du ble utskrevet?

Prior. pas Diff Prior ansatte Spørsmål2 -3 5 53. Fikk du hjelp til å finne ut hva du burde spørre legen om? 3 -1 4 19. Hvis du måtte vente, f.d. beskj. om hvor lenge ventetiden ville vare?5 4 1 62. Var det tilstrekkelig med oppholdsrom for pasienter og pårørende? 10 3 7 13. Ihv.gr. oppl. du fast gruppe pleiepersonale som tok hånd om deg?12 -5 17 35. Fikk du anledning til å snakke med lege på tomannshånd?13 1 12 40. Fikk du snakke med den legen som skulle operere deg før operasjonen? 18 -3 21 60. Likte du værelsestemperaturen i sykerommet? 21 -4 25 12. Ihvgr hadde pleiepersonalet tid nok til deg når du trengte det?27 -4 31 17. F.d. inntrykk a a arbeidet på sykehuset virket godt organisert?30 -4 34 20. Ihv.gr.oppl.viktig info om d&d.t. kom fram til rette pers på shuset?34 5 29 42. Gjorde informasjonen før operasjonen deg trygg på det som skulle skje?38 -2 40 23. Enkelt for d nær. Pår. å f nødv info o.deg mens du lå på sykehuset?40 0 40 63. Varigheten av syke.h.oppholdet passe, ble du utskrevet til riktig tid? 48 1 47 22. Ihv.gr bl d pårørende tatt godt imot n.d.henv.s.t. pers. p sykehuset?54 2 52 32. Ble d møtt m høflighet og respekt av pleiepers på sengep du lå på?56 5 51 29. Hvis samme helseprobl. igj, ønsker behandl. på Ringerike sykehus?58 2 56 15. I hvilken grad hadde du tillit til at legene var faglig dyktige?

Prior. pas Diff Prior ansatte Spørsmål43 26 17 4. Ihv.gr. snakket legene til deg slik at du forsto dem?45 22 23 27. Oppl. d.a. sykehuspersonalet tok bestemmelser over hodet på deg?46 28 18 7. Hadde d ubesv.sp.m om med.d sk. ta da du ble utskrevet f.s.h?48 29 19 36. Gav sykehuspers. deg motstr. info om helseproblemet/behandl?54 30 24 9. Gjorde ressursmessige forhold (p.u.p.)gjorde at du f dårligere beh?56 37 19 45. Fortsatte å stikke i.v. i stedet for å tilkalle en som kunne det bedre? 61 60 1 59. Opplevde du at det trakk fra vinduene på sykerommet?

Områder som ansatte og pasienter har vurdert likt

Forbedringsområder som ansatte har undervurdert

Områder som oppleves som mye bedre enn de ansatte tror

Under-estimated problems

Equal estimated problems

Over-estimated problems

…information about what to do if you get a relapse, or get symptoms or health problems when you are back home?

…information about what symptoms or health problems to look out for after you left the hospital?

Patients’priority

Providers’priority

…adequate length of stay?

…did the physicians talk to you in an understandable manner?

27

Healthcare is a setting-centered system

28

Rehabilitation

GP

Communitynurse

EmergencyHospital

The patient is travelling in a chain of microsystems who are not sufficient integrated

29

“Every system

is perfectly

designed

to get the results

it gets”

Batalden & Stoltz 1993

We need to transform the system

30



meetings as good

as possible



meetings as good

as possible

31

1999 Patient focused redesign

1999 - 2005Multidisciplinary

microsystem teams are redesigning 60 different processes

32

A

Knee replacement care process

B

We wanted people to think process not function

C D E

No one isaccountable for thepatient’s “end toend” experience

organisational/departmental boundaries

Asthma care process

Chest pain care process

Hospital CEO

Ortopedic

Generell surgery

Internal medicine

Maternity

Gynecology

2003 Horizontal mesosystem development

Internal medicine

Mesosystem team (MET) heart diseases

COLD

Pneumonia

Mesosystem team (MET) pulmonary diseases

Chest pain

Heart failure

Team 1

Team 4

Team 7

Team 9

Team 12

Team 11

Team 13

OutpatientClinic



physician

Team 15

Team 16

Team 3

Team 17

Team 19

Team 20

Team 22

Team 26

The patient is the only person who know the whole journey through health care, so the MET’s define and describe the mesosystems based on focus group material together with patients.

Team 2

Team 5

Team 6Team 8 Team

21Team 10

Team 23

Team 24

Team 25

Patients and families belong to the MET’s

Information Information Information Information Information Information Information

Interaction Interaction Interaction Interaction Interaction Interaction

Competence

Patient get

symptomsVisit GP

Orthopedist Knee school

Hospitaladmission

Operation Rehabilitation

Discharge

Rehabilitation

Control

Team and aims

Documents and links

Abstract

Measurements Monitorering av praksis

2004 : The online mesosystem guidelines are based on generalizable scientific evidence + particular context

Total Knee Replacement

Mesosystem responsible physician: Accepted date:

Within 8 years an amount of 50 mesosystems were defined, and the organization was redesigned to be

able to coordinate the mesosystem interactions

Dismantling silos

2005 Balanced clinical monitoring system development

(Nelson, Batalden & Plume 1996)

39

We started with a pilot at the maternity ward

40

Freak point

Shift of level

Trend

The clinicians are learning to understand variation with statistical process control (SPC) by doing small tests of change

Looking for special cause variations like:

41

A Cardiotocography (CTG)- challenge

(Wikipedia)

During labour, when the midwifes are using CTG to analyzethe situation, they are

mandated by law to sign the paper with date and

time. Was this always done?

42

Monitoring - baselineXmR-diagram for %-andelen signerte CTG-registreringer

per pasient i ulike faser av forbedringsarbeidet

0

10

20

30

40

50

60

70

80

90

100

20 22 24 26 28 30 32 34 36 38

Sekvenser av 20 pasienter i kronologisk rekkefølge, sortert etter inntak

Pro

sent

Andelen signerte CTG Gj.snitt X Øvre kontrollgrense Nedre kontrollgrense

1. Baseline

Baseline: A mean of 40% of the CTG outputs for each of the 20 patient had been signed,

and the variation was big.

Sequences of 20 consecutive patients

43

I-chart: Percent signed CTG’s per patient during seven tests of improvement, Maternity ward 2005

XmR-diagram for %-andelen signerte CTG-registreringer per pasient i ulike faser av forbedringsarbeidet

0

10

20

30

40

50

60

70

80

90

100

20 22 24 26 28 30 32 34 36 38 243

246

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250

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701

703

705

707

709

711

713

715

717

719


Pros

ent


1. Baseline 2. og 3: Ingen sikker endring

• Six months later, •the mean increased from 41 to 73% (78%)• ..but, no shifts of level were found

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Still only common cause variations


An improvement cycleXmR-diagram for %-andelen signerte CTG-registreringer

per pasient i ulike faser av forbedringsarbeidet

0

10

20

30

40

50

60

70

80

90

100

20 22 24 26 28 30 32 34 36 38 243

246

248

250

252

254

256

258

261

263

701

703

705

707

709

711

713

715

717

719

199

201

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217

219

248

250

252

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499

503

505

507

509

512

514

516

518

520 74 71 69 67 65 63 61 59 57 55


Pro

sent


1. Baseline 2. og 3: nochange

4. Signifikant improvement vs

baseline

5. Sign. improvementvs phase 3, one

freak point

6. Two freak

points

7.No freak points

8. Everything else than 100%

is a special cause variation

i j

Sequences of 8 x 20 consecutive patients for each test

Per

cent

signed

CTG

’s


45

NB: Dichotomous data like this, do better on a

p-chart in the future

What was the secret of their success?

1. Training and certification

2. An updated control-chart on the whiteboard

3. More collaboration in the CTG-analyses among the midwifes

4. Personal follow up by the leader – No shame and blame!!!!

– But: How can we improve our system to make it easier for you to always sign the CTG’s?

46

Monitoring patient experiencesusing small questionnaires based on the qualitative and quantitative studies described above.

Index # 3 Emotional control, maternity mesosystem

The patients seem to have good emotional control

48

Clinical value compassDraft 2

Ringerike Maternity Ward 2007

(Nelson, Batalden & Plume 1996)

49

Team 1

Team 4

Team 7

Team 9

Team 12

Team 11

Team 13

OutpatientClinic



physician

Team 15

Team 16

Team 3

Team 17

Team 19

Team 20

Team 22

Team 26

The healthcare system is so complex, that we have to use

information technology to be able monitor, manage and improve the system

Team 2

Team 5

Team 6Team 8 Team

21Team 10

Team 23

Team 24

Team 25

The complex healthcare system

50

The mesosystem teams develop balanced measures (indicators) and dashboards to provide real-time

information to microsystems and leaders

Pasient

Mesosystem team (MET)

Dashboard

Microsystem teams

51

IntegrationDIPS NPR MFR

Satis-faction

.

Adverse events ...

Processing Data connected to clinicalkey process variables (indicators) SPC

Presentation

The electronic monitoring system is

bringing continual information based on real-time data from a

system of:

52

Real-time-monitoring example:Percent perineal tears 3 & 4 degree per vaginal childbirths per month

October2010

July 2009

Real-time monitoringstarted in August 2010

The x-axis is temporary invisible, a problem that soon will be solved by the contractor

Consecutive months from August 31, 2008 to January 31, 2011

53

2009 Transitional care system development

Rehabilitation

GP

Communitynurse

EmergencyHospital

54

Cross-site collaboration

• Develop a system for defining and describing micro- and mesosystems together with patient, family, primary care, general practitioners, social care and the hospital.

55

Transitional care, an example

• A rehabilitation care team from the hospital(ART) started in august 2008 to ambulate between the hospital and the primary care.

• The purpose was to build knowledge in the patients individual caregiver system about what to do when the patient gets symptoms and health problems when the patient is back home.

56

Test results on one of the target groups• The change was tested by interviews and measurements on

one of the target groups: Chronic obstructive lung disease (COLD).

• The interviews showed that the ward nurses are saving about 2 hours discharge work on each «ART-COLD-patient»

• Within one year, more than 50 physicians were referring patients to ART

• The primary nurse center reported that ART has made them able to avoid a lot of hospitalizations by giving the patient adequate home-care, in different situations they were not able to handle before.

Test result august 2010

Included: 21 COLD patients,with more than 12

months recorded history before and after start-

up ART in 2008.

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2010 Web-based patient information system

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www.hospitality.no/ringerike

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Vestre Viken Health Trust (is a unit of 4 hospitals)

Kongsberg Ringerike

Bærum Drammen

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Vestre Viken Health Trust is removing the local

hospital leadership, and building siloes across four

hospitals, to provide evidence based medicine to the patient, and make the organization look simpler

and easier to manage from the top

CEO

The challengeof complex healthcare organizations

62

Context + Mechanism = Outcome

• it is not possible to “spread” the Ringerike mesosystems to the other three hospitals in our new big organization.

• We need to learn to know the new context, and find out what mechanisms that work in this new, big setting, before we can start to build something new together.

• Even Ringerike hospital will not be the same as it was, because of large structural changes.

• But the continual improvement culture and system thinking at Ringerike is multidisciplinary and strong and is “sitting in the walls” (as we say in Norway) after all this years.

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