Plan for Call 3 - ICHOM

Change management on the ground Breakout Session

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Format Topic

Time

1. Introduction to the session and our panelists

13:30 – 13:35

2. Panel Presentations

13:35 – 14:20

• Boston Children's Hospital • Aneurin Bevan University Health Board

• Great Ormond Street Hospital • Erasmus MC 3. Audience Q&A and panel discussion

14:20 – 15:00

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Our Panelists today:

Carolyn Rogers-Vizena

Adele Cahill

Guy Thorburn

Jan Hazelzet

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Cleft Lip/Palate Standard Set: The Boston Children’s Hospital Experience

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Our hospital

Quaternary referral center in Boston, USA ▪ 404 pediatric beds ▪ Satellite hospital + OR ▪ >12 satellite clinics ▪ Community affiliations ▪ Harvard Medical School

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May-Nov 2014: CL/P working group Conditions Covered Cleft lip | Cleft palate | Cleft lip and alveolus | Cleft lip and palate | Robin sequence | CL&P with other congenital anomalies Treatment approaches covered Audiology | Otology | Nursing | Speech/Language | Genetics | Feeding/Nutrition | Surgery (Plastic) | Pediatrics | Social work | Oral-maxillofacial surgery | Dentistry Orthodontics | Psychology/ Psychiatry

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The Working Group recommended key measurement time points

Baseline index event (first doctor’s visit)

Surgical 3 months Intervention post operation

5 years

8 years

12 years

12 years

Baseline Patient-Reported Form

5 Year Clinical Form

Baseline Parent-Reported Form

8 Year Patient-Reported Form

Baseline Clinical Form

12 Year Patient-Reported Form

Baseline Administrative Form

12 Year Parent-Reported Form

Post-Operative Clinical Form


Post-Operative Administrative Form

22 Year Patient-Reported form

3 Month Clinical Form


5 Year Parent-Reported Form

22 Year Administrative Form

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Jan 2015: implementation strategy

Key strategic elements 1

Support and commitment from hospital leadership 2

Engage multi-disciplinary collaborators to serve as project Advisory Committee 3

Establish a Core Team to move project forward 8

BCH Advisory Team: Multidisciplinary    

Audiology Dentistry Feeding / Nutrition Genetics

Quarterly Meetings

 IT / ISD       

Nursing Oral Surgery Orthodontics Otology Pediatrics Plastic Surgery Program for Patient Safety and Quality  Psychiatry / Psychology  Social Work  Speech / Language 9

Feb-July 2015: data collection strategy

Core team assessed data collection strategies

Medium tech

   

vs.

Low tech

vs.

High tech

Integrate with medical record Electronic PROMs Automate as much data collection as possible Outside vendor to streamline process 10

November 2015: collect PRO’s

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November 2015: PRO parent feedback

“I thought it was great! I’ve never thought to ask those type of questions.” “It was a great distraction!” “I really didn't know how he truly felt about his face until he took it. So I have to say it opened my eyes to his insecurities. Thank you.”

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BCH Experience: current status

Working on IT integration for clinical data Barriers to clinical data collection ▪ Infrastructure ▪ Financial ▪ Clinician time constraints and data entry fatigue ▪ Patient privacy and data security

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What could be improved next time

Start smaller then grow bigger ▪ Essential outcomes measures Start low-tech, introduce high-tech strategies based on need ▪ Start earlier ▪ Save money

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The key success factors 1

Commitment from hospital leaders ▪ Members who “bridge the gap” between hospital admin and clinical departments

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Motivated and engaged team members ▪ Primarily highly committed volunteers ▪ Core team with dedicated time

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Dedicated IT support

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Parkinson's Disease Standard Set: The Aneurin Bevan University Health Board Experience

Adele Cahill Assistant Director (Procurement) Programme Implementation Manager

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Aneurin Bevan University Health Board

Context  One of 7 Health Boards in Wales  An Integrated Health System  Serves 700,000 population  14,000 staff  1300 Doctors and 300+ GPs

 Turnover £1.2 Billion 17

WHY? Two key drivers for change: 1

National direction: Making Prudent Health care happen - Securing health and well being for future generations  Clear priority to develop and use international outcomes based measures to inform and drive change

2 •

Local UHB strategic vision: To ensure Value in Health Care  Allocating resources for the greatest benefit to patients across the whole system  Maximising the opportunities an integrated health system provides  Leading the way, with a culture to support this – a meeting of minds

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The Journey - Key factors ALREADY ENGAGED  Introduced to ICHOM via Director of Finance & Procurement

2014

2015

•

Participation in the Hip & Knee & Heart Failure Standard Set(s)



Capturing costing, various methodologies (TDAbc and PLCs)



April: Signed a Strategic Partnership Alliance with ICHOM



May : DoF/Medical Director signed up some willing staff with a real interest in making a difference to drive agenda forward (Triumvirate C/F/M)



June : Launched the Value programme within the UHB



June 2015: Agreed a pilot/proof of concept within Neurophysiology team



Oct : Go Live -standard set to measure outcomes in Parkinson’s 19

The Journey: Our Plan - Which Condition? Why? Why Parkinson’s? • Well circumscribed disease area • Managed in a limited number of clinical settings (1500 patients / 6 settings) • Potentially fewer logistical challenges as a starting point • Senior Clinicians wanting to participate somehow • Test in single clinic – NOT the whole pathway

Initial Aim/ Scope: • Test the use of the ICHOM Standard Set to measure outcomes (patient and clinician perspective(s) • Understand the IT solutions/challenges in doing so 20

The Journey: Our Plan – The phased implementation 1. June 2015: Project kick off 2. July – Sept 2015: Preparation Phase 3. Oct – Dec 2015: Go Live in DEV Environment - UAT 4. Jan - Feb 2016: Go Live in LIVE environment

5. March 2016: Start Small, Scale up and roll out

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The Journey: (1) Project Kick Off Meeting

Reservations from Clinicians

Our promise/ input

 Some clinical dialogue/engagement beforehand  Senior Consultant Dr Church keen to understand more ……. BUT wanted long term commitment, not an audit or short termism wanted to understand impact on current work flow  Clinical Nurse Specialist – sceptical Burden of measuring more - change for change sake Take time away from facing the patient - Tick box exercise  BUT agreed that if this would improve the patient experience /outcomes we should ‘give it a go’.

 Right amount of autonomy and freedom to act given by Executives. Be honest with our findings, support  Give confidence in the solution  Trust in delivering  Positive approach  Collaborative at every stage 22

The Journey: (2) Preparation Phase Process Mapping in pilot clinic:  Exercise was simple and well received  Capacity to provide support from a HCA was identified  Burden on clinician minimal , many items routinely collected  Majority of those not collected were to be reported by the patient

Solution

IT Assessment:  PCs in clinic a  HCA ability to use IT a  Capability IT in waiting room x  Three possible ways forwards

External provider

Internal Solution LOW TECH

Hybrid Approach

 Engaged early with IT & Informatics  One absolute! – MUST connect to PAS  Used tablet, enabled a single API in waiting room for Wi-Fi access (Low cost !)

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The Journey (3) – User Acceptance Testing

DEV Environment

 Volume testing before putting into LIVE Environment  Used period (4 wks) to get continuous feedback from patients  Made changes / refined the form week after week  E.g. size of text, terminology/language  Used period to get continuous feedback from clinicians  E.g. Dashboard setup – ‘So What!’

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The Journey (4) LIVE (January ‘16) LIVE Environment

 Audited data completion and storage of outcomes in warehouse  Clinical Engagement – allowed us back week after week to keep testing  Patient involvement – supported by Implementation manager, project support and HCA  Weekly forum to capture and rectify any issues, Clinician, Nurse Specialist, IT and Implementation Manager. SOME FINDINGS  Developing the E Form, more challenging than anticipated – perseverance of IT Third party involved from the IT side – hadn’t foreseen the challenges around pulling and pushing form  HCA support – Not consistent, intermittent – fundamental to the success 25

BARRIERS: or OPPORTUNITIES?

 IT (Always a challenge why should it be different this time?) Known Barriers

Other Barriers (Not expected) Observations

 Our choice  Confusion around which solution  Confusion in the market around offerings, state of readiness!  Burden of measurement

    

Restrictions with Clinic Environment Clinic Flow – Setting? HCA support Shared staffing Relationships - Patients, carers and family 26

SUCCESSES – It’s Working     

Patients like it, feel involved. Peer to Peer conversations in the Waiting Room Burden of Measurement – Minimal – Positive feedback CNS Data informing and prioritising the clinical consultation Outcomes are feeding through into PAS and data warehouse, ability to start reporting (when time is right)  Enabling Service Re-design – early changes impacting on patient experience.  Further transformation of services – considering cohorting /MDTs

Patient +/- Carer arrives in clinic waiting room

Patient / Carer completes PROM’s on tablet

Other outcomes pulled from admin data

Pt seen by Dr who can r/v outcomes in real time 27

LESSONS LEARNT – Moving On We now have understanding of

Next time we would

Our next Steps in Parkinson’s

   

The work, commitment The concerns The restrictions Realistic around the challenges

 

Improve interaction between work and the Service Better understanding of the IT constraints, commit dedicated IT support Be realistic around capacity and timeframes



    

And beyond



Completed assessment in 5 more clinics Introducing costing IT is working – considering scalability? Service reviewing Service re-design and transformation – cohorting patients/Booking systems …. Becoming business as usual - Sustainability Any beyond Parkinson’s ……….. A plan to implement in a range of other conditions using both the ICHOM and other tools in line with local and national programme(s) 28

Perseverance: Great Ormond Street Hospital

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Great Ormond St Hospital: Background

    

Tertiary/Quaternary Children’s Hospital 400 Beds One of 10 centralised Cleft Centres in UK Well-established history of Cleft Outcomes reporting Clinical Outcomes are a Hospital Priority

‘The child first and always’

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Great Ormond St Hospital: Key Lessons 1

Slow implementation of ICHOM ▪ Why? ▪ Collecting bad luck!

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Perseverance and Back-up plans

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Building implementation into ‘routine’ ▪ Sustainable ▪ Maintaining focus on quality

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Just keep swimming!

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Just keep swimming!

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Just so long as…

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Great Ormond St Hospital: Specific Challenges 3 surgeons, 4x major sick leave in 18 months Change in Trust leadership ▪ Chief Executive/Medical Director ▪ Dept managers & Management Structure

Pre-existing UK Cleft outcomes ▪ Quality Dashboard of (process) measures ▪ 25% of Cleft team time is outcome measurement ▪ CleftQ research approval (2 sites, 2 approvals)

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Great Ormond St Hospital: Generic Challenges

NHS focus on process measures:  Outcomes are much more difficult to measure consistently across sites than process measures  Harder to ‘cheat’

No money:  Reducing complications to save money (or resources) by saving patient harm is ‘no brainer’  BUT often takes initial resources with lag phase

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Journal for Healthcare Quality 37

Cost of Complications



10 palate repairs with major wound healing problems, matched controls, to age 5yrs



24 v 8 Clinic appointments



2 v 0 extra procedures, 4.8 nights extra inpatient



5 v 0 ongoing structural problems at age 5 (2 fistulae, 3 VPI)

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Great Ormond St Hospital: Hints and tips 1

Have a back-up plan

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Lo-tech first to prove concept

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Duplication of key roles for resilience? ▪ Clinical leads ▪ Executive sponsors

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Continuous monitoring of outcomes ▪ CUSUM/VLAD ▪ G Roberts, G Thorburn et al Burns (2012)

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Have a back-up plan!

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Have a back-up plan

2


3


4


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Data collection: start low tech

 High tech, computerised patient surveys seem the ideal option but… in our patients  Post clinic web-based survey 0/9  iPad during clinics 4/7 but poor feedback and completeness  Pen, paper, clipboard 25/25 complete  However patient database essential for targeting outcomes measurement

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Have a back-up plan

2


3


4


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Have a back-up plan

2


3


4


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Continuous monitoring

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Advantages of continuous monitoring

1. Early warning of potential issues 1. Early warning of data quality and return rates 1. Easy to use 1. Ability to improve final results

1.

Ability to focus on positive results and replicate them 47

Stepwise reduction of complications

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Value Based Healthcare (in Erasmus MC) Jan A. Hazelzet, MD PhD CMIO & professor in Healthcare Quality and Outcome Dpt of Public Health [email protected] @JanHazelzet

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Erasmus MC

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Erasmus MC

• • • • • • •

550.000 outpatient visits /y 1200 beds 13.000 employees 1.4 billion € turnover PhD theses: 243 (2015) Publications: 3397 (2015) Students: 3000 http://www.erasmusmc.nl 51

2018 Strategy: Our guiding principle is creating added value for the patient and society.

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Value Based Healthcare

Patient Centered

Best Outcomes

Lowest Costs

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Start Implementation of VBHC Q3 2014

Management & Organization

Product

Performance

Systems

&

&

&

Processes

Value

Resources

People & Culture

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Management & Organization  VBHC Ambition is part of corporate strategy  Legitimized by Board of Exec.  Discussed on a regular base by Board of Medical Leadership

 Commitment from Department Leadership

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Product & Processes        

Disease oriented – Team based – Full (hospital) cycle – Care path – Direct participation of patients – Determination of Outcome measures Choice of Instruments Blue print of support

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Systems & Resources  EMR in transition  Separate IT Platform: Data Capture Tool: LimeSurvey / GemsTracker https://gemstracker.org  Results apparent in the consultation room  Program is financed by separate budget  Team of methodological experts support in outcome instruments  Start of measuring costs by TDABC

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People & Culture  Enthusiastic team of consultants (Erasmus MC Center for VBHC)  The VBHC concept is known in the organization

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VBHC support in 5 sessions

Patient survey 1

1 Care path and Process measures

* Theory VBHC * Which Single Medical Condition * Care Path structure

Patient survey 2

2 Results hierarchy: Outcome Measures and Initial Conditions * Feedback patient surveys

3 Definitive Outcome Measures & Instruments * Determining outcome measures (max 10); * Determining most important

* Brainstorm and defining total set outcome measures

initial patient conditions

* Brainstorm and defining Initial conditions

* Defining network (inter)national for peer review / panel

* Choice of instruments

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Final Care- and Measure Path, Organizational Innovations & Project planning * Measure instruments in final care path * Defining tasks

5 Check on Metrics * After 1 month pilot adaptation of care path when necessary * Agreement on official launch

* Start implementation IT platform

Patient participation in the sessions

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People & Culture  Enthusiastic team of consultants (Erasmus MC Center for VBHC)  Communication of the VBHC concept  Broad positive acceptance  Use of outcome results in consultation room  Start of benchmark and improvement cycle

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Diagnoses VBHC in Erasmus MC 1st Half 2016

2nd Half 2016

1st Half 2017

Set Outcome Measures defined

Set Outcome Measures in development

Planned to start

Brain Tumors

Frail Elderly

NeMo (neurom. & mitoch. afw)

Bladder Cancer

Familiar hypercholesterolemia

Multiple sclerosis

Stroke

Cervix Cancer

Palliative Care

Breast Cancer

Pediatric Brain Tumor

Hemophilia

Turner Syndrome

Obstruction icterus

Auto-immune Diseases

Sickle cell

Pregnancy & Child Birth

Hemifacial Microsomia

Larynx Cancer

Head and Neck Tumors

Congenital Cardiac Anomalies

Cleft Lip Palate

Liver Insufficiency

IBD

Prostate Cancer

Peripheral Vascular Disease

Hip & Knee Replacement

Lung Cancer

Pediatric Cardio Thoracic Surgery

Macula Degeneration

Kidney Transplantation

Obesity

Liver Cancer Colorectal Cancer Alzheimer’s Disease Cataract

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Since April 2015

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 

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  64

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The World is not makeable  Life goes on (priority goes to: new building, new EMR, reorganization..)  Disease orientation: Responsibilities, Costs…  Care Path?  Team based: I do my part…..  Team leadership: who….  Registration burden: what to do with all the other indicators…  How to control the outcome instrument diversity (>20 diseases)  Licenses of all the instruments  Uneasiness / incompetence of discussing the outcome results with patients  Analysis and interpretation of the data is not that easy

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Next steps  Dashboard presentation with references for patient and physicians  Communication training  Team cohesion & skills support expertise  References for benchmarking  Methodology (PROMIS?)  Other languages, techniques etc. 67

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Thank you to our panelists and audience

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Plan for Call 3 - ICHOM

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