Improving the Reliability of Care and the Healthcare Culture

Twila Burdick has written an article on her interpretation of the Global State of Operational Excellence Survey Report - Critical Challenges & Future Trends - 2018/2019.  Click here to download the full Survey Report 2018/19.  

The Most Comprehensive Study of Critical Challenges and Future Trends within Operational Excellence

With nearly 1000 respondents, 37 insightful questions, detailed analysis & insights from 40 industry thought leaders, and the BTOES Insights executive team, this 130 page report is recognised as the most comprehensive study of critical challenges and future trends within Operational Excellence, and is considered a key resource for the industry. Areas covered include:

• The Critical Operational Excellence Challenges faced by executives.

• The Current Scope of Operational Excellence.

• How is Operational Excellence success measured?

• Key Findings & Roadblocks.

• What are executives focusing on over the next 12-18 months?

• What have been the greatest developments?

• What are the key drivers pushing change in Operational Excellence?

• Industry Perspectives.

• Small, Medium & Large Corporation Perspectives.

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• Detailed Analysis & Insights from 40 Industry Thought Leaders.

• Analysis of key themes, including Cultural Transformation, Customer Delight, Sustaining an Operational Excellence program, Need for end-to-end Business Transformation, Keeping up with new technologies/impact of digitalization and Leadership Buy-in & Understanding.

 

 

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Improving the Reliability of Care and the Healthcare Culture

As in the past, this year’s “The Global State of Operational Excellence” report provides an insightful snapshot of the issues facing organizations committed to reliably executing business strategy in pursuit of delighting their customers better than their competitors.  It is no surprise that changing company culture is at the top of the list, with 53.1% of the respondents identifying it as their most critical challenge. Click here to read the full Survey Report 2018/19. 

 

 

While changing culture is a problem for all industries, healthcare faces some unique challenges.  

Clinical care delivery is labor intensive with many people involved in performing different interdependent functions with a key role being that of the physician. Click here to read more Articles on The Global State of Operational Excellence: Critical Challenges & Future Trends - Research Report 2018/19.

Physicians are highly trained professionals who make diagnostic and treatment decisions, exercising individual professional judgement. This dependence on individual autonomy and performance, a deep cultural assumption, makes care reliability--doing the right things right—very difficult.

Healthcare has a profound effect on individual pain and suffering and because of that and its cost, there is significant interest in understanding how healthcare can be transformed.  Researchers have been studying change efforts that have worked and what has made them successful.

 

 

Health care researchers in 2016*presented a conceptual framework for analyzing the adoption of innovations in healthcare based on emerging implementation science identified four attributes that influence the adoption of innovations:

1. external environment

2. characteristics of the organization

3. characteristics of the innovation such as the quality of evidence

4. implementation process

In 2017**, social scientists reviewed a large-scale healthcare delivery improvement, the Michigan project to reduce central line infections, and concluded that the results could be attributed to implementing an evidence-based checklist along with cultural change as described by Dr. Peter Pronovost,  “creating clinical communities and influencing peer norms”. He said that changing clinical practice required both technical and adaptive factors, “the science must be robust, yet it must address values, beliefs, and attributes of the groups involved”, underscoring the importance of culture.

 

 

Banner Health

Banner Health, a regional healthcare provider consisting of more than 25 hospitals and other services with corporate offices in Phoenix, Arizona, assessed the healthcare environment and made a strategic decision to improve clinical care reliability. Recognizing the pivotal role of physicians in clinical decision making, it asked doctors to apply “evidence” from clinical research to care practices. An improvement process referred to as “Define-Design-Implement” (as shown below) provided a framework for the implementation.

 

Physicians were asked to join and lead multi-disciplinary Clinical Consensus Groups (CCGs) organized by medical specialty (e.g., obstetrics, emergency care).  Members of CCGs met regularly and identified “evidence-based practices”. Drawing on their training as scientists, CCG members read journal articles, consulted with professional societies, and met with colleagues to “define” the clinical conditions and their appropriate treatment. This part of the process focused on doing the right thing.

 

 

"Design", simulation and implementation 

Following agreement, clinical practices went through a “design” step to be sure that the details of what needed to be done could be put in place, including supplies, clinical automation, staff training, and more. Whenever possible, computerized decision support aids were developed to assist physicians with their diagnosis and treatment decisions, rather than asking them to rely solely on memory. The design process was led by engineers with expertise in how processes can best be efficient and effective.  After design was completed, it was tested in a simulated environment or onsite to ensure that the design made it possible to do things right.

After the design was tested, it was “implemented” according to a detailed plan that allowed for time to train people at the front lines and communicate the changes broadly.  

 

 

Metrics for performance

To close the loop, metrics for performance were monitored by the CCGs.  This included leading and lagging indicators, that were automatically generated by clinical technology systems whenever possible.  Issues identified could then be addressed whether they were related to individual performance or the system design.

 

 

Physician autonomy

This effort was led by the organization’s Chief Medical Officer, a senior officer who was part of the senior management team.  His involvement in the work demonstrated the organization’s commitment to physicians. He also ensured that resources to support the CCGs were put in place, adding skills related to process engineering, project management, data analysis, and informatics.

Because physician autonomy has been such an important part of the clinical care delivery culture, the development and implementation of consistent clinical practices across the organization was a significant, tangible change. Physicians in the CCGs demonstrated that they wanted to improve care for all patients by applying the best science available even when it meant changing their own practice, a powerful example for their colleagues as well as for other clinical disciplines.  Clinical automation enabled evidence-based care delivery. This new way of “acting” led to a different way of “thinking” about clinical decision making, changing the culture of clinical care.

Banner’s success in reducing clinical variation with this approach took place over several years with documented  improvement results in a number of areas. More than 20 CCGs with more than 200 clinicians as members were formed and structures and resources to support the work were put in place.  

 

 

Clinical Research 

The clinical improvement research cited earlier provided a lens to review Banner’s experience with clinical reliability.  Banner’s technical approach included defining clinical standards based on clinical research, designing delivery processes according to engineering principles, and implementing and monitoring progress on an ongoing basis. It addressed cultural factors by engaging clinical decision makers in the process, honoring their clinical expertise, and supporting their ongoing work.  The importance of the external environment that is pushing for improvement along with the internal structures and resources was recognized. The integrity of changes based on clinical research was key as well-trained clinicians found it hard to argue against the evidence and the engagement of the physicians in the overall implementation was vital.

 

Changing culture in every industry will continue to be challenging, but the Banner experience demonstrated that in healthcare, improvement in clinical care is possible and barriers to change created by the culture can be addressed, an important lesson learned.