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 Special Advisor and Project Leader Tone Reneflot Thoresen Senior Advisor Aleidis Skard Brandrud 1 Vestre Viken Hospitals Area 27 square kilometer 450 000 inhabitants Ringerike Hospital 2 Vestre Viken Health Trust (is a unit of four hospitals) 9 500 employees Kongsberg Ringerike Bærum Drammen 3 Sogn og fjordane Til ValdresRingerike hospital Hemsedal Buskerud Oppland 1000 employes 75 000 inhabitants 20 000 tourist a day Buskerud E 16 Hallingdal sjukestugu RV 7 Geilo Randsfjorden RV 7 Oppland Hardangervidda Norefjell Jevnaker Hallingdal local health center Ringerike sykehus 120 km north of Ringerike Tyrifjorden Nordmark E 16 Ringerike Hospital Oslo Hönefoss 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 Project The 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 The process 2010 Web-based patient behind the information system nomination 2009 Transitional care system ….no development quick 2005 Balanced clinical monitoring system development fix! 2004 Electronic mesosystem guidelines 2003 Horizontal mesosystem development with organizational adjustments 1999 Patient focused redesign 1996 Strategy: Integrated multidisciplinary care within and between microsystems 9 THE BACKGROUND R es ultat 6 + 1 indeks er (max poeng 100) 100 90 80 70 60 50 40 30 20 10 0 t r g e rd in da arh Leger Pleie b rørende Stan å aniser tsig Info prøve P g u Or or F 10 A continual improvement system is needed BOX 2 Continual improvement system Success factor I: INFORMATION 1. Provide continual and reliable information about best practice 2. Provide continual and reliable information about current practice 3. Benchmark systems and outcomes to others Success factor II: ENGAGEMENT 4. Anchor the improvement work to the leadership at all stages 5. Focus on and engage the patient and family in all stages of the improvement work 6. Anchor the changes to the professional environment 7. Engage the staff in all stages of the improvement work Success factor III: INFRASTRUCTURE 8. Base the infrastructure on improvement knowledge 9. Multidisciplinary improvement teams tailored to the topic 10. Develop a learning system tailored to the different target groups 11. Develop a system to facillitate the improvement work 12. Develop a follow-up system to secure sustainability (Brandrud AS, Schreiner, A Hjortdahl P, Helljesen GS, Nyen B & Nelson EG. BMJ Qual Saf 2011). 11 The theoretical framework The embedded Continual improvement systems of healthcare The model of improvement The BTS Model for Self-care Geopol. Improvement system market system • What are we trying to accomplish? • How will we know that a change is an improvement? Ind. careg. • What changes can we make that will result in improvement? & patient Macro- system system Act Plan Study Do (“Focus PDSA”: Micro- Meso- Langley, Nolan & Nolan 1994) system system Aleidis Skard Brandrud 6 Batalden & Stoltz 1993Nelson, Batalden & Godfrey 2007 Langley, Nolan & Nolan 1994 “Every system is perfectly designed to get exactly the results it gets” (Paul Batalden) “Improving healthcare means improving systems of care applying quality improvement methodology” Aleidis Skard Brandrud 12 (Don Berwick, Institute for Healthcare Improvement) 12 Everybody's task is to contribute to make this chain of meetings as good as possible 13 Most Norwegian hospitals are trying to make the care Healthcare safer by building siloes to provide more evidence is a complex based medicine, and to make the system organization look simpler CEO 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 A chain of microsystems is the patients mesosystem Team 14 Team Team Team 7 Team 13 19 11 Team Team Team Team 5 Team 9 Team 1 Team 17 20 22 15 Team Team Team Team Team Team 2 Team 6 Team Team Team Team Team Team8 10 26 3 4 12 16 21 23 24 25 Outpatient Primary Primary care AdmissionDetection Treatment Discharge Clinic care nurse physician 17 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 % 5 % 35 % 24 % 35% Predictability 32% Treatment/care 24% Respect and dignity 5 % Costs 4 % Facilities 32 % Aleidis Skard Brandrud 2002 19 “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) 100 90 80 70 60 Resultat 6 + 1 indekser 50 40 30 20 10 0 Leger Pleie (max poeng 100) Info prøver Standard Pårørende Organisering organized information about patient satisfaction Pasienterfaringer somatiske avd. The national study is only providing silo Ringerike sykehus, PasOpp 2006 F orPutsiredigbctaabrilhitety 21 22 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 • Inviting patients and family Technique (CIT) from a specific mesosystem (Gremler 2004, Brandrud et al 2011) • 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 studieThen we av make gyn-pasienters a questionnaire out utsagn of the respondents comments, and send it to a sample of about 200- 300 patients from the same mesosystem 25 KvantitativThe undersøkelse same questionnaire av de ansattes is given toperspektiv påthe de sammestaff, asking pasienterfaringene 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 Patients’ Providers’ForbedringsområderUnder-estimated som ansatte har undervurdert problems priority priority Prior. pas Diff Prior ansatte Spørsmål 1 -26 27 46. Tilbud…information - snakke ut m. jordmor about om what sykd.sit. to eller do annet if you sæ.viktig get for a deg? relapse, 6 -16 22 54. Fikk du info om normale og unormale reaksjoner på sykdommen din? 7 -24 32 or25. get Info symptoms selv kunne gjøre or vhealth tilbakefall problems eller ekstra whenskj. etter you kom arehjem? back home? 8 -24 32 44. Fikk du snakke med den legen som opererte deg etter operasjonen? 11 -16 27 …information24. Fikk du informasjon about om what hvilke symptoms plager du kunne or regne health med problems fremover? 14 -47 61 to48. look I hvilken out grad for ble after du vist you rundt lefti avdelingen? the hospital? 16 -19 35 64. I hvilken grad fikk du snakke med legen før du ble utskrevet? Områder som ansatteEqual og pasienter estimated har vurdert problems likt Prior. pas Diff Prior ansatte Spørsmål 2 -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 …adequateav syke.h.oppholdet length passe, bleof dustay? 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? Områder som oppleves som mye bedre enn de ansatte tror Over-estimated problems Prior.