performance measurement in healthcare - ivf as an example
DESCRIPTION
Measuring service performance in IVFTRANSCRIPT
Performance enhancement in IVF
Sawad ThotathilVice President, Performance Improvement
[email protected]+1 7815308634
To attain high performance, you need
• Tools for determining performance. “If you don’t measure, you cant improve it”
• Characteristics of a high performance team – Tools are useless in an environment unwilling to learn or not ready for change
How are you doing now?
• You would need to know how you are performing now – Measure of current performance
• Where do you stand today with regard to the parameter you are measuring?
• Static or snapshot measures such as Average pregnancy rates are misleading because it hides the patterns. Example: Average pregnancy rate over a period of 20 months is 35 percent
• A team relying on annual averages are like driving a car looking into the rearview mirror
Which is more useful to tell you how you are performing?
1)Time series display 2)Typical assessment
Annual average is 35%
What did you realize?
• You just realized that you are not always at the nice figure of 35%
• But this is the true state of performance over time
• Unfortunately, you had to have all the 20 months data in front of you in order to make that curve
• Unfortunately , this variation is what the patient experiences
How do you really need to measure?
• Real time so that you see data as they are happening so that identify poor performance quickly and take corrective action
• OR identify positive effect of a new intervention. Example: you introduced a new protocol and want to know whether it is more effective
• Patterns in the data are more useful than an ‘average’• Only patterns will help you to differentiate the 2
different types of change : ‘special causes’ and ‘systemic issues’
What do you think?1) Could something have gone wrong that resulted in 23% or is it normal for my system?2) What about the lows of 14%?3) WHAT EXACTLY IS MY CURRENT SYSTEM CAPABILITY?
You also need control limits as above (Control limits are the statistically calculated limits of system capability)This system pregnancy rate should vary only between 53.1 and 18.8%. 2 inferences1. Those 2 months did have a ‘special cause’ for the dip because they are outside the
control limits2. But are you happy with the wide 53.1-18.8 limits?
What would you do if you are concerned only about the ‘special cause’ dip?1. You will need to
investigate what has changed in the various variables during those 2 months
2. Ensure that the variable does not negatively affect again
3. DO NOT overhaul your system
4. Common error: what usually happens is that when you have a dip, you race to re-look your entire system. “I think we should change the media”
Problem with dip in IUI resultsSpecial cause detected – smoke emissions in the tube warmer
Tube warmer replaced
What would you do if you are concerned also about system capability which has too wide variation of 53.1-18.8 or the mean of 35% is not satisfactory?1. You will need to re-look at
the entire system2. The problem is not time
related (such as failure in incubator in those months or a bad lot of oil) but something inherently wrong with your system
3. Minor tweaks will not radically change the outcomes
4. PDSA (plan-do-study-act). Example: Make a change in protocol
Redesign of the laboratory process to shorten patient waiting time
During the study, mean waiting time was 15.07 and varied from 23.28 to 6.26 minutes…look what happens from day 21
See the new mean waiting time as well width of variation in new system
Process redesign is not easy and can involve looking at numerous factors simultaneously as in this patient discharge delay project
Discharge delay
Discharge summary typing problems Drug indenting
Patient
Billing issues
Delay in correction
Corrections in medicineAfter preperation
Delay in collecting file from ward
Medication not typed properly
Delay of transfer of file to billing
Server problems
Computer slow
No pharmacological namesmentioned
Drug not indented
Errors in indenting
Daily indenting not done?
Pharmacy
Delay in refundOf medicines
No provision for refunOf drugs
Vehicle not ready
At request discharge
No money ready
Insurance clearancedelay
Variation in rateOf surgery
Bill cancellation?
HIS
Server problems
Doctors
Rate of procedures not explained or misinformation
Writing summary slowly
Not writing on previous day
Advising cross-consultation on discharge day
Mother and baby discharge timeNot synchronised
Investigations advised on discharge day
Rounds at irregular times
Medicines not written on file
Not available for corrections in summary
Report collection On discharge day
Not available for Final sign
Not available on sunday
Handwriting not legible
Waiting for reports before discharge
Characteristics of a high performance team
Success parameters
• Technology – quickly and widely disseminated, “you can purchase off the shelf”
• Protocols –the learning curve (average doctor will reach an acceptable target eventually)
• Social operating mechanism – key to higher performance (how quickly you learn and implement things)
Characteristic of the culture audit
Hospital A – slow learner took a year to achieve consistent satisfactory outcomes, but patient numbers remained static for years after that
Hospital B – reached good outcomes in 3 months, consistent excellent outcomes and patient numbers increased by 18% Year on Year, most failed patients came back
Patient centeredness
Objective of team members was to get work done
Objective to provide good care
Team work Each member secluded in his/her own role
Get along and assist each other. Good knowledge sharing
Innovation “I have been in this field for many years so I know ”
Constant lookout for new ideas
Communication Top down. Junior members do not voice their views as they are not listened to
Flat structure. Juniors have comfortable conversations with the top
Leadership Demanding of respect/obedience. Fear of the leadership
Approachable, Encouraging
Trust Juniors need to be constantly monitored as “they may go wrong”
Adequate. Devolution of authority where needed
Conflict Brushed under the carpet Conflict resolution not delayed mostly
Identity Us and They : “They don’t listen to us nurses” “those nurses don’t do their work”
“WE think the patients like it this way”
So how does organizational culture affect performance?
• Knowledge sharing• Common objectives and goals• To understand deeper, let us look at how 16
different cardiac surgery units in the US learned and implemented Minimal invasive cardiac surgery ( Harvard Business school study)
Some teams learned the technique quicker than others..what were the key factors speeding up learning?
• NOT the repute or seniority of the surgeon• NOT the frequency of cases during the initial
learning phase• NOT the lag between training and the first
cases• Controlled for factors such as equipment
quality, training etc
Learning Factor 1 – The team was designed for learning
• Surgeon handpicked members of other specialties (anesthesia, nursing , perfusion). i.e. their ability to work well together based on their prior experience working together
• Constant team
Learning Factor 2 – Implementation was framed as an organizational challenge
• Emphasis on granularity – Team got down to details, Surgeon takes initiative to get different members to meet, discuss and review details before and after the cases. SOPs developed together
• Conversation was granular – regular formal and informal meetings, the smallest details of the various steps were discussed, even terminology for communication was agreed upon . “ we want to be familiar with what everyone was doing”
Learning Factor 3 – Surgeon actively lead the implementation and learning
• Ensured stability of the team without change in members as far as was possible
• Deliberately scheduled similar type of cases in the initial period
• Ensuring that the team met and discussed before the case
• Surgeon provided a safe environment to express opinions, views..
• Put in place a system to monitor the processes and outcome
How all this affects learning a new procedure like Ultrasound guided embryo transfer?
• These factors result in establishment of ‘safe and open’ communication channels between the various team members
• The 3 components of the task become clear to all – Task description, Purpose, Expected outcome
• Feedback learning is possible when one gets enough info about what needs to happen and about what happened and what needs to be changed to obtain a better outcome.
A snapshot of ET in Hospital A and B
• Watch the quality of conversation – sharing of task details, objectives
• Which conversation reflects a better way to learn?
• Which conversation shows the quality and depth of interaction between the members?
Comparison of team communication
Scenario in hospital A• Task description – place the catheter into
the uterus under ultrasound visualization and release the embryos
• Purpose– Deposit the embryos inside the uterus without difficulty and to the satisfaction of the doctor
• Expected result – Emptying of the catheter as confirmed by the embryologist
Scenario in hospital B• Task description-Visualize the
endometrium, the position of the outer at ext. OS, the threading of the inner and then deposition just below the fundus
• Purpose -Place the catheter with careful visualization of outer catheter and inner catheter tip (without manipulation of cervix and damage to the endometrium) Deposit slowly near the fundus hopefully visualizing the emptying of the catheter
• Expected result – Deposition of the embryos in as exact position as possible and without damage or manipulation
Mastering a surgical or tech skill
• No correlation with manual dexterity, demographics, grades
• “Recent work suggests ….efficient hand motion during surgery may be more closely related to planning and pre-operative visualization than precise motor control during subtasks” ..Cambridge Handbook of Expertise and Expert Performance
• Learning is thus related to preparatory visualization of the task, clarity on purpose and outcome and deliberate seeking of feedback
Key challenges
• Acknowledging a need for change (whether to solve a problem or improvise )
• Sense of urgency – “we need to do something about this”
• Enablers (right people having the right resources) combined with incentives where necessary
• Intrinsic motivation• What is the social operating system in your
team?
Sawad [email protected]
Expertise areas• 8000 plus IVF/ICSI cases• Quality improvement• High performance teams• Statistical process control• Hospital patient flow
optimization• Service design and optimization• Project design and execution• Change management
Professional education• Harvard Business School, Boston, USA• Institute of Healthcare Improvement,
Boston, USA• South Australia Center for Healthcare
Improvement, Adelaide, Australia• University of New South Wales,
Sydney, Australia• Six Sigma Green belt trained• Monash University, Melbourne,
Australia• Calicut Medical College, Calicut, India