Doctor in the Cockpit

Transcription

1 Doctor in the Cockpit Diffusion of aviation innovations in hospitals Dirk F. de Korne, PhD MSc Deputy Director, Health Innovation Assistant Professor, Health Services Management & Organisation Singapore Healthcare Management Congress, 19 August 2013

2 Total number of deaths ann. How safe are hospitals? (James 2000) DANGEROUS (>1/1000) REGULATED ULTRA-SAFE (<1/100K) 100,000 10,000 American Hospitals Car Driving 1, Bungee Jumping Mountain Climbing Private Charters Chemical Factories ,000 10, ,000 1,000,000 10,000,000 Nr. encounters per death Corporate Airlines European Railways Nuclear plants

3 (Amalberti et al. Ann Intern Med 2005:756-64)

4 What do we know about patient safety? > In U.S. hospitals 44,000-98,000 annual deaths due to preventable iatrogenic harm (IOM, 1999) > 20-30% of hospitalized patients experience harm (Classen et al. 2011) > 30% of U.S. health care expenditures are unnecessary or wasted (IOM 2010; ibid. 2012) > In Dutch hospitals annually 1,735-1,960 annual deaths due to preventable iatrogenic harm and about 30,000 patients got serious iatrogenic harm (2.3%). (De Bruijne et al., 2007)

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7 Main causes adverse event hospitals (De Bruine et al., 2007) Human factors (knowledge, behaviour, skills): 56% Organisational factors: 14% Technical factors: 4%

8 Tenerife, 27 March 1977

9 Accidental causal chain ( Swiss cheese model, Reason 1990) Organizational Factors Latente failures Unsafe Supervision Latent failures Preconditions for Unsafe Acts Active and latent failures Unsafe Acts Active failures Failed or absent defenses Plane collision

10 System dynamics model for safety conditions ( feedback loops, Bouloiz et al 2013)

11 What has aviation learned since Tenerife? Decrease of hierarchie co-efficient in the cockpit and importance of team work Recognize personal limitations Disclosure of (near) incidents Standardization and checklists >>> System & Culture Change

12 Diffusion of innovations (Rogers 1995) Innovation = an idea, practice or objective perceived as new by an individual, a group, or an organisation Diffusion = the process in which an innovation is communicated, through certain channels over time, among the members of a social system

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14 Medical innovations diffuse slowly (Balas & Boren 2000) From research trial to clinical practice: 17 years

15 Spread and sustainability of innovations in health services organisations (Greenhalgh et al. 2005)

16 Framework for analysis (Greenhalgh et al. 2005, adapted)

17 Learning from quality experiences in other sectors Quality dimension(s) Quality issue Type(s) of industry with comparable experience Model Efficient Accessible Patient centered Safe Process orientation Manufacturing, Aviation Process Reengineering Safe Safe design of operating areas Offshore, Aviation Marking Safe Awareness of risks and unsafe conditions Aviation Crew Resource Management Efficient Effective Accessible Patient centered Efficient Effective Accessible Patient centered Efficient Effective Costs of non compliance Manufacturing Quality Costing Process orientation Manufacturing, Automobile Industry Value Chain Performance assessment Printing Benchmarking

18 Diffusing Aviation Innovations in Hospitals Patient Corporate philosofie ( why? ): Fear reduction Traveller Taxi service Planning system Critical check points Time out Crew Resource Managem ent Black box Marking de Korne et al. JCJ 2010:339-47

19 Application philosophy KLM planning reservation seat on plane = reservation of consult or reservation of surgery

20 Rotterdam Eye Hospital, Netherlands

21 Fear Reduction

22 Rotterdam Eye Hospital - Figures 145,000 outpatient visits (510 p/day) 14,000 surgeries (50 p/day) 4 OR s + 2 Daysurgery OR s 9 beds 93 % daycase 50 % outside of Rotterdam 26,000 emergency visits (70 p/day )(7/24) 25 outpatient rooms 400 employees 30 ophthalmologists + 20 residents care, teaching & research

23 World Association of Eye Hospitals

24 Learning from peers in your own sector > choose organizations your doctors esteem > exchange of staff members > make the nurse your consultant > stimulate implementation in professional organization > benchmark results

25 Singapore National Eye Centre

26 Singapore National Eye Centre - Figures 280,000 outpatient visits 36,000 surgeries 9 OR s 0 beds 98% daycase 30 outpatient rooms 560 employees 64 ophthalmologists + 20 residents care, teaching & research: SERI national centre, part of SingHealth

27 Safety Improvement: Risk Analysis & Management

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29 The Rotterdam Eye Hospital

30 Number of (Near) Wrong Side Surgeries Number of Surgeries Effects of a Time Out before surgery Developments in (Near) Wrong Side Surgeries 10 8 Extra Pre-Op Checks Introduct ion Time Out Procedure Wrong Side Sentinel Events Reported Near Wrong Side Events Number of Surgeries de Korne et al. JCJ 2010:339-47

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32 Crew > Team Resource Management Safety audits of processes and (team) activities and feedback by aviation experts Classroom training sessions and lectures on safety awareness and human factors by aviation experts Video recording of (team) activities and feedback by aviation experts (black box) Flight simulator session Boeing with feedback on team

33 Team Resource Management

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35 Seduction

36 Het Oogziekenhuis Rotterdam

37 Pilot and physician

38 Flight crew and nursing team

39 Eye Care Air

40 The modern-day flight attendant is more like a safety professional, almost a different profession from that what it was in the 1950s and 1960s when American stewardesses were celebrated icons of American womanhood

41 SIA stewardess Ms Ong Teng Teng (37) was inspired by the way nurses cared for her son Lukas when he had to undergo surgery as a baby When I was flying, I was happy for myself (..) now I am satisfied when I can nurse a patient back to health.

42 Flight Data Recorder start The Rotterdam Eye Hospital Het Oogziekenhuis Rotterdam The Rotterdam Eye Hospital

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46 Team training improves safety culture

47 Advances in Health Care Management 2013;14:

48 Het Oogziekenhuis Rotterdam

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50 Crew Resource Management

51 Safe system design Launch of tower top section in action

52 Safe Safe system design

53 % of surgical cases Are the surgical instruments positioned correctly? 60 p< ,1 53, , ,1 10,7 0 sep-08 mar-09 mar-09 oct-09 jan-11 not marked not marked marked marked marked de Korne et al. BMJ Qual Saf 2012:746-52

54 Risk management is related to context Appendicitis surgery, Izi, Nigeria

55 System approach: pilot vs. doctor selection

56 Pre-screening on non-technical skills Checklist Professional Profile - Resilience - Dominance - Stress tolerance - Assertiveness - Impulse control - Openness - Ambition - Need for variation - Accurary - Teamwork - Perseverance - Altruism - Autonomy - Empathy - Persuasiveness

57 Computerized Pilot Aptitude Screening System COMPASS Control & coordination Slalom Orientation Multi-task management Mathematics Short term memory

58 Preliminary scores: n=97 physicians vs. n=715 pilots OOGZH NL CONTROL SLALOM MEMORY MATH ORIENT TASKMNGR

59 Preliminary CPP results (N_physicians=98; N_KLMpilots=715; N_Emiratespilots=2,133) n=97 physicians)

60 Preliminary CPP results (N_surgeons=98; N_KLMpilots=715; N_Emiratespilots=2,133)

61 System approach: patient in the lead

62 11-item post-retinal surgery discharge checklist DOMAIN ITEM A. Physical safety 1. Posture advice Physical safety 2. Eye protection 3. Activities of daily living (ADL) B. Medication safety 4. Prescription checked Medication safety 5. Eye drops administering 6. Medication reconciliation C. Post-op hospital contact 7. Emergency Post-op hospital contact Patient peer community 8. Complaints 9. Follow-up visit 10. Helpdesk D. Patient peer community 11. Retina patient forum

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65 Non checked post-surgical information items AV=10.8% AV=10.8% Vankan et al. submitted

66 System approach: standardisation and spread Intensive collaboration of ophthalmic departments in Dutch hospitals in order to improve the quality of ophthalmic care by sharing knowledge

67 Integrated Eye Care Network: 12 hospitals, > 70 ophthalmologists 12 hospitals > 70 ophthalmologists > 200 opticians & optometrists > 100 general practitioners 3 rehabilitation institutes

68 Currently moving to The I-bus

69 Comparable right-siting questions in Singapore Stable chronic eye patients (glaucoma, diabetic retinopathy) [ integrated care delivery value chain ] Specialist Outpatient Clinic Primary Care Clinic Ophthalmologist Non-Ophthalmologist Centralized Decentralized

70 Many possible barriers for right-siting (Venketasubramanian et al. 2008) Patient: emotional attachment to specialist; greater confidence in specialist; fear that is will be difficult to return, increased cost if referred back post-discharge; proximity; etc. Specialist: reduced confidence in non-specialist; income generated by seeing patients; etc. Non-specialist: feeling uncomfortable managing complicated cases; lack of time; etc. Health system factors: gap between primary care and hospital care; reimbursement not aligned with care pathway; lack of supporting chain EMR; etc.

71 Integrated Eye Care Model System dynamics modeling SEED and SiDRP DATA REFERENCE WORKLOAD OPHTHALMOLOGISTS HOSPITAL ADMIN DATA ophthalmologist gap TIME TO HIRE OPHTHALMOLOGIST population PREVALENCE RATE OF EYE CONDITION AVERAGE VISIT PER PATIENTS PER YEAR desired ophthalmologist hiring ophthalmologist Ophthalmologists attrition ophthalmologist population with eye condition potential patients ENROLLMENT RATE total soc visit per year ATTRITION RATE SOC average workload per ophthalmologists compensation of ophthalmologists effect of workload on attrition soc ATTRITION RATE OPHTHALMOLOGISTS REFERENCE FRACT ELIGIBLE FOR REFERRAL TO SOC indicated fract eligible for referral to soc effect of clinical outcome on referral INITIAL CLINICAL OUTCOME clinical outcome referral to soc effect of pec on enrollment rate of adherence to diagnosis and treatment protocals by non opthalmologists new patients potential referral to pec FRACT ELIGIBLE FOR REFERRAL TO PEC AVERAGE VISIT PER PATIENT PEC Patients With Specialist Outpatient Clinic referral to pec Patients With Primary Eye Care Clinics TOTAL COST PEC total visit per primary eye care clinic attrition soc PEC and HOSPITAL ADMIN DATA average cost pec attrition pec indicated referral rate desired non ophthalmologists effect of cost on referral ATTRITION RATE PEC effect of fcompensation of ophthalmologists attractiveness of primary eye care clinics to referred patients average workload non ophthalmologists INITIAL REFERRAL RATE AVERAGE COST PER PATIENT SOC REFERENCE WORKLOAD NON OPHTHALMOLOGISTS waiting time effect of average workload on referral to pec effect of workload on attrition pec REFERENCE QUALITY OF CARE thoroughness of diagnosis and treatment consultation time per patient quality of training hiring non ophthalmologists Non Ophthalmologists attrition non ophthalmologists effect of quality of care on attrition of non ophthalmologists TIME TO HIRE NON OPHTHALMOLOGISTS non ophthalmologists gap ATTRITION RATE NON OPHTHALMOLOGISTS

72 Example: existing data from SiDRP study 1. Image capture sites Polyclinics Optometrists General Practitioners 2. Image transmitted to SAILOR Tele-Ophthalmology 3. Image grading L 4. Report and recommendation to Clinicians Pilot service to GPs, private healthcare groups, optometrists in Singapore and overseas

73 Conclusions: diffusion of innovations Methods not copied, but adapted to fit the local context Open innovation and co-creation : use industry experts and collaboration to seduce hospital professionals Integration of clinical admin research perspectives in professional organisation ( user system ) Systems approach request systems expertise

74 Divided house However, patient value = health results / dollar = integration

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76 Spread and sustainability of innovations in health services organisations (Greenhalgh et al. 2005)

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78 Look forward!

79 Thank you! Dirk de Korne E dirk.de.korne@snec.com.sg T