Total Clinical Outcomes Management: Theory and Method

1. Total Clinical Outcomes Management:Theory and Method Richard A. Epstein, Ph.D., M.P.H. Michael J. Cull, Ph.D., M.S.N. Department of Psychiatry

2. Road Map • The importance of shared vision • Managing information asymmetry • The role of standardized assessment • Implementation examples

3. “To organize the world’s information and make it universally accessible and useful.”

4. “Our investment in data-mining is part of our drive to deliver what our customers want: the item, at the right store, at the right time, at the right price.” “To organize the world’s information and make it universally accessible and useful.”

5. “Our investment in data-mining is part of our drive to deliver what our customers want: the item, at the right store, at the right time, at the right price.” “To organize the world’s information and make it universally accessible and useful.” “The behavioral health system, at all levels, should always make decisions based on the needs and well-being of the people served.”

6. Step 1: Sit downStep 2: Hold on for 8 seconds

7. Landing a passenger jet on the Hudson

8. A Successful Landing • Capt. Sullenberger credited teamwork, preparation and strict adherence to protocols for the successful landing.

9. Success in Health Care

10. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 Infant Mortality Rate Deaths per 1,000 births International Comparison, 2004

11. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 Ambulatory Care Visits for Adverse Drug Effects Visits per 1,000 population per year By Gender, Race, and Region, 2004 Annual Averages, by Care Setting

13. Health Care Failures • Ignorance – science has given us incomplete information • Ineptitude – science has provided a solution, we fail to apply it correctly AtulGwande, 2009

14. Ignorance • Evidence-based practice • Practice-based evidence

15. Ineptitude • Organizing information • Standardize practice • Support rational decision making

16. The cost of ineptitude • Poor Quality • Inefficiency • Poor resource allocation • Excess costs

17. Combating ineptitude • Bias • Complexity • Goal incongruence

18. Bias • Stereotyping • Moral hazard • Treatment Framing • Probability • Confirmation bias

19. Complexity • Co-morbidity • Treatment options • Governance and financing

20. Goal Incongruence • Multiple perspectives • Information asymmetry • Motive/”agenda”

21. The Case for Decision Support • Eliminates bias • Manages complexity • Supports creation of a shared vision

22. Shared Vision: Child/Family • Child and family centric • Strengths based • Culturally and contextually sensitive

23. “12 Angry Men” Video Clip

24. “12 Angry Men” • Multiple perspectives? • Group think? Strong-arming? • Disagreement? • Bias? • How will they discuss their disagreement? • Can they reach a shared vision?

25. Managing Complexity: Aviation • Checklists developed in 1935 to manage complexities of the Boeing model 299 long-range bomber • In 1968 NTSB recommended a re-evaluation of checklists after the crash of an American World Airways B-707 • Pre-flight checklists are now “standard of care”

26. Reducing Bias & Complexity: Medicine • Critical care • Pronovost et al. (2003) – Use of “daily goals” checklists associated with improved communication and reduced length of ICU stay. • Catheter related infections • Pronovost et al. (2006) – Use of checklists and team empowerment associated with 66% reduction in catheter-related infections. • Surgery • Makary et al. (2007) – Use of operating room briefing tool improved team communication and reduced risk of “wrong-side” surgeries • Haynes et al. (2009) – Use of checklists associated with reduced risk of death and other surgery outcomes

27. Example: Surgical Safety • Surgery is integral to global health • 234 million operations each year • Many complications are preventable • Evaluated the effectiveness of improving team communication on outcomes

28. Hospitals • Toronto, Canada • New Delhi, India • Amman, Jordan • Auckland, New Zealand • Manila, Philippines • Ifakara, Tanzania • Long, England • Seattle, Washington

29. Intervention • Measured outcomes before and after intervention • Intervention was a 19-point checklist • Checklist had three parts: • Sign in • Time out • Sign out

30. Sign In • Before anesthesia, team verbally confirms: • Verification of patient identity, surgical site, procedure, and consent • Surgical site is appropriately marked • Pulse oximeter is on the patient and functioning • All team members are aware of patient allergies • Patient risk of airway obstruction and aspiration has been evaluated and appropriate equipment is available • Blood and fluids are available

31. Time out • Before incision, team verbally confirms: • All team members are introduced by name and role • Patient identity, surgical site, and procedure • Review of anticipated critical events • Administration of prophylactic antibiotics before incision or that they are not indicated • Essential imaging results are displayed

32. Sign Out • Before patient leaves the OR: • Nurse reviews aloud with the team: • Name of the procedure as recorded • That needle, sponge, and instrument counts are complete • That specimen is correctly labeled • Whether there are any equipment issues • Team reviews aloud key concerns for recovery and patient care

33. Results

34. Summary • Introducing surgical checklist: • Reduced surgical site infections and death by ½ • Increased compliance with safety process measures • What did the checklist accomplish? • Ensured similar information for the team • Improved team communication • Supported shared vision

35. Break

36. Road Map • The importance of shared vision • Managing information asymmetry • The role of standardized assessment • Implementation examples

37. Data-driven decision making

38. Service planning exercise • Case vignette • System-level service plan • Importance of measurement and communication

39. “Bender” Video Clip 1

40. Identify 3 service plan needs

41. “Bender” Video Clip 2

42. Okay, now what?

43. Measurement as Communication • Purpose of all measurement is to communicate • Time (e.g., days), Temperature (e.g., Fo, Co), Value (e.g., dollars) • Physical sciences • Concern phenomena accessible via instrumentation • Instrumentation improves; measurement stays the same • Human and social sciences • Sometimes concern phenomena similarly measured • Many times involves phenomena not readily accessible

44. Social Science Measurement • Logical empiricist perspective • Measurement is application of procedure to show verifiable truth from observation • Implication is that some real phenomenon exists and that this “truth” can be revealed • Classical test and item response theories are based on a similar philosophies

45. Communication Theory • Traditional perspective also empiricist • Knowledge transfers from one mind to another • Main critique of the “transfer” model • Overly linear • A  B with no room for impact of B on A and information coming from A • Constitutive / constructivist model • Communication as shared meaning making

46. Shared Meaning Making

47. Communication and Measurement • From a communication / constructivist perspective, measurement is: • Less about “revealing truth” • More about “creating shared meaning” • Classical test theory • Multiple items; internal consistency reliability

48. Internal Consistency Reliability • Cronbach’s alpha is the statistic used to define internal consistency reliability • The equation is as follows:

49. Classical Test and Communication Theories • Complex systems require clear and concise communication about multiple constructs • Classical test theory: reliability = redundancy • Inter-rater reliability is therefore both the • Relevant measure of reliability • Concept most related to shared meaning • Directly facilitates decision support

50. Measurement Helps • Reduce bias • Integrate multiple perspectives • Attend to all relevant information • Communicate and use information at all system levels