Integration of health and social care – predicting the quality, costs and consequences 17.4.2018

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Improving the information base and optimising service
solutions to support social welfare and healthcare reform.
Evidence-based clinical pathways: the application
of health economics, data systems and quality
improvement.
THL Helsinki, Finland 16th-19thApril, 2018
Professor James Dunbar
Deakin University
Victoria, Australia

2. Deakin University CRICOS Provider Code: 00113B
The Project

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Mapping Clinical Pathways for tracker
conditions
Shine a torch on the patient’s experience

4. Deakin University CRICOS Provider Code: 00113B
Mapping Clinical Pathways for tracker
conditions
Shine a torch on the patient’s experience
• Standardised pathway for each tracker
condition,
• evidence-based, multidisciplinary
management plans,

5. Deakin University CRICOS Provider Code: 00113B
Mapping Clinical Pathways for tracker
conditions
Shine a torch on the patient’s experience
• Standardised pathway for tracker
condition,
• evidence-based, multidisciplinary
management plans,
• identified appropriate sequence
of clinical interventions, timeframes, and
outcomes.

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Quality of Care
• Minimum Data Set derived from Duodecim
guidelines
• Registries and other databases
• (access and equity)
Evaluation of health care interventions

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Quality of Care
• Minimum Data Set derived from Duodecim
guidelines
Convenience for patients
• Only patients experience the whole pathway
• Their priorities are different from doctors
• Patients can contribute to redesign
Evaluation of health care interventions

8. Deakin University CRICOS Provider Code: 00113B
Quality of Care
• Minimum Data Set derived from Duodecim
guidelines
Convenience for patients
• Only patients experience the whole pathway
• Their priorities are different from doctors
• Patients can contribute to redesign
Cost
• Economic decision tree component costs
must match clinical algorithm
Evaluation of health care interventions

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HbA1c among type 2 diabetes patients
in North Karelia, 2013-2014

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Type 2 diabetes report, North Karelia

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Tracker conditions are:
Clinical pathways for a few key conditions
that cross primary, secondary and social
care.
• Map each process (step) on the
patient’s journey.
• Look for waste – slips, lapses and
errors especially at hand overs,
• Determine cost for each process.
• Basis for redesign of an improved
pathway

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The pilgrim and the patient’s
experience

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The outset of the
journey can look well
organised and paved for
an easy path

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A piece of very simple advice can be invaluable
The journey
can be long and
daunting but
starts with a
single step

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Others have been there
first and may not be
interested in your
journey

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Different paths can
look equally plausible

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It helps to have guidance

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We need to remember our fallibility.

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We need to
have belief in
our journey

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The journey
can get rocky
and slippery

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A piece of very simple advice can be invaluable

22. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluable
Beware of false
prophets

23. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluable
Advice can
sometimes be
confusing

24. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluable
Sometimes
when you
reach an
apparent
impasse you
have to wade
through

25. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluable
Others have right of
way and should be
given due courtesy

26. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluable
The journey can
be tough and
you have to be
prepared to have
a few blisters
and bruises

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A piece of very simple advice can be invaluable
There is a
time for
work and
a time for
rest

28. Deakin University CRICOS Provider Code: 00113B
A piece of very simple advice can be invaluableAlong the journey
rewards are all
the sweeter for
having earned
them

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A piece of very simple advice can be invaluableI would really like
to emphasise that
last point!

30. Understanding the Patient Journey
Process Mapping

31. CONTEXT
‘80% of the problem is in the system not the people’
W. Edwards Deming

32. Process mapping….
• Views the system from the patient
perspective following their journey
across organisational boundaries
• Helps staff understand how complex
and confusing processes appear to the
patient
• Diagnostic and used as a basis for
redesign, actively involving frontline staff
in the process. (Shows how things actually are)

33. Process has inputs and outputs
Input OutputProcess
Definition - a process is a series of connected
steps or actions to achieve an outcome

34. A
Diagnostic process
B
Looking at Patient Processes
C D E
• 30 - 70% of work
doesn’t add
value for patient
• up to 50% of
process steps
involve a “hand-
off”, leading to
error, duplication
or delay
• no one is
accountable for
the patient’s
“end to end”
experience
• job roles tend to
be narrow and
fragmented
Organisational /departmental boundaries
Emergency care process
Treatment process

35. High level process map
6 – 12 steps
– Generate in set time e.g. 20 minutes
– Use to identify scope and identify problem
Low Level or Detailed process map
dozens of steps
– To establish loops and complexity
– Good to establish roles and relationships within
processes
– Use again in later phase to show effect of redesign

36. Appts
Hospital
GP
Another
Hospital
Appts.
Appts.
Hospital
Register
on
System
Consultant
Secretary
Consultant Screening
Referral
1 – 3 days
Consultant
Secretary
Appt.
made
Letter
sent
Patient
Attends
OPD
Appts
hospital
1 – 3 days
1 Day -12 weeks
GP Referral – Attend OPD Appointment
High Level Map

37. Analysing the process map
• How many steps in your process?
• How many duplications?
• How many handovers?
• What is the approximate time of or between
each step?
• Where are possible delays?
• Where are major bottlenecks?
• How many steps do not add value for
patients?
• Where are the problems for patients and staff?

38. Walk the Patient Journey for
yourself

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A piece of very simple advice can be invaluableCathedral of
Santiago de
Compostela

40. Outcome from redesigned Processes:
• Comparison with first process map
• Waste removed
• Cost savings calculated
• Health and social care better integrated
• Minimum data set for quality set up.

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Thank you and any questions?
Photos of the Camino de Santiago by courtesy of
Professor James D Best
Dean, LKC School of Medicine, NTU, Singapore
Professor James Dunbar
Deakin University
Victoria, Australia