Traffic Jam Learning ; learn the key concepts and skills for 21st century healthcare while driving or just sitting
This Glossary is about Population and Personalised Care the latter being a style of clinical and general management which always considers the patients’ perspective as the most important and is committed to increasing patient Engagement, Empowerment or Involvement, which may be regarded as synonyms. Personalised care is an element of patient centred care and is the other side of the coin from population care. This is a diffuse and fast moving field with language evolving at a rapid rate. Here are the key terms and concepts.
- Value – “What is gained relative to what we give up – the benefit relative to the cost but not only to the direct cost, which is the efficiency of a service, but the Opportunity Cost, or the Opportunity Lost to put it another way and there are three dimensions to value in healthcare
- o Allocative value, determined by how the assets are distributed to different sub groups in the population
- o Technical value, determined by how well resources are used for all the people in need in the population
- o Personalised value, determined by how well the decisions relate to the values of each individual
Waste is any activity in a process that consumes resources without adding value for the patient
The relationship between the cost of an intervention and its impact.
Optimality is reached when resources or productivity create maximal benefit with the least harm. Beyond optimality there is overuse.
Programme Budgeting and Marginal Analysis;
The fundamental idea behind programme budgeting is decision making based on explicit criteria related to the wellbeing of the whole population, as opposed to decision making by compromise among various institutional, parochial, or other vested interests. Marginal Analysis consists of starting with a particular mix of services and analyzing changes in that mix. If resources can be shifted to produce greater benefit then this should be done.
The value of the next best alternative forgone as a result of the decision made.
Equity is a subjective judgment of unfairness.
- System – A set of activities with a common set of objectives with an annual report.
- o Network – If a system is a set of activities with a common set of objectives, the network is the set of organizations and individuals that deliver the systems.
- o Pathway – The actual care process of care experienced by each individual patient/client; also described as maps that define best practice.
- o Quality -The degree to which a service meets preset standards of goodness in the delivery of the system’s objectives.
- Culture – “Culture is the shared assumptions of a group that is has learned in coping with external tasks and dealing with internal relationships. Akey cultural issue is the development of a culture of stewardship.
- Population healthcare –the design and delivery of the care with a primary focus on the population in need, not the healthcare institutions, where the populations in need are defined not bureaucratically but by the optimum population size for high value care for individuals and the group in need Population medicine or population clinical practice – a style of practise in which the clinician feels, and is given responsibility for, all of the people in the population in need whether or not they have been referred
- Personalised Care or Personalised Medicine – the tailoring of care to take into account each individual’ s unique needs, preferences and values. The term has become popularised recently to describe clinical decision making in the era of the genome but another term for clinical decision making incorporating genomic information is
- o Stratified Medicine – decision making based on the patients degree of risk, including risk suggested by genomics and based on the long standing practice of risk stratification of elderly people based on social and medical, but not genomic characteristics
- o Precision Medicine – decision making taking into account genomic information either in diagnosis – ‘molecular diagnostics’ –or choice of drug treatment –‘pharmacogenomics’.
- Principal and Agent – legally the patient is the principal, the clinician the agent, even if there is no money involved. Some people feel the shift in the balance of power occurred with the founding of the NHS when the patient was not charged for consulting the GP. The pendulum swung further because of
- o Information Asymmetry – the fact that the clinician has, until the advent of the Internet much more technical knowledge
- o Trust – Faith in another to perform a task that is not in the other’s interest
- o Autonomy – Freedom to make decisions or act without reference to others
- o Informed Consent – Consent to treatment given with full understanding of the magnitude and probabilities of the good and adverse outcomes
- Empathy – In his book on Emotional Intelligence Daniel Goldman identifies three types of empathy – cognitive empathy is the ability to understand what another person is thinking Emotional empathy is the ability to feel what another person is feeling. Empathic concern is the ability to sense what another person needs for you.
- Evidence and Value based decision making – Decision making that ensures the patient is fully informed about the strength of evidence about the probability and magnitude of both risks and benefits of the options being considered and that the patient has been helped to reflect on, clarify and express their preferences based on the value they place on the possible benefit, the possible harm and on the risk they are taking.
- o Health Literacy – The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information. The term Statistical literacy – the ability to understand and communicate probabilities which is shared by both patients and clinicians, sometimes called risk literacy is increasingly used
- o Framing – the conscious or unconscious presentation of data in ways that influence their interpretation and decision making
- o Shared Decision Making – is a style of decision making in which clinicians and patients are both involved
- o Preference Sensitive Decision Making – is a style of decision making in which the patient’s preferences are explicitly elicited, to avoid
- o Silent Misdiagnosis – namely failure to diagnose accurately the patient’s values and preferences even though their disease has been correctly diagnosed
- o Informed Consent
- o Patient Decision Aids – a tool to support the patient during decision making, particularly before and after the face to face consultation and they are increasingly delivered using digital means variously called eHealth, mHealth, digital health or Telemedicine which may be regarded as synonyms
- Patient defined and reported outcomes are objective measures using validated tools
subjective measures of outcome, including the degree to which the treatment addressed the problem that was bothering the patient most, rather than their diagnosis and the patient’s experience.
Necessary, Appropriate, Inappropriate or Futile Classification of interventions based on the probabilities of benefit and harm
Burden of Treatment – the impact of the process of care on the affected individual and their carers
Technical Value in Healthcare: determined by how well resources are used within services for each individual and the whole population .
…the proper objective is the value of health care delivery, or the patient health outcomes relative to the total cost (inputs) of attaining those outcomes. (1)
Productivity is measured by the relationship between outputs and cost, for example the number of peopletreated per bed per year . Efficiency is measured by the relationship between outcomes, not outputs, and costs, where the costs may be expressed not only as money but also as carbon or time, including the time of patients and carers. Technical value has to take into account not only efficiency but also the possibility of overuse and underuse
This is not only achieved by evidence-based decision-making, essential though that is. The balance of good to harm changes as the amount of resources invested in an intervention or service increases as Avedis Donabedian showed in his classic diagram in 1980 which is reproduced below:
Value is replacing quality as the dominant paradigm for healthcare in the 21st century. Value is of course increased by quality improvement, by doing things better, cheaper, safer and greener; but doing things right is only half the story – it is also essential to do the right things by making the right decisions about identifying and discontinuing lower value activities.
Allocative Value in Healthcare: determined by how assets are allocated to services for different purposes.
Allocative value, or allocative efficiency as it is also known, has until recently being largely ignored in healthcare in part because of the dominant part that the United States plays in thinking and writing about healthcare. Allocative value requires a consideration not only of institutional quality but also of the impact that a healthcare service has on the population. There has recently been good work through the Choosing Wisely Campaign but the main aim is to reduce costs, not to help decision making for a whole population. Allocative value is a hot topic when needing to make a finite sum cover a whole population.
There are three levels of decision making needed to increase Allocative value in healthcare once the decision on how much to top slice for research and education and the decision on geographical resource allocation has been made. These three levels of allocative decision making are:
- Between programs, for example between cancer and mental health or vice versa
- Within program between system, for example between asthma, COPD, sleep apnoea and breathlessness within the respiratory program and
- Within system, for example within the resources available for COPD
Personal Value in Healthcare: the delivery of services informed by what matters to the individual.
GREAT PROGRESS BUT OUTSTANDING PROBLEMS REMAIN
Tremendous progress has been made over the last forty years due to the second healthcare revolution, with the first healthcare revolution having been the public health revolution of the nineteenth century. Hip replacement, transplantation, and chemotherapy are examples of the high tech revolution funded by increased investment and, in the last twenty years, optimised by improvements in quality, safety and evidence based decision making. However there are still three outstanding problems which are found in every health service no matter how they are structured and funded: One of these problems is huge and unwarranted variation in access, quality, cost and outcome, and an analysis of unwarranted variation reveals the other two –
- Overuse, which leads to waste, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients and often, patient harm, even when the quality of care is high
- Underuse which leads to failure to prevent the diseases that healthcare can prevent, stroke and vascular dementia in atrial fibrillation for example, and often inequity
In the next decade need and demand will increase by at least 20 % so what can we do to tackle these outstanding problems and meet the growing need and demand?
SHIFTING THE FOCUS TO VALUE
The first step is to focus on value – on triple value The key transformation is from a focus on the quality of service for the patients treated by the individual institutions in Oxfordshire to improving value for the population as a whole and for every individual in the population with triple aims
- Increasing personal value by ensuring that we focus on each individual’s problem as well as their diagnosis and ensuring that their values are taken into account in personalised decision making
- Increasing allocative value by ensuring the optimal distribution of resources not only between different programmes such as the programme for people with cancer and the programme for people with mental health problems but also the population based systems within each programme for example within the respiratory health programme optimising allocation betten the services for people with asthma, those with copd and those wit hsleep apnea
- Increasing technical value from the way the resources are used for all the people with a particular health need such as back pain, or atrial fibrillation or being at the end of life not only by delivering high quality care efficiently but by relating to all the people in need and minimising bot over use and underuse
Low quality care is low value , but high quality care may be of low value too if it does not add value for the population or the individual. The focus has to be on value
HOW CAN WE GET BETTER VALUE
Firstly we need to continue to
1. Prevent disease, disability, dementia and frailty to reduce need
2. Improve outcome by provide only effective, evidence based interventions
3. Improve outcome by increasing quality and safety of process
4. Increase productivity by reducing cost
These measures reduce need and improve efficiency BUT we also need to increase value by
- Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered and relating that to the problem that bothers them most and their values and preferences
- Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity
- Ensuring that those people in the population who will derive most value from a service reach that service
- Implementing high value innovation funded by reduced spending on lower value interventions
- Increasing rates of higher value intervention eg helping a higher proportion of people die well at home funded by reduced spending on lower value care in hospital in that population
The Oxford Value Improvement Programme is focused on developing the systems, culture and skills required for all nine of these key tasks and improving the tenth factor – the morale of the people who deliver the service
We have different resources for different needs, which can help drive improvements organisationally, individually or both.
Our aim is to help organisations transform their culture and develop integrated systems of care. We will help single organisations that want to transform its culture/service or a group of organisations that want to work together to develop networks to deliver integrated systems of care to their populations.
We start with a transformation workshop which helps the key people in the organisation:
- Identify the main pressures they will face in the next decade
- Agree on the principal features of a service transformed to flourish in the new environment
As a result of the Transformation Workshop, organisations can commit to one of our transformation programmes:
These programmes are designed for people who want to lead improvement of health and healthcare – either a whole professional group that knows it needs new skills and knowledge to flourish in the new paradigm or individuals who want to transform the care they provide but are too busy for an MBA.
Professional Development Programme – helping very busy people create and adapt to the new paradigm
Individual & Organisational Development
Masters level modules – on the Five Giants we still have to conquer and the Enablers of transformation
The How To Handbooks – Knowledge Geared For Action
As well as enhancing the Transformation Programmes, the How To Handbooks can be read alone. They are available on paper, Kindle, and digital versions are available for Iphone, Smartphone, Mac, or PC. The first set of titles is:
- How To Create the Right Healthcare Culture
- How To Manage Knowledge in a Health Service (coming soon!)
Healthcare Foundations is a BVHC podcast service. A subscription to this service entitles you to receive podcasts on current healthcare topics that are important to you – topics such as redistribution of resources, streamlining, reducing waste and increasing value will be illuminated by introducing you to distillates from the 1000 greatest books about or relevant to the health of populations and the delivery of high value healthcare. We also have podcasts from 1000 great articles on the science of health service management.
Master the language of healthcare -Language creates the social reality of the world in which we work. Being clear about the meaning of terms is one of the key steps in shaping culture. Even if a word has more than one meaning, it is essential that everyone in a health service is aware of this and agrees which meaning should be used. For this reason, BVHC has developed the Glossary of 21st Century Healthcare and a range of other resources to help clarify, and make more consistent, the language of healthcare.
The BetterValueHealthcare Bookstore – for really good coffee and 1000 really important book
We also create bespoke solutions to meet your needs – find out more here.
How can we meet increasing need & demand with no more money?
Clinical advances of the last fifty years have led to dramatic increases in life expectancy and years of life free from disability. However, every health service still faces five outstanding problems and four new challenges that are interlinked:
Better Value Healthcare (BVHC) is a solutions company, which manufactures resources to solve problems, meet challenges and engage the drivers of change.
BVHC recognizes that the the problems facing health services cannot by solved by money (even if this were an option) or by reorganising the bureaucracy of healthcare. They can, however, be solved by good leadership and harnessing the drivers for change, which will transform the square peg of 20th century healthcare into a service that fits with the needs of the 21st century. A new paradigm is needed …
A revolution NOT a re-organisation!
BVHC’s resources can transform your health service while directly addressing your most pressing problems. Our solutions will help to address different aspects of the problems all health services face.
The mission of the Surgical Leadership Academy is to help surgeons become even better leaders
In England alone there are about two thousand surgeons in management and leadership positions in addition many young surgeons see the need to develop understanding of management and leadership to prepare them for the health service or academic jobs.
The distinction, and relationship, between management and leadership is now generally agreed with leaders shaping and changing culture whereas managers work within the culture of the organisation. Almost all leaders are also managers but not all managers are part of leadership. Both activities are of vital importance for delivering high quality, safe and high value service to both individual patients and populations.
The principle of the Institute should be for action learning and people to bring problems either at face to face meetings or, increasingly, on-line action learning programmes. There are a very wide range of issues involved in leadership and management, but it is recommended that the Institute focus on those issues that are particular to surgery, contextual leadership and management to use the jargon.
How do we know that walking does more good than harm?
One source of evidence is that the people who walk say that walking makes them feel, and look, good. But this does not prove that walking is beneficial or, as is said when new medical treatments are evaluated, that it does more good than harm. It might be that people who feel good about themselves and who are healthy, walk more than people who are depressed or unwell, and there is probably some truth in that
A second method is to question people with a problem such as heart disease or depression about their lifestyle before they became ill, and compare their answers with the results of interviews of another group of people chosen because they are identical to the group that is ill – for example, same gender, same social class, same job – in fact being as similar to the people with the disease as possible except for the fact that they do not have the disease. This approach produces scientific evidence but, like all scientific methods, has its flaws. For example, one study of four questionnaires used in interviewing people about their exercise habits demonstrated that very different results were obtained, depending on which questionnaire was used. The answers given by the same people ranged from 81 minutes in response to one questionnaire to 242 minutes in response to another.
Pedometers do away with the problem of both memory and questionnaires, but you cannot go backwards in time so studies of walking, and other forms of exercise, have to rely on memory as well as questionnaires, and both are unreliable
In spite of these difficulties, there is now a large amount of evidence about the benefits of walking.
A drug has indications and contra-indications. The indications are the reason why a drug should be prescribed, the contra-indications are reasons why it should not be prescribed. For example, bacterial infection of the tonsils is an indication for penicillin, but allergy to penicillin is a contra-indication. There are many indications for walking, but what about the contra-indications? Some people with chronic conditions worry about taking more exercise, but there are no chronic conditions or diseases for which walking is contra-indicated. Walking has been shown to be beneficial for many diseases, including:
- heart disease
- intermittent claudication;
- lung diseases;
- psychological problems
One reason why walking is helpful in so many chronic diseases is that it tackles a complication common to all chronic conditions – loss of fitness. Disease has direct and indirect effects. The disease directly affects certain parts of the body. In coronary heart disease, for example, the arteries to the heart itself are affected; in neurological disease it is the brain. However, many chronic conditions also have indirect psychological and physical effects, most commonly depression and loss of fitness
A vicious cycle develops. The disease causes inactivity and the inactivity itself increases joint stiffness and the loss of muscle power, making the person feel even more depressed.