Institut de Formation et de Recherche sur les ... · 18-03-2009 · Anthony Staines, PhD Associate Professor, IFROSS, University of Lyon 3, France - Vice-Chairman of sanaCERT, Accreditation

System-wide strategies for holistic improvement

Institut de Formation et de Recherche sur les Organisations Sanitaires et Sociales

Institute for Education and Research on Healthcare and Social Organizations

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Anthony Staines, PhD

Associate Professor, IFROSS, University of Lyon 3, France - Vice-Chairman of sanaCERT, Accreditation Body for SwissHospitals, Switzerland - Staines Improvement Research, [email protected]

Göran HenriksChief of Learning and Innovation, Jönköping County Council, Sweden

Andrea Kabcenell, RN, MPHVice President, Institute for Healthcare Improvement, USA

International Forum on Quality and Safety in Health Care – A 1ICC – Berlin – Germany – March 18, 2009

v.1

The research

What is the impact of Quality Improvementprograms on clinical outcomes for patients?

March 18, 2009 ICC – Berlin - Germany - Anthony Staines - Göran Henriks- Andrea Kabcenell

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Literature review

Systematic review of quality improvementstrategies, done by the Health Evidence Networkfor the World Health Organization. This reviewshows that no scientific evidence of any strategy


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being superior to any other, in terms of efficiency orcost.

Øvretveit J. What are the best strategies for ensuring quality inhospitals. Geneva: WHO Regional Office for Europe's HeathEvidence Network (HEN); November 2003.

Literature review

Shortell & al – research in year 2000 including 3045CABG patients from 16 different hospitals.Evaluates the deployment of TQM in theorganization. Clinical results (length of stay,


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adverse events, mortality) vary by a factor of 2 to 4,but with no correlation with TQM implementation.

Shortell SM et al. Assessing the Impact of Total Quality Management

and Organizational Culture on Multiple Outcomes of Care forCoronary Artery Bypass Graft Surgery Patients. Medical Care.2000;38(2):207-217.

Research question

Can world class quality programmes in hospitalsshow evidence of improved clinical results?

If yes => What methods and tools do these hospitals useto succeed and how do they implement them? What is the


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to succeed and how do they implement them? What is theperception of these programs within the institution andwhat are their evidence-based results? What is the reasonfor these results?

If no => What is the phenomenon that prevents the goalfrom being reached or from being assessed?

Approach

Theory-building, inductive approach, as defined byGlaser & Strauss’ Grounded Theory

Case study – 3 cases


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Barney G. Glaser & Anselm L. Strauss, The discovery of groundedtheory; strategies for qualitative research, Chicago: AldinePub. Co., 1967.

R.K. Yin, Case Study Research: Design and Methods, Beverly

Hills, CA: SAGE Publications, 2003.

Case selection

Panel of 10 international experts, known for theirpublications hospital QI programs.

Could you recommend 3-5 hospitals that, to yourpoint of view, have most improved through QI / QMprograms ? output: list of 22 hospitals


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programs ? output: list of 22 hospitals

Selected the 3 most frequently recommended:1. Jönköping County Council – Sweden (3

recommendations)

2. Intermountain Healthcare – Salt Lake City – USA (4recom.)

3. Reinier de Graaf Group – Delft – Netherlands (2 recom.)

Case study design

Interviews on site (20-30 per case) including CEO,Director of Quality Management, Medical Director,Director of Nursing, 1 physician head ofdepartment, 3 heads of teams, 2 staff members,


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person in charge of risk management, 1 patient, 3external partners (primary care, Health Authorities,external evaluator or peer).

Observation (attitude, culture, symbols,cooperation, meetings, training sessions,architecture, leadership style, …)

Documentation research

FindingsFactors that canhelp or hinder QIprograms to cometo improvedpatient results

PLANdesign

Inspiring vision. Focusedand meaningful strategy

Prioritizing without exclusion

Dedicated organizationalstructure

Room for bottom-upwithin strategic frame

Credible leader

Adjusted informationsystemsAmbitions education

ACTImprove

Program managementmeets clinicians.

Goals, action plan

Culture of evidence-baseddecision making

BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill

- measurement- evidence-based- learningorganization

Outstanding ambition

Stable political and economic context

National context stimulatingclinical quality improvementand measurement

Move your dot

Rapid response teams

Quality management systems

Joiningcollaboratives

Financial resources

Environment characteristics Resources

Quality program organizationEducation

Leadership development

Quality as a globalbusiness strategy


9

Strategy spread

Identify, analyze,improve processes.

Motivating leaders, no dependency

Inspiring leadership style

Consistent steering

CHECKmeasureevaluate

Centralize process andoutcome evaluation data

Constant feedbackto professionals

Assess patientsatisfaction

Infrastructure& Capacity

Measurementsystems

Informationsystems

Physical symbolof QI program(e.g.. institute)

Size (volume)Integration

organization

Systemcharacteristics

Strategy spread


Crescendo over 15/20 years1.- design, raise awareness

2.- building infrastructure3.- implementing



Consistent steering

Prioritiesmaintained during crises

Stability of gen. managementand program management

Choosing tools compatible withstrategy and culture

DOimplement

business strategy

FindingsFactors used byleading QIprograms to cometo improvedpatient results Build


Programlogistics

Measurementsystems

Informationsystems

Physical symbolof QI program

Culture:- goodwill





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systemsof QI program(e.g.. institute)


Stability of generalmanagement and program

managementChoosing tools compatiblewith strategy and culture

FindingsFactors used byleading QIprograms to cometo improvedpatient results

PLANdesign

Inspiring vision. Focused andmeaningful strategy





11

structureRoom for bottom-up

within strategic frame

Credible leader




Strategy spread

DOimplement



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improve processes.Crescendo over 15/20 years

1.- design, raise awareness2.- building infrastructure

3.- implementing

Motivating leaders, nodependencyInspiring leadership styleConsistent steering

FindingsFactors used byleading QIprograms to cometo improvedpatient results Constant feedback

to professionals



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Goals, action plan



14

ACTImprove

Goals, action plan

Financial resources

Stable political and economiccontext


Environment characteristics

Move your dot



Joining collaboratives

ResourcesFindingsFactors used byleading QIprograms to cometo improvedpatient results


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System characteristics


Designing and running a QI program

The case of JönköpingCounty Council andRyhov Hospital, Sweden

Serving 330’000


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Serving 330’000inhabitants

10’000 employees

3 hospitals, 35 healthcenters

Member of the IHI“Pursuing Perfection”collaborative

Jönköping Höglandet

Location


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Värnamo

Europe Sweden Jönköping County

Source: Bojestig M. & Henriks G. « Transforming healthcare to a new levelof performance » - ISQua – Amsterdam - 2004


PLANdesign





Credible leader


ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources






18

Strategy spread




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

business strategy

Setting a clear and an inspiring vision

What would a clear and inspiring vision look like, foryour transformation program ?

How would you go about setting it ?

Take 3 minutes with your neighbor to discuss theabove.


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A clear and inspiring vision

Vision : «for a good life in an attractive county » Many vision statements emphasize « being the best in X

or Y treatment or services »

Jönköping promotes a holistic patient-centered vision,focused on quality of life, rather than disease or even


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focused on quality of life, rather than disease or evenhealth care


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The County Council vision:

For a good life in an attractive county

A focused and meaningful strategy

What would a focused and meaningful strategy looklike, for your transformation program ?

How would you go about defining it ?



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A focused and meaningful strategy

Strategic priorities are defined

They all focus on adding value for patients

They are communicated throughout theorganization using a graphic representation « the


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organization using a graphic representation « thediamond picture », helping to build high awarenessfor the strategy

IT

Envir.

Adm

AccessHow wereceive

Coopera-tion/flow

Clinicalimprovement

work

Patientsafety

Medication

Learning andinnovation

Strategic Improvement Areas

PreventionTaking careof oneself

Leadership

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V a l u e f o r p a t i e n t i n c r e a s e s

Goodfinances

Reliability

Source : Henriks G, Bojestig M, Karlsson S-O, « To do best possible and Pursuing Perfection, International Forum on Quality andSafety in Healthcare, Paris, April 2008


PLANdesign





Credible leader


ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources






25

Strategy spread




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

business strategy

A consistent crescendo over 15-20years

Quality improvement is viewed as « a journey inlearning » rather than a method for quick fixes.

Constant screening for new tools and methods Investigating and testing


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Investigating and testing

Adopted only if they fit the vision and culture.

A history of Quality Improvement in Healthcarein Jönköping county, Sweden

Patient Need Related Groups

Main processes defined

Balanced scorecard

Process Leader Education

Qulturum

Big Group Healthcare

Diamond picture

System thinking

Awareness

Process thinking

Redesign

Education

Movement

Full scale

Pursuing Perfection

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It is a long journey and we will always be on the way…

Main processes defined

Accreditations of laboratories

Organization Evaluation, (in Swedish: OG)

Awareness

Swedish Malcolm Baldridge Award (QUL)

Total Quality Management

Common Values & Improvement tools (Education for many)Source : Henriks G, Bojestig M,Karlsson S-O, « To do best possible andPursuing Perfection, International Forumon Quality and Safety in Healthcare,Paris, April 2008

Processes are identified andintegrated

A clear picture of the organization and its aims

An organizational map fully aligned with the vision

Driving processes and support processes builtaround the main clinical activities


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around the main clinical activities


29Source: System thinking and spreading knowledge, Bojestig M., Henriks, G., Provost L. IHI European Forum,Prague 2006


PLANdesign





Credible leader


ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources






30

Strategy spread




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

business strategy

Learning culture

”Learning”, a key component of the culture Learning has become the basic attitude within the

management team.

A major accident in another hospital is an opportunity toinvite the people involved and to learn.


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invite the people involved and to learn.

A mistake in a care process is an opportunity to have itdiscussed in a wide circle and to learn from it.

A pilot education for staff on clinical microsystems is anopportunity for the CEO to be present 21 days to showhow much this means to him and engaged management is

“this is a learning trip all the time”. CEO comment.


PLANdesign





Credible leader


ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources






32

Strategy spread




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

business strategy

Results of the program

Processes

Evidence of process improvements in a number ofdepartments

Considerable work undertaken to improve access. Evidence of lasting improvements in a number of departments


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Evidence of lasting improvements in a number of departments

Other departments questioning the foundation of the work

Evidence of some process improvements made tofollow evidence of effective practice. E.g. : Improved glucose control

Influenza vaccination

Breast feeding of newborns at the time of discharge

Outcomes Decrease in global mortality

Work on child asthma – best practice guidelines

Diabetes - HbA1c controlPeadiatric clinics (children age 19 and below) of

Jönköping County Council

40%

50%

60%

70%

80%

90%

100%

Patients with HbA1c > 9

Patients with HbA1c 6,7 - 8,9

Patients with HbA1c < 6,6


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0%

10%

20%

30%

40%

2003 2004 2005

Patients with HbA1c < 6,6

Influenza vaccination over time

70

6866

59

5260

70

80

90

100

Pe

rce

nt

2003Same activities as

the year before

Goal=68%

2004Same activities as the

2005Same activities as the

previous years. This is

no longer a project it

is a standard

Goal=75%


35

39

45

0

10

20

30

40

50

1999 2000 2001 2002 2003 2004 2005

Pe

rce

nt

2001starting to plan the

innovation

2002- Vaccination for free

- Vaccination registry

- Education in vaccination

for 250 nurses and 30

physicians

- TV-commercials and

adverts in the local press

- Goal=60%

Same activities as the

two previous years but

the TV-commercial

adjusted.

Goal=75%

Number of children with asthma admitted to hospital

15

20

25

30

35N

um

be

r/1

00

00 Värde för riket

1997 saknas

Värde för riket 2003-2005

saknas

Missingdata

Missingdata


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0

5

10

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Nu

mb

er/

10

00

0

Average

Jönköping

Blue line: survey between pediatric units. Work 98-99. Guidelines 2000, deploymentof guidelines 00-01. Comments explain lacking data.

data

Jönköping – factors that foster improvement

A strong emphasis on improvement culture

Quality seen as holistic – applied to everydepartment, every activity – quality as a businessstrategy


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strategy

Investment in becoming a learning organization

Quality should be exciting, fun

Bias towards bottom-up

Long-term view - stability

Jönköping – factors still in progress in 2006

The commitment of physicians toward QI variesconsiderably. While the leaders of QI within clinical departments are

usually physicians, some physicians have little ambition tobe deeply involved. But the physician culture is coming to


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be deeply involved. But the physician culture is coming toa tipping point.

Not yet sufficiently strong culture of measurement.

Clinical information systems not yet to standard

Specialized support to clinicians for statistics andfor the processing of data is still in development.

Clinical excellence

The case ofIntermountainHealthcare and LDSHospital, Salt Lake


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City, Utah, USA

Healthcare systemincluding 21 hospitals,health centers, ahealth plan. Private,non for profit.

Source http://fr.wikipedia.org

Intremountain Healthcare’s vision :clinical excellence

What strategy would you use to pursue clinicalexcellence in your transformation program ?

How would you go about it ?



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Clinical excellence at Intermountain

Evidence-based medicine as the key concept topursue clinical excellence.

The implementation of evidence-based medicine asan institutional responsibility, rather than the


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an institutional responsibility, rather than theresponsibility of an individual physician.

Process identification, priority setting.

Process and outcomes improvement through aspecific structure : clinical programs.


PLANdesign





Credible leader



ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources





42

Strategy spread

business strategy




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

Clinical programs structure

Clinical integrationExecutive team

Dev. team. n

Dev. team 2

Developmentteam 1 Guidance Council

Global coordination, budget,information systems,goal setting, priorities

Cardiovascular Neuromusculoskeletal Women & Newborn Primary Care


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Urban South RegionRegional program

management

Urban North RegionRegional program

management

Urban Central RegionRegional program

management

MD

Adapted from: Intermountain Healthcare, B. James

Program management

MDMD

MD MDMD MD

MDMD

goal setting, priorities Primary Care Oncology Intensive Medicine

Clinical program organization

Clinical program management teams Central:

1 Medical Director

1 nurse administrator

1 statistician


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1 statistician

Support team (IT, Finance, …)

Program management meets clinical teams everymonth (employed and non-employed physicians).Provide feedback on clinical outcomes.Improvement goals are set and resources neededare identified.


PLANdesign





Credible leader


ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot




Financial resources






45

Strategy spread




Consistent steering






Measurementsystems

Informationsystems



organization


Strategy spread






Consistent steering




DOimplement

business strategy

Goals are set - outcomes are trackede.g. : depression management

Detection of depression in PCsettings

Treatment for depression andother MH disorders based onbest practice guidelines

Detection : changes indetection rate

Treatment : use of standardtools, Rx retention rates andtypes, referral rates

Goals Measures


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best practice guidelines

Clinical outcomes in terms ofsymptoms, severity, andfunctional status

Satisfaction of patients,providers, employers

Costs to patients andemployers, and to IHutilization and operations

types, referral rates

Clinical outcomes : PHQ9and other tools, productivitysurveys

Satisfaction : surveys ofpatients, providers, employers

Costs : claims costs,absenteeism rates,operational costs, utilizationcosts

The role of the development team

Identify key processes with improvement potentialthrough evidence-based guidelines.

Write best practice guidelines (care process model)

Develop conceptual flow diagrams and clinicalpathways


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pathways

Define desired outcomes and tracking reports

Develop data flow and data systems

Research and generate care process model

Design and coordinate decision support

Produce monthly reports for program management

Plan physician and patient educational material

Care processmodel

e.g. depressionmanagement


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Source :http://intermountainhealthcare.org/xp/public/physician/

Clinical programs: tools

Clinical support (making it easyfor clinicians to do it right) Diabetes.

Patient worksheet. The clinicaldata system checks on lab values


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data system checks on lab valuesin the patient’s file and warnsabout potential problems to beinvestigated.

Patient self-history, filled by thepatient whilst waiting. 21 basicquestions. Right column foranswers = normal. Left column =to be investigated further.


Physician education Clinical learning days

Strategic improvementgoals are defined by thedevelopment team


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development team

Specialized departmentfor education material

Content defined by thedevelopment team


Patient education Specialized department

for support material forpatient education. Thecontent is defined by


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content is defined bythe development team,aligned with bestpractice guidelines.

Clinical programs : tools

Clinical information systems

Electronic medical record at LDS Hospital for 30years (world pioneer)

A PC in every patient room


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A PC in every patient room

Web application to monitor clinical results(process and outcomes indicators)

ABC costing system that can be used jointly withclinical information systems

Traditional clinical decision process


53

The institutional role in the clinicaldecision process at Intermountain

Clinicaloutcome


54

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DiabetesPercent of patients with HbA1c > 9


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Glycohemoglobin (HbA1c) shows blood sugar over time, chart shows overallimprovement of diabetes control in patients with diabetes (decrease in poor control).

Compliance with ventilator bundleguidelines


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Ventilator control

days


57

Appropriately reduced ventilator usage

Ventilator Associated Pneumonia


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Mortality rate : ICU and hospital


59

Introduction of guideline on electiveinduction of labor < 39 weeks gestation

25%

30%

35%

Pe

rce

nt

<3

9W

ee

ks

Percent of deliveries prior to 39 weeks

Implementation of 39 weekinduction best practice model


60

0%

5%

10%

15%

20%

Pe

rce

nt

<3

9W

ee

ks

Elective Deliveries < 39 WeeksElective Deliveries <39 Weeks

IHC System

25%

30%

35%


61

0%

5%

10%

15%

20%

1999

JanFebM

arAprM

ayJunJu

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ICU admissions by weeks gestation


62

Glucosecontrol inthe ICU


63

PLANdesign





Credible leader



ACTImprove


Goals, action plan


BuildInfrastructure

Programlogistics

Measurement

Culture:- goodwill





Move your dot

Rapid intervention teams



Financial resources




IllustrationReinier deGraaf Group


64

Strategy spread

DOimplement

business strategy






Consistent steering






Measurementsystems

Informationsystems



organization

System characteristics

Strategy spread

DOimplement






Consistent steering




Exceptional will to improve patientsafety

The case of the Reinier deGraaf Group in Delft, TheNetherlands

Teaching hospital

2 sites


65

2 sites

2’900 employees

Serving a region of about250’000 inhabitants

Member of the IHI“Pursuing Perfection”collaborative

Netherlands


66

Europe

Delft and region


67

Patient safety improvement work

The Reinier de Graaf Group is a member of the IHIPursuing Perfection collaborative.

Has learned about the Move Your Dot initiative onlowering Hospital Mortality.


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lowering Hospital Mortality.

Had seen Hospital Standardized Mortality Ratios forthe US and for the UK, but this data was notavailable for the Netherlands.

Worked for two years looking for partners in theNetherlands

Patient safety

Managed to find partnerships that led to HSMRsfigures for the Netherlands to be worked out by SirBrian Jarman.

Eventually launched a Move Your Dot initiative in


69

Eventually launched a Move Your Dot initiative inthe Netherlands

Hospital Standard Mortality RatiosThe Netherlands

80

100

120

140

HS

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5%

CIs

)2

00

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Patient safety

Despite a decent position, decided to lauch aninitiative to work on reducing mortality.

With the help of the Trigger tool, reviewed 60records of deceased patients in internal medicine,


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records of deceased patients in internal medicine,to understand what could be improved.

The Trigger Tool

Traditional reporting of errors or adverse events isoften not reliable, even in open cultures. It oftenunderestimates events and tends to cover onlywhat is assumed to be avoidable

The Trigger Tool provides a list of trigger criteria, to


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The Trigger Tool provides a list of trigger criteria, tobe used to review patient records, helping toidentify adverse events.

Resar, Roger. 2006, 'Patient Safety and Measurement - The Use of Trigger ToolMethodology', 11th European Forum for Quality Improvement in Health Care;Prague, Czech Republic: BMJ

Action taken

In order to reduce mortality, Reinier de Graaf Groupintroduced Rapid Intervention Teams.

The patient record review was spread to surgicaldepartments and then further to cardiology and


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departments and then further to cardiology andpulmonology.

Priorities not maintained during crises

1996 decision to merge with another smaller hospitalin the region

Controversial. Resistance from the population aroundthe smaller hospital. Resistance from the staff of thesmaller hospital.


74

1997 the medical director, the father of the QIprogram, leaves to head the national QualityImprovement Institute

1997 the CEO leaves

1999 the second CEO leaves

Since 2001, QI again part of the core strategy. Butteams are hard to remotivate after having placed QIaside for some time.

Discussion : the impact of transformationprograms on clinical results

How long does it take to be able to demonstrateimproved patient outcomes from a transformation /improvement program ?

Why does it take that amount of time ? Why does it take that amount of time ?

How does this knowledge influence the way youwould design your transformation program ?

Take 5 minutes to discuss the above with yourneighbor.


75

Cross-case conclusions

All three organizations are perceived as leading inquality improvement.

What is meant by quality improvement work isdiverse:


76

diverse: In its content

In the way it is implemented

There are committed leaders in all threeorganizations.

Cross-case conclusions

There are important differences in clinicalinformation systems capacities.

There are important differences in the availability ofclinical indicators.


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clinical indicators.

In all of the three institutions, despite theirperformance, it takes a lot of time until the hospitalis in a position to prove improved patient results.

The investment threshold

The observations of the three cases suggest apossible generalization: that there is an initial phasewhere the healthcare system needs to build aquality infrastructure.


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After this phase some process improvements maystart to show.

If these are sustained, outcomes improvement willstart to show.

Expectations

The expectations ofhealthcare leaders are thatthere is a direct correlationbetween QI work andresults for patients, based

Patientresults


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results for patients, basedon hopes generated bysome reported success ofQI in manufacturing.

QIwork

Literature review

In contrast, researchshows little evidence ofsignificantimprovements in patientresults due to QI on an

Patientresults


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results due to QI on aninstitutional basis

QIwork

World-class QI programs

The study of three “World class”quality programs shows that it ispossible to get to improved patientresults through QI. One of the programs we studied

showed improved outcomes in the

Patientresults


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showed improved outcomes in themajority of its departments.

One showed improved outcomes inone department and improvedprocess measures in a number ofdepartments.

The third was showing improvedprocess indicators in a fewdepartments.

QI work

Jönköping


The case suggests that therecould be a threshold (t) in QI,below which QI work does notlead to evidence of improvedpatient results.

Patientresults


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patient results.

QI workt


The initial investment goes into the balance sheet,not in the operating result.

Here, the investment is in building capacity andinfrastructure for QI: awareness, leadership will andcommitment, the political process of freeing up


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commitment, the political process of freeing upresources for QI, training staff, building culture,setting up indicators and data collection systems,and testing QI tools.

During this period (possibly around 10 years in thecases we studied) no correlation can be shownbetween patient results and QI work.


The impression is similar to being in a zone ofnoise, where signal is covered by noise – or that ofa zone of fog, where there is no visibility.

This could be due to too few measures or toinfrastructure building taking all the energy.


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infrastructure building taking all the energy.

Inverse correlations could even appear, becausethe more efficient a data collection system foradverse events or patients complaints becomes, themore it will be used, and the more adverse it willshow … until root causes are identified and systemsare redesigned and a decrease starts to show.

The institutional and context specificapplication of evidence-based medicine

An institutional deployment of evidence-basedmedicine, including designing context specificapplication tools for evidence-based guidelines, thatfit the organization to which they are applied, canincrease the potential to obtain improved outcomes.


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increase the potential to obtain improved outcomes.

Selecting best practices with a high potential,implementing them, monitoring, feeding backresults, discussing improvement targets.

What is done ? Applying Evidence-based medicine principles.

Best practice guidelines.

The institutional and context specificapplication of evidence-based medicine

How it is done ? IHC selects only interventions with high added value: high

clinical improvement potential for patients.

The responsibility for implementing EBM is institutional

Compliance to guidelines is measured, as well as patient


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Compliance to guidelines is measured, as well as patientoutcomes

Results are fed back to clinicians on a monthly basis

Results are discussed, goals are set, resources neededare identified, senior management intervenes to removebarriers if needed.

A set of interventions is deployed, all coordinated anddesigned for the outcomes improvement to happen.

The core business (clinical medicine) is managed!

Documents

Institut de Formation et de Recherche sur les ... · 18-03-2009 · Anthony Staines, PhD Associate Professor, IFROSS, University of Lyon 3, France - Vice-Chairman of sanaCERT, Accreditation