Application of Systems Thinking to Gain Efficiencies

Transcription

1 Application of Systems Thinking to Gain Efficiencies Max Salfinger, MD Denver, Colorado, USA KnowledgeLab 2016 Orlando, FL March 21, 2016

2 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 2

3 The journey sets the destination University Hospital, Basel-Switzerland University of Zurich, Dept. Medical Microbiology Sabbatical Denver, Colorado National Jewish, University Hospital, Webb-Waring Lung Institute New York State Department of Health, Albany, New York Florida Department of Health, Tallahassee, Florida October National Jewish Health, Denver, Colorado 2

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5 National Jewish Health National Jewish Health is the leading respiratory hospital in the nation. Founded 117 years ago as a nonprofit hospital, National Jewish Health today is the only facility in the world dedicated exclusively to groundbreaking medical research and treatment of patients with respiratory, cardiac, immune and related disorders. Patients and families come to National Jewish Health from around the world to receive cuttingedge, comprehensive, coordinated care. 5

6 Integrated/Holistic Expertise Advanced Diagnostic Laboratories Clinical Research Clinical Expertise Academic Research 6

7 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 7

8 Less known FL Facts Population: 20 million (3 rd most populous) Pensacola to Key West: 832 miles (almost to Chicago) Agriculture: Largest beef producer east of the Mississippi Number of tourists: 97 million (2014) Inventor of refrigeration: In 1849, Apalachicola physician Dr. John Gorrie ( ) discovered the cold-air process of refrigeration and patented an ice machine in He had experimented to find ways to lower the high temperatures of yellow fever patients. 8

9 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 9

10 Public Health Core Functions Disease prevention, control, and surveillance Integrated data management Reference and specialized testing Environmental health and protection Food safety Laboratory improvement and regulation Policy development Emergency response Public health-related research Training and education Partnerships and communication MMWR Recommendations and Reports, September 20, 2002, 51(RR14);

11 Then there were 3 PHL Jacksonville Tampa Miami 11

12 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 12

13 Systems Thinking Peter Senge in his landmark book The Fifth Discipline - The Art and Practice of the Learning Organization (1990), lists Systems Thinking as the first of the five components of a learning organization along with Personal Mastery, Mental Models, Building Shared Vision, and Team Learning. Systems thinking is a conceptual framework, a body of knowledge and tools that has been developed over the past fifty years, to make the full patterns clearer, and to help us see how to change them effectively. 13

14 Systems Thinking Some aphorisms describe systems thinking or the lack there of: Today s problems come from yesterday s solutions The harder you push the harder the system pushes back Behavior grows better before it grows worse The easy way out usually leads back in The cure can be worse than the disease Faster is slower Dividing an elephant in half does not produce two small elephants 14

15 Systems Thinking There is no blame: We tend to blame outside circumstances for our problems. Someone else the competitors, the press, the changing mood of the market place, the government did it to us. Systems thinking shows us that there is no outside; that you and the cause of your problems are part of a single system. 15

16 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 16

17 Implementing Efficiencies Vignette ONE: Outsourcing clinical chemistry/hematology Vignette TWO: Diagnosing multidrug-resistant tuberculosis sooner Vignette THREE: Implementing Severe Combined Immunodeficiency (SCID) into Newborn Screening panel 17

18 Vignette ONE Task at hand: Saving salary $$$ Clinical chemistry and hematology are not core functions of a Public Health Laboratory Identified 6 positions (5+1) Task at hand: Saving salary $$$ and if possible, not to lay off staff 18

19 Vignette ONE Task at hand: Impact statement Several County Health Departments relied on the service provided by PHL Discovered that County Health Departments NOT using the Public Health Laboratories were billed different prices for the same analyses by the commercial laboratories (up to 1,000% difference!) 19

20 Vignette ONE A decision was made: 67 County Health Departments belong to the same entity, the Florida Department of Health In order to provide the same service with the same price to all 67 County Health Departments, independent of volumes, one single Request for Proposal (RFP) was initiated Resulting in 20

21 Vignette ONE more than ONE Million Dollars saved per year By the way, none of the 6 staff were laid off we were able to reassign them to other laboratory sections where we had vacancies. 21

22 In 2011, the implementation team was awarded: Vignette ONE A Davis Productivity Award for Reduced Primary Care Laboratory Costs For County Health Departments 22

23 World TB Day March 24 On March 24, 1882, Dr. Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacteria that cause tuberculosis (TB). During this time, TB killed one out of every seven people living in the United States and Europe. Dr. Koch s discovery was the most important step taken toward the control and elimination of this deadly disease. In 1982, a century after Dr. Koch's announcement, the first World TB Day was sponsored by the World Health Organization and the International Union Against Tuberculosis and Lung Disease. The event was intended to educate the public about the devastating health and economic consequences of TB, its effect on resource-limited countries, and its continued tragic impact on global health. 23

24 Implementing Efficiencies Vignette ONE: Outsourcing clinical chemistry/hematology Vignette TWO: Diagnosing multidrug-resistant tuberculosis sooner Vignette THREE: Implementing Severe Combined Immunodeficiency (SCID) into Newborn Screening panel 24

25 WHO: Tuberculosis Burden 9 million people fell ill with TB in 2013, including 1.1 million cases among people living with HIV In 2013, 1.5 million people died from TB An estimated 550,000 children became ill with TB 25

26 WHO: MDR-TB Situation MDR Multidrug-resistant (resistant to Rifampin & Isoniazid) 480,000 people estimated to have developed MDR-TB in ,000 people died due to MDR-TB in % proportion of new cases with MDR-TB 26

27 CDC: Primary Resistance 27

28 Only the laboratory can diagnose drug-resistant tuberculosis 28

29 Demanding Instant Results! 20 Min 20 Hours 29

30 Vignette TWO MDR-TB is a costly affair. It is estimated that the care of such a patient can be costly ($250,000) compared to a drug-susceptible case ($25,000). The earlier the laboratory diagnosis of MDR-TB is made, the faster the patient receives adequate treatment, thus shortening the time period of transmitting MDR-TB and lessening the likelihood of developing MDR-TB when only mono-resistance to INH or RIF is initially detected. 30

31 Vignette TWO A decision was made: To offer 67 County Health Departments rapid molecular multidrug-resistant tuberculosis screening from the sputum (not waiting for a positive culture weeks or months later) June 2009, rolling out the Hain MTBDRplus test, a commercially available line probe assay that detects mutations associated with the majority of cases of rifampin (rpob) and isoniazid (katg and inha) resistance, which will become integral to the diagnosis and early detection of drug-resistant cases within our state. 31

32 Vignette TWO The State Public Health Laboratory used the universal MDR TB screening protocol for 577 individual patients. Florida reported 11 MDR TB cases for the period ; 9 were evaluated using the universal MDR TB screening protocol; and, of the 9; 6 were identified as RIF and INH resistant (MDR TB); 1 was RIF resistant only; and 2 were INH resistant only. Additionally, RIF resistance was detected in 3 of 4 RIF monoresistant cases for using the universal MDR TB screening protocol. Furthermore, INH resistance was detected in 19 of 23 INH monoresistant cases for the same period. 32

33 Vignette TWO In 2012, the Florida Department of Health was awarded the ASTHO Vision Award: ACHIEVING EXCELLENCE IN PUBLIC HEALTH THROUGH INNOVATION for the Multidrug-resistant Tuberculosis Screening Program Association of State and Territorial Health Officials 33

34 Implementing Efficiencies Vignette ONE: Outsourcing clinical chemistry/hematology Vignette TWO: Diagnosing multidrug-resistant tuberculosis sooner Vignette THREE: Implementing Severe Combined Immunodeficiency (SCID) into Newborn Screening panel 34

35 Newborn Screening Dr. Guthrie introduced the first newborn screening test in the United States for phenylketonuria (PKU) in the early '60s and the use of the Guthrie card to collect the heel stick blood for newborn screening is now standard. Dr. Guthrie began his clinical career as a cancer research doctor but became interested in preventing mental retardation after his second son John was born with developmental disabilities and his niece was diagnosed with PKU. 35

36 Newborn Screening Every year over 4 million US newborns are screened for genetic and metabolic conditions, and hearing loss as part of a process called newborn screening. For babies who test positive for one of these conditions, rapid identification and treatment makes the difference between health and disability - or even life and death. 36

37 Newborn Screening Severe Combined Immunodeficiency (SCID) is a primary immune deficiency. The defining characteristic is usually a severe defect in both the T- & B-lymphocyte systems. This usually results in the onset of one or more serious infections within the first few months of life. These infections are usually serious, and may even be life threatening; they may include pneumonia, meningitis or bloodstream infections. 37

38 Vignette THREE On May 21, 2010 Kathleen Sebelius, US Secretary of Health and Services, announced the addition of SCID to the core panel of 29 genetic disorders as part of her recommendation to adopt the national Recommended Uniform Screening Panel. SCID is the first nominated condition to be added to the core panel of disorders. 38

39 Vignette THREE July 2010 The Florida Genetics and Newborn Screening Program Advisory Council recommends to add SCID to the panel August 2010, Budget Issue Proposal issued May , Senate and House pass the budget, including line item for SCID implementation May 26, 2011, Incoming Governor vetoed a $1,952,084 line item from the Planning and Evaluation Trust Fund that would establish newborn screening for SCID in Florida. 39

40 Vignette THREE We were all devastated by the veto and determined to double our efforts the next year. The prevalence of SCID is approximately 1 in 100,000 births which translates into 2-3 babies each year in the State of Florida. Again, with advocacy by Angels for Life Foundation and Representative Matt Hudson, R-Naples, the line item for SCID implementation was again included in the budget and passed. The funds were available as of July 1,

41 Vignette THREE On November 29th, 2012 DOH held a press conference to announce testing for SCID. Testing began on October 1st, The first patient was identified with possible SCID on October 25th, Less than 20,000 specimens were tested when the first SCID patient was identified. Confirmatory testing showed patient as having SCID. 41

42 Vignette THREE So far, a dozen babies with SCID or variants have been diagnosed. Most importantly, all babies received timely, life-saving treatment and are doing great. Babies are priceless! 42

43 Lessons Learned Vignette ONE: Thoroughly assessing the impact of stakeholders paid off Vignette TWO: Investing in the laboratory resulted in savings in Tuberculosis Control Vignette THREE: We underestimated an incoming administration 43

44 Topics Short Bio Introduction - Florida Introduction - Public Health Laboratory Introduction - Systems Thinking Implementing Efficiencies Vignette 1 Vignette 2 Vignette 3 Diffusion of Innovations 44

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46 Diffusion of Innovations Innovators 2.5% Early Adopters 13.5% Early Majority 34% Late Majority 34% Laggards 16% Everett M. Rogers, ; published in 1958

47 Acknowledgments Dr. Phil Amuso, Tampa Susanne Crowe, Jacksonville Regina Taylor, Jacksonville Dr. David Ashkin, Lantana Sevim Ahmedov, Tallahassee Virginia TB Foundation Lois Taylor, Tallahassee Dr. Ming Chan, Jacksonville Representative Matt Hudson, R-Naples Angels for Life Foundation 47

48 Thank you!