Visibility: The New Value Proposition for Health Systems
Anne W. Snowdon Anne W. Snowdon, PhD World Health Innovation Network
Charles Alessi, MD
Patient Safety in Healthcare
One of the greatest challenges facing global health systems is patient safety‌ Error and adverse events are increasing; medication safety, surgical safety, home care safety, infection (CPSI, 2016) (Spine surgeon, Foreign Body in Surgical Sites, Dialysis patients, Chemotherapy error 990 patients)
Every year 70,000 Canadians experience
preventable serious injury while hospitalized…
…23,000 experience death that is preventable. Medical Error is now the 3rd leading cause of death. Baker, 2004
Challenges for Clinical Teams
“Clinicians become used to missing information (1:4 pts), equipment is missing or defective (1:3 pts), “cut corners” to get the work done “Accept poor reliability as the norm, and stop reporting problems” “Reporting is voluntary – fear of being blamed, receive no feedback, view reporting as unlikely to lead to change” (Baker, 2014)
Adverse Event Reporting Manual reports (“issues�) = 1400/yr Digital system = 3400/year (60100/week) External notifications = 3500/yr (140/day) System Action required = 2300/year (200/month)* (Syringe recall)
The Challenge of Device Recalls
In the case of the metal-on-metal joint implants it took 4–5 years before evidence was accumulated and reported. We are left with more than 500 000 patients with metal-onmetal prostheses in the USA and more than 40 000 in the UK who are at elevated risk of device failure, which will inevitably result in the burden of further surgical treatment as well as billions of dollars in costs to taxpayers (Lancet, 2015)
13.5% adverse events, nearly double the rate in hospitals (7.5%)
What is Common to all these Safety Challenges?
•
Not well documented, essentially “invisible” to the system
•
Life changing for patients and families, yet preventable
•
Learning is retrospective, not≈ prospective
•
Common to every country
•
Limited or no improvement in 10 years
Reframing the challenge of patient safety and care quality as a system infrastructure opportunity
“Adverse events and medical error are an outcome of a lack of well-developed supply chain infrastructure that would make it nearly impossible for errors to happen�
Where is Supply Chain well developed?: Grocery: tracks and traces every food item Airlines: trace every passenger Retail: tracks every retail item
Retail Pharmacy • Track, trace and recall every product to individual consumer in one hour or less • Can move product anywhere in Canada when needed on short notice • “Sentinel Surveillance” system - Walkerton
Key Features of a Highly Visible Healthcare System
Value for Patients
* Safe, effective care that is accessible when and where it
is needed to achieve quality of life, health and wellness • Informed of products, ability to report adverse events Ireland Case, Recall Challenge
Value for Clinicians and Provider Teams • Tracking across the continuum of care, identify root causes of adverse events • Reduced workload burden automated adverse event reports and recall notification • Product identification and patient outcomes tracking • Early warning systems and alerts for proactive, prevention of error (MRI example)
Value for Healthcare Organizations
• E-commerce and inventory savings $$$ • Automated safety reporting • Accurate data on value to support procurement Expired Product
Value for Industry • Visibility to assess product performance • Insights into Population segment of patients • Product innovation – next generation of product innovation • Product use during care processes – trends in adverse events, or error Recall to individuals, Liability
SOLUTIONS
1. Create policy frameworks to require Global Standards Adoption (GS1)
Create policy frameworks that align with global jurisdictions – adopt global GS1 standards * the catalyst to guide supply chain transformation * single most influential condition for success globally Grocery  example
2. Invest in Digital infrastructure to support clinical teams to reduce/remove risk of error
• Implement automated digital tracking tools and devices so that every healthcare provider can track every patient, procedure and product used linked to outcomes • Create “alerts” providing real time feedback to clinical teams to link individual patient and the outcomes they achieve to products, care processes and provider teams Airport example
3. Establish a national digital product registry • A digital registry of all health products, streamlines procurement, inventory management efficiency • Accessible to all health system stakeholders to access accurate and up-to-date data on all healthcare products • Enables post-market product safety surveillance to ensure that only the safest, high-performing products are used UK Joint registry
4. Create ”visibility scorecard” to measure progress 4. D esign a nd i mplement s upply c hain v isibility 4. Design and implement supply chain visibility
scorecards scorecards
• Measures impact of supply chain transformation on safety, cost, quality of care • Tracks safety outcomes and product recall • Informs clinicians, industry and health system leaders
5. Build leadership capacity in strategic supply chain management – Next generation of leaders in health systems
• Build leadership capacity in supply chain as a strategic asset across health systems • Leveraging the expertise and experience in the private sector - manufacturing and distribution • Prepare the next generation of leaders in our business schools to understand strategic supply chain in healthcare
6. Align national and global supply chain policies • Streamline global supply chain processes across global borders to maintain Canada’s viability as an international market and partner • Manage risk of counterfeit products crossing borders • Align supply chain policy frameworks and pathways with other global jurisdictions • Track global product outcomes, mitigate risk of shortages, ensure access to the safest, best available products globally
Tanya
Bernie
Carole Carola
Anna
Peter
Kapka
Sabina Kapka To read full stories: www.patientsafetyinstitute.ca
Terri
Donna
Thank you. snowdon@uwindsor.ca
DR. ANNE SNOWDON, ACADEMIC CHAIR, WIN (519) 817-2205 ANNE.SNOWDON@UWINDSOR.CA Find us online at http://worldhealthinnovationnetwork.com Follow us on Twitter @WIN_Health
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