Meet our inspiring Runners-up of the VBHC Prize 2020
These initiatives will be shared with you here in rotation.
Humanitas Research Hospital’s mission is:
- to improve patients’ lives by offering increasingly effective treatments based on an innovative organization,
- to invest in a research that creates real impact on the progress of Medicine,
- to guarantee access to healthcare for all citizens through a sustainable use of resources
- to train a physician/scientist/humanist able to work all around the world.
In the past 5 years some clinical pathways were reviewed with an improvement of value, but the hospital is a complex environment with different clinical behaviours, cross functional activities and shared assets and an integrated approach was needed.
In 2018 a quality model has been created, considering different working areas:
- Cultural change: without a positive Quality and Safety Culture, we couldn’t talk about problems, we couldn’t review processes and we couldn’t improve value. This area works on improving an effective and continuous communication, that focalized staff and clinicians on VBHC, giving them personalized feedbacks about their priorities.
Main results: 86% (371) specific Quality and Safety Goals obtained on 2019, + 30% incidence rate of aims reporting on 1000 days of stay
- System innovation: we work to discover, select and implement systems focused on clinical processes, helping doctors and nurses to offer the best quality in real time (i.e: using alert systems as Early Warning Score) or ex-post, collecting structured clinical data.
- Patient safety and infection control: we learn by adverse events and we improve implementing corrective actions. A professional team controls infections with a specific programme, organizing focalized workshops, monitoring and sharing results.
Main results: +5% on hands hygiene, sepsi mortality rate: 32% 2018 vs 25,5% 2019.
- Process improvement: we review our processes with a standard model. Clinicians designed the best standardized pathway based on clinical evidenced. Patients’ feedbacks and innovations are included in the new process redesign. Cycle of care’s sustainability is measured.
Main results: 6 clinical pathways reviewed that were the enables to redesign different cross-functional activities (i.e. the pre-admission process for more than 164 clinical conditions) and to make clinicians as active parts in suggesting clinical changes to create value.
- Data analytics: a Clinical Performance Information System (CPIS) was created to monitor and analyse clinical, processes and patients’ satisfaction data till the level of operating unit, patient and even individual physician.
Main results: 120 KPIs created on 2019, 15 different pages implemented on 2019 for 15 pathways.
- Patient experience: our structured approach is based on 4 pillars:
- Listening at the voice of patients and caregiver
- Personalization of clinical pathways
- Support to clinicians
- Improvement suggestions
Main results: 30.000 inpatient and outpatient surveys in 2019, 4 surveys on the complete cycle of care, structured interviews, weekly feedbacks to Directional Board.
Multidisciplinary approach is well-established. More than 15 MDTs are already in place, for assessing and planning/delivering treatments for specific-condition patients. A Change Management Program is in place with a comprehensive review of the organization, based on Centers and Interdisciplinary Teams, to bring decision making processes even closer to floors and units.
Humanitas started to collaborate with international and nation hospitals on performance management, on quality innovation, on processes and, as a results, on value.
Our quality model is an example of governance with an integrated and coordinated approach where everybody is responsible for value.
The Netherlands CP register is a unique and innovative value-based health care model, based on clinical outcomes, patient outcomes and individual goal attainment, and aimed at cost-effective personalized care. It combines a standardized follow up program and a treatment register.
Developed in recent years in collaboration with the patient organization CP Nederland, the first patients entered the program early 2020. In the first phase ten centers throughout the Netherlands are involved; from 2022 on national coverage will be realized.
Treatment register for personalized care
Cerebral Palsy (CP) is a group of permanent disorders that affect movement and is a result of a brain lesion during early development. It is the main cause of physical disability in children. Children with CP often have other problems, like intellectual, speech, hearing and eating impairments. There are approximately 7000 children with CP in The Netherlands: every 22 hours a child with CP is born. The care is organized in multidisciplinary teams of different specialists, like paediatric physiatrists, physical and occupational therapists, paediatric neurologists, orthopaedic surgeons, psychologists, social workers, speech therapists.
CP cannot be cured, but with the help of different treatments children with CP can improve their functioning, participation and quality of life. Not all children with CP are similar: some can walk, while others completely depend on other people. Because of this heterogeneity it is difficult to find solid evidence for treatments using traditional research methods. In the Netherlands CP register we collect data from the Dutch population in order to gain knowledge about long-term treatment effects. In this way we can predict which treatment is best for which type of patient, resulting in cost-effective personalized care while avoiding expensive ineffective treatments.
Follow up program
We implement a standardized screening program, based on the Swedish CPUP: Uppföljningsprogram för cerebral pares. CPUP reached spectacular results: after the introduction there was a significant decrease in secondary problems and the need for orthopaedic surgery, resulting in huge cost reduction.
A panel of parents and patients was included in the register design. Parents indicate a need to follow the development and treatment results, so they become active participants in the entire care cycle. A patient portal provides parents with feedback from the register. The Netherlands CP register combines individually defined goal setting and evaluation together by patient and physician (using Goal Attainment Scaling), clinical and patient reported outcomes (PROMs). In this way we reach meaningful care: care that matters to the patient.
Patient- centered and doctor driven
The IT platform GemsTracker is patient-centered, supporting the patient journey through all phases of care. If needed data can be shared, facilitating communication among health professionals.
GemsTracker is an outcome-based clinical support system that provides real-life feedback (visualized values over time, relative to norm data) to health professionals and patients. This supports shared decision making and allows the health professional to adjust treatment plans and continuously improve the quality of care. The platform also allows for comparison and benchmarking of achieved treatment outcome at institutional and clinicians level.
Prevalence of chronic pain in the general population is estimated to be 25% and is expected to increase as the effects of population ageing and increased levels of obesity and lack of physical activity (1).
Evaluation of chronic pain and its consequences on social, professional and family life remain a challenge for patients and healthcare providers. Even in dedicated structures such as pain clinics, evaluation of chronic pain is often limited to the auto-evaluation of pain scores (visual analogic score or numeric rating scale ranging from 0 (no pain) to 10 (worst imaginable pain). Moreover, these assessments are only performed promptly and lack continuous monitoring.
Most patients report inadequate management of their pain and its economic impact is greater than most other health due to its effects on rates of absenteeism and increased risk of leaving the labour market conditions (2).
A better evaluation and follow-up of chronic pain would allow a more efficient and faster management of patients.
The CPM application is proposed free of charge to all the patients treated at our pain clinic. It is easily downloaded on the patient’s smartphone. The treated population represents patients suffering from various chronic pain conditions, including back pain, fibromyalgia, complex regional pain syndrome, persistent post-surgical pain or cancer pain.
Patients will be first asked to complete various validated questionnaires exploring different dimensions such as quality of life (EQ-5D), disability (Oswestry questionnaire), mental status (Hospital anxiety and depression questionnaire) that will serve as baseline data. Specific questionnaires are also proposed in case of particular diagnostics, such as Fibromyalgia (Fibromyalgia Impact Questionnaire) or particular conditions such as neuropathic pain (DN4, Pain detect). When installed, the application also starts to record physical activity continuously through the built-in accelerometer of the smartphone. Numerous parameters of physical activity are measured, including the total walking distance, the maximal walking distance, the steps cadence and the rest periods. Previous studies have shown a good correlation between level of physical activity and pain intensity.
The application continuously monitors the patient’s outcomes throughout his treatment. Push notifications are automatically sent to patients at regular intervals but also at a preprogrammed frequency after the introduction of a new treatment or after interventional procedure. The push notifications consist of pain scores (numeric rating scale), validated questionnaires and request feed-back (eventual side-effects or complications).
All the collected data (NRS, questionnaires, physical activity parameters) are automatically transferred, stored and displayed in the electronic medical file of the patient. The physician in charge can thereby follow in real time the evolution of his patient and if necessary adapt the treatment without delay. In case of persistent high intensity of pain level, an alarm is sent to the physician. The patient can also follow the evolution and progress directly on his smartphone as results are displayed in simple and understandable graphics.
The CPM application also proposes educational (information on the various pain syndromes, available treatments and procedures) and therapeutic content (library of physiotherapy exercises to perform at home, relaxation and hypnosis sessions in virtual reality).
- Breivik H et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European Journal of Pain2006; 10: 287–333.
- Maniadakis N et al. The economic burden of back pain in the UK. Pain2000; 84: 95–103.
Fragility fractures equate to a loss of quality of life for patients and a high burden to the healthcare system, with over 500,000 fragility fractures reported in the UK in 2017. Hip fractures alone accounted for more than 72,000 unplanned hospital admissions and over 1.3 million hospital bed days in 2017/18 – this burden is predicted to increase further with the growing longevity of the UK population. Despite this, there are significant gaps in the identification of at-risk individuals and knowledge of optimal treatment pathways.
The aim of the project was three-fold:
- Identify patients with high risk of fragility fracture, evaluate bone sparing agents (BSAs) and educate and treat patients to improve bone health and prevent future fractures.
- Support GP practices in achieving long term goals of osteoporosis management and review and implementation of NICE CG 146
- Create health outcomes report to demonstrate the need for scalable rollout.
A supra-regional partnership project was created, harnessing the four academic health science geographies, Sunderland University and Interface Clinical Services within a joint-working agreement between the NHSA and Amgen covering a population of 16 million.
The project was implemented in three stages:
- Analysis and stratification – patient-level data within GP IT systems was analyzed in detail.
- Individual patient assessment: Interface Clinical Services pharmacist assessed all patients and made recommendations to the GP.
- GP reviewed recommendations, identified patients recalled for review, and patient management plans developed with the patient.
In the proof of concept wave, 71 GP practices were involved in Newcastle Gateshead CCG, North Tyneside CCG, and Northumberland CCG. The project has now been accepted as a project by the Northern Bone alliance to be scaled across the Northern region, the implementation and continuation of the partnership is currently in progress.
The patients involved in this project are those who are over 65 years old with have a high risk of future fracture. The patients are involved in their treatment decision through consultation with their GP. The assessment of the project by Sunderland University will seek patient feedback.
Early insights within 71 practices with an aggregate patient population of 579,508 participated in the audit with 28,657 patients included in the audit according to the identification criteria.
- 58% of patients diagnosed with osteoporosis were not currently receiving BSA and 30% had no history of ever being prescribed a BSA.
- 70% of patients with osteoporosis who were not currently receiving a BSA had previously been prescribed BSA in the past.
- Patients at high risk of fracture were not being treated, 37% of patients not receiving a BSA fall within the recommended threshold to treat.
What makes this project different:
- There has never been a project of this scale in osteoporosis in the UK.
- The project has moved from local level (East Lancs), to regional (NENC-AHSN), to supra-regional (Northern Bone) to national (shortlisted for national spread and adoption program). In addition, the project has received international interest from colleagues in Canada.
- Development and sharing of a ‘marketing pack’ including anticipated outcomes/case studies/ key messages – thereby supporting the value proposition for practices and CCGs.
- Provision of education and support for practices to develop QI skills – thereby supporting the sustainability of improvement.
Gestational Diabetes Mellitus (GDM) is a global phenomenon affecting over 15% pregnant women, especially in low- and middle-income countries significantly reported with higher prevalence of 22%-37% in different provinces of Pakistan provided with limited sample size. A large number of pregnant women have to suffer through adverse medical conditions in their gestational age include GDM and pre-eclampsia; both of these diseases are contributing towards threatening the fetus health. This initiative demonstrate the impact measured by a pilot study in Pakistan towards eliminating the risk of morbidity and mortality by establishing a patient-centric remote healthcare model called RAH@H (Remotely Accessible Healthcare at Home) by integrating digital health solutions for remote monitoring and management of discussed diseases in pregnant women via project-provided digital medical devices at home for a safe and secure delivery while saving lives at birth.
No other intermediary is placed between patient-end and project portal unlike most of the programs where primary care centers are involved as intermediary; for data collection followed by referrals. This initiative is expediting the process; saving time and cost providing quality access to the consultant directly.
Appropriate triage was performed on each pregnant woman on their visits to the gynecologist which were then referred to RAH@H to measure their eligibility to participate in the study based on their capability to comprehend English language; computer and internet literacy; acquaintance with smart phones; and internet accessibility at home. An informed consent has been sought from each patient.
Tailored user-guides and video were shared among the recruited patients and were trained on medical devices (digital Bluetooth-enabled blood pressure monitor, Bluetooth-enabled glucometer and RAH@H mobile application). These devices send frequent and updated data whenever patients tested their vitals to the mobile-app of RAH@H installed on their own smart phones which were in turn obtained by the clinicians on the RAH@H staff portal in real-time allowing virtual monitoring.
This was compounded by biweekly teleconsultations by the gynecologist and remote follow-ups were scheduled to monitor the development of health conditions of patients based on the data received on RAH@H staff portal hence drug adjustment was performed. Special counselling was done on fall prevention and associated emergency adequate measures.
A qualitative survey tool was developed and validated for- and among the participants to analyze the overall satisfaction and engagement level of patients and provider with the project. To-date, RAH@H has addressed 36 cases eliminating pre-eclampsia and post-partum diabetes ensuring patient safety; out of overall 48 current active patients which are registered in the RAH@H project.
It is a multi-country intervention that is currently being implemented in Pakistan and Saudi Arabia. The Pakistani government realized the advocacy to increase developments in digital healthcare and introduction of innovative connected health interventions serving the vulnerable community. Thus, RAHAH was developed and Saudi Arabia provided provision of support in implementing RAHAH in Pakistan via collaboration and partnership promoting sharing of knowledge and experience and building the capacity to collectively deal with the implementation challenges. The initiative believe RAH@H can bridge a critical gap in providing quality healthcare to the expectant mothers using an evidence-based approach which will demonstrate the value of the program in terms of delivering quality healthcare promising patient safety.
The NSE/EasyROM initiative is unique and different, because it is fully centered around the patient, as a starting point, end point and beyond. Our aim to have Recovery Approach (RA) Treatment and rehabilitation plans and PROMIS (Patient Reported Outcome Measurements Information System, leveraged by EasyROM), be the guiding vision for the entire Mental Health field. RA was first coined by Psychiatrist Dr. William Anthony in 1993 and is a model to mental disorder of substance abuse, that emphasizes and supports a person’s potential for recovery. It is a highly personal journey, rather than a pre-set protocolized outcome and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Recovery sees symptoms as a continuum of the norm rather than an abnormality and rejects sane-insane as a division. PROMIS is a set of person-centered measures that evaluates and monitors physical, mental, and social health in adults and children. It can be used with the general population and with individuals living with chronic conditions. PROMIS was the goal set by the NIH (USA’s National Institute of Health) in 2004 to develop an efficient state-of-the-art assessment system for self-reported health.
The PROMIS measures catalogue has 28 Dutch/Flemish Item Banks (as the questionnaires are called in there) and over 300 English and Spanish Item Banks. The EasyROM app is the patient-centered implementation of PROMIS, by providing a platform with a very low threshold in a very familiar, patient-friendly package, focused on the needs of the patients. By utilizing EasyROM into the RA Treatments, it is very easy to keep concentrated on the treatment steps and the effects and performance it makes on the road to recovery for the patient, in a structured and scientific way. Because such a journey is a deeply and very personal process, it needs treatment and support steps that work for the individual. Each treatment and rehabilitation plan is very fluid and follows the patients needs , instead of where the patient needs to fit in a certain fixed treatment plan.
EasyROM fixes the potential experimental character of RA, by providing a solid psychometric structure with T-Scores that can be compared and benchmarked. At scale, treatment steps used and their most effective outcome measurements can be re-used for new patients with similar symptoms and problems. This creates an upward spiral in knowledge and treatment methods, beneficial for all. As of NSE is a small practice with a limited case load and is providing a spring board for the entire scope, which includes all worldwide English and Spanish speaking patients that are using RA as a treatment and rehabilitation method. It is estimated that the NSE practice has saved more than €20-€25 million euros in Dutch health care costs, during its existence. Preliminary results using EasyROM have shown that screening and intake take up substantially less time. Start of treatment and rehabilitation plan is more focused and insight in effectiveness of steps taken are shown more quickly. This means quicker referral to medical specialist for higher care treatment or medication, instead of relying on external signs and off-chance notifications indicating the need for increased help.
EasyROM gives the visual insight, the numbers and the structured answers, useful for counselor, medical professional and patient. It is this visual insight, that gives patients also a hold to use motivate themselves for better therapy loyalty, making them more likely to stick to the treatment steps.