Evidence-Based Medicine and the Changing Nature of Health Care 2007 IOM Annual Meeting Summary (2008) / Chapter Skim
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4 Contending with the Changes
4 Contending with the Changes
Pages 93-108
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From page 93... ...
to improve care of patients on ventilators and discusses the major barriers inherent to health care that might limit broader implementation of this approach, and possible solutions. In his paper, Marc Boutin highlights the diversity of patients, each with differing life circumstances, cultural needs, preferences, and socioeconomic status.
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From page 94... ...
Devin Carr prototyped change in nursing practice for ventilator management. John Bingham and the Center for Clinical Improvement supported process mapping and performance audits.
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Teams of people, well-defined processes, and information technology tools work in concert to produce the desired result consistently. People provide compassion, pattern recognition, and judgment.
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The bundle is a set of standardized practices with specific process steps and measures of performance for each practice. The core team also drafts one or more overarching idealized processes that would result in consistent execution of the bundle.
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Metrics provide an early indicator of where we are and are not achieving reproducible performance on the set of standard practices, and we adapt education, tools, or process as needed. The rapid cycle iterative nature of the system development steps cannot be overemphasized.
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In addition, whenever clinical outcomes for a population deteriorate or diverge in the wrong direction from external benchmarks, we will know to reassess the standard set of practices for that population. Example of Expert Management of System-Supported Practice VUMC selected the ventilator management bundle as one of the test cases for our systems approach to practice.
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From page 99... ...
On the last Saturday in January 2007, 45 individuals from across VUMC participated in the cross-enterprise ventilator bundle design day. This group included medical and nursing leadership from each unit, postgraduate fellows, front-line nurses, pharmacy, respiratory therapy, infection control, nurse educators, informatics, evidence-based order set development, decision support and order entry, clinical documentation, business analytics, process reengineering, process audit, chief quality officer, and executives from the core team.
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From page 100... ...
to present the bundle of standard practices, together with definitions or patient-specific criteria directly in clinical work flow, and use exit checks for reminders if something was missed. In addition, we would create a process control dashboard, as illustrated in Figure 4-3, with a line for each ventilator patient on a unit and a column for each element of the bundle, with a red, yellow, or green (gray scale in figure)
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(b) Expansion on selection of stress ulcer prophylaxis.
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This outcome feedback will in time provide the evidence to guide continued refinement of the standard practices. Implications for Healthcare Workforce and Infrastructure Policy The demise of expert-based practice is inevitable.
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How might health care consistently produce the desired result while accommodating biological variation, uncertainty, and differing value systems? Third, other industries are able to isolate change and stage its introduction into routine production more systematically than health care.
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From page 104... ...
Continuous system development and refinement through iterative cycles of the system development steps might yield local standard practices, consistent with global knowledge yet adapted to local resources and capabilities, changing evidence, and system performance. The linked cycles of system-supported practice permit flexing of standard practice for individual patients based upon expert judgment, but under the control of monitors that can warn of problematic trends in real time.
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Second, we should call for health services and biomedical informatics research into techniques and technologies to support local development and iterative refinement of systems approaches to practice. For example, we might test approaches permitting "mass customization" of standard practices.
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From page 106... ...
In other words, as we embrace an epidemiological view and use public health decision models, we should also remember and embrace the promise of personalized medicine. In the patient-centered world of personalized medicine, we allow individual patient data, in the hands of an individual health professional, to be given equal standing with aggregated public health data: as the IOM Roundtable has stated, "to account appropriately for individual variation in patient needs." That is our ideal.
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1992. Comparative efficacy of alternative hand-washing agents in re ducing nosocomial infections in intensive care units.
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American Journal of Respiratory and Critical Care Medicine 157(4 Pt 1)
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