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Translating Evidence into Benefit for Patients The Impact of Clinical Leadership and Culture. Sharon Levine, M.D. Kaiser Permanente, California November, 2003. Kaiser Permanente. An “outsider” model of care delivery from the beginning - PowerPoint PPT Presentation
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Translating Evidence into Translating Evidence into Benefit for Patients Benefit for Patients
The Impact of The Impact of Clinical Leadership and CultureClinical Leadership and Culture
Sharon Levine, M.D.Sharon Levine, M.D.Kaiser Permanente, CaliforniaKaiser Permanente, California
November, 2003November, 2003
2
Kaiser PermanenteKaiser Permanente An “outsider” model of care delivery from An “outsider” model of care delivery from
the beginningthe beginning
Prepayment to a multi-specialty group Prepayment to a multi-specialty group practice: suspect from the beginningpractice: suspect from the beginning
Early ostracism: exclusion from participation Early ostracism: exclusion from participation
in organized medicine (AMA, county medical in organized medicine (AMA, county medical societies)societies)
Gradual acceptance after four decadesGradual acceptance after four decades
In the last decade, acknowledgment and In the last decade, acknowledgment and
respect: ability to measure and demonstrate respect: ability to measure and demonstrate
superior outcomessuperior outcomes
3
““Integrated delivery system”Integrated delivery system” RelationshipsRelationships
- Contractual - Contractual
- Partnership of equals- Partnership of equals
- Mutually exclusive- Mutually exclusive
- Shared fate- Shared fate
Co-ownership: shared accountability for Co-ownership: shared accountability for success of the wholesuccess of the whole
Organizational structure and relationships Organizational structure and relationships essentially unchanged since 1955essentially unchanged since 1955
4
An Evidence-Based Approach to An Evidence-Based Approach to Effective and Efficient Care DeliveryEffective and Efficient Care Delivery
Science and SociologyScience and Sociology
Science: Identify the “right thing” Science: Identify the “right thing” (30%)(30%) Systematic reviews of the evidenceSystematic reviews of the evidence Epidemologic researchEpidemologic research Outcomes measurement and identification of successful Outcomes measurement and identification of successful
practicespractices Evidence-based, clinical practice guideline developmentEvidence-based, clinical practice guideline development Design and development of care management Design and development of care management
programs for selected clinical priorities (eg., asthma, programs for selected clinical priorities (eg., asthma, diabetes) and populations (eg., frail elderly)diabetes) and populations (eg., frail elderly)
5
Translating Evidence into BenefitTranslating Evidence into Benefit
The Science The Science (30%)(30%)
Research Evidence Implementation Benefit
EpidemiologyEpidemiology Care Care Management Management InstituteInstitute
Clinical Clinical ResearchResearch
Drug Drug Information Information ServicesServices
Health Services Health Services ResearchResearch
6
Research Evidence Implementation Benefit
Translating Evidence into BenefitTranslating Evidence into Benefit
Sociology Sociology (70%)(70%)
– Integration– Aligned Incentives– Balanced Incentives
StructureStructure
CultureCulture
InfrastructureInfrastructure
– Physician Leadership
– Culture of accountability, commitment, pride, performance
– Systems support: from paper to electronic
– Information and data
– Education
7
Integration Along Multiple Integration Along Multiple DimensionsDimensions
Financing and Care Delivery: Single Financing and Care Delivery: Single revenue stream, shared responsibility for revenue stream, shared responsibility for allocationallocation
Across the continuum of care (community, Across the continuum of care (community, out-patient, in-patient, home care) and out-patient, in-patient, home care) and between primary care and specialty carebetween primary care and specialty care
Integration over time: Investment mind set, Integration over time: Investment mind set, long time horizonslong time horizons
Across the continuum of an illness or Across the continuum of an illness or condition: primary and secondary condition: primary and secondary prevention, diagnostic and therapeutic prevention, diagnostic and therapeutic services, supportive care, palliative careservices, supportive care, palliative care
8
Aligned IncentivesAligned Incentives Health Plan, Hospitals, Medical GroupHealth Plan, Hospitals, Medical Group
Shared fate, mutual exclusivityShared fate, mutual exclusivity
Partnership of equalsPartnership of equals
Primary care and specialist physicians: Co-located Primary care and specialist physicians: Co-located practice; shared ownership of patients/clinical practice; shared ownership of patients/clinical problems; facilitated referrals (e-Consult)problems; facilitated referrals (e-Consult)
Hospitalists providing inpatient careHospitalists providing inpatient care
Balanced IncentivesBalanced Incentives No “production” incentivesNo “production” incentives
No reward, incentive/personal benefit for under-No reward, incentive/personal benefit for under-utilizationutilization
Prepayment/capitation to the Medical Group; salary for Prepayment/capitation to the Medical Group; salary for physiciansphysicians
Incentives based on quality outcomes and patient Incentives based on quality outcomes and patient satisfactionsatisfaction
9
Physician LeadershipPhysician Leadership Self-governed, self-managed Medical GroupSelf-governed, self-managed Medical Group
Physicians manage all aspects of the business of the Physicians manage all aspects of the business of the Medical GroupMedical Group
““Every Physician a Leader”Every Physician a Leader”
–25-30% of physicians with some management responsibility, 25-30% of physicians with some management responsibility, administrative titleadministrative title
–Explicit effort to recruit physicians with leadership potential, Explicit effort to recruit physicians with leadership potential, leadership traitsleadership traits
Leader’s role: actively manage the cultureLeader’s role: actively manage the culture
Group ResponsibilityGroup Responsibility Culture of shared accountability for quality and cost of Culture of shared accountability for quality and cost of
health carehealth care
Peer accountability: collaborative practice, common chart; Peer accountability: collaborative practice, common chart; transparency of performance data;transparency of performance data;
Ownership of the problems and the solutionOwnership of the problems and the solution
Culture of commitment, not complianceCulture of commitment, not compliance
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Systems SupportSystems Support Many pieces currently in placeMany pieces currently in place
e-Consult, e-Rx, e-Refille-Consult, e-Rx, e-Refill
CIPS (Clinical Information Presentation System)CIPS (Clinical Information Presentation System)
Awaiting full implementation of electronic medical record Awaiting full implementation of electronic medical record (KP Health Connect) (KP Health Connect)
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Using Clinical Information SystemsUsing Clinical Information Systems
Preventive Health Preventive Health PromptPrompt
PILOTPILOT
Patient Encounter Patient Encounter data (OSCR)data (OSCR)
Disease registriesDisease registries
Electronic Medical Electronic Medical RecordRecord
12
Substantial Investment in Career-Long Substantial Investment in Career-Long Education and Professional DevelopmentEducation and Professional Development Continuing medical educationContinuing medical education
Clinician patient communicationClinician patient communication
Management trainingManagement training
Leadership DevelopmentLeadership Development
Systems training and supportSystems training and support
Training for collaborative practice/team-based careTraining for collaborative practice/team-based care
Education/information in lieu of regulation/prior Education/information in lieu of regulation/prior authorizationauthorization
13
Research Evidence Implementation Benefit
• Patient
– Better clinical outcomes
– Longer, more functional life
– Safer care
• System
– Increased efficiency
– Reputation
– Fewer errors, rework
• People– Professional satisfaction– Pride– Reputation – Commitment
Translating Evidence into BenefitTranslating Evidence into BenefitThe ResultsThe Results
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FOCUS ON THE CRITICAL FEWFOCUS ON THE CRITICAL FEW
53%
66%
80%
95%
Cum
ulat
ive
% o
f tot
al c
osts
0%
20%
40%
60%
80%
100%
Deciles (Members orderedfrom most to least costly)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
15
CARDIOVASCULAR DISEASE:CARDIOVASCULAR DISEASE: Leading cause of death in U.S.Leading cause of death in U.S.
10 Year effort to implement national 10 Year effort to implement national guidelines for hyperlipedemia, CHF, ACS, guidelines for hyperlipedemia, CHF, ACS, cardiac rehabilitation, and reduce cardiac rehabilitation, and reduce cardiovascular mortalitycardiovascular mortality
Multi-disciplinary steering groupMulti-disciplinary steering group
Physician champion for each guideline at Physician champion for each guideline at each facilityeach facility
Low Tech: Preprinted orders for ER, Low Tech: Preprinted orders for ER, hospital; algorithms for outpatient hospital; algorithms for outpatient treatmenttreatment
RN and Pharm D.-run cholesterol, cardiac RN and Pharm D.-run cholesterol, cardiac rehabilitation and congestive heart failure rehabilitation and congestive heart failure programsprograms
16
CARDIOVASCULAR DISEASE:CARDIOVASCULAR DISEASE:
High tech: CAD registry, CHF registry High tech: CAD registry, CHF registry with intelligent software system for with intelligent software system for outreach and trackingoutreach and tracking
CAD registry linked to registration CAD registry linked to registration system, with prompts at visit for system, with prompts at visit for cholesterol check; also to PILOT (patient cholesterol check; also to PILOT (patient integrated log, outreach and tracking) to integrated log, outreach and tracking) to generate “outreach” report with generate “outreach” report with patient’s LDL, beta-blocker and aspirin patient’s LDL, beta-blocker and aspirin use, provided quarterly to physiciansuse, provided quarterly to physicians
17
RESULTS: PROCESS GOALSRESULTS: PROCESS GOALS
By 2000, 99% use of beta-blockers in post By 2000, 99% use of beta-blockers in post MI patients at discharge, 80% at 1 year, MI patients at discharge, 80% at 1 year, 77% at 2 years77% at 2 years
LDL control < 130 improved from 22% to LDL control < 130 improved from 22% to 84% in post-MI patients (1996-2002) 84% in post-MI patients (1996-2002)
ASA at discharge for post-MI patients ASA at discharge for post-MI patients
93%93%
72% of CHF registry patients on 72% of CHF registry patients on
vasodilatorsvasodilators
64% of CHF patients on beta blockers64% of CHF patients on beta blockers
18
RESULTS: OUTCOME RESULTS: OUTCOME GOALSGOALS 15% decrease in death rate from CHF (1996-15% decrease in death rate from CHF (1996-
2001)2001)
25% decrease in CHF discharge rate (1998-25% decrease in CHF discharge rate (1998-2001)2001)
Age/sex/risk adjusted mortality rates for KFH Age/sex/risk adjusted mortality rates for KFH
hospitals declining 50-85% since 1993hospitals declining 50-85% since 1993
MI mortality rates up to 50% lower than MI mortality rates up to 50% lower than
similar hospitals across the state similar hospitals across the state
participating in National Registry of participating in National Registry of
Myocardial Infarction (NRMI)Myocardial Infarction (NRMI) Heart disease mortality more than 30% Heart disease mortality more than 30%
lower in the KPNC population than in the lower in the KPNC population than in the
non-KPNC population (after age and sex non-KPNC population (after age and sex
adjustment)adjustment)
The Healthy People 2010 goal for adult smoking prevalence is set at 12%. The California’s Tobacco Control Program in its 2003-2005 Master Plan, aims to reduce adult tobacco prevalence to 13% by 2005. The long-term California goal is to reduce adult tobacco prevalence to 10%.
2002 Current Adult Smokers
25.7%
19.6%
14%
20.8%
13.3%
10.5%
23%
16.4%
12.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
United States California KaiserPermanente
MenWomenOverall
2002 United States California Kaiser PermanenteMen 25.7% 19.6% 14%Women 20.8% 13.3% 10.5%Overall 23% 16.4% 12.2%
Source: Kaiser Permanente Division of Research - Preliminary Member Health Survey report prepared by Nancy P. Gordon, ScD, Division of Research 10/14/2003
Source: CDC-National Center for Chronic Disease Prevention & Health Promotion Behavioral Risk Factor Surveillance System 2002
1919
20
Science: Science: Sufficient evidence; high qualitySufficient evidence; high quality
Sociology:Sociology: Clinical peer leadershipClinical peer leadership
Passionate championsPassionate champions
High engagement processHigh engagement process
Decision support at the point of care across the continuumDecision support at the point of care across the continuum
Increasingly sophisticated technologyIncreasingly sophisticated technology
Practice supportPractice support
Unblinded sharing of performance data (“healthy Unblinded sharing of performance data (“healthy competition”)competition”)
Patient education, engagementPatient education, engagement
PerseverancePerseverance
Translating Evidence into Benefit Translating Evidence into Benefit What WorkedWhat Worked
21
CONCLUSIONCONCLUSION
A multi-modal, multi-specialty, clinician A multi-modal, multi-specialty, clinician peer-expert-led implementation of peer-expert-led implementation of national guidelines for cardiovascular national guidelines for cardiovascular disease management has led to a disease management has led to a substantial decline in cardiovascular substantial decline in cardiovascular mortalitymortality
On an absolute basis, compared to non-KPNC On an absolute basis, compared to non-KPNC mortalitymortality
On a relative basis, compared to cancer On a relative basis, compared to cancer mortalitymortality
Results: Cardiovascular Results: Cardiovascular Mortality Relative to Cancer Mortality Relative to Cancer MortalityMortality
0.50.550.6
0.650.7
0.750.8
0.850.9
Car
dio
vasc
ula
rm
ort
alit
y
Can
cer
Mo
rtal
ity
KPNC/non-KPNCCalif 1980
KPNC/non-KPNCCalif 1998
2222
23
vsKP NCal hospitals . all other hospitals in counties with KP hospitals
Source: OSHPD
0
5
10
15
20
25
8%
13%
KP THE REST
= statistically sig. p<0.01
30-Day Mortality After Acute Heart 30-Day Mortality After Acute Heart AttackAttack
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