Challenges of Standardization

Dennis Helling, PharmD, DSc, FCCP, FASHPExecutive Director Pharmacy Operations & TherapeuticsKaiser Permanente ColoradoClinical ProfessorUniversity of Colorado School of Pharmacy

Incremental vs. Transformational Change

To facilitate the spread of innovation that truly transforms, it must be developed on

a base of consistency and standardization.

Random Variation

• The level of random variation is a physical attribute of a process

• Reducing random variation requires a new process with a new level of random variation, superior to the original process

• Real life examples from KPCO

… the Journey

… an “Incubator of Innovation”

Model Refinemen

t

Idea

KPCO Clinical Pharmacy Services

Anticoagulation (25) Float Pool (4) Research (5)Cardiac Risk (22) Pharmacogenomics Research FellowCall Center (38) Primary Care (35) Residents PGY2 (6)Drug Information (2) Medication Safety (2) Therapeutic Initiatives

Travel Clinic (3)

Specialties (23)

Asthma / Allergy Hospital (1) Neurology

Cardiology/Heart Failure (2) Infectious Disease Oncology (2)

Continuing Care (3) Memory Clinic Palliative Care (3)

Diabetes/Endocrinology Behavioral Health (3) Transplant

GI Nephrology Weight Mgmt

Clinical Pharmacy Cardiac Risk Service (CPCRS)

Centralized telepharmacy model with computerized tracking system 21 clinical pharmacy specialists & 1 technician 800-1,000 patients per clinical pharmacist

Currently manage >14,000 patients with CAD In addition, also managing >800 patients with

peripheral vascular disease (PVD) Stroke patients 1,500

CPCRS Significantly Improves Cholesterol Care

•Standardizing secondary CAD prevention establishes new, more optimal, level of random variation in cholesterol care 0

20

40

60

80

100

120

1 2BEFORE & AFTER: Patients Reaching Cholesterol Goal

BEFORE & AFTER: Patients Screened for Cholesterol

26%

73%

55%

97%

Arch Intern Med 2005;165:49-54 Am J Card 2000;85:36A-42A

Transformational change

Early intervention

(< 90 days post-event)

Any intervention

All-cause mortality

89% reduction 76% reduction

Cardiac-related mortality

88% reduction 73% reduction

CPCRS Significantly Reduces Risk of Death

Pharmacotherapy 2007;27(10):1370-1378

Clinical Pharmacy Anticoagulation Service (CPAS)

Centralized telepharmacy service Cares for ~8,000 patients

Staffing 22 clinical pharmacists/specialists 3 pharmacy technicians ~500 patients per clinical pharmacist

CPAS Results/Outcomes

CHEST 2005;127:1515-22. J Thromb Thrombolysis 2003; 15:113-8. Arch Intern Med 2000;160:2926-32.

3.3%

63.5%

5.2%

55.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Complications INR Control

CPAS Usual Care

CPAS

•Standardizing anticoagulation management establishes new, more optimal, level of random variation

•40% reduction in risk of complications

Transformational change

Logo transition

Challenges

• Measuring and improving quality care delivery Defining standardized quality measures Critical to ensure apples-to-apples

comparisons

• Can standardization coexist with individual clinical judgment?

• Demonstrating the value of clinical services