How to Create A Culture of Continuous, Sustainable Improvement Christopher Kodama, MD, MBA

President, MultiCare Connected Care March 24, 2017

Objectives

• To outline governance and structure to support your physicians and staff

• To describe how to efficiently develop evidence-based guidelines & pathways

• Explain how to implement data analytics to engage your teams in performance improvement

2

Agenda

1.Who

2.Why

3.How

4.Case Studies

3

4

WHO MultiCare Health System

Key Attributes

• Washington State Footprint

• Integrated Healthcare Delivery System

• Tertiary Children’s Health Network

• Employed Provider Group of 800+

• Clinically Integrated Network of >2400 providers

5

6

MultiCare Connected Care

• Separate entity from MultiCare Health System

• Wholly owned by MultiCare Health System

• Commercial

• Physician-led

• Houses the CIN (MCC Network)

7

MCC Network

• Primary Care + Multispecialty

• Pediatric to Adult

• MultiCare-employed (MMA) & Independent

• Continuum of Care

• 2400+ physicians, AP’s, and ancillaries

• 80K+ covered lives

8

9

WHY A Case for Change

10

eco system (ee·koh·sis·tuh·m) n.

any system or network of interconnecting and interacting parts

Why Now?

Our Ecosystem

11

CONSTITUENTS COLLEAGUES

CONSUMER

POPULATIONS

CORPORATE COLLABORATORS

9.4%

9.1%

10.2%

www.worldbank.gov April 25, 2016

Comparisons

Affordability

13

$3 trillion $9,523

17.5% www.cms.gov, december 3, 2015

Current Value

• Life Expectancy

• Infant Mortality

• 2+ Chronic Conditions

• Obesity

14

www.commonwealthfund.com october 2015

Focus

QUALITY

S E R V I C E COST

15

Value Proposition

Q U A L I T Y S E R V I C E

COST

x = VALUE

16

Accountable Care

838

28.3M

http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion/

17

Paradigm Shifts

FROM TO

Sick care WELLNESS and disease management

Episodic Care SEAMLESS comprehensive care across the

continuum

Silos & Fragmented Care PERSON-CENTERED & Integrated

Exclusively Fee-For-Service TOTAL COST of Care

Duplication COORDINATED Providers

Bricks & Mortar Care VIRTUAL Care

Acute Care CONTINUUM of Care

Single EHR Single Source of INFORMATION

Patients POPULATIONS

18

A Transformational Mindset

19

20

HOW Approaching Performance Improvement

• Physician-led

• Reduce Clinical Variation & Standardize Care

• Improve and Sustain Clinical Outcomes

• Improve Patient Experience

• Reduce Costs

Clinical Collaboratives

21

• Evidence-based Care Pathways

• Order Sets

• Staff and Patient Education Tools

• Leading and Lagging Indicators

• Implementation Plan

• Communication Plan

Objectives

22

SYST

EM P

AR

TNER

SHIP

S Pe

rfo

rma

nce

Exc

elle

nce

Sta

nd

ard

s

CULTURE PROCESS TECHNOLOGY

Safety Team Learning

TRUST

HIGH RELIABILITY ORGANIZATION

STRUCTURE

Collaboratives Focused Interventions

5 Principles of HRO’s 1. Sensitivity to operations (Situational awareness) 2. Preoccupation with failure (Proactive instead of reactive 3. Reluctance to simplify (Multiple viewpoints) 4. Deference to expertise (Shared decision making) 5. Commitment to resilience (Containment capabilities)

Partners • Quality • Finance • Service Excellence • Colleagues (clinicians) • Business Operations • Corporate • Constituents • Consumers • Support Services (e.g. Carelines, Service Lines) • Human Potential (e.g. ILD, change management) • Information Technology • Business Intelligence

NO

YES

NO

Prioritization

YES

Collaborative Criteria?

Operational Priority?

23

What Qualifies As A Collaborative?

INCLUSION CRITERIA (Draft) • Addresses clinical variation

• Pareto analysis for high cost

• Risk contract requirement

• Continuum of care

• Purchaser potential priority (future contract requirement)

EXCLUSION CRITERIA (Draft) • Business Unit specific

• Department specific

24

Clinical Integration

25

MCC Board of Managers

Clinical Leadership Committee

Network Development Committee

Collaboratives

Standard Pathways

Guidelines

Core Performance Measures

Alignment

contract focus

multicare focus

What purchasers &

payors are telling us

is important to them

Our

interpretation of

what we think

matters most

Partnering for healing &

a healthy future

CO

LL

AB

OR

AT

IVE

S

26

Key Considerations

• PEOPLE

– right skills

– right temperament

– role clarity

• FOCUS & ALIGNMENT

– prioritization

– discipline

• INFORMATION-DRIVEN INSIGHT

– credible

– actionable

– real-time

• MEASURABLE

– deployment

– adoption

– favorable results

27

1 People

Executive Oversight

Quality Safety Steering Council

Physician Lead Operations Lead Clinical Lead

Lead

ers

hip

&

Dir

ect

ion

Co

ord

inat

ion

, A

lign

men

t &

A

cco

un

tab

ility

Critical Resources Operations Clinical Subject Matter Experts

Exe

cuti

on

28

1 People

Executive Oversight

Quality Safety Steering Council

Physician Lead Operations Lead Clinical Lead

Lead

ers

hip

&

Dir

ect

ion

Co

ord

inat

ion

, A

lign

men

t &

A

cco

un

tab

ility

Critical Resources

Operations Clinical Subject Matter Experts

Exe

cuti

on

29

2 Focus & Alignment

• Performance improvement framework

• Market differentiator for our CIN

• Staying relevant

• Aligned with strategic objectives (LEM)

Internal Opportunity

Existing Risk-Based

Contract Measures*

Anticipated Purchaser Priorities

Collaboratives

30

Alignment

31

Primary

Care

Critical

Care

Emergency

Services

Medicine Pediatrics Surgery Women’s

Services

Readmissions

LOS

Service Excellence

Mortality

*Cardiac is managed separately via the Pulse Heart Institute

50 40 55 40 50 70 30

>300

Clinical Collaboratives QI Contractual Deliverables

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Spine (Acute BP)

Ortho Joints

Spine (Surgical )

Heart Failure

AMI CAB

Gyn OB

Colon Glycemic Control

Surgery Collaborative

Pneumonia COPD Spirometry

Medicine Collaborative

Sepsis Resp

Failure Early

Mobility ARDS

Critical Care Collaborative

Cardiac Collaborative

Peds Cohort

Pediatric Collaborative

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Quality Improvement Plans Deliverable

Date

Potentially Avoidable Hospital Readmissions 30-Sep-15

Care Coordination for High-Risk Patients 30-Sep-15

Obstetrics and Maternity Care 31-Dec-15

Total Hip and Knee Surgery Bundle 31-Mar-16

Spinal Fusion Bundle 31-Mar-16

Cardiology Improvement 31-Mar-16

End of Life Care Improvement 30-Jun-16

Low Back Pain Improvement 30-Jun-16

Addiction and Dependence Treatment Improvement

30-Jun-16

Spine (Acute BP)

OB Gyn

CAB AMI Heart

Failure

Ortho Joints

Spine (Surgical )

Women’s Collaborative

Paying Attention to Your Ecosystem

32

3 • Evidence-Based Best Practice

– Care pathways

– Care guidelines

• Data analytics testing

• Data definitions and standards

• Rapid feedback loops

Information-Driven Insight

Data

Information

Knowledge

33

4 Measureable

• Specific

• Measureable

• Achievable

• Relevant

• Time-bound

34

Consistent Process

Stabilization Deployment /

Implementation Development Investigate

Prioritize / Establish Aims

35

0 month 1-3 months 3-9 months 9-12 months 12+ months

• SMART AIM statement for each collaborative

• Reporting needs identified

• Baseline data and current state process map.

• Prioritization of specific opportunities for improvement related to AIM.

• Draft practice guideline

• Care Guideline/Pathway

• Final order sets

• Training plan & materials

• Performance management plan

• Education materials

• Monthly/quarterly report on outcome metrics

• 3, 6, 9, 12 month follow up reports to assess and mitigate risks

GU

IDEL

INE

AP

PR

OV

AL

RACI Assessment

• Owns the project/problem

Responsible

• Must approve work before it is effective

Accountable

• Has information/capability necessary to complete the work

Consulted

• Must be notified of results, but need not be consulted

Informed

36

Role Clarity

Prioritize I/C A A I/C R C I

Investigate I A A I R C I

Develop C/R A A C/R R C C

Implement A A A A R C C

Stabilize A A A A R C I

37

Deployment

Stabilization Deployment /

Implementation Development Investigate

Prioritize / Establish Aims

• SMART AIM statement for each collaborative

• Reporting needs identified

• Baseline data and current state process map.

• Prioritization of specific opportunities for improvement related to AIM.

• Draft practice guideline

• Care Guideline/Pathway

• Final order sets

• Training plan & materials

• Performance management plan

• Education materials

• Monthly/quarterly report on outcome metrics

• 3, 6, 9, 12 month follow up reports to assess and mitigate risks

GU

IDEL

INE

AP

PR

OV

AL

38

Buy-in & Approval

18 months 6 months 6 weeks

39

Adoption

Rapid Feedback Loops • Leading (In Process):

– order set utilization

– NOREADMITS

• Lagging (Outcomes):

– Readmissions

– Elective induction rates

– Wound infections

• Public comments

• BI requests

• Physician Engagement

Other Forms of Engagement • Public comments

• BI requests

• Physician Engagement

40

41

by specific physician

name

42

USE CASE COPD

43

1 & 2 People, Focus & Alignment

Prioritize & Investigate

Develop & Implement

Stabilize

• Diverse range of stakeholders

• Patient-centered • System Objective

• Improving quality + lowering the cost

• Engagement and adoption

• Universal solution • Sustained results

44

3 Information-Driven Insight

• Building an enterprise-wide approach:

–Root cause analysis (system/facility/provider group/etc.)

–Order set

–Access to data

– Education & training

–Correlate processes with outcomes

45

4 • Correlate processes with outcomes

– 22% reduction in COPD readmissions from 2015 to YE 2016

– 95% of COPD patients assessed for readmission rate

– 89% increase in COPD Order Set utilization from 2015 to YE 2016

– 42% improvement in PCP notification

Measurable

46

USE CASE Women’s Health

47

1 & 2 People, Focus & Alignment

Prioritize & Investigate

Develop & Implement

Stabilize

• Agreed upon aspiration of standards

• Aligning systems & processes across the enterprise

• Highly engaged physicians and staff

• Channeling efforts and passion to yield results

• Realtime transparency to sustain improvements & results

48

3 Information-Driven Insight

Spark Change

Adoption success

Multiple reimbursement models

Real-time data

Predictable deployment

Marketable outcomes

49

4 • Improved care, efficiency and market share

– 68% reduction in episiotomy rate

– Consistently held Elective Induction rate to 0% for calendar year 2016

– 3-fold increase in the percent of non-invasive hysterectomy techniques

– Rate of exclusive breast feeding increased to 70% at YE 2016

Measureable

50

Wrap Up

51

The journey continues...

Lesson 2014 2015 2016

Top Down Initiated; tied to the ACO Implemented Built into organization-wide objectives

Rapid Sequential Clunky Improved Ongoing optimization

Change Management Ad hoc Implemented practice outreach; public comment periods

Integration into ACO committees

Resource Patchwork Budgeted & Purchased Service Level Agreements

Education Ad hoc Consistent CME events

Don’t Boil the Ocean Anecdotal prioritization Contract alignment Data-driven prioritization

Design + Deploy Strong design, limited deployment

Increased focus on deployment

Ongoing

Good Enough Ongoing Ongoing Ongoing

Approval Process Initial formal process Refinement Simplification

Physician Engagement Silo’d Employed Network

52

Next Steps

• Focused Interventions (HRO)

• Further alignment with operations

• Core measures prioritization

• Ongoing alignment across the organization

• HIE and data reporting

53

Objectives

To outline governance and structure to support your physicians and staff

To describe how to efficiently develop evidence-based guidelines & pathways

Explain how to implement data analytics to engage your teams in performance improvement

54

55

www.multicareconnectedcare.com