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

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““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

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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)

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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

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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

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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

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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

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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

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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

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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%

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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

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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

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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

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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

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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

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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