Process Approach To Medical Quality. Bob Matthews Doug Romer PriMed Physicians/MediSync

Transcription

1 Process Approach To Medical Quality Bob Matthews Doug Romer PriMed Physicians/MediSync

2 PriMed s Phase 1 Medical Quality Goals 1. 90% of patients achieve the evidence based outcome and process standards for: Major chronic diseases (i.e. HTN, Lipids, Diabetes, Asthma, CAD, CHF, COPD, Depression, Osteoporosis, WRAP 2. Achieve 1 st goal at the lowest possible cost 3. Create a quality method that is replicable from disease to disease a modular approach 4. Get paid for our accomplishments in quality and cost effectiveness 5. *Achieve substantial improvements in cost effectiveness (per ACO requirements)

3 Cost of Chronic Disease Seventy-five percent of the (monies) spent on health care in the U.S. is for treatment of the chronically ill. - The Commonwealth Fund

4 WRAP Chronic Disease Management Managing the Care Continuum (i.e. office, home, hospital, SNF) Early and/or Intensive Intervention in High Risk/High Cost Patients General Patient Safety (i.e. Medicine Reconciliation) Quality and Cost Improvement Collaborative Decision Making about Care Increased Options For Palliative End-of-Life Care Selecting Lower Cost Pharmaceuticals Lowering Admission and Re-admission Rates Case Management

5 Survey: What Do Most Medical Groups Do? 1. Remind doctors about the evidence based standards 2. Flag patients with target diagnosis 3. Install an EHR 4. Put quality pop-ups in the EHR 5. Get lists of patients who need more care (i.e. registry) 6. Hire nurses or others to remind or coach patients and docs about missing elements of care/quality

6

7 Group Mean Percent to Goal Medical Quality Goal: Move One Variable (i.e. BP) 10 1 st 2 nd 3 rd 4 th 5 th 6 th 7 th 8 th 9 th 10 th 11 th 12 th 13 th 14 th 15 th 16 th Time in Months

8 Lessons From Quality Theory (i.e. Six Sigma, Lean, TQM, etc.) 1. ALL modern schools of quality improvement are based upon standardized processes ( standard work in Lean parlance) 2. Process can outperform people (even the best people) 3. Complexity can only be tamed with process; intelligence is welcome but insufficient 4. All processes have a capability limit The limit for working out of your head is about 35% success for medium complex work 5. The more steps in the process, the higher success rate you need to achieve at each step in order to get to the desired outcome

9 Definition of Process A series of prescribed steps designed to achieve a specified outcome

10 Process vs. EBS vs Best Practices Goals 90% to EBS EBS / Best Practices WHAT should be done Processes HOW to accomplish EBS or Best Practices

11 Legacies of Bad Managed Care Commercial rates < Medicare rates Large panels of patients per doc Emphasis on speed & throughput Diabetic education wiped out of market except for group classes at hospital Mental Health wiped out in community Undersupply non-procedural medical subspecialists (i.e. Endo, Rheum) No innovations funded to date (e-visits; phone; health coaches; etc.) Per Ohio law & reg: NP and PA very late

12 Original 2003 Medical Quality Plan Create Quality Processes For: Select and Install New Tools Re-Design Care HTN Diabetes Lipids Asthma Osteoporosis Depression CHF CAD COPD EHR Knowledge Management Case Management Etc. Non-Physician Providers Additional Providers (Coaches, Educators, etc.) Case/Care Management Group Visits Telephone and Home Monitoring

13 Why Do Physician Focused Processes First? 1. If we wanted to become a process centric organization, we needed the physicians to become committed to process first (not last). If the doctors were not going to be involved in process, then the medical group could not sustain a process approach. 2. We wanted to maximize the effectiveness of office visits and other routines of care first, then use additional forms of intervention (i.e. case or care managers, etc.) to supplement NOT the other way around.

14 The Cost of Quality Improvement 1. All modalities of extra care (i.e. case management, education, coaching) will imply a cost but not necessarily any revenue. 2. There is an upper limit on the percent of patients who can get to goal with just an office visit We discovered it varies by diagnosis 3. We will add new modalities of care and/or case management once we reach optimal success with office visits understand the needs 4. Our total financial success favors getting patients to goal as soon and as inexpensively as possible

15 Total Patients 100K HTN 25K patients with 50% success 12.5K patients at goal 12.5K patients not at goal Diabetes 10K patients with 40% success 4K patients at goal 6K patients not at goal CHF 3K patients with 50% success 1.5K patients at goal 1.5K patients not at goal Asthma 6K patients with 40% success 4K patients at goal 6K patients not at goal

16 First Medical Quality Project: Create HTN Process 1. Use Six Sigma 2. Establish baseline performance

17 Percent of Patients Reaching JNC-7 BP Goal HTN Outcomes With or Without Co-Morbidities 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Elite Medical Groups Post Intervention Average US Performance Baseline 3/1/05 06/01/05 09/01/05 12/01/05 03/01/06 06/01/06 09/01/06 12/01/06 03/01/07 06/01/07 10/01/07 01/01/08 04/01/08 07/01/08 MediSync Groups

18 First Medical Quality Project: Create HTN Process 1. Use Six Sigma 2. Establish baseline performance 3. Create an Ishikawa or Fishbone Diagram to identify all the obstacles

19 STAFF B.P. Tech. Compliance (POLICIES/PROCEDURES) PROCESSES Measurements Reported Access. of Office for Pt. No Shows Policy/Comm. between Cardio., Spec.- Renal (Role Clarity) Phys., & PCP s Algorithm Home Monitor Paying bills (invoice) Process Little Old Lady Pt. provide full disclosure of meds. Process to f/u with Pt. INTERNAL ENVIRONMENT SYSTEMS -OFFICE, EQUIPMENT, MATERIALS, SUPPLIES, HARDWARE/SOFTWARE, ETC. BP Cuff Coverage ICG Test ICG Knowledge of HTN Role Clarification PCP, Cardio, Renal Review of Meds. (med. list) Inter-phys. variation Time Reluctance to treat Resistance to SBP Following visits not Pts. Pt. Population (defining) Delay of data results (over a month) Definition of Pt. White Coat Synd. Full disclosure of meds. No shows Money Dialysis of Pts. Knowledge of HTN Planning (med refill) Efficiency of Office Employer (perception) Pharmacy Insurance HTN % TO GOAL Algorithm Compliance White Coat Synd. Knowledge of HTN Cost Little Old Lady Compliance Motivation (lack of) Socio. / Econ./ Demographics / Ethnicity Ambul. BP monitoring Media PHYSICIANS PATIENTS HEALTHCARE ENVIRONMENT (EXTERNAL) INSUR. CO., GOV T. AGENCIES, SPEC., HOSPITAL, PHARM., ETC.

20 Creating the HTN Process 1. Use Six Sigma 2. Establish baseline performance 3. Start with an Ishikawa or Fishbone 4. Create a true process that Addresses every HTN patient, every visit Includes Impedance Cardiography Guides drug selection and dosing

21

22

23 Creating the HTN Process 1. Use Six Sigma 2. Establish baseline performance 3. Start with an Ishikawa or Fishbone 4. Create a true process that Addresses every HTN patient, every visit Includes Impedance Cardiography Guides drug selection and dosing 5. Solve controversy with statistics

24

25

26 Inside Expert s DOE Analysis of Usefulness of ICG Y-hat Model BP@Goal Factor Name Low High Exper A c t iv e Factor Name Coeff P(2 Tail) Tol Const A StatusCoded C A StatusCoded X B AlgFollow edcoded C B AlgFollow edcoded X C ICG_RightCoded C C ICG_RightCoded X R Multiple Response Prediction Adj R Std Error % Confidence Interval F Y-hat S-hat Lower Bound Upper Bound Sig F BP@Goal F LOF Sig F LOF Source SS df MS Regression Error Error Pure Error LOF Total

27 Inside Expert s DOE Analysis Usefulness of ICG PriMed Y bar Marginal Means SBP &DBP Combined at BP Goal Dec StatusCoded AlgFollowedCoded ICG_RightCoded Effect Levels

28 Creating the HTN Process 6. Measure use of HTN Process and outcomes 7. Unblinded publication of data What do you do with doctors who do not use HTN Process?

29 07/01/08 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of Patients Reaching JNC-7 BP Goal HTN Outcomes With or Without Co-Morbidities Elite Medical Groups Post Intervention Average US Performance 3/1/05 06/01/05 09/01/05 12/01/05 03/01/06 06/01/06 09/01/06 12/01/06 03/01/07 06/01/07 10/01/07 01/01/08 04/01/08 MediSync Groups Baseline

30 100% PriMed Quartile 1 % BP@Goal July 2006 Average: % Goal = 89% % Copy of Algorithm = 90% % Algorithm Followed = 80% %ICG Performed on Not at Goal Pts=25% 90% 80% 70% 60% 50% 40% % Goal % Copy Algorithm % Algorithm Followed % ICG Performed on Not At Goal Pts 30% 20% 10% 0% GREER RAN DALL ROMER, D SCH AERER THUNEY DER KSEN AHMAD PEREZ COUCH TOGLIATTI

31 100% PriMed Quartile 2 % BP@Goal July 2006 Average: % Goal = 77% % Copy of Algorithm = 91% % Algorithm followed = 85% % ICG Performed on Not at Goal Pts = 19% 90% 80% 70% 60% 50% 40% % Goal % Copy Algorithm % Algorithm Followed % ICG Performed on Not At Goal Pts 30% 20% 10% 0% ESTEP LUNA OCONNELL ZWIESLER SEILER MASON-ZIED FOR NADEL MELTZER TEATER OWUSU-DEKYI

32 PriMed Quartile 3 % BP@Goal July 2006 Average: % Goal = 69% % Copy of Algorithm = 87% % Algorithm Followed =74% %ICG Performed on Not at Goal Pts=11% 100% Aver 90% 80% 70% 60% 50% 40% % Goal % Copy Algorithm % Algorithm Followed % ICG Performed on Not At Goal Pts 30% 20% 10% 0% TWYMAN HAR RINGTON MAUER NAZIR HIRT CASWELL ADIB GRICE, P RED DY WELLER

33 100% PriMed Quartile 4 % BP@Goal July 2006 Average % Goal = 57% %Copy of Algorithm = 85% % Algorithm Followed= 73% %ICG Performed on Not at Goal Pts=18% 90% 80% 70% 60% 50% 40% % Goal % Copy Algorithm % Algorithm Followed % ICG Performed on Not At Goal Pts 30% 20% 10% 0% PORTER MCCARTHY SCH LONEGER BLAIR ADEGBILE JORDAN KANOMATA SHAH KEYES ROBINSON

34 Creating the HTN Process 8. Measure: HTN Process use and outcomes 9. Publish results What do you do with doctors who do not use HTN Process? 10. Link HTN Process compliance to physician compensation NOT based upon outcomes, based upon participation in the process

35 100% 100% 100% 100% 100% 100% % BP@Goal PriMed Quartile 1 April 2008 Averages: % BP@Goal = 98% % Protocol Followed = 95% 98% 98% 96% 96% 96% 96% 96% 96% 94% 92% % Goal %Protocol Followed 90% 88% 86% 84% ESTEP GREER SCHAERER TOGLIATTI WELLER MASON-ZIED OCONNELL BLAIR PORTER THUNEY ZWIESLER

36 % PriMed Quartile 2 April 2008 Averages: % BP@Goal = 92% % Protocol Followed = 92% 100% 95% 94% 94% 94% 93% 92% 92% 92% 90% 90% 90% 90% 90% 90% % Goal %Protocol Followed 85% 80% 75% AHMAD FROEHLICH PEREZ HIRT DERKSEN RANDALL COUCH ROMER, D KEYES ADIB JORDAN REDDY

37 % PriMed Quartile 3 April 2008 Averages: % BP@Goal = 88% % Protocol Followed = 91% 100% 95% 90% 89% 89% 88% 88% 88% 88% % Goal 86% 86% %Protocol Followed 85% 80% 75% GRICE, P MAUER TEATER CASWELL KANOMATA SCHLONEGER BAIG SEILER

38 % PriMed Quartile 4 April 2008 Averages: %BP@Goal = 79% % Protocol Followed = 82% 100% 90% 85% 85% 84% 83% 82% 80% 79% 78% 77% 70% 69% 67% 60% 50% % Goal %Protocol Followed 40% 30% 20% 10% 0% NAZIR SLAUGHENHAUPT OWUSU-DEKYI SHAH MCCARTHY LUNA KAISER HARRINGTON ROBINSON TWYMAN

39 Creating the HTN Process 8. Measure: HTN Process use and outcomes 9. Publish results What do you do with doctors who do not use HTN Process? 10. Link HTN Process compliance to physician compensation NOT based upon outcomes, based upon participation in the process 11. Constant work on group culture

40 Changing Medical Group Culture: Quality vs. Tradition Changing the group culture requires its own process LOTS of time discussing Group meetings Section meetings Site meetings Task Force meetings Board meetings Not agreeable to all physicians

41 Changing Group Culture Tradition vs. Quality Key: doctor knowledge Doctor judges what to do case-by-case Improve try harder Good process outperforms individual ability even if you are smart Follow the process steps every time Improve Process improve results

42 Percent of Patients Reaching JNC-7 BP Goal HTN Outcomes With or Without Co-Morbidities 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Elite Medical Groups Post Intervention Average US Performance Baseline 3/1/05 06/01/05 09/01/05 12/01/05 03/01/06 06/01/06 09/01/06 12/01/06 03/01/07 06/01/07 10/01/07 01/01/08 04/01/08 07/01/08 MediSync Groups

43 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% HTN vs Comorbid HTN Only Comorbid All % At Goal Nov-04 Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09

44

45 Minnesota Clinics PriMed Clinics 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0%

46 Conclusions 1. Processes are a very powerful approach to medical quality and cost management 2. You can reduce the total costs of success with processes 3. Launching process approach into medical groups takes a lot effort but can be successful