Overview of Variation Reduction and. Laura Holmes MD. Background. Wide variation in medical practice Jack Wennberg, MD, Dartmouth

Transcription

1 Overview of and the PAMF experience with VR Laura Holmes MD IHI International Summit 2014 Session L3 This presenter has nothing to disclose Background Wide variation in medical practice Jack Wennberg, MD, Dartmouth Clinical variation affects quality and cost Quality outcomes and cost are not always correlated 1

2 Dartmouth Atlas Medicare Spending per Capita in the last 6 months of life Local PAMF Variation 90% Urine Culture Acute Cystitis in Women yo in Urgent Care % % 60% % % 30% 50 20% 0 2

3 PAMF In 2008, a program was initiated at PAMF Started with Specialty Departments and now involves Primary Care There is a Team which includes Physician Champions, Analysts, and support staff working with physician groups 3

4 Not Top Down 4

5 Seed Tools Top 10 Diagnoses Top 10 Procedures National Guidelines Specialty Literature Hot Topics in the popular press Health plan or Managed Care guidelines PAMF Pillars of 5

6 1 st Pillar of Commitment to Meaningful Data Useful Makes sense Transparent Not judged as good or bad better or worse of Data creates the conversation! 6

7 PAMF Pillars of 2 nd Pillar of Physicians are the clinical experts We need their input and engagement for success We don t have the answers Physicians develop their own practice standards Evidence based practice Expert opinion Reduction Pilla rs of Variation Reduction 7

8 Practice Standards are not Cookbook Medicine Practice Standards in Goal is to decrease Physician Variation in clinical practice. Patient variation can t be eliminated so practice standards should be followed about 80% of the time 8

9 Value based care requires practice standard and clinical Practice Standards judgment + Clinical Judgment PAMF Pillars of 9

10 3 rd Pillar of Pillars of Variation Reduction VR Team is there to support clinicians We are their resource for improving quality becoming more affordable, thereby creating Value PAMF Pillars of 10

11 4 th Pillar of Variation REduction Improving Quality Quality is a focus of every project Medical Director of Quality is on VR Team Each project has at least one outcome measure Gains in one measure do not come at the expense others PAMF Pillars of 11

12 5 th Pillar of Affordability Reducing Cost of Care by providing our patients with appropriate, value driven care program has resulted in 46 million dollars in patient savings since 2008 Affordability Matters In All Circumstances PPO Patients Often have high deductibles, paying totally out of pocket for care HMO Patients Payment is fixed Spending more may not mean better quality With Affordable Care Act (ACA), numbers of capitated patients will rise 12

13 An Overview PAMF Physicians are the experts (not the VR team) They choose the topic They are given data, which is useful, non judgmental and transparent They develop the standard and move it forward The VR team is their resource for improving quality and affordability thereby VALUE for our patients Must Haves Organizational Buy In Senior leaders Clinicians Return on Investment Cultural Financial Measurement of Progress Dashboard Scorecard 13

14 Why Healthcare Providers Should Participate in VR An opportunity to Review literature and discuss best practice Create a proxy for evidence based medicine where none exists Know that one s practice meets current national guidelines or expert opinion standards Educate patients on current standards & guidelines for their particular needs Why Healthcare Providers Should Participate in VR Develop relationships with colleagues Know the cost of care Know your patients aren t incurring unnecessary costs because care is appropriate Improve access can open up appointment slots to serve new patients Patient safety reducing number of procedures reduces the number of potential complications (first do no harm) 14

15 How Much Staff Do You Need? In the beginning there was one Project Manager (.5 FTE) 6 Physician Champions (1.5 FTE) Analysts (1.5 FTE) Program Director (.5 FTE) Start Now! Tips for Success Start with a small team of true believers Create support teams for analytics and program management Get buy in at all levels Communicate, communicate, communicate There are risks and costs to a program of action. But they are far less than the long range risks and costs of comfortable inaction. JFK 15

16 Start Now! Start Here! Group Activity Divide into groups Read the scenario Play your role Report back what you experienced Let s Try It! 32 16

17 Spreading Standard Work You experienced how the VR process works but that is only ½ the process now the hard part is spreading the practice standard Visual Display Board 17

18 and the Hypertension Kaizen: Case Study 2010 改 ("kai") which means "change" or "to correct" and 善 ("zen") which means "good or for the best Kaizen in Healthcare Traditionally operational in nature. How do we engage physicians in change? How do we do a Clinical Kaizen? 18

19 Why Does HTN Matter? In % of our patients, 606,000 patient visits Three fold difference in cost of care for HTN We wanted a common clinical topic Wanted to engage the physicians Wanted to apply VR process to Primary Care We had: and the Hypertension Kaizen 21 of 350 adult primary care physicians Primary Care and subspecialist Seven clinical operations representatives MAs and RNs Data analyst Three patients 19

20 Overview of HTN Kaizen The group committed to a Comprehensive Standard : Standard work for measurement of blood pressure Feedback form to check the standard Standardized documentation EPIC Agreement on treatment Planned and scripted follow up Prepare the Organization for Spread 4 Months to train Primary Care MAs on blood pressure competency Present to our leadership to inform physician leads and develop operational support. Major challenge was a new improvement process applied to a common chronic condition across a large group of care teams. 20

21 Hypertension Kaizen: Did Spread Happen? What were the outcomes? Have we sustained it? 21