Collaboration & Quality Improvement “It Takes A Village” South East Michigan Quality Forum Health Trends Conference January 24, 2003 John E. Billi, M.D

Collaboration & Quality Improvement “It Takes A Village”

South East Michigan Quality Forum

Health Trends Conference

January 24, 2003John E. Billi, M.D.

Associate Dean, Clinical Affairs

Associate Vice President, Medical Affairs

University of Michigan

Identify Areas of Practice

Identify Areas of Practice

U of M Process for Evidence-based Guideline Adaptation & Implementation

Define OptimalClinical Practice

Define OptimalClinical Practice

Teams Design and Implement

Interventions


Interventions

Assess OutcomesAssess Outcomes

Health Care DatabaseHealth Care Database

Redesign Process, if Necessary


Institutional ActivitiesInstitutional Activities

External AgenciesExternal AgenciesWise, Billi. Jt. Comm. J. Q. Imp. 1995;21:465-476.

Characteristics of Delivery System


CQI Process

CQI Process CQI Process

CQI Process

CQI Process

Southeast Michigan Health Care Quality Forum

• Mission: To improve the quality of health care services provided to SEM residents, with primary emphasis upon promoting the scientific practice of medicine.

• Operated under the auspices of GDAHC• Established to bring together physician leaders, health

systems, health plans, business, labor to work collaboratively on quality improvement.

• Overall approach: – Start with existing, evidence-based, widely accepted,

credible practice guidelines. – Focus upon collaborative, value-added strategies to

increase use of guidelines at the point of care.

SEM Quality Forum

• Roles– Serve as locus of coordination, collaboration for QI

projects/activities within SEM.– Conduct community-wide QI initiatives.– Support efforts of other entities to promote use of

guidelines, evidence-based medicine.– Promote sharing of quality improvement strategies and

experiences.– Serve as a liaison between SEM QI activity and state,

national-level QI efforts.

SEM Quality Forum

• Membership

– 6 SEM health systems and physician leaders

– 3 auto companies

– UAW

– BCBSM

– MPRO

• Other organizations can join!

Southeast Michigan Quality Forum- Specifics• Who

– GM, Ford, Daimler-Chrysler, UAW, GDAHC, MPRO– UM, St John, Oakwood, Trinity, Henry Ford, DMC

• What – Coordinated, community-wide quality improvement

efforts• Pharmacy (antibiotics, generics, dose optimization)• Coronary disease (GAP)• Diabetes (coordinated physician interventions)

• Coordinate implementation of MQIC Guidelineshttp://www.gdahc.org/deliv.htm

ACC AMI GAP Projects: Southeast MI(Guidelines Applied in Practice)

• National pilot project, including 10 SEM hospitals; followed by SEM expansion project, with 18 additional SEM hospitals.

• Hypothesis: quality of inpatient AMI care can be improved through a performance improvement initiative that uses QI tools, emphasizes key targets of care and focuses on improving key processes of care.

• Partnership among American College of Cardiology, MPRO, GDAHC/Quality Forum and participating hospitals/physicians.

• Use of well-defined performance measures – ASA; beta blockers; cholesterol management, tobacco cessation…

ACC AMI GAP Project• Methods – a variety of interventions:

– the partnership– opinion leaders and physician champions– ACC AMI tool kit (order sets, posters…)– rapid cycle timeline measurement and analysis– collaborative model w/ learning sessions

• Both projects were 12 months duration• Results

– Performance on “early-in-stay” indicators shows substantial improvement when AMI/ACC standing order sets are used

– Performance on “at discharge” indicators shows substantial improvement when AMI discharge tool is used.

Drucker’s Three Questions and the Forum• Who are our customers?

– Patients, employers, physicians, health systems, health plans

• What do our customers find of value?– Improved quality, cost, access– Reduced administrative hassle and conflicting initiatives

• What are we uniquely qualified to provide that our customers find of value?– Coordination of quality improvement activities– Sharing of what works and what doesn’t– Elimination of barriers – dueling guidelines, measurements,

profiles, interventions

Benefits of Cooperation for the Physician and Health System

• Avoid the “Disease of the Month” problem• Eliminate

– conflicting guidelines (differences are not evidence based)– conflicting measures (A1C: 2x or 4x a year?)– conflicting measurement method (chart or claims?)– conflicting measurement process (If this is Tuesday, you

must be from HAP)– conflicting profiles (I’m a good BCN doctor, but a poor

MCARE doctor) – conflicting interventions (MPRO, MCARE, MHA, MAHP,

U of M)

Benefits of Cooperation for the Health Plans

• Gain synergy of their participating physicians receiving a consistent QI message from multiple sources

– Demonstrates respect for physician’s perspective, time and challenges

• Eventually reduce or eliminate costs, work and noise – Investment in development/maintenance of guidelines

– Cost of measuring each physician (doctors are multi-plan)

– Variability due to small numbers of members per doctor

– Better chance for external funding

Benefits of Cooperation for the Employers and Government Payers

• Higher probability of improving quality, cost and value

• Eventually reduce administrative costs

– Improved health plan efficiency lowers costs

• Allows a forum for redesigning the organization and financing of care across employers, payers, and providers

– New incentive alignment models – fee for benefit – performance-based contracting – need all at the table.

Barriers to Cooperation• Stuck in the half-way point to integration• Health Plans compete – invested $$ in guidelines, QI• Health Plans worried about HEDIS rules and NCQA credit• Lack of office systems in many doctors’ offices• Lack of a community health info system (CHIN)• Lack of a trusted intermediary to house data• HIPAA- confidentiality – physician, patient, plan• Lack of sources of funding or staff help for reengineering care process at the point

of care, in the doctor’s office – “no business case for quality”• “Measure to judge” - provider skeptical of use/release• Issues of risk adjustment• ACCME resists giving CME credit for QI!!!• Patient expectations, direct-to-consumer ads• Impatience

University of Michigan Efforts

• SE Michigan Quality Forum• Michigan Quality Improvement Consortium• Michigan Patient Safety Coalition• Patient Safety Conference, Toolkit, Workshops• MSMS Medical Economics and Quality• Medicare Carrier Advisory Committee• Evidence-based guidelines on the web

There’s plenty to do…but there’s plenty of help!

END

Traditional Care Episodic, uncoordinatedEpisodic, uncoordinated Focused on the acutely illFocused on the acutely ill Patient initiatedPatient initiated Patient education is sporadicPatient education is sporadic Communication among clinicians is sporadicCommunication among clinicians is sporadic

- Information scattered on paperInformation scattered on paper Process of care is variable Clinicians’ Clinicians’ opinionsopinions drive decisions drive decisions ExpensiveExpensive

Next Model of Health Care• Coordinated care• Integrated delivery systems• Population-based

– Outreach initiated by plan/physicians– Incorporates prevention and patient education

• Communication among providers & patients– Facilitated by information technology

• Standardized, evidence-based process– Guidelines, pathways, disease management

• Performance-based contracting– Clinical outcomes– Cost

“Crossing the Quality Chasm”

Health care should be: Safe Effective Patient-centered Timely Efficient Equitable - not vary due to gender, ethnicity,

geography, socioeconomic status

Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

The Coming Train Wreck...• Aging, growing population

• Dramatic advances in clinical capabilities

• Information technology requirements

• 40 million uninsured

• Unbounded patient demands vs. Taxpayer, employer, individual

willingness to pay

MQIC Intervention Strategies

• Public Education– Tools: public service announcements, pamphlets

• Physician Education– Tools: tool kit for physicians, patient handouts, MPRO

• Data Collection and Feedback– Tools: data collected by health plans, physician groups

Professional Values - Enduring• Altruism

– patients’ interests come first

• Commitment to self-improvement– master and incorporate new knowledge– contribute to the knowledge base of the

discipline

• Peer review– collective sense of responsibility and

accountability among medical professionals for the conduct of colleagues

Source: D Blumenthal, Health Affairs, Spring (I) 1994

Integrated Delivery Systems

• Organized system of care• Integrates:

– Providers (doctors, nurses, …)– Facilities (tertiary and community hospitals, nursing homes,…) – (Health plan)

• Full spectrum of services• Geographic coverage• Economically viable scale (contracting clout)• Ultimate goals: improve quality, lower cost

– Harder to do in reality than the “paper merger”

Source: Adapted from R Lichtenstein

Accountability for Cost and Quality

Integrated Health Systems should:• Promote clinical effectiveness research• Only use effective procedures, therapies, tests

(Evidence-based Medicine)• Develop and use clinical guidelines, clinical

pathways• Follow principles of Continuous Quality

Improvement (CQI)• Document fastidiously

Trends 2003 Trends 2003 Shifting Accountability DownwardShifting Accountability Downward

Performance-based contractingPerformance-based contracting Report cards: outcomes, costsReport cards: outcomes, costs Defined contribution health plansDefined contribution health plans Individualized Medical Savings Individualized Medical Savings

Accounts, with provider report cardsAccounts, with provider report cards Differential copays for high cost Differential copays for high cost

hospitals/groupshospitals/groups

Populations

Healthy Stable chronic disease

and stable at riskHigh risk orunstablechronic disease

Hospitalized

Acutely ill

University of Michigan Medical School

Evidence-Based Guidelines for Populations

Prevention & screeningpracticeguidelines

Stable chronic diseasepractice guidelines

High intensitymanagement principles

Criticalpathways

Acute carepracticeguidelines


Healthy

Acutely ill

HospitalizedStable chronic diseaseand stable at risk

High risk orunstablechronic disease

Specialist (& PCP)

Prevention &screeningpractice guidelines

Acute care practice guidelines


High intensity management principles

Critical pathways

Prevention/Screeningmanagement program

Acute illnessmanagement program

Chronic/stable illnessmanagement program

High intensitycase management &tracking program

Inpatient practice management

PCP (& Specialist)

PCP & Specialist Specialist (& PCP)

Medical Management Strategies

TEAM APPROACH(Physicians, Nurse Practitioners, Social Work…)


Healthy

Acutely Ill

Stable chronic diseaseand stable at risk

High risk or unstable chronic disease

Hospitalized

Specialist(& PCP)

Hospitalized

Healthy Stable chronic diseaseand stable at risk

High risk or unstablechronic disease

Acutely ill

Prevention & screeningpractice guidelines

Acute carepractice guidelines


High intensity management principles

Critical pathways

Prevention/Screeningmanagement program

Acute illnessmanagement program

Chronic/stable illnessmanagement program

High intensitycase management &tracking program

Inpatientpracticemanagement

PCP (& Specialist)

PCP & Specialist Specialist (& PCP)

Health Plan Design StrategiesHealth Plan Design Strategies

Principal Physician

Hospitalist

TEAM APPROACH(Physicians, Nurse Practitioners, Social Work)

Access to Specialists

Risk factoridentification, HRA

Patient educationcovered

Specialized management programs covered

Full preventiveservices covered

Targeted health behaviorprograms

Patient advocateHome contactsBenefit expansion

Continuous Quality Improvement

The Approach to Better Healthcare

A process for continuous improvement:- evidence based- consensus building - data driven

Can be used to address:- overuse- underuse- misuse

Quality Concerns• UnderuseUnderuse

– 60% of diabetic patients w/o HbAlc test in 199860% of diabetic patients w/o HbAlc test in 1998– Only 59% / 65% of GM women are receiving Only 59% / 65% of GM women are receiving

recommended screenings for cervical / breast cancerrecommended screenings for cervical / breast cancer

• OveruseOveruse– Hysterectomy rate in Flint MI 80% higher than KaiserHysterectomy rate in Flint MI 80% higher than Kaiser

– Cardiac catheterization rate in all Cardiac catheterization rate in all majormajor MI, OH, IN MI, OH, IN areas at least 160% higher than Kaiserareas at least 160% higher than Kaiser

• MisuseMisuse– 60% of cold / URI / bronchitis patients receive antibiotics60% of cold / URI / bronchitis patients receive antibiotics

Source: Bruce Bradley, General Motors

Identify Areas of Practice• High cost• High volume• Practice variation• High risk• Marketing factors• Regulatory factors• Guidelines available• Local clinical champion(s)• Other


Define Optimal Clinical Practice & Systems Processes

* Clinical panels adapt guidelines to local practice

* Collaborative critical pathways * Case management

Define Optimal Clinical Practice & Systems Processes

* Clinical panels adapt guidelines to local practice

* Collaborative critical pathways * Case management


Interventions


Interventions






External AgenciesExternal Agencies



CQI Process


CQI Process

CQI Process

Teams Design & Implement Interventions

• Data feedback• MIS-based intervention• Administrative interventions• Financial interventions• Educational models• Patient empowerment• Clinician empowerment• Other

Process for Practice Guideline Adaptation & Implementation



Teams Design & Implement Interventions* Data feedback* MIS-based intervention* Administrative interventions* Financial interventions* Educational models* Patient empowerment* Clinician empowerment* Other

Teams Design & Implement Interventions* Data feedback* MIS-based intervention* Administrative interventions* Financial interventions* Educational models* Patient empowerment* Clinician empowerment* Other






External AgenciesExternal Agencies



CQI Process


CQI Process

CQI Process

Define Optimal Clinical Practice Guideline

•Begin with best evidence-based guideline•Clinical panels adapt guidelines to local practice•Modify based on medical evidence, not opinion

•Practice guidelines•Case management principles•Collaborative critical pathways








Teams Design & Implement Interventions•Data feedback • MIS-based intervention•Administrative interventions•Financial interventions•Educational models•Patient empowerment•Clinician empowerment•Other

Teams Design & Implement Interventions•Data feedback • MIS-based intervention•Administrative interventions•Financial interventions•Educational models•Patient empowerment•Clinician empowerment•Other

Institutional Activities Develop financial packages Planning & Marketing Regulatory reporting

Institutional Activities Develop financial packages Planning & Marketing Regulatory reporting

External Agencies Payers Public Corporations Corporate alliances Government agencies

External Agencies Payers Public Corporations Corporate alliances Government agencies

Characteristics of Delivery System• Process driven

• collaboration of caregivers• process of care defined

•Variation reduced (“optimal practice”)• Predictable costs (cost-effectiveness)• Outcomes - optimal outcomes defined & measured

Characteristics of Delivery System• Process driven

• collaboration of caregivers• process of care defined

•Variation reduced (“optimal practice”)• Predictable costs (cost-effectiveness)• Outcomes - optimal outcomes defined & measured

CQI Process


CQI Process

CQI Process








•Identify barriers•Fine tune guidelines


•Identify barriers•Fine tune guidelines

Assess Outcomes•Clinical•Process•Costs (cost / benefit)•Patient satisfaction•Return to work, days off, days ill

Assess Outcomes•Clinical•Process•Costs (cost / benefit)•Patient satisfaction•Return to work, days off, days ill

Health Care Database• Clinical• Demographic• Economic• Nursing• Outcomes: function, satisfaction, productivity

Health Care Database• Clinical• Demographic• Economic• Nursing• Outcomes: function, satisfaction, productivity

Evidence-Based Medicine• Systematic process to encourage all practitioners

to apply the appropriate scientific evidence to individual clinical decisions.

• Evidence is not:– An expert’s or healthcare consultant’s opinion – A black box– The “Brand Name” clinical guideline book

• Evidence is:– scientific studies and meta-analyses– published in peer-reviewed journals– with appropriate methods and populations– showing significant outcomes

Practice Guidelines“I can’t keep all that evidence in my head…”

PG = A distillation of scientific evidence into a practical guide to assist a clinician in the management of a problem.

A prospective agreement among clinicians to use in the care of similar cases.

To reduce variation -- toward optimal

While permitting a doctor to vary -- with a reason!

Practice Guidelines

• Prospective agreement among clinicians for the management of typical cases

• Synthesis of knowledge of diagnoses & therapy

• Tool to improve appropriateness and efficiency

• Documentation of excellent process of care

• Evidence-based

8 Characteristics of Good Practice Guidelines

• Open development process (who developed it, why?)

• Focused on improving important, targeted health outcomes.

• Specify the most important question• Systematic use of the peer-reviewed

medical literature to support key steps.

8 Characteristics of Good Practice Guidelines

• Full disclosure of the level of evidence for each step in the guideline.

• “Expert opinion” minimized and labeled.• Include a care algorithm and key points.• Make available: supporting materials, text

rationales, literature reviews, evidence tables, patient education materials and bibliography.

UMHS Guidelines: http://cme.med.umich.edu/iCME

12 Characteristics of Good Uses of Practice Guidelines

• Start with good guidelines, including the source(s).

• Use the guidelines nested in a constructive, educationally-oriented quality improvement model.

• In the local endorsement process, involve true representatives of the clinicians whose practice the guideline covers.

• Allow local adaptation, with justification and documentation. Focus on aspects which may not be feasible.


• Carefully design implementation programs to encourage education, dialogue and constructive use of data.

• The guidelines and supporting materials, literature reviews and evidence tables must be broadly available.

• Help clinicians measure their performance with a “measure to improve” rather than a “measure to judge” philosophy.

• Measure only key steps supported by high grade scientific evidence. Don’t sweat the small stuff!


• Assess barriers to successful practice improvement. Make changes to overcome them.

• Activate allies to help with the changes: staff, patients, payers, employers, other physicians.

• Plan to modify the guidelines based on their use, as experience grows.

• Plan to update guidelines formally and regularly.

Documents

Collaboration & Quality Improvement “It Takes A Village” South East Michigan Quality Forum Health Trends Conference January 24, 2003 John E. Billi, M.D