Kaiser Permanente‟s Transformation Journey IHI International Forum – Qatar, May 2013 Alide Chase, Senior Vice President,

Medicare Care Delivery and Population Care

Kaiser Permanente

Imagine Health Care in the

Future

2

Integration

Virtual Care

Mobile

Genetics

What Would a Transformed

Organization Look Like? • A place where the patient‟s voice is heard and drives design

• A place where physicians and staff experience reward and joy

in their work

• Lean, judicious use of resources

• A place where there is continuous learning

• A PLACE THAT ISN‟T A PLACE BUT AN EXPERIENCE

ANYWHERE

3

The Kaiser Permanente

Journey

4

THE WILL

UNDERSTANDING & Acknowledging

Reality

IDEAS

Working Top-Down &

Bottom-Up

EXECUTION

Macro System

Meso & Micro

System

Working top-down

and bottom-up

Macro-

System

Meso- and

Micro- System

Transforming Quality and

Service Is a Challenge

5

• Lessons Learned:

• Seek support/Begin a social movement – the

journey is long and hard

• Ambitious vision & real plan to drive faster

improvement

• System level measures prompt transformation

• Redesign care across complex systems

• Leaders find themselves in new roles and working

differently (and happier)

• Rebuilding the infrastructure and improvement

capabilities needs substantial attention

• Not for the faint of

Building Will

6

• Our own storytelling….

• Using performance reporting to build will…

• Appealing to the heart

Leadership

7

"In our quest to be recognized by our key stakeholders as

the safest, most effective health care delivery system in

the country, providing the highest quality care and

customer-focused services … we will have the best

hospitals by the end of 2010 and you play a key role in

achieving this in each of your hospitals."

July 2009

Bernard J. Tyson

Executive Vice President, Health Plan and Hospital

Operations

Kaiser Foundation Health Plan and Kaiser Foundation

Hospitals

(In letter to Kaiser Foundation Hospital executives)

Our Vision is Total Health Support Our

Members Through All Stages of Life

8

Returning to Health

Living Well with

Chronic Conditions

Staying Healthy

Healthy Aging

Total

Health

8

Whole System Measures:

Develop 3 year goals

9

Population Health

• 2012 - Total Health Assessments for 10% of Members

• 2013 – Total Health Assessments for 15% of Members

• 2014 – Total Health Assessments for 20% of Members

Population Care

• 2012 - Maintain Medicare Stars Part C 5 stars in 4 regions

• 2013 – Maintain Medicare Stars in 6 Regions, increase one region to 5 stars

• 2014 – Medicare Stars Part 3 5 Stars in 7 Regions

Inpatient

• 2012 - Maintain HSMR below US Medicare, TJC Composite @ 90th percentile

• 2013 – Same as above

• 2014 – Same as above

Patient Safety

Service

Equitable Care

The IHI Triple Aim Initiative

10

Per Capita Cost

Experienc

e of Care

Population

Health

Measure Progress to Goal

11

• Be transparent with performance across the organization

• Celebrate high performers

• Be attentive to low performers

• Create a multi-year approach

• Align with accountabilities and incentives

The “Big Q”

12

The Big Q Performance Metrics Dashboard provides a comprehensive and integrated view of Kaiser Permanente Quality & Service performance.

• Clinical Effectiveness

• Safety

• Service

• Resource Stewardship

• Risk Management

• Equitable Care

Domains (Big Dots) and Sub

Domains Within the Big Q

13

Safety • Never Events - all

• BSI

• HAPU

• Falls

Risk

Management • Prof liability

Rpted claims per

100K members

Service • CAHPS

• HCAHPS

Equitable

Care

Clinical

Effectiveness • HSMR

• TJC

• HEDIS

Resource

Stewardship • Operating cost

PMPM

• Inpat Utiliz

14

Our Strategic Imperative Our strategic imperatives allow us to achieve our vision of total

health as we leverage our integrated care delivery system and

harness the value of technology.

15

Collaboration and Alignment – Working through Partnerships

Community Benefit – Making a Measurable Impact on the Health of the Communities We Serve

Strategic Imperatives

Transforming Care Delivery

“Best Care for Everyone”

Enabling Performance Through People

“Being the Best Place to Work”

Implementing Infrastructure

“Realizing Value”

Solving for Affordability

“Improving Cost Structure”

Growing Membership

“Expanding Access to KP Care”

Best Prevention and Promotion

of Healthy Behaviors

Best Care for Chronic

Conditions

Best Hospitals and Care

Continuum

Best Care Experience

Equitable Care

Areas of Focus

From Strategy to Execution

16

Dashboard

Mortality: Gap to US Medicare avg. increased

from 3 to 10 points

Mortality: Gap to US Medicare avg. increased

from 3 to 10 points

HEDIS: KP 2 points below US 90th percentile HEDIS: KP 2 points below US 90th percentile

JCAHO: KP 8 points below US 90th percentile but risingJCAHO: KP 8 points below US 90th percentile but rising

Safety: 21 never events in Q4 06, 4 quarter downward trend Safety: 21 never events in Q4 06, 4 quarter downward trend

Risk Management: downward trend since 2003, but level in 06-07 Risk Management: downward trend since 2003, but level in 06-07

Service: upward trend but KP below CAHPS 25th percentile

(not shown)

Service: upward trend but KP below CAHPS 25th percentile

(not shown)

Cost: still preliminary dataCost: still preliminary data

WHOLE SYSTEMS MEASURES – “Big Q”

Targets

Quality Goals TimelineDomain 2008 2009 2010

Reduce HSMR X%Reduce HSMR X%

Reduce HSMR X%

National 90th percentile

Three-quarters of way

between national average

and 90th percentile

90th percentile

No Measure less than

75th Percentile

90th percentile

No Measure less than 75th

Percentile

90th percentile

No Measure less than 75th

Percentile

Ambulatory Care

HEDIS

ZeroZeroZeroSafety (Never Events)

5% reduction in claims

from 20095% reduction in claims from 2008

5% reduction in claims from

2007Clinical Risk Management

TBDLong term goal under

development

Proposed: At or above 75%

local or National MarketService

TBDTBDTBDResource Stewardship

TBDTBDN/AEquitable Care

Halfway between national

average and 90th percentile

InpatientMortality Ratio

TJC Composite Index

1

DRAFT

Strategy

Big Aim

Execution in a System

17

Manage Local

Improvement Develop Capability

Spread and sustain Provide Leadership for

Large system Projects

Provide Day-to-Day

Leaders for Micro Systems

Source: IHI 2008

Define Breakthrough

goals

Achieving Results: Mortality

Reduction

• Inpatient mortality reduced 8 to 10 percent per year in the past four years, peaking in the 12 month period over the winter of 2009-2010 when HSMR dropped 10.4% from the previous 12 months.

• Overall, HSMR dropped 52% from 2008 to 2012 among KFH facilities after being relatively flat since internal nation-wide reporting began in the summer of 2006.

18

Dramatic Reduction in Risk Adjusted Hospital Mortality

Rati

o o

f o

bserv

ed

to

exp

ecte

d m

ort

ali

ty

>>

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2008 2009 2010 2011 2012

KP - All Facilities

US Medicare Overall

Kaiser Foundation Hospital

NOTE: Data above reflects rolling twelve month

average

Hospital Standardized Mortality Ratios

19

Significant Reduction in use of Inpatient

Beds National Patient Day Rate

Year-end

Projected

PDR = ?

Year-end PDR

Target = ?

20

225

250

275

300

325

350

Inpatient Days per 1000, Jan. 2009 – Sept. 2012 All Lines of Business, Unadjusted

All Regions

Source: PDR report, National Inpatient Analytic Data Mart, 2013.03.06

How Did We Get from There to

Here?

21

Most

Appropriate

Setting

Inpatient Mortality Reduction Driver

Reduce

Hospital

Mortality

No

Needless

Harm

Reduce

Overall

Admits and

Readmits

Preventable

Deterioration

Aim

Primary Drivers

Secondary Drivers Selected Initiatives

Sepsis Initiative

Sedation and Ambulation

Protocols

Blood Stream, C Diff, MRSA

Infection Reduction

Falls and Hospital Acquired

Pressure Ulcers

Perinatal Outcomes

Antibiotic Stewardship

Healthy Bones

Disease Programs

Readmission Diagnostic

Transition Bundle

Throughput: Ed, OR

Palliative Care

SNF Rounding

Preventable

Harm

Preventable

Complications

Population and

Chronic Care

Programs

Reliable and

Safe Transitions

Life Care

Planning

Home and

Continuum

Capacity 22

No Needless Harm: Impact of Sepsis Initiative

xxxxxx

Program Elements

Thousand of Lives Saved, Million of Lives Improved.

Sepsis Mortality

Hospital Standardized Mortality

Hospital Standardized Mortality Ratio*

0.5

0.6

0.7

0.8

0.9

1

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

2006 2007 2008 2009 2010 2011

HS

MR

Medicare NCAL

Successful Implementation of the Sepsis

Bundle:

• Quick and consistent ID of patients who

present with sepsis

• Stratification of risk by lactate testing

• Reliable execution of effective early goal

directed therapy

Lactate with BC

• Antibiotics w/n 1 hour

• CL placed with reading w/in 2 hours

• Hemodynamic targets met w/in 6 hours

• Repeat lactate – lactate clearance

Aggressive treatment/monitoring of those at

intermediate risk

New areas:

• Surgical Sepsis

• Pediatric Sepsis

23

Sepsis Bundle

24

25

No Needless Harm: Delirium Initiative Program Elements

• Multi-disciplinary team, comprised of a psychiatrist, clinical nurse specialist, social worker, and pharmacist conducts virtual rounding to support clinicians, patients, and their families.

• Virtual Rounds

• Staff Education

• Decision Support Tools

• Confusion Assessment Method (CAM) tool to assess patients and identify those with delirium

• Delirium Management Protocol and Medication Dosing Guide

Delirium: Sedation & Ambulation

Protocols

26

No Needless Harm: Infection Reduction

27

Hos 1

Hos 2

Hos 3

Hos 4

Hos 5

Hos 6

Hos 7

Hos 8

Hos 9

Hos 10

Hos 11

Hos 12

Hos 13

Hos 14

Hos 15

Hos 16

Hos 17

Hos 18

Hos 19

Hos 20

Hos 21

Hos 22

Hos 23

Hos 24

Hos 1

Hos 2

Hos 3

Hos 4

Hos 5

Hos 6

Hos 7

Hos 8

Hos 9

Hos 10

Hos 11

Hos 12

Top 25th

KP Avg

Reg 1

Reg 2

No Needless Harm: Central Line Infection

28

Hospital-Associated C. difficile

Infection (HA-CDI)

29

Notes: KPNC HA-CDI trend adjusted up by 39% to account for more sensitive C. diff lab toxin assay

implemented in May 2011. Presented as a rate per 1,000 inpatient admissions. HA-CDI incidence based

on CDC Laboratory-identified Event method.

Progra

m

Element

s

RIGHT Bundle

4 strategies for C diff

Immediate Isolation

for identification of

diarrhea

Environmental/room

and equipment

cleaning

Antibiotic Stewardship

Hand Hygiene

Cases

Prevente

d

1,408 HA-CDI cases

prevented since

7/1/2010

Days

Saved

14,080 patient days

saved since 7/1/2010

Each hospital-

acquired CDI case

contributes around 10

additional, attributable

patient days of

utilization compared

with inpatients who do

not acquire CDI in our

hospitals.

© 2012 Kaiser Foundation Health Plan, Inc. For internal use only.

30

No Needless Harm:

Hospital Acquired Pressure Ulcers

Note = *HAPU Stage 3+ includes unstageables/DTI (full thickness)

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12

Program Elements

Implemented prevention measures (SKIN bundle)

including

• Every surface changed out to low-pressure surfaces

• Ensuring effective and adequate turning and skin

protection

• Keeping patients dry and clean

• Ensuring adequate nutrition and hydration

No Needless Harm: Hospital Acquired Pressure Ulcers

31

Going

Upstream

• Reducing

overall Admits &

Readmits

32

Reducing Overall Admits

Population Care: Healthy Bones

33

• Program reduced hip fracture rates by more than 37 percent

• Uses a combination of bone density tests, anti-osteoporosis

medicines, and patient education in a consistent, standardized,

science-based way

• Program identifies members at-risk for osteoporosis and broken

bones

A

B

C

D

E

F

G

H

A

B

C

D

E

F

G

H

2005 2011

Improving AMI Outcomes

43% reduction in hospital AMI mortality rate

and 53% reduction in deaths since 2005

Year Total AMI

Admissions

Total AMI Hospital Deaths % Mortality

2005 6,406 390 6.1%

2007 5,576 279 5.0%

2009 5,154 189 3.7%

2011 5,254 183 3.5%

88

90

92

94

96

98

100

Q4

2005

Q2

2006

Q4

2006

Q2

2007

Q4

2007

Q2

2008

Q4

2008

Q2

2009

Q4

2009

Q2

2010

Q4

2010

Q2

2011

AMI Bundle

Program

Elements

Implemented more timely recognition and treatment of

AMI

Implemented prevention efforts (ALL)

Mortality

Reduction

43% reduction in mortality since 2005

Days Saved 800 days saved in 2011 compared to 2009

34

Improving AMI Outcomes

Program

Elements

• ALL: stands for Aspirin, Lisinopril, Lipid Lowering

• There is strong and powerful evidence for the clinical and cost effectiveness of increasing ALL use in CAD and diabetes (55+) populations

• Significant reductions in future cardiovascular

disease in patients with diabetes >55 years old OR prior cardiovascular disease

Results • Based on a study following 68,560 members with

diabetes or heart disease who tool 40mg of a lipid

lowering drug and 20 mg of a BP lowering drug

Lisinopril for two years, the treatment reduced

1,271 heart attacks and strokes in the first year.

• There was a 26% reduction per 1,000 members

among the highly adherent group and a 15%

reduction per 1,000 in the moderately adherent

group compared to a no-use group.

35

36

Stroke Mortality

373 / 4442

= 8.4%

mortality

483 / 4266

= 11.3%

mortality

Though

admissions have

increased, stroke

mortality has

decreased in the

past 3 years

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

2008 2009 2010 2011

Stroke Mortality Trends

Ischemic Stroke Raw Mortality All Stroke Raw Mortality

Program

Elements

Implemented more timely recognition and treatment of

AMI

Implemented prevention efforts (ALL)

Mortality

Reduction

43% reduction in mortality since 2005

Days Saved 800 days saved in 2011 compared to 2009

Going Even

Farther

Upstream

Total Health

• Obesity

Prevention

• Exercise as a

Vital Sign

• Healthy Eating

37

38

Obesity Prevention and Treatment in Care Delivery

2 3 Testing New Interventions

Implementation and Scale

Building a Foundation

across the Lifespan

38

1 Assessment/Planning

Early Implementation Understanding and Amplifying Successes

• Map breastfeeding beyond hospital

• Map Ob/GYN to pediatrics handoff

• Community interventions

• Prenatal POE

Healthy Beginnings (0-5) • Breastfeeding in hospitals

• Determine opportunity to spread

SCAL prenatal POE

• Evaluate effectiveness of early breastfeeding,

community interactions, Ob/Gyn to pediatrics handoff

School Age (5-17) • Healthy Schools – healthy eating

active living

• Test campaigns focused on

age-appropriate strategies

• Measure impact of age-appropriate strategies

Everyone – Entire Lifespan •Implement EVS, track BMI

• Identify risk factors

• Test referral resources: person,

online, community

• Implement effective interventions

• Link outcomes into KPHC registry/panel management

• Evaluate member engagement, population outcomes

Adult Treatment – Full Continuum • Assess evidence and gaps in services,

span from Prevention to Bariatric Surgery,

including worksite

• Evaluate effectiveness of

various interventions • Assess broader implementation and spread

Adult Treatment – Targeted • Pre-diabetes focus:

• Compare programs

• Pilot community interventions

and/or mobile platforms

• Assess implementing

effective pre-diabetes programs

• Test mobile platforms

• Implement registry

• Evaluate change in BMI against readiness for change

(effectiveness of identification and intervention)

Measurement and Evaluation

Guideline Development

Evidence-based Support Systems Core Elements

Our Investment in Technology

39

Sustained commitment …

Infrastructure

Sustained Commitment

Strategic

Financial

Tremendous Improvement in Member Satisfaction

with the Health Care they Receive

40

Ambulatory Service Performance: Health Care Rating

Legend: Blue = Program trend

Black = CAHPS benchmark

% o

f re

spondents

rating a

ll health c

are

in last ye

ar

as, 9, or

10

on a

scale

of 0 to 1

0 (

from

wors

t possib

le to b

est possib

le)

Drivers

• Focus on leadership

• Alignment of goals

• Engagement of front-line

Key Initiatives

• Access improvement practices

• Communications

• Culture of Excellence

75th percentile

Interregional CAHPS improvement

workgroup formed – sharing best

internal and external practices

Our EHR Vision

41

Kaiser Permanente EMR

History: Not an Easy Journey

42

1960s

Medical

informatics

emerged and

Kaiser

Permanente

began to

develop EMRs

using computer

punch cards

1970s 1980s

1980s

The regions

began to develop

homegrown

EMRs

1960s

© 2013 Kaiser Permanente

Kaiser Permanente EMR

History: Not an Easy Journey

43

2000

Hawaii Region

implements first

1990s

Ohio, Northwest

and Colorado

Regions honored

with Davies Awards

for their efforts with

EMRs

2000s 2010s 1990s

1998

Kaiser

Permanente

decides to choose

a single EMR

© 2013 Kaiser Permanente

1999

Colorado

Region‟s CIS

system chosen for

national

implementation

2002

Organization writes

off CIS and looks

for other options

2004

Kaiser Permanente

begins installation

of KP

HealthConnect,

largest private

electronic health

record system and

becomes

accessible through

kp.org

2011

All Kaiser

Permanente

regions are now

completed and

first mobile app is

launched

2006

Member access

becomes possible

2006

Southern California

Region is

completed

2010

Northern

California Region

is completed

Our Investment in Technology

44

The world‟s largest and one of the most

advanced civilian deployments of an

electronic health record

KP HealthConnect® was implemented 2004-2010 specifically to transform

care and service delivery

Our greatest benefits are the resulting

improvements in quality and effectiveness of

patient care

Kaiser Permanente HealthConnect®

Redefining Access – Empowering Patients

45

Doris Taylor, a KP member talks about contacting

her doctor from the convenience of her home. She

sends a secure message to her doctor via KP

HealthConnect. Dr. Liu receives Doris‟s question

and proceeds to reply almost instantaneously.

Transforming Access

The Largest Civil Deployment of

an EHR KP.org: My Health Manager Online

4M users

59M visits

5.6M prescriptions refilled

1.6M appointments made

9.7M visits

255K iPhone and

Android downloads

Mobile: My Health

Manager – anytime,

anywhere

46

Transforming Primary Care

Encounters

47

Care is not just delivered in face-to-face visits now. It is now done on the

phone and through secure emails. In 2003, there were essentially 0% secure

emails – Now it represents 28% of the primary care patient encounters. In

2010 KP provided care in 83 million patient encounters.

Taking Accountability for

Patient Populations

48

Clinical Outcomes in Southern California

Metric Improvement

Lives Saved Per

Decade1

Blood Pressure Control 38.9% 5,341 Lives

Colorectal cancer

screening 30.2% 4,788 Lives

Cholesterol Control 21.8% 1,751 Lives

Blood sugar control 11.5% 1.088 Lives

Smoking Cessation 17.0% 955 Lives

Breast Cancer

Screening 11.4% 570 Lives

Cervical Cancer

Screening 5.9% 59 Lives

Over

14,000

Lives

Saved1

Proactive Office Encounters

49

Identify missing labs, screenings,

kp.org status, etc.

Provide member instructions

Contact member and document encounter in

HealthConnect™

Vital sign collection & documentation

Identify and flag alerts for provider

Prepare patient for exams

Pre-encounter follow-up

After visit summary, care instructions,

follow-up appointment, educational

materials, access to kp.org

Follow-up contact and appointments

Proactive Office Encounters

50

Insert POE video

Systems: Panel Management

51

• Systematic approach

• Prominent role for primary care

physician

• Proactive outreach, beyond

office visits

• Leveraging technology and staff

Tools and processes for population care, to find and close care gaps, applied at the level of a primary care panel.

Patient Population Tools

52

The Panel Support tools have been shown to be effective

in improving patient quality of care and reducing “care

gaps” by up to 21%

Information Is Power at Many

Levels

53

Information is power:

• Power to know what the

problem is

• Power to know where to

act

• Power to know what to

change

Information driving reform:

• Five levels of information

work together to drive

improvement in the health

care system.

• They are all enabled and

dependent on the EHR for

data.

3. Patient population level

4. MD level – performance feedback

5. Patient level – empowerment

2. Organization level– Big Q

1. Health care knowledge level–

research / guidelines

Use of “Best” Oncology

Chemotherapy Protocols

54

1,000s of medical literature / published articles

600 KP oncologists came together, reviewed the latest

medical evidence

Convened on 203 standardized protocols

(from a previous 600+ protocols)

Care for each oncology

patient

Quality – Use of National

Oncology Protocols

% of Protocols - Used as is and Modified

By Region - Within One Month after Go-live

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

San Jose Vallejo Fresno Richmond Oakland San Rafael Fremont

% o

f P

roto

co

ls

% of National protocols - used as is % of National protocols - modif ied % of Unique protocols used

55

• Significantly high use of initial protocols „as is‟* , 63% - 84%

represents „reliability of care‟ and we see this sustained

throughout the rollouts. This high % is unprecedented when

comparing to other clinical content acceptance rates. The

current 2011 use of protocols is 87%.

• The protocols change with the latest evidence quickly.

Discussion

56

APPENDIX

57

Reducing Overall Admits

Population Care: Healthy Bones

58

Program Elements