Collaboration & Quality Improvement “It Takes A Village” South East Michigan Quality Forum

1. Collaboration & Quality Improvement “It Takes A Village”South East Michigan Quality Forum Health Trends Conference January 24, 2003 John E. Billi, M.D. Associate Dean, Clinical Affairs Associate Vice President, Medical Affairs University of Michigan

2. U of M Process for Evidence-based Guideline Adaptation & Implementation Characteristics of Delivery System Identify Areas of Practice Define Optimal Clinical Practice Teams Design and Implement Interventions CQI Process CQI Process CQI Process Health Care Database Redesign Process, if Necessary Assess Outcomes CQI Process CQI Process Institutional Activities External Agencies Wise, Billi. Jt. Comm. J. Q. Imp. 1995;21:465-476.

3. 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.

4. SEM Quality Forum • Roles • Serve as locus of coordination, collaborationfor 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.

5. SEM Quality Forum • Membership • 6 SEM health systems and physician leaders • 3 auto companies • UAW • BCBSM • MPRO • Other organizations can join!

6. 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 Guidelines http://www.gdahc.org/deliv.htm

7. 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…

8. 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.

9. 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

10. 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)

11. 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

12. 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.

13. 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

14. 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!

15. END

16. Traditional Care • Episodic, uncoordinated • Focused on the acutely ill • Patient initiated • Patient education is sporadic • Communication among clinicians is sporadic • Information scattered on paper • Process of care is variable • Clinicians’ opinions drive decisions • Expensive

17. 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

18. “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: ANew Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

19. 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

20. 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

21. 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

22. 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”

23. 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 Source: Adapted from R Lichtenstein

24. Trends 2003 Shifting Accountability Downward • Performance-based contracting • Report cards: outcomes, costs • Defined contribution health plans • Individualized Medical Savings Accounts, with provider report cards • Differential copays for high cost hospitals/groups

25. Populations Healthy Stable chronic diseaseand stable at risk High risk orunstablechronic disease Hospitalized Acutely ill University of Michigan Medical School

26. Evidence-Based Guidelines for Populations Prevention & screeningpractice guidelines Stable chronic diseasepractice guidelines High intensitymanagement principles Criticalpathways High risk orunstablechronic disease Hospitalized Stable chronic diseaseand stable at risk Healthy Acutely ill Acute care practice guidelines University of Michigan Medical School

27. Medical Management Strategies Inpatient High intensity practice case management & Prevention/Screening Chronic/stable illness management trackingprogram management program management program Prevention & screening practice guidelines High intensity Stable chronic disease Critical management principles practiceguidelines pathways Healthy Stable chronic diseaseand stable at risk High risk or unstable chronic disease Hospitalized Acutely Ill Acute care practice guidelines Acute illness management program Specialist (& PCP) Specialist (& PCP) PCP & Specialist PCP (& Specialist) TEAM APPROACH (Physicians, Nurse Practitioners, Social Work…) University of Michigan Medical School

28. Health Plan Design Strategies Patient advocate Home contacts Benefit expansion Full preventive services covered Targeted health behavior programs Risk factor identification, HRA Patient education covered Specialized management programs covered High intensity case management & tracking program Inpatient practice management Prevention/Screening management program Chronic/stable illness management program High intensity management principles Prevention & screening practice guidelines Stable chronic disease practice guidelines Critical pathways Healthy Stable chronic disease Hospitalized High risk or unstable and stable at risk chronic disease Acutely ill Acute care practice guidelines Acute illness management program Access to Specialists Principal Physician Hospitalist Specialist (& PCP) Specialist (& PCP) PCP (& Specialist) PCP & Specialist TEAM APPROACH (Physicians, Nurse Practitioners, Social Work)

29. Continuous Quality ImprovementThe Approach to Better Healthcare A process for continuous improvement: - evidence based - consensus building - data driven Can be used to address: - overuse - underuse - misuse

30. Quality Concerns • Underuse • 60% of diabetic patients w/o HbAlc test in 1998 • Only 59% / 65% of GM women are receiving recommended screenings for cervical / breast cancer • Overuse • Hysterectomy rate in Flint MI 80% higher than Kaiser • Cardiac catheterization rate in all major MI, OH, IN areas at least 160% higher than Kaiser • Misuse • 60% of cold / URI / bronchitis patients receive antibiotics Source: Bruce Bradley, General Motors

31. Process for Practice Guideline Adaptation & Implementation • Identify Areas of Practice • High cost • High volume • Practice variation • High risk • Marketing factors • Regulatory factors • Guidelines available • Local clinical champion(s) • Other Characteristics of Delivery System • Teams Design & Implement Interventions • Data feedback • MIS-based intervention • Administrative interventions • Financial interventions • Educational models • Patient empowerment • Clinician empowerment • Other Define Optimal Clinical Practice & Systems Processes * Clinical panels adapt guidelines to local practice * Collaborative critical pathways * Case management Teams Design and Implement Interventions CQI Process CQI Process CQI Process Health Care Database Redesign Process, if Necessary Assess Outcomes CQI Process CQI Process Institutional Activities External Agencies

32. Process for Practice Guideline Adaptation & Implementation • Identify Areas of Practice • High cost • High volume • Practice variation • High risk • Marketing factors • Regulatory factors • Guidelines available • Local clinical champion(s) • Other Characteristics of Delivery System • 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 CQI Process CQI Process CQI Process Health Care Database Redesign Process, if Necessary Assess Outcomes CQI Process CQI Process Institutional Activities External Agencies

33. Process for Practice Guideline Adaptation & Implementation • Identify Areas of Practice • High cost • High volume • Practice variation • High risk • Marketing factors • Regulatory factors • Guidelines available • Local clinical champion(s) • Other • 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 • 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 CQI Process CQI Process • Health Care Database • Clinical • Demographic • Economic • Nursing • Outcomes: function, satisfaction, productivity CQI Process • Assess Outcomes • Clinical • Process • Costs (cost / benefit) • Patient satisfaction • Return to work, days off, days ill • Redesign Process, • if Necessary • Identify barriers • Fine tune guidelines CQI Process CQI Process • Institutional Activities • Develop financial packages Planning & Marketing Regulatory reporting • External Agencies • Payers Public Corporations Corporate alliances Government agencies

34. 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

35. 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!

36. 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

37. 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.

38. 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

39. 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.

40. 12 Characteristics of Good Uses of Practice Guidelines • 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 onlykey steps supported by high grade scientific evidence. Don’t sweat the small stuff!

41. 12 Characteristics of Good Uses of Practice Guidelines • 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.