The Pressure ’ s On Cookbook Medicine? Or a Recipe for Success

1. The Pressure’s On Cookbook Medicine? Or a Recipe for Success CajunCodeFest April 24, 2014 Kenny J. Cole, MD Associate CMO and VP of Care Delivery Blue Cross Blue Shield of Louisiana

2. The Art and Science of Cooking • Two Approaches • Application of skill and knowledge • Highly trained chef • Customized • Tacit knowledge • Iterative process • Following a recipe • Requires less skill and training • Programmatic • Explicit knowledge • Sequential process

3. Good Cooking vs. Bad Cooking • What determines good vs. bad? • Taste • Finished Product • Outcome • Depends on the skill and knowledge of the chef OR adherence to the recipe

4. The Art and Science of Medicine • Two Approaches • Application of skill and knowledge • Highly trained clinician • Customized • Tacit knowledge • Iterative process • Following a “recipe” or protocol • Requires less skill and training • Programmatic • Explicit knowledge • Sequential process

5. Good vs. Bad Medicine • Depends on the Outcome • For sequential care processes  consistent application of a standardized protocol may lead to more reliable outcomes • Success depends upon rigid adherence to the protocol • For iterative care processes  success is usually dependent upon the skill and knowledge of the provider

6. Potential Problems or Challenges • Sequential Process  reluctance among chefs and clinicians that following a recipe or protocol may lead to a more reliable outcome • Entrenched provider mindsets • Change Management Strategies • Leadership Challenges • Iterative Process  Variation • Outcome depends on skill and knowledge

7. Sequential vs. Iterative • What determines which process to use? • State of evolution of knowledge • Knowledge that  Knowledge how  Knowledge why • Knowledge form – tacit  explicit • As the state of knowledge evolves, the location of knowledge may change • From skilled artisan • To codifying it in an explicit algorithm or piece of technology

8. The Knowledge Funnel Martin, Roger. Design of Business: Why Design Thinking is the Next Competitive Advantage; 2009

9. Our Current Healthcare System • The most expensive in the world • Per capita healthcare costs almost 50% higher than the next highest nation • Failure to yield consistently high-value care • ~30 to 50% of healthcare spending in the US is “pure waste” • Only 55% of effective care actually delivered Key quality and system performance indicators showing the US actually lagging behind other developed nations

10. A Perfect Storm • Patient safety and quality concerns • Demographic changes • Rapidly changing technologies and treatment • Digital transition • Workforce issues • Reimbursement changes • Rising consumerism

11. Future Health Care System • Transformation of Delivery System • From Volume-driven, Transaction-based • To Value-driven, Outcomes-based Value = Quality of Outcomes achieved per unit of Cost expended

12. Healthcare System Transformation • First delivery system transformation • Then evolve reimbursement mechanisms that emphasize value over volume • FFS  Performance-based contracts (QBPC) • Risk-based contracts (e.g., shared savings, bundled payments, capitation) • Requires Health Plan-Provider Collaboration

13. Transformation JourneyHow do we get there? Lean/Six Sigma first used in health care over a decade ago  Operational Processes Applying DMAIC methodology of Six Sigma or process improvement science Clinical Processes Improved outcomes Reward providers who demonstrate improved outcomes Help drive market share to these providers Enable value-based competition as providers then begin to compete on value rather than volume

14. Six Sigma Basics

15. 308,537 2 3 66,807 6,210 4 5 233 6 3.4 What does Six Sigma mean? • The term “Sigma” is a measurement of how far a given process deviates from perfection – a measure of the number of “defects”. Six Sigma correlates to just 3.4 defects per million opportunities. • A quality improvement methodology that applies statistics to measure and reduce variation in processes. • A management systemthat is comprehensive and flexible for achieving, sustaining, and maximizing success. DPMO ZB

16. Key Concepts Applied to Healthcare • Critical to Quality (CTQ): Attributes most important to the patient • Defect: Failing to deliver what the patient needs • Process Capability: What our process can deliver • Stable Operations: Ensuring consistent, predictable processes to improve what the patient needs

18. Goals of Three-Year Campaign • Measurable improvements in high blood pressure prevention, detection, and control • 80% of patients at goal according to JNC7 • 75% of AMGA membership adopt (at least one) campaign planks. • Engage and empower patients to actively manage their health. 18

19. 80% of Patients at Goal Blood Pressure Processes to Achieve Goal Hypertension Guideline used and adherence monitored Direct Care Staff trained in accurate BP measurement Prevention, engagement, and self-management program in place All patients not at goal and with new Rx seen within 30 days BP addressed for every hypertension patient, every primary care visit Registry usedto identify and track hypertension patients All team members trained in importance of BP goals All specialties intervene with patients not in control 19

20. Blood Pressure Goals in US Organization/GuidelineBP Goal JNC VII (2003) Uncomplicated <140/90 Diabetes/CKD <130/80 JNC VIII (2014) Age < 60 <140/90 Age > 60 <150/90 ADA (2013) Most diabetics <140/80 Younger/healthier <130/80 AHA (2011) Age >80 <145/90 NKF (2004) CKD <130/80

21. Both Systolic and Diastolic Blood Pressure control rates among COSEHC ATGOAL practices in the Southeast US at Period 4 Key: Percent (%) Average of all ATGOAL practices Individual ATGOAL practices Control Rate: < 140/90 mm Hg non-diabetic; < 140/80 mm Hg diabetic National Hypertension Control Rate = 50.1% Your practice FUP4_Baton Rouge Clinic www.cosehc.org

22. The Pressure’s On Baton Rouge Clinic Six Sigma Hypertension Project Initiative Goal: Increase the number of patients achieving adequate blood pressure control, defined as <140/90 in non-diabetics and <140/80 in patients with diabetes, from its current rate of 60% in the Baton Rouge Clinic internal medicine department to > 80% Place picture of initiative, team, or some type of illustration here

23. Define Phase Initiative Scope: All Baton Rouge Clinic internal medicine patients with a diagnosis of hypertension between the ages of 18 and 80. • Alignment with Strategic Plan: • Escalating healthcare costs to unsustainable levels • Emergence of new performance-based and risk-based payment mechanisms have evolving to incent providers to deliver increased value of services rendered • Improving BP control has the potential to significantly reduce morbidity and mortality due to uncontrolled hypertension and has enormous potential to decrease costs of care related to this condition • Problem Statement: • Hypertension remains uncontrolled in a substantial number of patients • Major contributing factor toward the development of several chronic diseases • Coronary artery disease • Congestive heart failure • Stroke • Chronic kidney disease Rate of controlled hypertension at start of project: 60%

24. Data mining Implementation difficulty 30% Medication expense Generic vs. brand name medications BP measurement accuracy Loss of physician autonomy/loss of control Professional resentment/unwillingness to embrace change Professional disagreement regarding evidence-based guidelines 40% Failure to recognize the need for change Increased work for physician’s nurses or for physicians Patient noncompliance Patient denial of a problem 30% Louisiana cuisine and culture (due to silent nature of disease) High sodium intake Priorities – where to spend money? High rates of obesity Patient ignorance regarding importance of adequate BP control Rating Sources of Causes/Reasons for Resistance (0-100%) Resistance Technical Political Cultural Mobilizing commitment Technical-Political-Cultural analysis

25. These are our patients, friends, and families

26. These are our patients, friends, and families

27. Total Medicare Reimbursements per Enrollee FUP3: Baton Rouge Clinic

28. How is our process performing current state? Baseline Process Capability Define Measure Control Analyze Improve

29. What is contributing to our DPMO? Critical Xs Define Measure Control Analyze Improve

30. What is contributing to our DPMO? All Patients: Diabetic Status Define Measure Control Analyze Improve P-Value = 0.000 P-Value = 0.000 Diabetic Status is statistically significant because there is a higher proportion of diabetics who are not in control compared to non-diabetics

31. What is contributing to our DPMO? All Patients: Age (65 or over) Define Measure Control Analyze Improve P-Value = 0.008 Age is statistically significant because there is a smaller proportion of patients 65 and older who are out of control compared to patients who are under 65

32. What is contributing to our DPMO? All Patients with measured BMI*: BMI Grouping Define Measure Control Analyze Improve P-Value = 0.000 *157 patients were removed because there was no BMI reading at the date of service bringing the total sample size to 6,057 BMI grouping is statistically significant because there is a larger proportion of extremely obese patients whose BP is out of control compared to other BMI groupings

33. What is contributing to our DPMO? All Patients: Providers in BRC Internal Medicine Define Measure Control Analyze Improve P-Value = 0.000

34. What is contributing to our DPMO? Patients Not In Control at Prior Visit*: Time Frame For Follow Up Define Measure Control Analyze Improve Prior Visit defined as most recent date of service from the sample visit. If a patient has more than one prior visit, the most recent is taken. Dates for prior visit range 8/7/12 to 3/26/123

35. Improve Phase Define Measure Control Analyze • Vitals Station • Specially trained nurses checking blood pressure to eliminate variance, minimize errors, and maximize accuracy of readings • Use of automated blood pressure cuffs? • Standardized evidence-based hypertension treatment protocol • Target to achieve evidence-based treatment goals in patients < age 80 • < 140/90 for uncomplicated hypertension • <140/80 for most diabetics • Add recall appointment feature in Epic • Specify 2-week follow-up period for all patients > 20 mmHg away from treatment goal • Specify 4-week follow-up period for all patients whose readings are < 20 mmHg away from treatment goal • Utilize “Remind me” feature in EMR to populate a registry of uncontrolled hypertensives to facilitate outreach and ensure timely follow-up • Create brochure for patients to educate about the risks of hypertension, importance of compliance with medications and appropriate follow-up Improve

38. What is the impact of our project to date? 9 out of 10 Pilot physicians improved BP control in first month Define Measure Control Analyze Improve

39. Summary/Conclusions • Baseline Process Capability ~60% • Diabetic Status, BMI, Age are statistically significant variables, but Provider is the most significant variable associated with failure to achieve hypertension control • Adherence to a standardized protocol improves hypertension control to 90%, establishing a NEW IMPROVED process capability • Achieving scalability will present a leadership challenge involving change management strategies aimed at overcoming entrenched provider mindsets • The process can be codified in such a way as to allow clinical personnel with lesser skill and training to achieved much better process capability • Has implications for the design of care delivery and which will involve NEW PAYMENT METHODOLOGIES to support delivery system transformation

40. The Future: From Worst to First • Diabetes • Hyperlipidemia • Congestive Heart Failure • HIV • Asthma/COPD • Respiratory Tract Infections • Depression • Many types of Cancer • Chest Pain • Back Pain

41. The Pressure’s On Cookbook Medicine? Or a Recipe for Success QUESTIONS? DISCUSSION