Collaboration

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Collaboration Quality Improvement It Takes A
VillageSouth 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
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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. 199521465-476.
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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.

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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.

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SEM Quality Forum

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

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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

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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

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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.

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Druckers 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 doesnt
• Elimination of barriers dueling guidelines,
  measurements, profiles, interventions

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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 (Im a good BCN doctor, but
  a poor MCARE doctor)
• conflicting interventions (MPRO, MCARE, MHA,
  MAHP, U of M)

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Benefits of Cooperation for the Health Plans

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

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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.

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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 doctors 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

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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
• Theres plenty to dobut theres plenty of help!

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END
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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

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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

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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.
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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

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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

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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
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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

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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
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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

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Populations

Healthy
Stable chronic diseaseand stable at risk
High risk orunstablechronic disease
Hospitalized
Acutely ill
University of Michigan Medical School
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Evidence-Based Guidelines for Populations

Prevention screeningpractice guidelines
Stable chronic diseasepractice guidelines
High intensitymanagement principles
Criticalpathways
Hospitalized
High risk orunstablechronic disease
Stable chronic diseaseand stable at risk
Healthy
Acutely ill
Acute care practice guidelines
University of Michigan Medical School
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Medical Management Strategies
Inpatient
High intensity
practice
case management
Prevention/Screening
Chronic/stable illness
management
tracking program
management program
management program

Prevention screening practice guidelines
High intensity
Stable chronic disease
Critical
management principles
practice guidelines
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
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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
Principal Physician
Hospitalist
Access to Specialists
Specialist ( PCP)
PCP ( Specialist)
Specialist ( PCP)
PCP Specialist
TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work)
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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

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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
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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
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Evidence-Based Medicine

• Systematic process to encourage all practitioners
  to apply the appropriate scientific evidence to
  individual clinical decisions.
• Evidence is not
• An experts or healthcare consultants 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

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Practice Guidelines

• I cant 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!

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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

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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.

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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

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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.

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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 only key steps supported by high grade
  scientific evidence. Dont sweat the small stuff!

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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.