It’s Not About The Box

April 9, 2013

Choosing Wisely

Filed under: Uncategorized — Matt Handley @ 8:09 am

Several months ago Consumer reports put out a guide to cancer screening tests – and it was better than any summary I have read in a medical journal.  Plain language and pragmatic, it summarized the evidence simply, and remembered that the bar for a screening test is proof of improved health, rather than case finding, etc.  Consumer Reports has ben addressing overuse for about 5 years, well before ABIM started Choosing Wisely.

In a nutshell Choosing Wisely is about the identification of low value care.  I won’t go through the description of the program – their website does that well .  Now at 41 specialty societies.  There are now 135 Choosing Wisely topics – the most egregious causes of waste.  While some of us have been working on this idea for some time, many people do not know much about this, including many in academe.

John Santa MD MPH is the director of the Health Ratings Center for Consumer Reports.  He spoke today at a Puget Sound Health Alliance about the the possibility of transitioning Choosing Wisely from a campaign to a movement.    Social movements are a type of group action – they carry out, resist or undo social change.  He points out that consumers/patients have lost faith with healthcare, and conversations like the ones recommended through Choosing Wisely are one way to rebuild that trust.  Painful as it can be for them, more and more specialty societies are stepping up to participate.

Campaign to Movement:  the principles for communication about Choosing Wisely

  • Go where people are (e.g., wikipedia, vogue)
  • Talk about what they are talking about (usually benefits) and connect your dots to theirs (risk, waste)
  • Use safety if you can
  • Use empathic stories
  • Provide structure for decision-making (because consumers are wary of not following doctors advice)

I love the idea of engaging/mobilizing consumer groups to change medical practice.  While engaging clinicians is ideal, that work is easier if we have also gone directly to patients.  John Santa has been at the thin edge of the wedge dealing with groups that feel they have something to lose through participating, even if it is in the best interest of patients.  His stories remind me of how lucky I am to work in a place where one of the core competencies of our medical group is providing patient centered care and organizing around our patients instead of around doctors.

November 12, 2012

The New Normal

Filed under: Uncategorized — Matt Handley @ 2:51 pm

Ed Ellison MD, the Executive Medical Director of KP Southern California and Elliot Fisher MD from the Dartmouth Institute for Health Policy, worked together to set the context for a combined meeting of Primary Care leaders and Resource Stewardship experts throughout KP.  In beautiful Pasadena California.

The “New Normal” Ed Ellison referred to:

More members +Less revenue + political /Regulatory uncertainty + aggressive competition + Best at getting better = KP transformation

The only way there is a positive future is if we can take better care of patients with fewer resources.  KPSC is aiming to bend their trend by 1% by eliminating waste.  The commitment to Quality is unshaken.   The challenge to every set of chiefs is to be the best at getting better – identifying positive deviance (the few who have cracked the nut and figured out how to get better outcomes across the spectrum) and spreading those practices.  And doing this in a way that builds a vital professional practice, a thriving business and demonstrating that we can transform healthcare.

KPSC is committed to expanding capacity within existing resources – not more bricks and mortar, but meeting patients’ needs more flexibly.

Ed leads with quality, relentlessly.  Ed love quotes, and my favorite one from the talk:  “Wherever you go, go with all your heart” Confusius.

The conference then backed the satellite up with Elliot Fisher looking at things from a national level.  The picture is one that we are familiar with – health care is the reason that our deficits are ballooning nationally, and the reason that we are having to cut state budgets for basically everything besides healthcare.  It just can’t go on.  He walked through the lens of variation, the building blocks of the Dartmouth Atlas that Elliot Fisher and Jack Wennberg developed, include the standard three categories of variation – effective care, reference sensitive care and supply sensitive care.  Great simple descriptions of all of these.

The great relatively new insight that he brought was the “gray area” decisions about intensity of care.  The propensity to intervene (starting as simply as the check back visit frequency for HTN) is correlated to overall spending, and they are clustered regionally.  We miss this when we just look at variation in effective care, and in preference sensitive care.

Lets start with clarifying aims (better health, better care, lower costs), better information to support improvement and inform patients, new models (create systems of care), and realign incentives (both financial and professional).  That enables accountable care organizations, a strategy to try to create system of care from the current chaos.  There are now 230 of these nationally, and over 500 pending at CMS.  I think of them as Kaiser wannabes.

Many of Elliott’s identified best practices are from Group Health or KP, and those that aren’t mostly are done in our practices.  But it will take more.  It will take more than these – it will take reliably doing all of these everywhere, and it will take us working together to discover more ways to get to the 30% cheaper that the country needs.

October 15, 2012

The Care Management Institute Annual Meeting

Filed under: Uncategorized — Matt Handley @ 3:02 pm

Kaiser’s Care Management Institute (CMI) is a remarkable organization – the engine for identifying/developing clinical content for spread across all of the KP regions – and Group Health gets to participate.  I am very lucky to have been a participant at the founding of CMI 15 years ago, and the organization continues to evolve and improve.

Jack Cochrane’s starts with a summary of the accomplishments of KP and GH – tops in Medicare and commercial, and learning how to improve faster and faster.  But excellence isn’t enough – we need to deliver those outcomes (or even better outcomes) at a lower price, if our society is to continue to excel.  We need an inflection point – away from “bending the cost curve” to lowering the cost of care.  How can we get there?

And then a pivot to a really revealing story.  I had not heard this one before – the 9-11 commission, trying to explain how so many smart people in different three letter acronyms (CIA/FBI/FAA, etc) allowed the events of 9-11 to happen – turned to health care.  The analogy they used is a group of specialists in a hospital – all well intended, but the right hand doesn’t know what the left hand is doing.  Seriously.  It is in the report.  When they needed an analogy for a disorganized effort that fails to achieve the desired outcome despite people being quite smart – they use healthcare.  But we don’t need to spend more time on blame-storming – we need to turn to solutions.

We need to be learning organizations – we need to learn and spread faster.  And that means learning from others also.  We need to work less on defending how things are and look to more transformative ideas.  It can be argued that the biggest thing that KP has strategically is a lead.  Smart people are about to adapt away from the fee for service model – there will be darwinian winners that are just as good at reimbursement for value as they were at fee for service.  If we don’t accelerate our own work we will be following shortly.  We need to be the conveners of innovators, with leaders resolved to help us evolve to new models of care.

Pretty cool to hear his words, feel his commitment and passion, in a room filled with the people who will lead us in the coming years.

April 30, 2012

Don Berwick presenting the Birnbaum Lecture

Filed under: Policy — Matt Handley @ 9:25 am

A great way to start a week in spring - Don Berwick is presenting at the Birnbaum lecture at the Convention center in Seattle.  Really looking forward to Don’s talk – take one of the foremost innovators in Health care and season him with time leading CMS, and you get a remarkable perspective.  Don has inspired me for years – I have had the opportunity to learn from him in many ways over many years, including having him shadow me in clinic.  His introduction includes many honorifics, including Knight Commander of the Most Excellent Order of the British Empire. Love that one.

To save notification Emails for those subscribed I will blog happily along and then just post the piece rather than live-blog the event.  ITs a great story, so a long post.

One of my favorite mantras is “No stories without data, and no data without stories” – and Don is the master of storytelling with data.  Today’s talk (not transcribed – but a good faith effort to relate the story):

Midway through residency in 1974 in a NICU rotation, he is awakened at 3 AM to perform an exchange transfusion (a procedure no longer necessary thanks to Rh testing) for a small baby, call her “Baby Gray”.  A sleepy resident, a lot of tubes and stopcocks and a bag of O neg blood.  Basically, in an exchange transfusion blood is taken out of the baby’s umbilical vein, a stopcock is turned and the blood is thrown away, the stopcock is turned and blood is taken out of the O neg bag, the stopcock is turned again and the blood is pushed into the umbilical vein of the baby.  Repeat this many, many times, to basically change out the baby’s blood cells and serum (which contains Mom’s antibodies).  But something went wrong that night.  It was hard to push the blood into the baby, and the baby didn’t look well.  Both the baby and our pediatric resident are tachycardic.  Don stops the process, called for lab tests and help.  A neonatology resident came in as the blood test came back.  The baby has a hematocrit of 90 (normal about 35 – 40).  Crisis.

The hospital where Don has done the procedure before delivered whole blood in one bag.  A different blood bank supplying the hospital where Baby Gray is used a different strategy for delivering the blood.  The red cells were separated from the plasma and red blood cells and plasma were delivered in two different bags.  Don had been using red blood cells without the plasma for the exchange transfusion.  Don sees the clear bag with the plasma dangling below and recognizes that he has been part of an error that has put the baby’s life at risk.  The neonatology resident saved the day (after some complication the baby does well) and reassured Don that this could have happened to anyone.

Don responded as most all of us would have (especially then).  He did not come forward and talk about the error so that it could prevent other patients and doctors from the same error and harm.  Don did nothing.  He carried the pain privately.  His internal dialogue has not kind. “How could I have done anything so stupid”.

Our knowledge of safety and error are now pretty good.  One of the first books about safety, “Human Error” by James Reason may be the best of its kind – the source of the “Swiss cheese model” – laying out the idea that latent causes of error (sleepy resident, non-standardized blood bank procedures, etc) happen to line up like holes in Swiss cheese.  Safety science has enabled us to build safer systems, including more just cultures.

Shift frames – Don Berwick as the self-described amateur ethicist.  Surely it is unethical to allow any other baby to be injured.   It is more than the error itself, it is in the silence that follows.  The silence that makes it so that the error is still possible for other patients, and that keeps the error from the family.  We are now all aligned around safety, just culture, disclosure and quality.

The ethical answers to this case scale to the question of our health system.  The fist locus is that the ethics of quality lie in the professionals that practice medicine.  The second locus of the ethics of quality is leaders.  Imagine that the next day, wracked by guilt, Don brings the cause to leaders so that things can be made safer.  ”You are not a superhero, and you can make mistakes – but the well being of your patients and of other patients depends on your sharing what goes wrong so that we can build stronger systems of support to minimize the errors humans make”.

There is an inescapable connection between the ethics and actions of individuals and leaders.

Segue (the one that Don’s wife believes is hard to follow)

There are many dimensions of quality that we know well – safety, effectiveness, patient centeredness, timeliness, efficiency and equity.   And some of these stories, especially safety, are compelling.  The story about the baby and the exchange transfusion “has us at hello” – heartstrings are tugged, and we feel for both the patient and for the caregiver.

But we can and need to expand the ethical call beyond just safety and effective care, to all of our quality goals.  Now the particular aim that needs to be driving us is Efficiency – the issue of cost.  We need to grapple with the premise that we have an ethical duty to address cost, for the sake of individuals and for society.  Our ability to do everything else that government might do for good is hanging in the balance.  We will not be able to fund schools or maintain support for the disadvantaged unless we address the costs of our health care system.  And we know that this burden is not necessary if we cease our concessions to waste.

We can use an analogy to environmental models (Dons’ recent article in JAMA) where no single strategy can fix our carbon problem, but many different strategies (“wedges” like solar power, more efficient cars, carbon sequestration, etc) can work together to get enough reduction to prevent catastrophic global warming.   In health care, there are 6 wedges of waste:

  • Overtreatment
  • Failures to coordinate care
  • Failures in care delivery
  • Excess administrative costs, excessive health care prices
  • Fraud and abuse.

The minimum estimates of the sum of health care spending for these categories is 21% of all health care spending, the median is 34% and the highest estimate is 47%.  Scary as those estimates are they should bring us hope – if we tackle waste we can continue to provide all the care we should and save considerable resources.  Over 9 years we are looking at $11,000,000,000.  There is a “T” involved in that number.

At the individual level, it is easy to see that the next “Baby Gray” will die unless leaders in health care accept their accountability to learn from error.  We are well down the road to making care safer, but the analogy to affordability has not achieved engagement.

The harm from the health care system on our society will not cease unless the leaders accept their responsibility for the waste in our system.  It is easy to see that while there are a set of excuses for all of the wastes, the analogy to safety is inescapable.

Health care leaders need to assume the responsibility without excuses to tackle waste.

Harm to an individual patient by medical error is different than the harm from waste.  With waste, you can’t name who is hurt.  No one wasteful act harms an individual.  But waste is theft and theft is wrong.  Waste threatens healthcare as a human right.

Don’s Principles for a Framework for action.

  • Put the patient first
  • Protect the disadvantaged
  • Start at Scale
  • Return the money
  • Act Locally

One step further to an ethics of improvement

  • Professionals have an duty to help improve the systems in which they work
  • Leaders have a duty to make #1 logical, feasible, and supported
  • No excuses for inaction on #1 and #2 are ethically acceptable.
  • The duty to improve across all five, and that includes waste
  • Those who educate professionals have a duty to prepare them for this important work

There is a lot of anguish over how we can get things on track – the public is looking for sanity to come out of this.  While politics and policy matter, they are insufficient to fix this.  It will necessarily fall to those who provide care, and those who make it possible for them to provide great care, to lead change to reduce waste and improve value.

Hard to listen to Don and not run out of the room and take action.  I know that my meetings later today will some different focus.

October 24, 2011

Care Management Institute Annual Meeting

Filed under: Uncategorized — Matt Handley @ 7:39 am

Yesterday kicked off the annual meeting for the KP Care Management Institute (CMI), KPs collection of talent from around the program for co-inventing and spreading innovation.  That is innovation defined as “A good idea well executed”.

Yesterday there were stirring words from Robie Pearl and Jack Cochrane, and the teams are ready to tackle the two topics – obesity and cancer care.  What would it take to provide patient centered care in these areas that lead to the best outcomes, as defined by patients?  I think that the major differences between work that has gone on previously and this effort are a patient centered design approach, and the recognition that the greatest levers we have may be the patient and their communities.  There has been a lot of pre-work from the staff at CMI, and we are breaking into two groups to tackle the topics, and then getting back together to challenge each other to think bigger and go farther on behalf of our patients.

Should be an exciting two days

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