It’s Not About The Box Improving Care at Group Health with People, Process and Technology

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.

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

March 25, 2011

Innovating through Engagement

Filed under: Uncategorized — Matt Handley @ 1:31 pm

What is possible when we have engagement – within the clinical team and with patients?   At the Group Health “Innovating Through Engagement” conference, stories are being told that suggest that the answer is – most anything.

The day focuses conversations on a few innovations that Group Health has been successful with.  Those of us who have been involved in them tend to see them as yesterday’s news – we forget how unusual and special these efforts have been, and how much our patients and the organization have benefited from them.

The Patient Centered Medical Home (Health affairs article summarizing the 2 year outcomes  health affairs ghc medical home )  what happened there – better care, happier patients, more engaged staff and lower costs.

EDHI – comprehensive strategy to reduce both hospitalizations and readmissions – resulting in benchmark performance on hospital days

Shared Decision Making for Preference Sensitive conditions  (older posts about this one, my favorite, here and here )  We now have the largest implementation of video decision aids in the country, leading to better care, happier patients and lower costs

Improving the Value of High End Imaging  (older posts here and here ) – same story – better care and lower costs (for the last 4 months the rate of ordering of CT and MRI by GH Physicians was reduced from baseline by 26%, and that baseline was already lower than the community.

My favorite themes for all of this work?  First – avoiding the cost of poor quality.  There is a lot of skepticism about the impact of improved quality on costs – some believing that underuse of expensive interventions is the main quality gap.  If we focus on value we see that first time quality and involving patient values in care decisions can lead to both better care and lower costs.

Second – Group Health staff are remarkable, and we work in what is essentially an incubator for innovation.  And it is innovation for patients’ sake, rather than just toying around with the next cool thing.  For any innovation to matter, it has to scale and be integrated into a larger story.  that takes both flexibility and standardization, two things that are easily seen as opposing values.  But it can work.

It is good to be us!

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