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Radiology Performance Measurement Guide


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									              Performance Improvement at
                   Kaiser Permanente
Ruth Shaber, MD
Medical Director, Care Management Institute
June 22, 2010

 KP History and Integrated Care
 KP Performance Improvement Model
 Case Studies

                                     Slide 2
Kaiser Permanente

 8.7 million members
 9 states +
  Washington, DC
 32 hospitals
 421 medical offices
 14,000 physicians
 160,000 employees
 KPHealthConnect
                        Slide 3
KP History

 Grand Coulee Dam –
 Richmond Ship Yards –
 Long standing Labor/
 Innovative Care Models

                           Slide 4
 Kaiser Permanente Model

 Social purpose                                    Kaiser Permanente defines
 Quality-driven                                    the integrated model of
 Shared accountability for                         health care financing and
  program success                Permanente         delivery through its unique
 Integration along multiple                        partnership among three
  dimensions                       Groups
 Prevention and care
  management focus
                                 Health Plan

                      Kaiser                     Kaiser
                    Foundation                 Foundation
                     Hospitals                 Health Plan

                                                                         Slide 5
  Quality Strategy
The foundation of our strategic plan is to deliver the highest quality care and service
through our fully-integrated care delivery system.
                                                                  Leading Prevention and Total Health
        Transforming Quality & Service                            Complete Care for Complex Conditions
            ―Realizing Our Potential‖                             Best Hospitals
                                                                  Service Excellence

   Data / Research              Evidence-Based Medicine           Best Practice Protocols                 Reliably Delivered

                                                                   Panel management
             Leading Prevention and Total                          Early detection
                        Health                                     Self care
                                                                   Home as the hub
                                                                   Chronic care
                    Complete Care
                                                                   High intensity member care
               for Complex Conditions
                                                                   Customized care

                                                                   Patient safety
                       Best Hospitals                              Transitions in care
                                                                   Efficiencies and effectiveness

                                                                   Culture and leadership
                     Service Excellence
                                                                   Hospital service
                                                                   Outpatient service

  Values:             Safe, Patient-centered, Timely, Equitable, Reliable, Accountable, Transparent, and Seamless
  Culture:            Empowered Unit-Based Teams, Performance Improvement, Continuous Learning; Culturally Competent
  Tools:              KP HealthConnect, / My Health Manager, Panel Tools / Care Registries, Barcoding, Big Q,
                                                                                                                               Slide 6
                      Predictive Modeling, Archimedes
Slide 7
Caring for the Whole Member

 Caring for the whole      Complete Care
  member proactively                      Chronic Conditions
                          • Diabetes
  addresses needs         • Coronary Artery Disease
  for:                    • Dyslipidemia
                          • Hypertension
   • Chronic conditions
     care                 • Tobacco use

   • Lifestyle and        • Diet
                          • Exercise
     behavior change
   • Prevention           • Cancer screening

                          • Colorectal Cancer screening
                          • Immunizations

                                                            Slide 8

             Slide 9
Systems: Panel Management

            Tools and processes for population care, to
            find and close care gaps, applied at the
            level of a primary care panel.

             Systematic approach
             Prominent role for primary care
             Proactive outreach, beyond office
             Leveraging technology and staff

                                                 Slide 10
Using a Systems Approach: POE

 Pre Encounter                    Office Encounter                   Post Encounter
Proactive                 Office Encounter Management               Immediate
  Identification          • Vital sign collection /                 • After visit summary,
• Identify missing          documentation                             after care
  labs, screening         • Identify and flag alerts for provider     instructions, follow-
  procedures, access                                                  up appointments,
  management,      • Room and prepare patient for              Health Ed materials,
  status, etc.              necessary exams                           how to access info
• Provide member          • Pre-encounter follow-up                   on
  instructions prior to                                             Future
  visit                      Proactive Office Support
                                                                    • Follow-up contact
• Contact member and                 • Phone calls                    and appointments
  document encounter                 • Letters                        per provider
  in KP                              • E-mail
 HealthConnect™                      • Inbox Management
                                                                                      Slide 11
Slide 12
KP Performance Improvement
  Initiated in 2007
  Designed after benchmarking top large
  Based on execution and improvement
  Engages ―top down and bottom up‖
  Front line staff owning the local process and
   the executives leading the strategy and
   cross-system redesign.                          Slide 13
KP Performance Improvement Model
What are we trying to accomplish?
How will we know change is an improvement?
What change can we make that will result in improvement?

                     Develop /                        Implement /
    Assess                               Test
                  Identify Change                       Control

  • Process Map    • Standardize &                     • Training
  • Baseline                                           • Policy &
    Data           • Reduce Waste                        Procedures
                   • Apply evidence                    • Spread Plan
                     based practice

                                                                    Slide 14
KP Performance Improvement Model
What are we trying to accomplish?
How will we know change is an improvement?
What change can we make that will result in improvement?

                     Develop /                        Implement /
    Assess                               Test
                  Identify Change                       Control

  • Process Map    • Standardize &                     • Training
  • Baseline                                           • Policy &
    Data           • Reduce Waste                        Procedures
                   • Apply evidence                    • Spread Plan
                     based practice

                                                                    Slide 15
Assessment - Learn By Asking

                               Slide 16
Get Out of The Office and onto the

                  LISTEN and DOCUMENT…
                  Voice of your Customers
                  Voice of your Workers
                  Voice of your Process

                                       Slide 17
Assessment – Pareto Charts

 a graphical display of the relative weights or
  frequencies of competing events, choices, or
 a bar chart, sorted from greatest to smallest, that
  summarizes the relative frequencies of events
 often includes a cumulative total line
 used to focus within a broad category containing
  many choices, based on factual or opinion-
  based information
                                                  Slide 18
Pareto Chart: SCAL Readmissions
                                              Conclusions:Patient Issues for Heart Failure Readmissions: Q3 2009 (n=69)

                           25                                                                                                                                             100%

                           20                                                                                                                                             80%
Number of Patient Issues


                           15                                                                                                                                             60%

                           10                                                                                                                                             40%
                                                                          8                 8
                                      29%                                                                  7
                                                                                                                            6                6

                           5                                                                                                                                              20%

                           0                                                                                                                                              0%
                                     Lack of        Psych-social   Did not accept HH Did not accept Did not present at Did not have     Did not accept Financial issues
                                 adherence to          issues             visit        referral to      follow -up       adequate       referral to HF
                                meds, therapies,                                     palliative care   appointment understanding of        program
                                daily w eights or                                                                      medications on
                                                                                                                                                                          Slide 19
                                       diet                                                                               med list

                                                                              # of causes                              Cumulative
Assessment: What are we trying
to accomplish?

Goal statements are S.M.A.R.T. and are the first steps you
and your team will take:

       S        Specific including the target population
       M        Measurable

       A        Attainable, Agreed upon

       R        Realistic, Relevant
       T        Time bound
                                                        Slide 20
  Example KP Aim Statements

 Clinical (NCal):
  We will reduce sepsis mortality through early detection and aggressive
  treatment of sepsis patients who present to the ED:
  - By June 30, 2009, increase to 55% the number of patients with suspected
  infections who get a lactate level tested.
  - By June 30, 2009, increase to 55% the number of sepsis patients who
  receive antibiotics within one hour of diagnosis.
  - By Dec 31, 2009, increase to 55% the number of severe sepsis patients
  who have their 1st central line reading within 2 hours of sepsis diagnosis.

 Operational (CO):
  In an effort to maximize the operational efficiency of surgical procedures at
  Exempla Saint Joseph Hospital, Perioperative Services will reduce
  unnecessary steps and standardize its total joint case turnover time in an
  effort to reduce the room turnover time from an average of 35 minutes to an
  average of 30 minutes by June 30, 2009.

                                                                             Slide 21
Process Mapping - baseline

 Before you start changing things you must define the
  current state of the process you are trying to improve
 Where there is no standard, there can be no continuous
 A process map is a visual representation of a system or
 It is a tool to help the improvement team understand the
  customer/supplier relationships throughout the process

                                                        Slide 22

                                                        - 22 -
KP Performance Improvement
What are we trying to accomplish?
How will we know change is an improvement?
What change can we make that will result in improvement?

                     Develop /                        Implement /
    Assess                               Test
                  Identify Change                       Control

  • Process Map    • Standardize &                     • Training
  • Baseline                                           • Policy &
    Data           • Reduce Waste                        Procedures
                   • Apply evidence                    • Spread Plan
                     based practice

                                                                    Slide 23
From Traditional “Craft” of Medicine

 An individual physician placing the patient’s
  needs before any other goal, drawing on
  extensive clinical knowledge gained through
  formal education and experience.
 Each clinical situation requires a unique
  diagnostic and treatment regimen customized
  for that particular patient
 Traditional Medicine’s promise: this approach
  will produce the best result possible for each
                                                   Slide 24
Towards profession-based practice

 Groups of peers, treating patients in a shared
 Coordinated care delivery processes (e.g.
  standing order sets)
 Individual clinicians adapt to specific patients
 Resulting in: less waste and less complex care
  with better outcomes

                                                 Slide 25
Clinical Pathways – Assessment

How to get started:
 What’s the evidence?
 Assessment by a group of clinical peers – often
 Measure practice variation: practice profiling
  (statistical comparisons of individual units of
 Why are we different? What is best care?
 Feed the variance back to the peer group: pull in
  literature, experts, special analyses
                                                 Slide 26
Components of a clinical pathway

Evidence base
  RCT to consensus-based
Workflow process
  How those steps fit together and who does them
Informatics and clinical decision support
  The tools that make the right thing the easiest thing to
Analytics & Evaluation
  Are the steps being accomplished reliably, and are the
  expected outcomes being achieved

                                                             Slide 27
Planning – mapping a process

 Identify the gaps where improvement is required
 Hardwire the desired change – either with
  people or technology
 Standardize

                                               Slide 28
Clinical Pathway for Early Sepsis
        Identify at triage if suspected infection and 2 SIRS criteria:
         To < 96.8 (36.0) or > 100.4 (38.0)
         HR > 90                                Suspected Sepsis
         RR > 20                                  Document SIRS
         WBC > 12K or < 4K or > 10% bands
         OR Altered Mental Status
    A     CBC, Lactate, BC
    R   Consider IV fluids and
    L           ABX                  stop
    Y                                    <2
    R                                                           IV fluids
    E   SBP ≤ 90?                Lactate high?           Consider ABX Repeat
    C                     no
                                        ≥4                  lactate in 6 hrs
    O          yes
    G                  SBP >90        Document Severe Sepsis
    N      20 ml/kg                        (Time Zero)
    I    fluid bolus
    T          SBP ≤ 90
    O   Document Septic                    Early Goal
    N   Shock (Time Zero)                                                      Slide 29

                                        Directed Therapy
KP Performance Improvement
What are we trying to accomplish?
How will we know change is an improvement?
What change can we make that will result in improvement?

                     Develop /                        Implement /
    Assess                               Test
                  Identify Change                       Control

  • Process Map    • Standardize &                     • Training
  • Baseline                                           • Policy &
    Data           • Reduce Waste                        Procedures
                   • Apply evidence                    • Spread Plan
                     based practice

                                                                    Slide 30
What Changes Can We Make that
will Result in Improvement?

―You can’t fatten a cow by weighing it‖
                             - Palestinian Proverb

                              • Improvement is
                                NOT about
                              • It is about change

                                                     Slide 31
Measurement for Improvement

 The purpose of measurement in Performance
  Improvement work is for learning, not judgment or
 Measures should be linked to the team’s goal
 Measures should be used to guide improvement and test
 Data should be plotted over time on annotated graphs
 A balanced set of measures reported daily, weekly, or
  monthly is necessary to determine if the process has
  improved, stayed the same, or become worse

                                                          Slide 32
Balanced Measures

 Outcome measure – in the voice of the patient
  • What is the desired result
 Process Measure – how the process works
  • Is the system delivering reliably
 Balancing measures – what’s happening in other
  areas as we improve outcomes

                                                  Slide 33
Tally sheets

 A simple instrument that allows one to quickly
  record (―tally up‖) retrospective or prospective
 Can be a simple log sheet that records
  information for events as they occur

                                                 Slide 34
The Sequence for Improvement

                             Make part     Spread a change to
                             of routine    other locations
                             operations                  to here!

              Test under     Implement a
              a variety of   change
                                             Act     Plan
              Test a
 Theory &     change
 Prediction                                 Study     Do
 Develop a
                       Don’t go from
 change                here …

                                                                Slide 35
Plan, Do, Study, Act

  Think big. Test small.
  Survey the team on how the change is
  Understand controlled failure is OK—it’s a
   chance for the team to learn.
  Debrief the failure so it is a learning
   experience, not a humiliation. (Ask, ―What
   did we learn? How could we have done this
   differently? What will we do now?‖)
  Celebrate success early and often!
                                                Slide 36
KP Performance Improvement
What are we trying to accomplish?
How will we know change is an improvement?
What change can we make that will result in improvement?

                     Develop /                        Implement /
    Assess                               Test
                  Identify Change                       Control

  • Process Map    • Standardize &                     • Training
  • Baseline                                           • Policy &
    Data           • Reduce Waste                        Procedures
                   • Apply evidence                    • Spread Plan
                     based practice

                                                                    Slide 37

   Leadership Support
   System wide metrics
   Provider Level Feedback
   Unit Level Reports
   Monthly updates at every dept meeting by dept
    member not quality department

                                                    Slide 38
Build Culture and Capability

                                   Principles                     What we “do”
                              •   Define organizational needs •   Align with strategy
                              •   Create system view          •   ID drivers and portfolios

                                                                                                Learning and improvement
                              •   Plan/ manage improvement •      Build capability to improve
           Reduce variation

                                                 Learning system
Top down

                                                                                                        Bottom up
                              •   Economic and social      •   Engaging the hearts and
                                  context for change           minds of the front line
                              •   Models of workplace      •   Creating ―line of sight‖
                                  learning                     to strategic goals
                              •   Team performance         •   Define high performing
                                                               unit-based teams
                                                                                                              Slide 39
How we develop Improvement skills
                                   Curricula & Learning Objectives

                      –   Understand evidenced based strategies for performance improvement

                                                                                                                              National Training
   Performance        –   Develop their operating strategy for the prototype process
   Improvement        –   Understand leadership sponsor and champion roles
  Executive Days      –   Understand drivers of performance locally
                      –   Gain a depth of knowledge with performance improvement methodology
   Improvement        –   Understand tools to apply and lead performance improvement projects
     Institute        –   Understand how to determine systems and drivers of performance

                      –   Receive exposure to PI concepts, the KP approach to PI and available resources, roles and
Operational Leaders       responsibilities, PI tools

                                                                                                                           Local Training
    Workshop          –   Obtain the knowledge to drive improvement and manage information in driving decision making
                          and the organizational culture necessary to drive world class improvement

                      –   Understand the KP approach to PI and leader’s role in execution
                      –   Understand the role of champions in improvement efforts
    Champion          –   Describe Performance Improvement timeline and process
    Workshop          –   Describe their role in the implementation of the performance improvement work
                      –   Define the difference between measurement for improvement and measurement for

                      –   Understand the approach to address their unit’s performance improvement project.
  Front-Line Staff    –   Develop and make robust tests of change for their performance improvement project
     RIM plus         –   Measure improvement using run charts
                      –   Use simple tools to standardize and simplify work areas and work flows
                                                                                                                Slide 40
KP-SCAL “Healthy Bones”

  In 2002, pre-HBMOC there were 1,743 hip
   fractures and 6,553 other fragility fractures in
   our target population.

  In 2008, KPSCR had 548,840 men and women
   members aged 60 and over with an estimated
   2,592 expected hip fractures.
                                                  Slide 41
Process Mapping

               ED                 FX Clinic
 FX                     Xray                               HH, SNF, Home, OT,PT
               UC                 Cast RM
                                                            Ortho, Endo, Rheum



       ID                                          TX w/           CONTINUE
      FX Pts                                       MEDS             MEDS/TX

               *Dual Energy X-ray Absorptiometry
                                                                              Slide 42

    Reduce the hip fracture rate by 25-50%.
    Increase the number of DXA scans in patients at
     risk for fragility fractures.
    Increase number of patients on anti-osteoporosis
     treatment who are at risk for fragility fractures.
           Standardize treatment of osteoporosis.
    Improve cost effectiveness.

                                                      Slide 43
Healthy Bones Model of Care

             Regional and Local Program Administration/Sponsorship
              Tracking and follow-up of fracture and at- risk patients

               OUTREACH                                       INREACH
    Region and Medical Centers target              DXA ordered by specialties and
  members who need a screening or post-         subspecialties using KPHC alerts and
      fracture DXA and/or treatment                the Proactive Office Encounter

                                    Order DXA
                             - Fracture patients ≥ 50
                                    - Men ≥ 70
                                  - Women ≥ 65

                             Healthy Bones Care Manager                           Slide 44
Key Program Components

   Physician and Administrative Champions at
    regional and local level AND a regional inter-
    disciplinary Healthy Bones Committee.
   Healthy Bones Care Manager with primary
    responsibility for providing ―Just In Time‖
    osteoporosis evaluation and treatment.
   Performance reporting and evaluation.

                                                 Slide 45
Key Program Components

     Healthy Bones database that identifies
      and stratifies members at risk for
      osteoporosis and/or hip fractures.
     Access to DXA – see demand calculator
      on http://ortho/vohs/
     Outreach/in-reach system.

                                           Slide 46
Healthy Bones Leadership

      Physician and Administrative Lead
      Regional/Local Committee comprised of
       representatives from:

       Ortho / Endo / Rheum, Pharmacy, Member
       Education, Physician Education, Preventive
       Health, Radiology, Primary Care ( FM /IM/
       PEDS), Women’s Health, Quality &
       Measurement, KPHC/Info Systems, Clinical
                                                    Slide 47
Healthy Bones Leadership

    Role of Committee:
    Establish regional policy, garner regional sponsorship,
     develop a model of care and build evidence, support
     tools and metrics.

                                                        Slide 48
     Process Reporting & Monitoring
     Sample Report
            Risk Group by 03/31/09       Region   ANT   BF     BP FON KRN LA             OC   PC   RV   SB   SD   WH WLA
Hip Fx Pts Need Rx                         2870 101      132    113    274    110    236 287 236 248 116 672 239 106
Osteoporosis Pts need Rx1                 23676 678     1508   1282   2787    842   1868 1870 1609 1656 1363 4372 2861 980
Fx Pts Needs Current DXA and/or Rx        13898 113      936    456   1976    273   1298 1814 675 1032 919 3250 487 669
Total                                     40444 892     2576   1851   5037   1225   3402 3971 2520 2936 2398 8294 3587 1755
                                          40444 #REF!
NON-COMPLIANCE Pts. by 03/31/09
   With Fx (pre/post Rx)                  13134 293 1045 970 1470 375 1075 1288 719 936 798 2042 1321 802
   Without Fx (pre/post Rx)               26634 541 2418 2247 2379 727 2522 2855 1528 2025 1863 3279 2544 1706
   Total                                  39768 834 3463 3217 3849 1102 3597 4143 2247 2961 2661 5321 3865 2508
                                          39768 #REF!
NEED DXA SCREENING Pts by 03/31/09
    Female 65+                            44310    480 3262 1681 5724 797 4167 4290 2107 3195 2984 8004 3632 3987
    Male 70+                              42316    319 3259 1673 4919 790 4331 5225 2032 2801 2637 6614 4055 3661
    Total                                 86626    799 6521 3354 10643 1587 8498 9515 4139 5996 5621 14618 7687 7648
                                                                                                                   Slide 49
Results - Process

    Between 2003-2007, increased HEDIS
     measurement of osteoporosis management in
     women (aged 67 and over) from 46% to 62%,
     becoming first in the nation for Health Plan
     performance and performing significantly
     above the national average each year.

    Between 2003-2008, increased percent of
     women, aged 65+ receiving DXA scans from
     20% to 67%. Increased percent of men aged
     70+ receiving DXA scans from 3% to 58%. Slide 50
Results - Outcomes

    In 2008, reduced expected hip fractures rate
     by 41%, equivalent to 1069 prevented
     fractures, with an estimated cost savings of
     $39.5 million and an estimated 257 lives
    In 2010, the potential savings from reduced
     hip fractures (based on the same
     performance in 2007) is estimated at $61.8
     million and an estimated 401 lives saved.
                                               Slide 51
The greatest decrease in hip fracture
rate occurred among members over
                    Decrease in Observed vs. Expected Fractures 2008

 Fracture rate

                                                                          Expect hip fx
                                                                          Obs hip fx
                        Over 85   80-84   75-79   70-74   65-69   60-64
                                                                                Slide 52
Case Study: Readmission Reduction in CHF
                                                                                                                  Where?    South Bay, KP-SCAL w/CMI
Goal: Reduce all cause 30-day
                                                                                                                  How?      •Coordinated concurrent medication
Heart Failure readmissions from                                                                                             reconciliation by Home Health RN,
15.7% to 10% by 4/1/08                                                                                                      PharmD, and Patient in the patients
                                                                                                                            •Improved identification of Heart
                                                                                                                            Failure patients in the Hospital
                                                                                                                            •Increased reliability of Home Health
       30 Day readmission rates-HF                                                                                          visit within 48 hours
                       reason                  •Kick Off Mtg
                                                                                                                            •Increased reliability of Out-patient
                (12 month roll up) •PDSAs Started:                                                                          Heart Failure Clinic follow up in one
                                         RIM    1. Concurrent
   SBAY 30 day HF readmission rates declining!                                     Pre-work       Med Rev                   week
                                                  Pre Work   PDSA cycles           started     2. Pt ID/HH ref.             •Implemented readmission diagnostic
      % pts. Readmitted for HF in 30 days

                                                   Started     started
                                                                                                                            tool to identify system gaps

                                                                                                                  Results   •Reduced 30-day re-hospitalization
                                                                                                                            rate to 9% (and 90 day readmission
                                                                                                 BEST in
                                            3.0                                                  Region!                    to 20%).
                                            1.0                   Pharmacist                                                •Improved the reliability of the
               TCP Pilot Sept Oct                             Nov Role Jan
                                                                    Dec          Feb Mar April
                                                                                  Gap      Design
                                                                                                                            Transitions Care Program
               Started                                            restructured
                                                             SCAL Regional on     Analysis
                                                                                 SouthBay  Wkshop                           component bundle measures from
                                                                  To focus
                                                                                  Complete Pt. ID
                                                                                                                            •Hard and soft $ value estimated at
                                                                                                                                                          Slide 53
             Case Study: On Time Clinic Start
                   Goal: Increase on-time start of appointments
                   from by on-time rooming of first appointment of
                   the day from 38% to 80%.                               Where?    Woodlawn Medical Center, KP-MAS

                                                                          How?      •Adjusted AM/PM staffing model
                                                                                    •Simplify duties for check-in and
                             KPMAS On-Time Starts Initiative                        waiting room management.
                              1st Appointments of the Day                           •Patients brought directly to exam
% Roomed On Time

                                                                          Results   • Initial evaluation- 82% success
                                 80.0%                                              rate of seeing 1st appointment on
                                 60.0%                                              time*
                                 40.0%                                              •Care sent out to contracted Urgent
                                                                                    Care facility during daytime hours
                                                                                    decreased from 83 patients in
                                   0.0%                                             March to 0 patients in November
                                            Feb '08   Aug '08   Feb '09
                                                                                    •Overtime decreased from 42.7 to
                      Goal: % Roomed        80.0%     80.0%     80.0%               7.5 hours (March to November)
                      on Time
                                                                                    •Initial hard dollar cost reductions
                      % Roomed on           38.46%    46.63%    53.21%              $130,000
                      Time                                                          •Additional soft savings and cost of
                      % of Pts checked in   67.46%    73.84%    80.65%              poor quality reductions Slide 54
                      on time / roomed
                      on time
Slide 55

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