Quality Improvement: Lessons for Workers Compensation Quality of Care Linda Rudolph, MD, MPH Medi-Cal Managed Care Division CA Department of Health Services May 1, 2003

What Do We Want? Quality The degree to which health services for individuals and populations increase the likelihood of desired patient outcomes given the current state of knowledge IOM, 1990 The extent to which health services meet their aim – improving health.

What Do We Want? ( DWC Focus Groups) accessible competent state of the art caring trusting patient-oriented patient-selected reasonably priced coordinated continuous DWC, Improving the QOC for Injured Workers, 2001

What Do We Want? (Institute of Medicine) Safe Effective Efficient Timely Patient Centered Equitable IOM, Crossing the Quality Chasm, 2001

What Do We Have?

Distrust Poor access to specialists Delays in care Fragmentation and lack of continuity Care not patient-centered Inefficient and ineffective care No accountability Improving the Quality of Care for Injured Workers: Focus Group Discussions. DWC. 2001

Every system is perfectly designed to produce the results that it does achieve. (Berwick/Batalden)

What can we do? Accountability Improvement

Accountability Policies and contracts Monitoring Measurement Reporting

You cant fatten a calf by weighing it…. Palestinian proverb

Improvement A systematic program for taking a system from one level of performance to a higher level of performance

Low Back Pain ¼ w.c. claims 1/3 w.c. costs

What Do We Have? Care highly variable Care inconsistent with guidelines Patient outcomes poor

Theory of Change Will Ideas Execution/supporting change

Low Back Pain = Chronic Illness

Care Model for Worker Health (adapted from IHI/Dr. Ed Wagoner)

Resources and Policies Resources to support injured workers and providers are easily accessible Insurers, State agencies, employers, and health care providers: – coordinate and partner with each other around worker and injured worker needs –promote and offer evidence-based effective interventions and programs System incentives are aligned for policy (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Health and W.C. System Specific goals for prevention and care management are part of the strategic and business plan. Senior leadership is committed to meeting the needs of injured workers.Encourage coordination among primary care and occupational medicine care System has adopted an effective performance improvement model. Incentives support these organizational goals. (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Self-Management Support Emphasize workers active and central role in managing illness Resources available to increase patient knowledge, confidence, and skills Workers assisted in setting shared goals Workers have access to peer support Workers assisted in improving communication with providers about health care. (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Decision Support Evidence-based guidelines and protocols integrated into practice systems Integrated expertise (occ med, specialists, mental health,w.c., workplace) Care team works to maximize cooperation, continuity, and patient outcomes Use of modalities proven to change practice behavior (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Delivery System Design Practice anticipates problems, provides services to maintain QOL and function Roles/responsibilities of team members defined, appropriate training provided Systems designed for regular communication and f/u (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Clinical Information System Registry of patients in need of services maintained Reminder system used for patients and care team Information system provides regular feedback to care team System allows for care planning (adapted from Institute for Healthcare Improvements Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Model for Improvement

Aims Reduce plain x-rays Reduce opiate prescriptions Increase patient self-management education Increase availability of modified work

From Aim to Improvement Define measures (process, outcome) Barrier analysis Identify available interventions Identify target population Outreach Implement interventions: Did it work? Start again!

Quality Improvement Collaboratives Medi-Care Medi-Cal Pursuing Perfection/Rewarding Results CPCA (HRSA) DHS CCHRI