1. Translating Evidence into Benefit for Patients The Impact of Clinical Leadership and Culture Sharon Levine, M.D. Kaiser Permanente, California November, 2003

2. 2 Kaiser Permanente An outsider model of care delivery from the beginning An outsider model of care delivery from the beginning Prepayment to a multi-specialty group practice: suspect from the beginning Prepayment to a multi-specialty group practice: suspect from the beginning Early ostracism: exclusion from participation in organized medicine (AMA, county medical societies) Early ostracism: exclusion from participation in organized medicine (AMA, county medical societies) Gradual acceptance after four decades Gradual acceptance after four decades In the last decade, acknowledgment and respect: ability to measure and demonstrate superior outcomes In the last decade, acknowledgment and respect: ability to measure and demonstrate superior outcomes

3. 3 Integrated delivery system Integrated delivery system Relationships Relationships - Contractual - Contractual - Partnership of equals - Partnership of equals - Mutually exclusive - Mutually exclusive - Shared fate Co-ownership: shared accountability for success of the whole Co-ownership: shared accountability for success of the whole Organizational structure and relationships essentially unchanged since 1955 Organizational structure and relationships essentially unchanged since 1955

4. 4 An Evidence-Based Approach to Effective and Efficient Care Delivery Science and Sociology Science: Identify the right thing (30%) Science: Identify the right thing (30%) Systematic reviews of the evidence Systematic reviews of the evidence Epidemologic research Epidemologic research Outcomes measurement and identification of successful practices Outcomes measurement and identification of successful practices Evidence-based, clinical practice guideline development Evidence-based, clinical practice guideline development Design and development of care management programs for selected clinical priorities (eg., asthma, diabetes) and populations (eg., frail elderly) Design and development of care management programs for selected clinical priorities (eg., asthma, diabetes) and populations (eg., frail elderly)

5. 5 Translating Evidence into Benefit The Science (30%) ResearchEvidenceImplementationBenefit Epidemiology Care Management Institute Clinical Research Drug Information Services Health Services Research

6. 6 ResearchEvidenceImplementation Benefit Translating Evidence into Benefit Sociology (70%) – – Integration – – Aligned Incentives – – Balanced Incentives Structure Culture Infrastructure – – Physician Leadership – – Culture of accountability, commitment, pride, performance – – Systems support: from paper to electronic – – Information and data – – Education

7. 7 Integration Along Multiple Dimensions Financing and Care Delivery: Single revenue stream, shared responsibility for allocation Financing and Care Delivery: Single revenue stream, shared responsibility for allocation Across the continuum of care (community, out- patient, in-patient, home care) and between primary care and specialty care Across the continuum of care (community, out- patient, in-patient, home care) and between primary care and specialty care Integration over time: Investment mind set, long time horizons Integration over time: Investment mind set, long time horizons Across the continuum of an illness or condition: primary and secondary prevention, diagnostic and therapeutic services, supportive care, palliative care Across the continuum of an illness or condition: primary and secondary prevention, diagnostic and therapeutic services, supportive care, palliative care

8. 8 Aligned Incentives Aligned Incentives Health Plan, Hospitals, Medical Group Health Plan, Hospitals, Medical Group Shared fate, mutual exclusivity Shared fate, mutual exclusivity Partnership of equals Partnership of equals Primary care and specialist physicians: Co-located practice; shared ownership of patients/clinical problems; facilitated referrals (e-Consult) Primary care and specialist physicians: Co-located practice; shared ownership of patients/clinical problems; facilitated referrals (e-Consult) Hospitalists providing inpatient care Hospitalists providing inpatient care Balanced Incentives Balanced Incentives No production incentives No production incentives No reward, incentive/personal benefit for under-utilization No reward, incentive/personal benefit for under-utilization Prepayment/capitation to the Medical Group; salary for physicians Prepayment/capitation to the Medical Group; salary for physicians Incentives based on quality outcomes and patient satisfaction Incentives based on quality outcomes and patient satisfaction

9. 9 Physician Leadership Physician Leadership Self-governed, self-managed Medical Group Self-governed, self-managed Medical Group Physicians manage all aspects of the business of the Medical Group Physicians manage all aspects of the business of the Medical Group Every Physician a Leader Every Physician a Leader – 25-30% of physicians with some management responsibility, administrative title – Explicit effort to recruit physicians with leadership potential, leadership traits Leaders role: actively manage the culture Leaders role: actively manage the culture Group Responsibility Group Responsibility Culture of shared accountability for quality and cost of health care Culture of shared accountability for quality and cost of health care Peer accountability: collaborative practice, common chart; transparency of performance data; Peer accountability: collaborative practice, common chart; transparency of performance data; Ownership of the problems and the solution Ownership of the problems and the solution Culture of commitment, not compliance Culture of commitment, not compliance

10. 10 Systems Support Systems Support Many pieces currently in place Many pieces currently in place e-Consult, e-Rx, e-Refill e-Consult, e-Rx, e-Refill CIPS (Clinical Information Presentation System) CIPS (Clinical Information Presentation System) Awaiting full implementation of electronic medical record (KP Health Connect) Awaiting full implementation of electronic medical record (KP Health Connect)

11. 11 Using Clinical Information Systems Preventive Health Prompt PILOT Patient Encounter data (OSCR) Disease registries Electronic Medical Record

12. 12 Substantial Investment in Career-Long Education and Professional Development Substantial Investment in Career-Long Education and Professional Development Continuing medical education Continuing medical education Clinician patient communication Clinician patient communication Management training Management training Leadership Development Leadership Development Systems training and support Systems training and support Training for collaborative practice/team-based care Training for collaborative practice/team-based care Education/information in lieu of regulation/prior authorization Education/information in lieu of regulation/prior authorization

13. 13 ResearchEvidenceImplementationBenefit Patient – – Better clinical outcomes – – Longer, more functional life – – Safer care System – – Increased efficiency – – Reputation – – Fewer errors, rework People – – Professional satisfaction – – Pride – – Reputation – – Commitment Translating Evidence into Benefit The Results

14. 14 FOCUS ON THE CRITICAL FEW

15. 15 CARDIOVASCULAR DISEASE: Leading cause of death in U.S. Leading cause of death in U.S. 10 Year effort to implement national guidelines for hyperlipedemia, CHF, ACS, cardiac rehabilitation, and reduce cardiovascular mortality 10 Year effort to implement national guidelines for hyperlipedemia, CHF, ACS, cardiac rehabilitation, and reduce cardiovascular mortality Multi-disciplinary steering group Multi-disciplinary steering group Physician champion for each guideline at each facility Physician champion for each guideline at each facility Low Tech: Preprinted orders for ER, hospital; algorithms for outpatient treatment Low Tech: Preprinted orders for ER, hospital; algorithms for outpatient treatment RN and Pharm D.-run cholesterol, cardiac rehabilitation and congestive heart failure programs RN and Pharm D.-run cholesterol, cardiac rehabilitation and congestive heart failure programs

16. 16 CARDIOVASCULAR DISEASE: High tech: CAD registry, CHF registry with intelligent software system for outreach and tracking High tech: CAD registry, CHF registry with intelligent software system for outreach and tracking CAD registry linked to registration system, with prompts at visit for cholesterol check; also to PILOT (patient integrated log, outreach and tracking) to generate outreach report with patients LDL, beta-blocker and aspirin use, provided quarterly to physicians CAD registry linked to registration system, with prompts at visit for cholesterol check; also to PILOT (patient integrated log, outreach and tracking) to generate outreach report with patients LDL, beta-blocker and aspirin use, provided quarterly to physicians

17. 17 RESULTS: PROCESS GOALS By 2000, 99% use of beta-blockers in post MI patients at discharge, 80% at 1 year, 77% at 2 years By 2000, 99% use of beta-blockers in post MI patients at discharge, 80% at 1 year, 77% at 2 years LDL control < 130 improved from 22% to 84% in post-MI patients (1996-2002) LDL control < 130 improved from 22% to 84% in post-MI patients (1996-2002) ASA at discharge for post-MI patients 93% ASA at discharge for post-MI patients 93% 72% of CHF registry patients on vasodilators 72% of CHF registry patients on vasodilators 64% of CHF patients on beta blockers 64% of CHF patients on beta blockers

18. 18 RESULTS: OUTCOME GOALS 15% decrease in death rate from CHF (1996-2001) 15% decrease in death rate from CHF (1996-2001) 25% decrease in CHF discharge rate (1998-2001) 25% decrease in CHF discharge rate (1998-2001) Age/sex/risk adjusted mortality rates for KFH hospitals declining 50-85% since 1993 Age/sex/risk adjusted mortality rates for KFH hospitals declining 50-85% since 1993 MI mortality rates up to 50% lower than similar hospitals across the state participating in National Registry of Myocardial Infarction (NRMI) MI mortality rates up to 50% lower than similar hospitals across the state participating in National Registry of Myocardial Infarction (NRMI) Heart disease mortality more than 30% lower in the KPNC population than in the non-KPNC population (after age and sex adjustment) Heart disease mortality more than 30% lower in the KPNC population than in the non-KPNC population (after age and sex adjustment)

19. The Healthy People 2010 goal for adult smoking prevalence is set at 12%. The Californias Tobacco Control Program in its 2003-2005 Master Plan, aims to reduce adult tobacco prevalence to 13% by 2005. The long-term California goal is to reduce adult tobacco prevalence to 10%. Source: Kaiser Permanente Division of Research - Preliminary Member Health Survey report prepared by Nancy P. Gordon, ScD, Division of Research 10/14/2003 Source: CDC-National Center for Chronic Disease Prevention & Health Promotion Behavioral Risk Factor Surveillance System 2002 19

20. 20 Science: Sufficient evidence; high quality Science: Sufficient evidence; high quality Sociology: Sociology: Clinical peer leadership Clinical peer leadership Passionate champions Passionate champions High engagement process High engagement process Decision support at the point of care across the continuum Decision support at the point of care across the continuum Increasingly sophisticated technology Increasingly sophisticated technology Practice support Practice support Unblinded sharing of performance data (healthy competition) Unblinded sharing of performance data (healthy competition) Patient education, engagement Patient education, engagement Perseverance Perseverance Translating Evidence into Benefit What Worked

21. 21 CONCLUSION A multi-modal, multi-specialty, clinician peer- expert-led implementation of national guidelines for cardiovascular disease management has led to a substantial decline in cardiovascular mortality A multi-modal, multi-specialty, clinician peer- expert-led implementation of national guidelines for cardiovascular disease management has led to a substantial decline in cardiovascular mortality On an absolute basis, compared to non-KPNC mortality On an absolute basis, compared to non-KPNC mortality On a relative basis, compared to cancer mortality On a relative basis, compared to cancer mortality

22. Results: Cardiovascular Mortality Relative to Cancer Mortality 22

23. 23 vsKPNCal hospitals. all other hospitals in counties with KP hospitals Source: OSHPD 0 5 10 15 20 25 8% 13% KPTHE REST = statistically sig. p<0.01 30-Day Mortality After Acute Heart Attack