Ncd2014 kottke ncd_prev_serv2014_03_11
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How to Strengthen Integrated Prevention in Health Services Thomas E. Kottke, MD, MSPH Medical Director for Population Health, Consulting Cardiologist, and Senior Clinical Investigator HealthPartners Professor of Medicine, University of Minnesota Minneapolis, Minnesota USA [email protected] 11 March 2014 Helsinki, FINLAND
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Transcript of Ncd2014 kottke ncd_prev_serv2014_03_11
How to Strengthen Integrated
Prevention in
Health Services Thomas E. Kottke, MD, MSPH
Medical Director for Population Health,
Consulting Cardiologist, and
Senior Clinical Investigator
HealthPartners
Professor of Medicine, University of Minnesota
Minneapolis, Minnesota USA
11 March 2014
Helsinki, FINLAND
Objectives of the presentation
By the end of the presentation, the participant will be able to
• Describe 5 reasons why preventive services
are difficult to deliver in clinical practice
• Describe 5 components that appear to be
necessary if preventive services are to be
delivered in the clinical setting
The Doctor’s Lament
“In studying a philosopher, the right
attitude is neither reverence nor
contempt, but first a kind of hypothetical
sympathy, until it is possible to know
what it feels like to believe in his
theories”
Bertrand Russell, A History of Western Philosophy
New York: Simon and Schuster, 1945, p 39
What is “time”?
“Time” is priority
Who sets the clinicians’ priorities?
Patients, purchasers, colleagues
Mayo Clin Proc 1993;68(8):785-791
Observation 1: Although the ability of physicians to
make apparently arbitrary decisions gives
them the appearance of independence, the
health care system limits their flexibility of
behavior.
Implication: While physician inaction may indicate a
lack of interest, social forces in the health
services system can prevent a physician
from acting on his or her intentions.
Eliot Freidson:
Occupational organization . . .
constitutes a dimension quite as
distinct and fully as important as its
knowledge.”
Profession of Medicine: A Study of the Sociology of
Applied Knowledge, 1970, introduction
You suggest the physician adopt an
intervention known to benefit the patient. . .
. . . but the physician does not act
Ask, “What is wrong
with this doctor?”
Ask, “How can we create
a system that makes the
right thing the easiest
thing to do?”
Follow Freidson’s advice
Observation 2: Issues of public health do not
compel action in the clinical setting.
Implication: Whenever possible, the benefit of clinical
preventive services should be described in
terms of benefit to patients or populations
for which the physician acknowledges
professional responsibility.
Observation 3: The health care system gives priority
to the urgent over the severe.
Implication: Unless preventive services are formally
given appropriate priority, treatment of
acute conditions, no matter how trivial, will
continue to displace them.
www.healthpartners.com/files/34613.pdf
Minnesota Community Measurement
Observation 4: Time constraints and patient
demand encourage the physician in the
clinical setting to be a respondent, not an
initiator.
Implication: Physicians need reminders to offer
preventive services, ideally both from
patients who ask for the services and from
system-initiated prompts on the patient
record.
Bored
Overloaded
Clinical Practice
Time
“Trying to improve my practice causes
all hell to break loose!!”
We conclude?
And we become passive
Observation 5: Preventive services do not fit well
with physicians’ images of their work or
themselves.
Implication: Because the characteristics of preventive
services and the work that physicians
consider ideal diverge so widely, it may be
necessary to delegate much of the
provision of preventive services to non-
physicians or to special teams of
physicians who enjoy these tasks.
The Internist’s Game
Preventive Services
Observation 6: The feedback naturally generated
from prescribing preventive services is
primarily negative feedback.
Implication: Preventive services systems will need to
provide clinicians with feedback about the
positive effects of the preventive services
that they are expected to deliver.
Relative Effects of Treatment on Survival with Myocardial
Infarction1 and Cessation with Smoking2
0
10
20
30
40
50
60
70
80
90
100
1Estimated from Gillum et al, 1983 2 Wilson et al., 1982
Myocardial infarction Untreated smoking Treated smoking
1970 1980
men
men
women
women
Success is the rule Failure is the rule
D=4 D=7
Observation 7: The clinician cannot provide
preventive services without adequate
resources.
Implication: Adequate resources, both fiscal and
organizational, must be allocated if
preventive services are to be delivered.
People will not adopt innovations even
though they are favorably disposed
towards them if they lack the money, the
skills, or the accessory resources that may
be needed.
Albert Bandura. Social Learning Theory. 1977
Multiple viewpoints about how to succeed
suggests a systems problem
IOM. Crossing the Quality Chasm 2001
The underlying principle:
Appreciating the behavior of
complex adaptive systems
Simple Rules Explain
Complex Systems
The Attributes of a Value-Driven Health Care
System
• Measurable, agreed-upon goals
• Public reporting of performance related to goals
• Resources to achieve the goals
• Alignment of stakeholder imperatives with achieving the
goals
• Continuous leadership
Kottke TE, Pronk NP, Isham GJ. The simple health system rules that create value.
Prev Chronic Dis 2012;9:110179
“Good judgment comes
from experience which
comes from poor
judgment.”
LaSalle D. Leffall, Jr., M.D.
Professor and Chairman
Department of Surgery
Howard University Hospital
(That’s why we have continuous quality improvement)
Continuous Quality Improvement
Hypothesize
Correct intervention
Did it
work?
Yes No
Test
hypothesis
Periodically
retest system
functioning
“Life before continuous
improvement”
“Well, there it goes again . . . and we just sit
here without opposable thumbs.”
Clinics now know how to “pick up the phone”
Wishful thinking about leadership
You
Wishful thinking about leadership
You
Leadership
“. . . Energizing [people] to
action.” (page 44)
“. . . Is biographical.”
“Leaders engender leadership
traits in others. They teach others
to be leaders.” (page 42)
New York: Harper Business, 1997
If you always do
what you’ve always done,
you will always get
what you’ve already got.
Other’s Models
Solberg, LI: Ann Fam Med 2007
HealthTexas Provider Network Initiative
Ballard DJ. Am J Prev Med 2007
HealthTexas Provider Network Initiative
1. Adult Clinical Preventive Services Medical Record Form**
2. Feedback of audit results to individual physicians**
3. Training of physician-to-physician academic detailers to share results and discuss best practice
4. Testing a team-based approach to improvement, followed by promotion of this strategy in the network Quality Improvement committee and to poortly performing clinics and physicians**
5. Unblinding of individual physician clinical preventive services performance**
6. Publishing a series of preventive service articles in internal group newsletters
Ballard DJ. Am J Prev Med 2007
HealthTexas Provider Network Initiative
7. Recognition of high achievers in clinical preventive services delivery
8. Discussions regarding linking physician performance to financial incentives**
9. Training physicians on rapid-cycle continuous quality improvement strategies
10. Providing “physician champions” with compensated time to develop and disseminate individual process improvement projects
11. Funding a network-wide ambulatory care improvement champion to focus on disseminating best practices across HealthTexas Provider Network.**
Ballard DJ. Am J Prev Med 2007
To be effective, you need a model that you
understand and helps you learn from experience.
Effective clinic organization
MD
RN
LPN
pt
MD
MD
MD
LPN
LPN
pt
pt
pt
pt
pt
pt
pt
pt
Conclusions - I
• Evidence-based guidelines are acceptable to clinicians (and help us agree upon which services to deliver)
• Clinicians believe that preventive services have value (so telling them about the importance of preventive services can not be expected to change behavior)
• Clinicians do not sense a need to provide more preventive services (but will deliver more services if stimulated to do so).
• Cooperation among health plans appears necessary for preventive services delivery (clinicians will do nothing in the presence of conflict)
• The “logjam” model is not applicable to preventive
services. Preventive services requires the input of
energy.
• Clinicians like using an iterative data-driven change
process to address problems that they face in their
clinics. However, skill in using the process is not
sufficient to raise preventive services rates.
• Leadership/agenda-setting is necessary to increase
preventive services delivery rates.
• If any stakeholder (patient, clinician, health system,
purchaser) breaks the chain of responsibility, services
will not be delivered.
• With systems and leadership, preventive services
delivery rates can exceed 90%!
Conclusions - II
Kiitos!
. . . think different . . . act differently
. . . optimize health
Suggested Readings
• Kottke TE, Pronk NP, Isham GJ. The simple health system rules that create value. Prev
Chronic Dis 2012;9:110179.
• Kottke TE, Blackburn H, Brekke ML, Solberg LI. The systematic practice of preventive
cardiology. Am J Cardiol 1987;59(6):690-694
• Kottke TE, Brekke ML, Solberg LI. Making "time" for preventive services. Mayo Clin
Proc 1993;68(8):785-791
• Plsek P. Redesigning Health Care with Insights from the Science of Complex Adaptive
Systems. In: Committee on Quality of Health Care in America, ed. Crossing the Quality
Chasm. Washington, DC: National Academy Press; 2001:309-22.
• Chaudhry R, Kottke TE, Naessens JM, Johnson TJ, Nyman MA, Cornelius LA, Petersen
JD. Busy physicians and adult preventive services. Mayo Clinic Proceedings 2000;
75:156-162.
• Tichy NM. The Leadership Engine. New York:Harperbusiness, 1997.
• Kottke, T.E. and Solberg, L.I. Optimizing practice through research: a preventive
services case study. Am J Prev Med, 2007;33(6): 505-6.
• Ballard DJ, Nicewander DA, Qin H, Fullerton C, Winter FD, Jr., Couch CE. Improving
delivery of clinical preventive services a multi-year journey. Am J Prev Med. Dec
2007;33(6):492-497.
• Rogers EM. Diffusion of Innovations. 4th ed. New York. Free Press, 1995.
• Ostrom E. Governing the Commons: The Evolution of Institutions for Collective Action.
New York: Cambridge University Press; 1990.
How to Strengthen Integrated
Prevention in
Health Services Thomas E. Kottke, MD, MSPH
Medical Director for Population Health,
Consulting Cardiologist, and
Senior Clinical Investigator
HealthPartners
Professor of Medicine, University of Minnesota
Minneapolis, Minnesota USA
11 March 2014
Helsinki, FINLAND
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