Ncd2014 kottke ncd_prev_serv2014_03_11


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Ncd2014 kottke ncd_prev_serv2014_03_11

  1. 1. 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
  2. 2. 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
  3. 3. The Doctor’s Lament
  4. 4. “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
  5. 5. What is “time”? “Time” is priority Who sets the clinicians’ priorities? Patients, purchasers, colleagues
  6. 6. Mayo Clin Proc 1993;68(8):785-791
  7. 7. 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.
  8. 8. 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
  9. 9. 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
  10. 10. 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.
  11. 11. 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.
  12. 12.
  13. 13. Minnesota Community Measurement
  14. 14. 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.
  15. 15. Bored Overloaded Clinical Practice Time
  16. 16. “Trying to improve my practice causes all hell to break loose!!” We conclude? And we become passive
  17. 17. 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.
  18. 18. The Internist’s Game
  19. 19. Preventive Services
  20. 20. 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.
  21. 21. 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
  22. 22. 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.
  23. 23. 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
  24. 24. Multiple viewpoints about how to succeed suggests a systems problem
  25. 25. IOM. Crossing the Quality Chasm 2001 The underlying principle: Appreciating the behavior of complex adaptive systems
  26. 26. Simple Rules Explain Complex Systems
  27. 27. 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
  28. 28. “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)
  29. 29. Continuous Quality Improvement Hypothesize Correct intervention Did it work? Yes No Test hypothesis Periodically retest system functioning
  30. 30. “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”
  31. 31. Wishful thinking about leadership You
  32. 32. Wishful thinking about leadership You
  33. 33. 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
  34. 34. If you always do what you’ve always done, you will always get what you’ve already got.
  35. 35. Other’s Models
  36. 36. Solberg, LI: Ann Fam Med 2007
  37. 37. HealthTexas Provider Network Initiative Ballard DJ. Am J Prev Med 2007
  38. 38. 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
  39. 39. 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
  40. 40. To be effective, you need a model that you understand and helps you learn from experience.
  41. 41. Effective clinic organization MD RN LPN pt MD MD MD LPN LPN pt pt pt pt pt pt pt pt
  42. 42. 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)
  43. 43. • 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
  44. 44. Kiitos! . . . think different . . . act differently . . . optimize health
  45. 45. 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.
  46. 46. 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