Fostering Transformational Change in an Integrated System: The Case of HIV Testing Steven M. Asch MD MPH VA GLAHS/UCLA/RAND
 
Examples of Broad Systemic Reforms for Quality
In the Early 1990s, a Prominent Health Care Provider Was at a Crossroads <ul><li>Its failings were widely publicized in th...
But Within 10 Years, Its Quality  Greatly Improved <ul><li>The organization’s quality of care was found “significantly bet...
The VA Implemented Important Reforms <ul><li>Expansion of primary care </li></ul><ul><li>Researcher-administrator partners...
The VA Implemented Important Reforms <ul><li>Performance tracking of key indicators especially chronic and preventive care...
2.3 2.9 Chronic conditions per patient 12 cities 26 facilities Sites 59 992 Random sample National 62 597 Administrative d...
Overall, VA Patients Were More Likely to Receive Recommended Care VA National Sample Asch Annals Int  Med 2004
National Sample Adjusted Overall Quality by Income (52-54) (54-56) (56-58)
The VA Scored Higher  Across the Spectrum of Health Care Diagnosis Follow-Up Screening Treatment
The VA Outpaced the National Sample  on Chronic and Preventive Care
The VA Scored Higher on Care that It Measured VA-Targeted Performance Measures Measures Unrelated to VA Targets
VA Also Scored Higher in Areas Related to Measured Processes   VA-Targeted Performance Measures Measures Unrelated to VA T...
Performance Measurement  Chain Reaction Influenza Vaccination Pneumonia Vaccination Tetanus Vaccination Checking Hearing T...
Lessons from Integrated VA Model <ul><li>Health information technology is important and easier for integrated systems, but...
HIV/Hepatitis QUERI <ul><li>VA as a QI laboratory </li></ul><ul><li>Teams HSR researchers and national QI managers </li></...
We Had to Make a Case to VA Managers <ul><li>HIV easier/cheaper to treat if detected early (~<$25,000/QALY) </li></ul><ul>...
They Asked Us a Question <ul><li>“ You’ve given us a strong rationale for long-term benefits of earlier identification, bu...
Business Case Modeling <ul><li>Data-driven models for making managerial or technical decisions  </li></ul><ul><li>Valuable...
Excerpt of Modeling Process
Quarter on Quarter Increases in Overall Costs Increasing HIV screening rates from…
Barriers to HIV Testing <ul><li>Organizational </li></ul><ul><ul><li>Cumbersome written informed consent & pre-test counse...
System Redesign <ul><ul><li>Streamlined counseling  </li></ul></ul><ul><ul><li>Telephonic notification of negative tests  ...
 
Provider Activation <ul><ul><li>Leverage group dynamics </li></ul></ul><ul><ul><li>Academic detailing </li></ul></ul><ul><...
Implementation and Evaluation Plan <ul><li>Prospective, controlled quasi-experimental implementation in southern CA and NV...
HIV Testing & Evaluation Rates One Year Post Intervention Site A Site B Site C Site D Site E Primary care clinics
Conclusion <ul><li>Integrated systems have many of the elements for transformational change. </li></ul><ul><li>Integrated ...
 
Upcoming SlideShare
Loading in …5
×

Steven Asch Fostering Transformational Change In An Integrated System

956 views

Published on

Fostering Transformational Change in an Integrated System: The Case of HIV Testing

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
956
On SlideShare
0
From Embeds
0
Number of Embeds
30
Actions
Shares
0
Downloads
13
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Transformational change, the topic of our conference these few days, is one of those topics that kind of scares you when you are invited to talk about it. You feel like your talk itself has to be transformational, and that is quite a hill to climb especially in present company. I’ll never live up to that but I will do my best, first by talking about what I see as the roots of such change, why I think such change is easier health systems that have integrated their financing and various aspects of delivery. Then I will give you an example that seems to have worked from my own integrated health care system.
  • Steven Asch Fostering Transformational Change In An Integrated System

    1. 1. Fostering Transformational Change in an Integrated System: The Case of HIV Testing Steven M. Asch MD MPH VA GLAHS/UCLA/RAND
    2. 3. Examples of Broad Systemic Reforms for Quality
    3. 4. In the Early 1990s, a Prominent Health Care Provider Was at a Crossroads <ul><li>Its failings were widely publicized in the news media and popular movies </li></ul><ul><li>Studies showed serious access, quality and satisfaction problems </li></ul><ul><li>Some argued that this health organization needed new management </li></ul>
    4. 5. But Within 10 Years, Its Quality Greatly Improved <ul><li>The organization’s quality of care was found “significantly better” than that of Medicare on 11 out of 12 measures (Jha 2003) </li></ul><ul><li>It provided better care than commercial insurers to diabetes patients on 7 out of 7 measures (Kerr 2004) </li></ul>
    5. 6. The VA Implemented Important Reforms <ul><li>Expansion of primary care </li></ul><ul><li>Researcher-administrator partnership </li></ul><ul><li>Electronic medical records system </li></ul><ul><ul><li>Tracks patients </li></ul></ul><ul><ul><li>Alerts clinicians of needed care </li></ul></ul>
    6. 7. The VA Implemented Important Reforms <ul><li>Performance tracking of key indicators especially chronic and preventive care </li></ul><ul><li>Managers held accountable </li></ul><ul><li>Able to allocate resources across integrated system </li></ul><ul><li>Big investment </li></ul>
    7. 8. 2.3 2.9 Chronic conditions per patient 12 cities 26 facilities Sites 59 992 Random sample National 62 597 Administrative data VA Age Number of patients Source
    8. 9. Overall, VA Patients Were More Likely to Receive Recommended Care VA National Sample Asch Annals Int Med 2004
    9. 10. National Sample Adjusted Overall Quality by Income (52-54) (54-56) (56-58)
    10. 11. The VA Scored Higher Across the Spectrum of Health Care Diagnosis Follow-Up Screening Treatment
    11. 12. The VA Outpaced the National Sample on Chronic and Preventive Care
    12. 13. The VA Scored Higher on Care that It Measured VA-Targeted Performance Measures Measures Unrelated to VA Targets
    13. 14. VA Also Scored Higher in Areas Related to Measured Processes VA-Targeted Performance Measures Measures Unrelated to VA Targets Related Performance Measures
    14. 15. Performance Measurement Chain Reaction Influenza Vaccination Pneumonia Vaccination Tetanus Vaccination Checking Hearing Targeted Process Related Processes
    15. 16. Lessons from Integrated VA Model <ul><li>Health information technology is important and easier for integrated systems, but it’s not enough </li></ul><ul><li>Performance measurement, QI, and accountability are also critical </li></ul><ul><li>Integration of service delivery and financing allows for strategic resource allocation </li></ul><ul><li>Organizational determinants of quality are just as important as individual determinants </li></ul>
    16. 17. HIV/Hepatitis QUERI <ul><li>VA as a QI laboratory </li></ul><ul><li>Teams HSR researchers and national QI managers </li></ul><ul><li>Translation project to improve HIV testing rates merged several streams of organizational change: </li></ul><ul><ul><li>Systemic redesign </li></ul></ul><ul><ul><li>Clinical reminders </li></ul></ul><ul><ul><li>Provider activation </li></ul></ul>
    17. 18. We Had to Make a Case to VA Managers <ul><li>HIV easier/cheaper to treat if detected early (~<$25,000/QALY) </li></ul><ul><li>VA has high prevalence of HIV (~2%) </li></ul><ul><li>VA performance falls short (~20%) </li></ul><ul><li>Therefore we should improve screening and testing rates </li></ul>
    18. 19. They Asked Us a Question <ul><li>“ You’ve given us a strong rationale for long-term benefits of earlier identification, but what is the short term impact of increasing screening and an acute influx of HIV patients on the system?” </li></ul><ul><li>or </li></ul><ul><li>“ Where is it coming out of my budget when?” </li></ul>
    19. 20. Business Case Modeling <ul><li>Data-driven models for making managerial or technical decisions </li></ul><ul><li>Valuable tool for program managers although underused in public sector </li></ul>
    20. 21. Excerpt of Modeling Process
    21. 22. Quarter on Quarter Increases in Overall Costs Increasing HIV screening rates from…
    22. 23. Barriers to HIV Testing <ul><li>Organizational </li></ul><ul><ul><li>Cumbersome written informed consent & pre-test counseling </li></ul></ul><ul><ul><li>Provider time constraints, especially post-test </li></ul></ul><ul><li>Provider behaviors </li></ul><ul><ul><li>Incomplete recognition of HIV risk factors </li></ul></ul><ul><ul><li>Belief that only trained counselors can do HIV counseling </li></ul></ul>
    23. 24. System Redesign <ul><ul><li>Streamlined counseling </li></ul></ul><ul><ul><li>Telephonic notification of negative tests </li></ul></ul><ul><ul><li>Removed restrictions on who could order tests </li></ul></ul><ul><ul><li>Audit-feedback: clinic level progress reports </li></ul></ul>
    24. 26. Provider Activation <ul><ul><li>Leverage group dynamics </li></ul></ul><ul><ul><li>Academic detailing </li></ul></ul><ul><ul><li>Social marketing </li></ul></ul><ul><ul><li>Opinion leaders </li></ul></ul>
    25. 27. Implementation and Evaluation Plan <ul><li>Prospective, controlled quasi-experimental implementation in southern CA and NV </li></ul><ul><li>Primary endpoints </li></ul><ul><ul><li>Rate of evaluation for HIV </li></ul></ul><ul><ul><li>Rate of HIV testing in at-risk patients </li></ul></ul>
    26. 28. HIV Testing & Evaluation Rates One Year Post Intervention Site A Site B Site C Site D Site E Primary care clinics
    27. 29. Conclusion <ul><li>Integrated systems have many of the elements for transformational change. </li></ul><ul><li>Integrated systems can serve as a laboratory for more focused QI programs </li></ul><ul><li>How these elements can be transferred to more distributed systemd remains an area for future research. </li></ul>

    ×