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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• 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.