Quality improvement –

Evaluation & Innovationat Kaiser Permanente’s Program Office

Jim Bellows, PhDDirector, Center for Evaluation & InnovationCarol Cain, PhDPrincipal Consultant, IncubationEstee Neuwirth, PhDSenior Manager, Evaluation & InnovationKP Care Management InstituteJune 23, 2009
Evaluation & Innovation

at Kaiser Permanente

Talk outline:

Our team: R&D at KP

Case study #1: Complex Chronic Conditio

Background on KP and informatics

Case study #2: Panel management

Case study #3: Transitions in Care
Knowledge Decision Support Transform ation Innovation 

Measurement

KP CMI’s Center for Evaluation and Innovation

CMI’s Mission and Principles

CMI works with its Regional partners to build a superior integrated 

care delivery system for KP members• Keeping patients at the center• Harnessing technology• Integrating capabilities across KP• Applying evidence• Measuring results• Spreading successful practices

CEI Mission

CMI’s Center for Evaluation and Innovation (CEI) supports performa

improvement across KP by providing performance metrics, identifyinfactors, evaluating impact, and supporting innovation
CMI Organizational Structure

Co-Executive Directors

Scott Young, M.D. and

Carolyn Mustille, RNP, MSN 

Center for Health Care Delivery and

Center for Health Care Analytics Center for Evaluation and Innovatio

Community Benefit Management & Administrative Support

Communications

Care Management Institute

Updated: MAY2009
CMI Portfolio

J Initiatives

• Palliative Care• Complete Care for Complex Conditions• Transitions in Care• Cardiovascular Disease

J Region-specific projectsJ Services

• Knowledge Services• Clinical Library• Network maintenance – Implementation, Analytic, etc

Our staff

J 12 FTEsJ By education

4 PhD7 Masters-level (2 ABD)

J By training

3 Health services research1 Sociology1 Biomedical informatics2 Statistics+ Public policy, public administration, business

J By work area

5 Analytics3 Quantitative evaluation1 Qualitative evaluation (+ contract support as needed)1 Innovation support and incubation
Our team

KP Care Management Institute’s

Center for Evaluation & Innovation
Research & Development

at Kaiser Permanente

Talk outline:

Our team: R&D at KP

Case study #1: Complex Chronic Conditio

Background on KP and informatics

Case study #2: Panel management

Case study #3: Transitions in Care
10

Program evaluation reveals variations in implementation

Key Components A B Patient identificationPatient engagementMulti-disciplinary care planningCase management/CoordinationProactive clinical managementPsychosocial supportTransitions managementEnd of life careHealth information technologyProgram management

10

Key: dark = robust; light = mechanism in place; N/A = not part of program objectives
Evaluation at each stage is focused 

on supporting further spread

J Typical evaluation of pilots focuses mainly on impacJ Potential adopters have other questions

• Does the innovation work once it is transferred, or was 

its initial promise mainly due to specific factors at the innovation site?

• How will the innovation affect our patients? Our staff? 

Our costs? Our roles and relationships?

• Which version seems to work best? • What site-specific factors are important?

?

?

?

?

?

For example:What does the early majority want to learn from early adopters?
Case study #1: Home monitoring for 

Complex Chronic Conditions

Test, Patient
America’s Largest Non-Profit 

Health Care Program

J Integrated hea

delivery syste

J 8.7 million meJ 14,000 physicJ 160,000 empl

including 41,0

J 8 regions in 9 

and D.C.

J 32 hospitals a

medical cente

J 421 medical oJ $38 billion ope

revenue (2007
A focus on information technology

Kaiser Permanente has made a 

multibillion dollar investment in HealthConnect, a secure natioelectronic data system that is:

3⁄4More than just an electronic record3⁄4A highly sophisticated information ma

and delivery system

3⁄4A programwide system that integrate

record with appointments, registratio

3⁄4A complete health care business sys

enhance the quality of patient care
Clinical decision support:

SmartSets

Opened Sub-Section

Individual Order within a Sub-Section
Clinical decision support:

Best Practice Alerts

Pop-up that alerts clinicians to patient safety or health maintenanutilization reminders, and quality reminders.

Best Practice Alerts
SmartText Used in Patient 

Instructions

SmartText

Text block that can include SmartLinks and SmartLists, and can be 

age/gender. Multiple Types (such as Progress Notes, Letter, Patient 

SmartText (ETX)
kp.org: MyChart

Personal health record (PHR)
CDS Infrastructure: Groupers

Grouper master file that defines groups of other master files; for exEDG terms for asthma can be placed into one VCG record.

Groupers (VCG)
KP HealthConnect

Community Library
KPHealthConnect is one of

many IT Systems
Evaluation & Innovation

at Kaiser Permanente

Talk outline:

Our team: R&D at KP

Case study #1: Complex Chronic Conditio

Background on KP and informatics

Case study #2: Panel management

Case study #3: Transitions in Care
Total Panel Ownership

Panel Care Management

Panel Mana

Specific toprocesses closing “ca

Accountability

& Incentives

“Know your panel”

Access

Culture change: PCP responsibility for 

patients who do not present

Total Panel Own

An overall appdelivering care“Advanced Me

Panel support staff

IT “Panel Support Tool”

Work flow
Team-based population care

Kaiser Permanente uses evidence-based guidelines, registries, and team-based population care for patients with chronic conditions, such as:3⁄4 Asthma (2.7% of members)3⁄4 Cardiovascular artery disease (3.4%)3⁄4 Chronic pain (5.1%)3⁄4 Depression (7.1%)3⁄4 Diabetes (9.3%)3⁄4 Heart failure (1.4%)3⁄4 Obesity (30% of adults)
PHASE: 

Proven preventive therapies

4 Drug InterventionsJ Antithrombotic medication 

3⁄4 Treatment with aspirin 81-325 mg 

daily unless contraindicated

3⁄4 If contraindicated, use of 

clopidogrel is recommended

J Lipid-lowering medications 

3⁄4 Treatment with statin is 

recommended even if LDL-C is <100 mg/dL

J ACE inhibitors

3⁄4 Treatment with ACE inhibitor 

long-term unless contraindicated

3⁄4 Beta blockers 

3⁄4 Treatment with a beta blocker for 

members with CAD, PAD, and AAA unless contraindicated

Controlling 3 risk factors

J Blood pressureJ Lipids

3⁄4 Statin dose sufficient t

C levels < 100 mg/dL

J Blood glucose control

3⁄4 HgA1c < 7.0 is optima

with diabetes

4 Lifestyle Changes

J Tobacco CessationJ Physical ActivityJ Healthy Eating

3⁄4 Recommend a diet ric

vegetables, legumes, grains, and n-3 polyun

J Weight Management

3⁄4 Weight management r

multiple risk factors
People

Dedicated PCP time

Support staff (MA, 

RN), protected time

Process

Identifying patients 

with care gaps and 

conducting outreach

IT T

Internally d

linked to 

data s

Generate list 

of patients, 

by care gaps

Prepare 

clinical data 

summaries 

Review patient 

status, decide 

on treatment

com

Panel Management process

RN or other licensed staff – Primary Care MDclinic-based or centralized

Clini
Diabetes - Blood Pressure Control 

20%25%30%35%40%45%50%55%60%

2004Q32004Q42005Q12005Q22005Q32005Q42006Q12006Q22006Q32006Q4

% of members with diabetes with BP <130/80 

Early signs of success

Pilot site launches Panel Management
Key features in the model of care

Patient

Chronic

Care

Mgmt

Previous Model

Key Features of Model:

 Physician care primarily reactive – visit based and 

responsive Limited capacity for risk stratification or proactive care management interventions Care management program siloed (more or less) from primary care team with ancillary staff 

“offloading” physician Minimal communication and coordination 

between physician and care manager

Panel Manage

Physician

Key Features of Mo

 Physician and team proactive, ac

clinical outcomes and patient satisfa Systematized process for coordin

and panel management team activiti Increased capacity & options for leveraging physician time and ancilto extend physician Sophisticated I.T. infrastructure population-level chronic care

CCM Panel

Management

Physician Staff
Population care gaps

Therapy Gaps Monitoring Gaps

Prevention Gaps
A focus on health promotion

Preventive Health Prompt (PHP)printed at every visit to track preventive services. A shared tool with copy to patient and to clinician. Includes due dates for:3⁄4 Mammogram3⁄4 Sigmoidoscopy3⁄4 Pap smear3⁄4 Immunizations3⁄4 Cholesterol check3⁄4 Routine physical3⁄4 Pneumonia vaccine, etc.
Whole-panel views –

vital signs for the primary care team 
Rapid Region-wide improvement after full 

transition to panel management

84.5%82.9%23.6%66.4%52.8%92.6%75.3%90.9%93.5%

Q4 2007

C

Breast Cancer Screening 82.0% 80.1%Cervical Cancer Screening 81.4% 87.1%DM LDL <100 (Commercial) 46.6% 52.6%DM LDL <100 (Medicare) 60.2% 64.5%DM HbA1c >9% (poor control) 24.9% < 20.4%DM Nephropathy Screening 89.4% 91.2%DM Retinopathy Screening 69.6% 69.3%DM LDL Screening 85.4% 85.4%DM HBA1c Screening 90.8% 92.7%

HEDIS 

90 Q4 2006 th %ile

HEDIS MeasureEffectiveness of Care 
Panel management –

Qualitative results 

J Patients like it – they appreciate the outreach and remind

• “When someone reminds you of your health, it’s really impo

and I really appreciate it.”

J PCPs feel more effective... but still feel crunched for tim

“Panel management doesn’t make my day any easier, but imy day better.”

J A surprise on staffing: The PMA role may be better suite

unlicensed medical assistants than to registered nurses

• The PMA role can feel like a broadening of role for a medic

assistant, but a restricted role for an RN

• Physicians tend to lean on RNs to make routine clinical 

recommendations, but...“It sounded like the nurse and the doctor were not talking to other. I don’t want the nurse knowing something that the dodoesn’t know.”
Spreading knowledge

J “Understanding Panel 

Management: A Comparative Study of an Emerging Approach to Population Care.” NeuwirthEB, Schmittdiel JA, Tallman K, Bellows J. Permanente Journal (2007) 11:3

J http://xnet.kp.org/permanentejournal/SU

M07/panel-management.html
Evaluation & Innovation

at Kaiser Permanente

Talk outline:

Our team: R&D at KP

Case study #1: Complex Chronic Conditio

Background on KP and informatics

Case study #2: Panel management

Case study #3: Transitions in Care
Patient-centered transitions design

CMI & Innovation Consultancy

observations storytelling synthesis brainstorming field testing refin

Laying the 

foundation

Imagining the 

possibilities

Building the 

future

May - Jun Aug 4-5 Deep Dive Sep - Dec 

http://ideabook.kp.org/groups/pt-transitions
2008 methodology breakthrough:

Video ethnography
Storytelling: “My blood pressure is 

lower than your blood pressure”

J One way Dr. Kuyawe tries 

patients out of the hospitathe panel support tool

J He actually shows patient

rate compared to other pa

J “Everyone wants to be co

he explains. 

J He may show a patient th

pressure on a graph and pit is the highest of his who

J No one wants this distinct

will actually work harder to blood pressure, for the encoming back and seeing hmoved lower on the graph

HI Transitions Design-6/08-PD
Findings | The Patient Perspective

J Patients focus on and value other things, not the transition itself:

• they are concerned about their condition and “getting well”, “going home” and “g

to normal”

• their hospitalization is an interruption of their normal life—it’s an “artificial” settin

J “One foot out the door”

• On the day of discharge, patients are emotionally focused on going home and a

capable of efficiently absorbing information

J The discharge process is often a “bad ending”

• lengthy and unpredictable time span• poor coordination between hospital floor and pharmacy

J Only after they get home and start to experience their recovery do patien

recognize and understand they face barriers to optimal recovery

• care information that is skimpy or hard to understand and interpret in relation to 

individual circumstances

• complex medication regimes• re-contacting the right person or department at Kaiser

J Caregivers play a far larger role in managing “transition” and recovery tha

be recognized by providers
Brainstorming & Enacting:

tools, roles, space, and processes
Field testing in West LA
CONCEPT

An online listing of patient care and home needs.

Caregivers are often overwovertaxed with all of the paneeds. Friends and family for these activities in order spread the responsibilities & caregiver’s needs amonpeople.

Halted Idea - ELECTRREGISTRY FOR PAT

Ideas evaluated & field tested
Real-time knowledge 

management: Blogging
Our approach

J What’s distinctive about our approach?

• Partnership among improvement, innovation

evaluation

– Evaluation not arms-length, but with suffic

independence

• Relevance and timeliness• Patient focus

– Voices of Our Members
Questions?
Thank you!

KP Care Management InstituteJim Bellows, PhDDirector, Center for Evaluation & Innovationjim.bellows@kp.orgCarol Cain, PhDPrincipal Consultant, Incubationcarol.h.cain@kp.orgEstee Neuwirth, PhDSenior Manager, Evaluation & Innovationestee.neuwirth@kp.org