quality improvement: lessons for workers compensation quality of care linda rudolph, md, mph...
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Quality Improvement: Lessons for Workers’ Compensation Quality
of Care
Linda Rudolph, MD, MPHMedi-Cal Managed Care Division
CA Department of Health ServicesMay 1, 2003
What Do We Want?Quality
• “The degree to which health services for
individuals and populations increase the likelihood of desired patient outcomes given the current state of knowledge” IOM, 1990
• The extent to which health services meet their aim – improving health.
What Do We Want? (DWC Focus Groups)
• accessible
• competent
• state of the art
• caring
• trusting
• patient-oriented
• patient-selected
• reasonably priced
• coordinated
• continuous
DWC, Improving the QOC for Injured Workers, 2001
What Do We Want?(Institute of Medicine)
• Safe• Effective• Efficient
• Timely
• Patient Centered
• Equitable
IOM, Crossing the Quality Chasm, 2001
What Do We Have?
What Do We Have?
• Distrust• Poor access to specialists• Delays in care• Fragmentation and lack of continuity• Care not patient-centered• Inefficient and ineffective care• No accountability
Improving the Quality of Care for Injured Workers: Focus Group Discussions. DWC. 2001
“Every system is perfectly designed to produce the results
that it does achieve.” (Berwick/Batalden)
What can we do?
• Accountability
• Improvement
Accountability
• Policies and contracts
• Monitoring
• Measurement
• Reporting
You can’t fatten a calf by weighing it….
Palestinian proverb
Improvement
A systematic program for taking a system from one level of performance to a higher level of performance
Low Back Pain
• ¼ w.c. claims
• 1/3 w.c. costs
What Do We Have?
• Care highly variable
• Care inconsistent with guidelines
• Patient outcomes poor
Theory of Change
• Will
• Ideas
• Execution/supporting change
Low Back Pain = Chronic Illness
Care Model for Worker Health(adapted from IHI/Dr. Ed Wagoner)
Resources and Policies• Resources to support injured workers and
providers are easily accessible• Insurers, State agencies, employers, and health
care providers:– coordinate and partner with each other around worker
and injured worker needs– promote and offer evidence-based effective
interventions and programs
• System incentives are aligned for policy
(adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Health and W.C. System
• Specific goals for prevention and care management are part of the strategic and business plan.
• Senior leadership is committed to meeting the needs of injured workers.Encourage coordination among primary care and occupational medicine care
• System has adopted an effective performance improvement model.
• Incentives support these organizational goals. (adapted from Institute for Healthcare Improvement’s Breakthrough Series
Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Self-Management Support• Emphasize worker’s active and central role in
managing illness• Resources available to increase patient knowledge,
confidence, and skills• Workers assisted in setting shared goals• Workers have access to peer support• Workers assisted in improving communication
with providers about health care. (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Decision Support• Evidence-based guidelines and protocols
integrated into practice systems• Integrated expertise (occ med, specialists, mental
health,w.c., workplace)• Care team works to maximize cooperation,
continuity, and patient outcomes• Use of modalities proven to change practice
behavior
(adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Delivery System Design
• Practice anticipates problems, provides services to maintain QOL and function
• Roles/responsibilities of team members defined, appropriate training provided
• Systems designed for regular communication and f/u
(adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Clinical Information System
• Registry of patients in need of services maintained• Reminder system used for patients and care team• Information system provides regular feedback to
care team• System allows for care planning
(adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)
Model for Improvement
Aims
• Reduce plain x-rays
• Reduce opiate prescriptions
• Increase patient self-management education
• Increase availability of modified work
From Aim to Improvement
• Define measures (process, outcome)• Barrier analysis• Identify available interventions• Identify target population• Outreach • Implement interventions:• Did it work?• Start again!
Quality Improvement Collaboratives
• Medi-Care
• Medi-Cal
• Pursuing Perfection/Rewarding Results
• CPCA (HRSA)
• DHS
• CCHRI
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