how to establish an evidence-based care delivery structure like allina health

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How to Establish an Evidence-Based Care Delivery Structure Like Allina HealthWebinar, April 27, 2016

Dr. Timothy Sielaff

Anna Kleckner, MPH, PhD

CMO & SVP Specialty Care and Research

Evidence-Based Practice Consultant

Learning Objectives

1. Identify necessary components in a system-wide evidence-based decision-making model

2. Understand how to provide consistent, optimal care to patients regardless of treatment location

3. Leverage existing data sources to monitor adherence to clinical practice guidelines

Jane’s Story

Screen

Dx mammo+ 1/2 day work

Bx+ full day work

Lung Bx & Ptx+ (1 HD)

Pos margin lumpectomy

Re-excision

Oncotype Dx

Chemotherapy

Jane’s Story

a) Yes – 7%

b) No – 45%

c) Both – 41%

d) Nei ther – 6%

Poll Question

Did Jane get great care? 82 respondents

90+ clinics

13 Hospitals

16 Pharmacies

Allina Health

Allina Health plus …

11 regional health systems

2,900 physicians

over 60 practices

24 specialties

13 EMRs

non-exclusive to Allina Health

Allina Integrated Medical Network

One promise

Shared clinical imperatives

Best practices

Variation in care

Clinical Service Lines (CSLs) –Program Committees

Neurosci

Breast, Lung, GI (Colo., Upper, HPB), Gyn Onc

Heart Failure, Structural, Prevention

Epilepsy, NeuroVasc (stroke, IR, telestroke), NeuroOnc

Uncertainty and Variation in Healthcare

difficult decisions & uncertainty

variation & waste1,2

1. Han PK, Klein WM and Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decision Making

November/December 2011 31: 828-838.

2. Delaune J and Everett W. Waste and Uncertainty in the U.S. Health Care System. New England Healthcare Institute. 2008.

Available at: http://www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf

Capturing Opportunities

Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.

Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.

Clinical practice guidelines

(CPGs)

Incorporating Evidence into Care

• Best available evidence

• Decision making

• Care delivery

www.healthcatalyst.comProprietary and Confidential 14

“Systematic, evidence-based process

improvement methods applied in various

sectors to achieve often striking results in

safety, quality, reliability, and value can be

similarly transformative for health care.”

Evidence-Based Decision Making (EBDM)

Best available evidence

Clinician's expertise

Patient's values & preferences

Shared decision making

Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM (2nd

edition). Edinburgh & New York: Churchill Livingstone, 2000.

Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. Shared Decision Making to Improve Care and Reduce Costs. N Engl J Med

2013; 368:6-8.

EBDM Challenges at Allina

• Variation in processes for developing CPGs

• No standard framework

• Providers are busy

• No system-wide policy or infrastructure

Poll Question

Does your organization have standard process for development of

system-wide best practices? 90 respondents

A) None or not sure – 16%

B) Just getting started – 24%

C) Half-way there – 30%

D) Well-established (I should be giving this webinar) – 3%

E) Not applicable – 27%

How Allina Built the EBDM Infrastructure

1. Implemented a System-Wide EBDM Policy

2. Established EBDM Governance

3. Tested Feasibility & Utility

Stage I Lung Cancer

IV Heparin

4. Prioritization Criteria

5. Culture of Collaboration

1. Implement a System-Wide EBDM Policy

Language

Terminology

EBDM Framework

Checklist

Language

Purpose Statement

• Improve care delivery and patient satisfaction

• To reduce variation in standards of practice across the system

• To standardize operational processes in guideline development

• Reduce costs

Language

Policy Statements

A. “Allina Health will follow a standard process for the development,

approval, revision, and implementation of Allina Health clinical

guidelines for specific clinical circumstances.

B. …ensure compliance with the processes and procedures within

the Allina Health Model for Evidence-Based Decision Making …”

Language

Expectations for Physicians

• Follow approved guidelines

• “Deviations” expected

• Documentation of deviations expected

Terminology

Policy

A comprehensive statement developed to assure appropriate

action or work is performed and is in compliance with applicable

regulation or law.

In general, policies define “what we do” and remain fairly

constant over time.

A policy:

● communicates what must be done and the desired

outcome of that action

● provides principles to guide decision making

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Terminology

Clinical Guideline

• Systematically developed statements designed to support the decision-making processes in

patient care

• Intended to optimize patient care and are informed by a systematic review of evidence and an

assessment of the benefits and harms of alternative care options

• Identify and evaluate the most current information about prevention, diagnosis, prognosis,

therapy, risk/benefit and cost effectiveness

Allina Health Clinical Guidelines have been, or are being, submitted

for approval through the Allina Health Quality Council, and may include

adoption of existing national clinical guidelines, or expert-driven

statements that meet the definition of System-Wide Clinical Guidelines.

• Different from policies, guidelines define and guide not what we do,

but why and how we do it.

• Expected to change along with evidence, and should be reviewed on

a regular basis.

EBDM Framework Allina Health Model for EBDM

Variation/ Gaps/ Inequities/QI opportunity

Synthesize Knowledge

Formalize Knowledge

Localize Knowledge

Implementation

& Evaluation

Process

Development

Process

Stakeholder

Review Process (Policy, Procedure, Guideline, Other)

Measureable Impact

Allina Information• Data Analytics• Critical Events

• PICO(TS) Framework

• Content Review

• Experts, Literature, Patients

• Library Services

• EBP Methodologist

• Project Management

• Stakeholder Review

• Strategic Alignment

• Quality Review

• CDS, Excellian

• Education

• Compliance

• Diffusion

• Analytics

• Research

Allina Health Resources

www.healthcatalyst.comProprietary and Confidential26

Checklist

2. EBDM Governance

• Endorsement body (monthly)

Policy experts endorse processes & format

• Peer review & approval body (monthly)

Quality experts (medical & executive)

• Tracking system

3-year (max) review cycle

• EBDM Core Team (quarterly)

Diverse group, customer voice

Stage I Lung Cancer IV Heparin

3. Proof of Feasibility & Utility

Stage I Lung Cancer Opportunities

• Establish consensus

• Allina Health “best practice”• NCCN, ACCP guideline

• High risk definition

• Monitoring & feedback

Site A B C

TreatmentSurgery

Surgery

Pre (N = 324) 69 31 81 19 96 4

Post (N = 100) 85 15 63 37 85 15

Difference by

Site+16 -16 -18 +18 -11 +11

Variation in treatment was 27% (surgery: 96% - 69%, RT: 31% - 4%)

Variation in treatment was 22% (surgery: 85% -63%, RT: 37% - 15%)

5% reduction in variation across the system

Stage I Lung Cancer: EBDM Model

Variation/ Gaps/ Inequities/QI opportunity

Formalize Knowledge

Localize Knowledge

Implementation

& Evaluation

Process

Development

Process

Stakeholder

Review

Process

(Policy, Procedure, Guideline,

Other)

Measureable Impact

• Content Review

• Quality Review

• CDS, Excellian

• Education

• Compliance

• Diffusion

• Analytics

• Research

• PICO Lit Search

• PICO Lit Review

• Analytics

• Newsletters, Intranet

• Analytics

• NCCN abstract/poster

• Charter

• Adopt Guidelines

• Committee Approval

• Quality Council

approval

IV Heparin Opportunities

• Standardization of IV Heparin

• Improve patient safety and patient experience

• Reduce costs:

• Use APTT instead of anti-Xa

• Adverse events, especially bleeding

• Improve safety monitoring of anticoagulation meds (Joint

Commission National Patient Safety Goals)

Pre: 20+ site-based documents (policies, protocols, etc.)

Post: 1 system-wide guideline, 4 system-wide protocols

IV Heparin: EBDM ModelVariation/ Gaps/ Inequities/QI

opportunity

Formalize Knowledge

Localize Knowledge

Implementation

& Evaluation

Process

Development

Process

Stakeholder

Review

Process

(Policy, Procedure, Guideline,

Other)

Measureable Impact

• Content Review

• Quality Review

• CDS, Excellian

• Education

• Compliance

• Diffusion

• Analytics

• Research

• PICO Lit Search

• PICO Lit Review

• Formulation of Work

Groups

• Charter/Aim

Statement

• Recommend aPTT

• 1 guideline, 4

protocols

• Screening tool

• Benchmarking

• Onsite visits

• Excellian

• Dashboard

Anticoagulation Safety Dashboard

Poll Question

How effective is your organization at implementing a new system-

wide best practice? 72 respondents

A) Not effective at all – 10%

B) Some better than others, depends – 44%

C) Effective, with some room to grow – 18%

D) Very effective (we should be doing a webinar) – 3%

E) Don’t know or Not applicable – 26%

Development Implementation & Diffusion

4. Prioritizing EBDM Initiatives

Identified variation

Volume

Readiness

Alignment

Motivation

Champion

Impact a commonly performed

process

Implementation capacity

Operations support

Clinical leadership support

obtained

Champion

5. Culture of Collaboration

• Collaborative vs. Punitive

Offering a service vs. requirement

• Clinical Service Line / Program Structure

• Start with low-hanging fruit

Gained momentum

Reduced skepticism

• Dedicated resource (1 FTE)

What’s Next?

• Expand policy and EBDM model to additional clinical areas and

conditions

- 20 approved guidelines in 1 year

• Upstream implementation consult

- Resource identification

• Implementation, measurement & communication of guideline

initiatives

- Evidence-Based Care Delivery Dashboard

The Cost of Jane’s Story

Screen

Dx mammo+ 1/2 day work

Bx+ full day work

Lung Bx & Ptx+ (1 Hosp d)

Re-excision

Oncotype Dx

Chemotherapy

$2,500

$4,500

$3,500

$5,000

$3,000

$12,500

$37,000

Lost job …

Screen

Dx mammo

Lung Bx & Ptx+ (1 Hosp d)

Re-excision

Oncotype Dx

Chemotherapy

$750 + $250 ½ day work

$2,000 + $500 full day work

$4,500

$3,000 + $500 + (1 Hosp day)

$5,000

$3,000

$12,500

$8,500

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