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