Matt Handley, Shared Decision Making Implementation Stories and Lessons Learned
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The document discusses the implementation of shared decision-making (SDM) in healthcare at Kaiser Permanente Washington, highlighting two key initiatives: preference-sensitive surgical conditions and life care planning. It outlines the strategies used to integrate SDM, including clinician training, decision aids distribution, and addressing cultural and technical challenges. Key learnings emphasize the importance of leadership, the difference between technical and cultural change, and the need for aspirational goals for effective implementation.
Matt Handley, Shared Decision Making Implementation Stories and Lessons Learned
- 1. Shared Decision Making Implementation Stories and Lessons Learned Matt Handley, MD Senior Medical Director for Quality and Safety Kaiser Permanente of Washington
- 3. Transforming the Culture 1. Schuerman, J. – ICSI, June 8, 2012 2. Coulter, A., Collins, A., Making Shared Decision-Making a Reality, The Kings Fund 2011 Shared Decision § Patient expertise • Experience of illness • Social circumstances • Attitude to risk • Values • Preferences § Provider expertise2 • Diagnosis • Disease etiology • Prognosis • Treatment options • Outcome possibilities § Shared decision • A mutual decision that best meets patient needs 3
- 4. Two Stories Implementation of Shared Decision Making for Preference Sensitive Surgical Conditions – The Story at Group Health/ Kaiser Permanente Washington Life Care Planning at Kaiser Permanente – Implementing the Respecting Choices model across all KP regions 4
- 5. The Group Health/Kaiser Permanente SDM Story • Implemented in 2009 across five specialties • Reliable distribution of decision aids • Mandatory training for surgeons • Over 65,000 patients involved • Outcomes consistent with studies • Published in Orthopedics, Gyn, Urology • Moving upstream into Primary Care • Expanding available topics • Expanding training to all clinicians Video Decision Aids • Hip osteoarthritis • Knee osteoarthritis • Spinal stenosis • Herniated disc • Benign Prostatic Hyperplasia • Uterine fibroids • Abnormal uterine bleeding • Early stage breast cancer • Breast reconstruction • Ductal carcinoma in situ 5
- 6. Approach to Implementation Aligned leadership – SDM is a strategic differentiator “Non-elective model of adoption” Start in Specialty, then move to Primary Care Workflow - Lean Process Improvement § Reliable distribution of decision aids § Incorporation into standard work of teams § Visual systems to make the work visible § Incorporation into manager/leader standard work Clinician training
- 7. Important Considerations for Implementation Recognize and support two complimentary approaches • Technical change § Reliable distribution of decision aids § Building “triggering events” into workflow • Adaptive/cultural change § Shift in culture to promote different conversations
- 8. Technical Change Reliable distribution of decision aids § We know how to do this – complicated but not complex Classic implementation strategies for underuse § Start with why § Walk the current process to understand local workflow § Work to understand and address barriers to change § Redesign workflow § Measure and feedback § PDCA § Relentless follow-up to continuously improve and manage drift
- 9. Adaptive/Cultural Change Cultural change is hard – complex rather than complicated • No data without stories, no stories without data • Recognize that clinicians believe that they already do this • Collect and share stories • Use the patient’s voice • Leadership presence
- 10. Surgeons can integrate the delivery of decision aids into referral process Every knee or hip replacement patient will be asked to view the decision aid before meeting their orthopedist At time of referral, a RN, PA, or MD reviews every new case and will place DVD order for the patient Ortho Workflow
- 11. Rings of Defense
- 13. In process measurement – volume of distribution 0 100 200 300 400 500 600 700 800 900 1000 2 0 0 9 0 1 2 0 0 9 0 2 2 0 0 9 0 3 2 0 0 9 0 4 2 0 0 9 0 5 2 0 0 9 0 6 2 0 0 9 0 7 2 0 0 9 0 8 2 0 0 9 0 9 2 0 0 9 1 0 2 0 0 9 1 1 2 0 0 9 1 2 2 0 1 0 0 1 2 0 1 0 0 2 2 0 1 0 0 3 2 0 1 0 0 4 2 0 1 0 0 5 2 0 1 0 0 6 2 0 1 0 0 7 2 0 1 0 0 8 2 0 1 0 0 9 2 0 1 0 1 0 2 0 1 0 1 1 2 0 1 0 1 2 2 0 1 1 0 1 2 0 1 1 0 2 2 0 1 1 0 3 2 0 1 1 0 4 2 0 1 1 0 5 2 0 1 1 0 6 2 0 1 1 0 7 2 0 1 1 0 8 2 0 1 1 0 9 2 0 1 1 1 0 2 0 1 1 1 1 2 0 1 1 1 2 2 0 1 2 0 1 2 0 1 2 0 2 2 0 1 2 0 3 2 0 1 2 0 4 2 0 1 2 0 5 2 0 1 2 0 6 2 0 1 2 0 7 2 0 1 2 0 8 2 0 1 2 0 9 2 0 1 2 1 0 Web Support Provider Pre-Visit Ordered By Period Count of Videos SDM Video Provider Specialty Site Authorizing Provider Shared Decision Making Videos: Monthly Distribution
- 14. In process measure – exposure to DA 5% 15% 25% 35% 45% 55% 65% 75% 85% 95% Jan-09 Apr-09 Jul-09 O ct-09 Jan-10 Apr-10 Jul-10 O ct-10 Jan-11 Apr-11 Jul-11 O ct-11 Jan-12 Apr-12 Jul-12 O ct-12 Jan-13 Apr-13 Jul-13 O ct-13 Jan-14 Percent Month Preference Sensitive Conditions- GP Percentage of Procedures Performed where Patient did not receive the video. (Hips, Back, Knee and Hysterectomy & Benign Prostatectomy) % Did not receive video Target
- 15. Clinician Training Mandatory training for all surgeons 4 hour interactive training with role play Highly reviewed by participants 90 minute Web based training for all staff | CONFIDENTIAL 15
- 18. Qualitative Provider Interviews • Overall positive or neutral about decision aids • Benefits of decision aids outweigh minor concerns • Patients are more informed • Time neutral or time saving
- 19. Life Care Planning is a KP National Quality Initiative 2012 2014 2015 2013 2017
- 20. Patients with Serious Illness • Normalizing the conversation for clinical teams • Identifying populations • Triggering events for conversations • Challenges to risk communication • Pilots using decision aids 20
- 21. Themes and Barriers It is easier to focus on the technical changes, rather than the cultural change For Preference Sensitive Surgical conditions • “I already do this” • While decision aids are great for risk communication and setting expectations for participation in decision making, clinicians can mistake them for SDM • Clinicians do not necessarily appreciate the difference between decision aids and educational materials • In fee for service practice, perceived risk to revenue For Serious Illness • Clinicians discomfort with the conversation • Discomfort with decision aids for risk communication • Scaling to the populations (incidence vs prevalence) • We benefit from moving conversations past health care delivery to communities 21
- 22. Key Learnings Be wary of Pilot-itis The Technical change is easier than the Adaptive/Cultural change (having different conversations) Leadership matters – it is hard to lead adaptive change The case for change should be mostly aspirational (best for patients) rather than critical (demonstration of current variation) There is a WIFM for clinicians § Patient centered – different conversations are reinforcing § Time neutral or time saving