Improving Health OutcomesRobert Compton, DDSExecutive Director

DISCLOSURE

Disclosure on DentaQuest Benefits

• ~ 20 million members

• 27 States• Partner with over 85

health plans• Administer 10 state

carve outs• Administer over $5

billion of dental benefits

Improving the Four Systems Impacting Oral Health

Achieving Optimal Oral Health for All

Congress Mandates Quality Improvement• The Children’s Health Insurance Plan Reauthorization Act of 2009

(CHIPRA), mandates that quality assessment programs be implemented to assess and improve the quality of care for children that receive oral health care under the Medicaid and CHIPRA programs.

• In 2009 the CMS proposed to the American Dental Association (ADA) that a Dental Quality Alliance be established to develop performance measures for oral health care and that the ADA take a leadership role in its formation.

Members of DQA Board of Directors DENTAL PROFESSIONAL ORGANIZATIONS Academy of General Dentistry American Academy of Oral & Maxillofacial

Pathology American Academy of Oral & Maxillofacial Radiology American Academy of Pediatric Dentistry American Academy of Periodontology American Association of Endodontists American Association of Oral and Maxillofacial

Surgeons American Association of Orthodontists American Association of Public Health Dentistry American College of Prosthodontists American Dental Association’s Board of Trustees American Dental Hygienists’ Association Council on Access, Prevention, and Interprofessional

Relationships (ADA) Council on Dental Benefit Programs (ADA) Council on Dental Practice (ADA) Council on Government Affairs (ADA)

GOVERNMENT AGENCIES• Agency for Healthcare Research and Quality• Centers for Disease Control and Prevention• Centers for Medicare and Medicaid Services • Health Resources and Services Administration • Medicaid and SCHIP Dental Association

DENTAL PLAN ASSOCIATIONS• America’s Health Insurance Plans• Delta Dental Plan Association• National Association of Dental Plans

OTHER MEMBERS• American Dental Education Association• American Medical Association • DentaQuest• The Joint Commission • National Network for Oral Health Access• Public Member

http://www.qualityforum.org/Home.aspx

http://www.qualitymeasures.ahrq.gov/

Science of Improvement• Walter A Shewhart, 1891-1967• W. Edward Deming, 1900-1993• Avedis Donabedian, 1919-2000• Don Berwick, 1949 -• Institute for Healthcare Improvement

1990

Improving the performance of dental practices• Quality of Care• Patient Experience• Practice Management• Finances Performance• Efficiency

There’s Help Doing This• Institute for Healthcare Improvement (IHI)• National Initiative for Children’s Healthcare Quality (NICQH)• DentaQuest Institute

People trained in the science of improvement:• Improvement Advisor• Project Manager• Project Coordinator

DentaQuest Institute: Online Learning Center

Necessary Ingredients to Improve• Will to improve• Ideas to Improve

– Improvement requires change – not simply doing more of the same– Not all change leads to improvement!

• Fundamental changes that lead to improvement will:– Alter the way work or activities are done or makeup of product– Produce measureable, positive results compared to historical results– Have a lasting impact

• Skills to Execute the Improvement

Central Principles for Improvement1. Knowing why (Aim or purpose)2. Have a method of feedback3. Develop a change that you think will result in improvement4. Test a change before you implement

A. Plan the testB. Run the testC. Review and summarize what was learnedD. Decide what action is warranted

5. Implement the changeA. Question is no longer whether it’s a good or appropriate change but

rather how to make it permanent

Associates for Process Improvement Model

IOM’s Aims of Quality Care• Safe• Effective• Efficient• Equitable• Patient-centered• Timely

The Aim Statement

Deming: Profound Knowledge (PF)

The interplay of the theories of systems, variation, knowledge and psychology• Appreciation for a system• Understanding of variation• Building knowledge• Human side of change

PF: Appreciation for a System• Most products and services are created by complex systems

• A system is an interdependent group of items, people, or processes working together towards a common purpose

• A process is a set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes

• Central Law of Improvement: Every system is perfectly designed to deliver the results it produces

Supporting Change with Data• Science is Latin for knowledge gained thru observation

• To make effective change we have to be observant– Our minds filter observations – selective memories– Present observations are affected by past observations

• Turning observation into data: – Data are observations that are recorded including from measurement

process• Collecting data starts with a plan

– What data will be collected– How they will be collected– Who will collect them– When and where will they be collected

Understanding Variation• Predictable versus Unpredictable• Statistics can differentiate the two based on patterns of data

variation over time1. Common causes: inherent in process (or system) over time,

affects everyone working on process, and affects all outcomes of the process. This is predictable and stable.

2. Special causes: Not part of the process (or system) all the time, or do not affect everyone, but arise because of special circumstances. This is not predictable and is unstable

Understanding Variation• Stable variation: Improvement can be made only thru

fundamental changes to the system.• Mix stable and unstable variation: if special causes can be

identified and fixed then process becomes stable and performance becomes predictable

• Separating common and special causes helps determine appropriate action for that process or system.

Fix Process or Make Change to System?

Real World Example of Unstable Variation

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

CY2012

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

YTD 2013

40%

50%

60%

70%

80%

90%

100%

110%

82%

73%

Total Payroll & Benefits as a Percent of Revenue

2012

2013

Developing a Change• The first respond for many people is just do more of the same

(more money, more people, more rules, more oversight, etc.)• Another ineffective response is to try to define the perfect

change– All change will include failures– Fail fast and fail small!

• Focus should be on changes that alter how work or activities get done which requires:– Understanding of processes and systems of work– Creative thinking– Adapting known good ideas (steal shamelessly!)

Principles for Testing a Change1. If possible keep on small scale initially and then increase

scale of test based on learning.2. As scale is expanded include differing conditions

A. Circumstances changeB. Different shifts of people on different daysC. Staff goes on vacation

3. Plan the test, including the collection of data

Questions about Change Process• When developing a change

– What are the sources of problems?• When testing a change

– Has the change affected performance?• When implementing a change

– Is performance being sustained after change?• When spreading improvements

– How many other sites have adopted the change?

Building Knowledge• A change is a prediction• The more knowledge about how a system functions the

better the prediction and likelihood of improvement• Start with current theories on how a system works.• Create ideas/theories (hypothesis) about what to change• Comparing predictions to results is key source of learning.• Improve our ideas for change on the results obtained• If change does not lead to improvement that’s important

knowledge to refine our theory.

Building KnowledgeThe foundation for improvement is building knowledge thru observation or measurement

Repeated learning cycles eventually categorizes most circumstances making for more useful future predictions

Collaborative learning shares this knowledge

The Human Side of Change• Helps us predict how people will respond to change and how to

gain their commitment.• Important contributions from psychology and change management

– Differences in people: preference, needs, learning styles, beliefs and values– Behavior is driven by motivation: our motivation may be different– Intrinsic and extrinsic motivation:

• Extrinsic lies outside the work activity itself (such as bonuses for achieving goal)• Intrinsic comes from the satisfaction of the work itself and fulfillment of social and personal

needs• People tend to adopt change more readily that align with existing attitudes and beliefs

– Fundamental attribution errors: easier to blame people than examine system– Attracting people to the change

The Human Side of Change• Five attributes to facilitate adoption of change:

– Relative advantage of the change over other changes or the status quo (What’s in it for me?)

– Compatibility with current culture and values– Minimal complexity in explaining the change– Allowing people to try and test the new change– Opportunities for people to observe the success of the change for

others• Leaders plan for the social impact of technical change and

make people part of the solution

Early Childhood Caries

Early Childhood Caries (ECC)• About 4.5 million children develop ECC annually

• Untreated ECC experienced by hundreds of thousands of children have profound consequences including death and serious morbidity.

• In 2000 the average cost of care across 5 children’s hospitals for a single admission for odontogenic infection was $3,223 and most children do not get definitive care for either the offending tooth or other carious teeth. The average length of stay was 5 days

• More than 2,100 Medicaid children in Louisiana had general anesthesia in 1 year alone with 60% being age 3 or younger and the anesthesia cost $1508 per admission

• At Boston Children’s Hospital before the ECC initiative there was a 9 months wait to get into the OR and the hospital’s cost was over $8,000.

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Early Childhood Caries Costs

The Logic Model of Theoretical Determinants of ECC

Based on Bartholomew and Mullen, Journal of Public Health Dentistry, 71 (2011) S20–S33

(Health Belief Model, Social Cognitive Theory, Theory of Reasoned Action, Transtheoretical Model, and Ecological Theory – See Appendix E)

Logic Model of Change: Theoretical Determinants of ECC

Based on Bartholomew and Mullen, Journal of Public Health Dentistry, 71 (2011) S20–S33

(Health Belief Model, Social Cognitive Theory, Theory of Reasoned Action, Transtheoretical Model, and Ecological Theory – See Appendix E)

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Determinants of Health

Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93

Behavioral Patterns

40%Genetic Predisposition

30%

Social Circumstances

15%

Health Care10%

Environmental Exposure

5%

Delivery System Design

Self- Management

Support

CommunityHealth System

http://www.improvingchroniccare.org

PatientPractice Team

Productive Interactions

Decision Support

Clinical Information

Systems

Improved Outcomes

Chronic Care Model

Prepared & Proactive Informed & Active

Chronic Care Model: Self Management Support

Empower and prepare patients to manage their health and health care• Emphasize the patient’s central role in managing their

health• Use effective self-management support strategies that

include assessment, goal-setting, action planning, problem-solving and follow-up

• Organize internal and community resources to provide ongoing self-management support to patients

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

ECC: Arrest Disease Process

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Risk-Based Disease Management ProtocolsINITIAL OR RECALL APPT• Medical history• Exam/X-rays• Caries Risk Assessment (CRA)• Behavioral assessment VISIT 1

• Self-management goals (diet, oral hygiene, home fluoride)• Fluoride varnish• Indicated clinical care

DISEASE MANAGEMENT VISIT• Clinical/X-ray exam• Caries Risk Assessment• Fluoride varnish• Re-define or re-emphasize self-management goals• Behavioral assessment

RESTORATIVE ITR VISIT(S)• Provide restorative care as

indicated• Provide ITR as indicated• Schedule OR time if indicated

CHILDREN AT HIGH RISK• Schedule next Disease

Management visit in 1 month

CHILDREN AT MEDIUM RISK• Schedule next Disease

Management visit in 3 months

CHILDREN AT LOW RISK• Schedule next Disease

Management visit in 6 month

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Patient’s Caries Risk Status is Not StaticECC disease management approach based on premise that a patient’s caries risk status is not static, but can be managed and improved over time.

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Ng MW, et al. Disease Management of early childhood caries: results of a pilot quality improvement project. Journal of Health Care for the Poor and Underserved 23 (2012): 193-209

Improved Outcomes and Patient Experience

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Financial Analysis from Boston Children’s HospitalLength of Evaluation Baseline Costs ECC Costs Net Savings

Additional ECC Costs ROI

3 months $699 $669 $30 $30.90 $0.99

6 months $1,092 $880 $212 $47.30 $4.48

9 months $1,660 $1,097 $563 $60.90 $9.23

12 months $2,025 $1,262 $763 $70.40 $10.83

24 months $2,678 $1,834 $844 $114.30 $7.38

Need to change Policy & Finance Systems for ECC• Should cover 4 fluoride treatments • Should cover disease management• Should cover ITR

$810,000 vs. $505,200400 Patients X $762 = $304,800 reduction in cost

What about ACO and Global Payment?

We Can Improve Health Care