As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:
How do we know we’re doing a good job? We’ve touched on it in past blog posts. It can be harder to determine than we give it credit for. One strategy we’ve come across in our work on CDC grants is to look for “positive deviance”. We look for microcosms of success within clinics, and then we try to learn from them and diffuse their methods throughout the clinic. With the help of Dr. Bob Badgett from the University of Kansas School of Medicine-Wichita, we have implemented processes in clinics in a few steps:
First, after deciding what outcome we want to measure, we benchmark what others are doing. If we use blood pressure control as an example, we can look at HEDIS data for national benchmarks, which showed that nationally in 2018 61% of commercially-insured patients with hypertension had good control, versus 59% in Medicaid HMOs and 69% in Medicare PPOs.
Next, we look at both individual and team performances in clinics. Let’s pretend that we are interested in the care of patients with high blood pressure at Moore Endocrinology, Inc. We would build a proprietary report to run through Moore Endocrinology Inc’s electronic health record (EHR) that would tell us the blood pressures of every patient seen by every doctor in the clinic and chart them out, like this fictional clinic team:
Most providers cluster around the vertical line that indicates the average rate of control of ~75% (pretty good compared to the national benchmarks). But look at providers 2 and 50. Their rates of control are significantly higher than the others on their team, at 87% and 88%. They are the positive deviants. We don’t just look at providers individually; positive deviants can be broken out into provider teams, and in the case of teaching clinics, even attending physicians (think Dr. Cox and Dr. Kelso on Scrubs). We don’t pay any attention to the negative deviants. All our efforts are put toward finding the people doing unusually well and helping others get to their level.
Next, we look at more granular data within the EHR to get insights into whether or not blood pressure drug regimens were altered appropriately whenever a patient presented with an uncontrolled blood pressure. For example, if a patient’s blood pressure was uncontrolled, did the provider change the dose of a medication, add another medication, or do something to encourage improved medication adherence on the part of the patient, like changing to a cheaper med, offering advice on pill boxes or alarms, or changing to longer-term prescriptions?
Then, with the consent of the providers in the clinic, we meet in small groups and do focused, structured group interviews to determine the practice habits of everyone, without revealing who in the group is the positive deviant, not even to that provider personally. And we find fascinating things. It’s possible that the positive deviant uses a different drug titration strategy than her peers. More likely, she’s encouraging patients to check more blood pressures at home. Maybe she utilizes the medical assistants on her team in an innovative way, such as coaching patients on adherence or proactively reaching out to patients who’ve historically had poor blood pressure control.
Finally, we work with the clinic to determine what clinic-wide changes can be implemented to make everyone else’s practice look more like the positive deviant’s.
The purpose of this blog post isn’t to pat ourselves on the back for a clever strategy in working with clinics. It’s to introduce this idea to you, someone involved with the health and health care insurance coverage of a population of employees.
If your business is a member of the Kansas Business Group on Health you should have received a request to complete a benchmarking survey over the last few weeks. What we’re trying to accomplish with the survey is much like what we’re doing with clinics. We want to find out which of our members is doing certain things particularly well. For example, perhaps Business X has a particularly low rate of spending on drugs; they’re a positive deviant. Without revealing who that business is, we would like to work with that business and other members of the Group to see what Business X is doing to keep costs down. Then we can work with other members of the Group to adopt similar strategies. It’s a team-based approach to take those little microcosms of success and let everyone else learn from them.
So if your business hasn’t had a chance to fill out the survey yet, please go to our website and fill it out (it won’t take more than 10 minutes to complete). Even if you aren’t yet a member of the KBGH, we still encourage you to complete it as it would be helpful to see what you’re doing. The survey will be kept completely anonymous on an organization level, and the data will only be provided in aggregate.
If you have any questions or comments, please contact us!