#LeadingVBHC – We talked to Ronald Navarro, MD from Kaiser Permanente after his presentation, Kaiser Permanente: Joint Arthroplasty Enhanced Recovery Model
Breanna Cunningham: Good evening. Bre Cunningham here with Dr. Navarro who gave a fantastic presentation earlier today on outpatients, shoulders, and what was the title of your talk?
Dr. Ronald Navarro: Yeah, length of stay reduction.
Cunningham: Length of stay reduction.
Navarro: And total joint arthoplasty, yes.
Cunningham: Dr. Navarro is at Kaiser Permanente. It’s a mammoth system that has continued to be on the cutting edge of innovation. Tell me how an organization that’s that large has been able to develop and rapidly implement some change in technology and just practices such as outpatient joints.
Navarro: Well, you know, we have long been a provider of healthcare in Southern California and in Northern California, and it first grew out of a need for typically the working class individual and their employed insurance, but in the old days, I’ll be honest with you, we weren’t the best player in town but over the years, because of our economies of scale and our systems integration of having everybody be fairly well aligned and the kind of goals that we wanted to achieve because in some ways it’s much like a single payer system within the realm, we’re all aligned for the same goals, we’ve really developed innovation because we want to do the right thing, as well as we’ve become an employer of choice in California because a lot of physicians who are really well meaning, they don’t want to have to deal with a lot of extraneous issues. They just want to practice medicine …
Navarro: … So it becomes an attractive employment opportunity for them, and they become partners in systems and have employment protection, as well as the ability to just practice medicine. That’s the milieu that you’re in and then because we have really smart people that we’ve been hiring, a lot of them have been pushing the edge of the envelope. We’ve been collecting data, analyzing the data, writing papers on the data, and then using that for quality improvement and process improvement internally. We say a lot of times we want to be the best at getting better, BAGB, best at getting better.
Cunningham: Nice. Now, in your presentation, you were showing a slide, I think it was on length of stay, and it was very transparent. I mean, you blocked out the names, but you were saying that this is something that is shared internally, where you’re taking this data and sharing it with everyone in your group. Tell me about how that process got started? Was it something where you immediately started sharing this data once it was made available or was it at first a blinded iteration of that that then became more transparent?
Navarro: Right. We still protect the individual provider’s data, although we can generate it. We don’t show an individual provider’s data to a provider at another medical center within our system of 13 medical centers in Southern California, but medical center to medical center, we still needed to walk our surgeons down the path of becoming more comfortable with comparing one to the other, which you know, we do find that surgeons, physicians in general, they want to do well, they want be A players, not C players, so showing them that their medical center may stack up well against another medical center brings great pride to them within the system, and if they’re not doing so well, it makes them think about how they can iterate and better adapt, and do better things.
Then, it leads to process improvement by looking at more granular data and seeing where they’re falling out, if on certain parts of the measures they’re not doing as well as others within the system. But yes, to answer your question, it did take a while to say, “Folks, this is what we’re going to do, this is the way that our forms will lay out,” and the scorecards, if you will, will describe what the data is and how it’s coming on, and frankly, they provided us feedback and said, “Why is that important? Why don’t you do this?” We actually listen to our surgeons so that they can help us to design the best scorecard that is most meaningful to drive the best results.
Cunningham: That’s excellent. Now, I’m going to switch subjects a little bit and go onto outpatients, and we talked a lot about outpatients, well, joints, but specifically hip and knee. There was a lot of presentations on that. You’re a shoulder guy, right?
Cunningham: Outpatients shoulder, what are some of the unique challenges to outpatients shoulder joints?
Navarro: I think that for us as shoulder surgeons, many things we don’t get brought into some of the other realms of care in terms of even within our own system, the total hip and knee arthoplasty surgeons have great classes that help to explain to patients that they may be able to benefit from going home on the same day if they so desire and if they have the right outcomes and the right mix of components to make them be amendable to a same day or a next day discharge, but in shoulder surgery, our systems aren’t always wrapped up into that, so we have to, as individual surgeons, maybe sometimes more speak to those issues ourselves, instead of sending the patient to a class per se, that kind of keeps reiterating the possibility of going home on the same day.
Cunningham: So more surgeon versus system dependent?
Cunningham: For infrastructure.
Navarro: And I probably look upon myself to say that I should build more systems that can help more of our shoulder surgeons and with other shoulder surgeons, build those systems so it was more systems dependent, because as you know, systems are battered and individuals to …
Navarro: … Drive best outcomes and change.
Cunningham: Sure. Another thing that you had mentioned in your talk is that while Kaiser values patient report outcome data, there isn’t really an infrastructure in place and there hasn’t necessarily been an initiative that’s rolled out system wide. There’s some pockets that are doing so. Tell me, how do you feel in your practice patient reported outcomes play a role, and what do you intend on doing in the future to meet those CGR type needs?
Navarro: Right, and that’s a great question. We all want them in play as quickly as possible. We understand the constraints of our system. We have an epic system that we proprietarily call “health connect” and it was rolled out in the middle 2000’s, 2005 to 2007, depending upon the medical center in Southern California, and at that time, the drive to have patient reported outcomes be embedded within it, in a way that is really convenient for the patient, that they can fill out at home, they can fill out online, they can fill out in the clinic when they’re coming back from a follow-up, that wasn’t a necessary aim and goal, so now to go back and it’s almost essentially like an update that Microsoft would give, the update of the epic program that we call Health Connect that would include this, would include a lot of extra work to build them.
We have gotten some basic ones in some of our systems in Northern California, they have inputted a couple of the typically used pros for hip and knee arthoplasty, and in Southern California we included one two question set that kind of does long term surveillance on a hip and knee arthoplasty, but to get a shoulder one and wrist one, an elbow one, a knee for sports one, an ankle one, those are all separate requests and so we’re just trying to build those with time and get the infrastructure available to build those, to be successful at that. We’re in the process of that, we’re just not there today. We know that we need to do it.
You and I spoke earlier and you know that I have a particular question on my own of saying, “Even if you have patient reported outcomes, can the patients successfully fill them out?” If we were publishing a paper, you and I, we would have to live at a standard of statistical significance that would expect a certain amount of a response rate. We’ve seen the patient reported outcomes. There’s not always a high response rate.
Cunningham: Minimally difference change, yeah. Right.
Navarro: Even if we have them in, does that mean that enough patients will respond and give us information that’s actionable? I don’t know. I’m not against patient reporting, I want to hear what the patients have to say, but to reliably collect them and keep them within an electronic medical record that has been in existence long before the need to actually have them is just what we’re coming up against, but I know I have faith in our system that we’ll eventually be there with them.
Cunningham: Right, that makes sense. Well, what’s interesting is, just like with HCAHPS and patient experience, for the CJR program through Medicare, they are using patient reported outcomes, right? Even if you only have a 30% capture rate, which might not be statistically significant, it’s going to be interesting to see how that plays out in the future.
Navarro: Yes, it will. I completely agree with you. I think that understanding which group of patients typically respond, is it the happy patient who’s had a successful surgery or the disgruntled patient? Some of that needs to be examined more to understand how we flavor the results and how we use them to identify opportunities.
Cunningham: Nice. I have a final question for you. Is the bow tie an “Every tie is a bow tie” situation with you?
Navarro: That’s funny. No, no. I recently learned for a niece’s wedding how to tie them last summer, and so I’ve been continuing to use them and I love them as an alternative to the …
Cunningham: You look sharp.
Navarro: Thank you so much.
Cunningham: And you know, I will say that my first question was going to be how many YouTube videos did you have to watch to do that? Because I often see my husband in front of the mirror just cursing, trying to get his tied.
Navarro: Right, it takes a while.
Cunningham: It’s tied lovely. Great work, great work.
Navarro: Thank you so much. Thanks for the opportunity.
Cunningham: Thanks for the talk. Be sure to continue following us as we live stream and on Twitter, Leading Value Based Conference, and with this, we are off. We’ll see you tomorrow.
Navarro: Thank you.