Team members from Sharp Rees-Stealy Medical Group (left to right): Vicki DeBaca, Vice President Health/Provider Services; Estelle, Wolfe, R.N. B.S., Patient Care Manager; and Jerry Penso, M.D., Associate Medical Director for Quality Programs　

Sharp Rees-Stealy Medical Group, based in San Diego, California, is one of the largest medical groups in the state. It provides care at 18 locations with 1600 employees and more than 340 physicians.

Beginning in 2002, Sharp-Rees Stealy participated in a statewide pay for performance (P4P) plan which established a uniform set of clinical and service measures and a single public report card for the state’s medical groups. Rather than focusing on the financial incentives, the medical group developed an internal program to improve clinical and patient experience outcomes: Incentives for Excellence. The P4P program thus became the catalyst for systemic change, broadening and strengthening improvement programs to significantly enhance the quality of care and service.

The CEO and Medical Director both came out publicly in support of the Incentives for Excellence program and were committed to achieving the targeted results. They backed up that support by providing the financial resources necessary to execute it. A P4P Committee was created that included leaders throughout the organization, including the vice president for utilization management and quality improvement, nursing leadership, laboratory leadership, radiology leadership, IT leadership, and physician leadership. These people served as liaisons to their departments to facilitate effective and efficient communication and implementation.

Organizational goals (with related IOM Aims in parentheses):

• To achieve breakthrough quality and patient service outcomes that make the organization the best place to care for patients, to work, and to practice medicine in the state and beyond. (Effective, Patient Centered, Timely)
• To create and institutionalize new systems and structures of care that will ensure continuous quality improvement and improved patient experience. (Safe, Efficient, Equitable)
• To create the information technology backbone that will support ongoing process improvement and measurable, superior patient outcomes. (Effective, Efficient)
• To achieve recognition for top performance among medical groups in the statewide P4P program. (By achieving this recognition, the group will have implemented all six IOM Aims.)

To help achieve these goals, the medical group adopted specific measurable objectives as part of its annual strategic plan. Many of these objectives, which are reformulated annually, were directly tied to the statewide P4P performance measures for both clinical quality and patient service. Examples have included:

• 20% improvement in the compliance rate for diabetic patients ages 21-75 having an HgbA1c annually,
• 5% improvement in the compliance rate for women ages 52-69 having a mammogram every two years,
• 5% improvement in the compliance rate for women ages 21-64 receiving cervical cancer screening every three years, and
• Overall office visit patient satisfaction score at or above the 65th percentile.

1. Care based on continuous healing relationships
Sharp Rees-Stealy Medical Group has 150,000 fully capitated lives for which they accept full financial risk, as well as other patients who do not belong to an HMO. Every patient (HMO and non-HMO) is assigned a primary care physician, making a single doctor accountable for directing and managing each patient’s health. Specialists within the group coordinate care with the primary care physicians, and their electronic health records system allows full sharing of clinical information. In the medical group, continuity applies not only to the primary care physician–patient relationship but extends between physicians, across specialties, to ensure that there is accountability throughout the entire continuum of care. Sharp Rees-Stealy built on these existing relationships to implement the Incentives for Excellence program.

2. Patient as source of control
The medical group made it a regular practice to listen and learn from patients/customers. The organization began to send out patient satisfaction surveys for all doctors at every site each month (more than 340 physicians) as a way to identify and fix problems and learn from patients’ good experiences in order to replicate them. Based on the responses to the surveys, it provided physician coaching and staff training to help everyone in the organization improve the patient experience.

3. Shared knowledge
As a way to create systemic change, Sharp Rees-Stealy created a multidisciplinary P4P Committee to coordinate the Incentives for Excellence program and promote shared knowledge among sites and departments. The team ensured that Incentives for Excellence was executed throughout the organization, at all of the sites and within all departments. Components of the program were often piloted at one site and then improved and standardized before being disseminated throughout the organization.

5. Evidence-based decision making
The group used internal as well as external guidelines (U.S. Preventive Services Task Force, NCQA, HEDIS) to direct its programs. Internally, it consulted experts within the medical group concerning the best ways to apply those guidelines. For example, the group established an active Practice Guidelines Committee to review and evaluate the literature and set guidelines for medical group practice. This committee ensured the organization’s ability to continue practicing state-of-the-art medicine.

7. The need for transparency
The annual P4P data were reported publicly on the state program’s website, available to all patients and consumers. Progress toward the organization’s strategic objectives was posted quarterly on its intranet, available to all physicians and employees. Transparent data also provided feedback to all physicians concerning their individual quality and service performance.

8. Anticipation of needs
Sharp Rees-Stealy Medical Group developed a data warehouse to identify, track, and evaluate patients who required services, and based on the data warehouse, developed reminder systems and disease registries to identify those who were missing needed services. It also hired diabetes case managers to focus on high-risk patients. The aim was to build a sophisticated, robust system to remind doctors and patients of recommended care.

10. Cooperation among clinicians
Although the nature of medicine has always required cooperation among clinicians, the group institutionalized it to a much greater extent. Multidisciplinary teams were formed (e.g., P4P Committee, Practice Guidelines Committee, Physician Advisory Committee, Mammogram Task Force, and DM9 team) to focus on ways to bring about systemic improvement, particularly in the areas affected by the P4P measures. These teams not only included physicians across specialties, but nurses and key staff members as well.

Results
Every clinical measure improved dramatically from the program’s inception, often with rapid improvements that catapulted the group to the top category in the state. Sharp Rees-Stealy Medical Group’s performance was rated #1 by Blue Cross for the entire state for reporting year 2006 (based on 2005 data), and was recognized as a top-performing medical group in the statewide P4P program for reporting years 2005 and 2006 (based on 2004 and 2005 data). For the latest measurement year (2005, which is reporting year 2006), the group demonstrated exceptional results in almost every measure. Two especially significant successes were the redesigned breast cancer screening program and the DM9 program, which targeted diabetic patients whose HbA1c reading was nine or greater, indicating their diabetes was completely out of control.

Breast Cancer Screening Redesign
This program grew out of the P4P Committee, which discussed some of the barriers to obtaining mammography. The group formed a Mammography Task Force in early 2006 to increase its mammography screening rate by improving access, customer service, and physician office efficiency. Over a period of six months, the task force redesigned the process:

• Instituted centralized radiology scheduling, with a single number to call;
• Instituted a system of standing orders and self-referrals, allowing women to call the central scheduling office directly to schedule their mammograms;
• Set up a computerized automated reminder system to notify women when they were due for a mammogram, to improve compliance;
• Began to offer women the option of scheduling their pap smear and mammogram on same day, for convenience; and
• Dramatically reduced wait times.

In the process, the program also improved patient satisfaction.

In addition, the group mobilized the call center staff to contact patients who were overdue for routine mammography; they began to call the targeted women and use the standing orders to immediately schedule their appointments. Mammogram backlogs were also identified and referred to administrative leadership, and as a result, capacity was increased at two sites to handle the higher volume.

DM9 Program
The DM9 program was designed to target diabetic patients with poor control of their disease. It represented a move from process improvement (which tracked, for example, how many patients received HgbA1c screening) to more complicated outcome improvement. Nearly 50 percent of these patients are now under better control since implementation of the plan, and the results have been sustained over time.

• 35% increase in chlamydia screening in eligible patients in just three years
• 28% improvement in asthma controller use, resulting in better patient management and less frequent asthma exacerbations
• Childhood immunization rates, already high, continued to improve almost to 100% for some vaccinations
• Cervical cancer screening rates ranked first in the entire state in 2005, a 10% improvement since 2003 that benefited more than 1800 additional women
• In April 2007, medical group overall patient satisfaction hit its highest mark since the inception of the program