Sentara Healthcare`s David Maizel, MD, on managing business and
Transcription
Sentara Healthcare`s David Maizel, MD, on managing business and
FALL 2011 A publication of HFMA Learning Solutions, Inc. A subsidiary of the Healthcare Financial Management Association Sentara Healthcare’s David Maizel, MD, on managing business and clinical risks FOR >>Retooling VALUE >>AVOIDING PATIENT HARM >>NAVIGATING THE REGULATORY Maze >>USING TECHNOLOGY TO IMPROVE DECISION MAKING 0)%(-2+8,);%=8,639+,%',%2+-2+0%2(7'%4) -XXEOIWEXLSYKLXJYPETTVSEGLXSREZMKEXIXLIX[MWXWERHXYVRWSJXLIGYVVIRXLIEPXLGEVI IRZMVSRQIRX2EZMKERX´WLIEPXLGEVITVSJIWWMSREPWLIPT]SYPIEHWXVEXIKMGEPP]3YVHITXLSJ MRHYWXV]I\TIVMIRGIERHTVSZIRQIXLSHWJSVVIHYGMRKGSWXW[LMPIMQTVSZMRKUYEPMX]KMZI ]SYXLITS[IVXSIZSPZI]SYVSVKERM^EXMSRQSVIUYMGOP]ERHTVSEGXMZIP]0IEVRQSVI EFSYXGVIEXMRKTSWMXMZIGLERKIEWQIEWYVEFPIEWMXMWWYWXEMREFPI REZMKERXGSQLIEPXLGEVI + ( $ /7 + & $ 5 ( 1$9,*$17&2168/7,1*,1&$//5,*+765(6(59('1$9,*$17&2168/7,1*,6127$&(57,),('38%/,&$&&2817,1*),50$1''2(61273529,'($8',7$77(672538%/,&$&&2817,1*6(59,&(66((1$9,*$17&2168/7,1*&20/,&(16,1* )25$&203/(7(/,67,1*2)35,9$7(,19(67,*$725/,&(16(6 This Is Not a Drill There’s an old morality puzzle: An art museum is on fire, and the firemen can make only one trip into the blazing building. They must choose what to save: a few of the museum’s most valued paintings or a stranded elderly woman. Of course, the firemen should save the woman. Yet, many people, while commending the firemen’s decision, would also grieve the loss of the art. Anyone who has ever been moved by a Van Gogh or a Warhol understands the intrinsic value that art evokes—not only to individuals but to the community as a whole. Wasn’t there some way to save the woman and the art? If museum directors had planned ahead and instituted precautions, could the fire have been prevented or at least contained? On the surface, a healthcare organization and a museum have little in common. Yet each has obligations to individual patients/patrons and to the community at large. If a hospital or physician practice burns down—or folds for financial reasons—the community would lose a valued asset: a source of jobs, community education, and local pride. As we all know, the healthcare industry is in the midst of cataclysmic change: cuts to Medicare and Medicaid, the transition to value-based payment, record-breaking mergers and acquisitions, and on and on. In other words, fireballs are flying from every direction. One reaction is to cite the futility of planning because so much is in flux. This issue of Leadership is about the reverse philosophy: To manage a raging fire, you need to erect the necessary safeguards while also investing in a future vision, forming needed partnerships, empowering staff, and tracking performance. Fireballs are flying from every direction… A commitment to value—improving quality and reducing costs—is a common risk strategy among the providers in this issue. For example, rural health system Winona Health has merged with local physicians and redesigned its service lines—reducing its 30-day readmission rate to just 2.2 percent, compared to the 18 percent national average (page 16). Another example: Sentara Williamsburg Medical Center has not had a single ventilator-associated pneumonia incident in more than seven years (page 22) On the outpatient side: Consultants in Medical Oncology and Hematology (CMOH) has helped its patients avoid more than $6.5 million in hospital and emergency department charges in 2010 by proactively managing common symptoms related to cancer treatments and underlying diseases and conditions (page 24). The case studies in this issue celebrate the rewards of planning and persistent follow-through. “We’re bending the healthcare cost curve by eliminating unnecessary expenditures,” says CMOH’s John Sprandio, MD. “This is better care for our patients, and less expensive care.” The lesson: It is possible in these risky times to keep patients safe while also securing your organization’s future (in the same or some altered form). But not without a well-executed plan. Managing Business and Clinical Risks Sections 6 Retooling for Value How healthcare organizations are reorganizing, merging, partnering, and redesigning with the goal of increasing value. Featured providers: St. Anthony’s Medical Center, St. John Providence Health System, St. John Providence Partners in Care, Sentara Healthcare, and Winona Health. 20 Avoiding Patient Harm How providers are reducing the likelihood that patients will suffer unnecessary infections, side effects, and other harm—while improving clinical and financial outcomes. Featured providers: Sentara Healthcare, Consultants in Medical Oncology and Hematology, St. John Hospital and Medical Center, and Ascension Health. 36 46 Navigating the Regulatory Maze How healthcare organizations are addressing the challenges involved in converting to ICD-10, complying with HIPAA, and meeting other regulatory challenges. Featured providers: St. Anthony’s Medical Center, Halifax Health, Borgess Medical Center, and Ascension Health. Using Technology to Improve > Decision Making How providers are leveraging EHRs, staffing software, and other technology to gain the intelligence needed to formulate the best business and clinical decisions. Featured providers: St. Anthony’s Medical Center and Sentara Healthcare. i$POJGFS)FBMUIJNQSPWFE UIFmOBODJBMQFSGPSNBODFPG PVSIPTQJUBMTJNNFEJBUFMZw 6FDQZLWK\RXU45&RGH$SS 6HQLRU9LFH3UHVLGHQWRI 2SHUDWLRQV 7HQHW+HDOWKFDUH&HQWUDO5HJLRQ+RVSLWDO1HWZRUN +)0$VWDII DQGYROXQWHHUVGHWHUPLQHGWKDW &RQLIHU·V%XVLQHVV2IÀFH0DQDJHPHQW6ROXWLRQV PHWVSHFLÀFFULWHULDGHYHORSHGXQGHUWKH+)0$ 3HHU5HYLHZ3URFHVV+)0$GRHVQRWHQGRUVHRU JXDUDQWHHWKHXVHRI WKLVSURGXFW &RQLIHU+HDOWK6ROXWLRQV,QF$OO5LJKWV5HVHUYHG 4 LeaDERSHIP HFMA.ORG/leadership www.hfma.org/leadership Editorial and Production Editor-in-Chief Robert Fromberg Technical Director Todd Nelson Advertising Representatives and Offices Central Cindy Dudley CLD Associates Tel: 847-295-0210 Fax: 847-574-5836 [email protected] East Coast Michael D. Stack MDSassociates Tel: 847-367-7120 Fax: 847-276-3421 [email protected] Southeast Steve Roth Powercast Media Tel: 520-742-0175 Fax: 847-620-2525 [email protected] Managing Editor Maggie Van Dyke Contributing Writer Lola Butcher Production Todd Douglas, Bold Yellow Advertising Production Manager Ellen Joyce B. Tarantino Photography Front cover: Roberto Alessio Internal images: Studio/lab Advertising and Sponsorship Director of Advertising and > eLearning Sales Chris Burke Phone: 708-492-3392 [email protected] Sponsorship Account Executive Kurt Belisle Phone: 815-549-1034 [email protected] Advertising Associate Carolyn Johnson Phone: 708-492-3310 [email protected] FALL 2011 West Coast Thomas R. Reil JJH&S Tel: 415-721-0644 Fax: 415-721-0665 [email protected] Leadership (ISSN: 1948-089X) > is published by: HFMA Learning Solutions, Inc. 2 Westbrook Corporate Center, Suite 700 Westchester, IL 60154 Phone: 708-531-9600 The Leadership initiative includes a print magazine that is published three times a year, a monthly e-newsletter, a website, special reports, and webcasts. Sign up to receive the free monthly e-newsletter—and regular updates— at www.hfma.org/leadership. ©2011 HFMA Learning Solutions, Inc., a subsidiary of the Healthcare Financial Management Association. Material published in Leadership is provided solely for the information and education of its readers. HFMA Learning Solutions, Inc. does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions in the articles are not those of HFMA Learning Solutions, Inc. 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SA E TH E D LEADERSHIP CONFERENCE V the A DRIVING VALUE MANAGING THE TRANSITION M A RC H 29 – 3 0, 2 0 1 2 JW Marriott, Chicago TE on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eaDERSHIP HFMA.ORG/leadership Retooling for Value Heeding calls for more accountability, four progressive healthcare organizations are already knee-deep in colossal change—reorganizing, merging, partnering, and reengineering—with the goal of differentiating themselves on quality and cost. 8 LeaDERSHIP HFMA.ORG/leadership A common complaint among leading-edge providers is the difficulty of keeping one foot in the envisioned future—where providers are paid based on performance—and one foot in the current fee-for-service system that still pays primarily on volume. “That is a challenge for all healthcare organizations right now,” says David R. Maizel, MD, corporate vice president, Sentara Healthcare and president of Sentara Medical Group. “How do we straddle this transition?” That transition looks even more precarious when other unknowns are factored in, including how many additional insured will be added to the ranks, how much reimbursement will actually decline, and whether bundled and other performance-based payment approaches will actually work in the real world. Yet the providers in this section are managing to keep a firm footing. While acknowledging the risks, they are investing time and dollars in major change initiatives designed to help them achieve patient-centered visions of higher quality, lower cost, and coordinated, populationbased care. While each provider in this section has a unique story to tell, similar strategies are being used by many (see Common Approaches on this page). One of these tactics: Building better partnerships—and trust— between hospitals and physicians, as illustrated in this first case study about St. Anthony’s Medical Center. Case Study: Giving Physicians Control > of A Cardiac Service Line St. Anthony’s Medical Center, a 767-bed hospital in suburban St. Louis, has heavily invested in its cardiac service line in recent years. In 2008, St. Anthony’s opened a new Heart and Surgical Pavilion—a four-story “heart hospital within a hospital.” It has also been steadily expanding its offerings of state-of-the-art diagnostics and treatments, including minimally invasive heart surgery and radiofrequency ablation. >> Common Approaches A number of similar reinvention strategies are being employed by the providers in this section. >>Building strong partnerships between hospitals and physicians via employment and comanagement, contracting arrangements, technology support, and practice acquisition >>Establishing mutual trust; two providers stress the importance of developing guiding principles (e.g., core values, goals) to help frame hospital-physician partnerships >>Restructuring service lines to reflect how patients actually use and view healthcare services—versus traditional silo-based organizational structures >>Merging and acquiring to create integrated continuums of care >>Redesigning ambulatory and primary care practices into medical home models >>Investing in EHRs, HIEs, and other IT to support crosscontinuum collaboration >>Shifting from a hospital-centric culture to population health management But the most innovative change occurred this past January, when St. Anthony’s partnered with 11 cardiologists to create the Heart Specialty Center. The newly employed physicians, who now sit on the hospital management team, are specifically responsible for the governance, finances, operations, and clinical care of the medical center’s cardiovascular service line—which includes interventional radiology and vascular surgery in addition to cardiac care and cardiovascular surgery. In addition, the cardiologists manage a hospitalowned outpatient practice. Because their authority spans outpatient and inpatient care, they are able to coordinate the continuum of services for their patients, from prevention and diagnostics to treatment and rehabilitation. David Morton, MD, medical director of the Heart Specialty Center, says the physicians want their success to be measured by improved quality scores and complication rates, as well as cost-saving decreases in lengths of stay and unnecessary readmissions. Morton initiated the effort that brought the hospital and physicians together. In his former position as president of a large cardiology private practice, he had become frustrated with the competitive and uncooperative relationships between hospitals and physicians. “We all feel strongly that unless physicians are involved in running and organizing an entire service line—both inpatient and outpatient—we will never be able to attain high clinical quality while also improving efficiency and lowering costs,” he says. 9 During their search for a hospital partner, Morton and his fellow physicians were offered—and rejected— hospital management contracts in which they could have maintained their private practice. They held out for an employment arrangement with St. Anthony’s because Morton believes it seals the fates of the physicians and hospital together. “It was a big step for St. Anthony’s to basically give up control of the entire cardiac service line— nearly 40 percent of hospital revenues,” says Morton. “At the same time, we physicians gave up our freedom to go back into private practice when we cut our ties with our old cardiology group. We are both stepping off the cliff together.” St. Anthony’s did not buy the cardiology group that Morton founded; rather, the hospital hired 11 members of that practice. The physicians’ compensation is tied to their performance. In the hospital’s FY12, says Morton, their pay will be based in part on how well the service line performs on 10 surgical and medical quality measures and goals, including decreased mortality for bypass surgery patients. As head of the Heart Specialty Center, Morton reports directly to St. Anthony’s CEO. The Center’s executive director, who manages day-to-day operations, reports to Morton. The Center is governed by a nine-member strategic council comprised of seven physicians, the Center’s executive director, and St. Anthony’s CEO, who serves as liaison between the heart program and other hospital administrators. “It was a big step for St. Anthony’s to basically give up control of the entire cardiac service line. At the same time, we physicians gave up our freedom to go back into private practice.” Reducing supply costs In addition to attracting patients to St. Anthony’s, the physicians are willingly identifying ways to reduce costs. “Given declining reimbursements for physicians and hospitals, it is in our best interest to ensure that we reduce costs in a way that will actually increase the quality of care,” says Morton. “We are able to use the monies that we save by reducing inefficiencies and supply costs to expand our facility and to improve care.” One of the first targets for cost savings: supplies. Interventional radiologists, vascular surgeons, and the cardiac catheterization laboratory at St. Anthony’s had historically contracted for supplies and medical devices separately, which led to triple inventories for common items, such as interventional catheters, stents, and pacemakers. Now that all three specialties are using common supplies, hospital materials management staff have been able to negotiate volume-based price discounts on these supplies, which is expected to save at least $1 million a year. Although the relationship is too new to analyze ROI implications, John Skeans, St. Anthony’s CFO and vice president of finance, likes what he sees so far. “Partnering with physicians does not always make sense. But given the quality of this group of cardiologists—all of whom can demonstrate proven positive outcomes—this is a financial win for us,” he says. Probability of Physician interest in alignment by model Percentage of physicians interested in more closely integrating with a hospital 42% Uninterested 58% Interested in closer hospital alignment The alignment models that physicians are most interested in pursuing in the next two years Directorships, stipends, and contracts 51% 46% Employment Joint venture of services 38% Comanagement Leasing 34% 21% Source: PwC Health Research Institute Physician Survey, 2011. Reprinted with permission. Data from PwC Health Research Institute 2011 survey of more than 1,000 physicians. LeaDERSHIP FALL 2011 Building the relationship 10 LeaDERSHIP HFMA.ORG/leadership Leading the change Photo: St. Anthony’s Medical Center. Reprinted with permission. The most important lesson learned, Morton says, is that the traditional distrust between hospital administrators and physicians must be overcome for a true partnership to be achieved. In St. Anthony’s case, the physicians and hospital leaders developed a set of guiding principles before they started negotiations, and Morton says that has proved to be invaluable. By agreeing to core values, goals, and a mission for the Heart Specialty Center in advance, all parties had a framework that made decisions about financial, governance, and operational issues much easier. “For this to work, both of you have to say, ‘Okay, this is something that we are going to do together as an entity, working together,’” says Morton. Cardiovascular surgeon James Scharff, MD, performs complex surgeries in a dedicated cardiovascular surgical suite AT St. Anthony’s Medical Center. Case Study: Organizing Community Physicians To Manage Populations The cardiologists St. Anthony’s hired had measured and benchmarked their quality of care over a number of years. “It’s one thing to say you are good; it’s another to have the data to show it,” says Morton. Keeping the patient in mind Morton and his colleagues have organized the Heart Specialty Center with the goal of providing patientcentered care. “Hospitals are traditionally set up to run the way that the hospital wants, but not necessarily the way patient care is carried out,” says Morton. “We have totally flipped that backwards so that now we are flowing with the patient.” In the past, for example, staff members in the preoperative area, operating room, cardiovascular intensive care unit (ICU), and telemetry unit had each reported to a different manager, which set up opportunities for conflict. Now all staff members who serve a cardiac surgery patient report to a single manager. Similarly, the physicians are adjusting staffing patterns to improve patient outcomes and ensure nurses spend more time at the bedside. In the cardiac cath lab, for example, administrative functions that were being performed by ICU-level nurses have been assigned to other staff members, freeing the nurses to focus on patient care. Morton advises making organizational changes incrementally to give staff time to adjust to the new way of doing business. “I think the restructuring has been hardest on middle management,” he says. “There is a long history of the way hospitals operate, and this is a foreign concept for many managers.” Like St. Anthony’s, St. John Providence Health System in southwest Michigan employs physicians (about 400); however, the vast majority of its medical staff are independent practitioners. Instead of hiring more physicians, the five-hospital system is working with its physician-hospital organization (PHO) to create a situation that will allow medical staff members to remain independent and participate in the accountable care movement. A major payer in the area, Blue Cross Blue Shield of Michigan (BCBSM), is pushing hospitals and physicians to create organized systems of care (OSC), which is the Michigan Blues’ twist on the accountable care organization (ACO) model. BCBSM plans to offer financial incentives to highly functioning OSCs by 2013, and St. John Providence Health System, which is part of Ascension Health, is getting ready. Guiding Principles for Organized Systems of Care >>An organized system of care (OSC) is a high-performing healthcare system with accountability for managing the delivery of healthcare services to a defined population of patients >>The patients attributed to a community of primary care practices define the population served by the OSC >>An OSC serves the needs of a community of patients in an effective and efficient manner across care settings and over time >>OSCs deliver effective, high-quality care consistent with Blue Cross Blue Shield of Michigan’s patient-centered medical home standards and Institute of Medicine standards >>OSCs focus on improving population health, enhancing patient experience, and reducing cost >>OSCs acquire and manage the tools and infrastructure needed to operate effectively Source: Blue Cross Blue Shield of Michigan. Reprinted with permission. 11 Building on the medical home Similarly, compared to traditional practices, these medical homes have achieved the following. NN A 7.5 percent lower rate of use for adult high-tech scans, such as magnetic resonance imaging NN A 9.9 percent lower rate of adult ED visits NN A 3.8 percent higher rate of generic drug prescriptions The insurer’s vision is to expand its medical home initiative so that primary care physicians, specialists, and hospitals work together to coordinate services for a defined patient population. “The OSC work that we plan to do for the next five years is going to build on that patient-centered medical home foundation that has been developed over the past few years with the Michigan provider community,” says Tom Leyden, director of Value Partnerships at BCBSM. Because BCBSM holds so much market share—dominating 70 percent of the commercial market in the greater Detroit area—its initiatives have a powerful influence on the state’s healthcare scene. For example, BCBSM has the nation’s largest patient-centered medical home effort. Using its own criteria, the payer began designating medical homes in 2009—and about 2,500 physicians have already achieved the Blues’ medical home designation. More than 200 of those designated Many things in life are unreliable. medical home practitioners are St. John Providence physicians, and others are working to meet the medical home criteria. “We continue to push as many of our physicians as we can to move in this direction because we think it’s going to be a requirement for being able to deliver on the Triple Aim of improving the experience of care, improving the health of populations, and reducing the per capita cost of health care,” says Eathorne. (The Triple Aim is a program of the Institute for Healthcare Improvement; www.ihi.org.) An initial assessment by BCBSM of its medical home program suggests Duke Realty isn’t one of them. that the model is delivering on its Few things are certain in life. But at Duke Realty we’re committed to promise of reducing costs by keeping consistently providing first-class real estate services you can depend on. patients healthy and avoiding compliWith more than 20 years in the healthcare real estate business, we have cations. Michigan medical home the expertise, flexibility and vision to handle all your real estate needs — practices had a 22 percent lower rate of from planning and development to ownership and management. adult inpatient admissions for condiPlus you can rely on us to deliver what we say we’ll do. In fact, in the tions that could have been managed by midst of one of the worst economic climates in recent history, Duke Realty was recognized by Forbes.com as one of the nation’s most trustworthy good outpatient care in 2011 than companies, a testament to our commitment to reliability. traditional primary care practices. With all of life’s little uncertainties, isn’t it nice to know you can count on Duke Realty? RELIABLE. ANSWERS. dukerealty.com/healthcare LeaDERSHIP FALL 2011 St. John Providence’s PHO—St. John Providence Partners in Care—is taking the lead on organizing about 2,200 physicians to participate in a St. John Providence OSC, while the health system is spearheading the technology investment and adoption needed to deliver organized and accountable care. “There is a lot of uncertainty around accountable care, and with that comes a lot of concern,” says Scott Eathorne, MD, medical director for the PHO. “But these effective partnership arrangements are keeping us focused on setting up the right structure for success.” 12 LeaDERSHIP HFMA.ORG/leadership To encourage hospitals and physicians to prepare for OSC contracts, BCBSM launched two OSC-specific initiatives this summer: systemwide patient registries and performance measurement across the continuum of care. A third initiative—care processes that span the OSC—is planned for early 2012. Sharing Technology Clinical IT is obviously key to the coordination of care that is at the heart of medical homes and ACOs, and St. John Providence has taken the lead on getting the IT infrastructure in place. The five hospitals in the St. John Providence Health System began using an electronic health record (EHR) about three years ago, and computerized physician order entry was installed this summer. While some affiliated physicians have acquired their own EHR technology, or used some IT tools made available by the health system, there has been no attempt to broadly connect the hospital and physicians—until now. The health system worked with St. John Providence Partners in Care, the PHO, to develop a comprehensive ambulatory clinical IT strategy that is getting under way this year. This includes a health information exchange (HIE), EHR, disease registry, e-prescribing, and a patient portal. “This will facilitate communication between providers, between the providers and the hospitals, and ultimately, between providers and patients through the patient portal,” says Eathorne. The goal of the new strategy is to have about 1,000 physicians who collectively manage the health of nearly 120,000 lives connected electronically by 2013. “There is a lot of uncertainty around accountable care, but these effective partnership arrangements are keeping us focused on setting up the right structure for success.” All physicians who contract with insurers through the PHO will be expected to adopt technology that allows them to share patient data, although a range of options will be permitted. Those physicians who have their own EHR systems, for example, may use the HIE; others may only use the disease registry function. Within the limitations allowed by law, St. John Providence is subsidizing the cost of the ambulatory EHR system. BCBSM and other payers are also providing financial incentives to encourage technology adoption, says Eathorne. BCBSM pays incremental bonuses to physicians as they add IT capabilities, such as patient registries or patient portals, that are associated with improved efficiency and quality of care. In addition, the PHO is working with physicians to help them become eligible for meaningful use subsidies. Top Challenges to Medical Home Transformation Percentage of responding patient-centered medical homes (PCMHs) that cited these issues as considerable or extreme challenges Projecting financial effects (practice revenue, costs, etc.) of the transformation to PCMH 36.0% Modifying or adopting an EHR system to support PCMH-related functions 37.5% Coordinating care for high-risk patients 38.0% Financing the transformation to PCMH Establishing care coordination agreements with referral physicians 42.9% 50.8% Source: The Patient-Centered Medical Home: 2011 Status and Needs Study, Medical Group Management Association (MGMA), 2011. Reprinted with permission. Data from 2011 MGMA survey of 341 medical practices. 13 Leaders of the St. John Providence Partners in Care PHO must get more than 2,000 physicians, most of whom are self-employed, to agree on a new way of doing business—which is no small task. For Eathorne, the experience has proved the value of establishing a vision and guiding principles. The vision for the St. John Providence OSC is to establish a partnership that takes advantage of the size of the physician network and the size and geographic scope of the St. John Providence Health System, as well as its relationship with its parent Ascension Health. To operate as an OSC, the physicians and hospital must figure out how to share governance, reduce wasteful procedures and diagnostics, coordinate care to improve patients’ outcomes, handle financial risk, distribute money, and get around other thorny issues that can be difficult to negotiate. “People ask, ‘Why are we doing this?’ By having established that driving vision, we continue to remind ourselves of what we wanted to do collaboratively, and then we can work through some of these difficult issues,” he says. One key to establishing the OSC framework for an effective partnership was bringing the six physician organizations that contracted under the PHO together around a common cause. The result of that effort was the formation of The Physician Alliance, a new physician organization serving the nearly 2,200 St. John Providenceaffiliated providers. A 50-50 partnership between The Physician Alliance and St. John Providence Health System is the foundation of the PHO. Various PHO committees are working through the details and establishing the relationships needed to better organize care and finetune the business model, says Eathorne. Another lesson: The changing dynamics in health care require new ways of thinking. Hospitals’ traditional status as the hub of the healthcare system may change in the accountable care era, when the payment system rewards physicians for keeping patients out of the hospital. “We are building this continuum of care that recognizes that individuals are best served when they have a longitudinal relationship with their primary providers,” says Eathorne. “It’s each hospital’s responsibility to understand its role in the continuum, and that, for the most part, inpatient care is a small part of the overall healthcare needs of any given individual.” That said, creating a partnership in which both the hospitals and physicians thrive together is essential to the success of an OSC. “Our goal here is not to put anybody in the red,” he says. “It is to work together so that, overall, we are well-positioned for when the full-scale change in the payment structure really occurs.” Case Study: Moving Toward a Coordinated Population-Based Approach Similar to St. John Providence, Sentara Healthcare, a 10-hospital system based in Norfolk, Va., had its eyes set on becoming an ACO. But then it saw the Centers for Medicare & Medicaid’s proposed ACO rule for the Medicare Shared Savings Program. The term “ACO” went out the window because Sentara leaders believe that the government’s proposed rule presents too many barriers to success. But the health system’s commitment to accountability remains strong. “What we talk about now is the need to do a better job of integrating all the key stakeholders into a model that will move us away from a fragmented approach to care to a much more coordinated approach to care,” says David R. Maizel, MD, the system’s corporate vice president and president of Sentara Medical Group. The health system’s strategic plan includes three imperatives (see the exhibit below). NN Score in the top 10 percent of all health systems on performance metrics related to clinical quality, patient satisfaction, employee engagement, and financial stewardship NN Grow through acquisitions NN Transform care delivery to ensure coordinated population health management Sentara’s EHR is a key component to these three strategies. The EHR—which already connects most of its hospitals, physician offices, and other care sites—is creating efficiencies and quality improvements that many health systems only dream about (see Section 4, page 50). Sentara’s 2010-2012 Strategic Goals Score in top 10% on performance metrics Transform care Vision Grow through acquisitions Source: Sentara Healthcare. Reprinted with permission. LeaDERSHIP FALL 2011 Setting a Vision 14 LeaDERSHIP HFMA.ORG/leadership “The first imperative is to be considered in the top 10 percent of health systems in everything that we do.” That technology—and the new levels of knowledge it brings because of the ability to capture and analyze data—is being used to create the optimal patient experience. “Everything that we’re doing from a transformation standpoint is really driven by our goal of being patient-centered,” says Maizel. Transforming care delivery As it moves from a fragmented care model to a more comprehensive, coordinated approach, Sentara is designing services around four specific patient groups: NN Healthy individuals who have occasional, minor acute problems and should mostly focus on wellness and preventive services NN Patients with one or two chronic illnesses who are generally stable but require management NN Patients who have multiple chronic conditions, some of which exacerbate one another, and require extensive management NN Persons with severe illnesses, such as cancer, that require intensive treatment, and those near the end of life who should have advanced care plans that guide decisions about treatment and palliation Setting high goals Hoping to differentiate itself on quality and cost—and reap pay-for-performance rewards and contracts from payers—Sentara aims to prove itself a top performer in four domains: NN Clinical quality and safety NN Patient satisfaction NN Employee engagement NN Financial stewardship “The first imperative is really to be considered in the top 10 percent of health systems in everything that we do,” says Maizel. Sentara has already achieved that status on some patient safety measures, thanks to a systemwide initiative that dates back to 2002 (see Section 2, page 22). Since that time, central line-related blood stream infections have been reduced by 90 percent across all Sentara hospitals, and ventilator-associated pneumonia has declined by 98 percent. Sentara, which tallied operating revenues of $3.39 billion for FY10, reported a 5.6 percent operating margin for the year. The system also enjoyed an employee-satisfaction win for the year when its survey vendor issued a “workplace excellence” award in recognition of high scores that reflect an engaged workforce. The award is given to fewer than 5 percent of the vendor’s clients. “We are identifying specific patient populations and how to really optimize the patient experience for those populations in the most cost-effective way,” says Maizel. To move toward this population health management model, Sentara started with an initiative to redesign primary care, converting practices it owns into patientcentered medical homes. The main goals are to build capacity so as to increase patient access and improve outcomes by serving patients in new ways. For example, the medical home practices now offer group visits for patients with certain chronic illnesses, such as diabetes. These give patients the opportunity to learn from each other, while freeing physicians to devote more time to managing each patient’s specific health needs. Providers in the pilot practices were initially concerned that the redesign would impact their productivity, and they were skeptical about patients’ reaction to the changes, says Maizel. “Our results from tracking the data demonstrate no reduction in productivity. In fact, access has improved,” he says. “And patients have noticed the changes and have commented on how much more engaged the staff is in meeting their needs. Patient satisfaction scores remain strong.” Additionally, the medical home practices have improved patient scheduling to accommodate same-day appointments, which help keep patients from going to the emergency department (ED) for urgent—but not emergency—conditions like earaches and sinus infections. Same-day appointments also allow patients with congestive heart failure and other chronic illnesses to receive immediate care, which may head off deterioration that would require hospital treatment. In a pilot for the redesign work at two practices, same-day appointments increased by 97 percent. We see solutions™ MedAssurant offers an integrated suite of comprehensive data analytics, care enhancement, and quality improvement services to health care organizations seeking to improve outcomes, lower costs, and ensure payment & claims integrity. Data-Driven Improvements in Health Care™ 301-809-4000 ext. 4321 www.medassurant.com 16 LeaDERSHIP HFMA.ORG/leadership The medical home model also helps keep patients who were recently discharged from the hospital from being readmitted. The percentage of patients who were seen by a primary care physician within seven days of a medical discharge doubled at one medical home pilot site and quadrupled at another. The result: 30-day hospital readmissions for patients with certain chronic conditions fell from 24 percent to 12 percent of inpatient discharges. Because Sentara’s eCare EHR system shares information between hospitals and physicians, primary care providers are notified immediately when one of their patients has visited an ED or been hospitalized. In one case, a primary care provider telephoned a patient before that patient was fully discharged from the ED, says Maizel. “The power of technology is pretty evident in a situation like that.” Five Sentara Medical Group clinics have completed the conversion to medical homes, and six others are in the process. By the end of 2012, all of the Sentaraowned primary care practices—about 15 to 20 percent of the primary care providers in the Norfolk-Virginia Beach area—will be redesigned, says Maizel. Expanding the improvement Converting its owned primary care practices to medical homes is just the beginning of Sentara’s redesign work. “We have started an outreach program to other primary care physicians in the market, regardless of whether they are independent, small practices, or members of larger group practices,” says Maizel. “Hopefully we can assist them in implementing some of what we have learned to help raise the bar in terms of how we are providing care to the citizens of our communities.” Beyond that, Sentara will be using lessons learned from the primary care conversions to help redesign its long-term care and home health services as the health system works to improve care across the continuum for all patient populations. “We really need to look at this longitudinally and across all venues of care— and how we transfer the care from one setting to the other,” he says. Growing to increase efficiency Sentara has acquired three hospitals in the past year, growing to become a system of 10 acute care hospitals, six outpatient care campuses, seven nursing homes, three assisted living centers, eight advanced imaging centers, and about 380 employed primary care and specialty physicians. More acquisitions are coming. Sentara’s leaders are looking for hospitals that have been successful in their markets but cannot afford the technology, quality, and clinical integration investments needed to succeed in the era of accountable care. “The reality is that Sentara can leverage the infrastructure that we currently have in place and deploy that to additional locations at a much lower cost than if an individual hospital was just trying to do it in one location,” says Maizel. “Partnering with us is a huge value-added proposition for both organizations as we come together and merge.” In the lead-up to a merger, Sentara spends a significant amount of time and energy doing an assessment of the cultural climate of all entities involved in the transaction. It also establishes an integration team with staff from both entities to address the various aspects of the merger, such as human resources, finance, and materials management. “It’s easy to assume the larger entity will dominate or exercise influence in all decisions,” says Maizel. “We have learned that each side brings value to the newly consolidated organization, and we need to be open and flexible in our approach.” Case Study: Integrating to Remain Independent Some observers believe that small, rural, independent hospitals will be unable to make the transition from fee-for-service medicine to value-based care delivery. The leaders at Winona Health, a fully integrated health system in Winona, Minn., think otherwise. The system includes a 99-bed hospital, a nursing home, and an assisted living community. Winona Health also employs 45 physicians, which is nearly the entire medical staff, since it consolidated with two physician practices. All components of the health system use the same EHR. Thus, Winona Health has assembled a well-rounded set of resources to deliver high-value health care. But the term “value” was not even in the healthcare vernacular when Winona started working closely with its medical staff to strengthen the community healthcare system. 17 Building for the community Several years ago, Winona Health extended an open-ended invitation to local physician practices. The system wanted physicians to know there was a local option if there ever came a time when they wanted to consolidate with a larger organization. “And that’s what happened—the time came,” says Allen. A large multispecialty practice merged with Winona Health in 2008, and one year later, a primary care practice followed suit. Winona Health’s primary motivation for acquiring the practices was to keep physicians locally employed in Winona, a community of about 28,000 residents. But the system’s leaders recognized that the consolidation of services would diversify and grow its revenues. We weren’t interested in just buying practices and then just having a bunch of different operations,” says Allen. “We were interested in truly having an integrated organization. Top-line revenue growth wasn’t our primary objective, but as we got into it, we understood there would be many benefits to the community if we did this well—and truly merged.” As the emphasis on value in healthcare delivery is becoming more pronounced, the wisdom of Winona Health’s willingness to integrate has become more clear. “Hospitals and clinics—or administrators and physicians—working together in the same organization is critical to success,” says Winona CEO Rachelle Schultz. “Whether you’re a small, rural, independent hospital or a large metropolitan system, the integration piece is going to be essential for the model that we need in the future.” Restructuring Service Lines In 2008, Winona Health reorganized its administrative structure into five service lines: NN Primary care services NN ED/urgent care services NN Inpatient services NN Surgical/specialty services NN Senior services “Whether you’re a small, rural, independent hospital or a large metropolitan system, the integration piece is going to be essential for the model that we need in the future.” Each service line is headed jointly by a full-time administrator and a practicing physician who devotes 20 percent of his or her time to service line administration. The primary role of the physician leader is to communicate, understand the needs of, and lead the rest of the medical staff through the change process under way in the healthcare system, particularly as it relates to the role of the physician in the future, says Schultz. “There is considerable physician input into the direction of the hospital and the initiatives we decide to put our time into,” says Brett Whyte, MD, the physician administrator for the ED/urgent care service line. For example, physician administrators work on protocol development, peer review, quality initiatives, and the hiring of provider staff. This organizational structure has proved itself through steadily improving clinical quality and efficiency, says Schultz. The hospital’s average inpatient length of stay has decreased in recent years, and its 30-day readmission rate is 2.2 percent, compared to the national average of more than 18 percent. Schultz attributes those successes to Winona Health’s coordination of services across the continuum of care. In addition, Winona Health has received pay-forperformance payments from insurers and from the federal government for its participation in the Physician Quality Reporting System and e-prescribing initiatives. Facing Challenges Just like other systems, Winona Health has found that some physicians are happy to give up the administrative hassles of running their practices in return for job security and more stable income, but they want the decision-making autonomy they have enjoyed in the past, says Whyte. LeaDERSHIP FALL 2011 The system’s leaders were working to ensure Winona had enough physicians to keep healthcare services local and focused on the community’s needs, says CFO Mike Allen. “Along the way, our fundamental goals of increasing our scope and preserving services for the community ended up presenting us with other opportunities that we didn’t even realize were out there,” he says. 18 LeaDERSHIP HFMA.ORG/leadership “Part of our jobs as physician-administrators is massaging the relationship with all providers into a place that works for both parties,” he says. The key, he has found, is involving physicians—and for that matter, nurses, orderlies, and all staff—in decision making so they are vested in making new initiatives work. For example, when Winona Health set a goal of attaining a Level IV trauma designation from the state of Minnesota, physician administrators tracked quality measures related to trauma management to show Winona Health’s performance, which helped staff members get on board. “Medical people like data and begin to believe in an initiative when they see improvement in the numbers,” says Whyte. Another challenge is the financial burden that came with merging with physician practices. “Beyond the acquisition costs, the biggest investment is the time it takes to build relationships, look for best practices, consolidate administrative functions, and assimilate cultures,” says Allen. “We have spent and continue to spend a lot of energy around all of these issues because they are drivers for success.” In today’s healthcare environment, the revenue produced by the typical outpatient clinic is not sufficient to pay the ever-rising costs of staff, equipment, utilities, and facilities needed to generate that revenue, says Allen. “But if you merge that physician clinic model into an integrated health system that already has a lab, radiology, surgery, and other services, you can find the efficiencies to help reduce or eliminate those losses,” he says. Long term, Winona expects to reap anticipated rewards. “The lesson is to commit to full integration, administratively and clinically, and trust that the efficiencies can be found to make the merger financially worthwhile,” says Allen. On the clinical side, Winona aims to achieve efficiencies and improve quality by creating a seamless continuum of care. “We’re trying to create the clinical processes that follow the patient according to his or her specific needs throughout the continuum of care— whether clinic to hospital to home care or to long-term care” says Allen. “These are not separate processes; it is one process of care delivered in different locations.” One step to achieving this seamless continuum: Developing evidence-based order sets for common complaints and diagnoses (for example, chest pain or shortness of breath) that can be used in various settings across the continuum. For example, if Whyte sees a patient with chest pain in the ED, he uses the same protocol that would be applied in an outpatient clinic or nursing home. “I now rely less on my memory to remember all the necessary tests or treatments that each patient needs,” says Whyte. All of these improvements reflect Winona’s goal of developing an integrated, coordinated model of care. Leaders of integrated health systems should understand the important role of ambulatory care in the healthcare delivery system as a whole. Hospitals are an important component but not at the exclusion of the rest of the system. Indeed, hospitalizations may signal the failure of meeting patient needs in the ambulatory setting, says Schultz. But today’s regulatory and payment environments make the hospital the dominant engine, creating a barrier to the culture change that needs to happen, she says. “It is a very difficult shift to make mentally because we’re operating in a hospital world when we really need to be operating in an integrated, crosscontinuum way,” says Schultz. >> Next: Avoiding Patient Harm Embracing integration opportunities Soon after Winona Health acquired the two physician practices, leaders instituted some changes to gain rapid economies of scale. For example, one of the first moves was to combine outpatient and inpatient laboratory and physical therapy departments. Winona Health’s hospital and clinic business offices have also been combined and will soon be using a single information system that manages the billing processes for inpatient and outpatient services. The goal: By 2013, Winona Health will be able to produce a single patient-friendly bill that includes ambulatory and hospital charges, says Allen. Key steps to achieving this goal include re-mapping the revenue cycle, creating standardized work processes, consolidating and integrating billing systems with the EHR, and automating as many steps as possible. Providers are reducing patients’ risks of suffering unnecessary infections, side effects, and other harm—while improving their organizations’ performance on quality and financial metrics. See Section 2, page 20. 20 LeaDERSHIP HFMA.ORG/leadership Avoiding Patient Harm Now that payers are beginning to tie payment to performance, the ROI for preventing patient harm extends beyond the moral and ethical payback. However, as these three providers stress, the primary motivation for improving patient safety is still immensely personal and altruistic. 22 LeaDERSHIP HFMA.ORG/leadership Providers have never needed a business rationale for trying to minimize the potential harm—including hospital-acquired infections, treatment side effects, and unnecessary hospital admissions—that can occur to patients. Primum non nocere, afterall, is a core medical ethic. Physicians, nurses, and all clinicians are motivated to “first, do no harm.” But the individual healthcare professional, no matter how committed to patient safety, can only do so much to reduce hospitalwide infection rates or communitywide emergency department (ED) visits. As the case studies in this section illustrate, systematic approaches—from a leader-driven safety commitment to the adoption of evidenced-based protocols—are required to achieve dramatic reductions in indicators of patient harm. Payment system changes and increased transparency are beginning to provide business rewards for investing in efforts to improve scores on metrics related to quality and patient safety. On the government front, Medicare’s new Inpatient Value-Based Purchasing Program will reward hospitals that provide high-quality care—and penalize those that do not. Private payers are following suit with similar performance-based contracts with providers. At the same time, patients can now go online and compare hospital-acquired infection, mortality, and readmission rates among providers in their communities—giving organizations another business rationale for making value-driven investments in patient safety. >> Common Approaches Some similar approaches to reducing patient harm are being used by all three providers featured in this section. >>Creating an organizationwide culture of safety—while recognizing the need for decentralized approaches >>Relying on standardized protocols, checklists, and other aides to remember critical patient care steps >>Empowering physicians, nurses, and other staff to spot and respond as a team to potential patient problems >>Ensuring that at-risk patients receive proactive care management >>Spreading successful best practices across units, organizations, and systems Case Study: Empowering Staff > to Save Lives Half of the ventilator-associated pneumonia (VAP) cases that occur in U.S. intensive care units (ICUs) each year—about 20,000—could be prevented, according to the Partnership for Patients. But Sentara Healthcare’s VAP track record suggests that many, many more patients could be spared from this serious hospital-acquired infection. Since 2002, the VAP rate in the entire 10-hospital Sentara system has fallen by 98 percent, from 124 VAP infections per year to the current rate of just two per year. One of the system’s hospitals—Sentara Williamsburg Medical Center—has not had a single VAP incidence in more than seven years. Most other hospitals in the Sentara system, which serves parts of Virginia and North Carolina, are also marking off multiple years with zero VAP incidents. Spreading a culture of safety These successes at Sentara Healthcare stem from a patient safety initiative launched at the system’s largest facility, Sentara Norfolk General Hospital, in 2002. An assessment identified three common problems that were contributing to safety incidents at Sentara Norfolk, according to a case study by The Commonwealth Fund (Klein, S. and McCarthy, D., Sentara Healthcare: Making Patient Safety an Enduring Organizational Value, March 15, 2011). NN Inadequate communication NN Noncompliance with policies NN Failure to recognize high-risk patient situations 23 After a successful pilot at Sentara Norfolk, this four-pronged program was expanded to the other Sentara hospitals in late 2003. Staffing for safety In addition to its zero-VAP record, 150-bed Sentara Williamsburg Medical Center in Williamsburg, Va. has had no central line-associated bloodstream infections in more than four years, and no urinary tract infections in more than two. John Kaiser, MD, the lead intensivist who works full-time in the hospital’s ICU, believes his job description contributes to the hospital’s patient safety record. Intensivists are critical care physicians who have special expertise in monitoring ICU patients. Some research has shown that ICUs managed exclusively by board-certified intensivists have significantly lower VAPs Down by 98 Percent > Across Sentara Ventilator-Associated Pneumonia (VAP) Rate/1,000 Vent Days 6.15 4.26 2.23 ‘02 ‘03 ‘04 1.57 ‘05 “Sentara has let me do my job, which is unusual in a large corporate structure.” mortality rates than ICUs with other staffing arrangements (Pronovost, P.J., et al, “Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review,” JAMA, 2002, vol. 288, no. 17, pp. 2151- 62). Despite the evidence that intensivists may save lives, only about 35 percent of hospitals responding to a 2010 Leapfrog Group survey had intensivists dedicated to the ICU during daytime hours. Kaiser and other physicians in a group practice used to share responsibility for covering the hospital’s ICU; Kaiser spent about half his time at the hospital and half in his office practice. In 2004, the hospital hired Kaiser to work five days a week in the ICU—with no other job responsibilities—while the other physicians in his former group practice provide night and weekend coverage, as needed. In the first quarter after hiring Kaiser, the ICU mortality rate at Sentara Williamsburg dropped by more than 30 percent. In addition, sepsis mortality, line infections, ventilator days, and ICU length of stay all went down. Just as telling: The ICU has maintained these positive outcomes since 2004. What exactly changed? “It was the same people taking care of the patients,” he says. “The only difference was I am here instead of taking calls, making rounds, and going back to the office.” The hospital pays Kaiser a fixed salary, which frees him from worrying about whether he is working enough billable visits and tasks. From the hospital’s perspective, that salary is covered many times over because, by improving patient safety, the ICU is eliminating the financial risks associated with hospitalacquired conditions and costly ICU stays. Sentara Williamsburg administrator Bob Graves points out that VAP increases ICU length of stay by at least five days. The cost of treating each VAP is estimated at between $11,800 and $25,000. Empowering staff 0.98 0.47 ‘06 ‘07 0.38 0.42 0.09 ‘08 ‘09 ‘10 Source: Sentara Healthcare. Reprinted with permission. Like other Sentara facilities, the Williamsburg hospital relies on standardized protocols, checklists, and other aides to remember critical and important patient care steps that help prevent VAP and other hospital-acquired conditions. However, the Sentara culture also recognizes physicians, nurses, and other clinicians as experts in their specific fields who are trained to spot and respond as a team to potential patient problems. LeaDERSHIP FALL 2011 This assessment informed the development of a Sentara-wide approach to patient safety, which includes four elements: NN Safety is a core organizational value, and safety performance influences the paychecks of Sentara’s top leaders, as well as frontline staff in each hospital NN Forty percent of the variable pay for Sentara’s top 100 leaders is linked to the system’s quality and safety measures, as are half of the performance measures in Sentara’s bonus program for frontline staff members NN All employees are encouraged to adopt safety habits that prevent errors (see the exhibit on page 24). NN Checklists, clinical protocols/guidelines, and other standardized tools are used to simplify work processes and limit the opportunities for human error NN Root-cause analysis is used to identify problems that contribute to safety incidents so that pinpointed solutions can be identified for systemic improvement 24 LeaDERSHIP HFMA.ORG/leadership Sentara Healthcare’s ErrorPrevention Toolbox >>Pay attention to detail: Follow the “stop, think, act, review” (STAR) method to focus attention and think before initiating a critical task >>Communicate clearly: Use repeat-backs and read-backs and ask clarifying questions to ensure that you understand requests >>Have a questioning attitude: If something doesn’t seem right, take time to figure out why >>Hand off effectively using a “5P” checklist: To ensure that all elements of a successful transfer are followed, the handoff should identify the patient/project, plan, purpose, problems, and precautions >>Never leave your wingman: Use peer checking and peer coaching as appropriate Source: The Commonwealth Fund, 2011. Reprinted with permission. “I encourage the ventilator techs to manage the ventilator flow,” says Kaiser. “Of course we discuss it, but if they are managing it, they are much more involved with what’s going on. If the nurses think they need to make a suggestion, they know I will listen to them. The more I listen to them, the more involved they become.” Kaiser’s perspective reflects one of Sentara Healthcare’s core strategies for creating a culture of safety: encourage “mindfulness” among staff members so they quickly recognize and respond to signals of emerging patient problems. “Sentara has let me do my job, which is unusual in a large corporate structure,” says Kaiser. Encouraging hospital-specific approaches While patient safety is a Sentara-wide goal, leaders have decentralized the how-to’s of patient safety, leaving many specific action steps up to each individual hospital. The Sentara hospitals share best practices, but each hospital has leeway in determining how it will meet its safety goals. For example, while some Sentara ICUs have dedicated intensivists, others use an electronic ICU remote monitoring system. The organization’s emphasis on safety has reduced the rate of serious safety events at Sentara hospitals by 80 percent between 2003 and 2010. At Sentara Williamsburg, Kaiser estimates that improved patient safety translates into 40 fewer deaths in the ICU each year than would be expected. Case Study: Reducing Cancer Care Complications Since converting to a patient-centered medical home, a Pennsylvania oncology practice has improved the care of its patients—and significantly lowered the overall costs of cancer care by doing so. “We’re bending the healthcare cost curve by eliminating unnecessary expenditures,” says John Sprandio, MD, lead physician at Consultants in Medical Oncology and Hematology (CMOH), Drexel Hill, Pa. “This is better care for our patients, and less expensive care.” When people talk about the potentially avoidable conditions associated with health care, they generally mean hospital-acquired infections, patient falls, blood clots, etc. While several common chemotherapy side effects—dehydration, diarrhea, nausea, and vomiting— are not entirely avoidable, they can potentially be managed to avoid severe debilitation and hospital intervention. Sprandio and his colleagues began reengineering their cancer care processes in 2004. Since then, the practice has demonstrated that it can keep cancer patients out of the hospital and the ED through proactive management of common symptoms related to cancer treatments, underlying diseases, and comorbid conditions. Indeed, the practice has reduced its patients’ ED use by 65 percent since 2004 and inpatient admissions by 43 percent since 2008. CMOH’s experience shows how an independent physician practice can dramatically change healthcare delivery. Between 2004 and 2010, CMOH patients had 55 percent fewer ED visits and 40 percent fewer hospitalizations compared to national benchmarks for chemotherapy patients. As a result, the oncology practice helped patients avoid more than $6.5 million in hospital and ED charges in 2010, according to a CMOH analysis. Significantly, the changes in care delivery did not negatively impact patient outcomes. The five-year survival rate for CMOH patients remains the same as the national average, just as it was before care processes were reengineered. Successfully Managing > Cancer Patients Consultants in Medical Oncology and Hematology has achieved the following. >>A 65 percent decrease in patient ED use since 2004 >>A 43 percent decrease in inpatient admissions since 2008 >>$6.5 million saved in avoidable hospital and ED charges in 2010 Source: Consultants in Medical Oncology and Hematology. 65> percent 43> percent 6.5> million 25 In 2010, CMOH became the first oncology practice to earn the National Committee for Quality Assurance’s (NCQA’s) imprimatur as a patient-centered medical home. All four CMOH locations have used electronic medical record technology since 2006, and they employ all the tenets of the NCQA’s medical home model. NN A team approach to patient care NN Care coordination NN Standardized clinical protocols NN Patient education, navigation, and engagement In addition to reducing costs for patients and payers, the medical home model is saving money for the oncology practice—specifically staffing-related costs. Nationally, on average, oncologists are supported by 8.2 support staff. In comparison, CMOH oncologists only rely on 5.5 support staff per physician. Sprandio attributes CMOH’s need for less support staff to three strategies: a team-based approach to care, the standardization of care protocols, and internally developed software tools. Just as primary care physicians are standardizing— and improving—the care of patients with diabetes, CMOH has improved the way it identifies and addresses a patient’s chemotherapy and cancer-related symptoms. For example, by standardizing the management of diarrhea, CMOH has experienced a 50 percent decrease “We think we are saving $8,000 or $9,000 a year per chemo patient because of the medical home model.” in patient admissions for the treatment of Clostridium difficile, a persistent bacteria that causes diarrhea. This has also resulted in fewer treatment delays related to that symptom. The practice has also standardized patient education, so that all members of the healthcare team provide patients with consistent information. Part of that education involves helping patients assume more responsibility by asking questions of their caregivers until they understand their medical situations. In addition, patients are taught to monitor their symptoms and promptly report troubling symptoms and side effects to CMOH nurses to avoid potential ED or hospital visits. CMOH nurses use symptom management protocols to address patients’ concerns—often over the telephone. For example, if a patient calls the phone triage line to ask about vomiting, the nurse will provide education on preventing dehydration, a side effect that frequently sends chemotherapy patients to the ED. LeaDERSHIP FALL 2011 Borrowing a primary care model 26 LeaDERSHIP HFMA.ORG/leadership For more than 75 percent of clinical calls, the patients manage their symptoms at home. Each CMOH office accommodates unscheduled visits, and about 10 percent of calls to the triage line result in such office visits. To date, one Medicaid health maintenance organization has an outcomes-based contract with CMOH that supports its medical home services, but Sprandio says national and local payers have expressed interest in innovative arrangements. He believes CMOH will enter into an oncology patient-centered medical home contract with performance-based payments and shared savings. “We think we are saving $8,000 or $9,000 a year per chemo patient because of the medical home model,” he says. “That is a conservative estimate, and it is substantial.” Case Study: Spreading Infection Prevention Successes Shortly after Ascension Health launched its systemwide Healthcare That Is Safe initiative in 2003, Mohamad Fakih, MD, asked the system to support a pilot project to reduce unnecessary urinary catheter use at his hospital. Fakih is medical director for infection prevention and control at Ascension’s St. John Hospital and Medical Center in Detroit. Catheter-associated urinary tract infections (CAUTIs) account for 80 percent of all urinary tract infections in hospitals, and are identified as avoidable hospital-acquired conditions. Although patients in ICUs often require catheters, these devices are frequently inserted—and remain in place—in non-ICU patients more out of habit than medical necessity. Noting that many urinary catheters at St. John did not have an appropriate reason for use, Fakih developed a program, with the help of multiple disciplines throughout the hospital, to educate nurses on how to reduce catheter use (see the exhibit below). At a Glance: Urinary Catheter Removal Program Nurse-initiated removal of unnecessary urinary catheters program Weeks 1-3 Week 4 Baseline: Collect urinary catheter prevalence with evaluation for indications (15 days). Prepare for implementation. Weeks 5 & 6 Implementation: Nursing staff education, daily assessment of urinary catheters, evaluation for indications, and discussion with nursing staff about removal of nonindicated catheters. Rationale given to obtain order to discontinue unnecessary urinary catheters with nursing (10 days). Weeks 7-12 After implementation: Urinary catheter prevalence, one day a week for six weeks (six days). Patient’s nurse to assess need for catheter on a daily basis. Quarterly Sustainability: Urinary catheter prevalence, one week quarterly (five consecutive days) for five quarters. Patient’s nurse to assess need for catheter on a daily basis. Source: St. John Hospital and Medical Center. Reprinted with permission. Data review and unit feedback 27 Spreading improvements St. John’s success in reducing urinary catheter use provides an example of how a systemwide patient safety program can inspire and support quality innovation at an individual hospital. In addition, it is an example of how a single hospital’s patient safety initiative can improve medical practice across a health system—and across the country. Since 2007, a toolkit that was developed through the St. John pilot has been used throughout Ascension Health, the nation’s largest not-for profit health system. This toolkit includes step-by-step guidelines, training posters, and other materials that help other hospitals adopt the St. John approach to reducing unnecessary urinary catheter use. The toolkit has also been adopted by the Michigan Health & Hospital Association (MHA) as a best practice for Michigan hospitals. Most recently, the Agency for Healthcare Research and Quality, in partnership with MHA, began promoting the toolkit as part of the national implementation of the Comprehensive Unit-Based Safety Program to Reduce CAUTIs. “This started with $70,000 and a lot of commitment,” says Fakih. Innovating at the local level St. John has addressed two types of inappropriate urinary catheter use: those that should never have been placed in the first place and those that were appropriately inserted but no longer needed. The direct costs added to a hospitalization because of a CAUTI are estimated at $500 to $1,000. But Fakih says even catheterized patients who do not suffer an infection may have longer inpatient stays—he estimates an additional 0.25 day because they cannot be discharged until they have urinated after catheter removal. Ann Hendrich, PhD, Ascension Health’s vice president of clinical excellence operations, says St. John inspired all other Ascension Health hospitals to follow its lead in reducing urinary catheter use. Nosocomial, or hospital-acquired, infections are one of Ascension Health’s priorities for action, identified in the health system’s Healthcare That Is Safe initiative. “These are things that we don’t want to have happen to us when we go in the hospital because they add needless harm, they are mostly preventable, and they cost the healthcare system and society a lot of money,” says Hendrich. Ascension Health’s Clinical Excellence Team, which includes representatives from all nine of the system’s regions, determines the best course of action for a specific safety issue—such as the reduction of urinary catheter use protocols developed at St. John—that falls under a priority for action. Each priority for action has an “affinity group”— clinical leaders and other key stakeholders from across Ascension Health—that is responsible for pushing the adoption of best practices to all the hospitals in the system. This roll-out approach is responsible for Ascension Health’s success in exceeding the original goal of the Healthcare That Is Safe initiative. As of 2010, the 70-hospital system had reduced preventable deaths by 1,500 people annually compared to 2004, and significantly reduced birth trauma and pressure ulcers, as well as hospital-acquired infections (Pryor, D., et al, “The Quality ‘Journey’ at Ascension Health: How We’ve Prevented at Least 1,500 Avoidable Deaths a Year—and Aim to Do Better,” Health Affairs, April 2011, pp. 604-611). >> Next: Navigating the Regulatory Maze Proactive providers are allocating time, attention, and financial resources to ensure their organizations comply with ICD-10, HIPAA, and other regulations. See Section 3, page 36. LeaDERSHIP FALL 2011 Ascension Health provided $70,000 to St. John to fund the nurse-driven program, which helped cover the salary of a nurse charged with implementing the program over the course of one year. The nurse’s responsibilities included providing training to nurses, collecting and evaluating data on catheter use, and rounding with two units a day to evaluate catheter use on a patient-by-patient basis. The program nurse educated other nurses during multidisciplinary rounds on the different units to evaluate the presence and need for the urinary catheter. “Whenever the catheter does not meet any criteria for necessity, the nurse recommends removal of the catheter,” says Fakih. In other words, the patient’s nurse owns the process of evaluating the need for the catheter. If the nurse determines that a catheter is not needed, the patient’s physician is called to obtain an order for its discontinuation. In its first year, the program reduced unnecessary urinary catheters by 45 percent. Further work addressing the placement of urinary catheters in the St. John ED has reduced unnecessary urinary catheter use even more. Five years after the program’s inception, urinary catheter use has dropped from 18 percent to 12 percent (not including the ICU, where urinary catheters are more frequently needed). ADVERTISEMENT Healthcare Reform and Accountable Care: Where Do We Stand? The Issues The term “healthcare reform” means many different things to many different people. Over the past several years, it has taken on added significance as President Obama has advanced plans to restructure healthcare delivery and make changes to how facilities are reimbursed for care. Although many disagree on whether reform as currently envisioned addresses these issues properly, it is generally agreed on both sides of the political aisle that real reform must reduce costs, improve the quality of care and improve the health of the population. In short, we must create payment models that reward value and not volume. on the subject of accountable care. TDI was founded in 1988 by Dr. John E. Wennberg as the Center for the Evaluative Clinical Sciences (CECS). Over the years, TDI has established a new discipline and educational focus in the evaluative clinical sciences, introduced and advanced the concept of shared decision-making for patients, demonstrated unwarranted variation in the practice and outcomes of medical treatment, and shown that more healthcare is not necessarily better care. “By demonstrating a healthy skepticism about new treatments and medical breakthroughs, investigating the risks and benefits of many common therapies and surgeries, and offering unique educational programs, TDI has produced more informed agents of change among physicians, health professionals, the media and the public,” said Todd Ebert Amerinet president and CEO. Overall do you view the ACO as... 50 42 (67%) 40 30 The common thread binding the foundations of reform is the idea of accountable care, which can be defined as a group of healthcare providers working together to assume shared accountability for the quality and cost of the care they provide to their community, with an overall focus on improving healthcare value. Moving to an accountable care model is a bold strategic initiative designed to position an organization for long-term success … in an uncertain future operating environment. This new, value-based system, is built around the integration and cooperation of providers who manage a population through team-based care. To do this, incentives must be aligned, and all stakeholders must focus on quality, efficiency and value. 20 11 (17%) 9 (14%) 10 1 (2%) 0 Not positive at all Somewhat negative Somewhat positive Very positive How extensively has your organization (and collaborating payers and providers) considered implementing an ACO? 50 49 (80%) 40 Against this backdrop, the 2011 Amerinet Executive Roundtable and corresponding survey sought to gather feedback and enhance knowledge concerning attitudes toward healthcare reform and accountable care. 30 20 11 (18%) 10 Amerinet engaged The Dartmouth Institute for Health Policy and Clinical Practice (TDI) to moderate the roundtable session and share nearly 40 years of research and information 1 (2%) 0 Currently implementing Planning for potential implementation Currently exploring Chart data from Amerinet Survey ADVERTISEMENT In terms of the Amerinet Executive Roundtable survey, respondents expressed a negative opinion about healthcare reform, which appears to be mainly due to the uncertainty and lack of direction surrounding it. Respondents were more positive about the general concept of ACOs, with more than 80 percent considering the implementation of an ACO. “The issue of healthcare reform is somewhat negative because assessing the real impact to consumers and providers is extremely difficult. While ACO’s have been touted as a step towards trying to manage the population’s health, the current proposed regulations will make it very difficult for providers to participate, with the risks great and the rewards small,” said John Matessino,” president and CEO of the Louisiana Hospital Association. “Through the ACO, we have the opportunity of putting providers back into the role of creating some solutions to help deal with the overall cost and quality of care and the fragmentation of care. With the ACO, we also begin to look at the appropriate utilization of scarce resources and access to those resources,” said Kevin Schoeplein, executive vice president, OSF Healthcare System. What became abundantly clear during the roundtable session was that whether ACO models take hold or not, the theory of accountable care – using systematic efforts to improve quality and reduce costs across the organization by addressing key issues such as capacity, patient engagement, process improvement and physician alignment – is essential for the survival of any healthcare organization in the future. Further illustrating the points to the left, the Amerinet survey asked member executives to identify their top priorities over the next two years (2011 and 2012). Their most frequent responses included: • • • • Meaningful use – 43 percent Physician alignment – 26 percent Quality – 22 percent Cost containment – 18 percent Other pressing issues included possible facility expansion, evaluation of service lines and physician recruitment. Among the highest impact healthcare trends identified were reimbursement cuts and episode of care/bundled payment options. The biggest drivers of healthcare costs centered on labor costs, overutilization of services and government laws. With this in mind, TDI offered three possible scenarios for the future of healthcare: Choice A Choice B Choice C The care model remains unchanged and costs continue to spiral Coverage expands, the care model evolves, and reimbursements are slashed The care model is transformed, quality improves, unwarranted variation is addressed, and cost is controlled Choice A is the “do nothing” approach. It means that there will be no payment reform and costs will continue to grow from 10-16 percent of GDP (twice the rate in other developed countries, with equivalent or better outcomes), eventually spiraling up to 30 percent of GDP. The result will be a bankrupt economy. Choice B shows that there will be limited reform that includes expanded coverage with no way to pay for it. This will result in slashed reimbursements and financial losses on every patient. The industry will react to these changes by getting more efficient and seeking out the procedures where reimbursement is profitable. Healthcare will survive, but on life support with almost no financial flexibility. Choice C is to reinvent the care model entirely. This includes understanding unwarranted variation in supply sensitive care to identify and eliminate waste; implementing shared decision making for patient-centered care; using comparative effectiveness research to identify and increase the use of effective care; dramatically increase the quality of care as measured by patient reported outcomes; and increase employee and patient satisfaction along the way. “Choice C is really about transforming the care model. We want to improve the quality of care, reduce unwarranted variation and control costs. This is the heart of the accountable care concept. Of all possible solutions, Choice C offers the most comprehensive approach to addressing our national priorities, as well as the economic trends and cost drivers,” said Craig Westling, M.S., M.P.H., managing director of Accountable Care and of the Office of Professional Education and Outreach at The Dartmouth Institute for Health Policy and Clinical Practice. “We don’t think that ACOs are the only solution – other innovative models emerge, too. But all the models will address the same core issues, and will ultimately result in ‘accountable care.’” ADVERTISEMENT This new approach would feature providers driving care improvement through: • Care coordination • Shared risk and rewards for cost and quality outcomes • Transparent reporting of metrics, ensuring a continuous focus on improvement • Freedom of beneficiary choice, so patients will be free to seek care from any provider Echoed Mina Ubbing, president and CEO, Fairfield Medical Center, “I think that the ACO has the very high potential of putting the patient back into the equation. We’re managing every other aspect through legislation and so on. And even though there’s certainly a lot of legislative risks with healthcare reform and specifically ACOs, it still gives us a chance to make sure that the providers are doing the right things for their patients.” What is an ACO? On March 31, 2011, The Department of Health and Human Services (HHS) released for public comment the long-awaited proposed rules governing accountable care organizations. In a fact sheet accompanying the 413 page document, HHS said, “ACOs create incentives for healthcare providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower growth in healthcare costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.” Further detailing the rationale behind ACOs, HHS said, “Today, more than half of Medicare beneficiaries have five or more chronic conditions such as diabetes, arthritis, hypertension and kidney disease. These patients often receive care from multiple physicians. A failure to coordinate care can often lead to patients not getting the care they need, receiving duplicative care and being at an increased risk of suffering medical errors. On average, each year, one in seven Medicare patients admitted to a hospital has been subject to a harmful medical mistake in the course of their care. And nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – a readmission many patients could have avoided if their care outside of the hospital had been aggressive and better coordinated.” Improving coordination and communication among physicians and other providers and suppliers through ACOs will help improve the care Medicare beneficiaries receive, while also helping lower costs. According to the analysis of the proposed regulation for ACOs, Medicare could potentially save as much as $960 million over three years. Several characteristics that will be essential for all ACOs: • Managing the continuum of care for patients as a real or virtually integrated delivery system • Being of sufficient size to support comprehensive performance measurement and expenditure projections • Having the capability of internally distributing shared savings and prospectively planning budgets and resource needs “As we move forward in terms of who the ACOs are, two things are really important: (1) Physician involvement, and (2) being community based. I know a lot of organizations are trying to pre-position themselves just because of who they are. So they might say, ‘We are the insurance company,’ ‘we are the hospital,’ ‘we are the physician group.’ And actually, what it’s going to require, I think, is an inclusiveness of all those parties to make it happen,” said Larry A. Mullins, president and CEO, Samaritan Health Services. Westling echoed those thoughts by adding, “CMS is not going to let anybody just repackage what they’re doing and call it an ACO. You’ve got to really show that you’re transforming care.” Key elements associated with accountable care models: Local Accountability • Fostering provider accountability for quality and per capita cost for patient population Standardized Performance Measurement • Increasing accountability on the part of providers should be accompanied by improved incentives and information for consumers Payment Reform • Transitioning payments from rewarding volume/intensity to increasing value • Restructuring payments to encourage collaboration and shared responsibility among providers and consistent incentives from payers Dr. William Weeks, associate professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School ADVERTISEMENT and associate professor and course director at TDI, explained a key area of the local accountability concept will be a firm grasp of local healthcare utilization patterns. “First we have to understand, Who are the patients? Who is it we’re talking about? And then we have to understand, What are their utilization patterns? And then we have to provide higher value by altering the processes, structures and outcomes of the care we provide.” Continued Craig Westling, “Local accountability is why the concept of ACOs has bipartisan support. Ultimately it’s about figuring out what works in your town. A key thing here is standardized performance measurement around quality and cost. CMS needs to create some level of standardized, transparent metrics so we can compare programs across the country.” The ACO model establishes a spending benchmark based on expected spending. If an ACO can improve quality while slowing spending growth, it receives shared savings from the payers. ACO-specific expenditure benchmarks will be based on historical trends and adjusted for patient mix. Contingent on meeting designated quality thresholds, ACOs with expenditures below their particular benchmark will be eligible for shared savings payments, which can be distributed among the providers within the ACO. These shared savings allow for investments – in health IT or medical homes, for example – that can in turn improve care and slow cost growth. How Do “Shared Savings” Models Work? How Do ACOs Achieve Results? What will be the measure of success for an ACO? CMS had defined five measurement domains with a total of 65 measures. Clearly, healthcare IT will be one of the foundational building blocks of accountable care. This is true from a coordination of care and ease of information sharing perspective, and also in the sense of using data to maximize results. Leveraging technology for business intelligence and modeling to predict use patterns will be important to proactively manage continuums of care. “Without the data, we can’t get the information we need to manage care,” said Westling. “We need the ability to know our community so we can assess risk and prevent illness before we see it in an acute setting.” “In terms of processes, there must be improved care coordination to reduce variation and waste. Up to 60 percent of the CMS spending goes towards chronic care. Overall, we’re trying to reduce waste … and a primary driver of costs is redundancy, so part of that coordination of care is eliminating unwarranted variation and providing the right care at the right place at the right time, every time,” continued Westling. 65 Performance Measures Grouped into 5 equally weighted domains Domain/ Sub-Category Measures Data Source 7 Survey 16 Claims/ Clinical Data Patient Safety 2 Claims Preventive Health 9 Clinical Data At-Risk Population Diabetes Heart Failure Coronary Artery Disease Hypertension COPD Frail Elderly 31 Claims/ Clinical Data Initial shared savings derived from spending below benchmarks Patient/Caregiver Experience Care Coordination • Care Coordination • Care Transitions • Coordination Information Systems Model data courtesy of The Dartmouth Institute The ACO model is addressing payment reform by moving away from volume into increasing value. “The movement toward collaboration carries a lot of risks, but it’s actually the only way that this will work,” said Westling. “The idea is to improve the value of care delivered. And I think it’s an important distinction. There’s obviously a lot of lingering bitterness toward managed care and HMOs in the past because too many decisions were based on cost. In ACOs, the quality piece is just as important as the cost piece. If you don’t meet your quality metrics, you’re not going to reap major savings.” • • • • • • Table data courtesy of The Dartmouth Institute ADVERTISEMENT What You Can Work on Right Now Whether or not healthcare organizations take the leap into joining or becoming an ACO, there are several things that any size and type of healthcare organization can do to prepare themselves for success in the upcoming era of value-based payment reform. Healthcare facilities must take a critical look at their operations in terms of the following areas: In regions where there are more intensive care unit beds, more patients will be cared for in the ICU. More specialists will result in more visits to specialists. In regions where there are relatively fewer medical resources, patients get less care; however, there is no evidence that these patients are worse off than their counterparts in high-resourced, high-spending regions. Patients do not experience improved survival or better quality of life if they live in regions with more care. In fact, the care they receive appears to be worse. Leadership Administrative leaders Clinical leaders Patients Informed patient choices Health risk assessments They report being less satisfied with their care than patients in regions that spend less, and having more trouble getting in to see their physicians. Partnerships Payers Community-based organizations Physicians Aligned incentives Access to timely data Provider groups Information Technology Ability to support ACO operations Most studies have found that mortality is no better in highspending regions, almost certainly because the benefits to some patients are counterbalanced by the harms to others. Hospitals can be dangerous places, where patients face the risk of medical error, adverse events and hospital-acquired antibiotic-resistant infections. As more physicians get involved in a patient’s care, it becomes less and less clear who is responsible, and miscommunication and mistakes become more likely. Greater use of diagnostic tests increases the risk of finding – and being treated for – abnormalities that are unlikely to have caused the patient any problem. Patients who receive care for conditions that would have never caused a problem can only experience the risk of the intervention. Processes Improved care coordination Capacity Appropriate workforce Chronic disease Reduction/conversion management of current capacity Point of care reminders Reduced waste Health information technology Next, organizations can start working on the following activities, even with current resources: Statistical Analysis – Assessing utilization patterns to find best practices and address supply-sensitive care. Supply-sensitive care also accounts for more than half of all Medicare spending. Understanding the problem of supplysensitive care is a critical first step toward improving the quality and affordability of healthcare, building organized delivery systems and scaling back costs and cost growth. Shared Decision Making – Helping patients make informed, evidence-based choices about preference-sensitive care. Shared Decision Making Microsystem Strategies – Improving clinical quality and to increase utilization of effective care. Comprehensive Care Centers – Improving coordination of care, support the efficient use of healthcare resources. Shared decision making is the collaboration between patients and caregivers to come to an agreement about a healthcare decision. It is especially useful when there is no clear “best” treatment option. Statistical Analysis The caregiver offers the patient information that will help him or her: According to the Dartmouth Atlas, supply-sensitive care refers to services where the supply of a specific resource has a major influence on utilization rates. The frequency of use of supply-sensitive care is largely due to differences in local capacity, and a payment system that ensures that existing capacity remains fully deployed. Simply put, in regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital. • Understand the likely outcomes of various options • Think about what is personally important about the risks and benefits of each option • Participate in decisions about medical care “This is probably the most important thing when it comes to the right thing to do. This is where it’s not just informed consent, ADVERTISEMENT this is where patients are understanding what their options are, and what the consequences of each decision might be. And then, making a fully-informed decision that is aligned with their values. Patients are then invested in their decisions and in the care that they receive. That is treating the patient in the right way. Doing this kind of thing is what’s going to make everything else flow better,” explained Westling. Microsystem Strategies A microsystem in healthcare delivery can be defined as a small group of people who work together on a regular basis to provide care to discrete subpopulations including the patients. It has clinical and business aims, linked processes, shared information environment and produces performance outcomes. They evolve over time and are (often) embedded in larger organizations. As a type of complex adaptive system, they must do the work, meet staff needs and maintain themselves as a clinical unit. Clinical microsystems are the front-line units that provide most healthcare to most people. They are the places where patients, families and care teams meet. Microsystems also include support staff, processes, technology and recurring patterns of information, behavior and results. Central to every clinical microsystem is the patient. The microsystem is the place where: • Care is made • Quality, safety, reliability, efficiency and innovation are made • Staff morale and patient satisfaction are made Microsystems are the building blocks that form hospitals and clinics. The quality of care can be no better than the quality produced by the small systems that come together to provide care. All healthcare professionals – and we believe all front-line clinical and support staff are professionals – have two jobs: Job 1 is to provide care. Job 2 is to improve care. For instance, if someone says ‘most of the time,’ what does that mean? Does it mean 51 percent? 96 percent? Or when looking at variation, people need to understand when to intervene in a process. What kind of variation is just normal in this process? Don’t intervene until you have an outlier that indicates a real issue. Because sometimes the most damaging thing you can do is tamper with something that doesn’t need an intervention. That potentially creates a whole new slew of problems. The bottom line is that it’s really important to use a common language throughout an organization, and to make it easy to understand.” Dr. Charles Sorenson, president and CEO, Intermountain Healthcare, offered, “Something that’s given us significant traction in quality improvement over the past 12 or so years is our extended senior management team having accountability to our board for the accomplishment of specific goals in clinical quality improvement, along with the other goals set by the board. It’s no longer just the doctor’s job, or the chief nursing officer’s job or somebody else’s job. Reviewing those goals is one of the first things we do when we meet with our regional operators – not just review the finance or the building program, but ask, ‘Where are you in your clinical quality, your patient safety goals?’ And that has helped also in terms of our alignment with physicians, because I’ve always felt that the most important component of learning with physicians has to be a shared understanding of our outcomes, and how we can improve them.” Comprehensive Care Centers “The idea behind comprehensive care centers is that you’re putting the patient at the center through the entire continuum of care, from education in the community, tools for the primary care providers, to help the patients make informed decisions. And then if the decision is made to have surgery, it’s really wellcoordinated throughout the hospital and follow-up. Medical home is a similar concept built around the primary care physician as care coordinator,” said Westling. Finding time to improve care can be difficult, but the only way to improve and maintain quality, safety, efficiency and flexibility is by blending analysis, change, measuring and redesigning into the regular patterns and the daily habits of front-line clinicians and staff. Absent the intelligent and dedicated improvement work by all staff in all units, the quality, efficiency and pride in work will not be made nor sustained. The medical home concept is one in which patients are cared for by a primary care physician who leads the medical team coordinating all aspects of preventive, acute and chronic needs of patients. Explained Westling, “You don’t have to get super-fancy or complicated with any performance improvement methodology. People need just a fundamental understanding of the concepts. The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967. In 2007, the AAP, American Academy of Family Physicians, American College of Physicians and American Osteopathic Association released the Joint Principles of the Patient-Centered Medical Home. ADVERTISEMENT Among the main principles listed were: Physician directed medical practice – The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Whole person orientation – The personal physician is responsible for providing for all the patient’s healthcare needs for all stages of life and taking responsibility for appropriately arranging care with other qualified providers. Care is coordinated and /or integrated across all elements of the healthcare system and the community, care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. Quality and safety are rooted in: • Evidence-based medicine and clinical decision-support tools guide decision making “The medical home model is one of the pilot projects that’s out there right now to actually enroll the most at-risk populations to see how effectively they can be managed, and what the cost of care is,” said Dr. Larry Mullins, president and CEO of Samaritan Health, whose organization recently undertook a pilot project in the development of a medical home concept. “In our case, we took the highest cost population we could find. Because we thought if we’re going to make a difference anywhere let’s start with that.” Regardless of an organization’s urgency in exploring the possibilities of ACO participation, there are a number of things they can do to assess their actual readiness. “From an organizational perspective you need to think about who is going to be on the leadership team. And you need to think about who’s participating: which physicians are participating, which practices are participating, which payers will be your best partners,” said Westling. • Utilization of information technology support optimal patient care, performance measurement, patient education and enhanced communication In addition to executive leadership, the involvement and buy-in of physicians is key. The new model must promote physician engagement at every level. Clinical and executive leadership must demonstrate they have a shared mission and vision or success of the accountability model. These objectives must also include programs of compensation and incentives that are viable internally among providers, but also must be aligned among all payers. Enhanced access to care is available through systems such as open scheduling and expanded hours. “Involvement in the quality improvement process is a great satisfier for most doctors. They no longer have to rely on how much • Accountability for continuous quality improvement through performance measurement and improvement • Active participation by the patient in decision-making Which of the following stipulations for ACOs (listed by CMS) does your organization currently have in place? 40 37 (59%) 28 (44%) 30 25 (40%) 23 (37%) 19 (30%) 20 11 (17%) 7 (11%) 10 4 (6%) 0 A formal legal structure to receive and distribute shared savings to participating providers Minimum of 5,000 Medicare beneficiaries required per ACO At least three years of participation Leadership and management structure that includes clinical and administrative systems Processes to promote evidence-based medicine Report on quality Report on cost measures Requirement to produce reports demonstrating the adoption of patient centered care Chart data from Amerinet Survey ADVERTISEMENT money they make to figure out whether they’re being successful, but can see on objective indicators that they are accomplishing results for their patients that are on a level of the very best reported any place in the world. And that brings a whole lot of professional satisfaction. I think that becomes an important way to inspire and retain good clinical people,” said Sorenson. The results of the Amerinet survey bear out some of the basics that must be in place. More than 44 percent of respondents said that they had implemented a leadership and management structure that included clinical and administrative systems. In terms of infrastructure, a high number of respondents (59 percent) were reporting on quality and 37 percent were reporting on cost measures. A relatively high number had also implemented processes to promote evidence-based medicine. Where respondents seem to be lagging is in the area of care coordination (only 11 percent reported the ability to produce patient-centered care reports) and the structure for payments for shared savings distribution (17 percent). For many Amerinet members in the rural healthcare setting, many questions still linger and may as of yet be unresolved. “I’m concerned we’re talking about too many physicians in populated areas. Well, I’m in a rural area. I can’t attract a physician to the rural area. Where are small hospitals, the communities and the patients going to receive care?” asked Bob Miller, CEO of Coshocton Hospital. Indeed, some of the challenges facing smaller, less integrated providers include the degree to which potentially burdensome requirements for participation are phased in or modified for rural or less integrated ACOs and how bonuses and performance thresholds are structured to encourage participation by less well-established provider groups (e.g. rural providers, FQHCs, RHCs). Although, because of consolidation and collaboration, capacity will shrink and some providers may be closed or absorbed by other entities, some see promise for rural providers. “Rural areas do have better outcomes with fewer resources,” said Weeks. “I think where they might have a bit of an advantage is that they have been providing higher value care for a pretty long time. So if I’m a company and I want to increase my earnings per share, I buy a company that’s got better earnings per share than me. If I’m a provider and I want to get greater cost shared savings I might buy or affiliate with someone that’s got lower costs overall and better outcomes.” What Now… Contact So what are providers to do at this point? Should they jump in with both feet, slowly test the waters or ignore it and hope it goes away? History shows that when Medicare funds a program, it often has a significant impact on care delivery and provider focus. The idea of accountable care seems to be the latest example. At its core, the concept, although idealistic, is grounded in goals and objectives that are keys to future success in healthcare: A strong emphasis on quality and coordinated care, with integration of community resources Leveraging technology and using predictive modeling to identify high risk individuals Enhancing transparency measures A final statement by one of the meeting participants may sum up the current situation best. “Just as we bring this to a close, I think all of us who have been in the business for a long time have gone through a lot of iterations of healthcare reform. About every 10 years we have healthcare reform. I think t he beauty of what we’re seeing now is – we talked all day long about collaboration – the fact that we now have a lightning rod that is forcing us all to focus on some key issues. And collaboration is going to occur.” Amerinet Customer Service 877-711-5600 [email protected] About Amerinet Inc. As a leading national healthcare solutions organization, Amerinet collaborates with acute and non-acute care providers to create and deliver unique solutions through performance improvement resources, guidance and ongoing support. With better product standardization and utilization, new financial tools beyond contracting and alliances that help lower costs, raise revenue and champion quality, Amerinet enriches healthcare delivery for its members and the communities they serve. To learn more about how Amerinet can help you successfully navigate the future of healthcare reform, visit www.amerinet-gpo.com. 36 LeaDERSHIP HFMA.ORG/leadership Navigating the Regulatory MaZE Recognizing the risks associated with an increasingly complex regulatory environment, providers are heading off potentially devastating fallouts by allocating time, attention, and capital to compliance efforts. 38 LeaDERSHIP HFMA.ORG/leadership Even as they make major investments in care delivery changes and absorb reimbursement cuts, providers are having to devote scarce resources to complying with ICD-10, RACs, HIPAA, Stark, and numerous other regulations and enforcement efforts. Many of these regulations promise to protect patients, as well as providers and payers, from fraud, data breaches, or other unintended harm. Others are designed to enhance transparency around quality and costs or improve clinical and claims reporting. It’s hard to argue with these goals. But the devil is in the details, as they say, especially for providers that have to ensure that they dot every “i” and cross every “t” to avoid potential financial penalties associated with noncompliance. The answer, according to the providers in this section, is preparation and vigilance. Case Study: Preparing for ICD-10 When Deborah Beezley, director of health information management at St. Anthony’s Medical Center in St. Louis, invited hospital managers to a meeting about a new medical coding system, she knew how to get their attention. Her message: Healthcare providers that do not adopt the new coding system by Oct. 1, 2013, will be unable to submit claims or receive payments from government or private payers. “It was one of those situations where I sent an email out and people listened,” she says. Everyone invited to that December 2010 kickoff meeting for St. Anthony’s implementation of the ICD-10 coding system showed up, and the hospital is now nearly through the first of a four-phase, three-year roadmap to hit the 2013 deadline. >> Common Approaches While the four case studies in this section focus on divergent regulatory requirements, some commonalities can be found in the providers’ approaches. >>Driving compliance in a top-down fashion with senior leaders providing visible and frequent support >>Focusing on how a regulation coincides with the provider’s quest to improve quality and reduce costs >>Devoting dollars, staff, and time to the compliance effort >>Collaborating directly with regulatory or enforcing agencies, when necessary, to determine the most appropriate response >>Studying how the regulation is being enforced—and how other providers are being affected >>Enlisting key stakeholders from service lines, departments, and units affected by the regulation in developing a multidisciplinary compliance approach >>Developing organization-specific policies and procedures, training materials, and other tools to help ensure compliance >>Using risk analysis and root-cause analysis to determine how the organization may be at risk of noncompliance— and/or determine targeted corrective actions to decrease the likelihood of repeat problems With all the other changes in the healthcare industry in the next few years, it is unfortunate timing that America’s diagnostic and procedure classification system must be overhauled at the same time. But the deadline has been postponed repeatedly, and knowledgeable providers know better than to expect additional delays. The ICD-10 medical coding system, endorsed by the World Health Organization in 1990, has already been implemented by virtually every other industrialized nation. The United States has continued to use ICD-9, but that system is running out of numeric capacity to expand and can no longer adequately support the information needs of today’s healthcare system. The ICD-10 system has more than 68,000 medical codes, compared to about 13,000 in the current ICD-9 coding system. But the scope of implementing ICD-10 is far greater than simply mastering new codes; the new system will affect a vast array of financial and operational processes, requiring careful preparation by a wide group of stakeholders. That is why St. Anthony’s CFO John Skeans advises hospital leaders to realize this issue cannot be postponed. “If you haven’t begun the process of planning and implementation for ICD-10, begin now and expect to be playing catch-up.” 39 Managing information system resources. Like many hospitals, St. Anthony’s is adopting a new electronic health record (EHR) this year, which is obviously a top priority for IT staff. Adopting the ICD-10 coding system will also require significant IT support, so planning ahead is essential to ensure staff resources are available. HIM compliance and risk management Stakeholders Management of impact to revenue cycle Operations and workflow change Industry payers and third parties Center for Clinical Effectiveness Tasks * DMAIC = Define, Measure, Analyze, Improve, and Control Source: St. Anthony’s Medical Center, St. Louis, Missouri. Reprinted with permission. LeaDERSHIP FALL 2011 Capital and operational budget for ICD-10 conversion. Beezley’s first step—almost a year ago—was to create St. Anthony’s goal is to have the ICD-10 conversion a 10-page executive summary designed to educate budget in place by December 2011. In addition to St. Anthony’s senior leaders about the importance and IT costs associated with the conversion, Skeans is scope of the ICD-10 implementation. budgeting for a long list of internal costs, including Those top leaders are key to maintaining the visibility NN Staff training of the ICD-10 project as an organizationwide priority. NN Extra labor costs (e.g., temporary staff) to support “During regular monthly manager meetings and leadercoding staff while they are being trained and gaining ship retreats, they continue to mention and discuss experience with the new codes this project as a critical milestone that has to be met,” NN Legal costs involved in updating vendor contracts says Beezley. to ensure they comply with the new coding system CFO Skeans monitors the ICD-10 project’s progress NN Updated encoding software on a monthly basis and ensures that Beezley’s team has NN Costs of modifying information services systems the support it needs from senior leadership. to accommodate new code sizes The purpose of the kickoff meeting for about 45 senior NN ICD-10 coding books and resources, such as leaders and managers was to engage the support of anatomical software or charts, that coders will leaders in meeting the 2013 deadline. Just because the need to code with greater specificity coding change has been anticipated for decades does not mean it was on everyone’s radar screen. “It was “These costs equate to additional expenses really amazing to me how many ancillary and support at the same time we are experiencing decreased department directors were unaware of the change that reimbursement,” he says. was coming,” says Beezley. “It became one of those ICD-10 Stakeholders and Tasks big eye-openers for our facility.” St. Anthony’s ICD-10 steering committee includes representatives Physicians from all departments that will be and clinicians affected by the coding change, including patient accounting, risk Managed Establish Information care, patient management, information services, coding Policy and services accounts, and measures procedure finance and clinical operations (see the using DMAIC* management exhibit on this page). Beezley asked each department Change Training management Integrated head to assign individuals to the of coders testing steering committee who have Stakeholders Vendors, Marketing experience in change management clearinghouses, and ancillary coming together and suppliers services and understand revenue cycle issues. for the patient Among other things, the steering Ongoing Software clinical committee ensures that several changes and documentation upgrades education overarching considerations are being addressed. Getting started 40 LeaDERSHIP HFMA.ORG/leadership “If you haven’t begun the process of planning and implementation for ICD-10, begin now and expect to be playing catch-up.” Education and training. Because the new codes are more numerous and more specific, medical coders are likely to need additional basic education about anatomy, physiology, pharmacology, and surgical procedures in addition to training on the new codes. In addition, physicians and nurses will need to be trained to provide more specific documentation to support the new codes. Other staff requiring jobspecific ICD-10 training include those in the patient financial services, patient access, scheduling, compliance, and legal departments. Data reporting and exchange. Medical codes underlie many data-driven functions and reporting, such as business intelligence and decision support, performance metrics, claims billing, clinical research projects, and tumor registries, says Beezley. “A personal concern that I have is how the ICD-10 conversion is going to affect reports and outside data transfers,” says Beezley. Thus, St. Anthony’s ICD-10 steering committee is paying close attention to ensure that the coding conversion does not jeopardize any ongoing data collection, analysis, and reporting. Engaging stakeholders While those hospitalwide concerns are being addressed, Beezley is systematically going department to department to help managers think through how the ICD-10 implementation will affect all aspects of their operations. During hour-long interviews with about 25 departments that use medical codes, Beezley is asking a series of questions designed to uncover specific ICD-10 to-do items related to training, software conversions, internal and external reporting, and budget needs. Responses are recorded in a detailed spreadsheet that will be used to create the work plan for a smooth conversion to the new system. “This is a good time to stress one-on-one with each department what exactly is needed to implement ICD-10,” she says. “People are beginning to understand the critical nature of this initiative, and we are gaining tremendous input into what we need to accomplish to ensure a successful conversion.” Case Study: Avoiding HIPAA Violations Like every good healthcare compliance officer, George Rousis at Halifax Health, a two-hospital system in Daytona Beach, Fla., has his eyes trained on the U.S. Office of Civil Rights (OCR). The OCR, responsible for enforcing provisions of the Health Insurance Portability and Accountability Act (HIPAA), has been very busy this year. As of mid-July, it had issued three enforcement actions against health systems, each of which had big dollars attached. In comparison, there were only two enforcements in 2010, and just one in each of the two previous years. This is just the beginning. A recent audit of seven hospitals by the U.S. Office of the Inspector General (OIG) found so many security problems related to electronic patient health information that the OCR has launched investigations into each hospital. In response to the OIG’s scathing report of security oversight, the OCR has contracted with a consultant to conduct 150 audits of hospitals and other covered entities by the end of 2012. Halifax Health, which has some 4,000 employees who can potentially access patient information, has not had a formal complaint lodged against it in two years. However, the health system has been contacted by the OCR six times in eight years to investigate complaints. Despite these interactions, Rousis is not nervous about the agency’s stepped-up enforcement activity. “I have never dealt with an investigator who I thought was totally unreasonable,” he says. However, Rousis believes the OCR’s new aggressiveness sends a message to all providers: HIPAA compliance must be a top priority. Understanding the risks OCR is responsible for enforcing the HIPAA privacy rule, which protects the privacy of personal health information that identifies individuals, and the HIPAA security rule, which sets standards for the security of electronic health information. Health systems must perform a risk assessment to ensure they are in full compliance with the HIPAA security rule, although the frequency and scope of those assessments is not specified in the rule. A risk assessment is also required for EHRs to meet the Stage 1 meaningful use criteria. 41 “CEOs need to know what is in the HIPAA enforcement cases, and then ask the question: ‘Could this happen to us?’ ” Recent OCR Enforcement Actions >>The OCR’s first enforcement action against a health system, back in 2008, stemmed from staff members at a Seattle-based health system taking laptops containing patient information offsite, where the laptops were lost or stolen >>A Massachusetts physician organization paid $1 million to settle with the OCR after an employee left patients’ billing information on a subway train >>A university-based health system settled for $875,000 after staff members inappropriately looked at the health records of celebrities >>A Maryland payer made its first mistake when it denied patients access to their medical records, which drew a $1.3 million penalty; its second error was refusing to cooperate with the OCR’s investigation, earning an additional $3 million penalty for its negligence Learning from others While compliance officers are working to protect their organizations against theoretical HIPAA violations, healthcare executives should familiarize themselves with actual cases that resulted in financial settlements or penalties. Rousis urges top leaders to read the OCR’s enforcement actions (available on the OCR website) because these cases document how poor judgment by staff members can turn into huge payouts by health systems. “CEOs need to know what is in the HIPAA enforcement cases, and then ask the question: ‘Could this happen to us?’” says Rousis. “If I was a CEO, I would want to know what my organization is doing to prevent similar breaches of personal health information.” Hospital executives should also study the OIG report that prompted the government to initiate its new audit program. In the OIG’s audits of seven large hospitals, 151 “vulnerabilities” were identified, of which 124 were categorized as high impact. These included unencrypted laptops and portable drives that contained personal health information, outdated antivirus software, unsecured networks, and the failure to detect rogue devices intruding on wireless networks (OIG, Nationwide Rollup Review of the Centers for Medicare & Medicaid Services Health Insurance Portability and Accountability Act of 1996 Oversight, May 16, 2011). “The OIG has already identified the security weaknesses found at hospitals during its own audits,” says Rousis. “A good place to start is to have your team look at those and report back how they are addressing them in your own shop.” LeaDERSHIP FALL 2011 In addition to the formal assessment that is conducted every few years, Halifax Health hires an outside consultant to conduct reviews to ensure that its HIPAA compliance plan is effective. “The risk assessment is going to tell you where you are most vulnerable,” says Rousis. For example, a recent risk assessment identified Halifax Health’s need to protect patient information that could potentially leave the health system’s premises. “Laptops, cell phones, USB flash drives, and all other mobile devices—in addition to paper—that leave the premises has become a high priority,” he says. For that reason, Halifax Health is using encryption technology to help ensure that patient-specific data cannot be accessed on computers and mobile devices in the event of a loss, theft, or other security breach. In addition, Halifax Health has adopted policies that prohibit employees from transmitting a patient’s personal health information onto any device—either corporate or personal—without encryption or other safeguards. Staff are also being trained to understand that they must have explicit approval from a supervisor before they take or send any patient information off the premises, such as to an external auditor or other business associate. The health system’s policy also delineates the internal process for reporting and addressing possible breaches of portable data, including how investigations will be conducted. The policy requires an analysis of the root causes behind the breach and implementation of corrective actions that will decrease the likelihood of a repeat problem. The biggest challenge to complying with HIPAA rules is the human factor, says Rousis. “This makes administrative policies especially challenging to monitor and enforce because you must rely on humans to do the right thing, or be aware of when they are acting imprudently,” he says. “With a technical safeguard like encryption, you can obtain virtually absolute assurance that information is inaccessible to anyone other than the person that has the decryption key. But even with encryption, we must rely on humans to set it up properly, and keep their passwords secret.” 42 LeaDERSHIP HFMA.ORG/leadership Case Study: Avoiding Anti-kickback Violations When Partnering with Physicians The opportunity to earn a 5 percent bonus through an insurer’s pay-for-performance program intrigued leaders at Borgess Medical Center in Kalamazoo, Mich. But they knew the money would be earned only if the hospital successfully engaged physicians in quality improvement initiatives—and that sharing the bonuses with physicians could risk violating the anti-kickback and civil monetary penalty statutes. These two statutes—along with Stark regulation— are designed to discourage physicians from allowing their personal financial considerations to influence their decisions about patient care, including their referrals to hospitals and other providers. Borgess undertook a lengthy process of seeking an opinion from the U.S. Office of the Inspector General (OIG): Could Borgess create a structure that allows medical staff physicians to share pay-for-performance incentives without violating federal law? OIG’s answer was yes—but that decision applies only to Borgess and comes with specific requirements. “You can use prior OIG opinions for guidance but you can’t assume that if Organization A got an OIG “It was a give and take that was constructive and respectful. it was two parties working together to come to a solution.” approval, then Organization B automatically gets the same thing,” says J. Patrick Dyson, Borgess Health’s executive vice president. “It’s probably advisable to get your own opinion and play it safe.” Seizing an opportunity Since 2006, Blue Cross Blue Shield of Michigan (BCBSM) has offered hospitals the opportunity to earn a bonus of up to 5 percent on total inpatient, outpatient, and rehabilitation payments if the hospitals achieve quality and efficiency goals. Borgess wanted to incentivize physicians to improve the quality of care—and increase Borgess’ chance of earning the pay-for-performance bonus—by allowing the physicians the opportunity to share the money. The hospital decided to create a limited liability company that would, ultimately, be owned by participating physicians. Pay for Quality Borgess Medical Center created a limited liability corporation (LLC) that allows it to split the quality portion of its pay-for-performance (P4P) award from Blue Cross Blue Shield of Michigan (BCBSM) with physicians who help meet quality targets. The LLC may receive up to 50 percent of the total quality bonus from BCBSM. The formula is based on the number of members as well as the hospital’s performance on quality-related metrics. P4P $ Payer MDs Per capita distributions P4P contract Hospital Up to 50% of P4P dollars Source: Borgess Medical Center. Reprinted with permission. Medical staff entry At least 10 physicians 43 Getting the opinion Winning the OIG’s approval for its plan required considerable effort, but Dyson was pleased with the experience and the result. “It was a give and take that was constructive and respectful,” he says. “It was two parties working together to come to a solution.” That said, getting the OIG approval took a long time—and cost about $25,000 in legal fees. The hospital started by submitting a proposal of how it wanted to set up BQIP, based on its understanding of regulations that govern relationships between hospitals and referring physicians. “The OIG identified some concerns and apprehensions,” says Dyson. “That enabled us to engage, through our legal counsel, in direct discussion with the OIG, saying, ‘Can we find ways to address your concerns?’” One of the OIG’s concerns was that physicians would be enticed to change their referral patterns simply to participate in BQIP and share the potential bonuses. For that reason, the BQIP documents were written to require that physicians must be on Borgess’ active medical staff for one year before they can join BQIP. Borgess also wanted to ensure the physicians in BQIP were really pursuing quality improvement. So each BQIP member must spend four hours a month working on quality improvement initiatives at the hospital. The quality indicators included in the BCBSM program are all included in the Specifications Manual for National Hospital Quality Measures, which includes measures that have been approved by The Joint Commission and the Centers for Medicare & Medicaid Services (CMS). Borgess changed the terms of its program over the next 19 months. In October 2008, it became the first hospital to receive OIG approval to split the financial rewards of an insurer’s pay-for-performance program with a broad group of physicians on its medical staff who help Borgess achieve quality targets—and it remains the only hospital to enjoy that status. Building in safeguards Today BQIP includes 26 physicians, each of whom provided a $2,000 capital contribution to participate. Additional physicians are expected to join this year, says Dyson. The hospital contracts with BQIP to share a portion of quality incentives it receives (see the exhibit on page 42). The physicians are eligible for up to 50 percent of bonuses that Borgess receives for quality performance, but—to ensure they are not overly focused on cost-cutting—they can receive none of the incentives that the health system receives for efficiency measures, as per the OIG opinion. The bonus money is distributed among BQIP members based on the number of physicians in the LLC, not based on the number of patients an individual physician refers to Borgess. “This was a safeguard to make sure somebody’s not motivated to shift volume purely for the incentive,” says Dyson. Case Study: Preparing for > Value-Based Purchasing Value-based purchasing is the government’s boldest move yet to reward hospitals that provide high-quality care—and penalize those that do not. Hospitals that score well on 21 performance metrics that are publicly posted on the Hospital Compare website (12 clinical process measures and nine patient experience measures) will receive incentive bonuses from CMS. The catch: The program will be funded in its initial year by a 1 percent DRG payment reduction. So any hospital that does not earn a quality bonus will, in effect, be financially penalized. In subsequent years, the DRG payment reduction will gradually increase, while the amount of the incentive payments and the number of performance measures evaluated will also increase. Ascension Health has calculated its financial risk associated with CMS’s value-based purchasing program. Based on a snapshot of its 70 acute care hospitals, Ascension Health—which posts revenues of more than $15 billion a year—might expect a financial hit of about $928,000 when the CMS introduces value-based purchasing in October 2012. However, if just eight Ascension Health hospitals improve their performance on quality measures and patient satisfaction in 2012—and earn quality bonuses— that small negative number could be turned into a small positive, says David Pryor, MD, Ascension Health’s chief medical officer. LeaDERSHIP FALL 2011 The purpose of the company—Borgess Quality Improvement Partners LLC, or BQIP—is to provide opportunities for physicians to work on hospital quality initiatives and to receive and distribute up to 50 percent of financial rewards that Borgess receives for its performance on quality measures. 44 LeaDERSHIP HFMA.ORG/leadership Focusing on the main issue “The overall financial impact to Ascension Health will likely be relatively small,” says Pryor. “But if you focus only on the overall financial impact, you miss the bigger picture.” That bigger picture is that value-based purchasing is just one of many government and private payer initiatives that link quality to payment. The even bigger picture, in Ascension Health’s view, is that improving quality reduces a health system’s expenses, which may have a much more significant impact on its financial performance. That is why the calculation of a potential $928,000 hit from CMS’s value-based purchasing program does not, in and of itself, drive an action plan. Rather, Ascension Health continues to work its quality program for reasons only strengthened by the theoretical CMS paycheck. “The far more important issue is the organization’s overall approach to improving quality,” says Pryor. Like many health systems, Ascension Health internally reports Hospital Compare measures for all its hospitals on a monthly basis, so leaders of each hospital can see how they compare to one another and to national benchmarks and work to improve on the facility’s shortcomings. As shown in the exhibit below, Ascension Health staff follow a continuous four-step process to improve performance on Hospital Compare measures. Value-Based Purchasing React to probable changes in measurement and incentives Identify best practices for each process measure Monitor performance with internal and external tools Implement processes to influence improved outcomes Source: Ascension Health. Reprinted with permission. “Fundamentally, we as an organization believe that good quality is also good business.” Calculating the financial benefits Ascension Health launched an aggressive quality initiative in 2003—well before payers were offering financial incentives tied to quality—and is saving 1,500 lives each year because of it (Pryor, D., et al, “The Quality ‘Journey’ at Ascension Health: How We’ve Prevented at Least 1,500 Avoidable Deaths a Year—and Aim to Do Better,” Health Affairs, April 2011, pp. 604-611). The health system started by choosing eight priorities for action, developed a set of evidencebased interventions to address each of these priorities, and disseminated the practices to all its hospitals. For example, to reduce the incidence of pressure ulcers, Ascension Health nurses adopted the standardized use of the S.K.I.N bundle: (S)election of appropriate surfaces, (K)eep patients moving, (I)ncontinence management, and (N)utrition management and hydration. Despite—or perhaps, in part, because of—its investment in patient safety, the Catholic health system is also financially robust: Earlier this year, Ascension Health announced a deal to acquire a four-hospital system, bringing its total to 73 acute care hospitals. After eight years of intense focus on quality improvement, the health system has some concrete examples of how improved quality translates into improved financial performance; for example, its malpractice costs declined by 36 percent between FY05 and FY10. However, calculating the cost-effectiveness of many individual quality programs is elusive, says Pryor. “We can point to examples that illustrate a direct tie between improving quality and reducing our overall operational costs. However, this is not the case with every quality improvement.” Unable to cast “higher quality equals lower costs” in stone, Ascension Health has adopted a divergent philosophy: “Fundamentally, we as an organization believe that good quality is also good business,” says Pryor. >> Next: Using Technology to Improve Decision Making Technology is becoming a critical tool for clinical and business decision making. See Section 4, page 46. ;LHT/LHS[OJSPLU[ZH]LYHNLH YLK\J[PVUPUKVVY[VKVJ[PTLZ PU[OLPYÄYZ[`LHY 0UUV]H[P]L7YVISLT:VS]LYZ7HY[ULYZ;OVZLHYLQ\Z[H ML^VM[OL[LYTZV\YJSPLU[Z\ZL[VKLZJYPIL;LHT/LHS[O>L JVTIPULL_WLYPLUJLKJSPUPJHSHUKI\ZPULZZSLHKLYZ^P[O J\[[PUNLKNLPUMVYTH[PVUZ`Z[LTZ[VVSZHUKYLZV\YJLZ[V YLHSPaLTLHUPUNM\S·HUKZ\Z[HPUHISL·VWLYH[PVUHSJSPUPJHS HUKÄUHUJPHSYLZ\S[ZSPRLNL[[PUNWH[PLU[ZZLLUMHZ[LYHUK PTWYV]PUNZH[PZMHJ[PVUYH[LZHUK`V\YYLW\[H[PVU@V\Y Z\JJLZZPZV\YTPZZPVU;OH[PZ^O`;LHT/LHS[OYHURZ PU JSPLU[ZH[PZMHJ[PVUHUKPZTVZ[SPRLS`[VILYLJVTTLUKLKI` OVZWP[HSL_LJ\[P]LZ[V[OLPYJVSSLHN\LZ =PZP[V\YUL^YLZV\YJLJLU[LYH[ ;LHT/LHS[O(K]HU[HNLJVT ,TLYNLUJ`4LKPJPULc(ULZ[OLZPHc/VZWP[HS4LKPJPULc )HZLKVUHPUKLWLUKLU[UH[PVUHSZ\Y]L`VMOVZWP[HSL_LJ\[P]LZ *SPUPJHS6\[ZV\YJPUN:LY]PJLZ 46 LeaDERSHIP HFMA.ORG/leadership Using Technology to Improve Decision Making Technology is helping healthcare leaders improve their decision-making ability at the bedside, in team meetings, and in the executive suite. 48 LeaDERSHIP HFMA.ORG/leadership As discussed in Section 3, the increased use of EHRs, mobile platforms, and other technologies can add to a healthcare organization’s risk profile. Data breaches and accompanying penalties can cost millions or even billions. Other risks include equipment breakdowns and investments in rarely used technologies. But the potential benefits to be gained from technology typically outweigh the risks. In particular, as illustrated in this section, technology is becoming a critical component of provider efforts to improve quality and reduce costs. The technology is helping them track data/trends and identify better approaches for improved efficiency and patient care—thus, allowing healthcare organizations to better manage risk and improve overall value. Case Study: Improving Patient Flow > and Nurse Staffing During a three-month period earlier this year, St. Anthony’s Medical Center in suburban St. Louis treated 1,000 more patients in its emergency department (ED) than during the same period two years earlier. This was possible because the St. Louis hospital eradicated its long-standing problem of ambulance diversions. “Eliminating diversions for St. Anthony’s is found money,” says CFO John Skeans. “We were basically telling patients that we were closed for business.” The ambulance diversion problem went away after St. Anthony’s developed a software program that helps managers quickly redeploy nurses to where they are most needed, improving the flow of patients from the ED to inpatient units. >> Common Approaches While every technology project is different, the two providers in this section share some common lessons learned. >>Focusing not on the technology, but on how the technology will improve patient care, increase efficiency, and improve the work environment for staff >>Overhauling workflow and processes before implementing the technology >>Designing technology around what staff and patients really need—and possibly saving dollars by forgoing bells and whistles >>Involving physicians, nurses, and other staff in technology design and implementation >>Using technology’s data analysis and tracking ability for better decision making—at all levels of management >>Determining and celebrating the ROI That technology is one component of a complete overhaul of the hospital’s nurse staffing system that resulted in a dramatic improvement in the hospital’s financial position. “Where other hospitals and health systems have had layoffs and salary freezes, we have continued to have merit increases,” says Sherry Nelson, St. Anthony’s vice president of patient care services and CNO. On top of that, St. Anthony’s will pay out “shared fruit” bonuses averaging $500 to each staff member because the hospital met its financial and patient experience goals for the fiscal year that ended June 30. It also paid out bonuses for the previous fiscal year. That is a far cry from 2009, when a cash flow crunch required St. Anthony’s to drastically cut expenses. The hospital chose to address the financial problem by addressing its single biggest expense: nurse labor costs. Not wanting to inadvertently harm quality, the hospital identified creative solutions to use nursing resources more wisely. The result: St. Anthony’s cut $25 million from its budget in 2009 and kept the hospital in the black— while improving the caliber of its nursing staff. 49 St. Anthony’s Amy Baker, MSN, RN, conducts a presurgical assessment with a patient. Hiring to save money “One of the things that is important to the bottom line is having the right staffing,” says Nelson. That is why St. Anthony’s staffing overhaul focused on reducing turnover among nurses, improving job satisfaction, and upgrading the level of nursing skill and experience. For starters, St. Anthony’s increased nursing hires by 8 percent in 2009 so that it could stop relying on expensive travel nurses. Nelson also sought to recruit highly skilled registered nurses (RN) and limit the number of practical and vocational nurses on staff. At the same time, Nelson instituted consistent work schedules in each unit, which improved morale and reduced absences that, in the past, had required the use of contract nurses. Those practices helped St. Anthony’s cut its travel nurse budget and achieve its ultimate goal of reducing turnover in the nursing ranks. The hospital’s total voluntary RN turnover rate fell from 15 percent in FY10 to 13.5 percent in FY11. Shifting resources St. Anthony’s also looked to technology—an internally developed software program called N Quality Staffing— to improve the allocation of nursing resources. Two hours into each shift, unit managers enter the unit’s patient census into the staffing software, along with the number of nurses, unit secretaries, aides, and other staff members on duty. The software program compares this real-time data with the unit’s standard patient-nurse ratio and gives a color-coded visual cue to automatically communicate staffing needs. The color orange means the unit is close to full capacity, and red means another nurse is needed. When nurse managers from all units gather for their daily huddles during each shift, they use this information to quickly reassign nurses to where they are needed most. Those staffing adjustments allow patients to move from the ED into an inpatient bed more quickly, freeing up ED beds and eliminating the need for ambulance diversions. “Improving throughput has increased revenue,” says Skeans. Investing in a new software program during a financial crunch seemed daunting. By focusing on what nursing leaders really needed to manage staffing, St. Anthony’s was able to develop a relatively simple system internally. “The commercial systems are more sophisticated, but this system lets nurse managers know visually if they have enough nursing staff to take more patients,” says Nelson. LeaDERSHIP FALL 2011 Photo: St. Anthony’s Medical Center. Reprinted with permission. “Every time we lose a nurse, it costs the organization approximately $60,000, so reducing turnover is at the forefront of what we’re working toward,” says Nelson. “My goal is that the best nurses in St. Louis see their career endpoint at St. Anthony’s Medical Center and that they would never want to work anywhere else.” To build on the success to date, Nelson continues to introduce new initiatives to boost nurse satisfaction. Because it is difficult to recruit experienced nurses in the highly competitive St. Louis market, St. Anthony’s must hire new graduates who have little real-world experience in the hospital setting. That is why the hospital created a nurse preceptor program in which experienced RNs receive bonuses for working one-on-one with new graduates to help them succeed on the job. 50 LeaDERSHIP HFMA.ORG/leadership Automating time and attendance Additionally, St. Anthony’s recently started using an automated system to standardize the capture of time and attendance information. Previously, nurse managers kept track manually of a nurse’s work absences, lunch hours that were missed because of too much work, and other payday-important information. This led to inconsistencies in applying attendance policies, misunderstandings, and on occasion, inaccurate paychecks that required time-consuming paperwork to fix. Under the new system, the time clock that nurses use is equipped with a computer screen that captures all details of a nurse’s time and attendance electronically. “You can swipe your badge and, for example, put in a code that says ‘pay through lunch,’” says Nelson. This system improves attendance because nurses know what the official record of their work attendance says. “This consistent, standardized approach will decrease our call-ins from nurses asking for time off because everybody will know where they stand,” says Nelson. Case Study: Improving Clinical Care Standardization and improvement is also central to Sentara Healthcare’s $237 million eCare system—which includes an electronic health record (EHR) and related technology. Six years into implementing eCare, Sentara leaders advise going full-out or staying home. “EHR rollout is not just the implementation of an application or a computer system; it’s an entire redesign of the approach to care delivery,” says Greg Hafer, RN, director of eCare operations. “It requires a commitment throughout the organization.” The eCare system includes: NN Computerized physician order entry (CPOE) NN Clinical decision support and standardized order sets and care plans NN Online documentation NN Medication administration with barcode scanning NN Electronic capture of images, lab results, surgical summaries, and all other data NN E-prescribing NN Data sharing with state and national patient registries NN A patient portal “Every time we lose a nurse, it costs the organization approximately $60,000, so reducing turnover is at the forefront of what we’re working toward.” Sentara, a 10-hospital integrated system based in Norfolk, Va., took home the Davies Award from the Healthcare Information and Management Systems Society (HIMSS) last year in recognition of its successful eCare implementation and the improved patient care— and value—that stemmed from it. In addition to achieving the top status—Stage 7— in the HIMSS Analytics rating system for EHR adoption, a Sentara hospital has appeared on Hospital & Health Networks’ “Most Wired” list in each of the past three years. Those accolades reflect Sentara’s investment for the long haul. “Very early on, we framed this as the biggest capital project Sentara has ever undertaken, bigger than investments we’ve made in new facilities,” says J. Miller Trimble, Sentara’s director of information technology. “That was an attention-getter for the entire health system. When you discuss EHR implementation in those terms, staff generally buy into making it a success.” After a two-year planning phase, Sentara implemented the eCare system at its first hospital in 2008—and its eighth hospital this year. (Two of the system’s 10 hospitals were acquired this year.) This past spring, the health system completed installation of the EHR technology in all locations of the Sentara Medical Group, which employs about 400 physicians. In addition, more than 55,000 patients are now using Sentara’s patient portal to communicate with physicians, schedule appointments, view test results, and request prescription refills. Planning thoroughly Sentara made sure that eCare was a clinically-driven project by creating a Physician Advisory Group comprised of more than 25 community physicians. Members of the advisory group were hand-picked from a pool of physicians who had volunteered to serve. “You bring to the table the physicians who are known technology champions, but you also bring those who are potentially naysayers so that you can engage them early,” says Hafer. He also recommends involving physicians who work in procedure-driven disciplines, such as surgery, because those areas present special challenges for the EHR. 52 LeaDERSHIP HFMA.ORG/leadership “You bring to the table the physicians who are known Technology champions, but you also bring those who are potentially naysayers so that you can engage them early.” The physicians helped select the vendor, advised on software design, and served as “super users” during implementation to help other physicians and staff members learn the technology. They were paid an hourly rate for the time devoted to eCare, similar to the way a medical director is paid for administrative hours. During the design phase, members of the Physician Advisory Group spent about four hours a week on eCare. Currently, the group meets for about two hours a month to monitor eCare issues. Redesigning processes Healthcare leaders need to recognize that overhauling work processes will present the biggest challenge to a successful EHR implementation—and offer the biggest benefit, says Trimble. Redesign processes before the new technology is installed, he advises. During the design phase and initial implementations, the eCare team included 100 clinical staff—nurses, pharmacists, radiology technicians, and others—who worked full time on the eCare initiative alongside 90 IT staff members. More than two years before eCare implementation at the first hospital, process improvement engineers were assigned to work with system-level process owners to redesign 18 major processes ranging from clinical communications to charge capture. Each of the redesign teams spent three months analyzing current processes, measuring performance, and identifying problems and opportunities. Using that information, team members designed ideal processes. For example, communication between clinical departments was identified as a process critical to both the quality and safety of patient care. Nursing departments and ancillary departments came together to define and develop key elements of patient information that were critical in the transition of patient care from one department to another. Team members then identified the changes that needed to occur to achieve these ideal processes and sorted them into four categories: NN Changes that would occur automatically when the EHR was implemented NN Changes that required action to exploit the EHR’s full potential NN Changes that had nothing to do with the EHR NN Changes that would happen at a future point after EHR adoption A lesson learned: Sentara leaders assumed that the process owners would communicate and embed the new processes at the hospital, but this did not happen as envisioned, says Trimble. About six months before “go-live” at the first hospital, the process improvement engineers had to be engaged to work directly with more than 40 departments to help leaders and staff members understand their existing processes and adopt the needed improvements. This worked well in all but three departments— medical records, surgery, and endoscopy—where the process changes overwhelmed the staff members’ ability to adapt, resulting in throughput problems when the EHR system was implemented. The problems were worked out during an optimization phase that is built into the EHR rollout at each Sentara facility. During this phase, members of the eCare optimization team work with clinical staff members to address implementation snags and ensure that the technology is being used—and achieving results— according to plan. Trimble says this optimization step is essential to generating and measuring the ROI for an EHR. Diving in Sentara leaders learned another important lesson during its initial eCare launch: Go “big bang” with all EHR features rather than phasing them in over time. In that first hospital implementation, CPOE was not introduced immediately. So physicians and staff members experienced successive waves of major change. “We learned that there was a tremendous amount of resiliency to tolerate the chaos that ensues with major workflow changes,” says Hafer. “But when you are constantly changing things, and there is no time in between for things to stabilize, people don’t tolerate that as well.” The big bang launch is now standard for Sentara eCare implementations. To prepare for such a highly disruptive event, each hospital performs competency and skill checks with staff members well before the 53 readings in different ways. The eCare data feed into Sentara’s key performance indicator (KPI) dashboard, which reports hyperglycemic and hypoglycemic rates at the department, hospital, and enterprise level. The KPI dashboard also tracks two other process measures— the average duration of central line placement and the percentage of heart failure patients weighed daily— that can influence adverse events and length of stay. By having access to that data in near-real time, senior leaders, department/unit managers, and bedside staff can be in constant communication about expectations and how to remove barriers to achieving clinical standards and performance metrics. “We are seeing continual improvements in the numbers on the KPI dashboard,” says Trimble. Making better decisions The eCare system provides information for better decision making at the bedside and all levels of management. In the paper-chart days, nurses had to flip through a patient’s record, trying to assimilate data from the recent past to identify a trend that might help inform a treatment decision. Now when Hafer rounds through medical/surgical units, he sees nurses consulting trend lines on computer screens that display, for example, a patient’s blood sugar levels over time to see how the current reading compares with the recent past. “We are seeing bedside staff starting to use data in a different manner,” he says. Meanwhile, managers throughout the Sentara organization are using those same blood sugar level Influenza Tracking at Sentara By tracking influenza-related volumes on a real-time basis, Sentara was able to keep up with H1N1 surges during the 2010-2011 flu season. Hospital Diagnoses Related to Influenza Filtered by Time, Days, Diagnosis, and Location 0.14 0.12 0.10 0.08 0.06 0.04 0.02 Source: Sentara Healthcare. Reprinted with permission. 01/24/11 01/23/11 01/22/11 01/21/11 01/20/11 01/19/11 01/18/11 01/17/11 01/16/11 01/15/11 01/14/11 01/13/11 01/12/11 01/11/11 01/10/11 01/09/11 01/08/11 01/07/11 01/06/11 01/05/11 01/04/11 01/03/11 01/02/11 01/01/11 12/31/10 12/30/10 12/29/10 12/28/10 12/27/10 12/26/10 0.00 LeaDERSHIP FALL 2011 “The ability to use EHR data to see systemwide trends as they are developing offers opportunities that Sentara leaders did not forsee.” technology goes live. For example, nursing staff demonstrate the process for medication administration with barcode scanning technology. “Probably the most important thing is to flood the units with enough support during the launch so that patient care is not delayed,” says Hafer. 54 LeaDERSHIP HFMA.ORG/leadership Improving business intelligence In addition to clinical indicators, the dashboard tracks compliance with CPOE use (down to the physician level) and medication barcode scanning. And it allows managers to monitor patient volume and revenue statistics (including margin analysis and revenue by payer trends) over time, and benchmark them against expected values at a hospital. Three times each day, the dashboard updates patient census and occupancy rates by facility, unit, type of service, and financial class. More detailed and frequent information is captured from Sentara’s EDs, including boarding hours, turnaround times for minor emergency care, arrival to triage, arrival to admission, boarding hours, and turnaround times for specific types of care. While some statistics are used for analysis and planning, others are used for immediate resource allocation. For example, every 15 minutes, the dashboard reports the average ED patient wait time, and when thresholds are exceeded, managers are alerted. The ability to use EHR data to see systemwide trends as they are developing offers opportunities that Sentara leaders did not foresee. When the H1N1 flu emerged in late 2009, for example, members of the infection control staff suggested that EHR data might be used to help hospitals plan and manage a surge in demand. The dashboard was changed to capture and report influenza-related diagnostic data, including upper respiratory diagnoses, flu-like symptoms, and viral syndromes, from hospital EDs and medical group practices every two hours. The information was presented graphically so that clinical staff members could see the trends from day to day and compare them with previous time periods (see the exhibit on page 53). “Because we had the EHR and the KPI dashboard in place, it really took very little work to get the information posted and available to the key people who needed to see it,” says Hafer. The dashboard helped leaders ensure that EDs and physician offices were appropriately staffed to handle surges of H1N1 patients. It also helped increase operational efficiency because staff members avoided stockpiling supplies; they could see the pace with which patient load was increasing and they could see how quickly they could get more supplies when they needed them. eCare’s Cumulative ROI Sentara Healthcare achieved $40.9 million—much more than the expected $29.3 million—in annualized ROI from its eCare EHR system in 2010. Results are for six hospitals, home health, and a Sentara-owned health plan. eCare Benefit Category Benefit (Millions) Reduced length of stay 8.7 Increased outpatient procedures 5.7 Increased unit efficiency/RN retention 9 Reduced transcription expense 2.7 Reduced medical records and supply costs 1.8 Reduced medical records staff 1.8 Reduced Sentara-owned health plan costs Improved charge capture 2 1.9 Reduced 63 administrative positions Reduced other costs Total 2 5.3 40.9 Source: Sentara Healthcare. Reprinted with permission. Calculating costs and benefits In 2010, Sentara calculated $48.5 million in financial benefits—more than $10 million over budgeted benefits for the year. Redesigned clinical and administrative processes factor heavily in the ROI for the eCare system, says Trimble. (See the exhibit above.) Among the wins: Sentara hospitals are avoiding more than 10,000 potential medication errors every month since adopting the medication barcode scanning. Improved patient throughput reduced patient length of stay by more than 16,000 days in the first two years— and the average turnaround time from ED to inpatient status has been cut to 90 minutes. The medical records function now costs $3 million less per year, while claims denials have decreased by $500,000 annually. “It requires a fair amount of up-front work and discipline to create the business case and ROI structure for an EHR,” says Trimble. “But if you apply the discipline to follow it and carry it out, it can certainly be done. We’ve been able to prove that.” >> Next: Last Word One physician leader’s take on managing clinical and business risks in today’s complex environment. See page 56. What could you do with The Power of Certainty? Imagine being so consistent and accurate in outpatient billing, you’d always feel like you’re on solid ground. You could repeatedly reach your revenue goals, without having to cut budgets. You could make confident financial decisions, without factoring in unexpected trip-ups. And you could do it all, without compliance issues and audits throwing you off balance. This is the advantage of going with a proven revenue management solution. This is The Power of CertaintyTM. Proven solutions for consistent, accurate outpatient charging. www.lynxmed.com /<1;0HGLFDO6\VWHPVQRZSDUWRI2SWXP,QVLJKW$OOULJKWVUHVHUYHG´/<1;µ/<1;0HGLFDO6\VWHPV(3RLQW,3RLQW&3RLQWDQGWKH3RZHURI&HUWDLQW\PD\EHWUDGHPDUNVRUUHJLVWHUHGWUDGHPDUNVRI/<1;0HGLFDO6\VWHPVLQWKH8QLWHG6WDWHV 56 LeaDERSHIP HFMA.ORG/leadership Engaging Physicians to Improve Value An interview with David Maizel, MD This is similar to what Maizel does now in his management role: “We also consider the impact of our recommendations: Is there only going to be a positive impact or are there going to be some unintended consequences we have to manage, mitigate, or minimize?” Training with Intention After practicing medicine for 25 years, David Maizel, MD, exchanged his white coat for a suit jacket to become president of Sentara Medical Group, and a few years later, corporate vice president of 10-hospital Sentara Healthcare in Norfolk, Va. Although he looks back with pride on his years as a family practice physician, Maizel finds his new role to be tailor made. He believes that many physicians possess a key leadership skill: problem solving. “Physicians can apply what we know about diagnosing and treating patients to the management side of health care.” Although not all physicians are inclined to take up leadership roles, many are willing and able to become more involved in efforts to improve healthcare delivery. The first step, says Maizel, is to extend an invitation. “We really need to break down the barriers and the fragmentation that has historically existed in health care, and to really embrace the notion that we are much better off if we all work together.” The second step is to provide training. Specifically, Maizel has found that physicians often need training in quality and process improvement methods. However, timing is key. Maizel suggests involving trainees in a specific improvement initiative where they can use their education to improve whatever that initiative is focusing on. “There’s huge power to that.” Sentara Medical Group used this approach when redesigning primary care practices into patient-centered medical homes (see page 13). About 50 physicians and managers were trained in Lean process improvement methodologies—and then served on teams that reengineered practices to make them more efficient and customer-focused. Mitigating Risks “As medical students and practicing physicians, we are trained to be good listeners,” says Maizel. “We gather facts by assessing a patient’s concerns or complaints and, depending on the situation, order some diagnostics to help narrow down the problem. We then use those facts to come up with a working diagnosis and plan.” In many ways, providing the best possible clinical care is about managing risks, he says. “When making recommendations to patients, we balance the potential treatment benefits against the possible harm that can result from those treatments.” Influencing the Future Rather than being discouraged by the level of uncertainty and risk in health care today, Maizel is inspired. “A lot of people are very concerned about where we are in health care right now. Some are saying, ‘Boy, maybe it’s time for me to get out,’” he says. “But I think this is one of the most exciting times in the history of our profession and our industry. I think if we take the right approach, we can really influence the way health care is going to be provided in this country for decades to come.” 1,024 opportunities to improve your hospital’s performance and counting Drive Clinical and Operational Performance Across Your Organization With a Single, Integrated View Press Ganey’s Clinical PerformerSM — an interactive clinical, operational and financial resource management solution — pulls together your hospital’s or system’s information into an integrated, intuitive view enabling collaborative analysis and decision-making. Clinical Performer reveals and prioritizes your greatest opportunities, whether there are 1,024 or just a few, so you can focus your improvement initiatives, simplify OPPE reporting and gain efficiencies. This solution provides easy-to-use information designed to help people at different levels of your organization, from executives and physicians to mid-level managers, get the actionable insights they need to accelerate improvement. In addition, you get strategic guidance and ongoing support from our dedicated Clinical Performance Executives — clinicians with hospital leadership experience — who partner with you to develop a game plan and drive results. Get ahead of payment reform now. Learn more at pressganey.com/ ImproveClinicalPerformanceHFMA10 or scan the tag. To scan the tag, download the free app for your smartphone at http://gettag.mobi. © 2011 Press Ganey Associates, Inc. All rights reserved. :KRKDVZRUOGFODVVH[SHULHQFH GHOLYHULQJZRUOGFODVVOHDGHUV" B. E.6PLWK For more than 30 years, B. E. Smith has successfully fit the skills of healthcare leaders with the needs of organizations like yours. So it’s not surprising that the tenure of executives placed by B. E. 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