Health Plan Helps Hospitals Achieve Better Grades

Hospitals sometimes face issues that CEOs wouldn't like to brag about. There may be lapses in quality of care, such as hospital-based infections or failure to adhere to treatment guidelines.

A hospital may fall below optimal standards, despite the fact that the facility may be working diligently at quality improvement.

When hospitals face these issues, they don't often look to a health plan for help, but that's the case in California.

An evolving pilot program in the Golden State involves a health plan, Blue Shield of California; and a hospital system, Adventist Health as well as the California Health Care Coalition (CHCC), a membership organization of public and private sector employers, unions, employer organizations, and health & welfare trust funds representing 4 million Californians.

Under the three-year pilot program, the hospital, providers, and payers are looking to improve healthcare quality and trim costs, and all the while, working together. That's the goal at least.

They are doing this in their own neighborhood, without waiting for Congress, or the President or anybody in Washington, DC, telling them how to improve patient care. This pilot represents an interesting scenario, and we should all watch how it unfolds.

The planning began in 2007, when Blue Shield and CHCC began talking about a coordinated pilot to improve quality, while lowering costs. Blue Shield and CHCC signed an agreement to run the Hospital Quality Improvement Pilot and find a hospital to work with them.

The CHCC had been concerned that there was a "disconnect" between high costs and the actual quality of care in California hospitals. The costs were going up, that's for sure. And what about that quality of care? Was it inconsistent?

"Our goal was to work in local markets and improve quality as a means to reduce overall healthcare costs," says Michael O'Neil, Blue Shield of California's director of healthcare value.

Specifically, Blue Shield was looking at California's central valley. "We looked at what would be an appropriate provider partner and Adventist came to the top of the list."

The Adventist healthcare system includes 17 hospitals, 14 home care agencies, and four joint-venture retirement centers.

Adventist wasn't selected because the healthcare system was rated at the top. Or that it was solidly even in its performance.

The hospitals' report cards yielded grades that showed there were needed improvements, according to Blue Shield and Adventist officials. A 90% score judged by the California Hospital Assessment & Reporting Task Force means that the hospital has achieved top 10% scores. That is what Adventist wants.

Hospital officials say there are some elements in Adventist's healthcare delivery system rated highly, but others were average, and some fairly low. Generally, there are specific areas of care or documentation that are cited for needed improvement.

"They do have a wide variation in their quality scores," says O'Neil, referring to Adventist. "But over the past several years, they have been working really diligently to improve quality internally and have been working with Johns Hopkins University. We felt there was good synergy about this."

In the fall of 2008, Adventist was picked to join the pilot, and the hospital system agreed. JoAline Olson, vice president for clinical innovation for the Roseville, CA-based Adventist, says the coalition came at a good time for Adventist because it was in the midst of a single-minded purpose: trying to improve quality for its patients.

Adventist Health was selected as a partner "due to its strong presence in the Central Valley Market and strong commitment to quality," according to Blue Shield officials.

Specifically, the health system showed a significant investment in raising quality across the system by, among other things, implementing IT infrastructure improvements, developing sustainable "culture changes," and creating physician/RN councils at the hospital and system levels to improve communication.

The pilot involves four Adventist Hospitals: Central Valley General Hospital and Hanford Community Medical Center, both in Hanford; San Joaquin Community Hospital in Bakersfield, and the Sonora Regional Medical Center in Sonora.

The three-way partnership aims to create an environment in which hospitals are supported and motivated to dramatically improve on different levels in measurable improvements: Clinical quality, patient safety, health outcomes, and patient satisfaction.

"We've been on a quality journey for several years," says Olson. "Our goal is to have 90% in three years and get rid of the variability. It would be fair to say there is room for improvement. We aim to increase quality, decrease cost, and provide the highest valued care for purchasers, payers, and ultimately for the patients."

We'll be waiting for the final grades, but this could serve as a model for other regions as all stakeholders struggle with improving quality and reducing costs.