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Healthcare Collaboration Strategies Gaining Ground

 |  By cclark@healthleadersmedia.com  
   October 25, 2012

This article appears in the October 2012 issue of HealthLeaders magazine.

With looming budget pressures and payment penalties, one would think most executives of high-performing organizations wouldn't eagerly share their "secret sauce" for better outcomes and lower costs, lest it give competitors an edge.

But from Los Angeles to Boston and from Michigan to Texas, that's exactly what's happening with a series of "collaboratories" designed to improve care for all patients, regardless of which health system provides their care. By being transparent about procedural sequences as well as results, all providers can learn what saves lives and lowers costs.

In American medicine today, "we just don't know what works best," says James Weinstein, DO, MS, president and CEO of Dartmouth-Hitchcock health system, a Lebanon, N.H.–based $1.3 billion organization that includes an academic medical center and a network of clinics.

Rather, he says, "In this country we've been flying the Healthcare Airlines with planes that have no instruments, no gas gauge, no flight attendant, and we don't know where we're going or what we're doing. And until we have transparency of results and share best practices among organizations to make all healthcare systems better, that's what we'll continue to fly."

How physicians and hospitals treat diseases and conditions—such as heart failure, joint malfunction, or sepsis—varies widely across systems and even within physician groups, depending on customs and cultures or how a region's physicians may have been taught, he says. For example, some orthopedic groups perform knee surgeries on both knees during the same operation, while others do so sequentially in different operations during the same hospitalization.

Which is best? Which is best for which patient?

Weinstein is a founding member of the national High Value Healthcare Collaborative, a partnership of 15 health systems across the country working to improve healthcare while lowering costs. He and Dartmouth-Hitchcock colleagues invited executives from the Cleveland Clinic, Denver Health, Intermountain Healthcare, and the Mayo Clinic to share and scrutinize each other's routines in nine procedures or diseases to see whose practices produced the best results.

Expensive knee replacement surgeries were studied first, in part because they are projected to grow seven-fold by 2030 when there will be 3.48 million procedures a year.

One system among them—Intermountain, a Salt lake City–based $4.7 billion system of 22 hospitals, physicians, clinics, and health plans—employed dedicated knee replacement teams in the operating room. That seemed to result in shorter lengths of stay and fewer patient complications. Now, others are adopting this practice in their systems.

When they looked at surgeon volume, it turned out that the more knees doctors replaced, the better their patients' outcomes, too.

Two members of the collaborative—Dartmouth-Hitchcock and the Mayo Clinic, a Rochester, Minn.–based $8.5 billion international organization that treats 1 million patients a year—had set aside a morning when patients who wanted new knees could attend a presurgical class to learn a timetable for reasonable recovery expectations, and perhaps learn to use crutches, which some would need after discharge. That practice reduced length of stay, lowered costs, and improved patient experience scores, Weinstein says.

Much of the data is preliminary but shows solid trends toward improvement by multiple measures, he says.

For example, since October 2010, when Dartmouth-Hitchcock started working with the HVHC, through March 2012, it has decreased inpatient stay for total knee replacement from 3.5 days to 2.5 days. A contributing factor is the introduction in September 2011 of mobility assistants on the inpatient side, who would help patients move around, show them how to do basic exercises at home to keep the joint mobile, and answer questions

David Jevsevar, MD, medical director of the Intermountain Southwest Region orthopedic clinical program, says that when his team introduced that preoperative class "we reduced our length of stay by almost a full day."

Steven A. VanNorman, MD, chief medical officer for the Southwest Region of Intermountain, adds, "When you tell patients ahead of time that they'll be up walking on day one, they work toward that. And again, this doesn't cost more and most of it costs less, and we improve outcomes and patient experience at the same time."

Hospital officials say that for Intermountain, the education program highlighted the risks and benefits of skilled nursing facilities. "We saw a decrease of 30% in our SNF admissions," Jevsevar says. "We believe this is a critical factor in our infection reduction rate, which decreased over 50%."

An important element, Weinstein emphasizes, is that patients make an informed choice about whether to undergo the operation. And that means they hear honest assessments from an interdisciplinary team about negative side effects, the chance that it might not work, and the potential need for a redo, even before they are referred to the surgeon.

"That's a huge change, and we know it's threatening to the medical professions," says Weinstein, himself an orthopedic surgeon. "We know that the surgeon wants to operate. But the patient may not understand the risk of a blood clot, or an infection, or that there might be a problem with the device, which if they did understand, they might not want to go through with surgery."

Weinstein—who until November was director of the the Dartmouth Institute for Health Policy and Clinical Practice, a member of the HVHC—says the prevailing system now used in the country must change if providers are serious about improvement. "Now, patients are not informed and they're not given what they need."

The HVHC's leaders wrote up their findings of their first knee replacement sharing experience in a June issue of Health Affairs, saying that the many lessons learned are getting packaged in protocols and repeated, so all health systems can improve, too.

In June, the Center for Medicare & Medicaid Innovation awarded the HVHC $26 million to expand its search for best practices in heart failure, high blood pressure, diabetes, and sepsis. Pneumonia, weight loss surgery, asthma, labor and delivery, and are on the list, too. An important component of that grant is to establish the best systems for enabling informed choice (shared decision-making), so patients have realistic expectations for procedures they agree to undergo, Weinstein says.

The collaborative now brings together 50 million patients from 15 organizations and their health systems, and every week, he says, "another healthcare system calls us asking to join. This is evidence of a groundswell of desire by these systems who understand that we're not getting this right. We better step up and do something."

The collaborative's next project, diabetes care, poses dozens of questions. "Do you need expensive medication versus a cheaper drug? How many times should we check blood sugar levels? And how many office visits do we need? And should we strive for a hemoglobin A1c of 7% or 6%? There's no protocol that's nationally accepted. Everybody now just does their own thing," Weinstein says.

Various procedures will be measured and worked into protocols that are tested and retested. "And I'm sure that we'll see lower cost and lower utilization of resources with better outcomes and more satisfied patients and providers as a result," he says.

While the HVHC may be the largest such collaborative, many others are launching smaller or system-specific projects. In addition to participating in HVHC, Intermountain has looked at practice variation within its hospitals, says VanNorman.

"It really requires a medical staff that has a culture of openness and sharing of data," he says. Some 60 physicians of the 250-member medical staff went through formal training to accomplish this, and the teams "are now accustomed to having our numbers put up on the wall."

At one Intermountain hospital, 245-licensed-bed Dixie Regional Medical Center in St. George, Utah, removing practice variation throughout the system resulted in a half-day reduction in length of stay for pneumonia patients, and readmission rates were reduced by 5 percentage points between 2009 and 2011, from 14% to 8.8%.

"One of the things we learned is that we didn't have the patient and the family engaged enough. They weren't that clear why they were in the hospital to start with, much less what they had to do to get out of the hospital," says VanNorman. Now the patients and their family members receive a brochure that identifies on day one, day two, and day three, how much oxygen a patient is expected to use or what distance they should be able to walk.

"And by day three, you're probably doing everything you're supposed to and you can go home," he says.

Another Intermountain effort focused on better recognition of the earliest signs of inpatient sepsis, which has reduced its severity, cost, and length of stay, VanNorman says.

The number of patients with higher severity-of-illness scores for patients with hospital-acquired sepsis dropped from 82% to 75% between 2009 to 2011, "indicating that we are catching symptoms sooner and preventing patients from becoming severely septic," says Kristine Otterson, Intermountain's process improvement projects coordinator for the Southwest Region. That decreased sepsis length of stay by just over a half a day and readmission rates by 2.7 percentage points, Otterson says, from 13.8% to 11.1%.

Of course making such dramatic changes can be controversial. Some physicians and surgeons don't like being told they have to adapt to a protocol. They call it "cookbook," and say it's not why they went to medical school, VanNorman says.

For example, the push to have patients consider alternatives before they see a surgeon has drawn some fire from specialists, says Jevsevar, an orthopedic surgeon.

"We think the decision should be an interdisciplinary one. We think that surgeons are biased toward intervention to help each specific patient and have a difficult time telling patients no," Jevsevar says.

As surgeons, he continues, "we develop a certain amount of confirmation bias where we've done things for so long we think we can get by with this diabetic patient, too, not understanding that at some point it's going to burn us."

Key to making collaboratives like this work, Jevsevar and VanNorman emphasize, is to have tight, correctly risk-adjusted patient outcome data for each doctor. That way, operators have a tougher time arguing—as many of them will—that their results weren't worse because their patients were sicker from the start.

In dealing with two such physicians, the data made a convincing case that led the surgeons to finally conclude, Jevsevar says, that the procedure "may be something I shouldn't be doing anymore."

Another collaborative unified all eight children's hospitals in Ohio to improve two problems: infection rates in orthopedics, neurosurgery, and cardiovascular surgery, and adverse drug events related to the use of narcotics.

The groups met and found wide variability in the timing and dosage of antibiotics usually given to patients just prior to surgery, says Vera Hupertz, MD, vice chair of quality and safety for Cleveland Clinic Children's Hospital.

A collaborative leader "simplified the process, standardized the dosing of antibiotics during and before surgery so that everybody gets a higher, stronger dose" and in intervals of three hours instead of four. Ever since, surgical site infections have dropped from 8 in 2010 to 7 in 2011 and to 1 in 2012 as of August 8.

The second issue involved the common problem of dangerous constipation in children treated with narcotic painkillers. "Constipation increased patients' morbidity and potentially the length of stay, yet it wasn't being aggressively addressed by the teams," Hupertz says. "We were able to evaluate which laxatives worked best and determine the best doses," and to date, adverse drug events have dropped by 33% since 2010.

It's not just big systems that are getting into the sharing mode. A dozen smaller hospitals in the California Central Valley are sharing practices to reduce infections.

For example, 202-licensed-bed Dameron Hospital in Stockton learned from the Patient Safety First collaborative how to tackle inpatient sepsis mortality rates of 25% in 2009, higher than the state average, says chief nursing officer Janine Hawkins, MBA, RN. In 2011, sepsis mortality was down to 16%, below the state average.

Patient Safety First is a three-year, $6 million effort that links hospitals throughout the state of California in a coordinated effort to improve patient safety through the sharing and implementation of best practices to eliminate healthcare-acquired infections. It was launched in 2010 by Anthem Blue Cross, California's three regional hospital associations, and the National Health Foundation.

The game-changing strategy was to get earlier recognition of sepsis symptoms and get physicians to insert central venous lines to get antibiotics into patients as soon as possible.

"One of our nurse managers developed the 'gold watch protocol,' " which uses a digital clock as a visual cue. As soon as a septic patient is identified, a time-sensitive series of events occur, drawing laboratory tests, conducting a thorough physical exam and appropriate fluid resuscitation, initiating antibiotics, and admitting the patient to intensive care. "Things have to happen quickly," she says. By having that clock hanging from the IV pole, everyone knows what time it is.

"We created a sense of urgency and developed a protocol that has become part of our daily operations," Hawkins says.

Weinstein, sees a "groundswell of acceptance that the systems need to do better," a kind of revolution to change the direction of "Healthcare Airlines" that is more important than the new law's expanded coverage. "I'm all for everybody being insured, but that doesn't mean you're going to have better healthcare. It's only if our systems change will that happen."


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This article appears in the October 2012 issue of HealthLeaders magazine.

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