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A Spinal Shift

Elyas Bakhtiari, for HealthLeaders Magazine, January 13, 2009
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"We had physician champions from orthospine and neurospine pull together to be able to fulfill objectives, which increased collaboration on both sides and provided a natural kind of organic decision to work together more," she says. "That's most efficacious for the patient because you have two experts from different backgrounds working together to improve the overall quality of care."

Success Key No. 2: Give physicians data
Physician champions are essential to most improvement efforts. McKinney took over the UCSF spine program with a projected $13.9 million loss for FY2008 and was able to turn that into a $6.1 million net improvement for the year, largely by providing physicians with data.

The focus was on two areas: clinical care optimization and vendor costs. In both cases, the hospital provided physicians information without any direct financial incentives, so it took physician leadership to coordinate how physicians use the data and to get surgeons to change behaviors.

On the clinical side, physicians were provided comparative outcome data for length of stay, blood loss, ICU utilization, and other clinical measures, and they benchmarked that data against results from 12 different hospitals with similar patient populations.

"Providing them the data was the first step, which enabled them to understand what types of changes they need to make," McKinney says. "We provided financial intelligence married with physicians' clinical intelligence to help them make the best decision, and they began looking at ways to make cost effective but still clinically effective changes."

The result was a decrease in length of stay by nearly half and a $2 million overall savings to the medical center.

A similar process worked with vendor costs. Physicians were given vendor pricing information and, with no financial incentives for doing so, were able to collectively save millions by finding implant and medical device alternatives that didn't jeopardize care.

Again, physician champions drove the change. "We created a formula with costs factored in and worked with a spine surgeon who was a physician champion and crucial to the initiative," McKinney says. "He sat with us to look at specific products and whether they were comparable and significantly interchangeable based on the type of procedure, the material the item was constructed of, as well as the level of complexity of the patient. That helped us have significant savings."

One surgeon began using an osteobiologic alternative to bone morphogenetic proteins—an expensive substance used in spinal fusions—that was about one-fifth the cost, saving the medical center about $800,000 on the spot.

"He then was able to share the results of the patient population, surgeon to surgeon, with other colleagues who then adopted the alternative," McKinney says.

Success Key No. 3: Improve patient navigation
Although surgeons are integral to any program, comprehensive spine care includes imaging, pain management, rehabilitation, and other disciplines. At its core, spine care is about navigating patients through the multidisciplinary team and triaging surgical and nonsurgical cases.

For that, many service lines rely on a patient navigator to coordinate the patient experience from preop education through postop treatment. The person filling the role may differ—UCSF relies on physician assistants, whereas Alegent uses nurses—but the goal is the same: educating patients and managing expectations.

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