Revisiting Clinical Protocols: Aligning a Healthy Bottom Line with Clinical Effectiveness

In today's economy, hospital executives are realizing that the variables they can control are quickly being dwarfed by the size of the problems they cannot control. This is a good time for executives to revisit clinical protocols as a way to position their hospitals in the face of a chaotic marketplace.

Clinical protocols are also a way to engage physicians who are more aware of their role in hospital operations than they were a decade ago. By taking the first steps to establish a clinical protocol committee, hospital leaders can bring physicians into the process of developing, updating, and improving clinical effectiveness. By bringing together stakeholders in this way, hospitals are better able to control their costs while also finding innovative ways to deliver quality patient care.

To understand the impact that clinical protocols can have in today's hospitals, it is important to understand the following:

• The troubling economic trends that are impacting hospitals, physicians, and patients
• The importance of clinical protocol committees in the face of economic challenge
• The best way to develop an effective clinical protocol committee

Troubling trends
Before delving into the reasons for updating protocols, take a minute to review some of the troubling trends that are emerging. The data clearly show that hospitals are facing many simultaneous negative pressures—unprecedented in our time—and they are being forced to look at innovative ways to control costs while maintaining quality care. Some of the most critical trends that are simultaneously facing hospitals, physicians, and patients today include:

• Patients are delaying medical care. Last year, 20% of Americans reported skipping or delaying medical care, up from 16% in 2006. This trend is resulting in more critical, costly care in the long run.
• Hospital revenue streams are changing as unemployment rises. Commercial insurance enrollment is down to 54.6% in 2009, compared to 59% in 2008, while Medicaid enrollment has grown from 11.9% to 14.5%. These shifts are negatively affecting hospitals' net revenues as the mix of reimbursements change and self-pay patients increase in number.
• Medical staffs are feeling the impact of a troubling economy and government oversight. The American Hospital Association's recent survey (November 2008) showed that 56% of surveyed hospitals are reporting an increase in the number of physicians seeking financial help through all sorts of mechanisms—from joint ventures to employment arrangements to ED call pay. The federal government is also changing the rules for how hospitals and physicians can affiliate, and is creating new options and models to be explored.
• The federal government is trying new and sometimes punitive approaches to control rapidly growing expenditures. CMS is trying such approaches as linking payments to quality, bundling payments, and initiating payment penalties for avoidable readmissions. At the same time the Senate Finance Committee is proposing measures that would move from a focus on quality reporting to taking 5% of CMS DRG payments from all hospitals and paying it back as a bonus for value outcomes. Only the top 25% of hospitals would receive the full bonus, the lowest 25% would receive none. Those in between would receive a portion. Essentially, those hospitals that may need the most help may receive the lowest payments.

As a result of these and other pressures, many hospitals are attempting to reduce their cost profiles in both the short term and the long term. In addition to the other difficult cost-cutting measures that hospital executives are undertaking, they should also revisit clinical protocol committees. Such committees can ensure effective patient treatment and position the hospital to take advantage of changing forms of reimbursement while benefitting the operational health of a hospital. Given the size of the chaos that hospitals and the country as a whole currently face, there may be less resistance to the concept.

Physician pushback eroding
Historically, physicians pushed back against protocols and resisted being told "how to practice medicine." Physicians usually voiced some common concerns: their training was likely better than those who are designing the protocols, their patients were sicker than the norm, or standardized protocols limited innovation. The lack of protocols, however, can have far-reaching consequences. For example, one 700-bed hospital chose to stay away from protocols and case management because of pushback from physicians. Upon review of the quality of this hospital's outcomes, it was poorly rated by national agencies, patients' length of stays were excessive due to delays in receiving routine tests, and services were dramatically overutilized. This represents a tremendous waste of resources and an increase in costs that could otherwise be avoided.

The recent economic downturn gives hospitals a good reason to revisit their protocols and most physicians can appreciate the rationale for looking at changes in the delivery system, even if they do not fully support the identified changes. Likewise, given the financial pressures that physician practices are facing, doctors are likely to appreciate any additional paid work in the form of serving on committees. Finally, serving on a protocol committee provides physicians with input in the process of identifying quality patient care while also balancing economic factors.

Most physicians and hospital staff join protocol committees with the shared goals to:

• Improve every patient's quality of care.
• Improve patient throughput.
• Lower the ALOS by determining a treatment plan in advance so care is coordinated in a more organized manner.
• Reduce readmissions because patients are healthier when they leave or because the protocol dictates that follow-up care take place.
• Increase the nursing staff's role in patient treatment, thus freeing up physicians to see more patients.
• Reduce supply costs by reducing the variation in types of medicines used.
• Improve documentation because any variances from the protocol are documented.
• Prepare for the coming changes in reimbursement.

Developing an effective clinical protocol committee
The concept behind clinical protocol committees is fairly straightforward—stakeholders are tasked with developing the highest quality, most cost-effective treatment pathway for a given illness and making that pathway the standard for how those patients will be treated. (Comparing clinical effectiveness is a more contemporary term that means much of the same.) Here are suggestions for taking the first steps towards developing a committee:

• Offer opportunities for every physician to be involved to some degree and make sure that the most highly respected physicians sign off on the end result.
• Include those physicians who are the most likely to be resistant. In the past, these physicians may have intentionally skipped critical meetings. Some hospitals believe that paying physicians to attend the meetings and to help develop the protocols is allowable under Stark, especially if they have to attend the meetings to receive payment.
• Be inclusive of the staff. Dietary and materials management may not need to attend every meeting, but they should be present when issues affecting their departments are discussed.
• Make it clear that the physician's judgment always trumps the protocol. Give proscriptive examples of when that might occur.
• Make it clear why the hospital is developing protocols. Any good "futurist" consultant can make the argument for why hospitals should be moving in this direction, and a presentation to the board may result in a direct mandate that it be done.
• Start with the small projects that have a reasonable chance of success. Protocols for myopia, hypothyroidism, obstetrics, and normal newborns can be done quickly and establish the legitimacy of the committee. Once the momentum is underway, move into areas such as pneumonia and osteoporosis.
• Know the limits. A little pushing to get your medical staff to work on slightly more complex diseases may be needed, but know when to stop. Until technology and biometrics can provide designer drugs tailored for each patient, intuition will play an important role.

Time is of the essence
In the midst of economic and organizational change, now is the time to re-engage physicians in the process of developing and updating protocols. Waiting until there is a financial crisis is too late and could be seen as an act of desperation by the very physicians whose buy-in is critical.

Physicians today are more aware of how hospitals operate than they were a decade ago when protocols were seen as the tool of managed care companies. They are also less likely to passively resist the measures if they are more reliant upon the hospital for financial help. Done correctly, the development of protocols will be embraced by physicians and help the hospital avoid other painful decisions in the face of economic challenges.