Should health systems care about health? What do they plan to do about it? These questions are not as snarky as they may seem. The real strategic choice facing hospitals and health systems over the next decade is whether they will evolve their mission from its focus on sick care to health care.
I posed this question last week to a number of chief financial officers from across the country who gathered for two days of idea exchange at our annual HealthLeaders Media CFO Exchange. The 29 CFOs represented a diverse group of health systems, from community and rural hospitals all the way to regional health systems. They were also diverse in terms of their physician alignment, degree of payer/provider integration, and experience with risk-bearing contacts and capitation.
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None of the CFOs disputed that their organizations need to make many changes to meet demands for more coordinated, cost-effective care. They said they will work diligently to improve overall health.
Investments in electronic health record systems, for example, that will be able to identify gaps in care, foster evidence-based medicine, and, hopefully, improve physician-to-physician and physician-to-patient communication.
But providers may only be willing to step so far into the realm of "health" care, which includes a range of services from more robust prevention programs and significant investments in primary care. When it comes down to whether American hospitals will fully evolve into organizations that seek to lead people toward healthy lives, there are many barriers. A few, which I have paraphrased, are:
Incentives are still not aligned for health systems and hospitals to lead the march.
Physicians and other community pillars are better positioned and experienced to lead.
The demand for acute/inpatient care and outpatient procedures is also expected to grow rapidly in the next decade, and that is the demand hospitals must meet.
The health systems that may be the true test cases may be physician-led, integrated systems with experience at capitation, patient-centered medical homes, and multispecialty practice. I moderated a Healthleaders Roundtable a couple of years back and still recall what Dean Health CEO Craig Samitt, MD, said about how his Madison, WI-based health system views growth.
"The ideal growth scenario for us is five years from now [is] we have triple the number of patients, each generating half the number of prior services that they generated previously," Samitt said.
The healthcare organization that is the furthest along in the "health" continuum to date may well be Kaiser Permanente, with nine million members, 37 hospitals, and more than 16,000 physicians. It has the structural advantages of being integrated with the health plan. And its scale affords certain other tools, such as an integrated electronic health record system that combines provider tools with member tools for managing health and communicating with the care team.
"The most direct way to think about it is how a person defines health rather than how a medical system defines health. If you ask people about their health, they talk not just about fear of disease," says Raymond J. Baxter, PhD, Kaiser Permanente's senior vice president, community benefit, research and health policy. "They don't draw the boundaries that [healthcare] professionals draw around that."
KP has taken an approach to take on the spectrum of levers that can influence a person's health. It does not constrain itself to the management of chronic disease and prevention, but has interest in community-based programs.
For example, a typical provider may prescribe an overweight patient to lose weight by eating healthier food and getting more exercise. But what is the health system doing to provide those resources? Some health systems will embrace KP's idea of supporting community walking trails, adding farmers' markets for local produce in urban food deserts, or working with schools to build healthier lunch menus.
Other health systems across the country are working on similar programs to various degrees, but whether they will place their hands on the steering wheel of overall "health" to drive down costs is an open question.
To learn more about Kaiser Permanente's Model for building community health and patient engagement, register for the HealthLeaders Media Rounds live/simulcast Kaiser Permanente's Model for Total Health from Washington, DC on October 16.
This article appears in the August 2012 issue of HealthLeaders magazine.
I n the mid-2000s, Sharp HealthCare was on two somewhat overlapping journeys, those grand goals that define health system improvement for large organizations. One was to fulfill its own self-appointed vision of the Sharp Experience, a service mission stated as "Become the best place for employees to work, the best place for physicians to practice medicine, the best place for patients to receive care, and ultimately the best health care system in the universe." Along the way Sharp also undertook the self-examination and improvement required for the Malcolm Baldrige National Quality Award, which it eventually achieved in 2007.
One of the core learnings along the path was that Sharp, for all its effort and lofty goals, still struggled to understand process, says Nancy Pratt, senior vice president for clinical effectiveness at Sharp HealthCare. "What is a process? What is a standard process versus a one-off process? Because in healthcare and in our organization we had a lot of individual processes that were not repeatable, and so you don't get the consistent results when you don't have a standardized, repeatable process," Pratt says. "There were some things that we needed to have on that consistent basis across the enterprise, whereas other things could vary for very good reasons. But to just have everything different because everybody feels like having it different wasn't going to make us successful."
It was important to make the distinction between what was an unorganized "collection of activities" and the goal of an "orchestrated process," Pratt says.
"People didn't understand that this collection of activities was a process and that we could map it as a flow. Just in defining it in a flow diagram, we could often see immediately what was wrong," Pratt says. Throughput in the emergency department was among the first processes to go through process mapping, and what they found was that physicians and nurses were not working in tandem as well as they could and that much of the patient experience was waiting.
"What we needed was an orchestrated process driven by a team where everybody understood everybody else's roles," Pratt says. "They knew what they were going to do. They knew the rough time frame they were going to do it in, and they accomplished it and got to a conclusion. And it happened so much faster because of that."
Blind process improvement for the pure sake of efficiency, however, is not the goal. Often process improvement efforts identify process waste that has an underlying patient safety or satisfaction reason, such as duplicate time spent with patients to make certain they understand their follow-up care plan. What has made the results sustainable has been that all process improvement is weighed against "what is value-added and what is not value-added to patient experience," says Susan Stone, vice president of patient care services and chief nursing officer for Sharp Memorial Hospital.
"What we did was really focus on reducing all the waste from the patient experience and what happened was that we saved our own time, saved our own redundancies and duplications of effort," Stone says. One of the biggest wastes identified was "multiple communications to multiple people," she says. When redundancies were eliminated and processes were standardized to optimize the patient experience, ED throughput was reduced from an average of 5 hours to 2.8 now. As a corollary, patient satisfaction jumped from the 30th percentile to the 96th, Stone says.
"The overall patient experience is so much more purposeful and the team members are more satisfied because what they're doing is meeting the needs of the patients and themselves while they're at it. It's kind of one of those things where we were looking at it from the patient experience, but we're also going to be thoughtful so that it makes sense for us, too. At this point in time with healthcare reform … and reimbursements going down, we all need to work smarter, not harder. But while we do that, we can focus on what's most important—providing the best patient care experience possible."
What blocks many healthcare organizations from sustainable process is complexity. The thought of mapping hundreds if not thousands of distinct processes is daunting. What helped Sharp to map processes from the ED to ICU and beyond was rooting those processes against a handful of "critical functions," Pratt says.
"There are a core set of critical functions that we do on every patient. That was kind of the nugget of truth that allowed us to simplify this to what's real," Pratt says. "Those common processes occur across the entire healthcare delivery system and all of those processes we identified key requirements for. When you do it at the macro level, then people can understand how it works for their individual jobs."
Those processes broke down into four stages:
Registration process: "Every patient that comes to our health system has a registration process, and there are critical things that have to happen there from a safety perspective to properly identify the patient," Pratt says. "There's an expectation that that happens at a rate of speed that's commensurate with what their needs are."
Diagnostic assessment: "There is an assessment process that needs to be done thoroughly and accurately by the right providers," Pratt says. "Even if it's a health maintenance activity, we're going to do some kind of diagnostic assessment. Those are critical processes that all have requirements to be safe, patient-centered, timely, efficient, and equitable."
Treatment process: "All of those patients are going to have some kind of treatment, whether it's health maintenance or to cure some process of illness that they have. So there's a treatment modality there, and there are critical requirements to that treatment process," Pratt explains.
Disposition/education: "Every patient is going to have some sort of education piece. If they're an outpatient, they're going to have some kind of instructions that they leave with. If they're an inpatient, they're going to have some instructions that they leave with," Pratt says.
Having consistent processes allows for an essential foundation of patient-centered care: customization. Susan Frampton, president of Planetree, a not-for-profit membership organization working to implement a comprehensive patient-centered model of care, says standardization and customization are not enemies.
"It all comes down to setting up systems up that allow for choice," says Frampton. "For example, every hospital has an admissions process. There's quite a bit of information that's collected at that time. And in a more traditional sense, it's always been information that clinicians think is important to have. A patient-centered approach would be to say, 'What aspects of the experience can we provide choice to patients around that will work for them and work for us? And what sort of systems do we have to have in place to support that?' "
An example would be patient-directed visitation. "You know, you add one question to that admissions paperwork that says, 'Who would you like to have available to you, and when would you like them to be able to be here?' And that information then gives the patient some choice about, 'Who is my support system, who do I need to have here?' If you have a system then where that same information goes into the care plan that the nursing staff is working with, and it's right up there with other important pieces of information—the nurses can really use that to help manage the patient."
This article appears in the August 2012 issue of HealthLeaders magazine.
This article appears in the July 2012 issue of HealthLeaders magazine.
Hospitals have known for years that there are many advantages to marketing a comprehensive set of women's health services as a single unit. Not only do women represent a huge consumer segment with their own growing list of healthcare needs, but they are also the chief decision-makers for their family's care.
The current challenge for many health systems is to create the operational and clinical structures required to deliver a truly comprehensive set of women's health services. North Shore-LIJ Health System set out four years ago to create the Katz Institute for Women's Health to provide that comprehensive structure.
"It's a major priority for us as an organization because we have to get way, way beyond thinking of women's health as being limited to pregnancy and delivery," says Michael Dowling, president and CEO of North Shore-LIJ Health System. "It's not an easy thing to do because women's health, in many ways, is almost everything. You have to cut across a multitude of departments and service lines to be able to put a coherent face and a coherent structure around the women's health delivery system. If it only becomes a marketing issue, it sounds good, but you've got no substance behind it and at the end of the day it will fail."
Jennifer Mieres, MD, senior vice president of North Shore-LIJ Office of Community and Public Health, says clinical research has focused in recent years on defining women's health more broadly and identifying gender-based differences in care delivery. Those gaps in delivery made little sense given the profile of healthcare spending. "When you look at U.S. healthcare expenditures, women spend a lot more in terms of health," says Mieres. "Inpatient expenses are about $188 billion for women compared to $165 billion for men. Home health expenditures are $24 billion for women compared to $14 billion for men."
With a clinical and business imperative to start with, North Shore-LIJ began to design a template for a women's health center of excellence, for which Mieres was appointed director. The strategic plan was built around four areas of focus:
Clinical services: Facilitate integration of multidisciplinary clinical services that address women's unique needs across the lifespan, focusing on prevention and treatment, and providing a convenient one-stop-shopping format.
Research: Integrate and expand the activities and programs of the women's health research agenda.
Community outreach: Integrate community outreach, education, and recruitment with the activities of the center of excellence.
Professional education and health literacy: Disseminate information on diseases specific to women, for health maintenance and disease prevention and for living with illness.
A vice president was appointed to each of the four areas of focus, with Stacey Rosen, MD, a practicing cardiologist, appointed VP of clinical services for the Katz Institute. A clinical services steering committee was formed with representatives from the major clinical areas of women's health, including the traditional practices dedicated strictly to women such as OB-GYN and gynecological and breast cancer, Mieres says, but also cardiology, neurology, endocrinology, radiology, urology, and rheumatology. Rosen began the integration process by going department by department to break down barriers—some structural and some cultural—that had kept women's health services from acting as a single unit and guiding patients to where they need to be.
"If you meet with the chairs of obstetrics and gynecology, they are going to be hard-pressed to deny that I am better at managing cardiac and hypertension and diabetes than they are," Rosen says. "And I don't deliver babies. So wouldn't it be great if every time their patient had an OB-GYN visit they were reminded about other nongynecologic opportunities for wellness?"
The bridge was different with each department, Rosen says. So for the GYN oncologists, the cardiologists could offer to preop screen their patients and follow them after their hysterectomies. Or for the psychiatrists, it might be adding a postpartum depression flyer in the materials given to mothers after delivery.
"I think that's how you start it," Rosen says. "You start it man-on-man. You start it very focused and small where there are maybe some little politically charged issues, and then your vertical silos start interacting with each other. I think back to the cardiac world. You know, a cath person used to hate the surgeon. If you had to send someone to open-heart surgery instead of putting stents in, that was a failure. But now every good cardiac program has complete integration of the services, and if the patient does well and everybody's service line does well, that's a success."
Beyond physician relations, a key initial step was to review the definition of women's health to encompass evidence-based care in three areas:
Conditions where women are uniquely affected, such as gynecologic disorders, obstetrics, and breast diseases
Conditions where women are affected disproportionately more than men, such as in osteoporosis, depression, and gallstone disease
Conditions where the manifestation in women is different from that in men, such as heart disease, lung cancer, or rheumatoid arthritis
Perhaps the trickiest in terms of clinical services integration is the latter. Better evidence on gender-based clinical guidelines has helped. Rosen and her team make sure the information is disseminated throughout the women's health organizational matrix so emergency physicians, OBs, and other disciplines that come in contact with women know, for example, that heart disease is still the No. 1 killer of women, and that a woman may present different symptoms than men will.
"In some instances, the disease is different," Rosen says. "There are women who will have chest pain with normal coronaries, normal arteries, and no blockages, and people in the past thought they were being 'histrionic.' And what we've learned through research over time is that there is something still wrong with their arteries—that it's not 'no disease,' but it's a different kind of disease. When women get diabetes, for instance, it's a much bigger risk factor for heart disease than men. There's that whole category of a very common disease sometimes being different in the female population."
The matrix for the clinical integration is based on having specific expertise—i.e., a specialist with an interest in clinical research in women's health within his or her particular discipline—and making the connections so that women get coordinated care. In that model, the vertical silo breaks down, so a cardiology program expands into a cardiovascular wellness program, Rosen says, citing a model being developed by Boston's Brigham and Women's Hospital.
"The program has a group of those doctors who focus on women and heart disease," Rosen says. "They do outreach and screening and prevention. They provide primary cardiac care to patients who identify as having the disease or are at risk. They integrate with noncardiac programs where heart disease is prevalent, including diabetes patients or high-risk maternity patients. In other words, the services then go away from the vertical cardiology and say, 'Well, where else are there women who are at risk or have heart disease that I can integrate services better?' That's how the clinical transformation in our organization needs to be. It needs to be a clinical practice that is for women in heart disease, but then it has to have sort of horizontal pods that go out to anywhere women would otherwise receive care."
The clinical integration link between those horizontal pods is a navigator model, specifically a staffed resource center that acts as a single phone number for women to call with any questions, Mieres says. The center is staffed by three full-time navigators and backed up by nurses and physicians when the clinical complexity requires a higher level of expertise.
"You call one number, and we can help you connect to anyone within our system, any service line, to deal with your complaints," Mieres says. "We women all have busy lives. Women want to be able to do one-stop shopping, so that's what we're trying to provide." The navigators ask basic questions about the health issue, and then guide the patient toward specific services, so, for example, a patient seeking information on a hip or knee replacement can get a first or second consult with one of the orthopedic surgeons who specialize in gender-specific aspects of the procedure, Mieres says.
This article appears in the July 2012 issue of HealthLeaders magazine.
The interventional cardiology program at The Mount Sinai Hospital in New York has grown from a total catheterization lab volume of just over 14,000 annual cases per year in 2007 to almost 20,000 last year. In that same time, as volume has grown, complication and mortality rates have been among the lowest in the region. Over five years, mortality in percutaneous interventions is at 0.21% and major complications at 0.52%.
Samin K. Sharma, MD, director of clinical cardiology and president of the Mount Sinai Heart Network, has broken down the program's success into 10 reasons and goals, from teamwork to a commitment of investment by leadership. Among the most critical has been "uniform standardized medical and non-medical protocols" which have been installed throughout the catheterization lab, from the senior interventionalists to everyone on the care team. Sharma says he knew the protocols were working when the health commissioner of New York state came to tour the lab to see for himself how they worked.
"I mentioned about the protocols and we showed the book to the health commissioner at that time," Sharma says. "He said, 'You're telling me that your interventional fellows know about the book?' I said, 'No problem. We can go back to the cath lab and you can ask my intervention fellows anything from this150-page book.' They opened it, asked questions, and the answers were perfect. That is why we emphasize so much teaching."
Sharma says having an enforced, communicated set of protocols is the key to success, but even with that there is no single set that will work for every cath lab team.
"I'm not saying that people should duplicate what we have, but clearly there should be a set protocol," Sharma says. "In this field, there is more than one right way to do things. At the same time, by and large, the concept has to be that when the variation occurs, that's where the trouble occurs."
Mount Sinai's protocols themselves are open for new evidence and team input, whether by a senior staff interventionalist or another clinician.
"Many times one of the voluntary physicians makes some good suggestions, so we will change our protocol based on incorporating their opinion," Sharma says. That sense of full teamwork extends to any communication following complications, he adds. "If an issue occurs, we discuss it openly. That is a key—that open communication. If you have a closed-door discussion with one or two people, then other people on the team don't know. On any major complications, we speak the next morning. Then monthly we have a one-hour discussion to review."
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This article appears in the June 2012 issue of HealthLeaders magazine.
The interventional cardiology program at The Mount Sinai Hospital consistently ranks as a top—if not the top—program in New York City in terms of volume and lowest complications. Samin K. Sharma, MD, director of clinical cardiology and president of The Mount Sinai Heart Network, says the reasons are quite simple.
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Leadership and teaching, adherence to a strict set of protocols, and communication all form the basis of the program's success in the city's fiercely competitive heart market. Even something as seemingly small as making sure there is a senior interventionalist on the floor can pay big dividends in quality. In 2008, the program at Mount Sinai performed 4,577 percutaneous cardiac interventions, with a risk-adjusted 30-day mortality rate of 0.62 for all cases.
"There are five of us interventionalists who are the backbone of this program at Mount Sinai," Sharma says. "One of us always stays until the lab is done. It could be midnight, could be 2:00 a.m., but we stay all night to help these other interventionalists to get a good outcome."
But having senior physicians around to mentor and guide is only a supplement to a program based on evidence-based protocols.
"We have a set protocol for all the routine and complex procedures," Sharma says. "If a complication should occur, we have protocols for how the procedure should be done from a technical point of view. Everything is standardized despite having up to 19 interventionalists who come and do the cases." Sharma says the protocols are followed by all physicians, even the voluntary physicians, who perform procedures at Mount Sinai. The key to adherence is constant teaching, he says. Sharma recalls a visit by the health commissioner of New York state who came to tour the lab to see how it worked.
"I mentioned about the protocol and we showed the book to the health commissioner at that time. He said, 'You're telling me that your interventional fellows know about the book?' I said, 'No problem. We can go back to the cath lab and you can ask my intervention fellows anything from this 150-page book.' They opened it, asked questions, and the answers were perfect. That is why we emphasize so much teaching for our interventional fellows who are the backbone of the success of the program."
The protocol adherence extends beyond the physicians to the entire cardiac intervention team.
"Protocol is for everyone. We have a separate protocol for the nurses and 17 staff nurse practitioners. Many of those protocols are part of the same protocol book because that's the part that always stays—what medicine to give once a patient gets into trouble and so forth." Nurses also have protocols for everything from handoffs to how they should sign out, he says. As rigid as the protocol is for the team, it is nonetheless a living document that is updated regularly when evidence is reviewed, Sharma says. And as much as a set of protocols works well for Mount Sinai, that same book might not be a fit somewhere else.
"I'm not saying that people should duplicate what we have, but clearly there should be a set protocol. In this field, there is more than one right way to do things. At the same time, by and large, the concept has to be that when the variation occurs, that's where the trouble occurs." Other programs may modify protocols based on their needs, as long as the principles are mandatory. It's also important that all team members feel a sense of ownership of the protocol, and that their suggestions are heard, he says.
"Many times one of the voluntary physicians makes some good suggestions, so we will change our protocol based on incorporating their opinion," Sharma says.
That sense of full teamwork extends to any communication following complications, Sharma says. "If an issue occurs, we discuss it openly. That is a key, that open communication. If you have a closed-door discussion with one or two people, then other people on the team don't know. On any major complications, we speak the next morning. Then monthly we have a one-hour discussion to review."
This article appears in the June 2012 issue of HealthLeaders magazine.
This article appears in the May 2012 issue of HealthLeaders magazine.
Editor's note: This piece is an excerpt from a fuller case study that is part of an upcoming Rounds event, Building ACO Foundations: Lessons From Kaiser Permanente's Integrated Delivery Model. To see the full case study, which includes additional lessons and more information, visit www.healthleadersmedia.com/rounds/.
No hospital or medical group would dare admit they do not practice team medicine, at least conceptually. But true team medicine is about more than an aspiration—it's an intentional structure built, led, and enabled to deliver care by a diverse, multidisciplinary team of physicians, nurses, pharmacists, counselors, and dozens of other professionals. Oakland, Calif.–based Kaiser Permanente, even with its massive scale of 8.9 million health plan members, more than 16,000 physicians, and 170,000 employees, is built around the team medicine concept.
To be sure, there are benefits to Kaiser Permanente's integrated structure, which allows aligned incentives between the Kaiser Foundation Health Plan and hospitals and the Permanente Medical Group physicians. Still, Kaiser Permanente leaders say the key to creating team medicine is less about alignment around reimbursement and more about a commitment to a different way of practicing healthcare, not just medical care.
Amy Compton-Phillips, MD, an internist and associate executive director of quality for the Permanente Federation, says team medicine requires thinking about the physician's role in a new way.
"Twenty-first century medicine has shifted from the solo clinical expert model to one where physicians serve as a leader of a healthcare team to focus on the total health of our patients," Compton-Phillips says. "The team works together to coordinate care seamlessly across specialties, settings, and disciplines."
When the patient engages with an entire team, it frees up all sorts of opportunities for improved outcomes and cost savings, says George C. Halvorson, chairman and CEO of Kaiser Permanente.
"Ideally you have the patient who sees their primary care site, their medical home, as their primary and central coordinating caregiver," Halvorson says. "And those sites function best if they're team-based and they've got doctors and nurses working together."
Team assignments are based on who is the most appropriate. "It doesn't necessarily have to be the physician speaking with a patient about a request for new prescriptions on the phone. Having a nurse calling and creating a little dialogue works very well and is more efficient," Halvorson says.
One of the criticisms leveled against team medicine is that it can have the adverse effect of diluting ownership, that because everyone has responsibility for the patient, no one has responsibility for the patient.
Murray Ross, PhD, vice president and director of the Kaiser Permanente Institute for Health Policy, says, "It's all about accountability. You have one entity accountable for the patient rather than five to seven entities that are all individually accountable, which means that none of them are. If there's no one in charge, there is no one to say, 'What should we be doing for this patient as a team?'"
Without a team structure, there is no incentive or method to look for care gaps that could cause more complications or expense for the patient, says Benjamin K. Chu, MD, an internist and group president of Kaiser Permanente Southern California and Hawaii.
"It is so important to have a mirror held up to us that forces us to look at our system as a whole," Chu says. "If you just say, 'It's your responsibility to do this, Dr. Primary Care,' or 'It's your responsibility to take care of these things, Dr. Hospitalist,' it's just not going to happen. There's no way that individuals acting alone can close those gaps or solve those problems."
Along with accountability has to come tools so that all members of the team know what the patient needs—sometimes even before the patient does.
"If you call up our call center to make an appointment, the call center agent will actually have a list of the gaps in your care plan," Chu says. "So, for example, if you haven't had a cancer screening or a mammography, or if your blood pressure has been out of order, they'll actually try to arrange for follow-up for you on the phone."
Beyond tools and accountability is the culture of team medicine, one that many physicians whose medical education and training have been built around a physician-centric model can be slow to embrace. Jack Cochran, MD, a plastic and reconstructive surgeon and executive director of the Permanente Federation, says he often hears Kaiser Permanente has been able to make significant strides only because of its model.
"I don't accept that," Cochran says. "We have made a concerted effort to learn and make substantial improvements in our care and outcomes over time. Our physicians combine professional satisfaction with a strong commitment to the mission of the organization. What is necessary is to move beyond self-interest. The physicians have to ask themselves, 'What is my personal mission?'"
The Permanente Medical Group is built around a core set of values and expectations. "We recruit physicians with a sense that we're a group practice. We stand for quality. We measure quality and results," Cochran says. "We think it's important that we tell patients we're going to give them the kind of quality they deserve. You then orient, evaluate, and promote people based on the same set of values and expectations. Eventually you end up with a culture that is very comfortable with a focus on quality, measurement, comparison, and improvement."
Robert Pearl, MD, a plastic and reconstructive surgeon and executive director and CEO of the Permanente Medical Group, says in a typical Kaiser Permanente referral, "our integrated delivery system structure allows the patient who, for example, needs orthopedic expertise to obtain it rapidly. We have the ability today for the primary care physician to call an orthopedic surgeon while you're in the examination room. We have the ability to offer you a same-day visit or to offer you a visit on a different day."
In a community-based medical staff model, Pearl says, the primary care physicians cannot get immediate assistance since they would need referral links to all of the orthopedists in the community, not just one or two. And they would need to have the phone and scheduling system integration to be able to offer the same-day schedule.
The team concept extends to acute hospital care, as well, Pearl says. His group realized it needed a specific team of physicians, nurses, and technicians to handle sepsis, which is the No. 1 killer of patients in the hospital, Pearl says. "You need a full sepsis team 24/7, able to respond to the emergency room immediately because the treatment is very complex and somewhat dangerous, but the result of doing it in the most timely fashion is you save the lives of a significant number of patients."
The early signs of sepsis can be difficult to diagnose, particularly with young people, Pearl says. "You need to have the expertise to draw appropriate laboratory tests, to provide high fluid administration and placement of central lines, and to provide intense treatment on a consistent basis for patients who at that moment don't look particularly sick, but you know they will be in 24–48 hours. To do that well requires a team of individuals with a broad skill set—physicians and nurses and other individuals who come to an emergency room, see a patient, and begin the treatment—because if you just let everyone do it who doesn't do it often enough, it's too late and the results are not as good as they could be."
The business model for most of healthcare today does not support team care. Typical fee-for-service reimbursement discriminates against the type of coordination that team-based care often requires, Halvorson says. But once the reimbursement plates have finally shifted and necessary tools are put in place, team medicine can have enormous power, he says.
"The business model has to support team care by paying for all the pieces," Halvorson says. "And then if you have the right computer system, the right care registry, and you've got the right set of caregivers, the combination of all those pieces is magical. It creates the energy and the synergy that you need to make a difference in the lives of those patients."
This article appears in the May 2012 issue of HealthLeaders magazine.
All hospitals have patient safety programs meant to reduce harm. Henry Ford Health System in Detroit took a more blunt approach in 2007: cut harm by 50%.
The board of the five-hospital health system—the 2011 recipient of the Malcolm Baldrige National Quality award—decided to launch a "No Harm" program under the guiding principle that "the highest priority of our quality work is to become a harmless organization." The system's leadership set a quantitative goal to reduce events of harm to patients by 50%. From 2008 to 2010, HFHS reduced system-wide harm events by 25%, and extended the program to 2013.
Live Simulcast from Henry Ford Health System: Learn how Baldrige-winner Henry Ford Health System has become a model for delivering high-quality healthcare at the HealthLeaders Media Rounds event, May 1.
The goal of 50% was not just arbitrary. It was meant to be a number big enough to be reachable but also create a sustaining momentum for the organization.
Having a system-wide goal creates a benchmark, and an expectation of staff members, says Jennifer Ritz, manager for quality improvement in surgical services and a member of the system's No Harm steering committee.
"I can tell you that 50% is a big goal, and there's a lot that goes into that calculation," Ritz says. "But I think what is so unique for us is that we go way beyond those specific metrics that we're measuring for harm reduction. We don't just do the metrics that are in the No Harm campaign. We take it further. Things snowball and we look at projects and we don't just say, ‘Okay, we're going to jump into this initiative because it will help us reduce harm and help us get to that end goal.' We look at prioritization and what is the most urgent area that we need to be focusing on right here and now to reduce the most harm."
The goal itself has a motivational power, but so too does the definition of harm to patients, which the Henry Ford campaign expanded. Harm itself was defined as:
"Any unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital."
Having such a broad definition of harm was an intentional choice. It ensured that quibbling over the definition of "preventable" was not going to be a barrier, says James Kalus, PharmD, senior clinical pharmacy manager and a member of the No Harm steering committee.
"From a clinical standpoint, you can always argue that something is not preventable," Kalus says. "From a pragmatic standpoint, if you say that you're only going to target preventable harm or you say that there's a difference between preventable and non-preventable, then you're also setting yourself up that zero is never the goal. If you say everything is preventable, then theoretically you can target a lower number."
In just a few years, the No Harm campaign has allowed Henry Ford to move the safety needle in large and small ways. Comparing the first six months of the campaign (January-June 2008) for the last six months of 2011, Henry Ford Hospital recorded the following improvements:
Overall harm has dropped 32%, which translates to 189 fewer harm events a month
This article appears in the March 2012 issue of HealthLeaders magazine.
Editor's note: This piece is an excerpt of a fuller case study that is part of an upcoming Rounds event, Create Your High-Performance, Patient-Centered Emergency Department. To see the complete case study, which includes three additional lessons and more information, visit www.healthleadersmedia.com/rounds/.
The emergency department at Cambridge Health Alliance's three EDs used to be like Disney World, and not in a good way, says Assaad Sayah, MD, chief of emergency medicine and president of the medical staff. It went like this:
Wait. Wait. Wait.
Go for a short ride.
Wait. Wait. Wait.
Go for a short ride.
The herky-jerky flow of many, if not most, American hospital EDs is the natural by-product of their structure, Sayah says.
"Historically, when patients go to emergency departments, they walk in and they're confused," Sayah says. "There's nobody to talk to them. At some point somebody recognizes they're in the emergency department and then the patients go into triage. They spend time in the triage and then they go back to the waiting room. Then they go into registration after a while. Then they go back into the waiting room, and then at some point they make it inside the ED."
Sayah and his team did a top-down assessment of the ED flow and found multiple bottlenecks at CHA's three Massachusetts EDs in Cambridge, Somerville, and Everett, which together saw 96,712 ED visits in FY 2010 and 97,381 ED visits in FY 2011. It was not an ED capacity problem, they found, as there was plenty of ED bed capacity. Too many steps were happening consecutively that did not need to. CHA undertook a reengineering of its patient flow process, resulting in huge improvements in patient satisfaction and other key metrics in just six months.
The first step was eliminating traditional triage and registration. CHA hired "patient partners," multilingual nonclinicians whose role is to greet ED patients when they walk in the door and collect three pieces of information: name, identifier such as Social Security number or date of birth, and chief complaint. Answers are entered by the patient partner into a "computer on wheels" and CHA's Epic-based electronic health record. The process takes approximately two minutes. "With those three questions, the patient is registered; they are in the computer, I can take care of them in the ED, and they're brought right in," Sayah says.
The next step is the merger of what used to be registration, triage, and what was called express care into rapid assessment. The patient partner brings the patient directly into a room in the rapid assessment area. The patient is seen by a nurse and usually an ED tech first, says Lisa Kingsley-Rocker, RN, BSN, emergency department nurse manager at CHA's Whidden Hospital campus in the densely populated, working-class city of Everett, adjacent to Boston. Triage ranks the patient according the AHRQ Emergency Severity Index score of acuity from 1 to 5, with 1 being the most acute and 5 the least.
While the less acute patient is in the rapid assessment room, the physician assistant orders whatever diagnostics need to be done. While waiting for results of those diagnostics, full registration is handled. After the patient is treated by the PA or given a prescription, the nurse discharges the patient directly from the room. "The average length of stay for rapid assessment patients is slightly over an hour, door to door," Sayah says.
Patients who are assessed, treated, and discharged straight from rapid assessment make up approximately 40% of overall ED volume at Whidden. Two quarters after the rapid assessment program went live, overall ED patient satisfaction jumped from the 15th percentile to the 65th. Patients who left without being seen—a key metric for waiting room holds—dropped from a peak of 4.04% in 2006 to 0.68% in FY 2011.
Those with higher severity are taken immediately to the main ED where they are assessed and seen by the ED specialists for more advanced diagnostics and assignment to inpatient admission.
CHA's new throughput process allows problems to be addressed with specificity and speed. "The ED tradition used to be one mighty river, so everybody came in and went through the same process," says Nancy Sears-Russell, RN, BSN, MS, associate chief nursing officer for emergency services. "Now it's many, many tributary rivers."
Luis Lobón, MD, site chief of emergency medicine at CHA's Cambridge Hospital campus, says physician-to-nurse communication was also a barrier to good patient flow and quality care when he arrived in 2007. Nurses would do assessments, only to hand off the patient to a provider who would most often see that patient independently.
"One of the practical things that I started to implement was to discuss the patients with my nurses," Lobón says. "As simple as that may sound, that was something that was unheard of." Lobón knew there was an issue when he showed up during the nurse triage on a patient and she asked, "Are you going to be with me in the room? I'm not used to that." When he would share his thoughts about the patient's diagnosis or treatment with the nurse, he would get another perplexed look. "They would ask, 'Why are you asking me this?' and I would say, 'Because we are working this patient together.' That concept did not exist. It was huge, huge."
Rocker, the ED nurse manager, agrees: "There's a lot more communication and team effort. We huddle going in to take care of the patient. The physician is telling us what they think. They're very open to nursing suggestions and nursing assessment pieces to the patient condition. More often the physician and nurse are evaluating the patient together. It's not one against the other. We're not waiting."
The ED transformation achieved another of its key metrics: zero, as in the amount of capital spent. All existing staff and space was reallocated.
"You work with whatever you can," Sayah says. "It's more of a function than a location or a physical plan." Part of the solution was as simple as replacing desks with beds in former registration rooms.
Additional lessons in the full case study are: Lesson 2: Fix the flow outside the ED; Lesson 3: Install leadership and compensation structures to build physician culture; and Lesson 4: Invest in the ED as a strategic part of integrated delivery enterprise.
Reprint HLR0312-10
This article appears in the March 2012 issue of HealthLeaders magazine.
When I first heard that Ford and other auto manufacturers were researching how to build health monitoring devices and interfaces into cars, my thoughts immediately turned to how my good ole boy mechanic would fix the darned thing.
"Well, Jim, yer valves are gonna need a good cleanin.' I can turn them brake rotors one more time but that there glucose monitor, that's a fac'try part and be about next Tuesday before I can get that in."
I have a well-earned distrust of gadgets and have learned that the best-engineered machines excel at the task for which they are designed reliably and simply. So a car that needs few repairs, is comfortable, gets good mileage, and lasts longer than the payments do is fine by me. But Ford sees a larger opportunity to add the car to those places where you are concerned about your health, specifically in monitoring it.
So Ford is developing "the car that cares," by linking health into the vehicle in three different ways, explains Gary Strumolo, manager of Infotainment, Interiors, and Health and Wellness at Ford Research and Innovation.
"The reality is that most people go their entire lives without suffering a serious auto accident, but if they suffer chronic illness, they suffer from that every day of their lives," Strumolo says. "So if we really want to extend this notion of automotive safety, we need to address those very real concerns. We thought we could do that by leveraging the connectivity capabilities that the SYNC platform provides us with devices that we bring into the car, build into the car, or are beamed into the vehicle."
Ford vehicles already include certain built-in devices, such as air filtration systems and anti-microbial interior coatings, he notes. Next in development is a heart rate monitoring seat that would mesh heartbeats with other input such as speed, steering, gas. and pedal pushes to gauge the driver's stress level. Strumolo says that data can be used to create a "work load estimator."
"This estimate is used to gauge what we do with information that comes into the car," he says. "So if the work load estimate is deemed high, and a phone call comes in, then we could route that call directly to voicemail, assuming the call is paired through SYNC and SYNC has control of the phone."
Another application would be for devices such as a continuous glucose monitor, which would be paired wirelessly with the SYNC system so that a diabetic driver could ask verbally for his glucose levels and trends, or even the driving parent of a diabetic child could get the same data about one of their children in the back seat.
"Imagine it is winter time and you have a coat on. You are probably not going to want to grab in there to get the device and check your glucose levels. We certainly don't want you to do that. We want you to keep your eyes on the road and hands on the wheel. So most likely drivers would not check. With this capability, checking would be very easy to do," Strumolo says.
A final category of health-related data is beamed-in information, which could include things like smog alerts that could guide a navigation system around areas of high smog. Or for allergy sufferers, data on higher levels of pollen could automatically turn on the recirculating mode of the AC system rather than bring in pollen-laden fresh air.
"With it all we think we can create something we call 'The car that cares.' It knows your condition. It is concerned with and uses information that you bring in, you beam in, or is information that is available through the inside of the car to help you during your drive. It is concerned with your daily safety, not just making sure you are secure if you get in an accident," he says.
Speaking of accidents, aren't heart rate monitors, glucose meters, and allergy alerts just more distraction for drivers? Ford does not think so.
A vehicle with health devices and data "is not adding any screens. All the information would be communicated verbally. It does not want you to look at the device. We are working carefully to make sure that when information is communicated that it is communicated properly and in a fashion that keeps your eyes on the road and your hands on the wheel," Strumolo says.
Any data gathered is instantaneous "vapor data" and is not stored, he says. "One thing we want to make sure is that the car is not turned into a medical device," he says. "The car is, in essence, a secondary display for some information that may be coming in through other means, either on a device that you wear or information that is beamed in from the cloud."
Automakers think there is a play here for a simple reason: Americans spend way too much time in their cars. Strumolo cites data from the Department of Transportation that Americans spend 500 million commuter hours a week in their cars, and that health and wellness apps are the third-fastest growing sector for wireless tools. Ford is counting on the intersection of those two data points to spell demand for Americans to turn their cars into an extension of their health lives, much as they have for entertainment.
Will it work? I am not so sure. Healthcare professionals know how difficult it is to engage people in actively monitoring their health in the best of circumstances. But in the big picture, this is just the start of a lot of other industries imagining how they can gather, use, and communicate health and wellness data back to the consumer.
Whether my mechanic can figure out how to install the dang thing is less certain.
The list of real challenges to emergency department improvement includes the fact that the ED is open 24 hours a day to treat anything from a scratch to a stroke, requires a multi-disciplinary team of doctors and nurses to work together quickly and efficiently, and for good or bad often represents the patient's impression of the hospital as a whole.
The leadership team at Massachusetts-based Cambridge Health Alliance faced the same challenges as any ED but with a few of its own, including its mission as an urban safety-net provider. Capital for expansion and renovation was limited.
So the team undertook a series of operational and clinical initiatives, including a review of throughput, a new staffing model for ED nurses, and boosting compensation along with accountability for physician performance.
In a new HealthLeaders Media Rounds case study, Create Your High-Performance, Patient-Centered Emergency Department the physician, nurse and executive leaders dive into specific steps they took to dramatically improve key ED performance metrics, including ambulance diversions, wait times, door-to-admit times and others.
As with any performance turnaround, the specific steps are enabled under a protective cover from leadership, including:
Commitment from the top
It may be one of the most-used clichés that any initiative undertaken at a hospital must have the mandate of the highest-levels of clinical and executive leadership to succeed. But saying that and meaning can that drive two different results and this is "where a lot of EDs fail," says Assaad Sayah, chief of emergency medicine at Cambridge Health Alliance.
Sayah says engineering something like patient throughput in the emergency department often requires "heavy lifting" in many departments that connect to the ED.
"This is basically where a lot of EDs fail," Sayah says. "Any ED can re-engineer their front end but it takes an institutional commitment to work on the throughput piece. And without that, it will fail."
One example for leadership having a stake on an issue like throughput is "code help," an alert system CHA put in place that allows for a clinical manager to call for help when the ED is clogged.
"Everybody gets called all the way from the administrator to the CEO, CMO, CNO and housekeeping," Sayah says. "It's all hands on deck. The idea is within 30 minutes the admitted patients will leave the emergency department and go upstairs to the floor."
The benefit is not just in the immediate fix, and the code is only used maybe twice a year, Sayah says. Knowing that leadership is available to help manage the situation has its own real and symbolic benefits.
A holistic view of the ED
Whether it is in investments in IT, or thinking about the larger physician staff, hospital leadership may have to view the ED as the hub of a larger clinical enterprise. So maybe the best investments that one can make for the ED might be in the primary care network. And perhaps putting the ED first is not always the best way to achieve results.
The ED was not the first department to go online as part of CHA's decade-old, system-wide electronic medical record implementation based on an Epic Systems platform. Bedside tracking and registration in the ED began two years ago after years of implementation on CHA's ambulatory network.
One of the benefits was that the physician's office—and not the ED—became the first stop for gathering patient history and other information that would have inevitably fallen on the ED had they been first, says Laura Nevill, RN, senior director for nursing informatics. "Their time in the triage would have gone from three minutes to 23 minutes because they'd be spending so much time trying to put in the medical and surgical history and the meds," Nevill says.
For more specific performance takeaways, additional resources, and registration to the exclusive live Rounds event featuring Cambridge Health Alliance on March 29, click here.
See Also: From Bleeder to Feeder: How an ED Turned Its Business Around
