Intermountain Health has developed nine system-wide clinical programs that align clinicians from across the the Utah-based integrated healthcare delivery system to deliver evidence-based best practices. Raj Srivastava, M.D., M.P.H., the chief clinical programs officer at Intermountain’s Health Delivery Institute (HDI), recently spoke about how health systems can spread and sustain evidence-based practices.
Speaking to a meeting of the Center for Learning Health System Sciences of the University of Minnesota, Srivastiva described how Intermountain has developed these programs in areas such as acute and ambulatory medical specialties, cardiovascular and behavioral health.
Besides leading HDI, Srivastiva is also a tenured professor of pediatrics at the University of Utah in the Division of Pediatric Hospital Medicine, and a practicing hospitalist at Primary Children's Hospital in Salt Lake City.
Intermountain operates in six states and has 33 hospitals, and 67,000 employees. One thing that has been really helpful in Intermountain’s journey, he said, especially on value-based care, is that it also has its own insurance plan with over a million members.
“There is this famous quote that it takes 17 years for research to become standard practice,” Srivastiva said, “We’ve got a couple of clinical programs in the Healthcare Delivery Institute that convene discipline experts to say, ‘what are those clinical best practices we should be focusing on?’ Then they get to lead the implementation of those models with region service line leaders. What has been exciting is we've been able to cut that 17 years down quite a bit.”
There are nine clinical programs, and the conveners help define best practices, he explained. Some of them sit on national societies and write those guidelines. The key is that they help lead the implementation. “One of the things we're really working on is sustaining,” Srivastiva said. Often in healthcare, projects get done but they aren’t continued. “We are not doing that anymore. We have committed to keep going, and if we're not sustaining, learning why.”
One of the challenges is extending these programs outside of Utah, Intermountain’s headquarters state, particularly with the recent merger with SCL Health.
“People might say to us, Yeah, well, you did it in Utah, but can you do it anywhere else? What we're going to try to do is take what we've learned in one state and try to do it in five other states as well. Srivastiva said. “We have the clinical best practice integration model based in implementation science and quality improvement frameworks. We realized that the only way to learn is have a framework and apply a lot of projects to the framework and see how to adjust the framework if needed, and learn. We have a class, the advanced training program, that really helps as well. That advanced training program is 34 years old. I've been teaching in it now for four years, and when I came in, we redefined it just a little bit, so it was more population health-focused, value-based care, and really taught this model of clinical best practice integration.”
SCL Health joined Intermountain two years ago. “Part of our plan is bringing people together from different regions to learn to work together, because that's really how you are going to get the power of this large organization, which is really what we're going for,” Srivastiva explained.
He said that the electronic medical record and other technology is part of the picture, and decision support can help nudge people to do things right at the point of care when they need it. Srivastiva noted that two years ago, they had nine EHRs when they merged. “We're going to one. We're going to Epic. The legacy Intermountain was on Cerner and SCL Health was on Epic. The decision was to make to go to Epic,” he said.
He stressed that their work involves measuring a team's adherence to the best practice. “That's the key here. We need to know what the frontline teams are doing, and more importantly, they need to know what they're doing so that we can have improvements.”
Intermountain is designing and implementing a systematic approach to driving high adherence to evidence-based best practices throughout its six states, 400 clinics, 33 hospitals, and every specialty and primary care.
“That's our challenge,” Srivastiva added. “We systematically prioritize at the level of the care process model the governance group that can decide what we are going to measure, and what are the key leverage points. We actually go build the measurement system around those because we've agreed that's what's important. We focus on helping the teams get adherence to those metrics.”
He listed five steps that are key: First, have the clinical team search, develop and identify that best practice. “Second, we have the clinical teams define a few key leverage points that have been shown, if the teams do those three to five things, it's going to lead to a better outcome, and then we certify that level of evidence,” Srivastiva said. “Third, we create a measurement system. That measurement system has to be done at the level of the front line. Fourth, you drive high adherence from the current state to ideal state at each site. And then collectively we we do a lot of quality improvement and implementation science here, understanding those barriers, devising the strategies. We test it and pilot, and then we spread it.”
The fifth step is to sustain the best practice. “Once we put in the effort, how do we sustain that and see if somebody's drifting, and then correct that drift?”
