Olympic Marathons: Performance Improvement Initiatives Help to Power the Long Race
At a time when the leaders of patient care organizations are facing intensifying pressure to shift away from a dependence on volume-based payment and to plunge into value-based care delivery, what strategies can help them lead their organizations to success under new paradigms? With Seema Verma herself, Administrator of the Centers for Medicare & Medicaid Services (CMS), bluntly warning hospital, medical group, and health system leaders that she and her fellow senior federal healthcare officials will be pushing hard to compel providers forward into value-based contracting, IT-facilitated continuous performance improvement strategies are looming large as a critical success factor in the shift to value.
Indeed, speaking during a webinar on August 27 sponsored by the Accountable Care Collaborative, Verma responded to questions about CMS’s effort to push provider organizations to take on two-sided risk in the context of the agency’s accountable care organization (ACO) programs, particularly the Medicare Shared Savings Program (MSSP).
Asked by the webinar host, Mark McClellan, M.D., director of the Duke-Margolis Center for Health Policy and co-chairman of the Accountable Care Learning Collaborative, about provider feedback on the proposed changes to the MSSP ACO program, Verma responded, “I think many people recognize that it’s time to take that next step and it’s time to evolve the program; it’s been six years. We also understand that there may be providers that are not ready. But, our focus is to work with providers that are serious about making the investments and providing better care for lower cost.” What’s more, she intoned, “We’re trying to transition the structure to encourage providers to take on risk because we know that is going to deliver better outcomes.”
And while none of that rhetorical forcefulness—some might even call it saber-rattling—should come as a surprise from Verma, it’s also true that she fully realizes how challenging the overall transition is turning out to be for the vast majority of patient care organizations, which have more-or-less-contentedly been inhabiting a discounted fee-for-service payment world, even as the discounts have progressively bitten more deeply into their operating revenues.
The reality? On the hospital and health system side of the industry, hospital senior leaders long ago shaved off excessive expenses when it came to such areas as the supply chain and facilities management. And what remains to tackle now is the Moby Dick of operations: reworking processes at the core of patient care delivery, in order to achieve significantly improved cost-effectiveness and patient outcomes; everything else has already been tackled. In short, it’s become eminently clear that clinical and operational transformation cannot happen without the thorough reengineering of core care delivery processes.
In that context, larger numbers of hospital and health system (and a few medical group) leaders have plunged ahead over the past decade-plus, and have moved to incorporate the use of formal performance improvement methodologies, among them Lean management, Six Sigma, the Toyota Production System for healthcare, and PDSA (Plan Do Study Act, formerly PDCA, or Plan Do Check Act) cycles of improvement, in order to achieve clinical and operational transformation. In practice, the quality leaders at most patient care organizations have liberally mixed the use of various methodologies, while others have relied primarily on one methodology, but have allowed the blending of concepts from others.
What’s more, the organizations on the leading edge are also strategically leveraging information technology and data analytics as a key facilitator to continuous performance improvement, particularly on the clinical side. Indeed, they are finding IT facilitation to be essential to success in achieving transformational change.
In Asheville, A Comprehensive Push Forward into Value
One of the patient care organizations that has been moving ahead determinedly in its use of IT-facilitated continuous performance improvement strategies is Mission Health, a six-hospital, 11,000-employee health system based in Asheville, North Carolina.
There, Chris DeRienzo, M.D., Mission Health’s chief quality officer, and Dawn Burgard, director of clinical performance improvement, have been helping to lead a comprehensive effort for several years, one that has already borne significant fruit. Back in 2010 and 2011, Mission Health leaders began mapping care delivery processes, adding in an analytics platform in 2013 and 2014. Burgard, who came to Mission Health in 2012, with a master black belt in Six Sigma and a certification in Lean management, and Dr. DeRienzo, who came in 2013, have turbocharged efforts in the organization since then. Among other developments, they early on brought on a cadre of 21 Lean management engineers, known as quality improvement advisors, or QIAs, and have built an enterprise-wide data warehouse.
One key tool that the leaders at Mission Health have built has been a dashboard called the Ambulatory CPM Explorer Dashboard, which is bringing near-real-time data to physicians. Among the accomplishments in the past few years:
- A 20-percent increase in full sepsis bundle and a 32-percent reduction in mortality from sepsis
- 12 lung cancer deaths avoided with 37 percent increase in screening
- 9 fewer rib fracture deaths and $350,000 in reduced direct costs
- A 42-percent reduction in in-hospital stroke mortality
- 11,000 more women screened for breast cancer, 6,000 more people screened for colorectal cancer, and a seven-fold increase in depression screening
And, in two specific areas—among numerous others—Mission Health leaders have leveraged performance improvement cycles to build and optimize key initiatives. One has been the creation of the organization’s Readmissions Predictor initiative, which has dramatically enhanced ambulatory care managers’ ability to efficiently predict which patients might be at the highest risk for readmission, following discharge. That initiative began in early 2017, and has been led directly by Dr. DeRienzo and by Mission Health’s CIO, John Brown.
Spending over a year to build, test, and validate the program, Mission Health leaders created a dashboard that uses smart algorithms to provide care managers with up-to-the-minute data every morning at the start of the workday, helping them to determine which individuals, post-discharge, are most likely to end up being readmitted, and allowing them to start their days focusing on those at highest risk for readmission.
A second very important initiative, which began a year and a half ago, has involved applying the Explorer Dashboard to monitor patient flow into and through the emergency department, and to take steps to respond to emerging patient-flow blockages created by surges in patients presenting in the ED. Now, Burgard reports, “We have triggers on our home page, so everyone in the hospital knows what surge status we’re in. And once a new color is triggered”—from a range of four colors (green, yellow, orange, red) that indicate the degree of blockage—"there’s a whole bunch of standard work—a Lean term that involves the standardization of the elimination of variation in processes—that teams and managers are expected to do, depending on surge level,” she says. “That’s the power of standard work. It allows us to get into that predictive space and helps us to become more efficient with the way we staff.” Using this set of processes, patient volume surging that had peaked at 4 percent of patients who left before being seen, in the summer of 2016, is now down to 1 percent, with the ability to see 300 patients every day in the flagship hospital’s ED now a standard volume that has been made the norm.
The core recipe, DeRienzo notes, has included the following: a reliable enterprise data warehouse; a reliable data visualization environment; “more structure in clinical program leadership among physicians, nurses, and administrators”; a cadre of Lean management engineers; and, “trusted advisors.”
At UPMC, Patient Engagement for Improved Outcomes
Numerous quality improvement methodology-infused initiatives are moving ahead as well at the 40-hospital UPMC health system, based in Pittsburgh. There, says Tami Minnier, R.N., M.S.N., UPMC’s chief quality officer, “We use all of them”—especially Lean management, Six Sigma, and PDSA principles and strategies. But, she quickly adds, “Coming into healthcare from manufacturing, I learned early on that healthcare wasn’t quite ready for all the terminology around performance improvement methodologies, so we avoid technical terminology here. I have a black belt in Lean, but I don’t get into the intricacies,” she testifies. “I found that it turned people off. We had people say, ‘We don’t build cars.’”
Instead, Minnier has helped to lead forward a number of initiatives, and, she says, “We use whatever tool makes most sense at the time, and have blended them over time over the 12 years that the Wolff Center has been in existence”—referring to the UPMC Wolff Center for Quality, Safety, and Innovation—“and over time, we’ve raised the bar and have introduced things like run charts, fishbones [the fishbone tool for root cause analysis], some of the tools people find useful. But we don’t say, let’s have a big Kaizen on Tuesday afternoon! We’ve been a bit savvy about how we do it.”
And, as one of her key partners in those endeavors, MaCalus Hogan, M.D., vice chair of orthopedic surgery, and medical director for outcomes and registries at the Wolff Center, says, “I’ve been educated in the Lean environment and learned a lot from Tami and her team. Efficiency is key” in every endeavor, he says. “And in the surgical environment, things are geared around doing things well and efficiently.” Together, Minnier and Dr. Hogan have been leading an initiative that has significantly improved both patient engagement, and improved clinical and satisfaction outcomes, around the entire cycle around total hip and knee replacement surgery, which they and their colleagues have implemented across the six highest-volume total joint replacement surgery facilities in the UPMC system. “We needed to go further in clinical care improvement, encompassing from how we prepare patients, to alignment on who were good candidates,” Minnier explains.
And, Minnier says, “One of the things that we learned early on was that there was pretty inconsistent preparation of patients planning to come in for hip or knee replacement. Some doctors and their offices did this really fantastic job of preparing their patients for surgery, and some didn’t quite have it together. So we did a good current-state assessment, using Lean and PDSA approaches. We looked at the current state of variations, and what types of resources and materials people had in place, and then brought together a new model of change, centered around an orthopedic nurse coordinator in every site. That role was to protect and prepare every patient for surgery, and most importantly, to think about what their care at home would be like after surgery.”
The initiative began three years ago, with the orthopedic nurse coordinators being brought in two-and-a-half years ago. Those coordinators, also referred to as “navigators,” ensure an orderly, comprehensive process to prepare patients and provide them with online education. Leveraging the organization’s patient portal, MyUPMC, office physicians can prescribe educational materials during the office visit, just as they’d prescribe medications. And, she says, “The process improvement of having an ortho nurse coordinator, coupled with the technology support, really allowed patients to arrive at a preoperative phase in a much more prepared, organized manner, to anticipate what would happen when they got to the hospital and how they’d be taken care of.” And, as a result of intensive continuous improvement cycles, “We’ve been able to eliminate pretty much all of the variation,” she testifies. “And every single member of these ortho nurse navigators, they meet on a monthly basis, share each other’s practices, they’ve become a resource group unto themselves. That’s how you perpetuate and sustain change.”
In the context of the joint replacement improvement process, Dr. Hogan and Minnier saw clearly the advantage of Hogan’s being a foot and ankle surgeon rather than being a joint replacement surgeon. As such, he brought into the process a level of credibility as a fellow surgeon; yet at the same time, he was in a different subspecialty, so he could not be seen as a threat to the joint replacement surgeons. And the results have been impressive: consistent educational and preparational processes, improved patient satisfaction, and in many cases, enhanced recovery outcomes.
The Power of Harnessing Analytics
Industry leaders interviewed for this article agree on the core truths about all this: that using formal improvement strategies, of whatever specific type, will yield results; and that part of the power of this to achieve clinical transformation is in effectively harnessing IT and data analytics to facilitate such work.
“In my experience, it doesn’t really matter which methodology you choose, but that you choose an improvement methodology or methodologies, and stick with your strategies; it’s the discipline that matters,” says George Reynolds, M.D., the clinical informatics executive advisor for CHIME (the Ann Arbor, Mich.-based College of Healthcare Information Management Executives), and principal in Reynolds Healthcare Advisers, LLC. Dr. Reynolds, who served as the CMIO at Children’s Hospital & Medical Center, in Omaha, Nebraska, for 11 years, and CIO for the last five years of that tenure, reports that “We did a version of PDCA [Plan Do Check Act—an earlier version of Plan Do Study Act], which is very easy to teach, but lacks the rigor and the discipline of Lean and Six Sigma. We would do well [at Children’s], but it was hard to maintain the changes.”
Meanwhile, Dr. Reynolds says firmly, leveraging data and analytics to power performance improvement cycles is “absolutely central to everything you do. And it doesn’t necessarily have to be really fancy bells and whistles, though I love fancy bells and whistles. You can do a lot with an Excel spreadsheet. You can do a lot with some fairly simple tools. But the more advanced tools become valuable” as organizations move forward into deeper and broader efforts.
Early on in the Proverbial Journey of 1,000 Miles
What remains disconcerting is how far behind most U.S. patient care organizations are starting out, says Robin Czajka, service line vice president for cost management at the Charlotte-based Premier Inc. Asked where she thinks the healthcare industry is, if this phenomenon could be compared to the proverbial journey of a thousand miles, the Chicago-based Czajka says that “I would say that we’re at the very beginning of it, frankly, having been in the industry for 25 years. You see pockets of great performance, and areas where we haven’t made any progress at all,” she says. “Some organizations are short of staff and mired in taking care of increasingly sick patients. So this needs to be a top priority. And we’re looking at a 5-percent growth year-over-year” in hospital costs. “The Medicare fund will be insolvent if we keep on this trajectory.”
What’s more, says Mary Frances Butler, a senior adviser at the Chicago-based Impact Advisors consulting firm, the level of progress in this area “will depend on the type of hospital.” There is a continuum of advancement, she notes, “from small community hospitals, all the way up to the mega-systems like Intermountain and Geisinger [the Salt Lake City-based Intermountain Health and the Danville, Pa.-based Geisinger Health], who have been at it a long time. Intermountain is an example of a leader in this. And, to the extent that leader organizations have been able to facilitate conversations through the C-suite and into the IT group, to get out of their silos,” they’ve made greater progress, she notes.
Premier’s Czajka has mixed sentiments with regard to the mixing or blending of specific methodologies. “It’s both good and bad; you can create some kinds of success, but you do lose some things; I’ve personally seen Lean be effective when done rigorously,” she says. “But as long as it’s cyclical, monitored, and sustainable, and as long as there are checks and balances,” any combination of methodologies can be made to work well, she says. The absolutely critical success factor? “Success in this area is always data-driven,” she insists. “And with Six Sigma, you take data over time and look at it and act. A lot of organizations will see a blip, for example, bed sores, and will react to it. But it may turn out to be a special-cause variation, maybe they got an unusual surge of admissions from a nursing home or something. When you start to employ a system like Lean, problem solvers become problem framers. So you need to look carefully at the data and analyze it, and act over time.”
The Power of Data-Focused Teams
One lesson shared by those in the trenches is the power of creating and nurturing purpose-specific teams focused intensively on the management of data to power performance improvement, particularly in the clinical area. Oscar Marroquin, M.D., a practicing cardiologist and epidemiologist in Pittsburgh, has been helping to lead a team of data experts there. That team, of about 25 data specialists, was first created five years ago. Of those, half are IT- and infrastructure-focused, and, says Dr. Marroquin, “The rest are a team of folks dedicated to data consumption issues. So we have clinical analysts, data visualization specialists, and a team of data scientists who are applying the right tools and methods, spanning from traditional analytical techniques to advanced computational deep learning and everything in between. Our task is to use the clinical data, and derive insights”—and all 12 clinically focused data specialists report to him.
And that work—“allowing people to ask questions to generate opportunities”—has paid off handsomely. Among the advances has been the creation of a data model that predicts the chances that patients who are being discharged will be readmitted. The model, based on the retrospective analysis of one million discharges, is also helping case managers to more effectively prepare patients for discharge, specifically by ensuring that patients being discharged are promptly scheduled for follow-up visits with their primary care physicians. “If those patients are seen within 30 days of discharge,” he notes, “there’s a 50-percent reduction in their 30-day rate of readmission.” The program is now active in six UPMC hospitals.
What it Really Means to be Data-Driven
Those industry leaders interviewed for this article are agreed on what healthcare IT leaders should know both about the adoption of performance improvement methodologies generally, as well as about the leveraging of IT and data to achieve success in clinical and operational transformation.
“If you’re going to embark on a Lean Six Sigma-driven journey, it rises and falls based on leadership,” says Mission Health’s Burgard. “We know that the methodologies work. But I always say, Lean is not a set of tools, it’s a mindset for how you’ll transform your organization. The same thing is true with technology. It all rises and falls on leadership. And senior leaders need to understand the methodology and the tools. That applies to technology, too.”
“I’ve been really impressed with the degree of partnership of our CIO John Brown, with our PI team,” says her colleague DeRienzo. “When I think about continuous improvement, there’s so much overlap between the improvement processes and the data processes. And by driving alignments across the entire system, including across the different teams, we’ve been able to make much broader progress.”
Importantly, says Premier Inc.’s Czajka, “It’s crucial to accept that data shouldn’t be the enemy of the good. The data is never going to be perfect,” she says. “Just make sure it’s directionally accurate.” What’s more, she says, “You need to train your people to use the data correctly. I can’t tell you how many times I meet with clients and they have these great data systems they’ve purchased, but no one is trained to work well with it. And,” she says, “figure out the data points that will actually drive improvement. I went into a member hospital that had about 100 data points they were asking people to focus on, in a dashboard. You can’t ask people to do that.” Working with leaders at that hospital, she was able to get them to narrow down those 100-some data points to 11 that could be focused on, for process improvement.
In the end, says UPMC’s Marroquin, “If we all are serious about transforming the way we care for patients, we need to do it in a data-driven way. There has to be a philosophical belief and commitment to do that, and then you have to create a team that’s dedicated to this work. I don’t think this is achievable in an ad hoc way.” Finally, he says, “This work is not for the faint of heart; it takes time and effort, but if you have the philosophical belief and institutional commitment, it’s doable.”
