Research by Lee Ann Jarousse

As the transformation of the nation's health care system gains momentum, hospitals and health systems are going to find themselves being held more accountable for patient outcomes. That's not all: Equally important is reducing the cost of care. There's no road map for the new imperative of better patient care, improved population health and reduced costs the so-called Triple Aim, developed by the Institute for Healthcare Improvement. Each health care organization needs to create its own path, and many are well on their way.

"We must declare it as our work," says Patricia Brown, president of Johns Hopkins HealthCare, Baltimore. "We need to demonstrate to our patients and the community that we are a high-quality, low-cost-institution."

Johns Hopkins is developing new delivery models that enhance patient safety, quality and efficiency a challenging job and not without risks. "This will be one of the most exciting 10 years in health care," Brown says. "Health care organizations will have to make some bets in regard to the direction they choose to go and the partnerships they choose to make." Not every bet will pay off, and organizations will have to be very nimble, recognizing what's failed and quickly changing gears.

The integration of the financial and clinical delivery processes is a critical step. Bringing together teams of professionals from both sides, "changes the whole dynamic," says Katharine Luther, R.N., vice president, hospital portfolio planning and administration at the IHI. Physicians will begin to question their practices and the implications on cost, and look for ways to enhance efficiency and effectiveness.

This gatefold examines new innovations in patient care and ways hospitals can become high-value organizations that provide patient-centered, fiscally prudent care.


CONTINUOUS QUALITY IMPROVEMENT: A CEO CHECKLIST FOR HIGH-VALUE CARE

Hospital executives must foster an environment that supports innovation in patient care delivery. The development and implementation of new care delivery systems are critical to success. The Institute of Medicine's CEO Checklist for High-Value Health Care focuses on strategies that have proven to be effective in enhancing quality and reducing costs. Hospital executives must recognize that high-value and lower-cost care are institutional aims that must be supported by a culture of continuous quality improvement.

Foundational elements

  • Governance priority. Demonstrate visible and determined leadership by the CEO and the board.
  • Culture of continuous improvement. Make a commitment to ongoing, real-time learning.

Infrastructure fundamentals

  • IT best practices. Provide automated, reliable information to and from the point of care.
  • Evidence-based protocols. Implement effective, efficient and consistent care.
  • Resource utilization. Optimize use of personnel, physical space and other resources.

Care delivery priorities

  • Integrated care. Provide the right care in the right setting by the right providers.
  • Shared decision-making. Facilitate patient-clinician collaboration on care plans.
  • Targeted services. Develop tailored community and clinic interventions for resource-intensive patients.

Reliability and feedback

  • Embedded safeguards. Provide support and prompts to reduce injury and infection.
  • Internal transparency. Share progress in performance, outcomes and cost measures.

FIVE STEPS: THE PATH TO INNOVATION

Organizations should support processes to facilitate the generation, testing and implementation of new ideas.

STEP 1 - Assess the problem

Organizations should conduct a thorough assessment of the problem or process in need of change. This includes conducting a literature review and internal and external interviews, including discussions with patients and families, to determine the scope of the problem across the industry and how other organizations have addressed it. This stage also should include an assessment of available resources to address the problem.

STEP 2 - Develop a plan

Once the assessment is complete and the scope of the issue is defined, brainstorming new solutions can begin. The information gleaned from the assessment should be used to conduct a risk analysis and to draw up a project plan that outlines the scope of the project, including the goal(s), projected cost, project champion, description of the problem being addressed and how the innovation will solve the problem.

STEP 3 - Test

This stage involves testing the innovation at the front line and validating its effectiveness. The testing phase should have defined start and end dates.

STEP 4 - Implementation

Too often, organizations invest heavily up front in brainstorming and idea generation and not enough in bringing innovative ideas into practice. Communication is important to create understanding and set expectations up front. An action plan should detail the implementation process, step-by-step.

STEP 5 - Post -implementation

The implementation process is not the final step in bringing innovation to fruition. It's important to continually assess and tweak the innovation. This time is also important for assessing ways to spread the innovation to other relevant areas within the organization.


[ IDEAS@WORK ]

Intermountain Healthcare Salt Lake City

Intermountain Healthcare is focused on being a high-quality, low-cost provider though elimination of clinical variation and adoption of evidence-based practices. The organization recently received a $9.7 million contract from the Centers for Medicare & Medicaid Services to further its efforts toward care delivery transformation. Intermountain plans to expand its use of electronic clinical decision support to better facilitate provider-patient communication and shared decision-making. The anticipated results: more than $67 million in medical cost savings over three years.

"We have a long history of doing this," says Lucy Savitz, director of research and education at Intermountain's Institute for Health Care Delivery Research. "We have a full cost-accounting system on the inpatient side that provides us the ability to look at cost savings."

Savitz cites an initiative to examine the induction of early labor as one way the organization has focused on eliminating variation to improve quality and cost. An electronic checklist was developed to eliminate unnecessary inductions. Women who arrive at the hospital for early induction are screened by nurses. If they meet the criteria, the induction proceeds. If they do not, the nurse informs the obstetrician and the procedure is cancelled unless the physician obtains approval from the chair of the obstetrics department. The rate of elective inductions that did not meet clinical guidelines fell from 28 percent to below 2 percent. The decrease resulted in a reduction in the length of time women spend in labor, allowing for an additional 1,500 deliveries each year without an expansion of nursing staff or beds. The protocol also is credited with reducing the rate of unplanned cesarean sections and admission rates to the newborn intensive care unit. In a study published in the June 2011 issue of Health Affairs, Savitz and Brent James, Intermountain's chief quality officer, estimate the protocol saves the organization about $50 million a year and if applied nationally, would result in $3.5 billion in savings a year.

Theadacare Appleton, WIS.

A redesign of patient care at ThedaCare in 2006 resulted in the development of collaborative care units with a focus on improving quality and reducing costs. The project stemmed from the organization's journey to Lean and its participation in the Institute for Healthcare Improvement's Transforming Care at the Bedside initiative. Under collaborative care, interdisciplinary teams, consisting of a physician, nurse, pharmacist and case manager, meet with patients within 90 minutes of admission to develop a plan of care. The model eliminates duplication and enhances clinician-patient communication. "The emphasis is on the patient," says Shana Herzfeldt, R.N., medical services manager. Since implementation, she says, physician, patient and employee satisfaction have increased. The average length of stay has decreased by about 10 to 15 percent and cost per case has decreased from 15 to 28 percent. Rooms in collaborative care units are designed differently. Each room has a bedside computer with medications and supplies also maintained at the bedside. "The environment is designed to reduce waste and improve quality," says Herzfeldt. "We need to design the space to support the type of care provided."


How We Did It:

This gatefold was produced by researching published studies and articles and conducting interviews with hospital and industry executives.

Research: Lee Ann Jarousse, ljarousse@healthforum.com

Design:Chuck Lazar, clazar@healthforum.com