Top health sys­tems cul­ti­vate cul­ture of trans­parency

Modern Healthcare - - NEWS - By Maria Castel­lucci

Ac­cess to data was crit­i­cal for the or­tho­pe­dic sur­geons at St. Luke’s Health Sys­tem in Boise, Idaho, when they launched a project to elim­i­nate hospi­tal-ac­quired in­fec­tions in 2011. It en­abled them to rou­tinely mon­i­tor the sys­tem’s in­fec­tion rate af­ter knee and hip re­place­ment surg­eries, laminec­tomy pro­ce­dures and spinal fu­sion surg­eries. The team used data to re­duce foot traf­fic in op­er­at­ing rooms and change how pa­tients’ skin was prepped.

Data avail­abil­ity en­cour­aged them to launch their Project Zero cam­paign. And in the past two years they’ve re­duced the hospi­tal’s in­fec­tion rate from 1.08 per 100 pro­ce­dures to 0.57 per 100 pro­ce­dures.

Dr. David Pate, CEO of St. Luke’s Health, said the Project Zero pro­gram was an ini­tia­tive the or­tho­pe­dic sur­geons be­gan them­selves. By al­low­ing physi­cians to ac­cess data eas­ily at any time, the cul­ture shifted to one that mo­ti­vated staff to de­velop their own goals.

“Real progress is done at the ser­vice level,” Pate said. “They look at their spe­cific data, and they set goals for them­selves. It re­ally moves the dial more broadly to­ward or­ga­ni­za­tional goal-set­ting.”

Fos­ter­ing a cul­ture of trans­parency on per­for­mance mea­sures is one of the key strate­gies used by St. Luke’s and the other health sys­tems that made this year’s list of Tru­ven Health An­a­lyt­ics’ 15 Top Health Sys­tems. But im­ple­ment­ing changes to im­prove qual­ity in an evolv­ing health­care re­im­burse­ment land­scape is a chal­lenge for the health sys­tems, their lead­ers ac­knowl­edged.

Tru­ven’s best per­form­ing sys­tems in­clude the top five from three cat­e­gories based on op­er­at­ing ex­penses: large sys­tems gen­er­at­ing ex­penses of more than $1.75 bil­lion; medium-size sys­tems gen­er­at­ing be­tween $750 mil­lion and $1.75 bil­lion; and small sys­tems with less than $750 mil­lion in op­er­at­ing ex­penses.

The 15 were se­lected from 338 health sys­tems across the U.S. Each was eval­u­ated based on pub­licly avail­able govern­ment data look­ing at nine per­for­mance mea­sures, in­clud­ing death rates, com­pli­ca­tions, 30-day read­mis­sions and lengths of stay.

Com­pli­ca­tion rates at the top-per­form­ing sys­tems were 15.1% lower than their peers. Mor­tal­ity rates were 14.7% lower among the top-ranked hos­pi­tals.

In a new mea­sure for this year, emer­gency de­part­ment wait times were 12.3% shorter at the hos­pi­tals that were among the top­per­form­ing sys­tems, ac­cord­ing to Tru­ven. “The emer­gency de­part­ment is im­por­tant be­cause it’s the source of the ma­jor­ity of ad­mis­sions to the hospi­tal,” said Jean Chenoweth, se­nior vice pres­i­dent of per­for­mance and im­prove­ment for Tru­ven Health An­a­lyt­ics. “Emer­gency de­part­ment wait time is an im­por­tant met­ric be­cause this is

of­ten the first con­tact the pa­tient has with the or­ga­ni­za­tion.”

Wait times af­fect pa­tient-ex­pe­ri­ence scores on the Hospi­tal Consumer As­sess­ment of Health­care Providers and Sys­tems sur­vey, Chenoweth said. Tru­ven in­cludes HCAHPS scores in its anal­y­sis. Top-per­form­ing sys­tems re­ported 2.7% bet­ter pa­tient-ex­pe­ri­ence scores than their peers, ac­cord­ing to the re­port.

For the sec­ond year, Tru­ven in­cluded Medi­care spend­ing per ben­e­fi­ciary in its rank­ings. The per­cent­age dif­fer­ence be­tween the top health sys­tems and their peers on Medi­care spend­ing de­creased from 5.2% in last year’s anal­y­sis to 4.9% this year. This likely re­flects an ef­fort by health sys­tems na­tion­wide to ad­dress the con­tin­uum of care, Chenoweth said.

Among the sys­tems rec­og­nized by Tru­ven this year, Sut­ter Health Val­ley Area in Sacra­mento, Calif., was rec­og­nized for the first time in the large-sys­tem cat­e­gory. A sub­sys­tem of Sut­ter Health, which also made the list, Sut­ter Health Val­ley Area op­er­ates 11 of Sut­ter’s 23 hos­pi­tals.

To make changes, Sut­ter ini­tially im­ple­ments a pro­gram at one fa­cil­ity. Af­ter mon­i­tor­ing its suc­cess, the pro­gram is adopted sys­temwide, said James Con­forti, pres­i­dent of Sut­ter Health Val­ley Area.

Sut­ter ap­points physi­cian lead­ers and holds staff fo­rums on what changes are com­ing and why. “We work very closely with our physi­cian lead­ers and nurse lead­ers to make sure we’re tak­ing a col­lab­o­ra­tive ap­proach,” Con­forti said.

Con­vert­ing all the hos­pi­tals in the sys­tem to a sin­gle elec­tronic health record ven­dor also helped the sys­tem in­te­grate its ap­proach.

The other win­ners in the large-sys­tem cat­e­gory in­clude the Mayo Foun­da­tion of Rochester, Minn., and Spec­trum Health of Grand Rapids, Mich., for the fifth time each; and Mercy in Ch­ester­field, Mo., and Sut­ter Health in Sacra­mento, both for the first time.

Scripps Health in San Diego was on the list for the fourth time in the medium-sys­tem cat­e­gory. The sys­tem has fos­tered a cul­ture that en­cour­ages staff mem­bers to openly dis­cuss goals.

The top lead­ers at the five-hospi­tal health sys­tem meet monthly to dis­cuss “lit­er­ally any­thing,” said Chris Van Gorder, CEO of Scripps Health.

Dubbed the Physi­cian Lead­er­ship Cabi­net, the meet­ings in­clude ev­ery chief of staff, chief nurse and chief ex­ec­u­tive from each Scripps hospi­tal.

“The agenda is re­ally set by our physi­cians in terms of deal­ing with things they’re con­cerned with,” Van Gorder said. “It could be our strate­gic plan, qual­ity is­sues or qual­ity met­rics. There is just no end of is­sues that we dis­cuss.”

Van Gorder said the meet­ings have helped the sys­tem ad­dress pro­to­cols dur­ing flu sea­son, im­ple­ment a staff vac­ci­na­tion pol­icy and pre­pare for the Ebola out­break in 2014.

Other win­ners in the medium-sys­tem cat­e­gory in­clude St. Luke’s Health Sys­tem; Ket­ter­ing Health Net­work in Day­ton, Ohio, and St. Vin­cent Health in In­di­anapo­lis, for the third time each; as well as TriHealth in Cincin­nati for the sec­ond time.

At MidMichi­gan Health, based in Mid­land, a first-time win­ner in the small-sys­tem cat­e­gory, in­for­ma­tion about the sys­tem’s per­for­mance is re­leased quar­terly, said Diane Postler-Slat­tery, CEO of the four-hospi­tal sys­tem. Qual­ity met­rics are also avail­able for ev­ery de­part­ment to mon­i­tor progress and set goals.

The avail­abil­ity of data mo­ti­vated the emer­gency de­part­ment staff at MidMichi­gan Health Med­i­cal Cen­ter-Mid­land to change pro­to­cols to im­prove ED through­put.

Us­ing de­tailed data from its EHR sys­tem as a guide, the ED formed three teams. One team fo­cused on the ad­mis­sion process, while oth­ers fo­cused on dis­charge and an­cil­lary test­ing.

As part of their changes, pa­tients are im­me­di­ately bed­ded if a room is avail­able, skip­ping triage. Pa­tients are also au­to­mat­i­cally as­signed to a physi­cian once they are reg­is­tered so they are quickly given pri­or­ity. Test re­sults are also given higher pri­or­ity and de­liv­ered to the physi­cian quickly. The changes have re­duced ED board­ing time for pa­tients at Mid­land from 9.2 hours a day in March 2015 to 3.7 hours a day in March 2016.

Postler-Slat­tery said that de­spite im­prove­ments, it can be chal­leng­ing to keep em­ploy­ees mo­ti­vated. “It’s hard … to keep em­ploy­ees en­gaged when you’re al­ways ask­ing them to do things dif­fer­ently in a shorter time frame,” she said.

The sys­tem has at­tempted to in­spire staff by en­cour­ag­ing com­mu­ni­ca­tion and a pos­i­tive out­look. The staff is en­cour­aged to dis­cuss “three good things” they ac­com­plished through­out the day, Postler-Slat­tery said.

Roper St. Fran­cis, a fourth-time Tru­ven win­ner in the small-sys­tems cat­e­gory based in Charleston, S.C., con­tin­ues to face chal­lenges as it adapts to a val­ue­based pay­ment model, said Dr. Todd Shu­man, chief physi­cian of­fi­cer at the three-hospi­tal sys­tem.

For ex­am­ple, Roper St. Fran­cis does not have a skilled­nurs­ing fa­cil­ity. The sys­tem has part­nered with com­mu­nity fa­cil­i­ties to ad­dress that care gap, Shu­man said.

Roper St. Fran­cis also opened its Tran­si­tional Care Clinic in 2014 to im­prove con­tin­uum of care. The clinic ad­dresses read­mis­sions in the emer­gency de­part­ment among un­der­in­sured and unin­sured pa­tients. The clinic is staffed with physi­cians, so­cial work­ers, di­eti­tians and nurses to help pa­tients man­age their health. Since it opened, the clinic has seen more than 1,580 new pa­tients. Of the 272 new pa­tients who vis­ited the clinic in the past year, 13 re­turned to the emer­gency room.

Shu­man said Roper St. Fran­cis has im­ple­mented pro­grams such as the Tran­si­tional Care Clinic to adapt to a health­care cli­mate de­pen­dent upon tran­si­tion of care.

“Each health sys­tem now needs to try to fig­ure out that co­or­di­nated care,” Shu­man said. “What do you own? Who do you part­ner with? Ul­ti­mately, (the sys­tem) has to con­trol that en­tire episode of care.”

Other win­ners in the small-sys­tem cat­e­gory in­clude Asante in Med­ford, Ore., and Tan­ner Health Sys­tem in Car­roll­ton, Ga., both for the fourth time; and Lovelace Health Sys­tem in Albuquerque for the first time.

“We work very closely with our physi­cian lead­ers and nurse lead­ers to make sure we’re tak­ing a col­lab­o­ra­tive ap­proach.” James Con­forti Pres­i­dent of Sut­ter Health Val­ley Area

Dr. Kevin Shea, an or­tho­pe­dic sur­geon and an ar­chi­tect of St. Luke’s Project Zero pro­gram, has helped the staff take aim at sur­gi­cal-site in­fec­tions.

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