Never set­tle: Top health sys­tems al­ways look­ing for ways to im­prove

Modern Healthcare - - NEWS - By Maria Castel­lucci

At Spec­trum Health, physi­cians and nurses are al­ways track­ing per­for­mance out­comes to look for ways to im­prove qual­ity of care.

The Grand Rapids, Mich.-based health sys­tem has as­sem­bled 150 clin­i­cal im­prove­ment teams of physi­cians and nurses that work to find and solve prob­lems across its 12 hospi­tals.

These teams use pa­tient data and staff in­put to pin­point chal­lenges. Events are then held to bring front­line staff to­gether to come up with the best way to tackle the prob­lem. The gath­er­ings are usu­ally at the Grand Rapids cam­pus and can take up to three days. The size of the events vary but at least two physi­cians are present. In the past year, 75 per­for­mance-im­prove­ment events have been or­ga­nized at Spec­trum. Once so­lu­tions are agreed on, the ini­tia­tive is ini­tially tested at one fa­cil­ity and then rolled out sys­temwide.

“We are good at iden­ti­fy­ing is­sues that could arise,” said Richard Breon, Spec­trum’s CEO.

This frame­work was used three years ago when staff de­cided they needed to come up with a stan­dard­ized process to de­crease catheter-as­so­ci­ated uri­nary tract in­fec­tions af­ter data showed im­prove­ments could be made.

Over the course of three days, a team of 20 physi­cians and nurses came up with stan­dard­ized ap­proaches to de­crease the in­fec­tions. Doc­tors now log a rea­son for the catheter in the electronic health record and nurses can re­move a catheter with­out physi­cian ap­proval. This en­cour­ages physi­cians to ques­tion whether a catheter is nec­es­sary and al­lows nurses to be more proac­tive in re­mov­ing the tubes.

Since then, the per­cent­age of pa­tients with an in­dwelling uri­nary catheter has de­clined from 15% in Jan­uary 2013 at the Grand Rapids cam­pus to 11% in May 2016.

“(We) are look­ing for op­por­tu­ni­ties to find prob­lems to solve,” said Dr. Michael Kramer, se­nior vice pres­i­dent of qual­ity and safety at Spec­trum.

Build­ing a cul­ture that en­cour­ages physi­cians and nurses to em­brace per­for­mance im­prove­ment is a key tenet at Spec­trum and the other or­ga­ni­za­tions that made this year’s list of 15 Top Health Sys­tems pub­lished an­nu­ally by Tru­ven Health An­a­lyt­ics, IBM Wat­son Health.

Tru­ven’s best-per­form­ing health sys­tems were nar­rowed from a to­tal of 337 sys­tems across the na­tion. Each was eval­u­ated through pub­lic govern­ment data that looked at nine per­for­mance met­rics, in­clud­ing com­pli­ca­tions, 30-day read­mis­sion rates, pa­tient ex­pe­ri­ence scores and lengths of stay. The data were from 2012 to 2015, de­pend­ing on the met­ric. Those that made the list have the best per­for­mance com­pared with all other sys­tems in their cat­e­gory, which es­tab­lishes the bench­mark for com­par­i­son.

The 15 sys­tems rep­re­sent the top five from three cat­e­gories based on to­tal 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.

Mor­tal­ity rates at the top-per­form­ing sys­tems were 13.4% lower than their peers and com­pli­ca­tion rates were 8.5% lower. The av­er­age length of stay was 10.2% shorter and wait times in the emer­gency de­part­ment were 17.5% shorter com­pared with the bench­mark.

“It strikes me that there is a clear fo­cus by sys­tems to im­prove mor­tal­ity and lower length of stay,” said Jean Chenoweth, Tru­ven’s se­nior vice pres­i­dent of per­for- mance and im­prove­ment. “They are tak­ing on op­er­a­tional is­sues that you have much greater con­trol over to stan­dard­ize.”

Hospi­tals, by com­par­i­son, have been able to tackle broader qual­ity and per­for­mance ini­tia­tives, Chenoweth said. For ex­am­ple, the best-per­form­ing sys­tems re­ported lower pa­tient-sat­is­fac­tion scores com­pared with the hospi­tals rec­og­nized in Tru­ven’s 100 Top Hospi­tals study re­leased last month. Pa­tient-sat­is­fac­tion scores were 2.5% bet­ter at top-per­form­ing sys­tems, but they were 3.8% bet­ter among the 100 top hospi­tals.

It may take a little more time for sys­tems to align with their af­fil­i­ate hospi­tals, Chenoweth said, adding “it’s like we’re watch­ing a slow-mov­ing ship.”

De­spite that, Chenoweth said the fo­cus by sys­tems to im­prove ef­fi­ciency while rein­ing in the cost of care proves value-based re­im­burse­ment is tak­ing hold. “No mat­ter what the Trump administration does, the in­dus­try is mov­ing to­ward more value-based care, and it doesn’t ap­pear there will be any changes to that.” The shift in re­im­burse­ment has opened op­por­tu­ni­ties for sys­tems to be more in­no­va­tive, usu­ally by en­cour­ag­ing their physi­cians and nurses to come up with new ways to im­prove care. This strong fo­cus on qual­ity will cause sys­tems “to be­come more mean­ing­ful to the com­mu­ni­ties they serve,” she added.

En­gag­ing in more out­comes-based ini­tia­tives has been an im­por­tant mis­sion for the lead­ers of HealthPart­ners, an in­te­grated de­liv­ery net­work based in Bloom­ing­ton, Minn.

For ex­am­ple, HealthPart­ners, which made Tru­ven’s list for the first time this year in the medium-sys­tem cat­e­gory, has made ef­forts to im­prove qual­ity of care for pa­tients strug­gling with men­tal ill­ness.

In­pa­tient beds at the seven-hos­pi­tal sys­tem are of­ten packed with pa­tients read­mit­ted to the fa­cil­ity be­cause

they have trou­ble re­ceiv­ing on­go­ing treat­ment for their men­tal health con­di­tions. These pa­tients are usu­ally home­less, said Mary Brain­erd, the sys­tem’s CEO.

To ad­dress the prob­lem, HealthPart­ners re­cently part­nered with Catholic Char­i­ties to cre­ate liv­ing cen­ters for men­tally ill home­less pa­tients. The fa­cil­i­ties are staffed with nurses who help en­sure pa­tients fol­low their care plans.

“We’ve worked re­ally hard to in­te­grate our men­tal healthcare ser­vices into com­mu­nity re­sources,” said Dr. Brian Rank, co-ex­ec­u­tive med­i­cal di­rec­tor of HealthPart­ners.

Even with the in­vest­ments by HealthPart­ners to help men­tally ill pa­tients, Brain­erd said there still aren’t enough beds or clin­i­cians to meet the de­mand. “I think the whole sys­tem for men­tal healthcare-at least in our re­gion-is still deeply flawed. And every day we have rea­son to wish we could do it dif­fer­ently,” she added.

Brain­erd said the lead­er­ship sees its physi­cians as a crit­i­cal re­source to tackle the many com­plex is­sues the sys­tem faces in its com­mu­ni­ties. For ex­am­ple, physi­cians came up with a plan in 2014 to de­crease opi­oids pre­scribed across the sys­tem’s care sites af­ter pa­tient data showed high rates of pre­scrib­ing.

Changes were made re­gard­ing who re­ceived opi­oid pre­scrip­tions and how fre­quently. As a re­sult, the num­ber of pa­tients pre­scribed opi­oids de­creased 17.4% from Fe­bru­ary 2015 to Fe­bru­ary 2017. “We rec­og­nized that we could have done bet­ter,” Rank said. Maury Re­gional Health, rec­og­nized this year by Tru­ven for the fourth time in the small-sys­tem cat­e­gory, has fos­tered a cul­ture that “con­stantly pur­sues ex­cel­lence,” said Alan Wat­son, CEO of the three-hos­pi­tal or­ga­ni­za­tion based in Columbia, Tenn.

Physi­cians com­pare read­mis­sions rates and lengths of stay at the sys­tem to the best hospi­tals in the coun­try. Doc­tors also par­tic­i­pate on ad­vi­sory boards to dis­cuss ar­eas in need of ex­tra at­ten­tion, Wat­son said.

Pa­tients are even called on to help set goals for the orga- niza­tion. When Maury Re­gional built a new crit­i­cal-ac­cess unit in 2016, pa­tients and their fam­i­lies were in­volved in the two-year plan­ning process. As a re­sult of their feedback, the unit has a des­ig­nated area for fam­ily to sit and re­lax as well as a pantry so food and snacks can be stored. The unit has open vis­i­ta­tion hours so fam­ily mem­bers can see a loved one at any time.

Pa­tient-sat­is­fac­tion scores have steadily im­proved over the past four years since Maury Re­gional has made it a goal to help pa­tients “feel more at home,” Wat­son said.

At Albuquerque-based Lovelace Health Sys­tem, a sec­ond-time win­ner in the small-sys­tem cat­e­gory, daily meet­ings with ex­ec­u­tive lead­ers across the sys­tem are con­ducted to dis­cuss is­sues big or small. “The point of the meet­ings is not to pun­ish but to talk about how we can do bet­ter,” said Dr. Gregory Nel­camp, chief med­i­cal di­rec­tor of the six-hos­pi­tal sys­tem.

The con­cerns brought up at those meet­ings are then fil­tered down to front­line staff dur­ing daily hud­dles so they can be aware of the chal­lenges and look for so­lu­tions.

Ac­cess to data is a key way for staff to cre­ate and mon­i­tor their ini­tia­tives. But it is only help­ful when data are avail­able in real time. “Look­ing at data that is very old is like driv­ing look­ing through a rearview mir­ror,” Nel­camp said. The sys­tem is now in the process of im­ple­ment­ing a new Epic Sys­tems Corp. EHR sys­tem, which Nel­camp said will help ad­vance Lovelace’s goals.

Physi­cians and nurses are in­spired to come up with ini­tia­tives to im­prove care be­cause they know their ideas will be heard and tried, Nel­camp said.

“We have made tremen­dous strides and as our cul­ture keeps ma­tur­ing, qual­ity has be­come not what we do but who we are,” Nel­camp added.

Spec­trum Health in Grand Rapids, Mich., uses fre­quent hud­dles among front­line staff and physi­cians to solve prob­lems across its 12 hospi­tals.

HealthPart­ners, an in­te­grated care de­liv­ery net­work based in Bloom­ing­ton, Minn., is us­ing part­ner­ships in the com­mu­nity to find so­lu­tions to vex­ing prob­lems.

At Lovelace Health Sys­tem in New Mex­ico, daily meet­ings among ex­ec­u­tive lead­er­ship and front­line staff fo­cus on qual­ity im­prove­ment.

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