‘We are cre­at­ing some­thing that no­body has ever done and that’s that unique out­come’

Modern Healthcare - - Q & A -

“Our hir­ing de­ci­sions are cru­cial right now. We need to fill this beau­ti­ful build­ing with the minds and the skilled hands that are go­ing to cre­ate those bet­ter out­comes.”

Shortly af­ter be­com­ing CEO of the Re­ha­bil­i­ta­tion In­sti­tute of Chicago in 2006, Dr. Joanne Smith gath­ered her team of sci­en­tists, lead­ers and clin­i­cians and chal­lenged them to set the in­sti­tu­tion on a new path. It was a slightly un­con­ven­tional move con­sid­er­ing the in­sti­tu­tion was peren­ni­ally ranked on var­i­ous lists as the top re­ha­bil­i­ta­tion hos­pi­tal in the na­tion. Still, Smith said that the or­ga­ni­za­tion could not nec­es­sar­ily prove it was get­ting the right out­comes for pa­tients. Flash for­ward 11 years. The newly branded Shirley Ryan Abil­i­tyLab opened the doors to its one-of-a-kind hos­pi­tal in down­town Chicago in March. For the first time, clin­i­cians and re­searchers work side-by-side ad­dress­ing pa­tient needs and study­ing new tech­niques to get them mov­ing again. Smith talked with Mod­ern Health­care Man­ag­ing Edi­tor Matthew We­in­stock about the Abil­i­tyLab’s unique ap­proach to pa­tient care. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: What was the thought be­hind putting re­searchers and clin­i­cians to­gether?

Dr. Joanne Smith: We chose the word “abil­ity” 10 years ago when no­body else was us­ing it be­cause it was a softer spin on dis­abil­ity; it was more pos­i­tive for the pa­tient, it was in­di­vid­ual.

We cre­ated a new vi­sion and what we are go­ing af­ter: mea­sur­ing our­selves by how many peo­ple we at­tract and how much abil­ity we cre­ate. And when I say peo­ple, I don’t just mean pa­tients, but also sci­en­tists and man­agers and great thinkers and sup­port­ers and nurses and clin­i­cians and board mem­bers and phi­lan­thropists and gov­ern­ments and leg­isla­tive peo­ple. We are cre­at­ing some­thing that no­body has ever done and that’s that unique out­come.

Abil­ity is our code word for re­cov­ery. It’s even our code word for cure. Pa­tients would come to me and say, “You know, Dr. Smith I am par­a­lyzed, but if I could just move my thumb, I know that with to­day’s tech­nol­ogy, the world’s my oys­ter. I could live by my­self. I could com­mu­ni­cate by my­self. Just work on mov­ing my thumb.”

We didn’t wait for this new build­ing; the build­ing was only a tool in our mind at that point in time. But we shifted our be­hav­iors. We were go­ing to em­bed science—all ap­plied and hu­man sub­ject science— with our pa­tients and our clin­i­cians be­cause we felt that if we sur­rounded the pa­tient with sci­en­tists and clin­i­cians, we would get that col­li­sion of thought and aware­ness and ob­ser­va­tion that would . . . raise all boats.

When we got into the de­sign of the build­ing, I had this word, this vi­sion of ad­vanc­ing hu­man abil­ity, then I had this new be­hav­ioral motto where we were go­ing to em­bed science around the clin­i­cians and, in fact, the cul­tures were go­ing to col­lide.

MH: What were the hur­dles for clin­i­cians and re­searchers to start work­ing side-by-side? How did you ad­dress work­flow and cul­ture?

Smith: Two key things. Pa­tients and clin­i­cians and sci­en­tists needed frontstage time, which is where ex­per­i­ment and stud­ies and ob­ser­va­tion and things could hap­pen out in the open. And then they needed backstage time where they could think and an­a­lyze and quan­tify and de­sign in a qui­eter, pri­vate space. So we de­signed the build­ing to have flex­i­bil­ity for both.

When the ar­chi­tects came in, they started think­ing about the pa­tient ex­pe­ri­ence be­cause that’s univer­sal. I said, “I don’t want you start­ing with pa­tient ex­pe­ri­ence.”

They all looked at each other and said, “You don’t care about the pa­tient ex­pe­ri­ence?”

“No, I care about the pa­tient ex­pe­ri­ence,” I said, “but what pa­tient wants to be in the hos­pi­tal? You can

give them nice bed linens and pretty ceil­ings and concierge sup­port and good food, but none of us want to be in the hos­pi­tal. Why are you there? You are there to get an out­come done and get out. So, I want you to de­sign the out­come first and the out­come is the in­te­gra­tion of science with clin­i­cal care . . . where pa­tients are go­ing to get more abil­ity. And then, once we fig­ured that out in the de­sign, then we will back into a good pa­tient ex­pe­ri­ence.”

MH: How has that tran­si­tion been for you to start to fo­cus on out­comes?

Smith: Our hir­ing de­ci­sions are cru­cial right now. We need to fill this beau­ti­ful build­ing with the minds and the skilled hands that are go­ing to cre­ate those bet­ter out­comes. As we do that, we are plac­ing bets with in­sur­ers and start­ing to cre­ate op­por­tu­ni­ties to do some ex­per­i­men­tal re­la­tion­ships with cer­tain pa­tient pop­u­la­tions.

You might guess that some of our pa­tients are not high-in­ci­dence in any one lo­cale in the coun­try. Let’s take pe­di­atrics for ex­am­ple. Say there are 30 bad brain in­juries for kids, but only two may hap­pen in Illi­nois. There is a model that we con­ceived that says, “We are the des­ti­na­tion for those kids. There isn’t an­other place that has the tools, equip­ment, the science and ca­pa­bil­ity that we do. Let’s work to­gether on an ex­per­i­men­tal process to study how we can jointly take care of these kids, get a bet­ter out­come at a more ef­fi­cient and ef­fec­tive cost, and in the long run, a bet­ter out­come, less suf­fer­ing and more abil­ity for the pa­tient.”

MH: Who are you talk­ing to?

Smith: It’s early stage, so I can’t say just yet. But, there is in­ter­est, and there is in­ter­est from work­ers’ com­pen­sa­tion com­pa­nies and rein­sur­ance com­pa­nies, be­cause those com­pa­nies have the most cat­a­strophic cases with the most life­time risk. So now you take an in­sur­ance com­pany with a life­time risk and they’ve got a bad burn or a spinal cord in­jury or bad brain in­jury. They fly that pa­tient across the coun­try. They know that short-term gains lead to long-term gains re­sult­ing in lower over­all life-care costs for the pa­tient and, ul­ti­mately, a bet­ter out­come.

MH: Are you be­gin­ning to de­fine your own out­comes met­rics?

Smith: Yes, ab­so­lutely. The out­comes en­deavor has two parts to it, one of which is called the abil­ity quo­tient, which is an­other word for the en­tire data­base of met­rics that will look at a pa­tient from a func­tional stand­point, whether it be cog­ni­tion, speech, bal­ance, eat­ing, swal­low­ing, what­ever, us­ing val­i­dated tools, but only those that are statistically im­por­tant to de­fine the pa­tient’s progress and pre­dict­ing the out­come.

The sec­ond part is a data­base we’ve cre­ated that in­cludes ev­ery pa­tient we have touched, both past and cur­rent—us­ing the abil­ity quo­tient for cur­rent pa­tients. And then be­ing able to query past pa­tients, even though they are not here any­more, on sim­i­lar met­rics or sim­i­lar points in time to un­der­stand pa­tient progress.

We be­lieve that we can ac­tu­ally pre­dict where a pa­tient should be with a cer­tain in­jury or cer­tain di­ag­no­sis at a cer­tain point in time. And if they are not, un­der­stand why and un­der­stand what in­ter­ven­tion we need to do in or­der to get them back on the curve. And then, soon af­ter that, as we be­gin to pre­dict where they should be, we are go­ing to be able to pre­dict what the cost is.

MH: How far away are you from be­ing able to pre­dict cost?

Smith: The cost piece is still fur­ther out, but pre­dict­ing their progress is hap­pen­ing right now.

What I am look­ing for up­front is for pro­gres­sive in­sur­ers to say, “Let’s try it out to­gether and learn and then share the ben­e­fits.” Right now, I can’t say I am go­ing to go fully at risk be­cause there is too much vari­abil­ity, par­tic­u­larly with some of the cat­a­strophic cases that we care for, which by the way, are most ex­pen­sive for them. What we are look­ing to do is cre­ate a model with pay­ers and take a de­fined num­ber of these pa­tients, study them on this model, study where the cost troughs and peaks are, look at how we can in­ter­vene and then be able to ap­ply that on a broader ba­sis.

MH: How vi­tal will this data­base be as you com­pete with skilled­nurs­ing fa­cil­i­ties?

Smith: Cru­cial. Our hy­poth­e­sis right now is that the only thing that they are ef­fec­tive at com­pe­ti­tion on is cost and with the strata of the pop­u­la­tion that may be very geri­atric with ba­sic stroke and/or ba­sic neu­ro­log­i­cal con­di­tions, and also, sim­ple joint re­place­ments.

Right now SNFs are do­ing well on those pop­u­la­tions and say­ing, “Give us some of those harder pop­u­la­tions.” But it is all based on cost, and shame on us in re­ha­bil­i­ta­tion be­cause we haven’t proven that our out­comes are bet­ter. We are, for the en­tire field, look­ing to prove that the out­comes are bet­ter.

MH: Go­ing be­yond that, if you can flash-for­ward a few years, what mark are you hop­ing the Abil­i­tyLab leaves?

Smith: Re­gret­tably, re­ha­bil­i­ta­tion has lost its power and its mojo in the do­main of medicine. And, in part, it is be­cause pre­vi­ously there was no science, and be­cause acute­care hospitals were re­ally fo­cused on cure and when they couldn’t cure, they dis­miss pa­tients to lower lev­els of care.

So one of the things I am hop­ing we have al­ready done is carv­ing al­most a new space of medicine. If I look at what Net­flix has done to TV, it’s spun it on its head. It is not TV, it is an en­tirely dif­fer­ent form of ac­cess­ing en­ter­tain­ment.

We used to be a re­ha­bil­i­ta­tion or­ga­ni­za­tion. I think we have now be­come some­thing that is not even in that space any more. It is some­where be­tween acute care and step-down care. And with the science that we are har­ness­ing in the clin­i­cal do­main, the pa­tients who can’t be “cured” in the acute­care world ac­tu­ally have great hope and op­por­tu­nity for a cure at this level.

So, I hope we are rais­ing all boats. I be­lieve we are carv­ing a new niche in medicine and we can raise the stan­dard for pa­tients with stroke and tu­mors and in­juries of the brain, spinal cord and ner­vous sys­tem, across the world.

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