Top health sys­tems strive to re­duce vari­a­tion in per­for­mance across net­work

Modern Healthcare - - Regulation - By Maria Castel­lucci

At the three hos­pi­tals in the Asante health sys­tem, the process for pre­vent­ing cen­tral line-as­so­ci­ated blood­stream in­fec­tions is de­signed to pro­ceed in ex­actly the same way. The nurse man­ager in each unit is tasked with round­ing on all pa­tients who have a cen­tral ve­nous catheter to check if it’s clean and prop­erly in place. To do this, she be­gins each shift by log­ging onto her per­son­al­ized dash­board, which is avail­able through the elec­tronic health record sys­tem. There she can view all the pa­tients on her floor who have a catheter in place.

Be­fore Asante rolled out a new EHR a few years ago, catheters were tracked in a pa­per log by nurses and infection pre­ven­tion­ists who were in charge of fol­low-up. This likely meant some pa­tients with catheters were be­ing missed, said Dr. Jamie Gre­bosky, Asante’s chief qual­ity of­fi­cer.

Now if er­rors or in­cor­rect pro­ce­dures are ob­served— us­ing Epic Sys­tems Corp. soft­ware—the man­ager speaks with the nurse in charge of that pa­tient to dis­cuss proper catheter main­te­nance. Fi­nally, they de­cide when the catheter can be re­moved to pre­vent an infection.

Mit­i­gat­ing vari­a­tion in per­for­mance across hos­pi­tals is a cen­tral qual­ity im­prove­ment strat­egy for Asante and the 14 other sys­tems rec­og­nized this year by IBM Wat­son Health.

The health sys­tems rely on ev­i­dence-based prac­tices, tech­nol­ogy and team­work to im­ple­ment stan­dard pro­cesses that aim to im­prove qual­ity of care. “The results are al­ways go­ing to be bet­ter if we do it to­gether rather than one place at a time,” said Lynn Brit­ton, CEO of Ch­ester­field, Mo.-based Mercy, which was rec­og­nized by IBM Wat­son for the third time.

At Asante, its work­flow was im­ple­mented sys­temwide in 2015 by clin­i­cians who worked to­gether on best ap­proaches to de­crease infection rates across the or­ga­ni­za­tion. The stan­dard pro­to­cols have paid off, with cen­tral line-as­so­ci­ated blood­stream infection rates across Asante drop­ping from 1.067 in 2015 to 0.282 in 2017. Asante hasn’t re­ported such an infection, known as CLABSI, since April 2017.

Asante’s struc­tured work on CLABSI preven­tion is in line with the sys­tem’s larger goal to mit­i­gate vari­a­tion in per­for­mance across all of its hos­pi­tals. The sys­tem reg-

ularly seeks out ways to stan­dard­ize care pro­cesses so qual­ity of care is the same at every fa­cil­ity.

“If there are best prac­tices for pre­vent­ing in­fec­tions and for treat­ing con­di­tions it should be the same no mat­ter where our pa­tients are re­ceiv­ing that care,” said Roy Vin­yard, CEO of the Med­ford, Ore.-based sys­tem.

Re­search backs up Asante’s ap­proach, showing ef­forts to stan­dard­ize care re­duce pa­tient safety in­ci­dents and im­prove qual­ity of care over­all.

Stan­dard­iz­ing care pro­cesses also en­cour­ages qual­ity im­prove­ment be­cause Asante lead­ers can more eas­ily bench­mark clin­i­cal per­for­mance and cre­ate stan­dard work work­flows and ex­pec­ta­tions for its clin­i­cians, Gre­bosky said.

“By stan­dard­iz­ing work, we have re­duced the num­ber of things that peo­ple have to do, but they have to do the things they’ve been told to do 100% of the time. Our thresh­old is per­fec­tion. We are go­ing to hold you ac­count­able,” he said.

Stan­dard­iza­tion is key

A sep­a­rate anal­y­sis by IBM Wat­son Health sup­ports the health sys­tems’ fo­cus on stan­dard­iz­ing pro­cesses across the or­ga­ni­za­tion. IBM Wat­son found that the in­di­vid­ual hos­pi­tals within the 15 Top Health Sys­tems per­formed com­pa­ra­bly on each of the nine CMS mea­sures used in the anal­y­sis.

“The hos­pi­tals in each sys­tem are all close to­gether on per­for­mance,” said Julie Shook, 100 Top Pro­gram di­rec­tor at IBM Wat­son Health. “It shows what the value of be­ing part of a sys­tem brings—they can help raise the bar and pro­vide a higher stan­dard that is de­liv­ered in each com­mu­nity.”

IBM Wat­son’s best-per­form­ing sys­tems were se­lected from a group of 338 health sys­tems across the U.S. The 15 sys­tems rec­og­nized rep­re­sent the top five from three cat­e­gories based on to­tal op­er­at­ing ex­penses: large sys­tems gen­er­at­ing ex­penses of more than $1.85 bil­lion; medium-sized sys­tems gen­er­at­ing be­tween $800 mil­lion and $1.85 bil­lion; and small sys­tems with less than $800 mil­lion in op­er­at­ing ex­penses.

The top-per­form­ing sys­tems per­formed bet­ter on all of the CMS mea­sures com­pared with the oth­ers in the data set. In­pa­tient mor­tal­ity rates at the 15 top sys­tems were 14.6% lower than their peers and com­pli­ca­tion rates were 17.3% lower. The av­er­age length of stay was 8.8% shorter and wait times in the emer­gency depart­ment were 18.2% shorter com­pared with the bench­mark.

Ad­di­tion­ally, the top health sys­tems’ hos­pi­tal-ac­quired infection rates, which were in­cluded for the first time this year by IBM Wat­son, were on av­er­age 16.2% lower than the other sys­tems.

At Sen­tara Health­care, which was rec­og­nized by IBM Wat­son for the first time this year in the large sys­tems cat­e­gory, physi­cians from every hos­pi­tal work to­gether on qual­ity im­prove­ment ef­forts so care is stan­dard­ized sys­temwide. “We look to get vari­a­tion out of the sys­tem—we are only as good as the weak­est hos­pi­tal in our sys­tem,” said Howard Kern, CEO of Sen­tara, which op­er­ates 12 hos­pi­tals in Vir­ginia and North Carolina.

Physi­cians and man­agers from across the sys­tem meet on a monthly ba­sis to dis­cuss qual­ity im­prove­ment ef­forts. Called the clin­i­cal lead­er­ship coun­cil, the mem­bers eval­u­ate per­for­mance mea­sures and dis­cuss what as­pects of clin­i­cal care can be im­proved. So­lu­tions are then dis­cussed by re­ly­ing on ev­i­dence-based prac­tices and clin­i­cal ex­per­tise.

For ex­am­ple, ef­forts to pre­vent un­nec­es­sary read­mis­sions are han­dled the same way at all 12 hos­pi­tals. The health sys­tem has es­tab­lished pro­to­cols that re­quire every pa­tient to have a fol­low-up ap­point­ment sched­uled with their physi­cian be­fore they leave the hos­pi­tal. Ad­di­tion­ally, pa­tients are given their pre­scribed med­i­ca­tions be­fore they leave. And then a few days af­ter pa­tients have re­turned home, a nurse man­ager or care co­or­di­na­tor calls the pa­tient to en­sure they are tak­ing the med­i­ca­tions and not ex­pe­ri­enc­ing any is­sues.

“We spend a lot of time think­ing about the fact that we are not just a hos­pi­tal com­pany, but that we pro­vide the en­tire con­tin­uum of care,” said Dr. Mu­rali Naidu, chief clin­i­cal of­fi­cer of Sen­tara. The ef­forts led to a sys­temwide de­cline in read­mis­sions, dip­ping to 13.9% in De­cem­ber 2016, com­pared with 14.6% in Jan­uary 2015.

Hos­pi­tals lead­ers are also en­cour­aged to dis­cuss their suc­cess­ful qual­ity im­prove­ment ini­tia­tives. Every hos­pi­tal treats a unique pa­tient pop­u­la­tion, so nurses and doc­tors are em­pow­ered to in­no­vate and come up with so­lu­tions that work for them. “We learn from any­where in the or­ga­ni­za­tion. A small com­mu­nity hos­pi­tal, a ru­ral hos­pi­tal might have a best prac­tice,” Kern said.

Tech­nol­ogy as a tool

The elec­tronic health record is a crit­i­cal com­po­nent of Mercy’s work to unify per­for­mance across its 45-hos­pi­tal net­work. About 12 years ago, Mercy in­vested in im­ple­ment­ing a sys­temwide, uni­form EHR from Epic, which has al­lowed the sys­tem to iden­tify where per­for­mance dif­fers be­tween its hos­pi­tals, said Dr. Keith Starke, Mercy’s chief qual­ity of­fi­cer.

“One of the ad­van­tages of be­ing on (a sin­gle EHR sys­tem) for quite a num­ber of years is the avail­abil­ity of the data to cre­ate a story around where we have op­por­tu­ni­ties for im­prove­ments,” he said.

The EHR is also used to es­tab­lish pro­to­cols across the sys­tem. For ex­am­ple, when Mercy be­gan work three years ago to de­crease rates of C. dif­fi­cile in­fec­tions, the EHR was de­ployed to help nurses iden­tify pa­tients at risk for the deadly and costly infection sooner.

Mercy pro­grammed pop-up alerts into the EHR that warned nurses of pa­tients who could get C. diff. The EHR iden­ti­fies the pa­tients by cap­tur­ing cer­tain data about them from the health record—such as if they’ve had a C. diff infection within the past year, re­cently been ad­mit­ted to an­other health­care fa­cil­ity or had an ab­nor­mal stool.

As a re­sult, Mercy has re­duced C. diff infection rates by 67% since 2016 from a base­line ra­tio of 1.32 down to 0.5 in the most re­cent quar­ter. The re­duc­tions also saved the sys­tem more than $5 mil­lion .

Asante re­lies on its EHR to help stan­dard­ize care as well. Physi­cian and nurse lead­ers have ac­cess to elec­tronic dash­boards with data cus­tom­ized specif­i­cally for them and their re­spon­si­bil­i­ties. “It has the things that are im­por­tant to you to man­age your work,” Gre­bosky said. “What we found was our lead­ers are not ea­ger to go out and grab the in­for­ma­tion. We have to push it right in front of them.”

The EHR also helps to en­sure the stan­dard pro­to­cols are fol­lowed con­sis­tently be­cause it re­minds clin­i­cians of what needs to be done. “We use tech­nol­ogy to make sure we are do­ing things 100% of the time,” Gre­bosky said.

Main­tain­ing a ra­zor-sharp fo­cus on all that needs to be done is the big­gest chal­lenge about stan­dard­iz­ing care pro­cesses, Asante CEO Vin­yard said.

“You have to have re­lent­less sys­temwide fo­cus. … It’s not a sprint but a marathon,” he said. “We im­prove every day, and we learn new things every day that can im­prove care, and then our goal is to spread it through­out the sys­tem. But it’s not easy and you can’t take your eye off the ball.” ●

“We look to get vari­a­tion out of the sys­tem—we are only as good as the weak­est hos­pi­tal in our sys­tem.”

Howard Kern CEO Sen­tara Health­care

At Asante, Chief Qual­ity and Pa­tient Safety Of­fi­cer Dr. Jamie Gre­bosky, left, says a sys­temwide ap­proach to han­dling in­fec­tions has led to a drop in cen­tral line-as­so­ci­ated blood­stream infection rates.

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