Top health systems strive to reduce variation in performance across network
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