Improving care quality and reducing cost are two of the highest priority goals for health care leaders. With health care costs continuing to rise and clinical outcomes increasingly linked to reimbursement, optimizing care and lowering costs are critical factors in determining the competitiveness and effectiveness of hospitals and health systems. Of all the approaches leaders can leverage to address these issues, reducing unwarranted clinical variance is receiving increased attention.
Within a health system, unwarranted clinical variance is understood as the difference in clinical practices and services that do not derive from unique patient needs and that may involve the overuse, underuse or misuse of medical services. If different clinicians in the same health system are using widely varying protocols to treat the same conditions, the result will be poorer patient outcomes and a less-than-clear picture of what it truly costs to treat the condition. Failing to address variations can negatively impact the ability to provide quality, consistent, safe and cost-effective care. A 2012 report from the Institute of Medicine found that inefficiencies in the U.S. health care system resulted in up to $750 billion of wasted spending in 2009, roughly 30 percent of total health care spending in that year. The report also estimated that approximately 75,000 deaths might have been prevented in 2005 if every U.S. state had provided care at a quality level on par with the best performing state.
Addressing unwarranted variance in care protocols and embedding those processes in the electronic health record (EHR) can be an effective way for health care leaders to impact both quality outcomes and their bottom lines. However, EHR-based processes will typically need to be matched with a system strategy that unlocks the potential of front-line clinical teams who are informed by good clinical data and a culture of improvement, quality and safety.
Intermountain Healthcare in Salt Lake City, Utah, recognized the link between variance, quality and cost early on thanks in part to Dr. Brent James. James was hired at Intermountain in 1986 as the director of medical research and continuing medical education. He brought with him a background in medical research, having previously held positions at the National Cancer Institute and the Harvard School of Public Health, as well as an interest in the theory and methods of W. Edwards Deming. Deming, who trained as an electrical engineer, believed that quality and cost are inextricably linked, and creating efficiencies in any process would lead to reduced costs and increased quality. Deming was also an advocate of considering systems as a whole, not as disparate smaller component parts that could be changed without influencing an entire operation.
“Once we understood the science of process management techniques as derived and applied in the business world could be brought into health care, we had our secret sauce and we knew we needed to teach that science to our teams,” said Todd Allen, senior executive medical director for the Healthcare Delivery Institute at Intermountain. “Through our Advanced Training Program in clinical process improvement, we train senior leaders, middle management and front-line health professionals in the theory and application of cost and quality control. The program has evolved over the years, but the core philosophy is still the same – the science of process management and change leadership is applied to health care leading to better quality, safety, cost and services outcomes. It turns out that clinical process management and improvement is our core business strategy.”
Intermountain used this philosophy to organize its most common care processes under the direction of an operations structure called clinical programs. Two of the first clinical programs developed were cardiovascular and women and newborns. Each clinical program is led by a physician, nurse and administration triad and is resourced with all those whose work affects the patient’s care and outcome. The multidisciplinary team is tasked with asking how they can improve the care processes within the program. Members of each clinical program regularly review the core care processes within their program using evidence from literature and data from Intermountain’s own EHR. They then work to continually refine and improve each care process. Organizing care in this way facilitates a broader, more longitudinal view of what’s necessary to treat a condition.
Intermountain has created Care Process Models (CPMs) within each clinical program that use a combination of existing evidence-based practice guidelines and historical EHR data. CPMs are meant to provide an evidence-based and standardized way to address the core clinical processes that matter most to their patients and clinicians. CPMs also include education, communication and data standards so process and outcome measures are truly meaningful and comparable across institutions. Together, these components have allowed Intermountain to create integrated CPMs to manage practice guidelines and digital workflows that actively guide physicians toward the clinical decisions that will improve outcomes for patients. The EHR data from every patient treated by CPMs offer further points to improve the next application of the CPM through a nearly real-time feedback loop.
“By integrating our Care Process Models into the EHR, we make sure that not only is the information where clinicians need it, when they need it, but it’s also baked into the soul of the organization,” Allen said. “We want to make it easy to do the right thing and take new measurements from ‘doing the right thing’ so that it’s even better the next time.”
The Royal Free London NHS Foundation Trust (RFL) is one of the largest hospital trusts in the NHS, employing more than 10,000 staff and serving 1.6 million patients across 20 sites in north London and Hertfordshire. It has three main hospitals – the Royal Free Hospital (founded in 1828 with the direct mission of providing free, quality care to patients with little or no means), Barnet Hospital and Chase Farm Hospital. The RFL provides specialist services in liver and kidney transplantation, rare cancers, hemophilia, HIV, infectious diseases, plastic surgery, immunology, neurology, Parkinson’s disease, vascular surgery, cardiology, amyloidosis and scleroderma. The Royal Free Hospital provides the only high-level isolation unit of its kind for the care of patients with the Ebola virus and other infectious diseases.
Because of its unique size and scope, the Royal Free London was concerned with reducing variation across its venues of care while increasing quality and decreasing costs.
“We found that there was a great deal of unwarranted variation in the way we delivered care that created less than ideal quality care for patients, and there were operational inefficiencies baked into that,” said Dr. Chris Streather, chief medical officer at the RFL. “We didn’t want to take a standardized cookbook approach to medicine, but we wanted to ensure that care was more predictable and evidence-based so that we could deliver it in a more cost-effective way.”
As RFL leaders began to search for established models and methods to reduce variance in care, they were introduced to Intermountain’s clinical program and CPM approach.
“There is quite a lot of admiration in the United Kingdom for some of the system-wide approaches for improving quality in the United States,” said Streather. “We looked at a number of places known for their international best practice, and the most advanced version of what we were trying to do was happening at Intermountain.”
With the help and facilitation of Cerner, the two organizations entered into a formal partnership in 2016 to bring the philosophies and practices behind Intermountain’s clinical programs and CPMs to the RFL in a trans-Atlantic knowledge sharing endeavor.
The partnership between Intermountain and the RFL involves teams from each organization visiting the other to observe and attend workshops and monthly teleconferencing so that Intermountain can provide remote support to the RFL as the trust implements clinical practice groups (CPGs), the RFL’s version of CPMs. The goal of these visits is for the RFL team to gain a deeper understanding of both the methodology and evidence behind Intermountain’s CPMs, and to get tactical education on how to familiarize clinical staff on methodology and help show them how to socialize these models for widespread adoption. Each visit is centered around a single theme to allow for a focused deep dive into that specialty. Special attention is also paid to who attends each visit to ensure all stakeholders are involved.
“When we visit Intermountain we bring senior-level executives, but we also take people who are directly involved in care,” said Streather. “It’s important for them to see what we’re doing in action somewhere else.”
Making a difference
Although realigning care at the RFL is still a work in progress, the introduction of the clinical practice group concept and its adaptation to the trust’s culture and needs is having an impact.
“The clinical practice groups are changing the way we provide care in a profound way,” said Streather. “We are segmenting clinicians into clinical themes and having them evaluate pathways of care and look at the data that informs those pathways to determine how we can improve them in a systematic way. We are also working with the Point of Care foundation which facilitates us working with patients and families in the design phase of all our clinical pathways.”
Alongside clinical perspective and evidence-based literature, incorporating the viewpoints and experiences of patients who are living with conditions into the care pathway design process is resulting in what Streather calls “idealized pathways” that will help improve both quality and operational efficiency. By incorporating these pathways into its EHR, the RFL will ensure that the methodology behind its care pathways is baked into the system’s digital infrastructure, making it easier for anyone, at any site, to follow the recommended method of care.
The clinical leadership for the digitization program is divided into the RFL’s four clinical divisions: Medicine, Surgery, Specialist Services, and Women’s, Children’s and Diagnostics. Each pathway is redesigned in a series of at least two workshops and then iterated upon using Plan, Do, Study, Act (PDSA) cycles and Institute for Healthcare Improvement (IHI)-based Quality Improvement methodology. The RFL has upwards of 80 clinicians involved in this process in each of the four divisions and has digitized seven pathways with plans to digitize additional pathways two at a time through a standard process. Incorporating the newly redesigned pathways into the EHR has had an immediate impact for the RFL.
“At two of our sites, we were immediately able to capture data-driven outcomes from the newly digitized pathways,” said Streather. “We have 44 pathways in operation, which represents about 60 to 70 percent of our clinical patient-facing activity. We are already on our way to digitizing 20 of those 44 pathways and will eventually have all 44 in the EHR.”
Working with Intermountain and redesigning their methods of care represents a considerable shift for the RFL and leaders have been deliberate about how these changes are introduced to doctors, nurses and others who provide care. C-suite leadership has been overwhelmingly supportive of the project, furthering the message that the trust is serious about reducing variance and improving care. Involving patients and clinicians in the design of care pathways has also given them a stake in the success of the project. Partnering with and adapting the methodology of an internationally recognized leader like Intermountain signaled to staff that the RFL was serious about improving care and has helped create buy in, Streather believes.
“I’ve rarely seen in the NHS such buy in from the clinical community,” he said. “It’s good to see that even after 18 months of introducing a complex program, we see the general enthusiasm growing daily.”
The partnership has provided value to the RFL on many levels. Chief among these is the willingness to be open to change and new ideas.
“I think one of the problems in health systems is that good practice happens in a lot of places, but we’re not very good at learning from excellence in other places,” said Streather. “There can be reticence to learn from others and there can sometimes be the resistance to adopting something that was someone else’s idea. The partnership with Intermountain has allowed us to learn the positive things, and the things they’ve found difficult, the pitfalls and bear traps they’ve discovered, and that’s made it easier to be open to the perspective of people that have walked the journey before us.”
The formalized nature of the partnership agreement has also allowed for knowledge sharing on a granular and practical level that might not have been possible if the RFL had passively observed Intermountain’s processes one or two times. Critical to the relationship’s success is that Intermountain leaders visit the RFL and can provide guidance and feedback in real time, on site.
Intermountain has also noted value in the partnership. Seeing their institutional processes adapted by other health systems is a validation of the approach. Part of the partnership has been learning that it is not a one-to-one process of dropping in methodology from Intermountain to the RFL, and that the trust has adapted the ideas to their own circumstances. Learning some of these differences has provided insight for Intermountain into what may be possible in the future.
“There are aspects of Royal Free care that Intermountain can learn from,” said Chris Wood, vice president, Cerner and medical executive for iCentra development at Intermountain Healthcare. “The way the Royal Free reaches out to the community, that’s a big push for Intermountain right now. How to address things like education, food and transportation, these are things the English government has been doing aggressively since WWII.”
Streather noted that seeking out partnerships to improve is an essential part of growth, but that it is not always easy.
“It takes humility to recognize that you don’t have all the answers and seek out people who are leaders in their field,” he said. “It doesn’t make sense to imagine that you can do a fundamental change program without working with other people.”
Wood agrees that creating partnerships is key to future growth.
“The power of building relationships is not just what can be done today, but what we can work on tomorrow,” said Wood. “The really great benefits of the relationship between Intermountain and the Royal Free are in the future of working together to apply what we already know in newer and better ways.”