Healthcare Transformation 021115

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Healthcare Transformation: From Service Lines to Programs

Michael N. Brant-Zawadzki, MD, FACRExecutive Medical Director, Physician EngagementExecutive Medical Director, Neurosciences InstituteHoag Memorial Hospital Presbyterian1 Hoag Drive, PO Box 6100Newport Beach, CA 764-5942 office(949) 764-6789 fax

Jack L. Cox, MD, MMMSenior VP &Chief Quality OfficerHoag Memorial Hospital

Allyson Brooks, MDExecutive Medical Director, Womens Health InstituteHoag Memorial Hospital

Junko Hara, PhDProgram Development and Scientific AdvisorOrange County Vital Brain Aging


The Affordable Care Act (ACA) helped focus our countrys need for more effective and more cost-efficient care that also improves the patient experiences - the so-called Triple Aim. One of that aims greatest challenges is the ongoing fragmentation of providers. This is particularly true among specialists, but lack of integration also exists at the primary care and specialized services interface. Traditional hospital and medical staff organizations contribute to the un-coordination of patient care. Transformation of care delivery methods to overcome this challenge is needed. We here describe our organizations recent experience with a model for achieving the Triple Aim in a variety of areas some inpatient, some ambulatory even community-based, by creating programmatically driven infrastructure under an Institute umbrella. This may be a useful tactic towards such transformation.

IntroductionThough often labeled as healthcare reform, the Affordable Care Acts (ACA) major initial impact has been on healthcare payment reform through re-structuring of the insurance model (including a shift of some payer burden to patients). The ACA did provide direction towards patient oriented, performance and cost accountable healthcare, but the tactics of transforming healthcare delivery at the point of service remains a significant challenge for providers. The ACAs model of at risk primary care medical homes as the major management tactic of healthcare delivery has been challenged by sub-optimal attention to the appropriate value of specialized services [Ref 1, 2], with substantial leakage to non-aligned specialty services. Clearly, closer teamwork amongst all providers, as well as the patient (now customer) community, is needed.

As Peter Drucker said, the most efficient organizations require well integrated specialists [Ref 3]. However, to date, specialized health care services have been largely fragmented, inefficient, and in part for those reasons, excessively expensive. Their incentive has been volume rather than value as many have stated, lacking true metrics of the latter. Incentives aside, most of the expense of healthcare care resides in specialized services, as complex healthcare problems require relatively expensive technology, dedicated facilities, and rely on more costly professional expertise, because that requires years of training and financial sacrifice on the parts of the providers. Yet specialized care is indispensable.

Methods: The Program ModelThe program model is one solution to the challenge posed by the above realities. This model integrates multidisciplinary specialists, focuses them on patient outcomes, and connects them to the health care access and triage functions of primary providers. Organizations like the Cleveland Clinic have pioneered this approach, and we have adapted it to a community hospital setting. In our growing health system affiliation, the program concept has been piloted in our hospital for the past 7 years. Our programs create and continually improve care pathways, each care pathway focusing on a specific patient condition or disorder.

Historically, hospitals have been structured around internal operations, and for financial accounting, as geographically functional units and cost centers (hospital departments - in the non-academic sense). For instance, the emergency room, the angiography suite, operating room suite, floor and intensive care nursing units, are cost centers. Aggregating operational units (cost centers), such as the catheterization laboratory, the arrhythmia ablation suite, the cardiac operating room, the cardiac ICU and floor unit with the work of variably aligned cardiologists and cardiac surgeons, has been termed a service line. Such units and service lines are internally focused, and measured by process efficiency, contribution margin, and perhaps transactional service satisfaction surveys of patients [Ref 4].

The program approach transcends the relatively short term orientation of this organization-centric infrastructure, to one focused on the longer term interests of the patient and their payer (increasingly the same entity). Programs measure the true value (outcomes/cost) of the health care delivery process [Ref 5]. Programs expand administratively led and administratively accountable service line entities to physician led, multidisciplinary teams accountable for process efficiencies, financial, but most importantly clinical outcomes. It has been shown that physician leadership is the key to improving quality [Ref 6-7]. As stated, each program focuses on a specific patient condition, disease, or disorder. Our programs include a spectrum of very common and basic conditions such as mother and baby (maternity), memory and cognitive disorders in our aging population, to much more intensive diseases such as stroke, cardiac valvular disease, cardiac arrhythmia, joint replacement, and a variety of organ specific cancer programs (brain tumor, melanoma, etc.), as examples.

Programs themselves are aggregated based on commonality and overlap of organ structures affected, and similarities of needed human as well as facility resources, under an Institute umbrella. Thus, the stroke, brain tumor, memory and cognitive disorders programs are some of the Neurosciences Institutes programs. The Institute serves the executive function of strategy development, resource procurement and allocation, and value monitoring. The Institute coordinates the common resources used by the programs (imaging technology, nursing floors, information systems, etc.), and marshals support from finance, IT, marketing, philanthropy, and other non-clinical but mission critical components of the organization (Figure1). Representatives from each support department participate in the regularly scheduled institute and program leadership committee meetings ad hoc.

Coordination and cross-integration is essential. For example, a patient in the brain tumor program may develop seizures requiring close coordination of their care with the epilepsy program. A new mother in the Womens Health Institutes maternity program may develop post-partum depression requiring the services of the Neuroscience Institutes neurobehavioral program. Critical to such integration is the presence of nurse navigators, each patient having access to a navigator who coordinates care amongst the various services provided throughout the entire organization, linking the in-patient and out-patient continuum. The navigators also lead the programs clinical metrics management, including aggregation of outcome data.Programs deliver community education, as well as continuing education of providers, and manage relevant clinical research projects. They are the engine of care innovation and also a magnet for philanthropy.

Results: Case studies.Stroke Program: In 2003, our stroke service line was marginal, and lagged in providing evidence-based or even organized care for stroke patients. The numerous private community general neurologists were hamstrung by their off-site location and demands of office patient practice. They couldnt respond rapidly enough given the evolving guidelines in management of acute ischemic stroke. Lack of specialized stroke experience lowered their comfort level with anticoagulants and the emerging use of intravenous thrombolytic therapy on-call after hours. Likewise, neurosurgical availability for acute hemorrhagic stroke with limited. Though there was a foundation of advanced neuroimaging and intra-arterial neurointerventional capability for treatment of stroke and aneurysms, the general neurologists did not utilize those resources well. The various operational units (emergency department, intensive care unit, nursing floor) were not organized around, or focused specifically on stroke patients. As a result, there was a low utilization of then evidence-based intravenous thrombolytic therapy with only a handful of patients receiving the treatment annually. The complication rate for such therapy was above the study group rate as published in the NIDS trial [Ref 8]. Length of stay and costs for treating stroke patients, who were housed throughout the hospital with non-specialized nurses were above national benchmarks. Patient and family dissatisfaction was high. No process metrics or clinical outcomes were available.

The needed transformation to programmatic change started with the recruitment of a dedicated stroke neurologist as the program director with support for his administrative time, and creation of a services agreement that facilitated attracting a team of neurohospitalists, (one of the first in the region). The team began creating evidence-based order sets for ischemic stroke that targeted the emergency department and a nursing floor, where initially 8 beds (now 20) were dedicated as the stroke unit with designated nursing staff. Evidence-based clinical pathways for ischemic, intracerebral, and subarachnoid hemorrhagic strokes were created. Standardized order set protocols provided guidelines with inclusion and exclusion criteria for intravenous thrombolytics, aiding com