HealthLeaders Media LIVE at Scripps Health Value by Designlive.healthleadersmedia.com/.../resources/...at_Scripps_Case_Study.pdf · Case Study // LESSON 1 ... Scripps Health’s shift

Featuring a live event on January 28, 201512 p.m.–3 p.m. ET (9 a.m.–12 p.m. PT) Scripps Health | San Diego

2 Analysis Case Studies 4 Lesson 1: Restructure the Leadership

Matrix to Build Accountability and Reduce Variation

7 Lesson 2: Empower the Healthcare Team to Experiment and Drive Value by Design

13 Lesson 3: Drive for Population Health Through Primary Care Redesign

16 Resource Guide Additional Resources From HealthLeaders Media

HealthLeaders Media LIVE at Scripps Health

Value by DesignA Blueprint for Slashing Waste, Lowering Costs, and Improving Quality

2January 28, 2015 I HealthLeaders Media LIVE I Value by Design

Can Value Ever Be Designed?

Analysis

Look behind what passes for

value-based healthcare these

days and you will see there

isn’t much design to it. Instead, many

so-called value-based systems are

chopped-up versions of existing sys-

tems that have been subjected to the

wringer of cost cutting.

The problem with the subtrac-

tive view of creating value is that it

uses efficiency tricks to sustain weak

systems of care. To truly create value

means taking a merciless, brutally

self-critical view of the system, its

leadership, and its ability to sustain

itself in the future. The board and

chief executive at Scripps Health

went through that in 2010, and they

didn’t like what they saw. President

and CEO Chris Van Gorder under-

stood that many health systems are

too vertically oriented around hos-

pital C-suite leadership teams, each

competing to push their hospital to

the top of the performance chart. In

a volume-based reimbursement envi-

ronment, that will work to drive up

efficiency and chase procedural care

dollars, but it is poison to creating

efficient systems of care between dif-

ferent parts of the health system.

But going too horizontal has its

fatal flaws as well, creating a top-

down layer of management detached

from the concerns of the ED or the

primary care office. With excessive

horizontal management, account-

ability becomes broader but more dif-

ficult to define. So Scripps is aiming

to achieve appropriate emphasis on

elements of both horizontal and verti-

cal management, with some success

so far.

The team was rebuilt in 2010

with four system leaders overseeing

the medical, clinical operations, sup-

port, and administrative divisions,

with a fifth for population health

added in 2012. But leadership teams

under a CEO and CNO are left at each

of Scripps’ five hospital campuses.

What has started under that

hybrid structure is a new way of look-

ing at healthcare process improve-

ment. By definition, improvement is

almost universally at the unit level—

fixing lab report delays in the ED, for

Leadership Programs DirectorHealthLeaders Media

JimMolpus


example, or strengthening patient access to primary care. To do that, you need

to empower the front line with resources and have the performance improve-

ment staff put some metrics on the problem and commit the resources to invest

capital when a solution is needed.

So far, Scripps leaders say they have taken $320 million in waste out of the

system, almost all of it on the inpatient side. The next steps will be to extend the

underlying system into ambulatory care and population health, which may be

considered a leap of faith in expertise for many hospital-based systems.

Jim Molpus is leadership programs director for HealthLeaders Media. He

may be contacted at [email protected].


What are defined as

health systems today

are not really health

systems at all, but loosely held con-

federations of healthcare providers

tied together by a marketing brand

and a Medicare number. The leader-

ship team at Scripps Health knew

at the start of this decade that com-

peting in the future of value-based

healthcare would require a new way

of providing healthcare—starting

with a change in the leadership struc-

ture.

By 2010, Scripps Health

President and CEO Chris Van Gorder

had already spent several years laying

a foundation of strong leadership

and accountability across Scripps’

five hospital campuses. Van Gorder

installed a chief executive (CE) and

chief nurse at each campus, giving

them numbers to hit and a mandate

for performance turnaround. “And it

worked magnificently,” Van Gorder

says.

Restructure the Leadership Matrix to Build Accountability and Reduce Variation

Case Study // LESSON 1

“We went from about 50–55 days

cash on hand and losing money to

where we are today, which is a very,

very strong balance sheet, strong

operations across the board, and a

real sense of accountability along

the way. But what it also did was

created variation, because every chief

executive did it their own way.”

But the structure also created

unhealthy internal competition, he

notes. “It was a constant competition

for capital resources,” Van Gorder

says. “Each believed that their

campus was more important than

any other campus, even if that meant

duplicating services that existed

relatively close by in the healthcare

system.”

By 2010, it became apparent

that a decentralized organizational

chart was going to create too much

variation—which translates into

waste and cost—for Scripps to

move forward. But creating a central

office model took away site-based

» Five hospital campuses

» More than 13,000 employees

» 1,980,000 annual patient visits

» 1,372 total licensed acute care beds

Scripps HealthSan Diego

BY JIM MOLPUS


accountability and incentive to change.

So Scripps developed a hybrid featuring four horizontal divisions that

crossed the healthcare system: corporate medical, clinical operations, support

services, and administrative services. Each division is headed by a corporate

senior vice president, each with goals to standardize clinical operations and

reduce variation across the system.

Under this hybrid model, campus CEs remain, but all capital requests go

through the system vice presidents for team and system analysis and approval.

CEs are still involved in final capital decisions through the Capital Requests

Committee, after they have been vetted through the corporate vice presidents

(and clinical care lines, where appropriate).

One of the cultural goals was not to lose the importance of accountability,

but to spread it around.

“It’s a shift from an individual-based accountability to a team-based

accountability,” Van Gorder says. “We didn’t really express it that way to begin

with, but we understood that healthcare is not administered by individuals. It’s

administered by teams of caregivers.”

That cultural shift required new ways of thinking about improvement, says

Barbara Price, corporate senior vice president of business and service line

development, and one of the senior leaders in the new structure.

“We discovered a few things that inherently run a little bit counter to

our culture overall in healthcare. One is that the concept of testing and doing

experiments is not a comfortable thing when you’re dealing with patients’ lives,”

Price says. “So we are actively engaged in training and helping people just get

comfortable with that.”

Another cultural shift involved moving away from the typical method of

healthcare problem solving, she says. “Over the years, if something needed to

be done, we would add another person to do it, right? We wouldn’t redesign the

process. We’d add more cost, and then we could turn around and charge the

payer because they would pay. We’re not in that environment anymore, so we

“SHIFTING THE CULTURE IS UGLY AND MESSY. SOME PEOPLE MAKE IT AND SOME PEOPLE DON’T.”

—Chris Van Gorder, president and CEO, Scripps Health


have to ask tough questions and simplify those processes that we’ve made so

complex by that historical approach.”

Still another challenge involved how people work and are motivated.

“In healthcare, we have a tendency toward heroics just by the nature of how

a health organization exists,” Price says. “So people come into the emergency

department: You have all kinds of resources that swarm around them to deal

with an emergent issue. So heroics are important, but so is consistency in how

we get day-to-day systems in place to prepare for patients.”

The system leaders recognized early on that the cultural transition would

be somewhat painful, Van Gorder says. However, an organizational philosophy

against layoffs gave staff members some reassurance. The system leadership

team also met regularly with the existing Scripps physician leaders and

the Scripps Leadership Academy alumni to answer questions and sustain

momentum.

“There’s a natural tendency to resist change,” Van Gorder says. “And the

horizontal model really meant everybody needed to change. Shifting the culture

is ugly and messy. Some people make it and some people don’t.”

SUCCESS METRICS

Scripps Health’s shift to a systemwide horizontal management structure has led to numerous benefits, including financial. Here is a look at performance improvement totals in recent fiscal years.

0

20

40

60

80

100

FY 2011 FY 2012 FY 2013 FY 2014 (goal)

$77 million

$64 million

$83 million

$97 million


Even the most diligent, com-

mitted health systems run

into a fundamental flaw in

system improvement very soon in the

process: how to drive system change

at the unit level. If you view system

improvement at the highest level,

then the initiatives often fail because

they are seen as top-down mandates.

If you let small units randomly chase

whatever quirk they identify, then

projects may not map to system goals

or add value overall to the patient.

Michelle Tressler, PhD, assistant

vice president for project manage-

ment and head of the Value by Design

internal staff, says sustainable

improvement blends both top-down

and bottom-up. Tressler says top-

down improvement works for a while,

but things eventually fail.

“Leaders try to fix things as an

organization, but they were not the

ones who were doing the work,”

Tressler says. “So it all falls apart

once you actually have to implement

because the devil’s in the details.

Empower the Healthcare Team to Experiment and Drive Value by Design


When you implement, you find the

holes between what sounds good on

paper versus what happens in reality.”

Quality improvement initiatives

are just that—initiatives. They are

fragile introductory steps that can

quickly fail if they do not become

embraced and systematized into

workflow.

“We didn’t really have a mecha-

nism to be able to link those togeth-

er,” Tressler says. “If we did manage

to create a process that worked

well, we didn’t have a good manage-

ment system in place to be able to

verify and ensure that that process

was being kept up to date and being

worked every single day, consistently

and reliably, to be able to produce the

outcomes that we knew they could.”

Scripps recognized it needed to

empower frontline staff to identify

gaps in care, but with support from

experts. The performance improve-

ment team now consists of nine proj-

ect engineers, many of whom have

management engineering or indus-


trial engineering backgrounds. All are trained in principles of Lean improvement,

Tressler says.

“They are the coaches for these teams that take on performance improve-

ment work,” she says. “They are there working with those managers, helping to

coach them every single day, not just on the tools and techniques, but also really

about how to ask the question differently and how to elicit ownership from the

front line.”

What makes the system work is the teams are assigned based on processes

that map to system goals.

“We are disseminated based on the needs of the organization,” Tressler says.

“Every year our organizational goals are outlined, and those goals prioritize

where our team works first. So there’s a lot of focus right now on the inpatient

setting of lowering costs and transforming work flow.”

Value by Design Project: Medication ReconciliationTo identify waste, the team started by mapping a patient’s journey through a

typical inpatient hospital stay (registration through discharge), says Mary Ellen

Doyle, corporate vice president for nursing operations.

“One of the things we discovered was how much time the nurse spends

when a patient is admitted, trying to collect and redo medication reconciliation,”

Doyle says. “When we did the initial time studies, we found the inpatient admit-

ting nurses spent anywhere from 40 to 50 minutes on a complicated medication

reconciliation.” Even then, there were times when getting an accurate medica-

tion list took two days of duplicating efforts. Occasionally, the medication list

remained incomplete.

Medication reconciliation had been “just a bunch of activity going on, not

a process,” says James LaBelle, MD, corporate senior vice president and chief

medical officer.

“You come into the ER and the nurse takes a medication history and writes it

“WHEN YOU IMPLEMENT, YOU FIND THE HOLES BETWEEN WHAT SOUNDS GOOD ON PAPER VERSUS WHAT HAPPENS IN REALITY.”

—Michelle Tressler, PhD, assistant vice president for project management, Scripps Health


down, a list,” LaBelle says. “The doc comes in, does the same thing. [But] the lists

are not concordant. The family brings in the medications. There are new, old, and

expired medications on there, and it gets altered. Then the patient goes up to

the floor, and the nurse takes a fourth medication history, and on and on it goes,

right? There isn’t a process by which a medication list is acquired on the initial

encounter and successive refinement occurs until we have a final medication list

that actually is accurate and the system is shown to be accurate.”

The team did a rapid improvement event and mapped out a goal of having

an accurate preliminary medication list by the time the physician writes the

admitting orders. When a patient is registered in the emergency department,

the patient access representative enters basic patient identifiers, and a soft-

ware solution automatically mines local regional and national pharmacies for

prescriptions that the patient has filled. Once the software list is downloaded,

a pharmacy technician meets with the patient, if possible, to review and revise

before the medication list is reviewed by the admitting ED physician.

Jeremy Delashmit, RN, an ED nurse who was involved in the medication

reconciliation project and other Value by Design projects, says the time that

ED nurses spend on medication reconciliation has dropped from 15 minutes to

three, and has saved the inpatient nurse anywhere from 27 to 45 minutes. In

addition to the time savings, of course, are the obvious quality and patient safety

benefits from having an accurate medication list with the physician before treat-

ment starts.

“It’s been highly accurate and highly successful for us,” Delashmit says. “I

get numerous comments from patients who come to us from anywhere in the

United States—Las Vegas, Hawaii, and so forth—who have just been thankful

for this because no one had ever done that for them before. It’s helped us treat

them more effectively.”

Value by Design Project: Physician Preference ItemsAnyone who says that physician preference items are the low-hanging fruit

of supply chain savings should try to pluck that fruit sometime and see what

happens. “When you pull doctors together who are very passionate about their

spinal implant device and the particular company they get it from and the assis-

tance they get from the sales representatives literally in the operating room,

that’s not really low-hanging fruit,” Van Gorder says.

What Scripps did four years ago was the typical tactic of reducing the


number of approved vendors and devices down to a very select few. Pretty soon

the savings didn’t look like savings at all, says James Bruffey, MD, an orthopedic

surgeon and spine specialist at Scripps Clinic.

“Within the spine care line, we do a bunch of complex procedures,” Bruffey

says. “We have surgeons that approach things differently. The goal is always

the same, to take good care of your patients. One surgeon may want to do this

operation one way and the validity is there to support it versus another surgeon

having a preference for something else.”

When Scripps went to a restricted list of devices, no one fully considered the

actual volume and variety of procedures that were being done.

“So the decisions were made kind of in a vacuum and, for example, in my hos-

pital, once the vendors were picked, it excluded 50% of our current operational

activity,” Bruffey says. “So in other words, half of what we did was no longer

available to us from an implant standpoint.”

There was a better way, which involved all of the spine surgeons agreeing

to a system where new devices are tested and validated, and then added to the

formulary as long as the vendor meets the price defined for that category by the

Scripps surgical team.

“We are routinely reviewing the categories we’ve created to make sure that

there’s nothing that’s falling out,” Bruffey says. “If we need to create a new cat-

egory, we all look at the pricing that’s been requested and we will say to vendors,

‘No, you can’t have a new category. This falls into this category. We have a price

for that category. If you would like to participate with that product, you have to

place it into this category.’ ”

The cooperation among spine surgeons has saved $1,040,234 for the

system and created a new dialogue for improvement. So far, the program has

worked on a sense of team spirit, but evaluating incentives and gainsharing with

physicians remain goals for the future.

“The reality is, physicians want to help us save money. And they also want to

retain choice, if they can,” Van Gorder says. “So all of a sudden, the administra-

tors and the physicians are aligned to deal with a distributor who’s trying to

gouge us on, you know, ridiculous prices for a screw or something like that.”


Value by Design Project: ED FlowIt really doesn’t take sophisticated computer algorithms to go through what

happens in emergency department flow. It just takes some painstaking work to

go step by step through weeks of typical patient encounters. Rose Colangelo,

patient care manager for the emergency department, says that when the ED

team actually looked at what happened to patients, some bottlenecks immedi-

ately rose to the surface.

One huge area of wasted time for the patient was between the ED and radi-

ology, she says.

“So the order went into the computer, then radiology would get the order,”

Colangelo says. “Radiology would dispatch transport and then transport would

come to the ED, pick up the patient, and then take the patient to radiology.

When the test was done, radiology would again page transport. So we found

that there was about 40 minutes of just wasted time in that, which then adds

up because then the next patient has to wait that additional 40 minutes. By

the time you get to the fourth of fifth patient who’s waiting for a test, it could

already be like an hour and a half by that point.”

Dramatic results don’t always take dramatic changes, as the team found.

“So what we did is we took ownership of that transport by having a desig-

nated technical partner in the emergency department facilitate patient trans-

port,” Colangelo says. “So when a patient’s order goes into the system, radiology

calls directly to one of our technical partners who then facilitates that patient

going to radiology or CT. We’ve actually reduced our times from 40 minutes to

five minutes for our average now.”

There were other bottlenecks identified and fixed:

• Instead of having patients repeat their history several times, the initial

encounter asks for the chief complaint and the history is taken bedside

with both the nurse and physician.

• The lab would get backed up on blood work, often with only one lab tech

drawing blood. So, instead of paging the lab and having the tech walk in to

do blood work, nurses now do all routine blood draws, which has reduced

the time ordered to time reported from 35 minutes to 19.


• The computer system sometimes would indicate that an ED room was not

ready, even though the patient had been discharged much earlier. This was

the result of a workaround so nurses would not put patients in a room that

had not been cleaned, Colangelo says. But by simply adding a screen note

for rooms that are empty but need to be cleaned, the staff saved 10 min-

utes of wasted time by being more aware of which rooms were actually

ready.

In any process stream, improvement comes in managing and fixing many

small snags. The first step is to look at the stream, though. “It really is an amaz-

ing experience because we actually got to look at even the simplest things,”

Colangelo says.


In the first four years of Scripps’

move to Value by Design, most

of the emphasis has been on

the inpatient side, Van Gorder says.

Why? “Because revenue is

mostly on the hospital side,” he says.

“But we had the dialogue that if we

really wanted a robust healthcare

delivery system, we wouldn’t start

in the hospital. We’d start on the

ambulatory side, where most

healthcare is delivered.”

Even as the work started on

reducing waste on the inpatient

side, Scripps leaders hedged for an

ambulatory future. From a base of

only a half-dozen ambulatory sites a

decade ago, Scripps has more than

26 now, with property purchased

throughout the county for future

growth. In addition, two years

after the horizontal system leaders

were added, Van Gorder hired Anil

Keswani, MD, as corporate senior vice

president of ambulatory care and

population health management.

“I wanted a physician executive to

Drive for Population Health Through Primary Care Redesign


lead strategy and tactics to move the

organization into population health,”

Van Gorder says. “And every time

we’ve done something in the hospital,

we recognized it was eventually

going to shift into the ambulatory

environment.”

By the time Keswani started,

Scripps had already seen gains in

efficiency on the inpatient side, and

care navigators were starting to fill

gaps in the continuum, particularly

around areas like readmission that

were tied to reimbursement.

“When I came on, we had some

wildly successful programs, but we

also need to improve the primary care

design so that there is still a captain

of the ship,” he says. “So the last two

years have been heavily focused on

primary care redesign. One could

argue it’s really primary care design,

because we never really designed

things in the first place in healthcare.”

The goal was to “develop a team

around the primary care provider” to

help them manage patients, Keswani


says. “We purposefully steered away from the official medical home programs,

because the literature did not show improved value for patients.”

Siu Ming Geary, MD, a primary care provider and vice president of

ambulatory care at Scripps Clinic, says the redesigned care team consists of two

full-time physicians, one physician extender who is either a nurse practitioner

or physician assistant, plus a licensed vocational nurse. In a conventional PCP

model, the physicians and the extender each would have a panel of patients, but

in the Scripps care team, the extender spends 75% of the time seeing patients

who are part of the two physicians’ panels. The other 25% of the time is spent

“on population management, answering phone calls or returning messages.”

“We accomplish several things with this care team. One is that everyone

works at the top of their license,” Geary says. “What we find is that physicians

are much more efficient when they’re not interrupted multiple times during

the day doing things that could be potentially done by an LVN or a nurse

practitioner. The PCPs don’t have to wait until the end of the day to catch up,

which enhances both physician and staff satisfaction. And there’s significant

decrease in turnaround time for messages, forms, or orders.”

New teams needed new standardized work and communication, as well. The

standard work sets designate certain kinds of patients to be seen by physicians

and other kinds to be treated by the nurse practitioner. The care team holds a

huddle every morning to review the day and make any necessary adjustments to

get patients in.

Geary says this care team improves patient flow over the standard team of

one nurse and one physician.

“If you have one physician and one nurse, the nurse is managing patients,

but they also do your phone calls, they do your messages. They may do your

authorizations. If they’re busy doing something and it has to be done, they can’t

get on to the next patient,” Geary says. “That is a blockage that can follow you

the rest of the day.”

“WE ACCOMPLISH SEVERAL THINGS WITH THIS CARE TEAM. ONE IS THAT EVERYONE WORKS AT THE TOP OF THEIR LICENSE.”

—Siu Ming Geary, MD, primary care provider and vice president of ambulatory care, Scripps Clinic


Keswani says he started the work knowing that the path to improved

patient care and access in primary care meant raising physician and staff

engagement. In his previous job, he had seen a transformation at Advocate

Health Care in Illinois that took physician satisfaction from the fourth percentile

to the 97th. He says he has seen the same upward movement at Scripps.

“Once the physicians know that you do care for them and you do genuinely

care for their needs and you’re willing to measure it and focus on it, they’re more

apt to want to do more than what you ask. We’ve built the model by asking

them what is going to work in terms of physician and staff engagement, and

then the metrics will come afterwards.”


For Further StudyLeadership at Scripps Health has developed a Value by Design program that improves clinical and operational processes and leads to improved outcomes. For further study, consider the following resources:

RESOURCE

GUIDE

Clinical Quality: Reassessing Care Metrics and Leadership Models

This piece is adapted from Senior

Research Analyst Michael Zeis’ piece

in the July 2014 HealthLeaders Media

Intelligence Report, The New Quality

Equation: Measuring Success and

Eliminating Waste.

Clinical quality is fundamental

to healthcare, and while that won’t

change, the industry itself is. Payers,

increasingly, are requiring better

clinical results in return for better

reimbursements. Providers, too, are

developing initiatives and incentives

around clinical quality processes and

outcomes. Technology offers more

ways to measure and communicate,

but it also can be a burden. And, of

course, there is continuing pressure

to control the cost of care, creating both challenges and opportunities for the

clinical team. The HealthLeaders Media survey on clinical quality uncovers some

areas where change is prompting rethinking and recalibration.

ACHIEVING CLINICAL QUALITY

SOURCE: HealthLeaders Media Intelligence Report, The New Quality Equation: Measuring Success and Eliminating Waste, July 2014

2%

15%

18%

35%

37%

40%

41%

47%

56%

None

Sufficient resources

IT/analytics skills

Effective care team communication

Integration of clinical data

Continuous improvement techniques

Physician support

Clinical staff support

Leadership support

Base = 404, Multi-Response

What are the three biggest contributors to the success your organization has experienced to date in achieving clinical quality?

http://www.healthleadersmedia.com/intelligence/detail.cfm?content_id=305915&year=2014











About the HostScripps Health is a $2.6 billion, non-profit

501(c)(3) healthcare system in San Diego,

California. Scripps treats nearly 500,000

patients annually through the dedication of

more than 2,600 affiliated physicians and

nearly 13,000 employees across five hospital

campuses, plus an ambulatory care network

of clinics, physicians’ offices, outpatient

centers, and home healthcare services.

The Scripps legacy of providing healthcare

services in San Diego originated in 1924,

when philanthropist Ellen Browning Scripps

founded Scripps Memorial Hospital and

Scripps Metabolic Clinic in La Jolla, California.

About UsHealthLeaders Media is a leading multi-

platform media company dedicated to

meeting the business information needs

of healthcare executives and professionals.

To keep up with the latest on trends in

physician alignment and other critical

issues facing healthcare senior leaders,

go to www.healthleadersmedia.com.

Vice President and PublisherRAFAEL [email protected]

Leadership Programs DirectorJIM [email protected]

Editorial Director EDWARD [email protected]

Managing EditorBOB [email protected]

Media Sales Operations ManagerALEX [email protected]

SponsorshipFor information regarding underwriting opportunities for HealthLeaders Media LIVE, contact [email protected] or 800-753-0131.

Copyright ©2014 HealthLeaders Media, 100 Winners Circle, Suite 300, Brentwood, TN 37027 • Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Strategies for Managing the Postacute EnvironmentThis piece is adapted from Senior Leadership Editor Philip Betbeze’s

September 5, 2014, online column. To see his weekly column, visit www.

healthleadersmedia.com/Leadership.

Managing the entire continuum of care may be beyond your organization’s

current capabilities, but that doesn’t mean you can’t try risk-based

reimbursement through Medicare’s bundled payment program. Hospitals and

health systems at the vanguard of managing a patient’s entire spectrum of

healthcare needs are few. Years of fee-for-service reimbursement combined

with a desire to focus on their core competency has left many hospitals and

health systems without owned components for managing the post-discharge

experience for patients.

www.healthleadersmedia.com

mailto:pmattioli%40healthleadersmedia.com?subject=

http://www.healthleadersmedia.com/enewsletter-308105/Strategies-for-Managing-the-PostAcute-Environment.html




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HealthLeaders Media LIVE at Scripps Health Value by Designlive.healthleadersmedia.com/.../resources/...at_Scripps_Case_Study.pdf · Case Study // LESSON 1 ... Scripps Health’s shift