Improvement Project: A Heartcare Collaborative...Management explains; “A differentiation business model is based on pursuing a set of generic strategies that allows a company to

Improvement Project: A Heartcare Collaborative

Portfolio Paper

Gretchen L. Blake

LEAD 585 Leading Quality Improvement Initiatives

Dr. Michael Corriere

Fall 2012

Gretchen Blake - LEAD 585 2

Abstract

As the landscape of healthcare has changed drastically over the last ten years in

particular, employing improvement methodology and quality tools to lead change is even more

important today as hospitals and other healthcare entities continually search for the most

effective tactics to drive better clinical outcomes while creating a competitive advantage; this

despite the challenges of increased consumerism in publically reported data and decreased

reimbursement for governmental pay-for-performance mandates. This paper will analyze Via

Christi’s Heart Care Process Improvement Team activities from the initial deployment in 2003 to

the current state and take the audience through the changes and challenges in driving improved

outcomes, decreased morbidity, mortality, hospital length of stay and readmission for cardiac

patients within our community.


Introduction: Via Christ Health

The largest provider of healthcare services in Kansas, Via Christi is a Catholic tertiary

health system that encompasses acute care, post acute care, behavioral heath, physician clinics,

home health, senior residences and other ancillary services that collectively employ over 10,000

employees with a history extending over 100 years when the early catholic ministries of the

Sisters of the Sorrowful Mother and the Sisters of St Joseph of Wichita formed St Francis

Hospital and St Joseph hospitals respectively. On October 1, 1995, the two ministries came

together to form Via Christi Health System which translates to “The Way of Christ”.

Via Christi sponsoring congregations Marian Health System and Ascension Health

encompass a rich catholic heritage that is guided by a strong mission statement as the foundation

for all of which we do; “Inspired by the Gospel and our Catholic tradition, we serve as a healing

presence with special concern for our neighbors who are vulnerable.” This is complimented by

our Core Values of Human Dignity – the recognition and sacredness or each person; Stewardship

as the responsibility to care for the resources that are entrusted to us and lastly, Excellence -

extending ourselves in outstanding services.

Situational Analysis: A Push for Quality

In 2002 cardiac outcomes data submitted to the Centers for Medicare and Medicaid

(CMS) suggested Via Christi’s mortality rate could be improved. In addition, this data also

indicated despite nationally accepted and published evidence-based guidelines for cardiac care;

our patients were not consistently receiving that care. Further, in 2003, market force began to

penalize hospitals who failed to publically report cardiac care and other lagging indicators

through 2% reduction in reimbursement for not participating in Core Measures disease-specific

measures. As other hospitals in the state were facing similar results, the Kansas Foundation for

Medical Care (KFMC), the states quality improvement organization (QIO) began to mobilize the


AMI and Heart Failure (HF) collaborative to address this disparity in care with all Kansas

hospitals encouraged to participate. It was quickly understood most hospitals within the Wichita

area were facing similar situations in caring for cardiac patients. Dr. Eric Peterson, a professor of

medicine in the division of cardiology at Duke University Medical Center and director of the

Duke Clinical Research Institute may have best summed up the disparity when he made the

following comment at the 2001 AHA Outcomes Congress; “It is disturbing to me that I can go

into McDonalds tomorrow, order a Big Mac and be assured that I will get ketchup in my bag

99% of the time. And yet, I can walk into a hospital with a heart attack and not be assured I will

get aspirin, heparin, and beta blockers. Something is very wrong here.”

As local hospitals became inspired to improve, each began requesting cardiologist to

become involved as a “champion” to participate in the KFMC collaborative, each were

approaching the same independent cardiologist who practiced at many of the competing hospitals

who finally asked the question; “Why can’t we all work together?” Initially each resistant, the

fundamental question became; could competing city hospitals work together to develop a

standardized approach and implementation of citywide methodologies to provide evidence-based

care to patients with acute myocardial infarction and heart failure across the city? Thus, the

Wichita Citywide Heart Care Collaborative was created.

A Shared Approach to Heartcare

Based on the fundamental question, in the fall of 2003, five hospitals joined together to

form the Wichita Citywide Collaborative with the goal to improve care for patients in the

community who present to hospitals with AMI and HF. The multidisciplinary team led by our

physician champion included bedside nurses, APRN’s, quality professionals, dietitians,

pharmacist and other ad hoc subject matter experts from each hospital. The framework for our


activities included the adoption of the Institute of Healthcare Improvement (IHI) model for

improvement using rapid deployment of a series of PDSA cycles (www.ihi.org).

As hospitals began to explore where to begin improvement activities, we realized not all

were organizationally the same; some had emergency departments, others did not, some offered

open heart surgery, others did not. In finding common ground, the initial focus became the

development of standardized physician order sets based on ACC/AHA Class I recommendations.

The order-sets highlighted appropriate interventions for implementation through a “checkbox”

series that made it quick and foolproof for selecting the evidence-based therapy and combined

AMI and HF care into one set. In addition, discharge planning forms ensured all elements for

follow-up and the continuum of care were addressed and then complimented by a standardized

patient education booklets that were simplified concentrating only on the most important take-

aways with patient interaction and written at a sixth grade level to provide the greatest

opportunity for understanding often complex and overwhelming foreign jargon and instructions

for care. Physician compliance was also enhanced by incorporating guidelines into practitioners'

daily workflow needs, providing prompt feedback on their performance, incorporating their

suggestions made at the point of care, and using process measurements.

Initially unfunded, the collaborative work was cooperatively accomplished through

innovation and a shoe-string approach. Eventually, the team was able to secure a restricted

educational grant from two pharmaceutical companies who focused on cardiovascular

medications and allowed the collaborative to professionally print the educational booklets

designed by the team (See Figure A; Citywide Collaborative Tools).

Throughout the 18-months of intensive use of PDSA cycles of change, the team utilized

the goal of continually asking; “What can we change by next Tuesday?” The goal was not to


collect loads and months of data; small snapshots were collected to see if changes being made

during the PDSA cycles were leading to improvement – which may or may not have been

statistically significant, yet were clinically relevant. The ongoing data submitted to CMS was

then monitored through annotated run charts to trend over time and understand if this change was

sustained improvement with the use of the tools being tracked for compliance. In addition, all

tools utilized contained the Wichita Citywide Collaborative logo so everyone knew these tools

were evidence-based and approved for use by each Medical Executive Committee and Board of

Trustees. The combined efforts of the collaborative and use of the tools yielded much greater

compliance than any one hospital working alone. The mantra was – regardless of which hospital

you sought cardiac care in the community, patients would receive the same level of evidence-

based care shown to dramatically improve outcomes and decrease the likelihood of readmission.

This is not to say that change came easily or without frustration and long hours, in fact,

even communication was at times challenging; we joke that it even took several PDSA cycles to

figure out how to effectively communicate and send emails. Yet, in the end, all five hospitals

experienced significant improvement in Core Measure data and realized that despite being in

competition for volume, our goal was the same – to provide the best care possible for our

patients in the community (Figure B: Core Measures Data; Figure C: John Eisenberg Award).

Fast Forward Ten Years

Moving into the next decade in which over 10,000 baby boomers become Medicare

eligible every day, Via Christi realized the environmental constraints facing healthcare

throughout the United States. As the community continues to age and the need for services grows

exponentially, there is a tremendous strain on the system which translates to more expensive

rates for individuals, businesses who provide healthcare benefits, the government and healthcare


providers who despite the efforts over the last 10 years to increase compliance with Core

Measures, we continued to lag. Interestingly, the United States spends more money per person

on healthcare in the world, yet U.S. residents do not live any longer nor experience better

outcomes as a result of the increased care. This means as a healthcare provider, we are

challenged to find a way to meet increased demands with better quality care at a lower cost.

In addition to a customer need business model, Via Christi understood the need to focus

on implementing distinctive competencies and differentiation as a strategy. As the text Strategic

Management explains; “A differentiation business model is based on pursuing a set of generic

strategies that allows a company to achieve a competitive advantage by creating a product that

the customers perceives as different of distinct in some important way” (Hall, p. 166, 2010). For

Via Christi, this means we must excel in providing quality care and outcomes publically reported

on such websites as the Centers for Medicare and Medicaid’s (CMS) Hospitals Compare.gov

site, The Leapfrog Group or the Commonwealth Funds Why Not the Best.org consumers are able

to shop for which hospital they would like to use much like such organizations as Consumer

Reports which rate products and services based on established criteria. For healthcare

organizations which are highly regulated by the government and other authorities having

jurisdiction, this is relatively a new concept and with open insurance plans allowing a choice; it

is a game changer in the way hospitals perform. In fact, CMS now decreases the amount of

reimbursement by 2% for hospitals that fail to perform in the top 10th

percentile for evidence-

based care bundles for heart attack, heart failure, pneumonia, surgical site infection prevention

and readmissions within 30-days of discharge. By 2014, this decrease in reimbursement is

expected to be as high as 4% with mortality and other indicators being added. This is truly a

game changer for the healthcare industry and without rapid improvement and innovative


programs, many hospitals will find they cannot sustain and will close their doors to providing

care – unfortunately, many in areas that are rural and impose a community need. No longer is

healthcare a given; the shift is from pay-for-participating to one of pay-for-performance.

Higher Stakes: A Call to Action

Via Christi has been on a rapid course to redevelop the way it delivers care set to be

complete by the year 2020 and coined “Vision 20/20”. As an innovated and goal of integrated

healthcare organization and care team, the goal is to build healthier communities while

delivering quality and cost-effective services, it is the hope this will align and position our

organization to meet the continued challenges.

The cornerstone of this is through patient centered care in which the needs of those we

serve are at the heart of all activities and are clinician-led. In addition, part of the care model

includes clinical integration which means the purposeful coordination of care delivery that yields

a seamless experience for the patient and their family. In addition, Via Christi is committed to

delivering the safest and highest quality care aimed at the best value for population health – this

is built on delivering the right care at the right time in the right setting. As part of this service,

we extend this to our employees and physicians by striving to be the best place to work and to

practice medicine so that we share in our passion to the art and science of care. And lastly, we

strive to build healthier communities through models of best practice and evidence-based care.

To compliment the initial work done by the Citywide Collaborative, four core process

improvement teams have been created to drive the compliance to these evidence-based bundles

that have been shown to decrease morbidity, mortality, hospital length of stay and readmission

rates through the use of IHI’s model for rapid cycle improvement sprinkled with lean-six sigma

when indicated. With the creation of the branch of the process improvement department which


employs six-sigma black belts from manufacturing and aircraft industries, the partnership with

quality professionals and physician-led teams that include multidisciplinary subject matter

experts, we believe we will be able to sustain and hardwire the work through the use of process

improvement tools.

Performance measures are vital for any organization in driving process improvement.

Simply stated, if you don’t measure it, you cannot manage it – whether the “it” is a service or a

product, as our textbook indicates; measures that are based on useful statistics enable effective

organizations to define the meaning of success numerically (Summers, 2009, p. 250). Those

organizations who truly understand this use performance measures to align daily activities with

the strategic initiatives and plan at every level of operations. The balance of cost, quality features

and options with the availability of the product or service assists an organization with business

capacity, customer satisfaction and revenue.

Recommendations

Healthcare is certainly a focus for many and it is no wonder as it currently accounts for

nearly 12% of our national GNP with healthcare cost continuing to grow each year and which are

found in the three major sectors of our economy; public, non-profit and for-profit. In addition to

the sheer financial implications, there are the “social transformations” that are occurring at an

alarming pace as well as the many unique service lines that are present in healthcare (Starr,

1982). Organizations exist in an environment of rapid change, stringent regulations and

imminent healthcare reform. Take into account that most healthcare institutions do not employ

physicians, rather see them as customers; they face problems gaining input and involvement with

strategic planning. In addition, quality and patient safety expectations are continually increasing

and having the data necessary to drive improvement is often not available or is outdated and


limited. Lastly, strategic change frequently fails because individuals fail to adopt the behaviors

needed to successfully implement positive change. To tackle these challenges, my

recommendations are first, equip leadership with the skills necessary to adapt the change and

bring physicians to the table in partnership with executive leaders. Secondly, having data readily

available is key to the organizations ability to make changes that will lead to improvement and

the full integration of a single source electronic health record is vital.

My final recommendation is in terms of learning to deliver quality care at a lower cost;

specialized training in the methodologies of lean-six sigma and devoting resources to this branch

of service is fundamental and non-negotiable. Although a non-revenue producing department as

compared to traditional medical and nursing units, process improvement uncovers the dark green

dollars that naturally promote higher quality, better outcomes and patient safety.

Closing

With healthcare on the minds of most Americans, particularly within the political

landscape, governmental pressure and reimbursement tied to quality and patient safety, and

publically reported outcomes, healthcare organizations can no longer deliver “average” care.

Leadership will need to become fully engaged and allow appropriate resources to drive higher

quality, understanding that lower costs only come after resources and time are spent on creating a

culture in which excellence is weaved into the daily fabric of how care is delivered. This comes

from not only technology that is electronic, but also in the investment of lean six-sigma

methodologies, physician integration and ultimately, patient centered lenses. The next ten years

will no doubt be challenging and many hospitals may be forced to close their doors; the rest will

need place innovation as the cornerstone of how they conduct the business of patient care.


Figure A: Wichita Citywide Collaborative Tools


Figure B: AMI/HF Core Measure Compliance



Figure C: John Eisenberg Award


Resources Cited:

Schilling, L. (2009). Implementing and Sustaining Improvement in Healthcare. The Joint

Commission Accreditation of Healthcare Organizations.

Fox, J., et al (2006). A Cooperative Approach to Standardizing Care for Patients with AMI or

Heart Failure. Joint Commission Journal on Quality and Patient Safety; 32(12): 682-7

IHI Model for Improvement. Retrieved December 15, 2012 from http://www.ihi.org/knowledge

/Pages/HowtoImprove/default.aspx

Hill, C.L., Jones, G.R. (2010). Strategic Management: An Integrated Approach, Ninth Edition.

Houghton-Mifflin: Massachusetts

Summers, D.C. (2009) Quality Management: Creating and Sustaining Organizational

Effectiveness. Person Prentice Hall. Upper Saddle River, NJ.

Starr, P (1982). The Social Transformation of American Medicine: The Rise of a Sovereign

Profession and the Making of a Vast Industry. Basic Books.

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Improvement Project: A Heartcare Collaborative...Management explains; “A differentiation business model is based on pursuing a set of generic strategies that allows a company to