Many are talking about the need for physicians and hospital leaders to collaborate to improve quality and reduce cost but the real question is: In what ways is it being done successfully? Are the right questions being asked? Regardless of the organization's current profitability, healthcare leadership and physicians should be asking themselves:
1. How will the hospital and physicians build a close, collaborative working relationship?
2. What meaningful data is needed to drive evidence-based decisions?
3. Do we have a methodology that invites innovation, streamlines efforts and produces results quickly?
4. Is our approach to change aggressive enough to tackle the tough issues and hold each other accountable to the outcomes?
5. Are we positioned to manage global payments and incentivize physicians?
There is a sense of urgency to move forward with strategies that will target the priority areas of opportunity and yield results quickly. Since Congress enacted the Patient Protection and Affordable Care Act in 2010, hospitals have known that they must reduce their costs and improve quality. The law requires Medicare to enact value-based purchasing, which rewards high-quality providers, and cut payments to encourage efficiency. And where Medicare goes, its almost certain commercial payors will eventually follow. In addition, the law also creates certain programs that promote financial integration of hospitals and physicians through global budgeting. All of this creates a big challenge for hospitals — they must improve quality. Yet, physicians, not hospitals, direct care and control a large portion of quality and cost. This means hospitals must work closely with physicians in any and all improvement efforts.
One strategy that addresses the national imperatives and offers answers to the five questions above is something we at Verras refer to as physician-directed, data-driven best practice improvements. This approach targets clinical variation and enables hospital leaders and physicians to make data-driven decisions that optimize quality care and reduce costs.
Strengthening relationships between physicians and hospital leadership
Any effort of this nature must have the goal of enhancing collaborative working relationships between physicians and hospital leadership. It can include strategic planning and scenario analysis with all involved knowing the goal is to combine expertise and knowledge to innovate. The approach has to include physicians and hospital leaders together from the beginning and throughout a change process. Trust in the team approach and a group commitment to make needed changes will motivate involvement and change.
Paul Summerside, MD, MMM, CMO of BayCare Clinic in Green Bay, Wis., explains that physicians need to be held accountable for taking part in quality improvement. "We provide a tremendous amount of scenario analysis. Our CEO does business strategy with every department every year, and we as administration have a consulting mentality," he says. "The challenge is getting it done without forcing people to do it. Rely on them to make the right decisions based on this data, and if they don’t move on it, then as a last resort, we call them on it and hold them accountable. If you make the hypotheses that you have motivated physicians, and you make the information clear, they will then do the right things, sometimes even better. At the end of the day, the CMO cannot do the work; you have to get the information to the ones doing the work so that they can do the work better. "
Meaningful data must be used to drive change
Healthcare leaders are inundated with all kinds of data. But is it useful and is it being used to drive change? Meaningful data that is evidenced-based, used to inform decisions and drive action is what is needed most. For physician directed, best-practice improvement, data is needed to identify clinical variation and the greatest areas of clinical and financial improvements. Then, data must be analyzed to identify best practices, and processes must be changed to adopt these best practices.
Using data to improve clinical guidelines and produce results quickly
After initial analysis, hospital leaders and physicians should use the data to adjust care processes so that cost and quality improvements are achieved. Many times physicians and hospital leaders have good intentions to address these issues but find them overwhelming. They often state that some of the issues uncovered have been around for a long time and they continue a trial and error approach to change. The results of this can be devastating because failed attempts can negatively impact working relationships and dampen the enthusiasm of those involved. Another risk is the length of time that it takes for results to be achieved, if at all. In today's environment, hospitals and physicians do not have 12 months or two years to initiate the changes and see results. Efforts must produce results within weeks of discovery.
Addressing variation begins with one-on-one physician meetings to build relationships, seek information and review data. In addition, order set content is reviewed and patterns of utilization identified. Often documentation issues are found and discussed. The alignment between the physician practices and the hospital operations is evaluated to clearly define what changes need to be made to reduce the variation. Then it is about executing strategies. This is difficult work as monitors are put in place and all parties assume their unique accountability in the variation. As changes are implemented, data can be rerun and feedback offered to evaluate the effectiveness of the change. This is key to keep people motivated and trusting of the process.
One consistent question comes up during this effort: Is it good to standardize practice to this degree? The answer is that both standardization and individualization of care is necessary to be successful. It is an ongoing dynamic to be managed. In addressing practice variation, it is critical that the physician be able to use his/her clinical judgment to individualize patient care and it is equally critical for that physician to be aware of best practices and apply that standard in his or her care.
"We are seeing a push under the guise of standardization. I consider standardization and commoditizing as the antithesis of what our patients want. They want personalized experience, as much as they can get it. Instead of standardizing practices, I prefer to think of it as optimizing processes," says Dr. Summerside. "This allows high quality, while remaining nimble.
Sustainable outcomes and accountability: Tackling tough issues
Capturing and communicating outcomes breeds a culture of accountability. The commitment to change has to be present, then action must be taken, and results reviewed.
This monitoring and reporting requires tenacity and determination. The human tendency is to revert back to old habits and practices in the midst of ongoing changes or external pressures. And if there is no feedback or data that communicates how we are doing the gains are at risk. Successful implementation does depend on the aggressiveness and ability of leadership and physicians to tackle those tough issues that have newly developed or have been looming for years.
People have to be held accountable and cannot choose to opt out of involvement while others work to improve outcomes.
"As a large specialty group we survey all obituaries within about a 50-mile radius and cross-reference with our clinic registration. Anyone that died within 30 days of being seen, the cases are pulled and reviewed by the department. Every month, we find an unexpected result and learning experience that we would not have found,” says Dr. Summerside, who offers this as an example of an activity that he and his team have committed to doing.
Laying the foundation for the future
This kind of effort is needed in all hospitals and physician practices today just to be accountable for the care being delivered to patients. Leaders have a responsibility to make evidenced-based decisions and changes that improve quality and decrease cost in preparation for what is to come in healthcare. No one has to start from scratch with improvements. No hospital or physician has to feel overwhelmed in the process. Tools, like those offered by Verras, can accelerate results and also lay the foundation for physicians and hospitals to innovate ways to manage global payments and incentivize physicians.
In an article previously published in Becker's Hospital Review, Bill Mohlenbrock, CMO of Verras, explains how global payments offer opportunities for hospitals, but can be problematic if payment distribution isn't managed properly "Under global payments, hospitals receive a single payment that administrators will be compelled to share with physicians. Unless these financial distributions are objective, transparent and prospectively designed to reward physicians for high quality, cost efficient care, the potential for acrimonious hospital-physician relations are significant," writes Dr. Mohlenbrock. "However, when astute community hospitals, health systems and physician groups properly prepare themselves for global budgeting, their hospital-physician relations will actually be enhanced through financial rewards generated by effective clinical and operational efficiencies."
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1. How will the hospital and physicians build a close, collaborative working relationship?
2. What meaningful data is needed to drive evidence-based decisions?
3. Do we have a methodology that invites innovation, streamlines efforts and produces results quickly?
4. Is our approach to change aggressive enough to tackle the tough issues and hold each other accountable to the outcomes?
5. Are we positioned to manage global payments and incentivize physicians?
There is a sense of urgency to move forward with strategies that will target the priority areas of opportunity and yield results quickly. Since Congress enacted the Patient Protection and Affordable Care Act in 2010, hospitals have known that they must reduce their costs and improve quality. The law requires Medicare to enact value-based purchasing, which rewards high-quality providers, and cut payments to encourage efficiency. And where Medicare goes, its almost certain commercial payors will eventually follow. In addition, the law also creates certain programs that promote financial integration of hospitals and physicians through global budgeting. All of this creates a big challenge for hospitals — they must improve quality. Yet, physicians, not hospitals, direct care and control a large portion of quality and cost. This means hospitals must work closely with physicians in any and all improvement efforts.
One strategy that addresses the national imperatives and offers answers to the five questions above is something we at Verras refer to as physician-directed, data-driven best practice improvements. This approach targets clinical variation and enables hospital leaders and physicians to make data-driven decisions that optimize quality care and reduce costs.
Strengthening relationships between physicians and hospital leadership
Any effort of this nature must have the goal of enhancing collaborative working relationships between physicians and hospital leadership. It can include strategic planning and scenario analysis with all involved knowing the goal is to combine expertise and knowledge to innovate. The approach has to include physicians and hospital leaders together from the beginning and throughout a change process. Trust in the team approach and a group commitment to make needed changes will motivate involvement and change.
Paul Summerside, MD, MMM, CMO of BayCare Clinic in Green Bay, Wis., explains that physicians need to be held accountable for taking part in quality improvement. "We provide a tremendous amount of scenario analysis. Our CEO does business strategy with every department every year, and we as administration have a consulting mentality," he says. "The challenge is getting it done without forcing people to do it. Rely on them to make the right decisions based on this data, and if they don’t move on it, then as a last resort, we call them on it and hold them accountable. If you make the hypotheses that you have motivated physicians, and you make the information clear, they will then do the right things, sometimes even better. At the end of the day, the CMO cannot do the work; you have to get the information to the ones doing the work so that they can do the work better. "
Meaningful data must be used to drive change
Healthcare leaders are inundated with all kinds of data. But is it useful and is it being used to drive change? Meaningful data that is evidenced-based, used to inform decisions and drive action is what is needed most. For physician directed, best-practice improvement, data is needed to identify clinical variation and the greatest areas of clinical and financial improvements. Then, data must be analyzed to identify best practices, and processes must be changed to adopt these best practices.
- Initial analysis. Healthcare leaders should begin by providing physicians with an initial analysis of quality and cost performance by Diagnosis Related Group and/or by practice and then provide regular reports so they can track any improvement or decline. We recommend the initial analysis include three years of data from all payors with all cases plotted in a way that physicians can easily identify best practice and outlier cases. Then, hospital leaders, working with the physicians, can identify which DRGs present the greatest opportunity. DRGs with the most variation that are also high-cost and high-volume are prime candidates.
- Determine the cause(s) of variation. Once the areas of opportunity have been identified it is crucial to do a deep dive to identify what is causing the clincal variation. This involves reviewing a statistically significant number of charts for each physician and identifying practice patterns of all the physicians involved in writing orders for those patients. All orders are reviewed, as they relate to consults, hospitalists and the attending physician. As patterns are identified, interviews are conducted with the hospital departments that also contribute to that issue. For instance, if duplicate labs are being ordered by the emergency and inpatient departments, the lab manager, inpatient unit and the ER representatives would all be interviewed to gain insight into the issue. Though this is a time consuming process it does provide the specific reasons for the variation and reveal the actions needed to improve the outcome. This offers the opportunity for physicians and hospital operations leaders to work together on resolving the issues.
A key factor in utilizing the data is to reveal the best practices of each physican and physican group. This acknowledges areas where patient care is being managed well and helps to set the bar internally for best practice. Therefore, data should be reported by revenue code, physican group and individual physician. The goal is to allow the physician to look at all of his or her cases and see the practice patterns that enhanced the care and patterns that impeded the care.
- Analyze data for homogenius patient populations. It is important to utilize the best practice approach in a homogenious patient population when interpreting the data. This will take the concerns of comparing very ill patients to less severe patients off the table. From this level of data the specific actions that are causing the best practices and outliers can be identified. The following illustration is an example of specific findings for a specific patient population.
It is apparent that to address the patterns in the outlier patients clinical leaders and departments must work in tandem with the physicians. As physicians and clinical leaders review the data, each will see ways to address it. "Surgeons, for example, will be more nimble at looking at evolving technologies, business challenges, etc., if they feel personally connected and able to make day-to-day decisions within their timeframe," says Dr. Summerside.
- Review data in a one-on-one setting. It is critical that the data not be used in punitive ways. This process will fail if physicians feel like they are being judged or put on the spot with the data. In fact, the experience in hospitals conducting this work has been very positive, as most physicians and leaders want to see the data and be a part of making the changes.
Using data to improve clinical guidelines and produce results quickly
After initial analysis, hospital leaders and physicians should use the data to adjust care processes so that cost and quality improvements are achieved. Many times physicians and hospital leaders have good intentions to address these issues but find them overwhelming. They often state that some of the issues uncovered have been around for a long time and they continue a trial and error approach to change. The results of this can be devastating because failed attempts can negatively impact working relationships and dampen the enthusiasm of those involved. Another risk is the length of time that it takes for results to be achieved, if at all. In today's environment, hospitals and physicians do not have 12 months or two years to initiate the changes and see results. Efforts must produce results within weeks of discovery.
Addressing variation begins with one-on-one physician meetings to build relationships, seek information and review data. In addition, order set content is reviewed and patterns of utilization identified. Often documentation issues are found and discussed. The alignment between the physician practices and the hospital operations is evaluated to clearly define what changes need to be made to reduce the variation. Then it is about executing strategies. This is difficult work as monitors are put in place and all parties assume their unique accountability in the variation. As changes are implemented, data can be rerun and feedback offered to evaluate the effectiveness of the change. This is key to keep people motivated and trusting of the process.
One consistent question comes up during this effort: Is it good to standardize practice to this degree? The answer is that both standardization and individualization of care is necessary to be successful. It is an ongoing dynamic to be managed. In addressing practice variation, it is critical that the physician be able to use his/her clinical judgment to individualize patient care and it is equally critical for that physician to be aware of best practices and apply that standard in his or her care.
"We are seeing a push under the guise of standardization. I consider standardization and commoditizing as the antithesis of what our patients want. They want personalized experience, as much as they can get it. Instead of standardizing practices, I prefer to think of it as optimizing processes," says Dr. Summerside. "This allows high quality, while remaining nimble.
Sustainable outcomes and accountability: Tackling tough issues
Capturing and communicating outcomes breeds a culture of accountability. The commitment to change has to be present, then action must be taken, and results reviewed.
This monitoring and reporting requires tenacity and determination. The human tendency is to revert back to old habits and practices in the midst of ongoing changes or external pressures. And if there is no feedback or data that communicates how we are doing the gains are at risk. Successful implementation does depend on the aggressiveness and ability of leadership and physicians to tackle those tough issues that have newly developed or have been looming for years.
People have to be held accountable and cannot choose to opt out of involvement while others work to improve outcomes.
"As a large specialty group we survey all obituaries within about a 50-mile radius and cross-reference with our clinic registration. Anyone that died within 30 days of being seen, the cases are pulled and reviewed by the department. Every month, we find an unexpected result and learning experience that we would not have found,” says Dr. Summerside, who offers this as an example of an activity that he and his team have committed to doing.
Laying the foundation for the future
This kind of effort is needed in all hospitals and physician practices today just to be accountable for the care being delivered to patients. Leaders have a responsibility to make evidenced-based decisions and changes that improve quality and decrease cost in preparation for what is to come in healthcare. No one has to start from scratch with improvements. No hospital or physician has to feel overwhelmed in the process. Tools, like those offered by Verras, can accelerate results and also lay the foundation for physicians and hospitals to innovate ways to manage global payments and incentivize physicians.
In an article previously published in Becker's Hospital Review, Bill Mohlenbrock, CMO of Verras, explains how global payments offer opportunities for hospitals, but can be problematic if payment distribution isn't managed properly "Under global payments, hospitals receive a single payment that administrators will be compelled to share with physicians. Unless these financial distributions are objective, transparent and prospectively designed to reward physicians for high quality, cost efficient care, the potential for acrimonious hospital-physician relations are significant," writes Dr. Mohlenbrock. "However, when astute community hospitals, health systems and physician groups properly prepare themselves for global budgeting, their hospital-physician relations will actually be enhanced through financial rewards generated by effective clinical and operational efficiencies."
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Getting Ahead of the Curve – 12 Weeks to Evidence-Based Best Practices