Providence Regional Medical Center in Everett, Wash., is one of those rare hospitals that doesn't lose money on Medicare patients. Providence breaks even on them, even though its regional payor for Medicare pays about $1,000 less per enrollee than the national average.
Tom Brennan, vice president of service line and business development at Providence, explains how the hospital keeps costs in check.
Q: Can you explain how you keep costs down?
Tom Brennan: Our mantra is, "How can we do it better?" We are constantly trying to improve performance and utilize a variety of approaches. One way is by hosting Kaizen events [a Japanese method that brings together everyone involved in an intense debate on an improvement issue]. For example, we recently held a five-day Kaizen event with community physicians and other caregivers to find ways to better manage patient handoffs and coordination of care. It gave people a chance to really question how they do things.
We have really tried to think through what information should be collected from patients and when. For example, hospitals are always asking the patient for the same information, again and again, at various points of care. We tried to come up with ways to hold on to previously collected information and pass it on to the next caregiver rather than collect it again.
Another project came out of a Kaizen "workout" that brought multiple organizations together to examine care processes for heart attack. We found that information could be gathered earlier in the process. The EMT arriving first at the scene of a heart attack could ask most of the questions that the cardiologist would have to ask when the patient finally arrived at the hospital. We could provide a standard template for the EMT to collect it. Having easily retrievable information before the patient arrives at the hospital will speed up care. A few minutes of time can mean the difference between life and death.
Q: Providence has only 80 employed physicians while the other physicians on staff are essentially free agents. How do you persuade these physicians to align with the hospital?
TB: Physicians are trained to care for individual patients and don't think in terms of patient populations. They need to connect the dots. It's easy for them to see how their practice benefits when they all work the same way. If you can bring the issue from "my practice" to "my group" to "my program," they are more likely to buy into proposed changes.
We also do a lot of collaborating with the Everett Clinic, an independent multispecialty practice with more than 220 physicians. Many years ago, the hospital and the clinic created a hospitalist program to help standardize care.
Q: Can you explain how Providence physicians standardize care?
TB: Standardizing care is a big part of making hospitals more efficient. If you have 16 orthopedic surgeons all doing hip replacements differently, the nurses and the scrub techs have to learn 16 different ways of doing it, which makes it almost impossible for them to get it right each time. The answer is to standardize.
Five years ago, the hospital developed guidelines to care for patients with deep vein thrombosis. Each physician had an opinion, coming from a particular professional society, so we had a lot of debate. It was clear that no one was going to get the exact protocol they wanted, but we were able to choose a protocol based on an open discussion that included every discipline involved in the care. Then we sent around drafts of the protocol for comment and made some modifications.
Now we have the protocol. Physicians can ignore it and do what they want to do, but that takes work. When a physician requests an order and deviates from the standard protocol, he or she has to explain why and identify an alterative therapy.
We also track utilization of the protocol. One high-volume physician did not buy into a certain protocol, so the section head and the chief medical officer sat down with him and asked, without defensiveness, "Tell us what we got wrong?" They had a good discussion, shared the data and the physician ended up adopting the protocol.
Q: Do you have new goals for standardization?
We want to consolidate volume for certain procedures among fewer surgeons so that they can gather more expertise. This is always a challenge for a community hospital, but we think in the long run it will be the right thing to do.
Q: One of your innovations is to keep post-op heart surgery patients in the same room, instead of moving them from the ICU to telemetry. What does this do for you?
TB: We found we were losing half a day of active therapy when patients were being moved from the ICU to the telemetry unit. So we wanted to see if it was possible to shorten the lost time by combining the ICU and the telemetry unit. Patients would stay put and the therapy for them would change, based on their progressing needs.
This meant making some fundamental changes in the ICU. For example, the halls had to be wider so that telemetry patients could walk around for rehabilitation. You can't easily do that in an existing facility. And the ICU nurses had to be cross-trained in telemetry, which meant taking on more ambulation work and learning discharge planning and education, which is what telemetry units do.
This change took three years of planning, including site visits to other institutions that had already made these changes and waiting for new space to open up in the hospital. When our women and children's unit moved to new space in 2002, we could gut the old space and built a new 15-bed unit.
It was well worth the effort. Length of stay for heart surgery patients has dropped by half a day and patient satisfaction is off the charts. We are routinely place among Press Ganey's top 10 percent of hospitals for patient satisfaction.
Q: What are you doing to control readmissions?
TB: We noticed that a lot of readmissions come from nursing homes. So physicians from our heart failure and heart surgery programs decided to go to the nursing homes and tell the staff what to expect with newly discharged patients. When they know what to expect, they do not panic and readmit the patient at two in the morning.
We also try to make sure that patients don't have acute episodes that would require readmission, such as fluid in the lungs for heart failure patients. To prevent this, we have outreach programs making sure these patients are taking their medications and checking their weight.
Q: What are some of your other innovations?
TB: We have worked hard over the years on projects involving glucose management and blood utilization. Through a data-driven process involving many disciplines, we evaluated blood utilization patterns of patients in the OR, in the units and prior to discharge to see if there was a way to reduce transfusions and use of blood products.
Over time we developed outpatient preparatory protocols and added an in-house expert, continuing to collect data and review processes. As a result, less than 15 percent of our open-heart patients are transfused or receive blood products. Now we’re applying the same principles to orthopedics.
Learn more about Providence Regional Medical Center Everett.