“Improving value” in health care is a vague and opaque concept. Frontline clinicians, while generally supportive of the goals of improving quality and reducing cost, struggle to identify how the current emphasis on value is relevant to their daily clinical practice. Yet these frontline staff are best positioned to recognize opportunities to reduce waste and improve care. Centralized data and high-level strategy are too blunt to discern where there is real and harmful waste. Clinical context is critical.
At Brigham and Women’s Hospital, we launched the Brigham Care Redesign Incubator and Startup Program (BCRISP) to take a grassroots approach to care redesign. We asked our 5,000-plus doctors, nurses, physician assistants, pharmacists, and other clinical staff where they saw inefficiencies and poor outcomes, and how they would improve the situation.
BCRISP is structured like a venture capital fund, with the goals of engaging our clinicians, capitalizing on their knowledge and experience, spurring rapid piloting of proposed ideas, and scaling and sustaining projects that demonstrate results. We thought that by focusing on quick results, reinvesting in projects that show value, and offering central support and guidance, we could best address the challenge of sustaining innovations.
At the launch of BCRISP in 2013, we sought as many initial ideas and proposals as possible, requesting only a short description of the problem and solution, rather than a detailed business plan. A key part of each submission was a rough return on investment (ROI) calculation. We believed that one reason many clinician-driven pilots failed to translate into sustainable initiatives was that clinical-minded leaders often did not consider the financial implications of a project until late in the process. Budget requests at that point were usually unexpected by the finance office. What’s more, proposals often were not designed in the most cost-effective manner, since costs had been an afterthought.
We were conscious of the danger that the ROI requirement could constrain innovation. Our definition of financial return was broad, considering dollars saved for society as a whole, patients, payers, and our internal stakeholders. We did not overtly prioritize cost control over revenue growth, or the reverse. Our insistence on ROI likely closed off some truly novel, blue-sky approaches to care redesign. But we reasoned that if these ideas were inconsistent with Brigham and Women’s existing strategic and financial foundation, they would not be sustainable within our organization, and pilot projects would simply be an exercise in frustration.
The short written proposals were reviewed by a committee of senior leaders, including health system senior VPs, Chief Medical Officers, and financial and clinical leaders. We asked the committee to identify pilots that would improve care and were also consistent with our organizational strategy. In sum, by requiring that initial proposals include a clear delineation of both clinical benefit and financial effect, BCRISP highlighted these aspects up front.
Teams that were named semifinalists were asked to pitch their projects to senior leaders in a “Shark Tank”–style event. Based on these presentations, we identified projects for further investment. The pilot teams presented their interim results five months later, and their final outcomes 10 months after selection. At each event, the senior leadership review committee was encouraged to ask probing and difficult questions of the teams. Together we worked to hone projects to most effectively deliver results for our patients.
Several challenges remain. As with most provider organizations in the United States, our payment models are mixed, with emerging arrangements that reward value, but a substantial percentage still focused on traditional fee-for-service. Additionally, we have historically considered our cost base as relatively fixed. Reducing unnecessary utilization may not generate much internal cost savings in the short term.
Still, by engaging frontline clinicians and senior leaders in discussions of both the clinical and financial issues surrounding care improvement, and by putting real money behind good ideas, we believe we have been largely successful in identifying, supporting, and sustaining innovation in clinical care delivery. To date, BCRISP projects have delivered an estimated $4.5 million in annual total medical expense reduction, with 165 proposals leading to the implementation of 25 pilots across 3 cohorts. Of the 25 pilots, only 3 have been discontinued in the three years since we started the program.
Our experience shows that structured support for grassroots clinical innovation is key to delivering better outcomes for our patients. We hope that BCRISP will help to identify the Facebook or Uber of care redesign.
This blog post originally appeared in NEJM Catalyst on May 19, 2016.