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Leading Quality in Changing Times

Blog Post · May 31, 2017

Since the origin of the Hippocratic Oath, quality in medicine has focused on the individual abilities of practitioners to “use treatment to help the sick according to [their] ability and judgment.” America’s health care system has consequently evolved as a sick-care system — structurally, financially, and operationally supporting disconnected silos of physician practices, hospitals, and payers in a fee-for-service model.

This centuries-old model is finally beginning to shift. The last decade has seen a proliferation of health system leaders like me who carry the titles of Chief Quality Officer, Chief Clinical Officer, Chief Population Health Officer, etc., and are charged with helping their organizations redefine quality in health care. While responding to disease will always be important, many leaders recognize that we must purposefully shift from the siloed, fee-for-service world, through the present pay-for-value environment, ultimately landing in a place where America grades us more directly on how well we prevent disease rather than on how well we treat it.

In this brave new world of population health management — which for some is neither new nor brave — the following four organizing principles can help quality leaders (whatever their title) support their organizations through what is truly the greatest transformation since the days of Hippocrates.

Principle 1 — A consistent and connected enterprise-wide patient experience is becoming table stakes.

When my grandfather needed bypass surgery 20 years ago, I vividly remember my grandmother talking about how his surgeon’s bedside manner left much to be desired, even though that’s not what mattered most at the time. To quote directly: “He may be an [expletive], but he is a [expletive-ingly] good surgeon.”

Two decades later, it’s clear that technical prowess alone — be it that of a surgeon, a hospital, or a health system — is not sufficient to deliver on a population health vision of quality. Outcomes for post-op patients are highly dependent on what happens before and after their trips to the OR, and it’s impossible to define what continuum-level quality looks like without patients at the table. At Mission Health, we rely heavily on members of our Patient-Family Advisory Councils (PFACs) to inform this work. Our cardiac PFAC even told leadership to amend our CABG patient education pamphlets to explicitly say, “Heart surgery will hurt!” so that patients wouldn’t be surprised by their initial or ongoing (but improving) post-operative pain.

Creating a consistent, consumer-friendly experience across a disparate practice–to–hospital–to–post-acute–to–home enterprise is neither easy nor straightforward, but as a guiding principle it’s a no-regrets move toward delivering quality in a population health world.

Principle 2 — No matter what your title is, you can’t do this alone.

Whether you are a Chief Quality Officer, Population Health President, or Outcomes Czar, it is impossible to lead quality from the world of regulatory-required metrics into population health without incredibly deep and strong partnerships. This means no matter your role, you must have a tight alignment with hospital leaders (including the President/CEO, COO, CNO, and CMO); practice leaders (primary care and subspecialists); leaders from IT, finance, and HR; and the organization’s population health arm.

We’ve had to rethink how we approach everything at Mission from care management to clinical optimization — connecting teams beyond their traditional hospital, practice, or plan-centric structures, and implementing technological solutions to decrease the friction required to do so. For example, we’ve had to simultaneously speed up implementation of our care process models (clinical algorithms built into easy-to-use electronic medical record workflows) while diffusing them across a broadening network of employed, aligned, and completely independent practices.

These tasks are impossible to accomplish without widely patent arteries of communication. It is critical to ground population health management on the principles of open communication and alignment across entity and executive lines.

Principle 3 — A culture of continuous improvement lifts many boats.

Quality leaders must set audacious goals (e.g., zero preventable harms) and at the same time chart the path for clinicians and operational leaders to reach them. At Mission, we start each year at least $35 million in the hole because our input costs (e.g., labor, medical supplies, and drugs) rise significantly while reimbursement is essentially flat within a payer mix that is proportionally older, sicker, and less likely to be insured than state and national averages. Driving out that much cost year after year while simultaneously reducing harm can lead to change fatigue and clinician burnout, but it’s simply necessary to both survive and support our transformation to population health.

We’ve approached this challenge by giving frontline staff responsibility for owning our performance improvement (PI) and quality work. We have superb Lean experts, but like any limited resource, even PI can become a bottleneck. Our approach, called Mission: reNEW, gives nurses and other bedside providers the tools of continuous improvement. We ask them to identify hassles and barriers in their work and then facilitate their efforts to methodically improve processes, eliminate hassles, and achieve the ultimate goal of maximizing joy in the workplace.

A culture of continuous improvement is a truly powerful flywheel once it gets going. In partnership with vendors Standout (a strengths-based tool approach to driving improved communication and engagement within teams) and Life-XT (which provides tools and techniques to increase resilience and enhance personal well-being), in one year we drove out $32 million in operating inefficiencies, while simultaneously increasing the metric of fully engaged team members by over 100%. In the same period, we reduced inpatient “Harm Across the Board” (a metric from the Hospital Improvement Innovation Network) at the enterprise-wide level by 8%.

Principle 4 — Maximizing pay for value means tightly aligning metric programs across payer, entity, and provider lines.

The holy grail of our present pay-for-value environment is a parsimonious, all-payer, all-provider, clinically meaningful metric set. Since such a thing will never exist, I believe the best that quality leaders can do is strive to align programs as much as possible, engaging operational leaders and clinicians at an appropriately detailed level without overburdening them with hundreds of metrics.

At Mission, any time we have the option to choose metrics, we ground our choices first in what we believe matters most to patient outcomes, and then to what drives the most harmony in both metric definition and target achievement. Our internal incentive programs for providers and executives alike include measures that connect to mandatory pay-for-value metrics (e.g., ACO quality measures, CMS Value-Based Purchasing measures). In doing so, we can both track accountability for locally relevant outcomes (e.g., measuring neonatologists on the NICU’s CLABSI rates and individual practices on their practice-specific ACO outcomes) while rolling performance up to hospital, group, and enterprise levels.

At the same time, we’ve sought to broaden the metrics to which people are exposed to include population health measures. This represents a significant and uncomfortable change for many physicians, but is one clinical leaders and executives have faced for some time, as payers demand responsibility for outcomes that occur long after discharge. For example, we measure subspecialty practices on several population health measures that would traditionally fall only into primary care’s bucket, including asking orthopedists to address tobacco cessation and hospitalists to screen for depression.

The train delivering us into a world where quality is measured at the population level has long left the station. It is unstoppable, and that’s not a bad thing. To make any meaningful dent in America’s lagging public health outcomes and to ensure affordability for future generations, we must transform the way we pay for and provide health care. Physicians, hospitals, and health systems all face the enormous challenge of managing this transformation during a period of great uncertainty. Yet it is during these periods of uncertainty that leaders in any industry best prove their worth.


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