The “Give a Darn” Method for Outcomes Measurement

Interview · February 8, 2018

Amy Compton-Phillips and Tom Lee head shots

Thomas H. Lee, MD, interviews Amy Compton-Phillips, MD, Executive Vice President and Chief Clinical Officer for Providence St. Joseph Health.


Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with Amy Compton Phillips, the Executive Vice President and Chief Clinical Officer for Providence Health and Services and the Theme Leader of NEJM Catalyst Care Redesign. In my opinion, one of the great leaders in health care today, she has been doing cool, creative things, first at Kaiser and now for the last few years at Providence St. Joe’s. Amy, you’ve taken the concept of value, stuff that people like Michael Porter and I write and talk about, and you’re actually doing it. Thanks for taking the time today to talk to us about the program you been creating.

Amy Compton-Phillips:  I appreciate the opportunity. Thanks, Tom.

Lee:  First, to tantalize our audience, tell me something that you’re really, really proud of, something specific that you feel is completely cool [and] that’s going to make me jealous.

Compton-Phillips:  Can I cheat and have a two-part answer to that question? Because something that we should be proud of at Providence St. Joseph is the environment, and that environment is one that looks around at what health care is doing today and says, while we have medical miracles that abound, our ability to deliver those miracles for everyone in the country — whether you’re urban or rural or whether you’re rich or poor or whether you’re based in the north or the south — it’s not evenly distributed. Because we have not really solved for that, Providence St. Joseph looked around and said, you know, we are an industry ripe for disruption, and how do we do that? How do we disrupt ourselves? How do we think differently about how to solve the problems in health care?

[We] started creating an environment that allows us to try different things, take risks, and think out of the box. We’ve been working with a lot of partnerships from outside of health care to say, let’s do the things that it takes to really mix up the way we are doing things. That’s part one, creating an environment that’s completely innovative, taking risks, while keeping excellent patient outcomes at the center and the heart of everything we do.

But the second half of the answer is that one of the key ways we are creating that environment is by leveraging data in different ways, and that’s by unlocking the secrets of the information that we all know that we have, but we haven’t been able to present in a way that is compelling. Part of that magic is we have great people now within Providence St. Joseph, including our Chief Medical Analytics Officer, Ari Robicsek. He’s this interesting combination of a physician data scientist — a data savant, who’s able to tease out information — and an artist who’s able to present information in a way that is compelling and tells a story. Because of that, we can get information back to clinicians and to caregivers in a way that helps them to see how they’re doing and what they’re doing.

And because nobody comes to work to do the wrong thing every day, when physicians and nurses see [that] what they’re doing has no judgement, that just illuminates their practice, you don’t have to tell them to change, you don’t have to ask them to change — they inherently want to do the right thing for their patients, and they inherently start doing the things to make their practice better. Having this this innovative atmosphere combined with a data structure and transparency that allows for change to happen has been a fabulous combination.

Lee:  Okay. You’re being effective. I am jealous. I’m sitting here thinking of my colleagues in Boston — we kind of invented the box or claim credit for it, and you’re going outside of it. You’re not only going outside of it, you’re organizing to go outside of the box systemically, whereas for us it’s sort of like occasional acts of creativity and rebellion. Tell me, how at Providence St. Joe’s are you organized to do this kind of innovation?

Compton-Phillips:  We have a clinical structure that is organized around care delivery, so we have traditional things like quality. But we also have our Chief Value Officer in the mix. We have our Chief Medical Analytics Officer who says value is exactly like you and Michael Porter told us ages ago now, and Elizabeth Teisberg told us, that value is outcomes over cost. We put a lot of thought into saying, what are the outcomes that matter to patients and how might we start measuring those? We have clinical institutes [where] we went to the clinicians who do our major kind of service lines/patient conditions — cardiovascular and cancer — so we went to the experts who work at our clinical institute and said, what are the outcomes that matter to you?

We use something called the “give a darn” test. What are the outcomes that your colleagues would care about if they were better than their neighbor? And what are the outcomes that your patients would care about if you were better than your neighbor? If a measure is in both those sets, then that’s an outcome that matters. So we’ve used our institutes to say what matters. We use our analytics to measure what matters and measure the cost, then we present that information back. That’s on the value side.

We also have an innovation infrastructure where we brought in a person who helped build the Amazon Kindle, a man named Aaron Martin, who said okay, how do we start adding things like digital into the mix and telehealth into the mix? And then we bought in a Chief Financial Officer from Microsoft who said okay, how does Microsoft and how does the tech industry use the information in different ways? We have been coming to innovation from the value framework on the clinical side but also combining it with tech thinking to come up with different kinds of solutions to solve for value. It’s been fun.

Lee:  All right, these “give a darn” measures that you alluded to, that was something that gave me a fit of jealousy when I first heard about it. Can you tell us a little more about it, and give us some examples and tell us about how you’re using this subset of measures that you’re classifying as “give a darn” measures?

Compton-Phillips:  Sure. Let’s take, for example, hips and knees, some of the classic things that every system is working on ever since the CMS pilots came out. There are a lot of measures that you can look at on whether or not you’re doing well with hips and knees, and it’s everything from length of stay, to infection rates, to revision rates, to all these inside baseball measures. And if you ask a patient why they get their hip replaced, they would very rarely tell you [it’s] to avoid a hospital readmission or to shorten my length of stay. Right? They want their function to be better.

We recognized — as did the International Consortium for Health Outcomes Measures — we said, okay, what is the world of measurement? Everything from what the American Orthopedics Association has on their list, that CMS has on their list, [to what] ICHOM has on their list, and we used that as superset to start narrowing down what the measures of the “give a darn” test would be.

The ones that passed the “give a darn” test were things like functional status, [and] infection rates made it in, length of stay made it in. It was really things that made a difference to patients’ outcomes that made it onto our short list. We then are able to display that in an index for that particular one. We roll it up into 100. We’ve asked the physicians in the institute to say, do we risk-adjust? If we do risk-adjust, how do we risk-adjust so that we can have comparable information?

Then we display that information in an unblinded fashion for the clinicians, and administrators supporting them, to compare how they’re doing in terms of both outcomes and cost compared to everyone else in our system. What that sets up is a learning system, because it turns out that there are some people doing well on outcomes and low on cost. The first stab we had at it was, oh man — should we fire all the bad doctors who are expensive with bad outcomes? But when you look at it, it turns out that it is not at all the case, because there are a lot of things that go into that mix. Part of it is indirect cost in one facility and high-cost area that had different overhead. We had to start teasing out, what are the things that are in the control of the clinicians and how do we just display that?

When you do that, and break it out into categories like length of stay, cost of supplies, and OR time, it turns out that no one physician, no one facility has everything nailed. Even though we have overall excellent people providing high-quality outcomes at a low price point, they might be particularly high in pharmaceutical costs and someone else is high in length of stay, and because length of stay contributes more to the cost structure, overall they’re more expensive. But there are still opportunities for everybody to improve. And what’s that done — being able to show this information without judgement, just for visualization purposes — it gets people talking to each other.

In our little beta test that we had of our system, all we did was show the information to our clinical leaders at our institute, and said here is your information, what do you think about it? Over the course of 2 months, they took $750,000 out of the cost of care and increased patient outcomes slightly, just by showing them the information. No physician likes being in the wrong part of that quadrant. Because they saw the areas they had the opportunity to do something different in, they started doing different things. They talked to their colleagues, figured out what it was, and were able to do it. It’s holding up a mirror where so often we don’t have a mirror in health care, to know what we’re doing and know what to change. When people have a mirror, they’re perfectly happy to do things differently if it makes outcomes better for their patients.

Lee:  My hope and fancy is that these “give a darn” measures are a path toward making measures not something that’s deadening for our physician colleagues, but that actually renews them and helps fight burnout resilience. Is that too optimistic?

Compton-Phillips:  I don’t think it’s optimistic at all, I think it’s realistic, and I think that’s exactly what our clinicians would tell you because they’re not being overwhelmed by minutia. They’re having the few things they care about and have tools to help do something about it. There is probably nothing more disempowering than being shown information and being held accountable without any actionable possibility to change it. In this case, they’re being empowered rather than being managed.

Lee:  That’s great. Now, you mentioned ICHOM, the International Consortium for Health Outcomes Measurement, and that’s the group that’s been pushing the concept of PROMs and standardizing them for some time. It started not far from where I see my patients in Boston, and you’ve gone and hired away some of its leaders. That tells me that you’re interested in PROMs. What’s your thinking these days about PROMs? Is it an idea whose time has come?

Compton-Phillips:  It’s absolutely an idea whose time has come. When you think about measures that matter, go back to that hip replacement that we talked about. What matters more than whether or not you can go up and down steps and walk your daughter down the aisle at a wedding or play golf again? I mean, that’s why people go to health care. You need to know whether or not life is better after going to health care and for that you have to ask the patient. We believe at Providence St. Joseph that it’s an idea whose not only time has come, but it should be the North Star guiding us in terms of determining whether or not the work we’re doing is adding value to our patients and the communities we serve.

Lee:  I’m thrilled that you’re doing this work and I don’t think I’m overstating when I say you’re not only providing a North Star for Providence St. Joe’s, but for the rest of the country as well, and I’m delighted that you seem to be having a great time while you’re doing it. I’m hoping we can keep checking in with you and that you will continue to have a steady stream of things that are going to make me and lots of other people health care jealous and inspired at the same time.

Compton-Phillips:  We hope that people come on the journey with us and that we can learn from them and they can learn from us, and together all of us will help make great care affordable and available for everybody in the U.S., because that’s the ultimate aim.

Lee:  Thanks so much, Amy.

Compton-Phillips:  Thanks, Tom, appreciate it.

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