Care Redesign

Mission and Externalities: The Imperative for Prioritization

Article · September 19, 2018

One of the main problems in health care quality improvement is that we care too much. Almost to a person, those involved desire deeply to help all people who come to us for care. It’s an incredibly noble sentiment and one that’s a source of great strength for us as an industry. But it does make prioritization difficult. And difficulty with focus can make it difficult for an organization to succeed.

Choosing Organizational Priorities

Consider this example: A quality committee at your clinic or delivery organization is hearing proposals from two groups competing for the same resources. Group A would like to focus on optimizing atrial fibrillation treatment and anticoagulation, and Group B would like to focus on deploying a concussion management protocol. Sound familiar? We faced this discussion at a recent quality meeting.

Organizations face resource allocation and prioritization decisions on a daily basis. Sometimes the decisions evolve arbitrarily, as a result of the personalities involved and the flow of discussions at a particular meeting on one day. This leaves the organization with dozens of top priorities competing with one another for precious staff attention. One source of the chaos is that many of the decisions don’t explicitly consider the actual trade-offs being considered.

This lack of explicitness and certainty around the relative merit of options can make for a chaotic operating environment. As a natural consequence, many organizations evolve to letting the crisis of the day and marketplace forces determine their prioritization.

How many times have we heard that “we need to do this because it’s a part of MACRA” or that “this is a priority because it’s a CMS value-based purchasing initiative”? The dizzying array of external clinical metrics that are in the contracts held by organizations can leave clinicians and leaders whipsawed and confused when trying to focus organization effort. We call these external clinical metrics — those by which we are measured and over which we have no direct control — externalities, borrowing the term from economics. This externally fed frenetic energy is often unfortunate, as the focus of our people is our largest resource allocation decision.

Enter Mission and Externalities

Swedish Health Services is a nonprofit health care provider in the greater Seattle area with five hospital campuses, plus ambulatory care centers and a network of more than 100 primary care and specialty clinics throughout the greater Puget Sound area. Our mission is “to improve the health and well-being of those we serve.” Many health care delivery organizations have similarly phrased mission statements. We have found that trying to explicitly determine the amount of health and well-being created by a given program — an imperfect exercise to be sure — can be helpful in achieving a sense of the relative order of organizational priorities. We call that focus prioritization; we consider both the mission and the externalities.

Health Care Quality Improvement Prioritization - Keeping the Focus on the Union of Mission and Externalities

  Click To Enlarge.

In the above real-life example of atrial fibrillation versus concussion protocols, we prioritized by using the mission and externalities framework and crunched some numbers. We found that we serve roughly 11,000 patients with atrial fibrillation in cardiology or in primary care who have atrial fibrillation on their problem list. Like other health systems described in the literature, we have significant gaps in our reliable assessment of stroke risk, and the stroke risk associated with atrial fibrillation can be significant.

Back-of-the-envelope math shows that we have significant opportunity to improve our care. In fact, we have approximately 1,000 patients with a CHA2DS2-VASc score of 2 or more who are not on anticoagulation and thousands more who don’t even have a structured assessment of their stroke risk. The absolute risk reduction for anticoagulation therapy can range from 2% to 10%. Optimizing anticoagulation in patients with atrial fibrillation could prevent maybe 200 to 300 strokes per year.

Post-concussion care is important, but carries a lower burden of illness. According to our internal data, we see roughly 600 patients with concussion in our system per year. The literature-based opportunities to improve care of concussed patients are less clear. Here, an estimation of the upper bounds of an opportunity to improve concussion care is helpful.

For concussions to represent a better missional focus of effort — that is, that focusing effort in that area will better contribute to our mission — the opportunity to create health would require an intervention as powerful as preventing an illness as serious as a stroke in half the post-concussion patients, greater than the burden of disease in that population. Again, this is a first-order estimate, but challenging ourselves to move from the realm of opinion to the realm of data improves the quality of the resource allocation decision.

Looking at the relative consequences of focus on either atrial fibrillation or concussion care, neither one has direct impact from externalities for us. There are several measures in our Track 1 Medicare Shared Savings Program ACO that might benefit from a focus on atrial fibrillation, including an aspirin therapy for vascular disease metric and an all-cause admission metric for chronic conditions.

So, if we consider then the overlap of mission and externalities for atrial fibrillation and post-concussion care, we’d conclude that the missional focus on the health effects of atrial fibrillation quality improvement are likely greater than the concussion quality improvement. Similarly, the effect on externalities is relatively nil for both, but is likely more positive for atrial fibrillation. Prioritization using the mission and externalities framework can help clinicians and organizations make better, more rational resource allocation decisions.

Additional Considerations and Limitation

One caveat bears mention: Differing amounts of effort are required in various conditions to realize the changes in missional or externality effects. Some estimate of the effort is needed to make the proposed changes and is also required to have a rich dialogue.

There are limitations to this framework. First, there are inherent uncertainties in these estimates of missional or externality implications of various topics. Formal calculation of quality-adjusted life years, determination of marginal investment costs, as well as marginal returns on investment could be undertaken, but given the inherent uncertainties in the estimates, it’s not clear that the resources needed to formalize the estimates would lead to better decision-making.

Second, as different organizations have different missional goals, the relative ranking of different clinical priorities will differ from organization to organization. Similarly, the details of each organization’s financial situation potentially decrease the universality of the calculation of externalities across organizations.

Third, calculations based on maximizing utility for the greater good have an inherent tension with the interests of the individual patient, especially for low-volume conditions. A decision framework is best used only as a guide in a complex environment.

By application of a transparent and flexible prioritization framework to the myriad different competing priorities that beset clinicians and clinical delivery organizations, it is possible to achieve greater rationality and efficiency in the application of organizational resources. Ultimately, we can serve our patients better by maximizing the amount of good we are able to do for the populations of patients we serve.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Rural Health Care Is Rated Comparable or Worse Across Quadruple Aim Aspects

Care Redesign Survey: Lessons Learned from and for Rural Health

Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic density and resource availability, each locale affords lessons for the other.

Comprehensive Intervention Review at Lurie Childrens Hospital - improving patient flow and length of stay

Reducing Length of Stay in the ED

A comprehensive redesign of triage and ED care.

Pumonary Nurse Post-Discharge Follow-Up Note for Patients with COPD

TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System

A nurse-directed intervention targeting veterans who had been hospitalized for COPD resulted in improved access to ambulatory care and a reduced rate of readmissions.

RumballSmith03_pullquote personalized hospital ratings

Personalized Hospital Ratings — Transparency for the Internet Age

Patient user-determined weights could become a highly desirable feature of future hospital ratings.

Dispersion of Palliative Core Skills via a Train-the-Trainer Palliative Care Mentor Model

Back to the Future?

Restoring focus to palliative care through a train-the-trainer model for non-palliative care physicians.

Rosenbaum02_pullquote tailwinds

Twitter Tailwinds — Little Capsules of Gratitude

We would be remiss if we didn’t constantly and exactingly focus on addressing all of medicine’s shortcomings. But how to balance fixing what’s wrong with holding on to all that’s right?

Zane06_pullquote technology to save primary care

Embracing Technology to Save Primary Care

Adding providers won’t solve the health care crisis — but thoughtfully and deliberately deploying technology just might.

Griffin Myers Head Shot Oak Street Health

Rebuilding Health Care as It Should Be: Personal, Equitable, and Accountable

How Oak Street Health, a full-risk, value-based primary care model and social determinants practice, embeds itself in the community to keep its elderly population, “happy, healthy, and out of the hospital.”

Telemedicine Online Care Group Cleveland Clinic Express Care Online Quality Improvement - Next Steps

Ensuring Clinical Quality in Telemedicine

How Cleveland Clinic and Online Care Group designed a data-driven quality improvement telemedicine ecosystem.

Endless Forms Most Beautiful - Evolving Toward Higher-Value Care Cover Image

Endless Forms Most Beautiful: Evolving Toward Higher-Value Care

How Providence St. Joseph Health devised a Value-Oriented Architecture to guide physician practice.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Mental Health

29 Articles

Stay in Your Lane? Clinicians vs.…

Should physicians stay in their clinical lanes when it comes to behavior change and social…

Coordinated Care

126 Articles

Improving Care by Redesigning Payment

A state-run center of excellence uses benefit design to improve outcomes while controlling cost.

Primary Care

173 Articles

Care Redesign Survey: Lessons Learned from…

Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now