BY: MARK HAGLAND
Can faith-based hospitals and health systems continue to pursue intensive quality and patient safety improvement work during a time of recession and economic challenges? Absolutely, said the chief executives and chief medical and quality officers of three such health systems around the country. In fact, these Catholic leaders agreed quality improvement work and improvement in cost-effectiveness support each other because many initiatives that improve care quality and patient safety also improve the bottom line.
The executives, interviewed for this article, said they do this by reducing otherwise unprofitably extended lengths of stay — for example, those related to hospital-acquired infections — and they've got the results and the outcomes data to prove it. Further, they believe that the work they're doing in driving forward their mission-based quality care, while reducing operating costs, could provide insights to their peer organizations nationwide.
STRAIGHT-AHEAD PROGRESS IN CINCINNATI
Take for example Catholic Healthcare Partners (CHP), a Cincinnati-based health system. The 32-hospital Catholic group, with 36,500 staff across several states in the central and east-central U.S., was one of two Catholic health systems to be cited as Top 10 performers in the "Top 100 Hospitals: Health System Quality/Efficiency Benchmarks" study, announced from the business intelligence provider Thomson Reuters in August 2009. Thomson Reuters analysts use a balanced-scorecard approach that evaluates performance in the areas of mortality, medical complications, patient safety, expenses and five other clinical, financial and operational measures. See "Catholic Heathcare Partners: Strategic Planning in Light of the Recession," p. 32.
For Michael D. Connelly, president and chief executive at CHP, it was gratifying to receive such national recognition, especially when combined with the system's fifth-place ranking in 2008 in a national study by the Joint Commission comparing quality of care among 73 of the nation's largest health care systems. The Thomson Reuters designation validates the kind of work that Connelly and his colleagues are committed to day in and day out, he said. And when it comes to the current recession, he said, "The impact of the economy on our situation actually began five years ago."
"Keep in mind," he added. "We serve in Rust Belt communities like Scranton, Pa. and Youngstown, Toledo and Lima, Ohio, where there has been a steady manufacturing decline."
But a combination of intensive quality-focused work that also takes into account financial and economic realities has been a high priority for CHP leaders for years. As a result, he said, "When the stock market and financial system disaster hit in late 2008, it was just more of the same," economically speaking, for the regions in which CHP operates. In any case, he said, "We really believe that quality is actually more efficient" and that an operating model focused on quality while being cost-effective works very well for his health system.
What's more, said Stephen R. Grossbart, Ph.D., CHP chief quality officer, "If you look at what's happened in the past year with this recession, it hasn't stopped the progression toward more efficient and higher quality care delivery here at CHP. Just in the past year, our mortality rate has dropped 6 percent," the result of a strong initiative to lower that rate, focusing particularly on the early recognition of sepsis. Sepsis, he noted, accounts for up to one-third of occurrences of hospital mortality.
Indeed, Grossbart said, "Just by adopting evidence-based protocols for sepsis care, we've eliminated 107 deaths systemwide just since the beginning of the year." Further, the system regards length of stay not as an operational initiative, but as a quality initiative, recognizing that reducing patient safety events will help reduce length of stay. "And we've reduced length of stay by 3 percent this year systemwide," he said.
Clearly, this represents an improvement in patient safety, which is strongly tied to the health system's faith-based mission, while also improving its economic bottom line.
Finally, Connelly said, the system had invoked what he termed "educational collaboratives" as another major strategy. These collaboratives are multi-disciplinary initiatives around specific issues. The first was around prenatal safety in obstetrics. In that situation, clinician leaders from across the system met to discuss and adopt evidence-based safety standards for fetal monitoring procedures. In pursuing that initiative, system leaders brought in clinician experts on the issue of obstetrical prenatal safety, and those experts led discussions among the physicians and nurses in the obstetrical service.
This initiative, like several others at CHP, has involved the use of a special program called TeamSTEPPSTM, an evidence-based Department of Defense patient safety program developed in collaboration with the Agency for Healthcare Research and Quality. The use of TeamSTEPPSTM, along with the creation of a CHP Patient Safety Academy, Connelly noted, have been fundamental to several important strides in patient safety and care quality improvement systemwide.
What's more, he said, the strides made in holding down the cost per case across the system to a 1.39 percent aggregate growth between 2004 and 2008, even while the system's operating margin percent went from 2.9 to 1.2 percent, reflect the dovetailing of patient safety and quality improvement with work towards financial goals.
TRINITY HEALTH'S COMPREHENSIVE APPROACH TO CHANGE
The same can-do spirit appears active at Novi, Mich.-based Trinity Health, which owns 45 hospitals operating in eight states. Trinity Health, the other Catholic health system recognized among the top 10 highest-performing health systems in the Thomson Reuters study, has for several years been on an intensive quality and patient safety journey, noted Terry O'Rourke, MD, the health system's executive vice president and chief clinical officer, and Paul Conlon, Pharm.D., its senior vice president for clinical quality and patient safety respectively.
"Good, high quality care is also cost-effective care," O'Rourke said, echoing the sentiments of CHP's Connelly. "And the more that we can do to enhance quality and patient safety, the more cost-effective we can be, because some of the largest cost expenditures are related to patients' medical complications. So the degree to which we can eliminate some of those complications speaks not only to our mission and to our patients' benefit, but also to cost-effectiveness."
As for the recession, O'Rourke said, "This economic downturn has actually given us increased energy to do things we really needed to do, such as making our operating room environment more effective, efficient and productive. That has tremendous benefits for our nurses and surgeons and others, but [it] also has economic benefits along with that."
Indeed, one of many Trinity Health improvement initiatives — one that strongly combines patient safety and efficiency goals — has been in the operating room. O'Rourke, a former practicing surgeon, noted that Trinity Health had "looked at the accuracy of the preference-card system in our ORs, systemwide," referring to the kinds of systems all hospitals with operating rooms use to keep track of surgeons supply and other preferences. Trinity Health was already at 85 percent accuracy in most of its hospitals, but, as he pointed out, "That means that 15 percent of the time, the right surgical instruments were not all there, or instruments might have been opened unnecessarily." So Trinity clinicians and managers created an organization-wide program to improve accuracy. Since then the system's accuracy, facilitated by implementation of surgery information systems, has improved to 99 percent in most Trinity Health hospitals.
Not only are such results saving somewhere between $1.5 million and $2 million a year, they are enabling operating room nurses to spend more time with patients and less time tracking down missing instruments or doing paperwork to adjust for problems. In other words, efficiency and patient safety improvement often are one and the same.
More broadly, the staff at Trinity Health have already spent several years working to improve patient safety and care quality, while balancing those aspects of mission with the need to effectively steward resources. Among the key areas of progress has been the ongoing work to develop standardized workflow processes across the entire organization. In that quest, Conlon said, "We have several hundred protocols and alerts already in place."
Among the ostensibly simplest areas addressed is a systemwide initiative to eliminate patient falls. Another centers on urinary catheterization. Though a simple process, that procedure is responsible for a significant percentage of the hospital-acquired infections patients nationwide acquire every year. At Trinity Health, the organization's electronic medical record alerts nurses every 24 hours, querying whether every patient with urinary catheterization should continue to have the catheter kept in place. The simple act of asking nurses this question has led to a dramatic reduction in such infections, and not coincidentally, has helped save money by reducing lengths of stay extended because the patient acquired an infection (and which would not have been fully reimbursed).
What's more, Trinity Health's commitment to investing in clinical information technology, including electronic medical records and computerized physician order entry, has made it a model for health systems nationwide. The health sys-tem has used its clinical information system development to support and advance evidence-based medicine and reduce unnecessary variation across its many hospitals.
As for the recession, Conlon said, "The difficult economic time we find ourselves in really requires us to be very introspective about the changes that we do make. And in doing that and studying it, and not just reacting to the environment, you see different opportunities from what you might have seen otherwise."
In fact, he noted, "We stepped back a year ago and really started understanding some of the waste that we might have had in our system. And some of that waste turned out to be care that was not optimal."
SERVING SOME OF THE POOREST COMMUNITIES IN THE SOUTHWEST
At the Dallas-based CHRISTUS Health, balancing mission and margin has been a high-profile priority for years, noted Thomas Royer, MD, president and CEO, and John Gillean, MD, chief quality officer.
For one thing, the Catholic health system, with 22 acute-care hospitals in five states (plus a wide range of non-acute facilities and services, and several hospitals in Mexico), has its largest concentration of facilities in Texas, Louisiana and New Mexico. These states happen to have the highest percentages of uninsured people of any states in the U.S. As a result, CHRISTUS Health has had to work to offset the costs of providing significant amounts of uncompensated care in its emergency departments in core service areas.
Among these:
- A process for identifying high-risk patient safety areas, then collaboratively creating clinical protocols to address them and, finally, rolling out those protocols systemwide
- Appointing a corporate-led, system-wide quality team
- Developing a "navigator program" that helps patients with limited access to primary health care services and resources to navigate the health care system and obtain needed services
- Establishing a community-based chronic care management program
CHRISTUS Health is also proceeding apace with the opening of retail clinics in Walmart stores, with eight established so far in Texas and several more set for development in Texas and Louisiana.
Royer said, "We've reduced our costs by over $25 million in our system over the past year and a half" even as the organization has had to deal with the devastation of Hurricane Rita in 2006 and Hurricanes Ike and Gustav in 2008. Yet, he said, "We were able to provide $265 million in charity care in fiscal 2008 and $317 million as of June 30, 2009, because of our mission, to carry out the healing mission of Jesus and particularly to bring services to the vulnerable and underserved. And I can't think of any program that has been more focused on the underserved and poor in that region."
The bottom line? Careful and precise balance. "We believe that any organization that will survive will have to be a high-quality, low-cost provider," he said. "But we can't do that and walk away from our mission."
In fact, quality improvement is at the bull's-eye of the target when it comes to making changes in CHRISTUS Health operations, Royer and Gillean noted. Not only is quality improvement vital in and of itself, it also can reduce costs, sometimes quite significantly. As a result, they said, quality improvement is more important than ever during an economic downturn. CHRISTUS Health's work in the obstetrical area perfectly illustrates the contention, they said.
Clinician leaders have established an obstetrics program that requires all nurses to go through fetal monitoring certification, a process that dramatically reduces so-called "bad baby" malpractice cases. Creation of the program and the testing of all nurses systemwide took about 18 months.
The result? "We've gone from a peak of 23 'bad baby' cases a year systemwide several years ago to zero cases last year," Royer said. "And we had no dollar claims paid last year, something that is almost unheard-of."
Clearly, the economic return from this patient-safety-driven initiative has been substantial. But that's exactly what Royer and others interviewed agree on when they say that the current recession, rather than significantly hampering quality and patient safety efforts, is actually spurring initiatives that can both improve patient care quality and save money or make clinical care more efficient and cost-effective.
It might seem counter-intuitive to some, but becoming optimally cost-effective actually requires ongoing significant investment in information technology, noted George Conklin, senior vice-president and chief information officer of CHRISTUS Health.
"From Dr. Royer's perspective, we believe that health care is one of the most information-intensive industries in the world," Conklin said. "And as such, in order for us to be the high-quality, low-cost provider, we have to make the appropriate investment in information technology. So as a proportion of revenues, it's not a question for us of it being the highest or lowest percentage of organizational revenues, it's a question of it being the right percentage."
Conklin is helping to lead the implementation of clinical information technology across all of the system's hospitals. Not only does he believe full implementation will improve clinician efficiency; he and the other CHRISTUS leaders anticipate receiving federal funding available through the economic stimulus package passed by the U.S. Congress in February 2008.
In the end, all those interviewed for this article agree, the success of quality and patient safety efforts, measured both in terms of improved clinical outcomes and financial results, will come through transformation of the culture of hospital organizations to a culture of quality and constant improvement.
As CHP's Connelly put it, "The sponsors of our hospitals came to these communities that were struggling over 100 years ago, and they're still struggling now, for a variety of different reasons. But these people worked with what they had, and really worked hard at it, and worked together as a team, and used their mission as a motivating tool to move forward on all this. And there really is a business case for this quality improvement work, one that is still valid today."
MARK HAGLAND is the author of Transformative Quality: The Emerging Revolution in Health Care Performance (New York: Productivity Press, 2009).