Five years ago, leaders at the Memorial Hermann Health System, the largest not-for-profit health system in the Houston metro area, with 17 hospitals and 260 care delivery sites, looking for a strategy to improve patient outcomes and control costs at the same time, arrived at the concept of what they labeled “Clinical Care Redesign,” a massive, ongoing effort to rework clinical care delivery and operations. The initiative was and is led by Erin Asprec, who at that time was Memorial Hermann’s transformation officer, and today has the title executive vice president and COO.
As Asprec and her colleagues note, “Clinical Care Redesign was a complete transformation of the organization’s longstanding business practices that re-envisioned the way Memorial Hermann cared for patients. It touched the entire spectrum of care and impacted every facility, every department, every employee and every patient to ultimately achieve value-based care: a model wherein Memorial Hermann provided the highest quality care with the best service at the lowest possible cost.” For their comprehensive work to re-vision care delivery, the leaders at Memorial Hermann have been named the third-place-winning team in our annual Innovator Awards program.
The Clinical Care Redesign (CCR) initiative began five years ago, starting with an in-depth analysis of the patient journey across Memorial Hermann’s continuum of care, with, as the health system’s leaders describe it, an examination of “all processes and touchpoints, and identifying opportunities to improve clinical care. The goal was to streamline practices, improve safety and reliability of care, develop standards for medical necessity, reduce costs by eliminating unnecessary variation, and ultimately, create a better experience for the people who entrust Memorial Hermann with their lives and the lives of their loved ones.” The Memorial Hermann folks have focused on four areas that they believed might yield the greatest return on investment of effort, time, and resources. First is reducing clinical care variation, “by targeting specific APR-DRGs (taking into consideration the patient’s diagnosis, the severity of his or her condition and the risk of mortality) and establishing a foundation and work processes that support evidence-based standards of care.”
Second is “care progression,” which means “empowering the patient’s multidisciplinary care team to help move patients toward discharge through a flexible model for daily meetings to review every patient, every day, including tools and processes to identify and resolve barriers to care progress.” Third is case management, encompassing “increasing the effectiveness of case management to provide earlier intervention in patient placement and discharge planning with an aim to create seamless and coordinated care for the patient throughout their care.” And fourth is “clinical documentation integrity,” which has involved “increasing the accuracy and diligence of all clinical documentation to ensure all necessary steps are taken and documented appropriately.”
The results speak for themselves: through continuous benchmarking and measurement, Memorial Hermann leaders note today that “Through Clinical Care Redesign, the system has already achieved a savings of $236 million on a goal of $200 million since its rollout. In addition, the program has led to improvement in experience and mortality, and a decrease in readmissions.” Among the key changes: care delivery is more standardized than ever before, with clinical pathways established in core areas, including COPD/pneumonia, tracheotomy and ventilation, and coronary artery bypass graft, or CABG, to name a few, as well the standardization of surgical supply packs. Reducing unnecessary variation, a key focus, has proven to be a huge success.
At the same time, the Memorial Hermann leaders note, their Clinical Care Redesign work has helped them in their accountable care organization (ACO) development, as they have committed to continuing to move forward into value-based contracting. Memorial Hermann participates in the Medicare Shared Savings Program (MSSP), as well as in ACO contracts with all the major private health plans operating in the Houston metro area—Aetna, Humana, Cigna, and UnitedHealthcare. Altogether, they say, between 500,000 and 600,000 patients/plan members are attributed.
Looking back at the start of the work, COO Asprec says that, “From a broad-brush standpoint, Clinical Care Redesign started in 2017. Here in Houston, we had the oil bust, and the economy was poor, and frankly, our financials were challenged, as were those of other organizations, at the time. So to turn that challenge into an opportunity, CCR was born. And we wanted to improve quality, outcomes, and cost. And now, our system is very intently moving towards value, and our definition for value is the highest quality and outcomes, a phenomenal patient experience, and an improved cost profile. It literally is the initiative that will help us get to value. It’s continued past the five-year mark, and will continue until we can show what we’re doing is best for patients. We started out in the inpatient space only; now we’re following up in the outpatient space and across the continuum.”
Among the critical success factors so far, says Matthew Harbison, M.D., vice president of hospital care and case management services, has been the establishment early on of clinical practice committees, or CPCs, in every area of the initiative’s work, with about 33 CPCs being active at any one time. The CPCs, Dr. Harbison says, have been absolutely instrumental in reducing unnecessary variation and waste. Harbison is board-certified in internal medicine and pediatrics, and practices hospitalist medicine.
Meanwhile, Nnaemeka G. Okafor, chief analytics and informatics officer and an emergency physician by training, notes that, from the beginning, “We understood this would be a team approach, something that neither the physicians, nurses, respiratory therapists, or administrators, etc., could design by themselves. So in each area of activity, we would begin by creating a collaborative design among stakeholders, identify the potential options for implementation. Implement what worked. And measuring efficiencies and return on investment.”
What have been some of the biggest challenges in the work so far? “As you can imagine, finding new opportunities each year becomes trickier as you do the work and accomplish goals,” says Christine Lanza, the health system’s associate vice president of finance. We will have achieved $275 million of savings by the end of this year; and we’ve completed our target process, identifying targets in each area. So part of the challenge is finding those new opportunities. We use benchmarking measures for length of stay, and cost measures for supply chain. There’s a lot of collaboration and partnership; that’s the key. Nor is this process at all finance-led; instead, I’m there helping the teams. And everybody has great ideas. And will they be cost-effective? It’s a balanced approach” to determine what is worth addressing.
Harbison adds that, “We also understood that if we were going to tackle an issue, we needed to determine what the KPIs [key performance indicators] were for that issue. For example, we developed about ten KPIs for fragility fracture, which is a measure of our clinical performance around caring for patients who have experienced bone fractures”—such as hip fractures. “For example, someone falls in their home and fractures their hip, and is then brought to us for surgery. We mapped out the entire process of care for that urgent condition in the CPCs, and identified key elements of the process as patients move through our care delivery system, measuring our success at each time point or measure. We honestly created a beautiful clinical performance dashboard for it, one of the best I’ve seen, involving a large number of elements, such as time to the orthopedic surgeon seeing the patient, time to imaging, time to OR [operating room], time to the administration of a nerve block—in the elderly population, you want to avoid administering nerve blocks whenever possible. Now, we’re looking at delirium prevention and are developing a delirium prevention bundle. And without Dr. Okafor and his and his team’s discipline around the analytics, we wouldn’t have been able to develop an effective clinical pathway in this area.”
Okafor says that, “For us, I think the biggest challenge has been prioritizing what we should go after, given limited resources. There certainly has been no shortage of ideas. We have to figure out what we can tackle first and project the value of something. Sometimes that would hurt people’s feelings, if they had pet projects to bring forward,” he adds. “So prioritizing projects has helped, as has being transparent, saying to a group, well, you’re number seven on the list, for example.”
Further, Okafor opines, “You always start with clarity on the problem you’re trying to solve, and then define it. Discharge, for example, means different things. Getting definitions is key, as that’s what’s required to translate to the purely technical people, to know what data to pull. And as Dr. Harbison has made clear, measure, measure, measure before you cut. How will we use the data? That has been what we’ve tried to be disciplined with. And we know that it’s not just enough to show people the data. We’ve needed to create regular touchpoints and have needed to be transparent with the information that we have, while asking participants to be transparent with us around the barriers they’ve faced.”
“And,” Asprec adds, “not everything works. So one of the lessons learned in all this has been that sometimes what you design doesn’t produce the intended result. But we’ve created a culture where we can produce the outcomes we’re producing.”
All the leaders have heaped praise on Asprec for her leadership in the ongoing initiative. “One of the critical elements has been Erin’s leadership; she has been very consistent around the goals of this mission; and this is a long-term strategy,” Harbison says. “She was really consistent particularly across the first three years, in being consistent with vision.”
Asprec herself praises everyone involved in the initiative, saying that “The whole team has exhibited focus, accountability, and willingness to lift barriers, as well as being open to change.”
“And I think accountability is huge here,” Lanza says. “Erin really holds people accountable. And that’s a huge, important key.”
What should the leaders of patient care organizations around the country think about, as they consider taking on something like Clinical Care Redesign? Okafor says that “You will need a combination of transparency and willingness to negotiate, to say, here’s what we would like to accomplish. And then the person says, no, I have twelve things on my plate. So a negotiation takes place. So having the ability to transparently negotiate for what you need to have happen, is key. And this is a team sport. There is no one person who can get all this done.”
