Hospitals, medical groups, and health systems have taken a page from the playbook of manufacturing and other industries to achieve measurable improvements in care quality and the bottom line
The manufacturing industry has long used concepts of six sigma and lean management to drive improvements in quality. And the idea of applying data to improve performance-which years ago spread to other industries such as air transportation, retailing, and shipping-has in recent years caught the attention of healthcare administrators, who hope to achieve measurable results in healthcare. To be sure, hospitals and factories are worlds apart in many ways, but-as leading provider organizations have already demonstrated-they share common tools when it comes to quality.
THE BIG PICTURE
One organization that has the benefit of a broad view of data-driven performance improvement in the healthcare arena is the Premier healthcare alliance, whose membership includes 2,300 hospitals and 70,000 outpatient facilities. Premier's leaders cite as their mission the goal of improving the efficiency of its member hospitals, as well as the health of the communities that the provider organizations serve.
Richard Bankowitz, M.D., Premier's enterprise-wide chief medical officer, believes that continuous quality improvement tools have a lot to offer health providers. As evidence, he points to the Hospital Quality Incentive Demonstration (HQID) Project, which Premier has been jointly running with CMS as a six-year demonstration project focused on evidence-based care. Top-performing hospitals have been those with a data-driven culture, using data to identify opportunities for performance improvement or monitor their progress, he says.
THE EMERGING TREND IS THAT EVERY HOSPITAL FACILITY IN THE COUNTRY IS INSTALLING TECHNOLOGY THAT ALLOWS THEM TO CAPTURE AND REPORT THAT DATA. THAT IS A NEW WORLD.-J. MICHAEL KRAMER, M.D.
Premier has expanded on the demonstration project, forming a collaborative of 200 hospitals across the U.S. They share five goals: reducing preventable mortality, improving patient safety, increasing the amount of evidence-based care provided, improving patient satisfaction, and reducing cost. Data-driven quality improvement is at the core of the collaborative, Bankowitz says. “We focus on defining, measuring, and determining the definitions of what we want to measure, and we focus on setting targets that are quantifiable. And we focus on transparency, so that everyone in the collaborative knows where they are; everyone knows the top performer and the bottom performer; everyone knows we have pockets of excellence.”
Premier's vast databases contain about one in five discharges in the U.S. Using them as a basis, Premier has been able to show hospitals where they stand relative to top performers, risk-adjusted mortality, and see their performance according to clinical product line or department. “They are able to set performance thresholds and use this wealth of data to see if they are providing the best care possible,” he says.
According to Bankowitz, CMIOs have noted that their participation in the collaborative has allowed them to use standardized measurements; use transparency to create a climate of healthy competition; and accelerate improvements by sharing best practices. Barriers, of course, still exist. Among them, data can be difficult and labor-intensive to obtain; and actionable data has to be timely, accurate, placed in context of relative performance, and it must be easy to find opportunities. He adds that it's important for clinicians to focus on the big picture, by concentrating on best practices and figuring out how to reach that goal without getting caught up in nuances. It's also important to realize that not everything in healthcare can be standardized. “The question is, ‘How much variation is justified?’” he says.
Bankowitz says that being a data-driven performance organization doesn't necessarily mean hiring additional staff; but staff should be employed more effectively. Sometimes it could mean investing in products for automated data collection or data analysis, but these have a return by shifting labor from manual data collection, which that then can be shifted to bedside care.
Both EHRs and computerized physician order entry (CPOE) are helpful, he says. But it is also necessary to have the means to do near real-time data analysis to aggregate data and determine where opportunities exist. Also useful are tools that look at physician practice patterns, as well as those that go beyond CPOE to provide alerts for interventions. Overall, the most successful hospitals have support from their boards of directors.
Bankowitz maintains that during its first two years the collaborative has prevented or avoided 2,000 in-hospital deaths, and reduced the average cost of a discharge by $600 on an inflation-adjusted basis, for a total of $2 billion in savings.
Trinity Health, Novi, Mich., has taken an early lead in transforming itself into a data-driven quality organization. In 2000 it established its Genesis project, a $400 million endeavor to standardize its clinical supply chain throughout its hospital network. So far, 28 of its 45 hospitals have completed the Genesis transformation, according to vice president and CMIO J. Michael Kramer, M.D.
All 28 of the Genesis-certified hospitals are operating on a common clinical supply chain and financial system, with data residing in a common data warehouse, including 8 million patient records and the hospital's complete financial supplies and clinical medical record within their acute care, ED and operative facilities, Kramer says. He estimates Trinity's EMR has close to 60,000 discrete data elements.
The central data repository allows Trinity to have performance data at its fingertips, Kramer says. “If I wanted to know how I am performing on catheter-assisted urinary tract infections, I could tell you that, for elective surgeries last year we reduced catheter-assisted urinary infections by 50 percent.” The commonality of infrastructure, reporting data warehouse allows all of the associated healthcare organizations in the network to move forward together with a common purpose, he says.
One of the major benefits of Trinity's Genesis program is that the performance improvements achieved with evidence-based best practices are pushed through to all of the hospitals in the network. Recently, for example, an examination of Trinity's budget cycle showed drops in the length of stay. By looking at the reporting systems in place, Trinity was able to pinpoint the improvement to one hospital that had hired a hospice group focused on reducing the length of stay.
According to E.J. Ledesma, the organization's director of performance leadership, Trinity has created a dashboard that allows the leaders of each hospital to quickly assess where they stood against their targets and how they compared to their peers. “We were creating a dashboard that allows conversations to occur between leaders across the organization in a transparent manner,” he says. The dashboard has been in use for a year.
Ledesma says the dashboard is quite sophisticated, and Trinity has developed into an executive information system that allows the user to see key financial, productivity, and quality metrics. Users can see a snapshot of data in 10 minutes, but sophisticated users can drill down to see long-term trends.
The dashboard concept allows all of the hospitals to share their best practices. All of the hospitals put in their key initiatives, according to category, along with a description of what they are trying to attain. The information is available to all of the leaders in the Trinity organization. The dashboard incorporates monthly reports of the initiatives.
Explains Kramer: “There is an architecture of performance improvement that involves having an understanding of performance in major categories of outcome. Every month E.J. and I get a quality dashboard and financial dashboard on various aspects of the organization.” Outliers are identified and analysts are called in at both the corporate level and local level to understand the data and translate it for the rest of the organization, he says. The process is transparent throughout the Trinity organization. The same tools that are available to the corporate level are also available to experts at the regional and facility levels, he says.
Ledesma calls the Genesis project a “humanizing process, because it creates the type of value that the patient deserves.”
Kramer notes under meaningful use, hospitals in 2012 will be required to electronically report quality measures on certain high priority diseases to the department of Health and Human Services. “The emerging trend is that every hospital facility in the country is installing technology that allows them to capture and report that data. That is a new world.”
Healthcare Informatics 2011 March;28(3):36-40