Evidence-Driven Quality Improvement, the Ascension Way

April 10, 2013
St. Louis-based Ascension Health, one of the largest multi-hospital health systems in the U.S., has been a virtual beehive of process and performance improvement in recent years. Leaders of the 81-hospital system (with about 1,400 associated or affiliated care facilities) have been spreading performance improvement —both clinical and non-clinical—across all of its 30-plus regional organizations, known as Health Ministries, all with the goal, in the words of health system leaders, "transform healthcare by providing the highest-quality care to all, with special attention to those who are poor and vulnerable." And a core component of their work has been leveraging information technology to facilitate every type of process improvement in its hospitals and clinics.

St. Louis-based Ascension Health, one of the largest multi-hospital health systems in the U.S., has been a virtual beehive of process and performance improvement in recent years. Leaders of the 81-hospital system (with about 1,400 associated or affiliated care facilities) have been spreading performance improvement —both clinical and non-clinical—across all of its 30-plus regional organizations, known as Health Ministries, all with the goal, in the words of health system leaders, "transform healthcare by providing the highest-quality care to all, with special attention to those who are poor and vulnerable." And a core component of their work has been leveraging information technology to facilitate every type of process improvement in its hospitals and clinics.

Among the numerous performance improvement initiatives moving forward within Ascension Health are the following:
• The ongoing rollout of core electronic health record (EHR) and computerized physician order entry (CPOE) systems across all of the health system’s hospitals, on multiple platforms; about 40% of Ascension Health hospitals are live on CPOE at this time, (up from 17% last year) with the rest moving forward to implement within the next year or so.
• Access and use of a foundational set of evidence-based physician order sets (derived initially from a commercially developed set from the Los Angeles-based Zynx Health). The evidence-based order sets are adapted for optimized workflow on a facility-  and hHealth mMinistry -level after local clinician input. They contain key clinical process indicators that underscore quality and safety initiatives as ‘blue ribbon’ type items whenever evidence is present to suggest impact on improved quality or efficiency.
• Project Symphony:  a System-wide administrative data and process management and standardization project focused primarily on the domains of human resources, supply chain and finance, but also including a focus on the unification of such Enterprise Resource Planning data with aggregated clinical data from across the System known as the Ministry Intelligence Center
• Healing without Harm: a System-wide program to approach, monitor, record, and continuously improve patient safety and care reliability across all care environments

Clinical informatics, data analytics, performance improvement leadership and large-scale change and educational efforts have been critical to all these advances. Jeffrey Rose, M.D., vice president-clinical excellence, informatics for Ascension Health, has been involved with the teams facilitating work for each of these initiatives. Dr. Rose, who will present related information system initiatives with attendees of the Healthcare Informatics Executive Summit, to be held May 6-8 in Orlando, spoke recently with HCI Editor-in-Chief Mark Hagland, regarding the performance improvement and automation initiatives taking place at Ascension Health, and the role of informatics. Below are excerpts from that interview.
Where are you in the Ascension Health journey toward performance improvement and automation right now?
All of our acute-care facilities and ambulatory facilities are in various stages with implementation of point-of-care clinical information system infrastructure, in concert with parallel programs in quality, efficiency and operational process areas. The Informatics work has been focused on electronic health records, of course, but connected at every opportunity to the other safety and quality efforts, with the underlying goal of acquiring and using clinical and business intelligence knowledge from these efforts to connect caregiver communities and their patients.
As the numerous electronic health record projects progress, they do so in concert with system-wide administrative data, process management and standardization in the form of Project Symphony. Each of the Health Ministries is devoting great coordinated effort to the implementation of these business and clinical information systems. Such a massive transformative information-centered effort has different facilities in different stages of their plans with respect to the electronic health record projects, ranging from those who have fully attested for meaningful use to others are almost ready to go. Some organizations are at advanced stages according to the HIMSS Analytics schematic HIMSS stage attainments, and others are merely beginning their journey. We are comprised of an extremely diverse group of hospitals, using varied platforms for the clinical information system use, but all aimed at the core goals of improving care quality and information flow across the communities they serve.

Jeffrey Rose, M.D.

Tell us a bit more about your efforts around patient safety and care quality.                  
Ascension Health has an intensive program, Healing without Harm by 2014, which is focused on inculcating principles of high reliability and reduction of all preventable harmful events in our complex care processes in which all the Health Ministries are involved. While such error measurement and reduction projects obviously involve informatics and clinical processes, they are heavily focused on operational and associate interactions in culturally safe environments to communicate technically and interpersonally in the interest of safest clinical practices.

What are some of the elements involved in the program?
Key to Healing without Harm by 2014 is coordination of care efforts regardless of the domain or environment where care is delivered, and intensive education and training about the best ways for reliable communication in the interest of patient safety; the goal being to eliminate any kind of error, and potential for error, within the complex care delivery processes. All of our associates, from the frontline to the executive suite, and regardless of profession, are involved in an intensive program that teaches principles of high reliability, values and standardizes error or potential error reporting, evaluate events carefully and is aimed at creating a culture of safety.

Has clinical IT been an important support and facilitator in that area?
Clinical Informatics tools and data are critical to most care processes and therefore can play a vital role in assuring safer practices and eliminating potential mistakes when well implemented. This has been repeatedly noted in literature detailing benefits of HIT. It is of supreme importance, recently emphasized in the IOM report on IT and patient safety, that informatics and EMR projects not be undertaken without careful consideration of the process they impact, if improvements rather than degradation of maximally safe practices are to be achieved. We do not see informatics or electronic health records as soloists in the performance of highly reliable optimal quality care, but rather as fundamental instruments in a much larger orchestra of care delivery artists. Yes, it’s an integral part. Informatics can bolster safety with regard to communication, legibility, clinical decision support, checklists, protocols, alerts and reminders, but only if it enables safe workflow and provides relevant information and process support to caregivers focused on high reliability service delivery.
Does your ongoing rollout of evidence-based order sets support the unified processes?
We believe so. Order sets are merely one kind of clinical decision support tool that must be developed or adopted in concert with EMR implementations and, in particular, CPOE. From a quality and safety perspective, such sets or protocols can, and have been, used in varying ways in our paper world.  Now we have powerful new tools to allow clinicians to do their work more quickly and reliably, based on evidence-supported clinical content that can be evolved and tailored to incorporate and disseminate best practices, act as reminders and evidence informers, function as safety checklists, indicate costs, suggest appropriate practices, coordinate care, collect clinical information, speed and smooth workflow and record regulatory information..

A foundation set of collaboratively developed order sets are being adopted in varying degrees, depending on what the Health Ministries—about 30—need, what their physicians are prepared to accept, and how incorporation of the order sets is to be embedded in the EMR platform. A Health Ministry may use a foundational set in en-toto, created, or they can modify or author material themselves (across a facility), making sure that regardless of the socialization techniques, they contain key clinical process elements. Each EMR clinical leadership team is choosing how they want to incorporate the order sets and the key process indicators. The project leaders collaborate and communicate in multiple levels of clinically driven governance from facility to System level that support our safety and quality efforts in concert with our Clinical Excellence, clinician integration and other key System committees overseeing the progress.
When it comes down to it, you can’t tell physicians what to do, but you can bring them together, correct?
Physicians are autonomous creatures and not particularly amenable to being told what to do, but my experience has been that when facts, logic, workflow and high reliability principles are convincing, they are quite willing to collaborate and strive for excellence together. In addition to clinician team collaboration at facility and Health Ministry levels, we have seen shared vision and leadership drive remarkable cohesion in the interest of best care. We’ve also collaborated across healthcare systems with Catholic Healthcare West and Adventist (East) Health, to develop what we called Care Collaborative order sets.  The Care Collaborative provides 1,200 condition-based, procedure-based, and convenience-based, order sets, derived from Zynx and used throughout the three systems.

About 60 percent of these sets are based on Zynx order content, with modifications from clinicians. Approximately 40 percent are convenience-based work-flow enhancer based sets. The total library covers the major DRG conditions; many key acute care procedures, and those conditions most important to national quality initiatives (CAP, HF, MI, DVT, sepsis, surgical complications etc.) The order sets cover 199 total conditions that reach into many specialties and subspecialties.  However, there is still much to be done to meet specific practitioner needs.
In addition to covering multiple DRGs in the acute-care environment, we’re now moving into the ambulatory world as well. We work to ensure we include those elements of specific order sets that affect mortality, cost, length of stay, readmissions and quality indicators for the Affordable Care Act, the Deficit Reduction Act, all the other things the Centers for Medicare and Medicaid Services (CMS) [is focused; elements that have been associated with reimbursement in the new, emerging world of healthcare reform.  

Those particularly relevant items within the order set that have been shown by reviewed literature to affect mortality, cost, length of stay, and quality of care—are intentionally flagged for inclusion in order sets that may have been authored previously or independently by health ministries. Clinicians should be able to structure the order sets to meet their workflow and culture and they should contain the reportable key process indicators. It’s like establishing blue-ribbon items in the order sets, regardless of what may make them attractive to the clinicians. This is how we relate the order sets to our other key safety initiatives.

It is important to note, achieving safe and reliable, high-quality care is not simply a matter of having order sets. It is a matter of having programs and education while encouraging mind-set changes in practitioners in a host of very substantive ways.  That mindset should be reinforced with workflow compatible decision support tools for quality assurance wherever possible.
Philosophically, where do you strike the balance between standardization and customization?
There are a number of axes along which you can get standardization to occur. The most compelling in the clinical world is where you can create standardization around quality and safety. Another axis is around creating improved efficiency and/or reimbursement in the context of value-based purchasing or accountable care organizations. This an improvement in care transitions and best practice that is becoming a focus of enhanced reimbursement, despite the fact it has long been the ‘right thing to do’. Another axis is the IT axis. Standardizing infrastructure and system software brings economies of scale and interoperability along with outcome analytics and decision support feedback on health management at the point of care.
Do you think that that balance will be shaped fundamentally differently in different types of hospital organizations?
We face some unique challenges in our large and distributed leadership organization than more tightly integrated care model organizations (e.g. Kaiser, Geisinger, or IHC). Ascension Health can be considered a microcosm of healthcare providers across America beccause of our multiple systems and physician affiliation models. The drive toward standardization requires very different management skills and operating systems in this type of system. Responding to local market pressures, fulfillment of our Mission to meet the needs of those who are poor and vulnerable while focusing on infrastructure development as we continue to grow is one reason we seek quality processes and information convergence as unifying threads among multiple communities and styles of provider practice.
What have the biggest challenges in this area for you?
I think the biggest challenge we have had to face, as have our colleagues in healthcare, is the balance between standardization and autonomy.

What have been the biggest advances been in your organization in this area, the biggest triumphs so far?
Ascension Health has a terrific clinical information systems project management office that works in close conjunction with Clinical Excellence and oversees the progress of individual projects across the country; coordinating that is no small task. We work based on a clinical vision for HIT that is supported through integrated governance at multiple levels in our complex organization.

We are able to think and act in response to local cultures and pressures without losing sight of the need for independent standardization in many areas, one of which was the foundation set of clinical order-set content that Health Ministries can derive value as they develop their own clinical system work on their own timetable and according to their own culture. And our emphasis on unified approaches to measuring and tracking our many efforts is vital to quality and reliability management.

One built-in challenge is the diversity of your EHR vendor situation, correct?

That’s correct; approximately half of our Health Ministries are on a Cerner platform and those implementations are not completely common. In addition, we have Allscripts, Meditech, McKesson and several other EMR sites functioning.

What have the biggest lessons learned been so far? And what would your advice be for CIOs and CMIOs in all this?
Listen to your users and your clinical experts. Respect the workflow and culture. Advance relentlessly on convergent ideals of quality and safety. Leverage learnings across your institutions. Prepare for continuous evolution of both systems. Be aware of, and mitigate, any risks of using those systems. Know that high reliability extends to systems as well as to caregivers and patients.
Have the physicians advanced in their acceptance of all of these things?
We have seen acceptance of team-based high reliability care delivery, common and widely shared clinical decision support tools and content, and acceptance of more single-system thinking. Meaningful use has driven intense work on necessary infrastructure issues. I think the desired by-product is that physicians are beginning to see the value of information systems, clinical decision support, and point-of-care quality enhancers, in ways that they never saw before.

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