Note: MultiCare Health System’s Clinical Collaboratives project was named a semifinalist in the 2016 Healthcare Informatics Innovator Awards Program. Short descriptions of the projects of all of the semifinalists in this year’s program can be seen here.
At Tacoma, Wash.-based MultiCare Health System, a six-hospital integrated healthcare delivery system, physician-led, multidisciplinary teams, called Clinical Collaboratives, are developing and deploying system-wide improvement strategies that have resulted in some stunning clinical outcome improvements and measureable financial benefits. Even more impressive is the fact that MultiCare has successfully implemented a sustainable approach for standardizing best-practice, value-based care across not just a health system, but also across its commercial accountable care organization (ACO), called MultiCare Connected Care, and its clinically integrated network.
In 2011, MultiCare created the two initial Collaboratives focused on improving outcomes for sepsis and heart failure. The significant outcomes from this initiative – a 65 percent reduction in sepsis mortality rate – prompted the health system leadership to accelerate its investment in the Collaboratives and there are now seven Collaboratives across the system focused on critical care, medicine, surgery, primary care, emergency services, women’s services and pediatrics.
Healthcare Informatics’ Assistant Editor Heather Landi spoke with MultiCare leadership involved in the Clinical Collaboratives project to discuss the genesis of the project, the challenges of implementing it and the lessons learned. The second part of the interview will dive more deeply into the project’s impact on improving clinical outcomes and the project’s next steps. Taking part in the interview were: Florence Chang, executive vice president and chief operating officer, MultiCare Health System; Christopher Kodama, M.D., president, MultiCare Connected Care; Albert Marinez, director of information intelligence at MultiCare Health System; Christi McCarren, R.N., senior vice president, retail health and service lines, MultiCare Health System and Kate Mundell, program manager, Clinical Collaboratives, MultiCare Connected Care. Below are excerpts from that interview:
Tell me about the genesis of the Clinical Collaboratives project?
Christopher Kodama, M.D.: There were a couple of things that contributed to the original genesis of this effort. One was a broad recognition among senior leadership, at that time, particularly Florence [Chang], that we needed to transform data into actionable information to eliminate variation and improve clinical care and patient outcomes. Florence’s original work at MultiCare Health System was as a consultant to help with implementation of our electronic health records (EHRs) platform. We’ve been on Epic for over 15 years now, starting with ambulatory, and Florence came on board to help us with the implementation in the acute care environment, and then she ultimately stayed on as chief information officer. What was always interesting to me is that Florence is quite visionary. She is currently VP and COO for MultiCare Health System, but even during the period of time when we were implementing the EHRs, it was really a means to a bigger end. The EHR was the way to start gathering discreet data in a standard sort of way. So we were beginning of examining what’s next and where do we need to go with this so that we are actually harnessing the power of all this data that we spent all this time, energy and investment in creating platforms to support. And so that’s where Florence had initiated conversations with Health Catalyst to look at, okay, how do we create our own enterprise data warehousing function to start a process of harnessing that data into actionable information that is going to accelerate improvement?
Subsequently, we broke this into three buckets of work—one was the technical infrastructure around the enterprise data warehouse (EDW) and the data mart creation; the second was around the recognition that we needed some sort of singular governance and direction around analytics and knowledge management for the enterprise; and then the third had to do more with the logistics and standards around security and data definitions.
Now concurrent with that, Christi [McCarren] was already working, initially and primarily from an acute or hospital-based point of view, on cost improvement in the way that we delivery care. So Christi was already working with members of our finance team and our operations teams to start invoking a discipline around how to prioritize and identify the greatest opportunities that would have the greatest impact around cost without compromising quality.
So, if you fast forward a couple of years, the intersection of those two sensibilities—the analytics and transformation of data into actionable information and knowledge coupled with this discipline around prioritization and cost discipline and improvement—is where we landed. Those were the key components of the recipe for success. It began with a recognition that we needed to accelerate our performance in terms of quality, service and cost, and we had a lot of tools that were needed to put this together and we needed to add an operational sensibility into that discipline.
What were the first steps to get this project started?
Christi McCarren, R.N.: In began in 2010 with the identification of significant practice variability between two hospitals with regard to sepsis. And so with that, we’re going to approach this as a system and learn from each other, which was a new step for us. With significant executive physician senior leadership, we were able to bring a group of people together representing a multidisciplinary team of physicians and clinicians from all of our hospitals. And the progress that we made there, just by shining a light on it, standardizing the process, doing evidence-based practice, looking at the research and then implementing it, we saw dramatic results right away. And, so, because of the momentum that this team gained, we said, we’ve got something here. When you pull a group of committed clinicians together and give them the right set of resources, meaning the project management support and the financial support, they can really move quickly and they become really engaged in the process.
Christi McCarren, R.N.
Kodama: How we approached it isn’t necessarily how I’d recommend others approach it. Using the lens of hindsight, I’d say the way we started was very grassroots. We started with engaging physicians, clinicians and other analyst functions in the journey. There was a lot of excitement, so that was the positive thing about starting with the grassroots approach. One of the things we caution people about taking that kind of approach going forward is the level of success with that particular approach is predicated upon the cultural appetite of the organization to embrace this type of knowledge-driven insight engine. If an organization is innately hard-wired to look at how to take information, quickly research and then come up with tactics to improve, then a grassroots solution is probably okay. For our organization at the time, we were entrenched in what I think many healthcare systems have been traditionally, which is largely financially-driven data sources and not a lot of access to real-time data, particularly from the clinical activity side, or the quality side in terms of process measures. It was more of a struggle for us to get lift off because there wasn’t this top-down universal appreciation for the fact that we were going to need to shift the way that we looked at information and what information would be meaningful for us in order to truly effect positive change. At a grassroots level, we focused on a hospital-based disease process, sepsis, and then also a more continuum of care-based disease process that spans beyond the hospital walls into the out-patient community, congestive health failure.
What were some of the early challenges of this work?
McCarren: The biggest challenge early on was that we underestimated the amount of infrastructure and support that we were going to need. What Florence did as she allowed us to put Kate [Mundell, program manager] over all of the Collaborative and her leadership has helped to propel us forward.
Florence Chang: Like any other major initiative, there success criteria is number one, organizational commitment from the top. I think we recognized this as an important initiative and from the organization’s senior leadership, like myself, we sponsored this effort, endorsed it and supported it. The second piece you need to have a dedicated leader, somebody who it is their business, every morning, to wake up think about this program and have the appropriate project management skill sets to really help stand up this initiative.
What were some lessons learned during those two initial Collaboratives projects?
Kodama: We learned some really unique lessons from each of those. I think we saw more immediate, dramatic gains and improvements around reductions in sepsis mortality. I think part of that is due to the fact that it was a little bit more contained and controllable, with a smaller group of stakeholders; heart failure is pretty big and it’s very dependent on outpatient-based decisions. That was a key lesson for us. As a result, we’ve actually established a lot of processes and discipline that helped us as we grew the number of Collaboratives. So we took it to the next level of, how do you actually test that and scale it? We increased the number of Collaboratives from two to six, and we were very clear for the need to prioritize and not try to boil the ocean.
McCarren: Because of the work we were able to do with sepsis, we decided to continue on and also continue to monitor it. The critical care collaborative still looks at all the sepsis metrics, so if there is any point at which our mortality rises at one place, then we form an ad hoc group to look at it and get it back in line. It’s an ongoing process and it hasn’t always been smooth. In the beginning, everybody was following the guidelines and the rates were coming down nicely at all of our hospitals. Then all the sudden, the physician champion at one of the hospitals left and the performance started to derail a bit. We had to pull that all back together and get it back on track. That’s the value of having an ongoing monitoring process. And we also understood that we had to have enough bench strength in terms of our physician group that it could go along without one individual. If you are going to hard wire it, it has to be much broader than one physician to keep it moving. So at that point, we starting designating physician champions and medical directors at each of our facilities and they became part of the leadership group.
From the data standpoint, we were fortunate to have our information intelligence team help develop a dashboard for us early on that identified the process metrics, so we could easily look at where we were falling down relative to the process. That data has been really important in terms of keeping physicians engaged and not wasting a lot of time in chart review.
Albert Marinez – The critical success factor, across all of this, has always been that we have from the get-go started with data in mind. Or, you could say, with the end in mind that the analytics function was going to be a catalyst to get us to our end goal. Having the appropriate business intelligence capabilities and applications available to the Collaborative leaders, and having the data analyst resources available, was critical to enable those Collaborative leaders, and certainly Chris, Kate and Christi from an executive oversight perspective, to hold their Collaboratives accountable to objective information. And that in and of itself, I suspect, was a cultural change in how we operated before. Previously, it was more like picking up the phone and saying, “I got this idea to change something and I want a report that gives me a historical overview of X.” But there was no systematic approach to saying, “I want to take what I’m trying to change and I want to deliver it in a dynamic fashion to a group of 10, 15 or 50 individuals.” And then those individuals are going to use these tools as part of their workflow processes, to not only get the improvement but maintain the improvement over a period of time. I think that cultural shift really started with the intent at the beginning that we were going to use data and analytics to be a catalyst to getting to our end goal. The data and analytics function has remained front and center all along the way, and that’s supported by leadership, and that has helped shift our culture from a reactionary perspective to now asking questions proactively to help us get ahead of the curve of what we can expect in our future.
Mundell: As an example, as we launched a new Collaborative late last year, the leadership at the business unit level said, “We can’t do that until we have an app.” At MultiCare, what that means is, we can’t do that until we have an application that provides us insight into the data. So this is a group of physicians and clinicians who didn’t feel comfortable making a step forward in their work and identifying what work they would go after until they had the data first, and that was a substantial shift in thinking.