University Hospitals of Cleveland: Innovating Forward Through a Focus on Zero Harm
Can a focus on zero harm, one that also encompasses a health equity lens, move an integrated health system forward into superior quality outcomes and improved efficiency and effectiveness? That’s precisely what the senior leaders at University Hospitals of Cleveland have been focused on finding out.
In the opening keynote presentation at the Midwest Healthcare Innovation Summit on Tuesday, September 28 at the Westin Cleveland Downtown, Peter Pronovost, M.D., Ph.D., UHC’s chief quality and clinical transformation officer and Patrick Runnels, M.D., the organization’s chief medical officer of population health, spoke to the issues involved, in their session, entitled “How Innovation Can Help Healthcare: Putting a Dent in the Trillion-Dollar Problem.”
As noted on University Hospitals’ website, “The System’s 1032-bed, tertiary medical center, University Hospitals Cleveland Medical Center, is an affiliate of Case Western Reserve University. Included on UH’s main campus are University Hospitals Rainbow Babies & Children’s Hospital, among the nation’s best children’s hospitals; and University Hospitals Seidman Cancer Center, part of National Cancer Institute-designated Case Comprehensive Cancer Center at Case Western Reserve University (the nation's highest designation). More than 28,000 physicians and employees constitute University Hospitals and its partnership hospitals, making it Northeast Ohio’s second largest private sector employer. UH performs more than 10.8 million outpatient procedures and over 142,000 inpatient discharges annually.”
The website also notes that “University Hospitals’ goal is to provide comprehensive primary and community-based care – the kind of health care people need most – as well as access to the highest quality specialty care when necessary.”
Dr. Pronovost began the presentation, and opened it with a slide that says simply, “Leading With Love.” He explained that slide by stating that “The secret of innovation is feeling that love, feeling connection to the secret of the universe.” And, per the focus on a zero-harm strategy, he said that “Healthcare has preventable harm as at least the third-leading cause of death; and if we include managing chronic illness and behaviors, it’s even more. We squander over $1.4 trillion, over one-third of dollars spent, on waste. And medicine leaves about one in three people feeling they weren’t listened to or respected and are afraid to go home, after an admission. And if you’re poor, a person of color, or a woman, all of those outcomes are much, much worse. So we’ve aligned ourselves around the concept of zero harm, including zero experience of harm and zero inequities.”
He showed a slide that read, “Stop believing harm is inevitable & start believing it is preventable.”
Included on that slide were four goals. The first was “Eliminate Physical Harm: Ensure checklists and standard procedures are followed to eliminate mindless variation and augment mindful variation.” The second: “Eliminate Emotional Suffering: Ensure patients have an exceptional experience, that they feel respected and heard. Improve access to care.” The third: “Eliminate Defects in Value: Defects in value occur when clinical decisions are made that increase cost, but do not improve quality.” And, the fourth: “Eliminate Inequities: In all the ways we may cause harm, people of color, the poor, and the elderly suffer far greater and more frequently than others.”
“The first perspective we want you to take,” Pronovost said, “is this need for a new narrative, of looking at the world differently. The stories we tell define how we act in the world, whether we see how others are competitive or collaborative. And if you don’t change that narrative of trying to get to zero harm, you’ll never get there. And it’s hard to change that narrative, but it’s what we need to do.”
Indeed, he went on, “Innovation, throughout all of history has simply been when we accelerate idea sets: how you bring things together to create new ideas. And it’s not about individual intelligence; it’s about collective intelligence, so we’re drawing from different ideas. How did we develop innovation at University Hospitals? We took, for example, a logistic platform that’s being used at FedEx and elsewhere, because our nurses were spending 24 percent of their time looking for supplies. It’s disrespectful and dangerous, but has been the norm. We brought in behavioral scientists, data analysts, and many others.”
What’s more, Pronovost said, one key to success in innovation work is focusing on “ideas with impact.” In that regard, he showed a slide that articulated five key bullet points:
Ø Align around purpose and goal
Ø Seek out diverse ideas, industries, disciplines, and roles [to support discussions around potential changes]
Ø Create a mixing bowl, with a culture of humility, curiosity, compassion, and profound respect for others, and with a structure that allows for ideas to meet and mate
Ø Build collective intelligence
Ø Create culture and structure for ideas to flow
Further, Pronovost said, “Once you have the different groups, you need to create a mixing bowl that creates a culture of respect and openness to new perspectives. And then we need to create the structure that allows people to connect. Pat and I would have discussions on Saturdays about bringing in behavioral economists and others. And once you have the innovation, how do you spread that innovation? We need to challenge ourselves to be much more of a bluebird than a red robin.”
Showing a slide that involved a photo of a bluebird and a robin, Pronovost noted that, in London early in the twentieth century, the covers of glass milk bottles that were delivered to customers’ doorsteps, were made of paper. And “London at that time was filled with these birds, who would peck through the covers of the milk containers and suck out the milk. Then the milk companies changed the covers to aluminum. And the robins, who are solitary birds, are gone from London now. Why? Because they never shared their wisdom. The bluebirds are flocking birds, so the wisdom around that was quickly disseminated,” which led to their surviving the technological change from paper to aluminum covers on glass milk bottles.
As an example of how new narratives can be created, he referenced the fact that, historically, “Our patient transport team weren’t thought of as part of the care team. Many are people of color. And many felt that their voice would never be heard. The same was true of our environmental services: “I will stop believing that I am just a housekeeper.” That all changed, he said, once the organization’s senior leaders made decided to ensure that transport staff were included as valued members of the organization’s overall team. All those team members, he added, now feel themselves integral to the success of the organization overall.
Thinking more deeply about the patient experience
What’s more, Pronovost noted, the patient experience must be incorporated into all strategic thinking. “I’m going to share two brief stories,” he said. “Helen is a 64-year-old woman who was admitted 14 times with heart failure and had 15 ED visits, during 2018-2019. And she got excellent care in the ED and in the inpatient hospital. She received great transactional care. What they missed was that the reason Helen came back so often was that she had anxiety that had not been diagnosed; and she missed most of her appointments, because her daughter had died of a narcotic overdose, sadly. And Helen was taking care of her disabled granddaughter, so she missed most of her doctor appointment. And so she ended up costing the healthcare system $1.4 million. Meanwhile, Rose is a 64-year-old woman with heart failure and some kidney disease. But she received the benefit of a machine learning algorithm that triggers, notifying the provider and patient; Rose had the benefit of coming into care in a care management program that has a social worker and nurse navigator. Rose cost $6,800, was never admitted to the hospital, to the ED, and thrives. Helen is now getting the benefit of therapies. This is about evolving care forward to be proactive and relational.”
Given all that, Pronovost said, “We look at defects in helping people stay well; defects in helping people get well (40 percent of diabetics aren’t diagnosed); and then defects in getting better. Defects we’re swimming in, but are largely invisible.
Two years ago, our annual wellness visit was a pathetic 14 percent. Our goal is 65 percent, and we’re already above 50 percent. The innovation largely came from our medical assistants. And we have an ACO that has more than 600,000 people.”
On a fundamental level, Pronovost said, the goal for any patient care organization working to improve its performance must be to “help people get well. One of our principles of innovating is designing care around patients’ needs, rather than around subspecialist physicians’ needs. Diabetes care was confusing for patients; there was no navigation to our various types of clinics. So we said, a major element in improvement will be in diabetes education, so we made diabetes educators central. And we decided to focus on diabetics whose a1c is not controlled, and to work with them. This one thing, CINEMA, more than doubled the number of patients getting on the right medicine. And again, dramatic improvements in their a1c, cholesterol, weight, triglycerides.”
Rethinking the architecture of behavioral health
Dr. Runnels then spoke, noting that, “As a country, we wildly under-invested in behavioral health services for four decades. Public health systems typically underfunded care. And if you were a psychiatrist, psychiatric nurse practitioner, psychologist, etc., everything looked wrong; everything was structured in order to reduce cost. So as a clinician, you were doing the best you could, calling medications in on your own, dealing with prior authorizations on your own, and that left you maybe a little bit numb, but you accepted it. So as a healthcare system, we underinvested in this. The pandemic has had a big impact on the workforce. People are feeling even more overwhelmed than they were.”
In order to rework things in the system, Runnels said, “There were things that we did that represent different levels of culture change, which is key” to transformation. “The first thing we did was to create access clinic, which was really a refined consult service. We shifted our paradigm from that the doctors and psychiatrists stayed with patients forever, to short-term interactions. It took culture change because psychiatrists had to give up some of their long-term patient relationships that they treasured. It took us a long time digging into that loss.”
Further, Runnels said, “Then we realized that half the people we referred to didn’t even access the services, because of their expectations. So we then put primary care and social work at the forefront, with psychiatrists coaching others. And that was a major culture change for the psychiatrists. Then we realized that we needed to develop centers around our system, the first of which is opening next week.”
These centers have been labeled “behavioral health hubs.” And the other key element in that initiative, he said, “was clinical case management. We recognized that behavioral health isn’t just behavioral health. One case manager found that when she identified herself as a patient advocate, that got a great response, he noted.
Then, Runnels showed a slide entitled “The Wise Compassion Leadership Matrix,” and included four different styles of leadership, as follows:
1: caring avoidance: letting empathy be a barrier to action
2: wise compassion: getting tough things done in a human way
3: ineffective indifference; lacking interesting in and concern for others
4: uncaring education: putting results before people’s well-being
Obviously, style number two, “wise compassion,” which combines both wisdom and compassion, is the best style. What are the elements of wise compassion? The slide showed nine elements:
Ø Introspective: Examines their beliefs to consider how their actions affect the world around them
Ø Acts with a Purpose: Makes choices that align with a commitment to have a positive impact on important issues
Ø Thinks Critically: Explores a topic from all angles before asking a well-thought-out decision
Ø Empathetic: Connects to feelings outside their own by viewing concepts through the lens of another
Ø Collaborates and Communicates Openly: Embraces the inspiration and participation of others by accepting new ideas and perspectives
Ø A Team Player: Works well in a team and engages their peers by leveraging their unique, individual skill sets
Ø Influences Peers: Sets a positive example for the people around them
Ø Hopeful and Optimistic: Stays positive and committed to achieving their goal
Ø Adaptable and Resilient: Embraces challenges and overcomes setbacks
Pronovost spoke once again, focusing on the metrics that have been documented for UHC’s accountable care organization (ACO), a participant in the Medicare Shared Savings Program (MSSP). Their ACO’s overall quality score has risen consistently year by year from 2017 to 2020, going from 73.4 percent in 2017 to 82.7 percent in 2018, to 97.4 percent in 2019, to 100 percent in 2020—a remarkable achievement. What’s more, at the same time, costs have gone down considerably. Average per-member-per-year costs in the organization’s ACO have gone from $10,172 to $9,956 to $9,740, to $8,286 during that same time.
In all this, the two executives emphasized, one of the keys is for everyone involved in creating change to focus on making “I will” statements—to commit to the collective push for continuous improvement in clinical and operational performance.
