As the U.S. healthcare system shifts inexorably further away from fee-for-service payment and towards value-based reimbursement, one area of importance that is looming larger than ever before is that of variation in clinical practice and care delivery. Variation in the way that physicians, nurses, and other clinicians deliver care was largely unchallenged under fee-for-service reimbursement, because there was no need to standardize care patterns to produce better patient outcomes or to reduce or curb costs. That underlying landscape is changing now, and the leaders of more and more patient care organizations are expending the time and effort needed to uncover variation and standardize care practices.
Nancy Lakier, R.N. is the founder, CEO and managing principal of Novia Strategies, a San Diego-based healthcare consulting firm that advises hospitals and health systems on improving their operations, quality and financial strength. Lakier sat down recently with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss her and her colleagues’ work in the crucial area of uncovering and eliminating unnecessary clinical variation. Below are excerpts from their interview.
You’ve been in healthcare for a number of years, and have had a broad range of professional experiences. Please share with me some of the experiences that brought you into this type of consulting.
I was the CNO at Scripps Health, and over operations at Scripps-La Jolla, and was recruited down there when I was up in Los Angeles, as they were anticipating a major hit coming from managed care. They had called me back in 1989, and I worked there from 1990 to 1995. And they had been right—very shortly after I arrived, that organization was feeling the strong effects of managed care. It was something of a “perfect storm” of difficult challenges: the economy was in a slump, they were cutting back on military bases, and managed care was taking a big bite in order to save money.
And one thing that I ended up developing was what we called the Lakier Predictable Factor. Essentially, it was a methodology for understanding the trajectories of predictable patients. For example, if you’re 40-something years old and you go in for a total hip replacement, you’ll probably have a relatively smooth and predictable course of care, whereas, for example, the 85-year-old who’s diabetic and breaks their hip, will not have that same predictable trajectory.
And, without realizing it at the time, we were really breaking new ground with that approach. So I partnered with a physician, Dr. Bruce Campbell, and we developed a clinical redesign. We did this across the whole hospital, but started with certain populations, and worked our way through. We were working with a limited database in those days, but we used it and put together teams of physicians, nurses, therapists, etc., to say—for the predictable populations, what were the right protocols? What drugs, supplies, should we use? When you look at implants, instead of 30 vendors, can we reduce that number? So we started looking at changing practice—using lighter anesthetics, decreasing time on ventilator, getting patients up and moving faster—and all those elements were starting to bring down lengths of stay. And working forward in that direction led to a lot of questioning of previously unquestioned practices: for example, why are you ordering a chest x-ray every day? The reality was that physicians practiced based on how they had been trained at the particular medical schools that they had attended, rather than anyone adhering to best demonstrated practices.
So one of the things that we started seeing is that we were reducing the cost, and literally moving the mean line in terms of cost-effectiveness as well as in terms of clinical outcomes. At that time, we were getting one, two, three days’ reductions in lengths of stay—but also improvement in outcomes in every one of the patient populations we addressed. And also, we put in very robust case management to manage the unpredictable. So, for example, what needs to happen with this 84-year-old diabetic who’s broken their hip? We essentially were examining the practice patterns around the care of both predictable and unpredictable patients. And that inevitably led to us directing a team to look at labor issues, because if you’re reducing length of stay, then you also need to look at staffing. So we also ended up creating a productivity task force.
How long did it take to achieve a transformation of your processes at Scripps?
It really took about two years at Scripps-La Jolla, and then we refined the methodology and spread it to the other four hospitals.
Looking at the landscape right now in healthcare, what is your sense of the readiness of clinicians and administrators in hospitals nationwide to pursue the examination and reduction of clinical variation, in the current environment.
It’s still all over the gamut. Leadership is feeling it for sure, in terms of realizing that this kind of work is needed. The rank and file is still a mixed bag. Some physicians are like, ohmygosh, I need to do this; some haven’t even heard about it. Some have heard about it, but they’re planning to retire in five years and think they can just slip out. The younger physicians are ready for it and have been prepared psychologically for it.
And it’s scary for senior leadership, because their jobs are on the line. Sometimes, that means challenging front-line physicians. And administration has always stayed away from that. And we never told physicians what to do—or nurses. We gave them great data. And today, the data we can give people—our data set is amazing. And the other day, I was looking at a general surgeon who does a lot of bariatric care, and that general surgeon also does appendectomies. And they were using a $381 special bariatric pack for their appendectomies. The question is, do you need that specialized surgical pack? And a lot of times, we hardly finish the sentence, when they say, why are they pulling a special bariatric pack for me? And sometimes, it turns out it’s the mid-levels who are doing the ordering. So a lot of times, the data tells them about potential opportunities.
And when you provide physicians with risk-adjusted morbidity, mortality, and costs—you can’t argue with that. And providing them those scorecards—that brings change just like that. They’re also very competitive souls. And, historically, physicians—it was very much also drilled into them that You, Doctor, are ultimately responsible for the lives of these patients—no team concept. At the end of the day, they had the weight of the world on their shoulders, and that weight is being redistributed.
What should CIOs and CMIOs think about this kind of work?
First of all, I think that they are critical partners in a couple of different ways; and they are instrumental in helping to evaluate and discern systems. The vendors will tell us that every one of them can do everything for you. But from an IT perspective, it’s about partnering with the CMO, CNO, and COO, to help them define what the critical elements are that they need, and then look at the (vendor) system and comparer its capabilities to those needs. At the end of the day, what are those critical elements are needed? Because we know what drives change. And you don’t need everything the vendors offer. And my personal philosophy is simplify, simplify, simplify: get rid of the noise. If you can’t get rid of the noise, frankly, it’s hard to drive change.
I think everyone working in a hospital now is shell-shocked by these waves upon waves of change, to be honest.
Absolutely, they are! So work with the senior leaders to really help define what’s important to them, and to help them define the flexibility needed in the (vendor) system. And then after you have the data system, you need to be able to have a fluid process with the rest of the clinical word, so that you can adjust. So for instance, if you went back and said, OK, we know that sometimes, multiple MRIs are needed. And we went to let every physician know when the last MRI was. Because a patient who’s been admitted may have had an outpatient MRI last week. So you need to have that pop up. Or the protocols. And sometimes, the informatics department will say, we’ll put that on our list and get that to you in about 16 months…! So it’s key for CIOs to say, what are our priorities?
Aligning what IT must do with the top priorities of the organization is important, then, correct?
Yes, absolutely. We do something called operationalizing the strategic plan. Because a lot of organizations have a strategic plan but don’t know how to make it happen. And IT is a key part of that. So we sit down and look at the strategic plan with leaders and ask them, OK, what will it take to do that? And pretty soon you find out things like, OK, it’s going to take five years’ work for the IT department to accomplish something that has to happen in five months. OK, so that’s not going to happen. So we call it having a vision and planning session with senior leaders to help embed the goals into their planning to help make it happen. And for me, the way to operationalize a plan like that is that you’ve got to take it deep into the organization and embed those pieces.
That’s why I believe that it is about clinicians and hospital experts. Because we can walk down and talk the talk with the nurses, the pharmacists, and the therapists, at the patient care level. And that’s what it takes.
Overall, what are the biggest challenges to tackle in eliminating variation, in your view?
The biggest challenge is ensuring you’re using a good data set. That’s critical. The second core element—I talk about core tenets often—it has to be multidisciplinary. You must bring in best demonstrated practices. And then you have to listen to the organizational culture and be respectful—truly understand their patients and their operations and be respectful of that, and integrate the change so you’re in alignment with their vision and their values—it’s really their values. Now, there are many times they want us to drive change. You can drive change and be respectful of their values. That’s key. And then you have to embed it. Often consultants say, here’s what you need to do, now, nurse, do this, doctor do this, etc. But it doesn’t stick, unless you put it into staff accountabilities, unless you embed data collection into your EHR. And you can put in protocols that will never be used. Too often, people think something will happen, and it just won’t.
Do you believe that physicians and nurses are more willing to be data-driven in their clinical practice, if it’s data they can trust?
Yes, absolutely, but the data set has to be valid, the data has to be risk-adjusted, and the people have to be credible. But then, yes. And at the end of the day, they have to make the final decisions; they can’t be told by outsiders what to do.
What would your parting advice be for CIOs and CMIOs, around everything we’ve discussed here?
I think it would be the need to collaborate with the other senior leaders, as we’ve discussed; the need to assist in finding good data sets; and then, to partner with them in driving that change. And that means really looking at their operations to ensure that they have flexibility in their operations, to be responsive. Building IT departments that can be responsive to these clinical change needs. And also, we can take disparate data sets and put in crosswalks. But IT leaders need to be thinking about, what does the future entail? And how can I build those crosswalks for the future? Another tenet is that of pragmatism and simplicity. As you said, don’t boil the ocean. It is so critically important that people simplify and look pragmatically at what can be done, and not try to design the best widget. You mentioned Lean and Six Sigma, and there are elements that can be used, but the key is to think about this pragmatically.