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 share her perspectives on the important topic of clinical transformation, and its implications for patient care leaders in this current moment of unprecedented change, in the U.S. healthcare system’s shift from volume to value. Below are excerpts from that interview.
Let’s talk about the processes that enable clinical transformation. And, where are we on that journey of 1,000 miles as a healthcare system, around learning to do clinical transformation?
I believe that healthcare systems [patient care organizations] are still in the process of determining how to provide care that ensures quality at the lowest cost; yet their operational systems are not fully aligned with those outcomes. And while many of them are doing amazing things, there is some pretty substantive infrastructure rebuild that’s needed in order to rebuild that. For instance, at that high, 40,000-foot level, many organizations have recently merged, or acquired, or been acquired by someone else, so they’re sorting out what services they need to provide, where they should provide them, who should provide them, and how they should provide them, and it’s highly likely that their current infrastructure is not highly aligned with their strategic plan for the future. Coupled with that, there’s the care continuum problem. We have historically been an acute-care-focused health system, with rehab providers, home health, community providers, etc., [constellated around an acute-care core]; so now, the other substantive transition we’re going through is, what care is going to be provided, by whom, and where, and then integrating patients and families into the process.
And finally, related to this, we have very little data that’s actually usable at the point of decision. So the third transformation that has to occur is in the information that people have, and to ensure that it’s not too little and not too much, and that it informs the decision-maker, so that they can make solid decisions based on the information they have at hand.
I often reference the fact that the healthcare industry is undergoing its Industrial Age Revolution and its Information Age Revolution at the same time, whereas all the other major industries in the U.S. went through their Industrial Age Revolutions a long time ago. What are your thoughts on that?
I agree, but I would divide the Industrial Age Revolution into two parts. One is, we have robotics and all kinds of new implants, and surgical procedures that make our ability to provide much more comprehensive care than in the past. For instance, we can place someone with spinal cord injury in apparatii in mechanisms that allow them to move. So there’s the technological revolution going on in the care delivery arena. But the second element there is the provision of data to patients and providers. For instance, there are monitoring devices tied to an iPhone that can automatically send the blood sugar of the patient. There’s a hospital in the Southeast that’s providing apps to integrate patients into the care delivery process and get more insight into patient medical compliance. So there’s that, around high-tech engagement in care processes.
But there’s the third element of who is the staff, where do you need them, and what is the work of that staff? So we see substantive changes in the roles and functions of staff. For instance, case management used to be an inpatient function; now it’s a continuum function. Mid-level providers are another example—they need far more expertise and skills to keep up with the technological component; there’s a lot more quaternary care taking place across the country.
Where does the mapping and analysis of care delivery processes fit into all of this, in your view?
That actually goes back to the data, and having the right information in the right place. We have a lot of data, but we don’t have a lot of good information that compares and contrasts what processes are critical. And let me go back up and answer that question—one of the key pieces is, do organizations know how to actually deliver and drive quality and process improvement work, which you’re referencing in terms of the outcome? I believe that clinical redesign is the approach, the methodology of looking at how care is delivered, looking at how and when it’s delivered, and in what settings, and also that care is being delivered by the right staff person. And the key is to know how to take that data and turn it into real information that gets results.
So how do I mine the data? How do I pull it out, so that a physician, nurse, pharmacist, will have quick and easy access to the data? How do I pull it out to make it easy to use? And how do I get results? You have to embed the data into processes to get action. For instance, around lengths of stay. Where were the gaps in order data, where patients sat in a bed for two or three days without anything happening? So a physician can look at the gaps—but you need to embed processes—who’s going to do the work to change processes? And what do we expect? And are we getting what we should be seeing?
For instance, a lot of time, we get the data, someone needs to make a decision, and then we need to follow that up with hundreds if not thousands of steps to make the changes—those are some critical steps that have to be taken.
What are the impediments to clinical transformation, in terms of process change and culture? Because it’s not that anyone wants to deliver sub-optimal care, but rather, that systems of processes have been sub-optimal. Clinicians certainly want to deliver the highest-quality care they’re capable of.
I agree with you completely that healthcare has amazingly committed physicians, nurses, pharmacists, etc., who really want to do the right thing; one of the things that’s providing the barriers is that leadership is pulled in so many directions that they don’t have the time to personally engage in and support the effort—not because they don’t want to, but because they lack the time. In order to reduce costs, they’ve cut staff, so there are greater spans of control and areas of responsibility for senior leaders now than in the past, which results in those leaders lacking the time to actively support change. And staff members totally don’t have the time, because their time is totally taken up in the immediate clinical tasks at hand.
And so the amount of leadership that’s needed to support these changes, is huge. And the other thing is that you’re talking about something very near and dear to the hearts of these dedicated professionals, and that is how they take care of patients. It matters. So there’s a lot of passion involved in these discussions. But I do firmly believe that it takes that level of leadership and support to drive these kinds of changes. They don’t have to do the work but they have to visibly support it. The other element is credibility. This is not just process improvement. I can map a process, streamline that process, and improve it. This is substantively more complex than basic process improvement, because the results are critically important to get in a very efficient manner.
What should CIOs and CMIOs be doing in all of this?
They’re two groups, of course, so I’ll take them one at a time. The CMIO, I believe, is critically important in terms of understanding what information the medical staff needs, to make decisions, and to be that leader who can support and be engaged and involved. Not to do, but to be informed, and where they feel they can articulate that to their colleagues on the medical staff and help support and drive that change in what happens. The CIOs, I think, are in a very interesting place, because we’ve had a substantive period in which we’ve selected and implemented EHRs [electronic health records] and clinical information systems; and all the merger and acquisition activity has spurred further activity. But now, the effort will be around how to get solid information out of the EHR, and use that information. The EHR itself won’t be the be-all and end-all. It will be about accessing the right information at the right time, to make decisions.
CIOs and CMIOs have a tremendous opportunity in this, but are under also unprecedented pressure in their roles.
I would agree completely. A good example is MACRA [the Medicare Access and CHIP Reauthorization Act of 2015]. Many still don’t know what it is, and many still don’t know how to collect the data they need for MACRA. They’re going to be looking to hospital organizations to help them. And I believe the impact of that will be felt in October; that’s when they have to submit or choose not to. And EMRs don’t always have that data. A lot of organizations still don’t have it, and it’s still not something most organizations can get out of their EHRs.
Given everything we’ve discussed so far, what do you think will happen in the next couple of years?
Regardless of what any eventual replacement for healthcare reform [any replacement of the Affordable Care Act, or ACA] might possibly be, the indicators that value, and reducing cost, will be at the forefront. And that’s because reimbursement will go down across the continuum of healthcare. And we’re going to have to figure out how to do things very differently, for less cost. And the emphasis will be on continuing to reduce cost while retaining quality. And we’re going to have to continue to reduce cost while improving outcomes, in hard data.
I think the key that I would say, with regard to the critical success factors to driving the clinical transformation that’s needed and to drive clinical redesign, that, first, you need a good risk-adjusted data set; second, you need clinical redesign with the right approach, to get results, so that means really knowing how to engage physicians, and how to integrate clinicians across processes; and third, it will require embedding data into this, and that means clinical dashboards. Those will result in substantive quality improvements and savings, if done correctly. And the last thing is that securing physician engagement requires credibility. So it really is best facilitated by clinicians who understand how to drive this process. And the last thing, we talked about leadership engagement, and I talked about how to demonstrate the leadership support needed—it involves setting clear goals around quality and cost, ROI efforts around these efforts—and then holding the change leaders accountable. It really is about driving change in a different way, and then using the IT systems to embed the change, and to make sure you’re collaborating with the IT department, to drive the timelines and strategies that will drive change.