Advocate Health Care views itself as a clinical enterprise. The entire health system is focused on quality and safety. Improving quality is good for business and generally reduces costs over time, says Lee Sacks, MD, executive vice president and chief medical officer (CMO) of Advocate Health Care and CEO of Advocate Physician Partners. He recently discussed the health system's ongoing efforts to enhance quality and value with hfm.

Q.Advocate Physician Partners has received positive response to its recent value report. Could you share how you define value for physicians, hospitals, and consumers?

A. The clinical integration program creates value for physicians by supporting their efforts to improve outcomes and provide efficient care. The physicians benefit by being part of an organization that is a common interface with multiple payers, has a single set of metrics, and has delegated credentialing. The hospitals see value with the alignment of incentives with the physicians and the focus of the physicians on driving outcomes and efficiency.

Consumers or patients benefit from an integrated delivery network that is focused on population management and working together to better coordinate care. Some of the value created by Advocate Physician Partners is in nontraditional areas, such as a recognition of the importance of reducing absenteeism from the workplace, or minimizing "presenteeism," which can be a result of chronic conditions that are not well managed. Another area is in increasing generic prescribing, which lowers the overall cost of prescription medications and can enhance compliance.

Q. How can hospitals manage quality and cost at a time when the financial incentives are in transition from volume-based to quality-based? And how can hospitals make the changes in care delivery today that may help them financially in the future, yet hurt them financially today?

A. I've always taken the position that improving quality is good for business and generally will reduce your cost position over time. Although it's not always a one-for-one, there are plenty of examples. We've decreased the frequency of ventilator-associated pneumonia and central-line-associated bloodstream infections and taken millions of dollars of costs out of the organization with that opened-up capacity for critical care beds, where in some cases we haven't had capacity, and as such have had to divert patients and cases away from the organization. But it depends how you look at it. If people are afraid to work on improvement because right now they get paid for volume and improvement is going to decrease their revenue stream, then they aren't looking at it the right way.

Q. When looking at areas to focus on from a quality measurement perspective, how do you determine which are the priority areas? Is the decision based on internal criteria, national measures, or some other method? And who is involved in determining the focus areas?

A. It's all of the above, but I'll give you some specifics. At a high level, we started with saying that we wanted to pick metrics to focus on for improvement that had the biggest impact on creating value, which meant dealing with the common chronic diseases: diabetes, congestive heart failure, coronary disease, and asthma. Then as we got into more specifics, we only wanted to take measures that have been developed or endorsed by credible national bodies such as NQF or CMS, and we wanted to take measures that are easy to obtain from our data systems. On day one, our data systems were a lot less sophisticated than they are today. So it's been a journey as well, because in the beginning, much of the data came from claims systems, whereas today more and more data come from clinical systems.

This process is overseen at the Advocate Physician Partners level by the Quality Improvement/Clinical Integration Committee, which consists of physicians representing all of our sites and a variety of specialties. They have a measures subcommittee. The full-year process, which starts in January, reviews where we are, makes updates, and sends preliminary recommendations to the board, usually in June. Then in October, after staff have had a chance to review and identify any logistical issues, the board approves the final set of metrics for the coming year. The updated measures get implemented in January.

Q. How integrated into your organization is quality? Is it part of the performance appraisal system for all staff, just the executive team, or only the clinicians? If it is part of the performance system, is the compensation tied directly to the measures? In other words, if you attain X goal, then Y percent of your compensation or bonus is earned.

A. Jim Skogsbergh, Advocate's CEO, has said this enough times that everybody in the organization repeats it: First and foremost, we're a clinical enterprise. We're obsessed with quality and safety. We've had a balanced scorecard for the last five years with six key result areas. The first result area is health outcomes, which is all about quality and safety. There's a report card to the board, then one for the executive management team, another for all of our sites, and then one for their teams.

It cascades down to the manager level and everybody who remotely has an impact on quality-information systems, infection control, housekeeping. All of those managers have a measure related to quality, and their overall performance on the scorecard factors into their merit compensation increase. The health outcomes component this year is 40 percent of the plan. It's the biggest component of the plan. We literally get rewarded for improving outcomes, which has sharpened the focus of the organization.

Q. Do you have a quality scoreboard for your organization? If so, who is involved in creating what is on the scoreboard and updating the measures you're attracting? What is on your scoreboard?

A. We call it the health outcomes dashboard, and it gets updated every month. Once a year, we review it and change metrics and weightings. We have a Health Outcomes Council, which consists of our vice presidents of medical management, the chief nurse executives, some of the clinical support services staff, and our medical staff presidents. The council meets, reviews recommendations, and asks questions. It's an iterative process.

Then the council meets with our senior leadership team, which consists of our hospital and medical group presidents as well as the system executive team. The third iteration is for the Health Outcomes Council to look at targets on the measures that we've agreed on. The fourth iteration is to make recommendations on the weighting. Then that all gets sent to the system executive team, and ultimately it goes to the board.

The 2010 dashboard hospital measures include a bundle for overall performance on Hospital Quality Alliance (HQA) metrics, ICU mortality, falls with injury rate, 30-day readmission rate, length of stay, sepsis mortality, post-operative venous thromboembolus/pulmonary embolus, and computerized provider order entry (CPOE). The medical groups have 116 measures from the Advocate Physician Partners clinical integration program, while home care has three Medicare measures (rehospitalization rate, ambulation, and oral medication). Risk-adjusted complications and mortality are two high-level measures that are shown over time as the overall outcome of the system focus on health outcomes.

Q. At a recent conference, you said that "infrastructure is the secret sauce" to hospital-physician integration. Could you explain that point for our readers? What are some other critical success factors for clinical integration and healthcare value?

A. Infrastructure is what supports the hospital-physician integration and drives improvement. It includes a shared vision with trust, a governance structure, physician leadership, data systems, timely reports, and a culture that supports transparency and improvement.

Q. How has your organization embraced your focus on clinical excellence and value?

A. The focus on quality, outcomes, and safety resonates across the organization. There's a lot of pride among the associates for what we're doing, and there's a lot of pride among our voluntary medical staff and the other professional caregivers, nurses, and pharmacists. As a side benefit, you can talk about where the focus has reduced costs and accomplished other things, but they get excited about the way we have improved outcomes and have enhanced safety. Some of it is how we've been able to share the results and help the associates and caregivers appreciate how many patients they have impacted in a positive way.



About Lee B. Sacks, MD


Lee B. Sacks, MD, has been executive vice president and chief medical officer (CMO) of Advocate Health Care since 1997 and CEO of Advocate Physician Partners (APP), Oak Brook, Ill., since 1995. He is responsible for clinical support services, information systems, risk management/insurance, supply chain, research and medical education, and clinical laboratory services. APP is the umbrella organization over the eight Advocate physician hospital organizations (PHOs) and the medical groups that determines Advocate's managed care strategy, negotiates the managed care contracts, and enhances medical management.

He practiced family medicine in a three-person practice from 1980 to1992, when the practice became affiliated with Lutheran General Medical Group. He has held management roles since 1990, serving as medical director, vice president of Lutheran General Health Plan (PHO), and vice president of primary care development for Lutheran General HealthSystem, prior to the merger that created Advocate in 1995.


Publication Date: Wednesday, December 01, 2010

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