Inside IT

Richard Bankowitz

As our nation contemplates the best ways to drive improvements in healthcare quality and safe reductions in healthcare costs, the healthcare industry is coming to the conclusion that, as the old adage suggests, there is strength in numbers.

More and more providers are realizing that, although all change is local, many problems are universal. As a result, the popularity of peer-to-peer quality and cost improvement collaborative projects is increasing. One reason is that providers realize collaborative learning works. This is especially true if, as is often the case, that solution provides an insight that has general applicability (for example, when a successful solution implemented in a small, rural facility in Montana could also work in a large Chicago hospital). The sharing of evidence-based best practices in a collaborative, peer-to-peer setting has been proven to yield positive patient outcomes and, in many cases, associated cost reductions.

What are the keys to achieving success within this type of collaborative format? Participants in the Premier healthcare alliance's QUEST collaborative cite three specific attributes of the collaborative that help them achieve results beyond what was possible to achieve alone. These keys to success depend on the development of a common infrastructure-much of which can be supported by technology:

  • A standardized set of common, well-defined metrics by which all participants agree to be objectively measured
  • A set of clearly defined, stable targets that provide the ability to compare progress relative to peers
  • The ability to share information and best practice across a collaborative-a process that accelerates implementation of successful strategies while preventing groups from reinventing the wheel


A Standard Set of Common Metrics

To create meaningful metrics, hospitals need a way to collect data on relevant outcomes such as mortality, harm, adherence to evidence-based care, patient satisfaction, cost, and waste. Just as important, there must be a way to tie these outcomes back to specific patients, clinicians, and departments, so that the hospital can act on the information. In fact, we have observed that with regard to objective metrics, best-performing hospitals have three things in common:

  • They are data-driven (i.e., they make decisions using data, not opinion or special interests)
  • They are transparent with data (everyone knows how the hospital is doing and where problems exist) 
  •  They hold individuals and teams accountable for results (excuses are simply not acceptable; plans for closing gaps are expected)

Because there is a common set of industry-accepted definitions, evidence-based care and patient satisfaction are currently the easiest outcomes to define. Although one might think outcomes such as mortality, readmissions, and length of stay are simple to define, they require numerous decisions regarding inclusions/exclusions, outliers, and risk adjustment methods, none of which are standardized. Cost is difficult to measure in a standard way because institutions vary widely in what they include as part of inpatient cost. Measuring harm and waste is particularly difficult, because there are no comprehensive standard measures of either. As a result, hospitals will need to either partner with an outside organization that can develop the methodologies for measuring these outcomes or invent the methodologies themselves.

This is where a collaborative-one that works to define these measures in an objective and agreed upon way, in which those outcomes being measured have reached a consensus with specific methodologies and have achieved participant buy-in-can play a vital role. When those being measured can come to a consensus on how they will be measured, a number of arguments are preempted down the road when outcomes are, perhaps, as good as one assumed.

Clear Targets-and the Ability to Compare Them

Institutions need external data to inform them of where they stand relative to peers and to create the will for change. Lacking external data to create a burning platform for improvement, hospitals can develop a false sense of security in the face of mediocre outcomes. A set of peer comparative data are needed. These data are sometimes called benchmarking data, but might more properly be called "target" data, because healthcare organizations must actively target and strive for achieving best practices rather than passively observe their positions relative to a benchmark. Because best practices are constantly changing, information on peer best practice performance that is dynamic and can be updated frequently is best. Even better is the ability to have complete data transparency so that peer institutions engaged in improvement can share outcomes fully and openly.

Members of improvement-focused collaboratives have an advantage here because they have a wide range of outcomes from which to review. Sometimes multihospital systems can use data in the same way. But individual hospitals are at a disadvantage without some sort of objective measure of how they are performing compared with an external best practice.


Sharing Information and Best Practices Across a Collaborative

The will to change is not enough; organizations need practical, proven ideas on how to improve quality of care while safely reducing cost. That's why it is critical that hospitals find ways to partner with similarly engaged hospitals in an effort to share best practice. For instance, as a part of the QUEST collaborative, participants use an underlying portal technology to exchange ideas, post best practices, and share related protocols and documents. Hospitals should consider this type of technological capability when planning their performance infrastructure. No institution has all the answers, but together, a large group of hospitals may point the way toward improvement.


Execution Is Key

These critical success factors will be of little value unless an organization also sets up an infrastructure for execution. Much of this infrastructure is amenable to support from technology. For instance, a successful infrastructure should include:

  • An ability to monitor progress in a way that is transparent to everyone within the institution
  • A way to hold people accountable (that is, to tie specific outcomes to specific individuals or teams)
  • A means to hardwire best practices (for example, hardwiring best practices for avoidance of hospital-acquired conditions through technology that alerts in real-time so hospitals can immediately intervene and mitigate or prevent harm)

In addition to data tools, hospitals need employees who are knowledgeable in the use of these tools. More important, they should have systems in place to hold people accountable for results. Just as important, they should be able to present meaningful, actionable information-information that is accurate, timely, reconciled, relevant, and of sufficient detail-to clinicians and operational/financial executives while making the case regarding the interconnectedness of these stakeholders.

Technological solutions are often useful in redistributing the work effort. Technology infrastructure should lessen or eliminate the need for collecting data by "dogging" papers and printouts, thereby allowing clinicians to spend more time serving patients or implementing systemwide solutions.

There is nothing that motivates institutions more than seeing their name on the bottom of performance rankings. Although such a position doesn't necessarily equate to poor patient care, it does suggest that improvements could  be made. How better to improve than to leverage the successes of peers? Many providers have found that collaboration among their peers accelerates their improvement efforts. It is this type of collaborative execution that can help align our fragmented healthcare system and allow us to more quickly improve the health of the communities we serve.

Richard Bankowitz, MD,  is enterprisewide chief medical officer, Premier Inc., Charlotte, N.C. (

Publication Date: Monday, March 01, 2010

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