An interview with Brent James
Asked how Intermountain Healthcare has earned its high-quality reputation, Brent James, MD, MStat, repeatedly says, "There's nothing new here. This is just good management."
What is unique, James emphasizes, is how Intermountain has applied well-tested approaches—specifically, data-driven process management as preached by quality guru W. Edwards Deming—to its core mission: patient care delivery.
"Most hospital systems have a mission statement that says we exist to deliver care to patients," says James, Intermountain's chief quality officer. "Yet, if you apply the old litmus test, 'You manage what you measure,' you'll find that the role of administration in most healthcare organizations is to manage a facility within which independent physicians deliver care. Leaders vigorously track budgets and variance reports. But those reports are typically organized around departments within a hospital—versus the care that is delivered by that hospital."
About 17 years ago, Intermountain leaders decided it was time to truly measure what they wanted to manage. "We decided that we were not behaving in a way that reflected our mission. We were managing facilities mostly, but our core business was care delivery."
The result of Intermountain's soul-searching is an enviable data-driven clinical management system. Physicians, nurses, and other front-line staff can drill down into data to identify evidence-based practices to improve outcomes. At the same time, leaders have access to comparative data and other intelligence that allows them to identify trends, remove barriers for improvement, and hold the right people accountable.
Intermountain's approach has brought numerous accolades and brag-worthy results. "We count our successes in lives. Each year, I can point to thousands of Intermountain patients who would have died—but did not. We have also taken well over $150 million in variable costs out of Intermountain in the last couple of years. That's a massive ROI."
James sums up Intermountain's journey in four steps: The first was getting its mission right. The second was focusing on its core work. Using a technique called key process analysis, Intermountain identified four core processes.
To prioritize improvement efforts, Intermountain identified its two highest volume clinical processes: the management of ischemic heart disease and pregnancy, labor, and delivery.
The third and most challenging step was building the data systems needed to manage and track these clinical processes. Intermountain found that it was missing around 30 percent to 50 percent of critical data elements—and had to essentially build these data systems from scratch.
"The fourth step is to create a management structure that uses data for accountability and change," says James. "Once we had the data, we started to hire physicians and nurses and carefully train them to take accountability for our new clinical budgets."
The key role of senior leaders is to build the infrastructure, says James. "The people at the front lines are the only ones who understand the work processes well. They're dedicated, hardworking, and smart. But they don't control the systems within which they work. We do, at the management level.
"The most important part of infrastructure is the data systems you use," he continues. "Data are your ability to see as an organization. I visit many places where management reports don't align to the work. This means that management is always out of sync with the frontline reality, and you get so much sand in the gears from that. It slows you down. The role of senior management is to clean that up."
Brent James, MD, MStat, is chief quality officer and executive director, Institute for Health Care Delivery Research, Intermountain Healthcare, Salt Lake City, Utah.
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