Bedside Quality and Bottom-Line Results
Teams of physician, nurse, and finance leaders explain how collaboration can improve quality, control cost, and promote community trust.
By Sarah Fister Gale
Spectrum Health, a $1.2 billion healthcare organization based in Grand Rapids, Mich., has drawn a quantifiable connection between improving quality and reducing costs. During a two-year period, the organization cut $15 million from its operating budget and increased revenue by $10 million as a direct result of its data-driven quality-of-care initiatives—and Spectrum is not the only one. The organization is one of several healthcare institutions using physician-led team initiatives to identify areas for improvement that will increase efficiency and reduce costs. At a time when government and consumers scrutinize hospital prices, making this quality/cost connection and sharing those success stories with the public are important ways healthcare operations can differentiate themselves in a highly competitive market.
“Consumers need to be able to understand the value equation of health care, just like they do for any other purchase,” says Joseph J. Fifer, FHFMA, CPA, vice president of hospital finance at Spectrum Health. “Healthcare purchasers have no understanding of what things cost, or how health care is financed, and we as executives are partially to blame for that.”
One way that Spectrum is helping consumers more accurately evaluate healthcare costs is through complete fiscal transparency. “All of our financial and quality data is on the web site, and I am very proud of that,” Fifer says. That includes a quality report card and current prices for common healthcare services.
Spectrum’s quality programs have won the organization more than 50 awards in the past five years, including being named among the top 100 cardiovascular hospitals in the country. Some examples of its successes include proactive health management programs that have led to significant reductions in complications and medical errors for cancer patients at its Children’s Hospital and an overall reduction in bypass mortality rates to 0.9 percent, when the industry average is 2.2 percent.
Achieving these successes has required a combination of physician-led team efforts and a lot of healthy competition, says John Byrnes, MD, senior vice president of system quality at Spectrum Health.
As head of the quality team and a physician himself, he knew that the best way to pull physicians together and focus them on a common goal is to show them comparative data.
“Doctors are trained to respond to data. If you feed them information about their performance and the performance of their peers, they will become terribly competitive,” Byrnes says.
Finance and Clinical Team Up
The value of performance outcome data is undeniable; however, many healthcare organizations find it difficult to mine because they don’t know how to find it, Byrnes says. “The big secret is that every hospital is sitting on a gold mine of data.”
The place to get that data is the finance department. “Everything you do to a patient or give to a patient is tracked in the financial and medical coding systems,” he says, adding that the only way for the clinical staff to gain access to that information is by creating a good relationship with the financial team. “In an ideal world, the chief quality officer will build a bridge with the CFO and together design a method to mine that data.”
Byrnes suggests adding finance people and data analysts to the quality teams to bring a financial perspective to clinical efforts, and to enable finance people to see first-hand the impact of their decisions on patients. He also notes that being able to show decision makers a return on investment for quality initiatives makes it much easier to win additional resources for future efforts.
Greg Pagliuzza, CFO and vice president of finance for Rush North Shore Medical Center in Skokie, Ill., agrees. “The most important thing we do is deliver high-quality care, but you can only do that if you have the money,” he says.
When the finance team and clinical staff work together, Pagliuzza says, they can identify areas for improvement that benefit patients, physicians, and administration. At Rush, for example, a quality committee focuses on controlling pharmaceutical costs for patients. Although drug costs have increased annually by several percent for the average hospital, Rush’s costs have averaged about two percent per year in the past three years thanks to this committee’s structured review policy. Together, physicians and administrative leaders identify which drugs are most beneficial for the treatment of illnesses, using cost effectiveness as one of the factors. “It’s a cooperative effort, and you only get that when you work together,” he says.
Rush also has seen benefits from implementing clinical pathways for key treatments, such as knee and hip replacement surgeries. Rush cut the average hospital stay from four days to three, while infection rates have dropped to almost zero. To do it, the physician groups identify and track every step in the treatment process and put patients on a critical path to recovery by reducing wait times between treatment steps. Working together, physicians and nurses track patients to make sure tests are conducted and results are collected more efficiently, and they ensure patients get to surgery, recovery, and rehabilitation in a timely fashion. “The pathway runs like clockwork,” Pagliuzza says. “Everyone knows what’s expected, and as a result, patients don’t linger.”
Physicians Take the Lead
Including finance on quality efforts can build a link between the financial and clinical teams, but Spectrum’s Fifer warns that finance people must not try to run the show. “Change needs to be led by the doctors,” he says. “I’m not qualified to tell physicians that they need to reduce their complication rates, but I am qualified to benchmark the data and show them the results. Combining financial data with quality data can be influential.”
An example of Spectrum’s combination of quality and financial information includes its blood transfusion rate for knee replacement surgeries. Prior to Spectrum’s data-driven quality-of-care initiative, the hospital used blood transfusions in response to surgery-site infections in 31 percent of patients, Byrnes says. Following the new initiative, the blood transfusion rate dropped to 13.5 percent.
In addition to increasing the quality of care by decreasing the need for blood transfusions, the hospital also saved money. On average, Spectrum performs 1,300 knee replacements per year. With 31 percent of knee replacement patients requiring blood transfusions, which cost $300 each, the hospital spent $241,000 per year on transfusions. When the average rate of transfusions for knee replacement patients dropped to 13.5 percent, the annual cost dropped to $105,300, which translates into a $135,000 annual savings, Byrnes says.
In addition to involving finance officers and other C-level executives in quality and cost initiatives, healthcare facilities should also take a bottom-up approach to improving care.
At Jupiter Medical Center in Jupiter, Fla., health leaders gather quality and efficiency ideas from the staff and nursing level. Once a month, a group called Unit Champions for Quality meets to discuss core measures and other quality initiatives, says Mary Bishop, Jupiter’s chief nursing officer.
“At the staff level, staff members and nurses meet with us once a month to discuss quality initiatives and how we can improve quality for our patients,” she says. “[The staff members and nurses] have some great suggestions and probably the best ideas because they’re the ones at the bedside.”
Fewer Complications
Once quality successes have been achieved, sharing those stories with the community helps define the public’s perceived value of healthcare services, says Ed Murphy, MD, CEO of Carilion Clinic, based in Roanoke, Va. “At the end of the day, we need a quality proposition that will show the value that we offer to the community.”
One of Murphy’s examples of a quality solution to the healthcare cost quandary is reducing patient complications. “If you decrease hospital-acquired infections and complications, you obviously save money,” he says, adding that it also results in a better patient experience, with less time in the hospital and faster recovery. That leads to happy patients and happy administrators.
Achieving increased efficiency through an improved quality strategy, however, requires changes in the way health care is delivered. It requires physician-led groups empowered to identify those areas where quality improvements are achievable.
Sometimes the smallest changes can deliver the biggest results. For example, physicians on a quality team at Carilion established a consensus about the care of patients on ventilators in one intensive care unit in the hospital. In the one unit, patients on ventilators would be cared for only by physicians who practiced full-time in the hospital. Also, they arrived at a consensus approach regarding “weaning” patients off the ventilators. As a result, Carilion reduced the number of ventilator days in that unit by 70 percent and reduced ventilator-associated pneumonia by 90 percent. Ventilator-associated pneumonia can have a mortality rate as high as 30 percent, Murphy says.
“When doctors are made responsible for quality improvements, they will root out fragmentation and variation, and hold themselves accountable as a group.” He says, however, that quality cannot be a “physicians only” club. “Doctors, nurses, therapists, and anyone else who cares for patients must be part of the team.”
Nurses especially need to be included in the efforts and be seen as respected contributors. Kelly Miles, vice president and chief nursing officer for Shands Jacksonville in Florida, says it can be a challenge to get all of the disciplines to coordinate toward common goals, but it’s imperative to achieving quality. “Every area is interested in enhancing its own services, but that’s not good enough,” she says. “We need to work together.”
Three years ago, Shands identified performance improvement opportunities for physician-driven outcomes whose success also required strong nurse involvement. For example, when heart attack patients arrive at the Shands emergency department, they are given an aspirin by physician order. To speed the aspirin delivery time, nurses, and administration established a protocol of inquiring whether it has been administered and keeping track of those patients’ early progress.
“Historically, that wasn’t how things happened, but now multiple people own that outcome,” she says. “In the end, patients don’t care who is responsible for the quality of their outcomes. They just want quality care that is cost-effective.”