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In 2017, leaders at Providence
St. Joseph Health launched a strategy to address unnecessary clinical variation
in the health system. The goal was to examine practice patterns and identify
areas where more-expensive care did not result in better outcomes for the patients
served across the system’s 51 hospitals and 829 clinics.
After starting with a focus on orthopedics,
the program expanded to eight clinical areas in 2018 and took hold as a central
organizational priority. Total savings from the initiative to date is
approximately $20 million.
“It’s a start,” says Caleb Stowell, MD, enterprise
director for value-based care at Providence St. Joseph Health.
Stowell and Kevin Fleming, COO for clinical
program services, will describe the program in detail during a presentation at HFMA’s 2019
Annual Conference, June
23-26 in Orlando. Below, they share insight about the keys to success in such an
Fleming (pictured at right): Coming from a large health system with many ministries across many
different states, we needed a way to speak with a common language across all
those sites to our physicians and to our caregivers who are involved in the
delivery of care. We needed it to be reliable and very data‑driven.
we wanted our clinicians to engage with us and our caregivers to engage with
us, we needed something that not just focused on cost but also had an emphasis
on clinical outcomes.
Stowell (pictured at right): It starts with the leadership commitment. That commitment was
required to do things that hadn't been done before, like integrating financial
data with clinical data—getting our folks who oversee our financial data system
to see the value in that and open that financial data to broader access.
that was in place, there was certainly the blocking and tackling of building
out the data models that incorporate those two perspectives, and a lot of
refinement in analytic methods and taxonomies that make that data more
meaningful and more explorable.
of that was built upon a leadership commitment to answering the right questions
and to building the tools that would surface the impact of practice variation
across our system.
The thing that was immediately clear once we started analyzing the data was the
extent of practice variation across the system. We wrote an article
on this in NEJM Catalyst that we
subtitled "Endless Forms Most Beautiful," which was a quote from
Charles Darwin recognizing the variation that exists in the natural
many ways, the variation we see in health care mimics that. Because physicians,
or clinicians more broadly, are trained in many different places, they pick up
various practice patterns, various interpretations of evidence that are
distinct from one another.
recently, we haven't had the ability to visualize that difference. Once we
started doing that, we could see there was tremendous variability in the total
cost to deliver a particular episode, like a joint replacement. That total-cost
variability was not correlated with quality.
asking ourselves: What are the practices that lie underneath cases that are low‑cost,
high‑quality, and are those things that we could replicate?
First we focused on identifying the most common practice variations with
financial impact. Taking joint replacements as an example, we found cost per
case was driven by a variety of practice choice: implant vendor and product
line, use of fibrin sealants or branded pain medications, differences in length
of stay or operative time, use of physical and occupational therapy. It was relatively
straightforward to describe the differences, but we’ve only scratched the
surface in effecting change.
to effect change, we’ve needed to conduct more detailed supplementary analyses.
We did this when noticing that the use of commercially impregnated antibiotic
bone cement varied widely across our system, with meaningful financial impact.
Connecting this variation with infection rates indicated no meaningful
correlation between the two in our system. This helped us message the
value-enhancing nature of the change, not simply the cost benefits.
date, what we've been talking about is practice variation that is identifiable
through our internal costing. It's facility‑based practice variation for
facility‑based costs. We're now using the same approach to build a similar
product suite for bundles so that you could understand the practice variation and
the outcome variation in the bundle.
We're somewhat lucky that, several years ago, the organization had started to
bring together groups of clinicians and administrative leaders from across the
health system in like‑minded service line areas called clinical institutes,
where we bring together folks who are focused on care for similar types of
had settings in place and teams in place that we could work with—not just from
the health system pushing things down but from getting involved regionally and
locally at the individual-hospital level to try and put this transparent
information in front of the clinicians.
wanted to give them an opportunity to look at their data as it compared to
other caregivers and clinicians across the health system and ask questions and
get, hopefully, actionable data that they could respond to and, if appropriate,
make changes in their practice patterns.
Fleming: We've seen changes in two key
areas. One set of changes is within clinician behavior and their practice
patterns. We have seen a number of changes, whether in the type of implant; the
type of pharmaceutical agents that are used; the approach to pain control; the
pathway that patients go through, which has impacts on length of stay; or even changes
to practices by the care teams in the perioperative environment.
also looked at [the initiative] as an opportunity for the health system to make
changes in how we do certain things. It became very clear that the approach we
had taken to engaging with the vendor community in the past wasn't bringing
sharing this data with physicians and getting some of their feedback on the key
pieces that mattered in those negotiations, as a health system we are now
approaching our relationships with vendors in a different way. It’s about
continuing to provide our physicians with the tools that they need to do their
job but doing so in a manner that focuses on value and the outcomes that we're
able to provide to the patients.
example, in the last year our health system engaged with total-joint surgeons
and spine surgeons to find an optimal balance between having a broad set of
choices and ensuring a sustainable price. In each case, the clinicians
supported a narrower set of choices that they felt would still offer an optimal
clinical outcome for their patients.
It certainly takes a fair amount of effort. We've talked throughout about the
role of leadership commitment, both to the idea of branding ourselves on value
and then putting the data resources in place behind it.
health system could say that that’s going to be their strategy. Getting the
resources to do it well is always a challenge.
thing that is more difficult to replicate is the many years, at least four or
five years, of work that preceded this where, as Kevin mentioned, physicians
and administrators have been working collaboratively on improvement—more
focused on quality initially. That goodwill and process of identifying
variations and spreading them across the system laid a solid foundation for
doing similar work more focused on cost and value.
At the end of the day, we found our clinicians to be universally engaged in
providing the best care they can to their patients. If an organization engages its
clinicians transparently with their data and a willingness to partner with them—not
looking to mandate their performance or their practice choices—I do think that
this roadmap can be beneficial for other organizations.
Nick Hut is managing editor, HFMA.
Interviewed for this article: Kevin
Fleming, COO, clinical program services, Providence St. Joseph Health, Renton,
Wash.; Caleb Stowell, MD, enterprise director, value-based care, Providence St.
Much more on this
initiative will be presented at HFMA’s Annual Conference,
June 23-26 in Orlando.
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