delivering value through a data-driven...

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Delivering Value through a Data-Driven Culture

PERFORMANCE EXCELLENCE | Delivering Value through a Data-Driven Culture6 PANELISTS

MODERATOR

American Hospital AssociationCHICAGO, IL. } SENIOR EDITOR, DATA AND RESEARCH

Suzanna Hoppszallern

James Brexler } PRESIDENT AND CEO

Doylestown HealthDOYLESTOWN, PA.

Eileen Jameson } SENIOR VICE PRESIDENT, OPERATIONS

Jefferson HealthABINGTON, PA.

Theresa Ledesma } DIRECTOR, PERFORMANCE EXCELLENCE

CareTech SolutionsTROY, MICH.

Scott Malaney } PRESIDENT AND CEO

Blanchard Valley Health SystemFINDLAY, OHIO

Matthew Costello } SENIOR EXECUTIVE DIRECTOR, HOSPITAL OPERATIONS

Doylestown HealthDOYLESTOWN, PA.

Barbara Karpinska } VICE PRESIDENT, AMBULATORY CARE SERVICES

University HospitalNEWARK, N.J.

EXECUTIVE DIALOGUE | Sponsored by CareTech Solutions | 2018

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Hospitals and health systems face many challenges in controlling costs and improving their health care delivery systems, compounded by implementing the electronic health record and both internal and external culture clashes over which best practices to incorporate. The need to identify improvement opportunities, solutions and to execute process efficiencies to improve quality, safety, cost and the delivery of care is at the forefront of clinicians and administrators alike. This executive dialogue explores ways organizations can develop a data-driven culture to help deliver high-quality, affordable care.

Delivering Value through a Data-Driven Culture

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PERFORMANCE EXCELLENCE | Delivering Value through a Data-Driven Culture


MODERATOR (Suzanna Hoppszallern, American Hospital Association): We’re looking at how we deliver value through a data-driven culture. What are the key opportunities for patient care improvement and operational efficiencies that are at the top of your list right now and how are you identifying these opportunities?

EILEEN JAMESON (Abington-Jefferson Health): We are focusing on a number of different quality and safety initiatives within Abington to be able to maximize the relationships within the Jefferson Health enterprise to address how we improve the quality and safety of the patient care we deliver.

One way we’ve approached this is through the formation of councils within the hospital to look at patient safety and quality, clinical care and excellence. Those are the primary drivers, while the patient experience, staff engagement, and financial and operational excellence are others. We’re also looking at how to effectively use publicly reported data, such as those from the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System, the Leapfrog Group and Healthgrades to help identify opportunities to improve safety and quality. One of the challenges is being able to create a data-driven culture based on our data and that available in public databases to identify opportunities

and develop a systematic approach to address them. We’re in the process of preparing a Baldrige application within the Commonwealth of Pennsylvania — another step toward developing standardized processes. It’s a well-used phrase, but we’re on a journey for safety and quality. We on the journey for Baldrige and we’re looking to marry those efforts as we go forward.

JIM BREXLER (Doylestown Health): We’re a 250-bed community hospital, but we also have a clinically integrated network that encompasses our retirement community, home care and physicians. One of the hallmarks of our network of care is that we’ve had data integration with our community-based physician practices to our institution since Y2K. We’ve been working with clinically integrated information for quite some time now. We use external data points to benchmark ourselves. We’re benchmarking on the same level as one of the Top 50 hospitals. We achieved that level by looking at the data and determining what we were missing and what we needed to do to get there.

One of the areas we’re struggling with is population health. We are working hard to take the data we receive from our accountable care organization and marry it with our institutional data. That will help us assign predictive risk scores to our primary care practices and to our community

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case managers who are managing population health issues. And it will help in creating a risk-stratification tool to allow us to get out in front and capture events before they happen. That’s a different way of thinking.

SCOTT MALANEY (Blanchard Valley Health System): You’re touching on a subject that is one of the main reasons why I wanted to be part of this discussion. How do you account for something that never happens?

BREXLER: It’s a learning curve, for sure. We’re three years into a series of risk-based contracts and we’re really careful not to put too much downside risk into the equation with some upside issues. We’re learning where the leverage points are within that and then we try to take that back into the payer world and negotiate better contract structures that go with that. It’s kind of exciting. I spent almost 40 years as a health care executive but, in reality, I was an illness-response executive. Today, I truly feel as though we’re organizing ourselves to manage the health and recovery of populations in a different way. So, the only way to get there is to work with data points that we typically never saw in the hospital, because they reside with the community practices. Now we’re integrating all of the data points that we have and creating algorithms that allow us to actually do something with that information.

THERESA LEDESMA (CareTech Solutions): When you look at what measures you really need to support population health, it’s not just what CMS or other governmental agencies require. You need to understand the pulse of your patient population to understand where those opportunities are and then use the data to guide improvements. It sounds as though you have a nice balance, Jim.

BREXLER: We’re learning. I don’t want to say that we’re there, but it has been fun to work with our primary care physicians and get them on board to identify their patients who are at risk. They are excited about the information that’s now available and they want to make a difference.

JAMESON: That’s the biggest challenge in being able to bring health care into the data realm. We haven’t always had the benefit of being able to mine big data.

MALANEY: I’m on the board of commissioners for The Joint Commission and we have discussions about the

efficacy of data. Much of what we’ve relied upon in the past is administrative data. We’ve relied too much on physician documentation that may not provide the whole picture. Now we are more data-driven and, hopefully, on the right track.

MATTHEW COSTELLO: (Doylestown Hospital): Jim highlighted much of what we’re doing. We have been working with our Doylestown Health physicians to develop clinical criteria. We’re trying to make sure that our primary care physicians are driving what’s best for their patients. We’re working closely with high-risk patients and their families to assist them and identify their needs to prevent readmissions. It’s been a tremendous success. Through our risk-based contracts, we have negotiated incentives for clinical outcomes and readmission rates. We’re doing all of these things to keep the folks in the community healthy.

BREXLER: Another thing we’ve worked hard on is determining what physicians really need to do their jobs and what data we need to move population health. The argument about big data is correct. There is such a thing as

Today, I truly feel as though we’re organizing ourselves to manage the health and recovery of populations in a different way.

– James Brexler Doylestown Health

We’ve relied too much on physician documentation that may not provide the whole picture. Now we are more data-driven and, hopefully, on the right track.

– Scott Malaney Blanchard Valley Health

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too much data. Too much data is often not actionable. We need to get down to what clinicians need to do their jobs.

BARBARA KARPINSKA (University Hospital): We are in an exciting and interesting place right now. Our CEO has been at University Hospital for less than two years; my boss has been there a year and I’ve been there for six months. Our chief medical officer also joined the team recently. There’s a new team in place and we are just at the beginning stages of really articulating what our path should be. We engaged a consulting firm to help us build a database for our performance benchmarks and a dashboard. For 2019, our focus is going to be workforce, quality, volume, growth and community. We are a safety net hospital for the Newark, N.J., community. In a nutshell, the most reliable data that we have are Press Ganey and CMS’ HCAHPS data. But we are working to change that. It’s a really exciting opportunity and we know that we can make a difference.

MALANEY: Blanchard Valley is located in Findlay, Ohio, the smallest city in the U.S. with two Fortune 500 companies’ headquarters. We also have some other multinational corporations with major facilities in our town. Almost everything we do is through direct contracts. They’re all self-insured. We really don’t deal with insurance companies; we deal with third-party administrators and leaders of

companies. Obviously, this is different from that of most health care organizations.

In 2003, we convinced some of those companies — Mar-athon Petroleum Corp., Whirlpool Corp., Ball Corp. and Cooper Tire & Rubber Co. — to take their claims data and dump it into a central database. So, we’ve been tracking data longitudinally since 2003. We bring the employers, our medical staff and administrative team together to look closely at the data. What is it telling us? We all agree that we want to take on major public health issues — blood glucose control, blood pressure and asthma. And we are getting better each quarter. We conducted a nonscientific study of blood glucose control, by looking at 100 patients with well-controlled blood glucose and 100 patients whose blood glucose was not well-controlled. Those whose blood glucose was poorly controlled often experienced hospital stays. What we learned is that it really didn’t matter what we did in the hospital if their blood glucose levels weren’t con-tained. It leads to significant problems. In 2009, Whirlpool asked us to partner on a patient-centered, medical-home pilot. It was a natural progression from the data collab-orative to partner in this way. That has led us to working with Geisinger to learn about and deploy patient naviga-tors. We have patient care navigators embedded into the community and in physicians’ offices. It’s a hockey game, of sorts. If they can keep someone out of the hospital or emergency department, they get a save. It’s kind of amaz-ing what we can do.

LEDESMA: As several of you mentioned, the big focus for many organizations is finding the right data to move the needle on clinical outcomes. We work hard to understand the different stakeholders within the process stream. If you don’t get the right people involved, you miss an opportunity and it could create an effect you don’t want, right? Being able to understand who’s involved and how they interact and what the intricacies are is what we are all about. I started my career at General Motors, but later worked for several health care organizations and understand the challenge of keeping patients out of the hospital. We found that many readmissions occurred after multiple ED visits by the patient. As part of our initiative to reduce readmissions, it was important to get patients


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involved and ask for their input. Patients are a central part of the process stream.

COSTELLO: That is really important, especially as we continue to work to determine what data are most meaningful. We work closely with our primary care physicians to identify risks and opportunities. We also helped to sponsor Health Quality Partners, which uses community-based, nurse care managers to support patients with chronic conditions. These nurses provide input on what’s going on in the community, information beyond what the data could ever provide. For example, one patient wasn’t compliant in taking his medications because he couldn’t find it in his medicine cabinet. So, we have to wrap the two pieces together, the data and the anecdotal feedback. We have to find a way to get ahead of this rather than just wait for the hospitalization itself.

MODERATOR: How are you integrating those anecdotal pieces of information from the field?

COSTELLO: We have several contracts that put us at risk and also provide us with data that we historically have not had. Payers have not traditionally shared information with hospitals, but now that they are attributed lives, there’s a responsibility there. We get direct information from self-insured organizations, third-party administrators or the payer itself. And so, we’ve taken that and the Medicare data, and we pull it all together. That leads to some powerful information, and we don’t have to wait on the retrospective billing data.

JAMESON: That gets to the culture of integration and interconnectedness. As Matt said, historically, we haven’t had a level of integration. But now we see how integration can really support the alignment of direction. We may have the ability to have that alignment. It really becomes an issue of culture and how you can get disparate parties to the table and get them aligned in the same direction. That becomes a critical piece.

COSTELLO: One of our challenges is getting information from nursing homes. Often, when a patient leaves, you don’t know where they go and then you get hit with a

readmission from a nursing home that you don’t even know about. How do we ever get to where we can really understand that?

JAMESON: That’s the role of a navigator and this has made a big difference in our bundled-payment initiatives. The navigator becomes the connection between acute care and the skilled nursing facility. He or she is able to monitor what’s

going on there. We look closely at admissions that come from skilled nursing homes and look to identify solutions.

BREXLER: We collect data from Medicare that give us information about where patients go. Under bundled payment, we have the 90-day period for which we’re responsible, right? For the first time, we have information about where patients go post-discharge. For our orthopedic patients, we’ve found that where the patient goes afterward makes a big difference. There’s a big variation in outcomes in the post-acute setting. We also looked at pneumonia to figure out what’s happening there. It’s all across the board. But the process helped us to identify data gaps and gave us information about the nursing homes. We’ve created a nursing home consortium that meets regularly and we hold them accountable and give them information about what they’re doing and what they’re not doing. By putting all of these pieces together, we can obtain meaningful information.

LEDESMA: When we look at data, we think we’re identifying what’s going to impact our performance and what’s going to move the needle. In my world, I look at process and culture because they have to align for your processes to be successful and sustainable. The most important thing that we often miss is figuring out whether the organization will

We look closely at admis-sions that come from skilled nursing homes and look to identify solutions.

– Eileen Jameson Jefferson Health


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be able to sustain change. How can we ingrain change into everyday practice? If I don’t engage my team and create the right culture, it blows up. We’ve instituted a sustainability plan with all the projects we are working on. Depending on the size, it could range from three months to a year. Within my project team, we’re continually touching, monitoring, moving and shifting to make sure that the improvements we’ve made are being built into everyday action. If I walk away and things fall apart, I didn’t do my job.

MODERATOR: How do you involve your boards? What data do you share with them?

MALANEY: In our board meetings, we easily spend as much time on quality as we do on finance. The board, for example, is working with senior management to adopt The Joint Commission’s zero patient harm commitment to the community. We’re in the process of defining what that means. Having access to The Joint Commission is helpful. We will be reporting to ourselves, to The Joint Commission and to the community about our progress. We’re in a smaller community and have a community-based board for the most part. We’re also on the Baldrige journey; we have a Baldridge award winner as our board chair and he’s also on the national Baldrige board. He has phenomenal resources and he’s a really good guy, too. But I think that is also a part of all this. So, for us, the quality journey is very integrated and ingrained with the board process.

MODERATOR: Do you have certain quality measures that the board is looking?

MALANEY: One of the reasons why we’ve chosen the zero patient harm is because we found our root cause-analysis methodology to be very helpful. We do a ton of them and

we do them very quickly after something happens that we don’t like. We recently looked at colon infections following surgery. We conducted a thorough review and benchmark assessment. We didn’t find anything necessarily wrong, but we changed our pre-op process and the infections went away. And then everybody felt better. Initially, when we looked at the data, it was difficult to understand. At first, the doctors said this was an anomaly and would get better over time. The board agreed, but closely monitored the data. But it continued to trend not the way we had hoped. That’s when we knew we had to take a deeper look at things.

BREXLER: Board engagement is critical. And our board won’t stand by quietly if they see something they don’t like. Our board is very involved. We have board members who sit on the hospital patient safety committee. Quality is a robust part of every board meeting — a great discussion. The board operates as a whole, as opposed to delegating quality to only a few people. An equally important issue is physician engagement. Physicians have to be really engaged. We have a wonderful group of physicians. We created a joint venture with our physicians so that all are equity owners with the institution for risk contracts. The dis-cussion about the continuum of care doesn’t happen in the traditional medical staff world where there are limitations and controls. You put it in a box where everybody has both economic and clinical alignment. Primary is sitting at the ta-ble, along with all the specialists. We built the structure so that no one party can outweigh the other. It a participative,

The most important thing that we often miss is figuring out whether the organization will be able to sustain change. How can we ingrain change into everyday practice?

– Theresa Ledesma CareTech Solutions


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shared-governance model. We’ve all got a stake in the deal. By creating common interest, we’re creating both clinical and financial integration. We’re seeing great progress.

COSTELLO: We’re able to sustain our results because our processes are hardwired. We’re not having as many problems with nursing homes anymore because more of our patients are going home after their stays. Some things are more difficult to make stick, typically where there’s more complex disease involved, such as congestive heart failure. It’s hard to get a handle on with regard to the data. This is when we really look to our care managers. We are able to measure how many admissions they’ve had. We want to know the cost of care. It’s had a huge impact nearly across the board. You have to target those things that require continued effort. You can’t have certain people fall off the radar screen.

MALANEY: Our organization decided three years ago to invest in what we call PMO [project management opportunities]. That came out of our experience with manufacturing. One of the learnings that really makes me shake my head is that despite knowing where you are and where you want to go, you still have about an 80 percent chance of failure. Even if you have all of the data you need, it does not in any way, shape or form

guarantee success. The project managers have helped us tremendously, by building gateways and processes. They are helping teams of people that have everyday jobs to keep the ball moving. It’s creating a positive pulse for our organization.

LEDESMA: To be successful, you need to have Lean ex-pertise, Six Sigma, which is the statistical analysis, and also project management skills. You must identify your chal-lenges, measure them to understand why they are broken and then use project management to oversee the identifi-cation and implementation of each solution. It’s important to hear from all of the stakeholders, including patients.

MODERATOR: How are others using the patient experience?

BREXLER: We have a patient advisory committee that has positively impacted the patient experience. One of the things that emerged was a better process for dealing with patients who have dementia. We now have a process to collect personal information and create a sheet so caregivers know what’s important to these patients. That connection with the patient and the family is amazing.

JAMESON: In addition to our work with patients and families, it’s important to remember the voice of the employee. We have more than 6,000 employees at Abington, and we’ve asked our employees to tell us their story as a patient or family member. We record their feedback and play it at management team meetings. It’s interesting because you have somebody who sees both sides — someone who’s worked the long shifts, but is also the daughter of an Alzheimer’s patient.

BREXLER: We’re blessed to have a huge volunteer core. The culture of Doylestown has been very much governed by a local women’s organization. We’re an independent hospital and volunteerism is huge. There’s a volunteer in every department. We transport every patient with a volunteer; it’s a very engaged group. Their feedback loop is important.

COSTELLO: Having the continual voice of the customer keeps us grounded and reminds us of what we’re about.


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A previous organization in which I worked moved its executive offices from the hospital to an office building across the street. I felt very disconnected, as if I were in a corporate environment, not in a health care environment. Today, part of my journey personally has been to return to an environment where I can still walk the halls and see folks and be in touch with the associates and families. That helps to set the tone within an organization as well.

MODERATOR: Barbara, how are you able to hear the voice of the patient?

KARPINSKA: I agree with Matt’s comments. I recently moved from Manhattan to Newark because I feel I cannot really serve the community well if I don’t understand it. Just recently, I started using the services of the hospital, so I again understand how it works and what the experience is. I ask the members of my team if they use our services. If not, why? Population health, and how we serve our community, has to start from within. If we can’t control our own popula-tion, how can we manage the community? I think that this is really where the culture change will occur.

MALANEY: Two of our board members go into the hospital or nursing home each quarter just to talk to people and get a pulse on how things are going. We really appreciate the support of the board in doing that and they’re very enthusiastic.

JAMESON: We do that as well, and it’s had a good effect overall because it is reported back to the entire board. On the ground level, folks would say that it’s beneficial because the artwork and flooring have been improved! It’s important for the board to see what it’s like.

LEDESMA: Changing the subject a bit, what types of proac-tive things do you do to address the data or to understand

what the data are doing with your organizations? Does she mean “what your organizations are doing with the data”?

COSTELLO: This may be a little granular, but each morning we have a daily safety huddle. We talk about events that have happened and decide whether we need to conduct a root-cause analysis. We discuss how many patients we hold in the emergency department. What’s the census? What’s the surgery schedule? Where might we have hurdles today? What did we experience yesterday? When was the last time we had a fall? When was the last time we had a reportable event? How many patients are in isolation? It provides a snapshot of the whole hospital so that everybody on the management team is aware. It helps.

LEDESMA: That’s not granular because it identifies exactly which processes are successful and which need fixing. That’s good.

JAMESON: We’re starting to look at the use of predictive analytics. For example, how can we look at what’s going on in the Emergency Trauma Center on Thursday, Friday and Saturday and predict what the patient flow will be on Monday. How many patients do we need to hold in the ETC, because we don’t have the beds. If we have 50 percent or more of our admissions coming from the ETC, we need to make sure we have a flow that supports the patient experience and clinical care. Instead of just being reactive to it, how can we predict it?

KARPINSKA: On that note, my dream is to be able to use predictive analytics to predict no-shows. That’s one of our biggest challenges because of the community we serve. Most of our patients use public transportation, so our no-show rates are within the 30-40 percent range.

Having the continual voice of the customer keeps us grounded and reminds us of what we’re about.

– Matthew Costello Doylestown Health

My dream is to be able to use predictive analytics to predict no-shows.

– Barbara Karpinska University Hospital


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Q & A W I T H J O S E S A N C H E Z

AHA Health Forum spoke with Jose Sanchez, president and CEO, Norwegian American Hospital, Chicago, at the AHA Annual Membership meeting about his organization’s efforts to develop a data-driven, patient-focused culture.

Which key performance indicators should your system focus on that will actually improve patient care and organizational inefficiencies?

The key quality metrics that we use are pretty much within the umbrella of the Centers for Medicare & Medicaid Services — all of the clinical indicators that I track through the integration of value-based purchasing. We focus on 30-day standardized hospital mortality rates for acute myocardial infarction, pneumonia, clinical outcomes for both hip and knee replacement, etc. We also focus on patient-safety metrics related to keeping a safe environment, such as infection rates and central line-associated blood stream infections. We are fully committed to providing the best possible care. To do that, we have become a data-driven organization so that we can make decisions based on understanding the population and the profile of the people who come through our doors.

When I joined Norwegian, the organization was in bankruptcy and struggling with a lack of physicians and community engagement, among other things. By focusing

on quality metrics, we’ve turned things around. When I first started, one of our approaches was to expand our network of physicians so that we could have broader reach within the market. But physician groups weren’t interested in coming to Norwegian. But, by focusing on quality, we

improved the organization’s financial position. We had both physicians and patients who were satisfied. And we were able to recruit more physicians.

How do you identify opportunities for improvement?

We make daily “in-touch” rounds every morning. These multidisciplinary rounds include

visiting floors to get a sense of what’s going on in each area of the hospital. We look closely at patients who have longer-than-expected stays. We look at throughput. It’s helpful. We look closely at patient and family feedback. We hired a patient experience officer to track every complaint and made sure to respond in a timely manner. Every month, I have breakfast with a different department. It’s their meeting, and they fill me in on what’s going on.

Another thing we do each month is to invite patients who’ve had bad experiences with the hospital to attend our leadership meeting. They get the opportunity to share their experience and tell us how they felt. It’s powerful.

How did the leadership team respond to your idea of bringing patients to that meeting?

In the beginning, there was a little resistance. But the messages are so important that now everyone understands the need to hear what our patients have to say, particularly when they have had a bad experience. That’s how we are changing the culture.

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