sep oct 2012 partners press-ganey

Truly Coordinated Care – the First Big Challenge for ACOsAs accountable care organizations proliferate, the challenges of following patients throughout the cycle of care are becoming clearer

A New Approach to Patient- centered CareTwo medical groups are �nding that focusing on the patient experience and strengthening relationships make patients stick to their practices

PartnersPartnersPartnersPartnersPartners

The Devil’s in the Methodology Readmissions Reduction Program targets a key source of high health costs, but rules pose big problems for hospitals

BACK PAGEFEATURESPECIAL REPORT

At Virginia Mason, Standard Processes Cut Waste, Improve Quality

A Production System for Health Care

ISSUE 25 | SEPTEMBER/OCTOBER 2012

Dear Colleague:

As this issue of Partners vividly illustrates, health reform has begun to take root across the country. Accountable care organizations are proliferating in both the commercial market and within the government’s two ACO programs. New payment reforms such as the Readmissions Reduction Program and value-based purchasing are now affecting reimbursements, creating a lot of uncertainty and anxiety in the industry.

Providers are working hard to improve the quality of care and the patient experience. New rules are coming at them almost weekly, as pay-for-reporting and pay-for-performance programs expand into new sectors such as medical practices and ambulatory surgery centers and older programs add new quality metrics and reporting requirements.

Our cover story is about how Virginia Mason Medical Center didn’t wait for reform to improve. It has spent the past decade adapting the Toyota production method to health care in the most rigorous manner of any provider in the U.S., rooting out waste and standardizing care protocols.

The special report, on ACOs, examines how three leading health systems are leading the way toward coordinated care across the continuum. Geisinger Health Care in Pennsylvania, Atrius Health in Massachusetts and Advocate Health Care in Illinois are pro�led.

Of special interest to readers is the Back Page, which is about the complex rules surrounding the Medicare readmissions program. We look at the methodology CMS is employing and explore our technical approach, which helps our clients understand the complex nuances that are associated with the readmissions program and on the broader scope of outcomes-based regulatory programs.

Underlying much of the content in this issue are data. Virginia Mason could not have changed its care protocols without access to data on utilization and ef�cacy. You can’t track readmissions accurately without powerful data tools. No ACO can even exist, let alone succeed, without a robust EMR infrastructure and data analytics.

At Press Ganey, we are working hard on expanding our capacity to provide the quality and quantity of data providers need to succeed under reform, as well as the analytics to make sense of it and take effective action. You will be hearing a lot more about that from us in the coming months.

Patrick RyanCEO

Press Ganey Partners is published by Press Ganey Associates, Inc., 404 Columbia Place, South Bend IN 46601, 800.232.8032. Quotation is permitted with attribution. Readers are permitted and encouraged to distribute copies within their organizations. Please direct comments or suggestions to [email protected]. All material is copyrighted by Press Ganey Associates, Inc.

A Quick Word

SPECIAL REPORT BACK PAGE

Contents

Training for New Battles As part of a year-long program, doctors at Lancaster General Health tour the Gettysburg Battle�eld to �nd out how the values, leadership, courage and organizational behaviors of three days of battle in 1863 apply to leadership issues being played out in today’s health care arena.

The Devil’s in the Methodology Just emerging from the wide shadow cast by the Centers for Medicare and Medicaid Services’ Hospital Inpatient Value-based Purchasing Program is another payment reform with potentially greater risk for hospitals: CMS’ Readmissions Reduction Program. The program targets a key source of high health costs, but the rules pose big problems for hospitals.

Truly Coordinated Care – the First Big Challenge for ACOs As accountable care organizations proliferate, the challenges of following patients throughout the cycle of care are becoming clearer. Also, we look at the state of play in both the commercial and public sector ACO markets.

Issue 25 | September/October 2012

A New Approach to Patient-centered Care Aurora Medical Group and Aurora Advanced Healthcare in Wisconsin and Illinois are �nding that focusing on the patient experience and strengthening the relationship between the patient, the doctor and the patient care team make patients stick to their practices.

22

The Lead News and Notes on Quality Improvement

2

The Learning Lab for Health Care Transformation Over the past decade, Virginia Mason Medical Center has achieved higher quality and safer care while lowering costs, improving patient satisfaction, almost eliminating staff turnover and staying competitive business-wise – all a result of a production system adapted from automobile manufacturing.

22

Empowering Engagement at a Children’s ED Under the banner, “One Team, One Goal: Compassionate Care for Your Child,” the CHRISTUS Santa Rosa pediatric emergency department has a new unity and vision.

30

Sign up for Partners Preview Email Press Ganey Partners subscribers can now get a sneak peek inside the next issue. To sign up for the preview, simply send an email to [email protected]. Please provide your full name, title, organization name and email address.

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FEATURE

8 12 32FOCUS

4

SPOTLIGHT

COVER STORY

2 Partners | September/October 2012

News and Notes on Quality Improvement

n Is There Really a “Weekend Effect”?

The old belief that hospital quality is worse on weekends, something many patients also are aware of, is taking on the aura of truth, even if nobody quite understands why it’s happening.

A Johns Hopkins study published in the Journal of Surgical Research reviewed more than 38,000 patient records of older adults who sustained head trauma over the weekend and found that they were 14% more likely to die from those injuries than patients with similar injuries who were hospitalized Monday through Friday, even after accounting for other factors.

“The underlying mechanism responsible for this disparity may be related to differences in weekday versus weekend staf�ng,” the study concluded. “However, this must be studied further so that the factors driving disparities in outcomes can be thoroughly understood and the increased risk associated with weekend treatment for head trauma can be eliminated.”

The study’s lead author, Eric B. Schneider, an epidemiologist at the Johns Hopkins University School

The Leadof Medicine’s Center for Surgical Trials and Outcomes Research, says: “There isn’t a medical reason for worse results on weekends. It’s more likely a difference in how hospitals operate over the weekend as opposed to during the week, meaning that there may be a real opportunity for hospitals to change how they operate and save lives.”

A separate study published in the Archives of Surgery reviewed 31,832 patient �les and found worse outcomes for patients undergoing urgent surgery for left-sided diverticulitis who were admitted on the weekend versus weekdays.

“Patients undergoing urgent surgery for left-sided diverticulitis who are admitted on a weekend have a higher risk for undergoing a Hartmann procedure and worse short-term outcomes compared with patients who are admitted on a weekday,” the study concluded. “Further research is warranted to investigate possible underlying mechanisms and to develop strategies for reducing this substantial weekend effect.”

Previous studies have documented the weekend effect for heart attack, stroke and aneurism, but none says precisely what is driving the phenomenon.

n Readmissions Program Expands

The Centers for Medicare and Medicaid Services (CMS) has added 72 hospitals and health systems to a program aimed at improving care transitions and reducing readmissions.

The Community-based Care Transitions Program, which was authorized by the 2010 federal health care overhaul, funds the testing of locally developed provider interventions aimed at improving care transitions and reducing Medicare costs.

The total of 200 acute-care hospitals now participating in the program are partnered with community-based organizations to provide nearly 185,800 Medicare bene�ciaries in 21 states with the targeted services, according to CMS.

The program was launched in the spring of 2011 as part of HHS’ $1 billion Partnership for Patients patient-safety and cost-control initiative, which the government predicted could save 60,000 lives over its �rst three years and save up to $50 billion in Medicare costs over a decade. Nearly one in �ve Medicare patients discharged from a hospital – approximately 2.6 million seniors – is readmitted within 30 days, at a cost of over $26 billion every year, according to CMS.

The program pays community-based organizations for each eligible bene�ciary when they are discharged and funds both care-transition services and systemic changes by the hospital.

Providers accepted to the �ve-year program sign two-year program agreements with CMS, and, if they meet the program’s goals, may renew for each year remaining in the program.

For more on readmissions see the Back Page (page 32).

3Partners | September/October 2012

n CMS Inpatient Psych Reporting Rule in Place

On Aug. 1, the Centers for Medicare and Medicaid Services announced the Inpatient Psychiatric Facility Prospective Payment System (IPFPPS) �nal rule for 2013, which requires reporting for cases as of Oct. 1, 2012. The �nal rule initiates the Inpatient Psychiatric Facilities Quality Reporting Program for freestanding psychiatric, acute-care and critical-access hospital care facilities with psychiatric inpatient programs that bill under IPFPPS. Fourth quarter 2012 data and �rst quarter 2013 data must be reported via QNet by Aug. 15, 2013 – and the �nancial impact is 2% of a facility’s annual payment update.

n Meet the New HCAHPS The Centers for Medicare and Medicaid Services (CMS) recently completed its plans for the new version of the HCAHPS survey. Hospitals are required to transition to the new version of HCAHPS beginning with Jan. 1, 2013, discharges. The expanded survey includes �ve additional questions. Three of the questions will be used to create the new care transitions domain, which will be reported on the Hospital Compare web site as a mean score. The care transition questions are:

n During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. (Possible answers: strongly disagree, disagree, agree, strongly agree.)

n When I left the hospital, I clearly understood the purpose for taking each of my medications (strongly disagree, disagree, agree, strongly agree, or I was not given any medication when I left the hospital).

n When I left the hospital, I had a good understanding of the things I was responsible for in managing my health (strongly disagree, disagree, agree, strongly agree).

Two additional background questions will be added to the “About You” section of the survey. CMS will be evaluating these questions to determine if they should be used within the patient-mix adjustment. The results from these questions will not be publicly reported.

The two new demographic questions are:

n During this hospital stay, were you admitted to this hospital through the emergency room? (yes/no)

n In general, how would you rate your overall mental or emotional health? (excellent/very good/good/fair/poor)

Hospitals had the option to begin collecting data using the expanded survey beginning with July 2012 discharges. For those that want to get a jump on the competition, HCAHPS improvement resources speci�c to the new transition-of-care domain are available to Press Ganey clients from within the Improvement Portal.

n CMS Taps CGCAHPS As Press Ganey has been predicting, the Centers for Medicare and Medicaid Services (CMS) has proposed adding a patient experience measure to the Physician Quality Reporting System (PQRS). The proposal calls for collecting Clinician and Group CAHPS (CGCAHPS) results beginning in 2013 for practices that participate in the PQRS Group Practice Reporting Option. Data collected by CMS in 2013 would be publicly reported in 2014 on the Physician Compare website.

CMS will not come out with a �nal rule until late in 2012 at the earliest. In the meantime, practices leveraging Press Ganey’s ongoing CGCAHPS Insights integrated solution will be able to continue improving the patient experience well ahead of any potential public reporting of data.


tour of the Gettysburg Battle�eld led by a retired Army of�cer and Civil War expert might seem like a stretch for a modern physician leadership training program, but don’t say that to one of

the doctors who has been through it.

Making a difference through communication and collective action and understanding how unilateral decisions made by independent-minded physicians can work against the goals of the larger organization are key lessons of Lancaster (Pa.) General Health’s Physician Leadership Academy (PLA). The battle�eld tour, led by Mark Snell, PhD, a professor of history at Shepherd University in Shepherdstown, W.Va., brings those lessons to life and is the high point of the year-long program.

Scheduled for midway through the program, Snell’s battle�eld metaphors explore how the values, leadership, courage and organizational behaviors of three days of battle in 1863 apply to leadership issues being played out in today’s health care arena. His tour includes a focus on “staff rides” that were developed not long after the Civil War as a cost-effective means of training of�cers to “think their way through” tactical and operational problems by using the terrain and historical context of an actual battle as a forum for sharpening tactical skills, re�ning intelligence interpretation and logistics planning, and gaining insights into the combat leadership challenges of their predecessors. Staff rides stimulate professional development, foster a deeper understanding of the operational art and promote unit cohesion and camaraderie.

ABy Betty A. Marton

Training for New Battles

TRAINING FOR NEW BATTLESFOCUS

A Physician Leadership Program at Lancaster General Health Explores Teamwork and Communication

Physicians spend the afternoon at Gettysburg absorbing insights into the qualities that make a great leader. Here, battle�eld tour guide Mark Snell, PhD, describes the importance of holding the high ground to physicians.

Betty A. Marton is a freelance writer based in New Paltz, N.Y. She can be reached at [email protected].


“We use the principles from Gettysburg as a way of showing the importance of communication and how the kind of independent thinking that we as physicians value so highly doesn’t necessarily help the bigger picture,” says Lee M. Duke II, MD, Lancaster General’s senior vice president and chief physician executive, who came up with the idea for the program. “The experience offers a host of teachable moments and valuable points of reference, as well as giving us a common bond.”

The 4-year-old program is part of a growing national trend among hospitals and health systems to educate physicians to understand and address the roles they need to play in containing health care costs and improving ef�ciencies. By providing them with the knowledge, tools and con�dence to become leaders within the hospital or their group practice, the PLA is fostering what it hopes will be a widespread and deep-rooted cultural change away from a focus on individual practice to one that puts the big picture – systemwide quality improvements and cost reductions – at its core.

“Our goal is to develop a group of physicians skilled in the art of medicine who focus not just on their individual cases and practices, but who can also talk about operational issues and can apply the best of what they do individually to the entire community,” Duke says.

A Structured Program

Drawing on a range of resources, including those available through the American College of Physician Executives, Duke developed the PLA, which has monthly 1½ hour sessions led by both internal and external teaching faculty. Instructors use a variety of approaches to explore such subjects as ethical leadership, quality initiatives, negotiation, change management, self-assessment and �nance, team building and clinical innovation.

The PLA curriculum also incorporates the experiences of key industries outside of medicine, turning, for example, to the Ritz Carlton for insights into how customer service concepts apply to the physician-patient relationship; the consulting �rm GenPac for approaches to waste and process improvement; and various MBA professors for discussions about the role and value of communication and ethics.

Although Duke and Carl Manelius, director of physician affairs, initially imagined 20 participants as the ideal size for each class, 26 physicians signed up for the �rst year and, out of the 50 or so inquiries they receive every year, subsequent classes have hovered around 28 to 30 participants.

“We work with everyone who is interested in applying by exploring what they see as their current strengths and what kinds of things they hope to bring to a leadership position,” Manelius says, noting that to date, eight of Lancaster General’s 10 department chairs have completed the course. “If more than one physician from a large practice applies at the same time, we talk with them to make sure that the timing and �t are right. So far, we haven’t turned anyone away, and our attendance rates for each session are around 90%, with a few at 100.”

In early 2011, after many years as deputy director of residency programs at Lancaster, Christine Stabler, MD, landed the next job she wanted: vice president for academic affairs. Although the position was a major step up with signi�cant new responsibilities, Stabler had the skills and con�dence she needed to go for it and, once installed, she felt “immensely prepared” to meet its challenges. And she has no doubt that her participation in the academy is at the root of her success.

“The Physician’s Leadership Academy gave me so many tools and brought me together with like-minded individuals who want to see the bigger picture when it comes to creating change within the health care system,” Stabler says.


“The program seems to have hit a nerve,” says Stabler, who in her new post is creating opportunities for both undergraduate and graduate students to learn about and apply leadership concepts and become part of the changing culture. “Our learning really accelerated in conversation with others, when we were able to share our insights and process. It’s designed to maximize and optimize the strengths of the attendees, who build on each others’ learning so we can take the necessary steps to transform ourselves from passive to active participants in creating change in our health care system.”

Christopher Hager, MD, a member of the �rst PLA class, has had a longstanding interest in leadership and has participated in other training within and outside of Lancaster Health. As one of three senior physician leaders of Lincoln Family Medicine, a

group practice within Lancaster Health, the skills and knowledge he’s acquired serve in a range of ways as he oversees and helps to manage about half a dozen practices.

“Leadership training exposes us to the kinds of things we don’t learn in medical school,” he says, “like learning how to help manage others’ performances to focusing on the customer experience. The session with the vice president of Ritz Carlton helped me realize that we have to treat our patients like people who have the choice of where to spend their health care dollars – because they do.”

Learning How to Negotiate

As a growing group of leadership-trained physicians, Hager and Stabler appreciate the added dimension and reach of the professional relationships with

Getting Away from the Grind

The program, which provides continuing medical education credits, is structured so that each session builds on the previous one, with formal presentations, activities to engage participants in the lesson and social time. Each session is held at a location away from the hospital to help remove the physicians from the pressures of their day-to-day work and is designed not only to be engaging, but to provide the experience of team building and foster a sense of collegiality that is often missing from physicians’ daily professional lives.

“Doctors’ lives are a grind,” Duke notes. “We provide good food in a nice setting so they feel like they’re getting away and are open to the kinds of dif�cult conversations that can arise when you engage people with different views and ways of thinking. And you know what? It’s fun.”

The sessions are supplemented by reading assignments from journal articles and such books as Better by Atul Gawande, MD; Getting to Yes by Roger Fisher, William Ury and Bruce Patton; Leading Change, by John Kotter; the Harvard Business Review’s On Leadership; and The Experience Economy: Work Is Theater and Every Business a Stage, by B. Joseph Pine II and James H. Gilmore. There are also homework assignments that help drive home the lessons being learned.

“These are men and women of the highest professional accomplishment, but they’re not necessarily prepared as leaders, able to address the clinical as well as the policy and business side of a hospital or large practice,” Manelius says. “Our task is to sensitize them and help them tune into issues of leadership as well as to help them learn the fundamentals of business and management that will prepare them to take on these new roles.”

Extending the Reach

For Stabler, who participated in the second PLA class from 2008-2009, the value of the tools and activities offered at each session of the program was exponentially increased by sharing the experience with her classmates, who came from different departments, specialties, generations and levels of experiences.

TRAINING FOR NEW BATTLESFOCUS

“We use the principles from Gettysburg as a way of showing the importance of communication and how the kind of independent thinking that we as physicians value so highly doesn’t necessarily help the bigger picture. The experience offers a host of teachable moments and valuable points of reference, as well as giving us a common bond.”

Lee M. Duke II, MD

Senior Vice President and Chief Physician Executive Lancaster General Health


who can simultaneously continue to provide care while applying �nancial disciplines. I’ve heard from several CEOs that because so much is in �ux, there’s no better time to be in health care and make a difference.”

Battle-tested Lessons

The Gettysburg tour is an apt analogy, for leaders and for those in the trenches. “Like health care organizations, the Army is a large organization with leaders, staff, subordinates and a mission to accomplish,” Snell says. “We look at how decisions were made by generals; how personalities in�uence outcomes; the upward and downward �ow of communication; and how such resources as personnel, equipment, supplies and �nancing shape the mission of an organization.”

Physicians spend the afternoon at the Gettysburg tour absorbing insights into the qualities that make a great leader – the ability to communicate well, the moral courage to make tough decisions and the ability to make sure resources are available when they’re needed. And he tries to drive home the medical aspects of the battle, which caused 51,000 deaths and left tens of thousands of soldiers wounded. Snell also relates the story of how the death of Confederate Gen. Stonewall Jackson forced Gen. Robert E. Lee to reorganize his troops less than one month before the battle, creating the same types of problems that would affect any large organization today.

The bonds formed among the physicians who participate in the PLA increases each year as more and more of them are able to build on shared experiences and common points of reference that are laying the ground for system-wide ef�ciencies and cost containments to take root.

“When physicians come out of their silos and talk to other physicians to solve problems and speak collectively, that’s what creates the shift,” Snell says. “That’s the platinum standard, and that’s where we’re headed.”

colleagues who share these similar interests and experience. This broader sense of community makes it easier to know who to call if they have a clinical or practice question and, Hager points out, the training also helped sharpen his ability to negotiate, something he thinks most physicians dislike.

“Pretty much everything we do involves negotiating,” he says, “whether it’s with another physician who’s not compliant with a policy, with an insurance company over a contracted rate, about hours and scheduling with a colleague or with a patient about a treatment plan.”

“It’s also helped me to think outside the box when it comes to marketing. What is the competitive advantage I offer patients over other physicians?” he adds. “This is something I try to drive home in my practice every day, because the bottom line is that it’s the right thing to do. It’s why we went to medical school.”

The need for a new approach to both clinical and practice issues to extend beyond the ranks of top hospital and health care executives is becoming increasingly apparent as evidenced by the growth of membership in the American College of Physician Executives (ACPE). Founded in 1975 to provide leadership and management skills to physicians and encourage them to assume more active roles in their organizations, the ACPE has grown from 64 to more than 10,000 members, as more and more physicians, nurses and health care organizations understand that everyone needs to play an active role in response to declining reimbursements and rising costs – issues that aren’t going away any time soon, according to Gregory Shea, adjunct professor of management and adjust senior fellow at the Leonard Davis Institute of Health Economics at the Wharton School, University of Pennsylvania.

“The pressure to reduce costs and increase quality is clearly growing, and there’s no indication that it won’t continue to grow for a long time,” Shea says. “There have always been physicians in senior leadership positions, but now we have to reach those in the trenches – clinicians who understand the strategic imperative, the national and local imperatives and


hat an awkward exchange!” I thought as I sat in the waiting room of a southeastern Wisconsin medical clinic, anonymously observing patient-

staff interactions. A staff member for an internal medicine practice had just opened the door to the waiting room, called her elderly female patient by �rst name, and then waited… and waited… and waited.

In the meantime, the elderly patient gripped her walker and struggled to gain the leverage to pull herself to her feet. As the patient worked to stand for roughly 15 seconds – seconds that seemed more like minutes – the staff member just stood in the doorway, all with a smile on her face, only 10 feet away.

A NEW APPROACH TO PATIENT-CENTERED CAREFEATURE

A New Approach to Patient-centered Care

Unfortunately, this is an all-too-common scene in practices and clinics across the country. A nurse or medical assistant opens the door to the waiting room, calls a patient’s �rst or last name, and then stands in the comfort of that doorway until the patient has gathered his or her belongings and approached the staff member. If the staff member is focused on the patient, then she might greet that patient with a smile and some small talk. However, it’s equally as common to see the nurse or assistant turn and begin walking to the exam room without a proper greeting.

In an age when more organizations explicitly focus on patient-centered care, a more personal, intimate way of acknowledging and interacting with the customer ought to be standard practice.

“WBy Daniel Bent, MBA, Manager,

Improvement Services, Press Ganey Associates


“Second chances to provide an excellent experience are getting harder to come by; in a world of increasing transparency and interconnectedness – where a person can share a story with hundreds of people in a click of a button – our ability to build trusting relationships and a solid reputation for personalized care is going to be the difference.”

For example, rather than call the patient’s name from the back of�ce doorway for everyone to hear, what if the nurse or assistant left that doorway, approached the patient where she sat, and personally invited her back to the exam room? What would that communicate to that patient in terms of sensitivity to her unique needs, both physical and emotional? Would it convey a more genuine respect for her privacy?

Several of the medical practices within Aurora Medical Group and Aurora Advanced Healthcare utilize this more personalized approach to patient interactions and have learned the answers to these questions. What they have seen is a signi�cant positive impact on the patient experience. The practices are part of Aurora Health Care, an integrated, not-for-pro�t health care system serving communities throughout eastern Wisconsin and northern Illinois.

“Our key purpose is to help people live well. To accomplish this, we’re �nding ways to individualize and personalize the patient interaction,” says Brad Kruger, senior director of clinical operations for Aurora Advanced Healthcare. “In addition, almost every health care organization in our market uses Epic as its electronic medical record vendor. With Epic’s ‘Care Everywhere’ solution, the switching costs for a patient in southeastern Wisconsin are minimal. The best way to make a patient ‘stick’ to your practice is by focusing on the patient experience and strengthening the relationship between the patient, the doctor, and the patient care team. Second chances to provide an excellent experience are getting harder to come by; in a world of increasing transparency and interconnectedness – where a person can share a story with hundreds of people in a click of a button – our ability to build trusting relationships and a solid reputation for personalized care is going to be the difference.”

When Lori Hundertmark, clinic operations manager for Aurora Advanced Healthcare, �rst attempted to change the standard staff-patient interaction at her Hartford clinic, she faced patient satisfaction scores in need of improvement. The clinic ranked near or below the 50th percentile nationally on questions such as, “concern for patient privacy” (46th),

“sensitivity to patient needs” (43rd), “cheerfulness of the practice” (39th), and “friendliness and courtesy of the nurse/assistant” (56th). The clinic’s loyalty metric, “likelihood of recommending the practice,” ranked at the 29th percentile. The challenge seemed daunting.

“We needed to take a big site and make it small,” Hundertmark says. “So, we tackled improvement by department rather than the clinic as a whole. We looked at each department, or ‘pod,’ and tried to make it feel like home to the patient. We also started with our strongest-performing pods and tried to enhance what each already was doing well. That allowed for some quick wins before we attempted to improve the other departments.”

Hundertmark’s approach was to personalize the patient interaction as much as possible, including the nurse call-back process. In order to rapidly effect change among her staff, she divided her improvement efforts into three key parts:

n Communication of Aurora’s service commitments to staff

n Rollout of new standards and staff training

n Rounding on staff and coaching to ensure consistent use of the service commitments

Communication of Service Commitments

Hundertmark clearly outlined for employees the service commitments Aurora expected of them. Caregivers no longer were permitted to call out patient names in the waiting room. Instead, the front desk staff communicated with the nursing caregivers to assist with identifying patients, and then the caregiver would enter the waiting area and invite each patient to the exam room. Eye contact and smiles were a necessity. Staff members also were expected to take ownership of the waiting area so that messes were cleaned up, patient issues were addressed before they became problems and patients were kept better informed of delays in the of�ce schedule.

Brad Kruger

Senior Director of Clinical Operations, Aurora Advanced Healthcare


Leadership Rounding and Coaching

Once staff initially had been trained on the service commitments, Hundertmark held the team accountable through leader rounding. Not only would she regularly walk through the waiting area to check on patients and the general appearance of the room, but she also took time to observe staff-patient interactions. If she witnessed behavior outside of Aurora’s service standards, she discussed it with the employee at that moment. “I wanted to address their behavior when it occurred so that they could feel what they did and put it in context,” says Hundertmark. “Staff also needed to exercise more personal awareness. For example, if an assistant called ‘Bill’ and there were only women in the chairs, she would have looked foolish. Not only would she have done something unacceptable in our clinic, but she also would have interrupted all of the patients for no good reason.”

Hundertmark emphasized that the department supervisors play an important role in the coaching process. “If I observe a staff member not smiling, I’ll ask her if she’s not feeling well or if something is wrong. I’ll then share my conversation with the supervisor and give her ownership to follow up with the caregiver. If the supervisor has had that crucial conversation with the caregiver and the behavior doesn’t improve, then I’ll get involved and have a conversation. If a positive change isn’t noted, then the supervisor works closely with the caregiver to assure the patient experience is not affected. It’s key for us to have the right people in the right job. Doing your job well, but doing it without kindness or compassion, doesn’t bene�t our patients.”

A patient service representative states: “The changes that we made provide the patient far better care and treatment. We have been made more aware of how we treat the patients to make a better experience for each one of them. We didn’t know we were doing things the way we were; someone needed to make us aware of how we are perceived. Now we are attentive to, and are held responsible for, the personal care we provide.”

However, as Hundertmark contemplated how best to communicate the service commitments to staff, she quickly realized that she �rst needed to change her own personal habits.

“Just like my staff, I found myself standing in the doorway when I called patients back to the exam room. I thought, ‘This is silly. The door isn’t going anywhere. Why am I so attached to this door knob?’ So, I needed to retrain myself to go into the waiting room and interact with the patients to set the example for the caregivers.”

Hundertmark also changed her habit of taking back hallways to navigate her of�ce building and, instead, walked directly through the waiting areas for each pod. This provided her greater visibility to her patients, a better awareness of the condition of the waiting room, and more opportunities to observe and interact with her staff.

Rollout and Training

In order to effectively introduce the new standards and train her staff, Hundertmark scheduled three half-hour, town-hall-style staff meetings per month over the lunch hour to personally demonstrate the habits she expected. She encouraged staff members to ask questions and participate in the demonstrations so that they felt more comfortable with what was being asked of them. The department supervisors also attended the meetings so that Hundertmark had those closest to the caregivers in the room with her to address questions to which she might not have the answers.

This training continues to be a monthly occurrence. It now has a more formal agenda during which Hundertmark reviews safety issues, the patient experience, the clinic’s CGCAHPS scores, and a dozen other items important to the performance of the clinic and the work of the caregivers.

A NEW APPROACH TO PATIENT-CENTERED CAREFEATURE


Hundertmark also bene�ted from the support of key physician leaders. David Chen, MD, and Bryan Jewett, MD, engaged their peers and provided support through physician rounding and coaching. They also ensured caregivers’ voices were heard during the change process. As a result, the clinic quickly addressed and resolved issues and prevented future problems.

The Results

Once implemented, Hundertmark and Kruger began to see slow but immediate changes in the patient satisfaction scores for the clinic. One year after implementing the service commitments, consistently rounding on staff and coaching for success, patient loyalty scores for “likelihood of recommending the practice” jumped from the 28th to the 73rd percentile. In addition, “concern for patient privacy” moved from the 48th to the 75th percentile, “sensitivity to patient needs” improved from the 43rd to the 83rd percentile and “friendliness and courtesy of the nurse/assistant” increased from the 56th to 88th percentile.

The Hartford clinic also has seen a 12% increase in patient volume, and is on pace to record 65,000 visits this year. “The interesting thing about that number is that Hartford serves an overall stable population,” says Kruger. “We didn’t see an increase in volume because new patients were suddenly moving to the area. So, we believe this validates the changes we’ve made and the care we’re providing are making a positive difference in the lives of our patients. They’re staying with us for their care, and telling their friends and family about their experiences.”

The Hartford clinic is now the seventh-largest clinic by volume within the Aurora system. While the speed of improvement has been impressive, the success of the clinic is ampli�ed by the number of patients with whom staff interacts.

Carrie Nash, LPN, a nurse in internal medicine, notes, “After implementing all the little daily improvements, they have added up to both a better patient experience and clinic atmosphere. It seems patients and employees are happier.”

“When I �rst arrived, it felt like caregivers could make a difference and wanted to make improvements,” adds Hundertmark. “Now, during our town hall meetings, we continually acknowledge and say a big ‘thank you’ to each caregiver at our site. Together, everyone from each department of the site has adjusted to change and has come to realize the

“It’s key for us to have the right people in the right job. Doing your job well, but doing it without kindness or compassion, doesn’t bene�t our patients.”

Lori Hundertmark

Clinic Operations Manager, Aurora Advanced Healthcare

importance of the patient experience as a part of every encounter. It’s so heart-warming to witness the dynamic changes taking place and see people truly enjoying their jobs.”

The effects of this more-personalized approach to patient care also positively affected Aurora’s CGCAHPS results. The Hartford clinic’s patients rate their care above the 75th percentile for the “overall doctor rating” and three of the four domains on the survey. Impressively, “of�ce staff quality” currently ranks at the 84th percentile.

As the Centers for Medicare and Medicaid Services moves to a value-based purchasing model for group practices and clinics, Aurora’s strategy not only will differentiate it in the marketplace, but also maximize future reimbursement. This is a concern not lost on other physician groups across the country. I’m continually hearing of more and more practices adopting a personalized approach to staff-patient interactions in preparation for an environment where the patient experience affects reimbursement. Will yours be the next?


n 14 years as a hospital nurse, AdvocateCare’s Lori Schoeling has cared for patients at their very worst. But only in the past 16 months as an embedded outpatient care manager

has she been able to change patients’ lives for the better. Working within the framework of Advocate Health Care, a Chicago-area integrated delivery system, she offers services at no charge to select patients. Her work is to help them tackle bigger logistical, transportation, �nancial, education and support issues that wind up exacerbating their existing medical problems. She is part educator, part counselor and part pushy aunt.

For an elderly dementia patient prone to falling, Schoeling has hired home health care workers, recruited occupational therapists to assess the home and secured free respite care for the patient’s 80-year-old husband. For a chronic back pain sufferer, known as a “problem patient” who peppered her doctor with phone calls, Schoeling became a sounding board and �rst point of contact. She then coordinated primary and specialty visits and secured surgical and recovery care.

I

Truly Coordinated Care – the First Big Challenge for ACOs

By Rachel Brand

TRULY COORDINATED CARE – THE FIRST BIG CHALLENGE FOR ACOsSPECIAL REPORT

Rachel Brand is a freelance writer based in Denver. She can be reached at [email protected].

Geisinger Health Plan places nursing professionals in physicians’ of�ces as members of the primary care team. As part of this innovative program, case manager Michelle Michael, RN, counsels a patient regarding his medications.


“Everything I do is for the patients,” Schoeling says. “I try to put myself in their place and treat them as I would my own family. (The back pain patient) was in pain, so she was not very good at communicating, so I helped her get appointments sooner and probably averted an emergency room visit. It’s the personal touch.”

Schoeling is among a growing tribe of outpatient care managers charged with coordinating the care of very ill patients. How well they can reach out to such patients; build trust with them; and keep them healthy, on their medications and out of the emergency room may determine the fate of the U.S. health care system. That’s because 3% to 5% of all patients consume 30% of medical dollars. If health care systems can better manage these patients, everyone wins.

Right now, coordinated care for patients with multiple chronic conditions remains a lofty goal. The current fragmented health care system tacitly encourages such patients to ping pong from doctor’s of�ce to emergency room, hospital to nursing home. When providers discharge patients or wave goodbye to them in the hospital or physician of�ce parking lot, they typically see their job as done. As a result, tests are duplicated. Instructions are forgotten. Handoffs are incomplete.

The Challenge and Opportunity of Coordinated Care

Some 40 million Americans live with a chronic health condition that limits their daily activities, according to the Institute for Health and Aging at University of California, San Francisco. A chronically ill person might be an overweight professional man with hypertension who is at risk for heart disease or a child who is developmentally or physically challenged and needs special care and interventions.

Chronic illness doesn’t end someone’s life, but patients live longer when connected to a network of friends, family, clinicians and community organizations for support. What’s more, if they do become acutely ill, evidence suggests that a

coordinated approach to delivering care to these patients pays substantial dividends in health care quality and ef�ciency. Yet coordinating care for patients with chronic diseases is complex and involves numerous providers and effective communication processes.

More than a decade ago, the Institute of Medicine’s Crossing the Quality Chasm report highlighted the care coordination failings in the U.S. health system, stating: “The delivery of care often is overly complex and uncoordinated, requiring steps and patient ‘handoffs’ that slow down care and decrease, rather than improve safety. These cumbersome processes waste resources; leave unaccountable voids in coverage; lead to loss of information; and fail to build on the strengths of all health professionals to ensure that care is appropriate, timely and safe.”

“We try to interrupt bad things from happening, Our goal is to pull all the pieces together across the continuum. We’re not waiting for a crisis, but trying to assess who might be at risk for a crisis, to prevent it and to make sure they understand everything they need to do if it happens.”

Sharon Rudnick

Vice President Outpatient Enterprise Care Management Advocate Health Care

The Affordable Care Act tries to solve the problem. Medicare will soon penalize hospitals with higher-than-expected readmission rates, an effort to spur post-acute care coordination (see story, page 32). Medicare has contracted with 154 accountable care organizations (ACOs), a form of integrated provider network. Not only do ACO contracts require that providers hit quality benchmarks in order to receive savings payments, but also, by improving quality, providers stand to lower costs and more easily reach savings goals. Commercial payers are also pursuing ACO-like relationships. It’s early in the game, but a review of the work at three major health systems – AdvocateCare, Geisinger Health Plan and Atrius Health – shows promising results on better coordinating the care of patient populations.


AdvocateCare: Interrupting Bad Outcomes

Oak Brook, Ill.-based Advocate Health Care is a sprawling integrated delivery system with 12 acute-care hospitals, 250 sites of care and an af�liated network of some 4,000 physicians. In January 2011, understanding the need to clinically integrate, AdvocateCare became the nation’s largest ACO. It signed a shared savings, performance-based contract with Blue Cross and Blue Shield of Illinois for its 380,000 HMO and PPO enrollees. The goal was to reduce costs not against Advocate’s historical patient medical costs, but against a benchmark rate of all Blue Cross providers, while improving quality.

The 60 enterprise outpatient care managers such as Schoeling are central to achieving this goal. Trained as nurses, licensed nurse practitioners or social workers, each care manager is responsible for 110 to 150 patients, drawn from the 2.4% of the Illinois Blues’ commercial population predicted to incur 27% of medical expenses. Patients are �agged in the computer system via a retrospective review of Blues claims data, which has been run through a predictive modeling system. Although such patients have no primary diagnosis, they could have diabetes, chronic obstructive pulmonary disorder, heart failure, dementia, hypertension, chronic pain, asthma, multiple sclerosis or even cancer.

These patients “really, really need help,” says Sharon Rudnick, vice president, outpatient enterprise care management at AdvocateCare. “They might be overweight; their blood work is not on target. They really need to modify their behavior in addition to receiving clinical care.”

Care managers follow no boilerplate approach, but their primary charge is to engage patients and build trust with them.

“What surprises me most is I actually have patients who refuse our services,” Schoeling says. “They think we work with the insurance company or we’re trying to sway them. They don’t believe it’s a free service; they think there’s another agenda.”

Once the initial hurdle of distrust is overcome, care managers work wonders. Introduced to patients as an extension of the physician, care managers serve as the �rst point of contact when a high-risk patient gets sick or simply has a question. Care managers are also quick to refer patients to outside help – to transportation and to home care, as well as making sure their electricity stays on. When a patient hits the emergency room, software alerts the care managers, who then follow up with patients to ensure they set up appointments with their doctors. They work with licensed social workers who have a Rolodex of community health care resources at their �ngertips. Finally, trained in motivational interviewing skills, care managers home in on the real reasons why patients struggle to look after themselves.

“We all know we need to exercise, shouldn’t smoke, should eat healthy,” Rudnick says. “So how do you tease out what really are their barriers to self-engagement?”

Overall, patients welcome the extra attention. AdvocateCare’s patient engagement rate is over 85%, compared to 40% to 65% for disease management programs hosted by health plans. For the �rst six months of 2011, AdvocateCare’s hospital admissions per member fell 10.6% compared with 2010 results, and emergency room visits were down 5.4%.

“We try to interrupt bad things from happening,” Rudnick says. “Our goal is to pull all the pieces together across the continuum. We’re not waiting for a crisis, but trying to assess who might be at risk for a crisis, to prevent it and to make sure they understand everything they need to do if it happens.”



Reducing Hospital Readmissions

Just as Schoeling keeps patients out of emergency rooms and hospitals, her peers work to help patients heal once they go inpatient. AdvocateCare offers several experimental programs to boost post-acute care quality and curb 30-day readmissions.

“On the inpatient side, we’re looking at the acute-post acute transition and how to better evaluate what patients’ needs are,” says Lee Sacks, MD, chief medical of�cer for AdvocateCare. “If they are going to the nursing home, what are the key information pieces needed so that the handoff is done correctly?”

One pilot program aims at patients who don’t qualify for home care but, based on a readmission risk predictive model, need extra support. Within two days of arriving home, the patient gets a visit from a nurse transition coach. The nurse reviews the patient’s understanding of discharge instructions, sets up a follow-up appointment with a primary care physician and reconciles medications. The nurse observes the patient for symptoms that indicate the need for further clinical care and coaches the patient on self-management.

“(The nurse says), ‘Let’s go through your medications, let’s take them out of your cabinet and reconcile them. Let’s talk about your disease. Let’s talk about weighing yourself and how you’re going to call your doctor if you’ve gained �ve pounds,’ ” says Becky Trella, vice president of AdvocateCare’s Post Acute Network.

From August to October 2011, the program reduced readmission rates by 26%. The 174 transition coach patients had an expected readmission rate of 12.67% but an actual readmission rate of 8.62%. Since the program provided a positive return on investment, AdvocateCare will expand it to other hospitals.

“On the inpatient side, we’re looking at the acute-post acute transition and how to better evaluate what patients’ needs are. If they are going to the nursing home, what are the key information pieces needed so that the handoff is done correctly?”

Lee Sacks, MD

Chief Medical Of�cer, Aurora Advanced Healthcare

AdvocateCare has also hired inpatient care managers who target patients at risk of readmission. For certain patients, the inpatient care manager develops a discharge plan and works closely with physicians and home care to ensure patients have the proper home medical equipment and community support to heal.

Finally, AdvocateCare places advance practice nurses (APNs) within unaf�liated, community nursing homes to oversee high-risk discharged patients.

To understand the program’s signi�cance, consider the “old” way, Trella says. Typically, a patient would arrive at a skilled nursing facility and see a doctor within three days, per Illinois state law. Visits would then slow to once a week. “The doctors are hard-pressed to be there often,” Trella says, “or the patient is assigned a physician on staff at the nursing home, and the handoffs are less than stellar.” Patients, unprepared, wonder where their doctor has gone. Nobody monitors the patients or notices if their health worsens.

By contrast, APNs see patients two to three times a week and stay on-site. Each nurse manages 20 to 25 patients. “They are much more up on what is going on with the patient,” Trella says. The nurse, for example, would check a congestive heart failure patient’s vitals, rehabilitation and level of heart failure. “They are constantly adjusting the plan of care and preventing readmissions, just because of that.”

The program is expensive, she acknowledges, but has lowered skilled nursing facility lengths of stay to 20 days versus the Illinois average of 27.5 days. Further, hospital readmission rates fell to 13.6% in 2011 from 22% in 2010.

“The skilled nursing facilities love having the APNs on site,” Trella says. “Patients feel so comforted by the APN’s presence; I’ve never had a patient complain. The nurses say how wonderful it is to have the APN around; other patients are asking for them.”



Care Coordination at Atrius Health

Atrius Health is an independent alliance of six ambulatory medical groups based in eastern and central Massachusetts. The six medical groups include about 50 practice sites, with 1,000 employed physicians, 1,450 other health care professionals and staff caring for 1 million adults and pediatric patients.

Blue Cross and Blue Shield of Massachusetts invited Atrius Health to join its Alternative Quality Contract (ACQ) in 2009. The ACQ, which initially involved 100,000 Atrius Health patients, aimed to reduce medical spending growth while holding providers accountable and providing �nancial incentives for performance on 60 indicators of quality, safety and outcomes.

Due to a long history with managed care contracting, “it’s in our DNA that we are responsible for managing more than just the patient in front of us,” says Rick Lopez, MD, chief physician executive of Atrius Health. “We already had systems for sharing �nancial risk and tracking patients, and the AQC allowed us to get focused around a very speci�c quality framework. At the same time, we were on a mission to bring down our cost structure.”

Care coordination was central to this effort. “We sat down with local hospitals and we’d ask, ‘When patients are discharged, what kind of care will they have? When they are in the hospital, what kind of testing and specialty care should be arranged? How should you communicate with us?’ ” Lopez says. “One quickly gets a sense of whether the hospital wants to collaborate or simply be a vendor.”

For those hospitals that have become preferred Atrius Health partners, the teams have worked on collaborative process improvement projects.

Information technology was another key area for collaboration with hospitals. Recognizing that achieving a reduction in readmissions and successful patient transfers from one setting to another is reliant upon all of the parties having the right information

at the right time, Atrius Health worked with Beth Israel Deaconess Medical Center and Epic Systems to set up a web portal that lets clinicians at Atrius Health and Beth Israel access each other’s medical record with a single click from within a patient’s record.

This ability to exchange data in real time when needed to support patient care was so successful that it was subsequently rolled out to half a dozen other hospital partners and was “widely and favorably received by the practice,” says Lopez.

As a measure of the potential outcomes that can be achieved through initiatives like those that it has implemented, Atrius Health showed signi�cant improvement on the clinical quality measures, including several dozen clinical process and outcomes measures.

“The skilled nursing facilities love having the APNs on site. Patients feel so comforted by the APN’s presence; I’ve never had a patient complain. The nurses say how wonderful it is to have the APN around; other patients are asking for them.”

Becky Trella

Vice President of Post Acute Network Advocate Health Care

other patients are asking for them.”other patients are asking for them.”

Geisinger Gets It Right

Pennsylvania’s Geisinger Health System has been a leader in delivery system innovation. Geisinger operates four acute-care hospitals, one inpatient drug and rehabilitation center, two ambulatory surgery centers, and 55 primary care and specialty ambulatory care sites.

Seeing cracks in the fee-for-service delivery model, in 2004 system leaders, including Thomas Graf, MD, the chairman of Geisinger’s community practice service line, began a primary care process redesign. In 2006, through a partnership between Geisinger Clinic and Geisinger Health Plan, Geisinger launched Proven Health Navigator (PHN), its own ACO-like system.


PHN is built on �ve pillars: physician-directed, team-delivered care; integrated population management; medical neighborhoods; quality outcomes; and compensation. PHN started at three clinics and has added a dozen care sites yearly.

“Our philosophy was to shift from the patient alone trying to navigate the health system to the medical team working together to manage through this confusing system,” Graf says.

If one were to design the ideal medical of�ce, with each person doing exactly what they are trained in, nothing more or less – it might look like PHN’s clinics. Physicians concentrate on “physician work” – making complex medical decisions and forming relationships with patients. Nurses take care of process measures. Nurse and patient care coordinators respond to patient needs. The electronic health record is leveraged as a member of the team, handling scheduling and prompting physicians to make routine medical decisions.

Doctors get to spend time doing the “puzzles,” Graf explains. “The time they spend with the patient is much more meaningful, and absolutely they like it. When you walk into a site that truly gets it, you can feel the difference. The sites have moved from reactionary controlled chaos to predictive care, to the feeling that we can know what is happening and are in control.”

By leveraging the health plan’s vast clinical data stores, analysts parse patients into clinically meaningful segments: healthy patients who want to stay that way, those with a mild chronic disease who wish to stabilize and multi-morbid patients whose lives are balanced on the head of a needle.

Each group receives a speci�c bundle of preventive care and followup. As in many organizations, patients with chronic conditions receive regular followup and support with transitions to specialists or to ancillary care settings. But those patients identi�ed as most at-risk (who are about 15% to 20% of the Medicare population and 5% of the commercial population) receive special attention from a unique team member. High-risk case managers – so-called “commando nurses” funded by Geisinger Health Plan – don’t do disease management but instead focus on the driving issue in the case, using technology-enabled, high-touch programs to closely follow this fragile population and manage emerging exacerbations.

PHN works closely with its medical neighborhood – the people and places that care for patients’ needs outside the system. While the health plan may have contractual relationships with providers, PHN works more informally, relying on the power of referrals to demand clinical excellence. PHN communicates expectations for access and quality to local nursing homes and home health agencies. If the agency can perform up to these standards, PHN refers patients.

Similar to AdvocateCare, PHN works beyond the system’s walls to reach nursing homes. To reduce the number of patients who are readmitted from nursing homes (a staggering one-third), Geisinger places its own advanced practice nurses within select long-term care and rehabilitation facilities. The nurses perform medication reconciliation, train staff on how to care for and reduce falls, and identify acute exacerbations before they worsen. Early results look promising: Hospital readmission rates plummeted a minimum 13% at the low end and as much as 67% at one nursing home. “It really changed the way we provide care in the nursing home,” Graf says.

In overall numbers, hospital admissions and readmissions for PHN Medicare patients have dropped about 20% versus non-PHN sites, and emergency room visits have leveled, while shooting up at non-PHN sites.

But perhaps most importantly, patients and providers believe that these changes have improved the way that patient care is delivered. Just six months after PHN launched, 72% of patients surveyed agreed with the statement, “quality of care is different and better than in the past.” And 86% of providers agreed that care was more comprehensive than in the past, while a whopping 93% would recommend PHN to other primary care providers.


The movement toward managing population health across the continuum of care – more popularly referred to by the acronym ACO – is gathering steam by the

day and may soon reach a critical mass – no longer just an experiment, but a key component of the U.S. health care system.

While the sheer number of accountable care organizations is still low, “it’s a small but very in�uential part of the market, says Paul Ginsburg, president of the Center for Studying Health System Change. “Everybody is watching it.”

Almost every day a group of physicians and other providers inks a contract with an insurer to become a commercial ACO, and a Medicare pilot of the concept – still in its infancy – is already bursting at the seams with 154 participants.

This phenomenal growth – beyond earlier estimates of the early potential of ACOs – comes as the evidence of their ability to deliver results is still debatable. It’s too early to say whether ACOs in the Medicare demonstration will save money or improve quality, though a few commercial ACOs show early signs of success.

In California, the nation’s most advanced ACO market, ACOs have formed not just for traditional or Medicare patient populations, but also to serve alternative patient groups. There’s talk of California ACOs competing against traditional insurers on the state’s health insurance exchange, and in the Golden State, physician integration, merger and partnering activity have reached a frenzied pace.

T

The ACO is Ascendant

THE ACO IS ASCENDANTSPECIAL REPORT

Shared Savings Program and Interest from Private Payers Drives Fast Growth of New Provider Model

By Rachel Brand

Rachel Brand is a freelance writer based in Denver. She can be reached at [email protected].

Paul Ginsburg, president of the Center for Studying Health System Change, says that in the future, ACOs may not be voluntary.


“The name of the game here is going to be integration and partnerships,” says Maribeth Shannon, director, market and policy monitor program, California Healthcare Foundation. “It’s going to be hard for anybody to go it alone.”

The available evidence is enough to ask the question: What can we learn from ACOs so far?

The Basics

Accountable care organizations are a key provision of the Affordable Care Act, aimed at slowing rising health care costs while delivering high-quality care under Medicare. Their core identity may be as a medical group, independent practice association, hospital or physician-hospital organization, but regardless, their payer contracts incentivize them to meet quality targets while holding down costs.

The ACO concept has gained popularity as a solution to the current fragmented, duplicative and costly health care system. In recent months, it has mushroomed in response to a requirement in the Affordable Care Act that directs Medicare in 2012 to begin experimental contracts with ACOs. In the long term, Medicare payments are likely to decline, putting pressure on providers to change how they organize and deliver care.

Perhaps for the �rst time, “payers and hospitals and possibly some doctors seem to have a consistent vision about where they would like to see the delivery of care go – to a more coordinated system, with a larger role for primary care physicians and more management of chronic disease,” Ginsburg says.

In the �rst seven months of this year, 154 ACOs won Medicare contracts and the number of bene�ciaries slated for ACO enrollment, 2.4 million, topped CMS’ three-year projection of 2 million.

Medicare ACOs include the Pioneer ACO Model – a CMS Innovation Center initiative designed to support organizations with experience in providing coordinated care to Medicare bene�ciaries at a lower cost – and the Medicare Shared Savings Program model, which provides incentives for ACOs that meet standards for quality performance and reduced cost while putting patients �rst. In addition, the Innovation Center is testing the Advance Payment ACO Model, which provides additional support to

physician-owned and rural providers participating in the Shared Savings Program who would bene�t from additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems.

Medicare ACOs Increasingly Physician-driven

As Medicare has issued ACO contracts, physicians have increasingly sought to win them.

“The initial Pioneer ACOs tended to be larger groups with a lot of capital to invest in technology,” says Kirk Clove, president of Rye Brook, N.Y.-based Collaborative Health Systems, a division of the for-pro�t, publicly traded insurer Universal American. CHS is partnering with 10 ACOs, and providing information technology and data analytics necessary for ACO success. Now, Clove says he’s seeing

groups from all over the country; from high-cost and low-cost areas, from urban and rural areas. “The predominant makeup is physician organizations, and secondarily, PHOs (physician-hospital organizations).”

Two-thirds of Pioneer ACOs feature hospitals in a starring role, as heads of integrated delivery systems such as Pennsylvania’s Geisinger Health System and Minnesota’s Park Nicolett Health Services and hubs of physician-hospital partnerships such as California’s Monarch HealthCare. The remaining 10 Pioneer ACOs are Independent Practice Associations such as Massachusetts’ Atrius Health and San Francisco’s Brown & Toland Physicians.

They were selected because they had a history of sharing risk and coordinating care, and had to commit to having the majority of their annual revenues by the end of 2013 coming from

ACO DISTRIBUTION BY STATE

Source: Leavitt Partners

n 20+n 10-19n 7-9n 4-6

n 2-3n 1n 0

NUMBER OF ACOs


THE ACO IS ASCENDANTSPECIAL REPORT

“outcomes-based” contracts that involve shared savings or �nancial risk. By 2014, in their Medicare contract, Pioneers will be required to take on more risk, with the potential for more reward.

By contrast, of the 89 Medicare Shared Savings Program ACOs announced in July, nearly half are physician-led organizations with fewer than 10,000 bene�ciaries, and one out of four are groups of fewer than 100 doctors that do not include a hospital in the mix. (CMS requires that providers have a minimum of 5,000 Medicare patients, which equates to a minimum of 25 physicians in the group). Typical of this wave of ACO participants are groups such as Coastal Carolina Health Care, a North Carolina-based, physician-owned and operated medical practice with over 50 providers and no hospital partner.

According to CHS, a signi�cant number of these smaller, newer groups are partnering with health plans (such as CHS) or management service organizations to provide information technology, informatics and analytics. Also: 20 Medicare Shared Savings Program ACOs have taken loans from CMS under the Advance Payment ACO Model. This program gives assistance to providers that suffer from, according to the program description, “lack of ready access to the capital needed to invest in infrastructure and staff for care coordination.”

Early Commercial Successes

Nobody knows exactly how many ACOs or ACO- like arrangements exist in the private market, but estimates by Leavitt Partners, a health care business intelligence �rm, indicated several hundred (see chart, page 19).

Several have already reported successes.

In the competitive Sacramento market of Northern California, one of the earliest ACOs is a shared-risk, shared-savings arrangement conceived of in 2007 that produced unprecedented zero premium increase in 2010.

Hill Physicians Medical Group, a 3,700-physician practice based in San Ramon, Calif., working under capitation; and Dignity Health (formerly Catholic Healthcare West), a hospital group with facilities across Northern California and working

in a fee-for-service model, partnered with insurer Blue Shield of California and purchaser California Public Employees Retirement System (CalPERS), in the ACO. By analyzing cost drivers, the partners identi�ed IT integration, drug cost reduction, reducing practice variation, care coordination and chronic care management as key to reducing costs and improving quality. In the �rst year, the partnership saved $20 million, split between the three partners, and reduced readmissions by 22%. Inpatient costs per day declined $240 for the ACO patient population, versus an increase of $200 for non-ACO members. Halfway through the second year, savings continued apace.

On the other side of the country, Blue Cross Blue Shield of Massachusetts saved $107 per patient in the second year of an ACO-like arrangement called the Alternative Quality Contract, when compared to the costs of traditional fee-for-service medicine. The Mass Blues contracted with 1,600 primary care physicians and 3,200 specialists in 11 physician groups. Doctors received a global budget that covered the continuum of care, and won incentive payments for reaching certain quality targets. While overall costs didn’t decline in the ACO, provider participants reduced the rate of increase by 2.8% per year, on average, while improving care for chronically ill adults.

California is the Future

With its long history of managed care, large integrated medical practices and high penetration rates of Medicare Advantage plans, California is fertile ground for ACO development. Indeed, the state has as many as 32 ACOs in contracts with payers, according to the California Healthcare Foundation, a non-pro�t, grant-making organization aimed at increasing health care accountability and transparency while boosting outcomes and access. Interest is coming from hospitals, payers, medical groups, even employers.

“One of the reasons we’ve seen (the ACO trend) take hold pretty strongly in California is our history of managed care,” says the California Healthcare Foundation’s Shannon. “We have large medical groups that have history of working under capitation.

“The initial Pioneer ACOs tended to be larger groups with a lot of capital to invest in technology. The predominant makeup is physician organizations, and secondarily, PHOs (physician-hospital organizations).”

Kirk Clove

President, Collaborative Health Systems


They are used to delivering good-quality care. The providers know how to deal with care coordination, and the patients do, too.”

What’s more, other states – such as Minnesota, Cleveland and Arizona – with a history of provider coordination should see ACOs take off, Shannon says.

But not all players are equal. It takes signi�cant dollars to invest in the information technology, advance practice nurses and other resources needed to successfully manage population health and lower costs.

“We’re �nding that the organizations embracing ACOs are the haves, versus the have-nots,” Shannon says. Hospitals with a good reputation, deep pockets and large market share, such as a children’s hospital or academic medical center, will likely �nd itself an essential part of an integrated delivery system becoming an ACO. Weaker, less-pro�table hospitals may be pushed to the side, she said.

Separately, specialty ACOs are emerging in California to handle particular patient groups. In December, the state’s Department of Health Care Services announced plans to contract with �ve ACO-like organizations to manage the care of seriously ill children. The kids, up to age 21, have a number of serious conditions such as cerebral palsy, cancer, heart disease or cystic �brosis, and the California Children’s Services program covers their care. While cost savings may be a byproduct of the pilot, the main goal is to better coordinate kids’ care.

And in Los Angeles County, the Regional Accountable Care Network, a self-proclaimed ACO, is forming between a large federally quali�ed health center and several hospitals to care for the region’s poor and uninsured. The goal is to improve population health.

Finally, there’s the idea of offering ACOs directly, without a health plan intermediary, on state exchanges, says Patrick Johnson, CEO of the California Association of Health Plans. The California Health Bene�t Exchange, like those in other states, aims to launch in 2014 as an electronic shopping place or portal through which individuals and small

businesses can buy health insurance. Buyers will be able to easily compare plans on price, coverage and quality.

“As the ACO concept evolves, can an ACO that isn’t a state-licensed HMO under state law qualify and compete on the exchange?” Johnson asks. “From conversations with some people high up in medical groups – they are looking at that. In California, you’ll see experiments with ‘delivering on the promise’ of managed care that exists already. Then, you’ll �nd some newer, different models that may try to achieve the goals of an ACO by internalizing those functions that insurers and health plans traditionally have achieved: generating revenue, managing contracts, applying quality control measures.”

Ginsburg concludes that right now, across the country and in government programs, it’s the fun stage of ACO development.

“They’re all volunteers,” he says. “And payment rates in Medicare are based on recent experience.”

In the future, Ginsburg warns, expect bundled rates across a community. “Then Medicare could say, we’re going to cut payment rates for providers who are not contracting with us on a bundled basis,” he says.

While the speed of this transition is hard to gauge, it will be driven by Medicare’s need to save money. “In the future, ACOs will be less voluntary.” Expect the commercial market to follow.


The Learning Lab for Health Care Transformation

By Todd Sloane, Editorial Manager, Press Ganey Associates

Virginia Mason’s Production System, Modeled on Toyota’s, is About Reforming Health Care from the Inside Out

THE LEARNING LAB FOR HEALTH CARE TRANSFORMATION COVER STORY

scene from the future of health care: On an inpatient unit, nurses work in U-shaped pods and spend almost all of their time on direct patient care. Nurses pull workstations into patient rooms, doing

their charting documentation “in �ow,” improving the accuracy of the chart. Nursing leaders and senior executives walk through, asking questions about how things are going. Production boards show the on-time status of the unit. Most supplies are located at the point of use. A nearby medication station has a light showing whether it is available. An electronic console shows the status of all incoming patients. Almost no steps or time are wasted.

A


Actually, the scene is today at Virginia Mason Medical Center in Seattle, but if health care organizations are to survive in a future of shrinking reimbursements and new demands for quality and ef�ciency, they should take a long, hard look at what Virginia Mason is up to in the Emerald City.

Over the past 11 years, Virginia Mason has become the learning lab of health care transformation. Its work has shown that it is possible to achieve higher quality and safer care while lowering costs, improving patient satisfaction, almost eliminating staff turnover and staying competitive business-wise.

The basis for this transformation is a management process called the Virginia Mason Production System (VMPS). It was adapted from the Toyota manufacturing process, which uses techniques of waste reduction and standard work to achieve the highest quality at the lowest possible cost. Other health systems have adapted elements of the Toyota system or other quality systems such as Six Sigma, but at Virginia Mason, standard work is now in the warp and woof of the institution.

The process of change began back in 2001, when the medical center adopted a new strategic plan, clearly establishing the patient as the ultimate bene�ciary of the care process (see page 29). Shortly thereafter, it also developed a new “Physician Compact,” de�ning a shared vision for the organization’s responsibilities and the physician’s responsibilities.

“The compact is about examining all of the operating assumptions in health care,” says Gary S. Kaplan, MD, the chairman and CEO of Virginia Mason. “The old, implied compact was around entitlement, protection and autonomy for doctors. It was maybe great for them, but it was clear that it wasn’t going to work if we were to move to a system built around teamwork, collaboration, evidence-based medicine, guidelines and pathways, and electronic medical records.”

The process of creating the compact was in some ways more important than the words on the page, Kaplan notes. The months-long process brought physicians together and made them much more aware of the goals of the organization.

The Search for a Management System

At the same time, Kaplan was trying to solve the medical center’s signi�cant �nancial and quality challenges. Three years prior, the hospital had posted its �rst year as a money-losing operation, a hit that was repeated the next year. The publication of the Institute of Medicine’s To Err is Human report pushed clinicians to question the safety and clinical effectiveness of the care they were providing. So Kaplan began casting around for a reliable management method to apply to a health care organization.

Gary S. Kaplan, MD, has led a 10-year effort at Virginia Mason Medical Center to reduce variation in care, eliminate waste, adopt evidence-based medicine and establish a blame-free culture of patient safety.

Although he surveyed some of the most prestigious health systems in the country, he could not �nd a methodology in health care that was successful in bringing about consistent quality and safety. “At that time, nobody in health care had done much with the Baldrige criteria. Six Sigma was just getting started, and nobody in health care had touched Lean or the Toyota Production System,” Kaplan says. “Almost serendipitously we found out what Boeing was up to right here in Seattle.”


Quietly, Boeing had applied Toyota methods to create a great track record of safety, quality and ef�ciency in building jets. “What we saw at Boeing and really liked about the Toyota Production System was it is a holistic philosophy, a way of thinking – even a way of life,” Kaplan says. “Through discussions with current and former leaders at Boeing and with other manufacturing �rms using Toyota, we realized that while manufacturing may seem very different super�cially from health care, this management methodology could bring about reliable results in any process.”

Not long thereafter, Kaplan led his entire senior management team, clinical leaders and even the board chairman of Virginia Mason to Japan to spend two weeks totally immersed in the Toyota process. It was not a risk-free trip, as local press had gotten wind of it, noting that a nonpro�t health system on the �nancial brink was spending an unknown amount of money to learn about how to control production costs.

The trip involved actual work on the shop �oors at Toyota and the Hitachi air conditioning plant. The team saw how real-time, not retrospective, quality assurance works. They saw little wasted motion, empowered employees who could “stop the line” if they saw something amiss, and managers out working alongside production workers. The Virginia Mason team members helped redesign some Hitachi production methods.

Very quickly, everyone on the trip saw how the Toyota Production System attributes could be applied to health care delivery.

“This whole thing is about large-scale culture change,” Kaplan says. “We arguably have changed faster than any other health care organization in the last decade, and what we are doing is challenging all the old assumptions. We learned this on that �rst trip to Japan. When we created the Virginia Mason Production System, we knew it would be more than a set of tools. It is not a process improvement method or a quality improvement method, but a complete management system. We use it for strategic planning, for budgeting, for management – everywhere in our organization.”

Virginia Mason Medical Center Virginia Mason Medical Center in Seattle is a nonpro�t, integrated health care system with a large, multispecialty group practice of more than 450 physicians; a 336-bed acute care hospital; the Benaroya Research Institute; a skilled nursing facility for patients with HIV/AIDS and other complex conditions; and the Virginia Mason Institute, a nonpro�t education and training organization dedicated to teaching the Virginia Mason Production System management method to other organizations. Virginia Mason was named Top Hospital of the Decade at the Leapfrog Group’s 10th anniversary gala in Washington, D.C., in 2010.

During 2011, Virginia Mason was also placed in the national spotlight with accolades for the book Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. The book details Virginia Mason’s journey in transforming health care during the past decade, long before the Affordable Care Act began to require change within the industry.

The medical center’s new pavilion was designed around reducing waste and providing patient-centered care.



A scene from Japan: Robert Mecklenburg, MD, the medical center’s chief medical of�cer, was preparing for the next day’s work at Hitachi. A sensei – a Japanese master teacher in the Toyota methods – was there. “Senseis are formidable people, highly respected,” Mecklenburg says. “They are relentless in critiquing work and �nding opportunities to improve the work you are doing.” The sensei asked through his interpreter for the doctor to sketch out the care pathway of a patient coming to Virginia Mason for a routine of�ce visit. He started to draw the path, including boxes representing waiting rooms. The sensei asked what those boxes represented. Learning that patients often spent 45 minutes waiting in these rooms for scheduled appointments, the sensei looked morti�ed.

At the end, he asked, “Aren’t you ashamed?” All Mecklenburg could do was nod yes.

“This is the harsh beauty of the teaching,” says Mecklenburg, now the medical director of the Center for Healthcare Solutions at the Virginia Mason Institute. “Not only was it disrespectful to keep patients who had put themselves in our care waiting, we had actually institutionalized the process of waiting. We allocated acres of space for it, with parking capacity, coffee in the waiting rooms, Internet connections and staff to track the queues. And I was ashamed. Eleven years later, I am still attempting to redeem myself.”

Building Buy-in

Once back in Seattle, the team members knew there was no turning back from the path they had embarked on in Japan. But they also knew how different this new way of doing things would be and how it might not resonate well with many longtime staff. Almost overnight, doctors and nurses with decades of professional experience would see their work upended. It would now be about eliminating variation in care, standardizing processes that lent themselves to it, utilizing evidence-based medicine and establishing a blame-free culture of patient safety.

“When we �rst raised the notion of standard work, our doctors were aghast,” Kaplan recalls. “You heard, ‘This is cookbook medicine, standardized mediocrity,’ and so on. And it took a long while, but once doctors began to understand it, that it is about lowering the burden of work and actually freeing them to spend more time with patients, more time with colleagues for academic pursuits, more time with family, then they began to be the biggest supporters. Now they say, ‘We need more standard work.’ ”

The VMPS was disseminated over time through dedicated resources and training of all medical center staff. The medical center created a Kaizen Promotion Of�ce dedicated exclusively to leading improvement efforts and disseminating VMPS tools and knowledge across the organization. (“Kaizen” is Japanese for “continuous incremental improvement.”) The of�ce has 25 full-time staff. Department leaders regularly rotate into the Kaizen of�ce and back into management, enhancing the development and spread of VMPS acumen in the organization.

Leaders, including Kaplan, spend a lot of time on the “genba,” or shop �oor, another key element of the production system. Continuous quality improvement requires continuous conversation about current processes and problems. Leaders also attend weekly “stand-up reports” – updates on the results of current improvement efforts. And a “Report Out” session every Friday in the medical center’s auditorium is open to all employees. There, teams working on that week’s improvement projects share their progress with colleagues.

Most of the projects are called Rapid Process Improvement Workshops, or RPIWs. These are typically �ve-day events involving a team that uses rigorous methods to examine a problem, come up with workable and adaptable solutions, test the solutions and ultimately disseminate them if they work.

“Not only was it disrespectful to keep patients who had put themselves in our care waiting, we had actually institutionalized the process of waiting. We allocated acres of space for it, with parking capacity, Starbucks in the waiting rooms, Internet connections and staff to track the queues.”

Robert Mecklenburg, MD

Medical Director, Center for Healthcare Solutions, Virginia Mason Institute


One such RPIW involved solving the issue of the time nurses wasted hunting for supplies in the units. A team identi�ed a set of high-use supplies, and a customized box was installed in each patient room with those supplies, which are replenished on a regular basis, dramatically reducing walk time to the central supply location.

Further RPIWs accelerated the revolution in nursing care. Nursing assignments were redesigned into small, geographically proximate patient group clusters to reduce walk time. A new inpatient tower was designed to limit steps nurses take. Patient handoffs took place in patient rooms, eliminating reporting rooms.

“A U-shaped cell is the most ef�cient layout for workers to reduce motion and waste of time. In health care we don’t organize our work in a way that optimizes our time and makes us more effective and ef�cient,” says Charleen Tachibana, RN, senior vice president and chief nursing of�cer at Virginia Mason. “The way nursing assignments used to be made often took nurses off to the end of a long hallway or

to different locations in the hospital. So they weren’t in ready access to their patients. One of the key roles as nurses is in patient safety, in making patients feel safe. You can’t do that if you are spending more than half your time away on non-nursing duties.”

Together, the changes led to dramatic results: Nurses now walk about 0.6 mile per day, down from more than �ve miles. From a productivity perspective, it is the daily equivalent of 21 additional nurses, each working a 12-hour shift. Conservatively, it amounts to more than $4 million in productivity gains every year. Most importantly, nurses now spend almost 90% of their time on direct patient care, up from less than 40% just a few years ago.

“The joy of this process is that by �xing these processes and reducing the burden of work associated with them, nurses can then be creative in how they deliver care. Standard work frees you up to do the higher-level art of good nursing care,” Tachibana says.

Patients can sense the changes, even if they might not understand exactly what is different about Virginia Mason. “When you take the waste out of processes, patient satisfaction improves,” Kaplan says. “Patients know it when waiting rooms are empty and you get right in.”

The patient experience is seen at Virginia Mason as a critical component of its quality equation, which is appropriateness X outcomes + service ÷ waste. “The service components of care are critical,” Kaplan says. “We are doing lots of things around it, including embedding experience-based design approaches into our rapid-cycle improvement workshops and having patients take part in the RPIWs.”

Patient Safety Alerts

Often, a threat to patient safety or a sloppy action causes a staff member to “stop the line,” using Virginia Mason’s Patient Safety Alert (PSA) system. If it is serious, staff and leaders must convene immediately to address the problem and �nd a


VIRGINIA MASON INPATIENT PATIENT SATISFACTION TRENDS, 2005 - 2012

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solution before care continues in that area. PSAs are categorized as red, orange or yellow. Red events are the most serious, for example, life-threatening “never” events, and anything else that could pose potential serious harm to a patient, including near misses, security issues, falls with injuries and serious pressure ulcers. Orange events are less severe and typically involve more than one department. Yellow alerts are simple process mistakes or latent errors. Of the errors reported, 1% are red alerts, 8% are orange and the rest are yellow.

There are 400 PSAs per month, but leaders want more. One recent PSA involved the supply chain, where a lack of surgical kits was seen as jeopardizing operations. Another was a broken elevator in a patient care area, affecting patient transport.

A nurse is empowered, even encouraged, to call out a physician for failing to follow protocols.

“The economic costs of defects are enormous, but they pale in comparison to the human cost of medical errors. And we know that without shining the brightest light on medical errors, or near misses, or even things that only cause staff concern, that we are not going to be able to prevent errors,” Kaplan says.

Virginia Mason’s board reviews all red PSAs and must sign off on a �nal report before the process is deemed mistake-proof.

The Coffee Collaborative

Part of the success of the VMPS is wringing waste from the system, but in 2004, despite three years of effort, Virginia Mason was faced with pressure from payers. Its quality was high, but its focus remained on care for acutely ill patients, and costs had not been adequately controlled.

That year, Starbucks, the coffee empire based in Seattle, had an ongoing issue with store personnel who had chronic back pain. Employees were frequently absent, and when present were not fully productive. The aggregate costs of treating back pain were high, and long delays for patients to receive an appointment at Virginia Mason led to longer absenteeism. Starbucks – through its insurance company – called on Virginia Mason to redesign how the medical center cared for patients with back pain.

VIRGINIA MASON MEDICAL CENTER PHYSICIAN COMPACT

Organization’s Responsibilities Physician’s Responsibilities

Foster Excellence

n Recruit and retain superior physicians and staff

n Support career development and professional satisfaction

n Acknowledge contributions to patient care and the organization

n Create opportunities to participate in or support research

Listen and Communicate

n Share information regarding strategic intent, organizational priorities and business decisions

n Offer opportunities for constructive dialogue

n Provide regular, written evaluation and feedback

Educate

n Support and facilitate teaching, GME and CME

n Provide information and tools necessary to improve practice

Reward

n Provide clear compensation with internal and market consistency, aligned with organizational goals

n Create an environment that supports teams and individuals

Lead

n Manage and lead organization with integrity and accountability

Focus on Patients

n Practice state-of-the-art, quality medicine

n Encourage patient involvement in care and treatment decisions

n Achieve and maintain optimal patient access

n Insist on seamless service

Collaborate on Care Delivery

n Include staff, physicians, and management on team

n Treat all members with respect

n Demonstrate the highest levels of ethical and professional conduct

n Behave in a manner consistent with group goals

n Participate in or support teaching

Listen and Communicate

n Communicate clinical information in clear, timely manner

n Request information, resources needed to provide care consistent with VM goals

n Provide and accept feedback

Take Ownership

n Implement VM-accepted clinical standards of care

n Participate in and support group decisions

n Focus on the economic aspects of our practice

Change

n Embrace innovation and continuous improvement

n Participate in necessary organizational change

© Virginia Mason Medical Center, 2001



Virginia Mason collaborated with Starbucks, the insurer and several other major employers to establish �ve governing principles for what would be called Marketplace Collaboratives to deal with these high-cost, high-volume problems.

The principles included:

n A focus on customers’ highest costs

n Adopt the customers’ de�nition of quality

n Create evidence-based clinical value streams

n Employ systems engineering to remove waste

n Use a cost-reduction business model

Virginia Mason then studied and “mapped” the back-pain value stream, revealing multiple areas of waste. It took too long for the spine clinic to answer the phone, too long a wait for the initial appointment, further long waits for MRIs, additional waits to see the physician again, and then more waiting to begin treatment.

The chief of physical medicine and rehabilitation at Virginia Mason decided that patients should be sorted into complicated and uncomplicated cases. The uncomplicated cases generally did not need an MRI or to wait to see an orthopedic surgeon. These patients could begin treatment right away with a physical therapist.

In order to eliminate waiting time, the clinic converted to a system of same-day appointments. Patients were evaluated by a team of a physical therapist and a physician. The physical therapist would see the patient �rst, take a history and conduct a physical exam. The physician then would join the therapist and hear the history; if pain medications or imaging studies were needed, the physician would order them. Physical therapy would commence at the �rst visit.

The process eliminated the high cost of specialists’ time, which runs more than $3 per minute. A physical therapist costs less than $1 per minute.

By evaluating the value of MRI for uncomplicated pain, use of this costly diagnostic tool dropped by nearly a third. The spine clinic was able to see many more patients in less space with providers who had much better skill-task alignment. All of this led to a pro�table service line.

Reducing the use of MRIs was far more dif�cult to implement than the other changes. Many physicians initially ignored the new evidence-based guidelines. So evidence-based decision-making was baked into the electronic medical record; the ordering screen requires physicians to check off a valid indication for an MRI.

Since the early work, clinical value streams have now been mapped for uncomplicated headache, large joint pain, breast concerns not related to cancer screening, diabetes, upper respiratory conditions, depression, chest pain and abdominal pain.

A scene from today at Virginia Mason Kirkland, a multispecialty clinic: Kim R. Pittenger, MD, a primary care physician, steps out of a patient exam room and stops at a “�ow station,” where his medical assistant quickly hands him a couple of notes and moves on to prep the next patient. Pittenger quickly enters notes on the last patient, returns a phone call, checks a lab result and moves on to the next patient. By doing small batches of non-direct care throughout the day, and working with a medical assistant

An RPIW in action: A team reports on its Rapid Process Improvement Workshop, one of hundreds that have been carried out at Virginia Mason.


PatientVision

To be the Quality Leaderand transform health care

MissionTo improve the health and

well-being of the patients we serve

ValuesTeamwork Integrity Excellence Service

Strategies

Quality

We relentlesslypursue the

highest qualityoutcomes of care

People

We attractand develop

the best team

Service

We create anextraordinary

patient experience

We foster aculture of learningand innovation

Innovation

Virginia Mason Team Medicine Foundational Elements

StrongEconomics

ResponsibleGovernance

IntegratedInformation

Systems

Education Research Virginia MasonFoundation

Virginia Mason Production System© 2011 Virginia Mason Medical Center

Our Strategic Plantrained to accurately prioritize the work presented to him, Pittenger can go home on time most days. Calls into the 10-physician group have dropped by 1,100 per week, because fewer patients are left waiting for callbacks and test results. “It has been proven through this work that doing small batches throughout the day is far more productive than huge batches at the beginning and the end of the day,” he says.

The practice has phased out most paper. It sends all prescriptions and orders most diagnostics electronically. Patients and staff email routine matters such as appointments. “Increasingly, we are able to physically pull the EMR into the visit, so the patient and provider can sit side by side and look at the chart and test results about their conditions. This creates that golden triangle of the doc, the EMR and the patient, so the computer isn’t just a distraction,” he says.

The Business Case for Quality

After its earlier �scal instability, Virginia Mason has operated in the black for years. In 2011 it earned $34 million on total revenue of $884 million.

Perhaps a more relevant statistic to the work it is doing today is that since 2004, the medical center’s cost of professional liability insurance has dropped nearly 60% – in a state without tort reform. This amounts to millions of dollars in annual savings every year in non-value-added expenditures tied to poor quality. Many hospitals are reluctant to be so public with their errors, fearing an increase in liability claims. Virginia Mason’s experience has been the opposite. Insurance carriers are asking Virginia Mason to teach other medical centers its approach to risk mitigation.

Kaplan believes that what his facility is doing is health reform in action. “There is no question we as a nation need to realign payment with value and cost, not volume. But we have found that by eliminating waste from our processes and systematically applying the principles of the Virginia Mason Production System, we are able to signi�cantly reduce our costs of operations to ensure pro�tability, even being 100% discounted fee-for-service.”

In 2008, in response to an overwhelming number of requests for Virginia Mason staff to share their experience and knowledge, the medical center established the Virginia Mason Institute to provide education and training in the Virginia Mason Production System to other organizations. Health care leaders from around the world have taken part in learning ranging from speakers and visits that provide a basic understanding of VMPS to in-depth education and hands-on work applying VMPS methods and tools.

“In our market, we are the lowest-cost tertiary provider by a signi�cant margin,” Kaplan says. “It is good business that has and will increasingly cause employers and health plans and individuals to choose Virginia Mason. And it allows us not to get caught up in the whole argument that we are not going to

change unless the payment system changes. We can educate others, and we can advocate for better-aligned payment systems as well, but given what is going on in health care, we can’t wait on payment change to innovate.”

That process is far from over. “Lean transformation takes a long time, and there is still a lot of opportunity to get better,” Kaplan says. He was soon to depart for another trip to Japan, an annual event for his team. “We still need to be challenged, by ourselves, by outsiders. Through our institute we are training others from the U.S. and other countries. The ultimate irony is that hospital executives from Japan now come to Virginia Mason to learn the Toyota method.”

© Virginia Mason Medical Center, 2011


or much of the time, especially during the spring and summer months when patient volumes are lower, the pediatric emergency department at CHRISTUS Santa Rosa

Health System in San Antonio managed well enough, seeing 70,000 patients annually in a space designed for 52,000. But when the winter months hit and volumes spiked, the frustrations and inef�ciencies that simmered quietly for most of the year bubbled to the surface. Staff morale withered as frustrated patients waited long hours to be seen in the small, crowded ED. Although patient satisfaction scores that hovered in the teens weren’t news to anyone, they still stung, and the staff, which took pride in its professionalism, felt stalled when it came to making any signi�cant changes.

Michael Howard took over as nursing director in 2008 and, working with Mindy Spigel, RN, MSN, director of organizational effectiveness, had ideas about the kinds of things that might begin to make a difference. But they both quickly realized that, despite

whatever tricks they might have up their sleeves, nothing would stick in the current climate. Real change had to come from members of the ED staff and reach deep into the culture of the organization.

“Many of the things we did are not new,” Spigel says, “but they worked because they came from within. Michael, in the position of servant leader, helped enable the staff to drive many of the things that needed to change, to identify the need for a shared vision that ultimately became the headline of the team’s story.”

New Kid on the Block

With only one-and-a-half years of nursing under her belt, Eva Davila, RN, charge nurse and precept, had the advantage of a motivated newbie. Unclouded by experience, she was open to new ideas and looked around for the kinds of things that might enable her to do her job better. She took on the role as chair of the Santa Rosa ED’s Unit Council as a way to make a difference.

FBy Betty A. Marton

Empowering Engagement at a Children’s ED

EMPOWERING ENGAGEMENT AT A CHILDREN’S EDSPOTLIGHT

The ED has been energized by a campaign called One Team, One Goal: Compassionate Care for Your Child.

Betty A. Marton is a freelance writer based in New Paltz, N.Y. She can be reached at [email protected].


“It was hard just being a new RN, and then I took that extra step as a leader to try to get people motivated and engaged,” Davila says. “I guess they thought, ‘Let’s give the new kid the challenge!’ ”

One of the �rst things Davila asked the Unit Council to do was to share ideas for how they could make improvements. Proffering a stack of sticky notes, thoughts such as “treating patients like family,” “committing to one another,” and “being there for one another” created an incipient sense of unity and became what they call the “Ten Commitments.” With stickies in hand, Davila also asked the Unit Council to brainstorm a vision statement.

Beginning with a wide range of key words offered by team members, the council came up with the phrase that members felt captured what they do and the reason they do it: “One Team, One Goal: Compassionate Care for Your Child.” They had banners of the slogan made and distributed them throughout the ED. Then, waiting with a young patient she had brought up to the medical/surgical �oor of the hospital, Davila noticed a framed photograph of the staff.

“It was prominently displayed and was clearly important,” she says. “When we did the same thing, it made such a big difference. It allowed patients to see who we are as individuals and how many people it takes for an ED to function. Patients mentioned the photo in the surveys, and our scores went up because of it.”

The recognition of the staff’s mutual purpose as well as each individual’s role also contributed to a discernable uptick in the attitude of the nursing staff. Encouraged, the Work Environment Group (WEG), a subgroup of the Unit Council with representatives from each area of the department, met to take on the challenge of reorganizing patient �ow. One of the WEG’s �rst ideas was to do away with the fast track that separated acute patients from non-acute patients on different sides of the ED. Mixing them up redistributed resources and freed space more quickly, helping patient wait times drop by an average of an hour and a half.

“The fast-track concept was built on the assumption that someone with an ear infection can be seen more quickly than someone with diabetes,” says Mark Rodkey, MD, ED medical director. “But it’s been proven that most providers see an average of three patients an hour no matter what the diagnosis.”

Building on Success

Direct bedding, where patients are triaged in the bed where they’re then seen by a provider, also shaved patients’ wait times, and other successes

fed the group’s brainstorming processes and helped break down resistance some of the older staff felt toward new ways of working. They came up with the idea of establishing partnerships between nurses – pods – so that they could help each other with such processes as discharges and orders. They also instituted a system of call backs, with technologists and secretaries contacting every patient’s family the day following a visit to the ED, to see if they have follow-up questions about medications or treatment.

This time-consuming process went through some changes before they determined the best approach and, according to Davila, while the calls aren’t anyone’s favorite job, everyone recognizes their value and how much patients appreciate them.

Other ideas, however, including a dedicated “asthma room” with reclining chairs and treating patients in chairs in the hallway, didn’t meet with such success.

“We try to give everything a few months because if it doesn’t work right away, the knee-jerk reaction is to say ‘See, this doesn’t work,’ when all we need is time to work out the kinks,” Davila says. “But it’s also important for people to know that if something doesn’t work, we’re not going to keep on doing it. It has to make things better, not just be different.”

The success of the Unit Council in driving these changes grew from the new authority the members had over their own decision-making processes and their subsequent ability to gain access to resources on the Press Ganey Improvement Portal. When Howard has an idea about something that he thinks needs to be improved, he’ll ask for ideas from the group. He also uses the scores to track speci�c patient comments about individuals for both a monthly recognition program and as a way to work with employees whose approach might need tweaking.

“By changing the process of asking for change, which is hard on any employee, they’ve become more willing to try new things,” Howard says. “If we get a negative patient comment tied directly to a nurse, I try to get them to think about their approach from the patient’s point of view, to see that the tone of voice or language that they’re using might be perceived as something different from what they intended.”

The Unit Council also began to organize group events outside of work, which gave older staff a chance to mix with new recruits and everyone an opportunity to get to know one another a little better. According to Davila, the morale the group builds in its off-hours carries on inside the ED, especially when things get tough.

“Morale does go down in the winter when we have so many people to see, but now we know better how to help each other and have the perspective that things will pick up,” she says.

The staff felt further supported when their requests for new equipment, such as thermometers, infant warmers, stretchers with built-in scales and even more comfortable stools for nursing stations, were satis�ed.

“Before we were in a kind of Catch-22. We couldn’t get new equipment because our scores were down,” says Norma Zuniga, RN, who was charge nurse at the time. “But when we began to get support and recognition from upper management, the staff realized that this is something to build on, something we can take pride in, and that made it easier to buy in to some of the changes. Before, people had no reason to strive for improvement.”

According to Kristina Tolsma, RN, Press Ganey scores play an ongoing role as a way for ED employees to gauge where the department is headed, and why.

“We see our scores every day, and when they’re low, nobody’s happy,” she says.

CHRISTUS Santa Rosa Pediatric ED Satisfaction Scores on RiseIncreases in Press Ganey Scores, 2010-2012

n Average overall: 19th to 65th percentile

n Nurses overall: 13th to 83rd percentile

n Wait time to doctor: 17th to 69th percentile

n Informed about delays: 22nd to 88th percentile

n Likelihood of recommending: 23rd to 72nd percentile


THE DEVIL’S IN THE METHODOLOGYTHE BACK PAGE

J ust emerging from the wide shadow cast by the Centers for Medicare and Medicaid Services’ Hospital Inpatient Value-based Purchasing Program (VBP) is another payment reform

with potentially greater risk for hospitals: CMS’ Readmissions Reduction Program.

Recently the dynamic has changed signi�cantly as health care providers have realized that the �nancial impact and potential penalties that are associated with the program are even more signi�cant than VBP and will require a serious clinical resource commitment to manage.

As of Oct.1, hospitals with what CMS methodology �nds to have excess readmissions can lose 1% of their Medicare payments, a penalty that will rise over the following two years to 3% – greater than the maximum potential loss under VBP. CMS’ goal is to reduce overall readmissions for the Medicare population initially within several speci�c disease categories. The list of diseases is likely to grow over time.

The measurement began with July 1, 2011, discharges, and the policy initially applies to acute myocardial infarction, heart failure and pneumonia. From �scal 2015 on, CMS is authorized to expand

By Vladimir Tikhtman, MHSA, Director, Clinical and Operational Products, Press Ganey Associates

The Devil’s in the Methodology

The Back Page

Readmissions Reduction Program Targets a Key Source of High Health Costs, but Rules Pose Big Problems for Hospitals


Editor’s note: In this paper, the �rst in a series, we have laid out the central issues and pitfalls surrounding the federal government’s Readmissions Reduction Program as well the methodology and approach that is adopted by Press Ganey. Subsequent articles will examine speci�c case studies showing how the program was implemented with the associated results.

conditions to chronic obstructive pulmonary disorder, several cardiac and vascular surgical procedures, and any other additional conditions or procedures chosen by those who administer the policy. Future measures require speci�c exclusions such as planned readmissions, unrelated readmission or transfers, but the current measures are all-cause, covering any readmission of a patient whose initial admission was for one of the listed conditions.

While the increased attention on unplanned or excessive readmissions seems appropriate given the associated �nancial burden that is placed on the Medicare system, the program as conceived and implemented by CMS is not without its critics and has generated a host of methodological and philosophical concerns.

Why Readmissions Matter

First, let’s recap some of the startling statistics that have in�uenced CMS to increase scrutiny of Medicare readmission rates and to work toward developing an incentive program for meaningful readmission reduction:

n Medicare spends an estimated $15 billion to $20 billion a year on rehospitalizations.

nNearly 20% of Medicare patients who had been discharged from a hospital were rehospitalized within 30 days.

n34% were rehospitalized within 90 days.

n56% were rehospitalized within a year.

nTwo-thirds of Medicare bene�ciaries are readmitted or die within one year of the initial hospitalization.

nMany readmissions needn’t happen. According to a 2005 study by the Medicare Payment Advisory Commission, 75% of 30-day and 15-day readmissions and 84% of seven-day readmissions were potentially preventable.

Based on these statistics, it is easy to understand why CMS would come to the conclusion that readmission rates are an important quality-of-care marker and would take steps to reduce readmission rates. This is particularly true due to the �nancial implications associated with high readmission rates.

Given the idea that a high readmission rate is often, although certainly not always, an indicator of less-than-ideal clinical outcomes and/or �nancial inef�ciency, why have the readmission rates remained so stubbornly high? The thought that excessive unplanned readmissions are undesirable is not a novel concept and, while nothing as overt as the new CMS program has existed in the past, hospitals have certainly attempted to control readmissions historically with little sustainable success.

As it turns out, there are a number of systemic and incentive-driven reasons why readmissions are hard to manage, setting aside the fact that many clinicians feel that readmission rates are not a good or meaningful indicator of clinical quality.

So what are some of the factors creating a dynamic that make it dif�cult to meaningfully reduce readmissions?

Misaligned incentives and volume-based reimbursement. Medicare’s fee-for-service system provides payments for each unit of service delivered; hospitals are paid for each discharge, and thus have an incentive to maximize discharges. Readmission reduction would lead to hospitals losing income, as fewer rehospitalizations would result in fewer billable discharges. One of the key critiques of the current version of the CMS readmissions initiative is that there is no �nancial incentive for hospitals that already show or attain a low readmission rate to help offset their loss in revenue and added administrative costs. For example, hiring a nurse practitioner to provide post-discharge followup within the patient’s home can be an effective strategy to reduce readmissions, but only adds to the hospital’s overhead without providing any additional Medicare revenue.



Poor coordination between hospital-based and community-based physicians. The current payment system disincentivizes coordinating care for a patient who leaves the hospital for post-discharge, community-based care by not allowing payment to both a hospitalist and a primary care physician on the same day for evaluation and management. CMS wants the continuity and connections for the patients, but won’t pay for physicians to talk to each other. So outside of the intrinsic desire to do right by their patient – a powerful motivator for most physicians – the current system is designed to �nancially reinforce clinical and informational silos. Thus, hospitalists may be unfamiliar with a patient’s health and social history and, once a patient is discharged to the outpatient setting, the primary-care doctor may be unfamiliar with the rationale behind care provided in the inpatient setting due to a lack of coordination.

Lack of partnerships between hospitals and post-acute facilities. Hospitals are highly dependent on the provision of high-quality post-discharge clinical care from other facilities such as skilled-nursing facilities and long-term acute care hospitals. After the patient is discharged, the hospital generally cedes control over the clinical care that their patients receive, have no incentive to follow the patient and are actually beholden to competing �nancial incentives. Nursing homes may send complex patients back to the hospital for �nancial rather than clinical reasons, such as when the per diem rate that the nursing home receives does not cover the skilled care and the expensive drugs that the patient might require.

A Readmissions TimelinenMeasurement began with July 1, 2011 discharges

n Effective Oct. 1, 2012, hospitals with observed readmission rates exceeding the expected level will be subject to reduced Medicare DRG payments:

n Fiscal year 2013: payment reduction capped at 1%

n Fiscal 2014: payment reduction capped at 2%

n Fiscal 2015 and beyond: payment reduction capped at 3%

nPolicy initially applies to:

nAcute myocardial infarction

nHeart failure

nPneumonia

nFrom FY 2015, the Secretary authorized to expand conditions to:

n Chronic obstructive pulmonary disorder

n Several cardiac and vascular surgical procedures

n Other conditions or procedures chosen by the Secretary of the Department of Health and Human Services

nFuture measures require speci�c exclusions such as planned readmissions, unrelated readmission, or transfers, but the current measures are all cause


Are Low Readmissions a Good Indicator of Quality?

As noted, not only is the CMS methodology in question, but the very root issue of whether or not readmission rates are even a good indicator of clinical quality is highly debatable. There are several central issues including the idea that many readmissions are a completely appropriate part of normal, high-quality care, while the current readmission methodology penalizes hospitals for any-cause readmissions.

Some research suggests that an overly aggressive stance on readmissions can result in an increase in the hospital mortality rate. It is common to hear clinicians take the position that the measurement period of 30 days for a readmission is too long and is more re�ective of factors beyond the control of the clinical care received at the hospital. Another major concern is that hospitals residing in communities that serve a low socioeconomic patient population will be disproportionally penalized due to lack of access to other forms of quality care in the community.

The following list summarizes several additional issues that have been articulated by hospital leaders concerned by the readmissions methodology:

nCMS’ de�nition of “readmission” includes readmissions that are unrelated to the initial diagnosis and will count against the target hospital even if the care is sought out in a different facility – for example, a pneumonia patient who subsequently seeks care in an acute care facility in connection with an elective surgery such as knee replacement within the 30-day window.

nNo built-in, positive economic incentive for hospitals with readmission rates near or below the national average, but the requirement for hospitals to implement costly measures to reduce readmission rates.

nThe potential of “gaming the system” – by initially limiting the scope of the program to just heart attack, heart failure and pneumonia there could exist an incentive for hospitals to alter their coding practices to reduce the number of readmissions attributable to those three diagnostic categories.

n The question around the lack of the inclusion of race, ethnicity and socioeconomic status in the risk adjustment methodology – all factors that have a strong correlation with higher readmission rates – potentially having a disproportionate impact on safety-net hospitals.

n The lack of data transparency from CMS and the inability for hospitals to track their patients post-discharge when they end up receiving care in other institutions since that care counts against them from a readmission perspective.

A Methodological and Technical Approach

Currently, there is a multitude of efforts to reduce readmissions around the country. Many of these efforts struggle with effectiveness. One of the key criticisms discussed in the literature is that many of these initiatives are not suf�ciently data-driven and do not have a good way of assessing improvement opportunity nor have the ability to track the impact of the various implemented interventions. Often, these programs are developed with a poor understanding of the underlying methodology driving the initiative and a lack of an understanding of the various issues outlined above.

The Press Ganey approach towards readmission reduction begins with our Clinical Advisory Service team educating hospitals on the complex nuances that are associated with the Readmission Reduction Program and on the broader scope of outcome-based regulatory programs. Utilizing an innovative, integrated data collection and reporting technology

“With every step of the overall readmission reduction process, the effectiveness of each initiative is measured through trended data to keep track of those strategies that have shown to be bene�cial in reducing preventable readmissions versus those that are less useful.”

Vladimir Tikhtman, MHSA

Director, Clinical and Operational Products, Press Ganey Associates



a readmission, are excluded in the assessment as well. By undergoing these initial steps, a hospital is afforded the opportunity to focus on only those patients who truly fall into the category of the potentially preventable readmission.

The next step in the readmission reduction protocol is a deep dive into the data utilizing the Clinical Performer application. Working in conjunction with hospital personnel, a clinical advisor will perform a root-cause analysis on those patients who have been identi�ed as being part of the “potentially preventable” cohort. The focus is on assessing the correlation between each individual patient’s severity and any signi�cant comorbidites to determine whether the pattern of readmission is appropriate.

Along with focusing on the individual patients, each physician’s readmission pattern is assessed for clinical appropriateness. Readmissions are assessed for multiple time periods, and not just the 30-day period required by CMS. Shorter time frames may

called Clinical PerformerSM and working closely with our Clinical Advisory Team, Press Ganey is able to provide hospitals with a data-driven method toward performance improvement.

The initial step in the Press Ganey approach is assessing the likelihood of any individual patient being a good candidate for a readmission based on the severity level of their illness and their risk of complications and mortality. This is determined utilizing a well-researched and highly reliable predictive model and allows the hospital to eliminate all of the readmissions that are unlikely to be prevented due to the patient’s acuity level.

This method empowers the hospital to reduce focus on those patients for whom a readmission was potentially not only unavoidable but perhaps even desirable. Those patients who don’t qualify as true preventable readmission candidates for other reasons, such as being a transfer admission or outside of the qualifying time period to count as

Steps in the Press Ganey Readmission Reduction ProgramnExamine the hospital’s current rate of readmissions from several angles, based on patients’

severity level of illness and risk of complications and mortality.

n Improve the internal hospital discharge planning process, beginning at the initial admission.

n Improve the transition from inpatient to outpatient status by providing all necessary documentation and instruction to the next level of care during the beginning, middle and end of the patient’s hospitalization.

n Enhance patient control through a discharge follow-up phone call.


Before the discharge occurs, the hospital will be advised on how to develop a consistent process for assessing potential social issues such as access to transportation, lack of a primary care physician, challenges in obtaining proper medication, social status and physical/resource limitations. A key challenge for many hospitals is making sure that they are consistent in service delivery during the weekend and off hours. Part of the focus will be to assess the data to see if variation in the readmission rates can be attributable to when the patient receives services.

Post-acute Care

The next area of focus is streamlining patient transition into the post-acute care environment. The hospital receives assistance developing a cohesive plan for transition to the next level of care, including home, primary care physician, home health, skilled nursing facility, long-term acute care hospital and rehabilitation facility.

Partner hospitals are encouraged to adopt a philosophy of “over-communication” by providing all necessary documentation and instruction to the next level of care during the beginning, middle and end of the patient’s hospitalization.

Along the same line of reasoning, hospitals are shown how to develop and consistently use a medication reconciliation form – what has been ordered in the past, current patient use and any potential future return to current discontinued medications. The clinical advisor facilitates the identi�cation of all existing community resources (dialysis centers, transportation services, patient delivery pharmacies, 24/7 caregivers). Hospitals are advised to set up meetings with institutions across the continuum of care to identify those providers who are willing to work closely with the hospital to actively reduce unplanned and unnecessary readmissions.

provide an indication of �aws in hospital processes of care, while the longer time period creates opportunities to focus on the issue of appropriate followup and patient education/understanding of self-care.

Anecdotal evidence suggests many hospitals are confused and/or overwhelmed by the challenge of responding to the new readmission rules, especially coming just as hospitals are absorbing the impact of value-based purchasing. However, additional and no-less-complex regulatory programs, designed to change the health care incentive model from focusing exclusively on volume to incorporating quality and outcomes, are right around the corner. As CMS expands the number and scope of these programs and other payers jump on the bandwagon, as all indications suggest that they will, an institution’s very survival will depend on how it navigates these colossal regulatory changes and challenges.

A Focus on Discharge

The next step in the Press Ganey approach is to improve the discharge planning process. Unless the hospital is already doing so, the clinical advisor will facilitate the initiation of planning for discharge at the very beginning of the sentinel or index admission. Based on the steps described above, a set of patients who are at high risk for readmission will be developed.

Once these patients have been identi�ed, a coordinated system of targeted care and disease management will be deployed through clinically integrated programming focusing on teamwork and a reduction in inef�ciency. A strong, patient-centric educational focus will be encouraged to facilitate patient knowledge about their conditions and symptoms utilizing a “teach-back” process of having patients repeat the instructions back to the provider so as to ensure that patients, or the primary care taker in those instances where the patient displays cognitive de�cits, understood the discharge instructions.

Discharge Calls

One of the most important steps in reducing unnecessary readmissions is proper patient followup after transitioning out of the acute care setting. A discharge follow-up phone call by someone familiar with the patient is a key component of readmission prevention planning. Ideally the follow-up call will come directly from the physician, since studies show this has a signi�cant impact on reducing unplanned readmission. Another important step is to set correct, realistic expectations from admission forward by instructing the patient and family members on discharge expectations. The hospital case management department will be advised to take the time to identify a “case manager” at a community-based site to maintain contact with the hospital case manager – whether this is an actual clinical care provider or a designated family member. A process to conduct assessments in the initial 24-48 hours of a discharge to reconcile medications, ensure follow-up appointment, etc. will be implemented as well.

Anecdotal evidence suggests many hospitals are confused and/or overwhelmed by the challenge of responding to the new readmission rules, especially coming just as hospitals are absorbing the impact of value-based purchasing. However, additional and equally complex regulatory programs, designed to change the health care incentive model from focusing exclusively on volume to incorporating quality and outcomes, are right around the corner. As CMS expands the number and scope of these programs, and other payers jump on the bandwagon – as all indications suggest that they will – an institution’s very survival will depend on how it navigates these huge regulatory changes and challenges.

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