HOW MUCH MONEY ARE YOU LEAVING ON THE TABLE WITH FRAGMENTED? HIGHLIGHTS As healthcare organizations consolidate, the result is a fragmented quality program with variability in reporting and objectives. Defining quality ensures that efforts are focused on activities that improve the outcomes of patient care. s should consider what work will be done at the local entity vs. what will be performed centrally in order to achieve system-wide standardization. Providers should identify the highest areas of opportunity and then move to standardize care by removing unwanted variation in both the inpatient and outpatient setting. IT S TIME TO CONSOLIDATE DISPARATE CONNIE D ARGENIO MANAGING DIRECTOR, HURON FRED HOSLER M.D., MPA, SENIOR DIRECTOR, HURON Quality of care has never been under more scrutiny than in the current era of healthcare reform. While public reporting of quality measures is driving a renewed push to improve the quality of care, it can also bring unexpected penalties for those health systems that fail to adapt to new ways of measuring quality. As organizations continue to consolidate, the result is a fragmented quality program with variability in reporting and objectives. Providers who take the right steps for establishing a matrixed system for quality reporting that is accountable, streamlined and aligned with system goals will not only capture efficiencies of scale, but will avoid paying penalties due to poor system performance. Define the Vision for Quality The first step to take when developing a unified health system quality program is to define what is meant by quality. While the Institute of Medicine defines quality of care as: Safe, effective and evidence-based, patient-centered, where the patient plays an active role in decision-making, efficient, reducing waste without compromising outcomes, timely, and equitable, delivered without discrimination. It should be up to each organization to define the scope. Some may choose to limit it to something as simple as: The management of clinical quality and patient safety within facility, practice, and population. huronconsultinggroup.com Limiting the scope ensures that the efforts around streamlining the quality and patient safety programs are focused on activities that improve the outcomes of patient care, rather than being wasted on tasks that are administrative or outside the realm of care delivery.
Equally important as defining the meaning of quality, especially for highly-matrixed and complex organizations, is providing individual entities a voice in the process. For example, one of our clients, a large academic health system on the East Coast, was looking to develop and deliver quality management core principles. The quality governance structure would be deployed across all entities, including a clinically integrated network and physician network. In this instance, the vision for quality required buy-in from executive leadership, entity leadership and providers across the system. Through an iterative and inclusive process that consisted of more than 40 interviews, an optimal future state was identified that all parties agreed upon. The end result was the creation of an integrated, CIN-inclusive quality management process and governance system that was customized to the client s specific needs. Decide What Should Be Standardized, Centralized or Managed Locally Once the scope of quality is defined, systems should consider what work will be done at the local entity-level versus centralized to achieve system-wide standardization and efficiencies of scale. The three models of shared services illustrated below centralized, decentralized and outsourced models are not limited to just supply chain management, but apply to quality programs as well. Unless provided in the articles of incorporation or the bylaws, local hospital boards will need to formally delegate quality oversight functions to the system quality office and document it in approved board minutes. Providers should identify the highest areas of opportunity and then move to standardize care by removing unwanted variation in both the inpatient and outpatient setting. Keep in mind there are pros and cons to each shared service model when considering which one might be right for your organization. Decentralized models can be creative, flexible, and are closer to the action but can also be redundant, ineffective and are non-standardized. Centralized models can leverage purchasing power and standardize processes, but can be inflexible and unresponsive. A shared services model can improve alignment of functional processes at both the facility and system level leading to a service-oriented culture, an efficient delivery model, and easy dissemination of leading practices. Centralization of selected functions is not always synonymous with run out of the corporate office. SHARED SERVICES DECENTRALIZED Service Culture CENTRALIZED Redundant Inefficient Creative Non-Standardized Flexible Closer to the Action Customer- Focused Business Intelligent Leading Practices Efficient Delivery Model Infrastructure Independent Entity Economics of Scale Leverage Purchasing Power Standard Processes Command and Control Inflexible Unresponsive Efficient Cost-Allocation Service Agreements Not Mission Invested Can be Held Accountable Detached from Business OUTSOURCED 2
For example, having a single system for physician credentialing and the development of Ongoing Professional Practice Evaluation (OPPE) reports can be an easy win to build a case for other standardized processes. Using a single occurrence reporting system, or aggregated claims data, can identify system-wide trends that would allow corrective actions to be taken with broader impact. One system we worked with recently identified a trend while they were reviewing claims data. They discovered five cases of adverse patient outcomes due to underutilization of appropriate VTE prophylaxis, so they implemented a systemwide re-education effort around its use. Using a common EMR and business analytics platform will maximize an organization s ability to automate data retrieval and standardize reporting to identify trends like this. Develop Organizational Guiding Principles for Governance and Quality Management As systems work to create a centralized governance and management model, it is necessary to establish guiding principles to guide future decision making. Enhance the patient and provider experience by making the right thing to do, the easy thing to do. Partner with patients and families for the highest quality care. A structured forum exists to manage quality. A strong technology infrastructure supports quality work. Clinical teams are created to develop, implement, and monitor evidence-based, best-practice system guidelines. Establish accountable organizational structure with streamlined reporting identify facility and system structural matrix components. Improve alignment of functional processes at facility and system level. All levels of leadership and staff engaged in a culture of quality. It is also important to develop principles for management of quality, which we define as the monitoring of routine operations at a process level. SYSTEM GOVERNANCE GUIDING PRINCIPLES EXAMPLES Chief Quality and Value Officer is responsible for quality management and oversight at the system level. A single point of contact is responsible for quality oversight and management at each operational unit. All leaders establish and sustain a culture of quality. Oversight of quality is centralized and coordinated across the care continuum. Consistent quality metrics are measured and reported to prioritize and drive quality outcomes. QUALITY MANAGEMENT GUIDING PRINCIPLES EXAMPLES Establish a standard health system way in which all members of health system will engage in quality work. Build formal capacity for quality improvement through training and coaching. Single performance improvement and change management methodology is used across the system. Care delivery is organized around value-added, front-line processes. A well-defined process exists to identify and prioritize high-value clinical processes. 3
Evidence-based best-practice guidelines are developed and blended into clinical workflows to reduce unwarranted variation. Data systems are designed to support and capture clinical processes. Transparent continuous feedback is exchanged at all levels including senior management. Technology is integrated to support processes and clinical decision making. Create Cross Continuum Quality Governance or Establish a Clear Model of Accountability The guiding principles will serve as the foundation to build a structure that will drive accountability across the continuum. As a growing number of organizations build clinically integrated networks, there is an opportunity to re-examine the flow of quality data and reset priorities for quality initiatives in both inpatient and outpatient settings. The figure below is an example of a strawman structure that can be used to support quality initiatives across the continuum. Representation from each of the member sites provides input and membership to a central Clinical Integration (CIC). The CIC has a standing quality committee that sets quality priorities to support contracting requirements, which is supported by a central project management office. Equally important as defining the meaning of quality, especially for highlymatrixed and complex organizations, is providing individual entities a voice in the process. This structure can also be adapted to fit a clinically integrated network into a regional model, with each region having anchor hospitals, employed physicians, and non-employed physician members of the regional CIN. CROSS CONTINUUM QUALITY GOVERNANCE CEO Executive Leadership Credentialing SYSTEM BOARD Clinical Integration CIC Quality Project Management Office Peer Review Physicians Council Advisory Boards MED EXEC COMMUNITIES Hospital #1 Hospital #2 Hospital #3 Hospital #4 Hospital #5 Hospital #6 PHYSICIAN ALIGNMENT ENTITIES Employed Physician Group PHO Other Physician Alignment Entities Home Health Other Entities Nursing Home/Rehab 4
Ensure Quality Initiatives Span Quality of Care With the governance structure in place, priorities can be set. Providers should identify the highest areas of opportunity and then move to standardize care by removing unwanted variation in both the inpatient and outpatient setting. Since transitions of care are a common source of inefficiency and variation, organizations can accelerate early success in bridging the gap by implementing an IT platform that spans the care continuum. As providers move to manage the health of populations while assuming increasing financial risk for the quality of care they provide the importance of managing patients in outpatient, as well as inpatient environments, and across transitions of care, has become increasingly important. With the trend toward hospital and health system consolidation, as well as increased hospitalphysician alignment, it is now essential to take a system-wide approach to quality program management. huronconsultinggroup.com 2016 Huron Consulting Group Inc. All Rights Reserved. Huron is a management consulting firm and not a CPA firm, and does not provide attest services, audits, or other engagements in accordance with standards established by the AICPA or auditing standards promulgated by the Public Company Accounting Oversight Board ( PCAOB ). Huron is not a law firm; it does not offer, and is not authorized to provide, legal advice or counseling in any jurisdiction. MU 160934 ABOUT THE AUTHORS Connie D Argenio Managing Director, Huron 312-583-8728 cdargenio@huronconsultinggroup.com Connie is a professional nurse with over 25 years of healthcare experience, including key roles in business development, strategy, and client relations, with a focus on clinical and financial improvement for healthcare providers nationally and internationally. Connie s experience includes partnering with hospital executives to improve clinical and financial outcomes through the appropriate and effective use of data/technology and consulting services. Fred Hosler, M.D., MPA Senior Director, Huron 615-335-0924 fhosler@huronconsultinggroup.com Dr. Hosler has 30 years of healthcare experience and is a physician consultant with expertise in clinical transformation and integration and physician leadership and governance. He focuses on repairing and galvanizing physician alliances and improving operational performance by leveraging physician leadership and governance to integrate processes and implement innovative physician alignment strategies that bring value to patients and improve outcomes and safety.