Typically, healthcare mergers have not led to consistent improvements in quality and outcomes. Research suggests mergers may cause a quality decline. When hospitals in Massachusetts were facing a merger, leaders sought to address the quality issue head-on and achieved substantial improvements in some categories, including a reduction in Clostridioides difficile cases.

When leaders from the Lahey Clinic and Beth Israel Deaconess in Cambridge, MA, announced their intentions to merge in 2017, multiple facilities took the opportunity to set quality goals that would improve outcomes and value. Years later, the newly formed Lahey Health System has made significant improvements, including a significant reduction in C. difficile cases.

When merger talks began, participants held learning sessions and roundtable discussions to confirm the system’s commitment to providing high-quality, high-value care, says Barbara A. Savage, director of performance measurement at Beth Israel Lahey Health. Quality goals were set with input from local leaders and a chief quality officer, says Richard Iseke, MD, chief quality officer at Beth Israel Lahey Health.

The initial quality improvement meetings led to a set of consensus-driven goals with appropriate threshold, target, and outcome criteria for incentive-based programs. The goals they set were reducing readmission rates, reducing C. difficile infections, and improving the patient experience.

Lahey assembled a forum for chief medical officers and chief nursing officers. That was expanded to include the quality and risk leaders from each facility or organization, along with patient experience leaders, physician-hospital organization leadership, human resources and employee health, and the chief medical informatics officer.

The chief quality officer and system performance measurement director worked together to develop a reporting calendar that would be used to set data submission dates. Data were reviewed in the forum before submission to the system and entity boards. Any deviations from the goal pathways were discussed in the forum, and the affected entity presented plans for addressing the problem.

Over three years, the effort produced significant improvement in reaching goals set by the health system and also in metrics related to performance on commercial value-based contracts, Iseke reports.

New Merger Revives Goals

Then, in 2019, Lahey Health System merged with seven other hospitals to create Beth Israel Lahey Health. Again, hospitals sought to improve service rather than succumbing to a possible downgrade in quality. Participants used the Lahey Health System framework to establish goals with broad consensus of leadership, Iseke says.

The board of trustees developed four goals based on the recommendation of the 10 hospital boards and their quality leaders: reducing C. difficile cases, reducing hospitalwide readmissions, improving Hospital Consumer Assessment of Healthcare Providers and Systems responsiveness scores, and creating an ambulatory measure focused on diabetes care.

Even deciding on the goals so soon after the merger was an accomplishment, says Yvonne Cheung, MD, MPH, chief quality officer and chair of the department of quality and safety at Mount Auburn Hospital in Cambridge, MA, part of Beth Israel Lahey Health.

“These are all institutions that, the day before the merger, were competing. The day after, they were sharing data and collaborating on best practices,” she says. “One of the best things we did was to have everyone meet in person and build relationships face to face. Then, it became easier to share data, show what we did well, [and] what we wished we were doing better.”

The health system focused on C. difficile because rates were high at the facilities, Iseke says. These infections affect patients significantly and put a heavy burden on staff.

Cheung notes C. difficile is a preventable hospital-acquired complication, making it a compelling choice for the health system’s quality improvement goals.

To reduce C. difficile cases, the health system focused on total cases to facilitate communicating goals and progress throughout the system, Iseke explains. Individual hospitals established goals that would improve value-based scores.

There were 389 C. difficile cases in the health system in the 12 months ending March 31, 2019. Quality leaders endorsed the initiative in April 2019, after which the chief medical and quality officers began sharing best practices for standardized testing protocols and antibiotic stewardship programs.

The improvements had been established in most of the hospitals by September. From there, the quality team monitored monthly scorecards. For the 12 months ending March 2020, C. difficile cases were down nearly 50% from the prior year.

“When we expanded to the bigger hospital system, the quality working group was able to expand and spread the model that had been successful before. [We] have been, collectively, able to move the needle, with a lot of great knowledge and information-sharing,” Cheung says. “We went from competitors to collaborators.”

Savage notes the C. difficile strategy and other interventions all were evidence-based. “It was all about how to apply the evidence from randomized trials so that it will actually work to achieve the better health outcomes that we’re trying to achieve in the real world,” she says.

Board Wanted Faster Results

Iseke notes the effort in the first merger resulted from a challenge the health system board issued. During the second merger, administrators wanted to see even faster improvements. “We essentially set up the classic structure-process-outcome model. We set up a structure to bring people together from all the organizations on a regular basis, to review the needs of the patients, the community, our staff, the board, our clinical leaders,” Iseke says. “We came up with a matrix of goals that were common to all of our organization so that we could select what we should focus on.”

With the assistance of an outside consulting firm, the team used various quality maps to score goals based on how many of those aims a goal would hit.

“There was a fair amount of negotiation, but we used evidence-based medicine to show what we thought could be achieved. We also used trend lines to show what could be achieved in a certain period,” Iseke says.

“We used Vizient data, CMS [Centers for Medicare & Medicaid] data, BlueCross data. We also brought in our ACOs [accountable care organizations] and primary care contracting groups so that everyone was on the same train going in the same direction,” Iseke continues. “We set up a series of measurements and reviews and in-depth reviews with institutions that were lagging.”

One of the hospitals joining the Lahey Health System had been performing better with C. difficile than the other facilities. Thus, a quality leader from that hospital showed the other facilities how to include some of the best practices that worked well. Soon, the other hospitals were showing better metrics.

“The system created a learning network and a friendly competition to adopt what was working and to drop what wasn’t,” Iseke says. “When we came into the Beth Israel Lahey Health system, we had multiple institutions and multiple EMRs [electronic medical records]. We ... showed that you could take the same model and scale it to three times the number of institutions.”

Whole Health System Affected

The team believed C. difficile affected the most people across the health system, Iseke says. All parts of the health system could contribute to improving C. difficile rates by optimal use of handwashing, antibiotics, and testing criteria, as opposed to some goals like readmissions and patient experience that some entities in the system could not affect so directly.

“We thought if we ever could bring the group together to use evidence-based medicine, it should be on C. difficile,” Iseke says. “We also had organizations in the earlier health system that had remarkably low rates. When we began to compare what they were doing, it turned out to be less around handwashing and more around being very detailed about strict criteria for locating, testing, and follow-up. C. difficile showed us that if you go after goals in a very rigorous, dramatic way, you can make dramatic improvements. Then, those practices can be applied to other quality goals.”

For example, a chief medical officer or chief quality officer may not be able to discuss C. difficile rates and testing, perhaps deferring the question to the infection control department.

That should be a red flag, Iseke says. “A chief quality officer and medical officer have got to know those details. If you don’t have those two working as partners, you will end up with some gaps in your process. That often leads to the results you don’t want,” he explains. “C. difficile taught us some of those lessons, and we’ve now applied some of that knowledge to readmissions. For that goal, we found out that the quality officers and chief medical officers were trying to do too much themselves, not assigning people to carry out some of the team tasks and holding them accountable.”

SOURCES

  • Richard Iseke, MD, Chief Quality Officer, Beth Israel Lahey Health, Cambridge, MA. Phone: (617) 278-8847. Email: richard.iseke@bilh.org.
  • Barbara A. Savage, Director, Performance Measurement, Beth Israel Lahey Health, Cambridge, MA. Phone: (617) 278-8819. Email: barbara.savage@bilh.org.
  • Yvonne Cheung, MD, MPH, Chief Quality Officer, Chair, Department of Quality and Safety, Mount
    Auburn Hospital, Cambridge, MA. Phone: (617) 575-8603. Email: ycheung@mah.harvard.edu.