Cutting data-to-care cycles where it counts

Sanford R. Kurtz, MD, joins us to discuss ways of accelerating the cycle of converting clinical research findings into patient care practices. He is vice president and chief medical officer at the Lahey Clinic in Burlington, MA. In addition to overseeing quality initiatives at the clinic, he is clinical associate professor of Pathology at Harvard Medical School. Kurtz is often an invited speaker at forums on clinical guideline practice, disease management, and making change for clinical improvement.

Q. At Lahey Clinic, you’re involved in the Accelerating Clinical Improvement initiative which specializes in converting clinical knowledge into real improvements in everyday patient care. Will you explain how it works?

A. We utilize Deming’s model, the plan-do-act cycle. Essentially we try to build two sets of competencies into all our improvement work. One is the competency to successfully implement improvement. The second is to make our improvements in a more rapid cycle time.

So our improvement model is pretty straightforward. It involves three large areas: (1) We have a workshop and a workbook for our improvement teams. (2) We create the teams. Each team has a facilitator and a data analyst and a sponsor. The teams reach an agreement on what they are trying to accomplish. (3) We look at current knowledge, from which we establish measures of quality.

We create our own measures and use external benchmarks. Then we create a cycle for learning and improvement. We develop a small test of change, and implement a change. Then we measure it and create another cycle of change and continue to make progress like that.

Leading indicators drive QI improvement

We establish measures based on our aims. For example, if it is to improve access in a clinical area, then the team establishes the measures of access. It might be third next available appointment, or it might be a measure based on when new patients need to come into the system.

Those measures are our leading indicators. Financial indicators frequently are lagging indicators. In other words, we know what they are, but they don’t help us change the cycle to improve things. So we try to find leading indicators. And we also try to pick indicators that are key levers, that is, they are critical measures absolutely necessary for success.

Q. What would be an example of a key lever?

A. I think access was a good one for us. I would say that new patients seen within one week of request is the leading indicator. And that’s a more important indicator than the number of visits if you’re looking at access. So that would be a key lever. Conversely, we don’t want to know the number of patients the doctor saw as a measure of access. We would like to know how many new patients he sees because new patients are much more important in terms of our growth over time.

Or, instead of knowing how many dollars a month we spend on pharmacy costs, it might be more important to have a measure of how many of our beta-blockers are on the managed care formulary.

Another example is pneumonia and the tendency to look at length of stay. In fact, one of the key levers is when people are switched to oral antibiotics because that determines how soon they can go home. How many hours from the time they are admitted until they are put on oral antibiotics will ultimately dictate the length of stay.

Q. You mentioned that each team has a sponsor. Why is that important?

A. Sponsorship is frequently lacking and that leads to failures in improvement projects. People can have a very good improvement model, and be very good at creating teams and team leadership. But frequently, no similar attention is paid to creating sponsorship at the highest organizational levels. So teams feel they’re operating in a vacuum. They have no ability to implement the changes needed to make their work successful.

One of the things we do with every improvement team is to ensure that sponsorship rests in leaders who are capable of understanding what they are responsible for, and who have the ability to implement changes created by the improvement team. We are trying to link sponsorship to the actual improvement cycle.

Q. How do you choose team sponsors?

A. We frequently like to have a physician in partnership with an administrator. We need physician accountability for many of the changes.

And then we might choose the vice president for ambulatory operations, for instance, because we know that in order to implement an improvement in access, we would need the vice president who is responsible for the appointment office. And for some changes, we might take someone from our board of governors.

Q. Have you been successful in acquiring that high a level of sponsorship?

A. You bet. Now not every team is successful, for all sorts of reasons, but I believe we have done two things to dramatically improve our success. The first is sponsorship by leaders, as I have described. Second, we have required that our key improvement projects be identified during the budget process so the finance department puts a value on the improvement process.

So from both from a strategic and a financial perspective, the organization feels that the few projects we are going to focus on are the critical ones and that they have a measurable value built into the budget. That has enhanced the accountability and the responsibility.

Frequently, what you find in large organizations is a group of improvement personnel that operate in a vacuum. They have no direct line authority to make change, and the savings generated are frequently determined by them.

For instance, if they take a day of length of stay and assume it’s $1,300, they multiply it by all the days that have been saved and they say that the organization saved $4 million or $5 million that year. Finance hasn’t signed off on that. The accounting can frequently be flawed. But then the improvement group presents their little report at the end of the year showing how many dollars they have saved. That, to me, is not a formula for success.

In our organization, we have the capability of doing only a few things very well. And the budget process lines up the needs of the institution with the resources we have to meet the needs. Finance is involved because the budget is based on some of the cost requirements or the improvement in revenue generated by those projects. So budgeting creates a level of accountability and aligns organizational needs with improvement initiatives.

Q. From your experience with accelerating clinical improvement, where should quality improvement managers be focusing their staffing and budgetary resources?

A. Our organization focuses on employee and patient satisfaction.

Q. Employee satisfaction — will you tell us more about your improvement efforts in that regard?

A. We have 3,000 or 4,000 employees. Through focus surveys and a whole series of process efforts, we have involved maybe 1,000 of them in areas they say are important. We’ve measured our employee satisfaction for the last three or four years. It’s something that we feel is very important. You cannot have good customer satisfaction without employees who are satisfied with their work.

Q. Do you have leading indicators by which you gauge employee satisfaction?

A. Some of the major drivers we focus on are work environment, supervision, compensation, and communication. We have questions that relate to each of those areas. Supervision might focus on: fairness, gives feedback, supports new approaches, and listens to what I have to say, for instance. For work environment, areas to gauge satisfaction could be: leaders treat employees with respect, opportunities for advancement, or reasonable job challenges. The other clinical areas we are working on are high-risk population management and physician panels.

We’re focusing more on identification of high-risk patients and on programs to monitor care than on management programs and clinical guidelines in the outpatient setting.It’s slightly radical. But we think it is the best way to create a major improvement in care and in financial performance in a short period of time.

Q. The Lahey Clinic 1998 Quality Report mentions the fall-risk reduction program for the elderly. Is that what you would describe as a strategy for high-risk population management?

A. That’s one of our efforts. And we have expanded beyond that. When you look at the literature, it turns out that 5% of a population can account for 50% of your cost. We have a special software system that prospectively identifies high-risk patients, and we’ve found that .6% of our managed care patients account for 30% of our total managed care expenditures. In other words, less than 1% of our managed care patients account for 30% of Lahey Clinic’s managed care costs.

We have a targeted, aggressive ambulatory case management program focusing on those patients. It extends out into the community where they live because part of the reason they generate all this cost is the hospitalizations and interactions with the emergency department. (For a description, see QI/TQM, December 1998, p. 163. For information on obtaining a copy of the Lahey Clinic 1998 Quality Report, see note, below.)

Q. Tell us about the physician panels — what are they, and how do they work?

A. Our primary care physicians have a group of managed care patients. They are responsible for the care of those patients and for the cost of the care. We use the term high-risk patient population management to help our physicians identify the most at-risk patients in their panel. Then we direct a program of care management to those patients and that inevitably leads to more cost effective health care.

In identifying high-risk populations, I strongly believe that our social systems and other approaches tend to focus on the elderly vs. less elderly people, the line being around the Medicare eligibility point. But that’s really an arbitrary designation.

We find that there are as many or more people in high-risk populations in the commercial programs as there are in Medicare. What we need to be doing is creating programs that deal with the burden of illness irrespective of the patients’ age.

For single free copies of the Lahey Clinic 1998 Quality Report, Lahey Clinic, Department of Public Affairs, 41 Mall Road, Burlington, MA 01805. Telephone: (781) 744-8733.