Group fosters cooperation in a competitive market

Business group builds trust where suspicion ruled

When employers in Kalamazoo, MI, formed a health benefits purchasing coalition in 1992, they expected to find meaningful evidence of quality service from the community’s three hospitals. "But when we started to look at the data, it was not there. We were looking for consistency and accountability, and what we found were inconsistent standards and measures among the hospitals," says Marilyn Bell, president and CEO of the Southwest Michigan Healthcare Coalition (SMHC).

So the coalition asked the hospitals to buy a standard software package to collect and report data from all patient charts. SMHC expected to compare the hospitals, one to the other. Protec-tive of their marketing efforts and competitive positions, however, the hospitals raised strong objections.

Bell says the coalition’s objective was "to focus not on who’s the best, but on who’s improving. If there was no improvement, then we might have to drill down to individual providers." The success or failure of the project would depend on the physicians’ willingness to change their practice patterns if they were out of line. "We didn’t want to do finger-pointing," she emphasizes. Instead, the coalition relied on persuasion through data and painstaking diplomacy.

Negotiations and accommodations

SMHC chose 30 high-cost DRGs for annual severity-adjusted reports. Information would consist of length of stay, total charges, and mortality. Included were congestive heart failure, medically managed back problems, heart attacks, and hysterectomies. It did agree to back away from requiring comparative data among three competing hospitals.

It’s not petty for hospitals to haggle over definitions of mortality and severity-adjustment methods, especially when tertiary care is involved, Bell observes. "So it takes a lot of talking through of definitions, and mainly, they come up with the right answers."

Preliminary reports compared each hospital to a national database. "The system doesn’t give answers, but the data tell where they need to improve and look at different practice patterns. With data, physicians are empowered," Bell notes.

One or two doctors usually rise as champions and start discussions among their peers. "We can’t mandate that doctors use practice guidelines or clinical pathways," she concedes. "The leadership has to come from them." Once physician leaders emerge, SMHC steps in to facilitate the design and use of the tools. Improvements have come from such simple changes as starting antibiotics in the emergency room instead of waiting until patients are admitted, sometimes that amounts to an eight-hour difference.

The diplomatic efforts did not stop with the physicians, however. The coalition embraced the CEOs as well as marketing and financial leaders from each hospital. (To learn how hospitals can cut door-to-antibiotic times, see QI/TQM, May 1999, p. 57.)

While SMHC sought meaningful measures of quality, the hospitals were extremely tense about who would see the quality reports and how they would be used. So SMHC made concessions of its own. "The definitions of charges are not always real numbers, but they were the most consistent measures we could settle on for comparison of our hospitals with national figures. Besides, when we look at financial data, they are always paired with outcome data," says Bell.

Apprehension ran high during preparations for the first quality reports to go public. Planning was slow and deliberate to protect the trust so dearly won by both sides. The result was this three-stage rollout:

1. The company that ran the data presented findings to a closed session of the SMHC board, which consists primarily of CEOs from member corporations. Hospital representatives were not invited.

2. Representatives of the SMHC membership and the hospitals met for an unveiling of the reports at a large, highly interactive event. A lively exchange of questions and information took place. Bell recalls that at that stage, the health care leaders seemed to realize that SMHC was more committed to quality of care than to defining who was better than the rest.

3. A press conference released the reports to the community at large. Well in advance, Bell and the hospital leaders sat down and delineated precisely what would be disclosed. Their agreement specified that local hospital data be aggregated instead of separated for each hospital. The comparisons were drawn between the expected figures and actual numbers.

However, "the real story at the press conference was that these hospitals got together to improve their quality," she says. In light of the fierce competition among the institutions, it was legitimate news. At the press conference, as at all public events, "our focus is always on how much the hospitals have improved. The main thing is for the public to understand that there are differences in the hospitals, not that one is the best." Now, Bell reports, the hospital leaders usually leave it to her to handle the presentation of information to the media.

Along with copious public praise for quality improvements, Bell continually applies pressure behind the scenes for additional improvement. It’s less of an uphill grind now that the physician leadership has hit its stride. A strong infrastructure of QI committees and positive experience with guidelines and clinical pathways fuel the movement.

One measure, mortality rates, is the topic of provocative debates. Although down considerably, the rates are not as low as expected. "We discuss each death," Bell explains. They consider the patient’s health problems as well as the cause of death. Such analysis is bringing larger issues to light. For example, "Should this patient have been in the hospital, or in a hospice program? If the family insisted on open-heart surgery for an 84-year-old with multiple chronic conditions, should the health care community strengthen its family teaching and advance directives programs? Is pain management and palliative care as good as it could be? Does the community have adequate hospice care?"

Bell says that with the basic trust-building complete, there is more room to explore improvements in community services adjacent to direct health care.

Need More Information?

For more on working with a coalition of corporate health benefits buyers, contact:

o Marilyn Bell, President and CEO, Southwest Michigan Healthcare Coalition, 303 N. Rose St., Suite 424, Kalamazoo, MI 49007. Telephone: (616) 342-5525.

For more on outcomes measurement software, contact:

o CIC — MediQual Division, 500 Nickerson Road, Marlborough, MA 01752. Telephone: (800) 350-6444. Web site: