Integrated outcomes critical to lasting change

Method attracts physician leaders

The hallmark of the integrated outcomes strategy is to engage the practicing physician as the hands-on leader. "This methodology makes it absolutely natural," notes co-designer Steve Shaha, PhD, president of the Institute for Integrated Outcomes in Amherst, NY.

Another distinction of the integrated outcomes method is that clinicians choose improvement initiatives based on their feasibility and relevance rather than on directives issued from administrative or finance departments. The technique uses interdisciplinary teams formed around measurable improvement goals. True to his background as a health care criteria designer for the Malcolm Baldrige National Quality Award, Shaha notes that for sustainable gains, the QI process must not favor one type of result to the detriment of another. Bona fide improvements embrace clinical, consumer, and cost outcomes.

The integrated outcomes model was born and raised at Children’s Hospital of Buffalo (NY), now an affiliate of Kaleida Health in Buffalo. Since then, the integrated outcomes method has proven itself through replication in other systems. Kaleida embraces a network of five hospitals. The network is affiliated with the School of Medicine and Biomedical Sciences of the State University of New York at Buffalo. About 4,000 academic and private-practice physicians are involved.

The Children’s Hospital drives pediatric care improvements for the region. Four years ago, the hospital’s quality specialists created the Center for Integrated Outcomes Healthcare (CIOH) as an entity within its larger QI program. Linda Brodsky, MD, director of Children’s pediatric otolaryngology service was voted into the position of CIOH director.

The consulting group, Institute for Integrated Outcomes, was invited to facilitate the development of physician-led initiatives. QI staff act as consultants on CIOH projects.

According to Laurie Giza, director of planning, research, and marketing at the Institute for Inte-grated Outcomes, CIOH currently has more than 20 initiatives in progress. "One of our biggest assets has been to accept that every department is working with very limited budgets and staff, and to acknowledge that we are stressed and overworked," says Giza, a co-designer of integrated outcomes. Short, superproductive meetings are key to the effectiveness and acceptance of the methodology.

Integrated outcomes in action

Following a hospitalwide orientation to the principles and processes of the integrated outcomes method, the CIOH executive committee invited physicians to submit one-page QI project proposals. Two stipulations applied:

1. A project would interest the initiator.

2. It would promise potential benefits for patients and the hospital.

Project leaders were told to expect about one hour of extra work per month.

Executive committee members represent these functional areas:

1. research;

2. clinical;

3. administrative;

4. nursing;

5. finance.

Among the pilot projects was the surgical correction of strabismus (crossed or "walled" eyes).

Goal: Determine which of two common clinical practices produced better results for patients whose conditions were correctable by an operation on one eye:

— surgery on one eye and one muscle;

— surgery on two eyes and two muscles.

Team leader: Practicing strabismus surgeon.

Team members:

— administrative liaison with CQI training and direct reporting relationship to top leadership;

— outside facilitator with data analysis skills;

— outpatient surgery nurse familiar with pre- and postoperative processes, as well as services for patients and their families;

— operating room nurse familiar with surgical and post-surgical care;

— finance department representative;

— medical records representative;

— information services representative;

— anesthesiologist;

— other strabismus surgeons, on occasion;

— ad hoc team members including post-anesthesia care unit nurse and patient complaint/satisfaction representative.

Lessons from the pilot phase:

The wisdom of configuring teams around problem areas rather than individual departments was immediately apparent.

"The rapidity of change is increased because people feed off each others’ ideas and individual departments don’t get burned out. We have one-hour team meetings. That makes the physicians very interested in participating," says Brodsky, who is also president of the Institute for Integrated Outcomes.

Celebratory air of excitement for continuous improvement:

Semiannual team meetings convene in March and September, always on a Friday from noon to 1:30 p.m. Representatives from 20 teams attend. Four to five teams present 10-minute "show-and-tell" sessions. "It’s a better way to disseminate information than dry statistics," states Brodsky, also a co-designer of the integrated outcomes methodology. "When people hear what others are doing, they begin to realize it can help them, too." She notes that this is a particularly effective way to disseminate practice improvements to physicians in community settings.

Teams define their tasks and measure their success according to desired outcomes and supporting data. Each of the project teams has seen positive results in one or all of the outcome areas measured. Here, for example, are details from the strabismus project:

Clinical measures: Degree of eye misalignment and amount of improvement in alignment. Surgery results were the same for one-muscle and two-muscle procedures.

Cost measures: Length of stay (LOS) at three stages (1) preoperative, (2) in the operating room, (3) postoperative; and operating room charges. Outcome was not significantly better for the two-muscle group.

Satisfaction measures: Patient’s perception of pain. Outcome was not significantly better for the two-muscle group.

Clinical practice changes: Physicians who relied on two-muscle surgery altered their practice patterns with patients eligible for the one-eye/one-muscle procedure. As a result of continuing collaboration and data collection, lessons learned from the one-eye/one-muscle practice patterns have been applied.

Project expanded to outpatient

Heartened by shorter LOS and higher satisfaction among strabismus patients, the physicians extended their efforts to the whole outpatient surgical area. The results: LOS down 50%, thanks to increased parental involvement in patient monitoring and discharge preparation. Costs are down 35% for outpatient strabismus patients and 12% for all patients. Satisfaction increased among parents, nurses, surgeons, and anesthesiologists. But that’s not the end of the story.

Revised anesthesia protocols for all outpatient surgical patients resulted in lower anesthetic drug doses, less vomiting, and other negative effects. The cost savings amounted to nearly $250 per case. When multiplied by the 3,000 cases to which these changes may apply, the savings are estimated at $750,000.

Perhaps the strongest appeal of integrated outcomes for doctors and other clinicians is that clinicians run the show. While there’s a great deal of lip service to the principle, it’s rare for organizational leaders to entrust a system’s financial health to clinicians by authorizing them to improve clinical quality, notes Shaha.

The improvements from integrated outcomes initiatives go beyond outpatient surgery. They include:

• Reduced medication prescribing errors in the hospital’s pediatric intensive care units due to a clinical pharmacist’s presence at clinical rounds and collaboration on clinical order writing.

• A cultural shift in the operating room that pleases the hospital staff and physicians. Staff re-designed the hospital’s surgical function, including the staffing patterns, informatics, and all aspects of supply ordering and handling. "Our approach is generalizable, but it is not cookie cutter medicine," states Brodsky.

A character sketch of integrated outcomes

In principle, the methodology is adaptable enough to thrive in nearly any organization. But don’t underestimate its simplicity. Once it takes hold, it will change the entire system. Here are its basic features:

Leadership believes in and endorses the team approach to success. When individuals create solutions in a vacuum, there is a predictable degree of resistance and lack of success in implementation.

Outcomes are the sole measure of success. Three types of outcomes command equal importance: Clinical, financial, and satisfaction for all the stakeholders.

Administrative buy-in and investment are complete and tangible. This includes time off from other duties by key personnel and resources to engage outside experts at strategic points.

Initiatives percolate from the front line. People who do the jobs can best gauge which changes will work, and they own the energy to refine the processes. Shaha points out that practicing physicians make the most successful leaders for clinical projects — but that doesn’t necessarily apply for nonclinical.

Offshoot initiatives evolve from early successes. Integrated outcomes methodology runs counter to common assumptions that change should start in areas of high volumes, costs, or sticky clinical challenges. When the frontline workers prioritize objectives for change, even if they start small, the areas of greatest concern at the system level invariably arise as offshoot initiatives. At that point, staff are primed to address them with confidence and experience. n

Need More Information?

For more on the integrated outcomes method, contact:

o Laurie Giza, Institute for Integrated Outcomes, P.O. Box 722, Amherst, NY 14226. Telephone: (716) 310-0722.