Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Culture Change Helps Health System's Hospitalists Become One Team (Part 1 of 2)

2/4/2016 1:11:30 PM | 1 comments

In a previous post, I discussed how the Adventist Health Central Valley Network (CVN) set out to achieve meaningful integration among its clinical services.
 
To recap, the network chose CEP America to manage both the ED and hospitalist programs at three of its hospitals (Adventist medical centers Selma, Hanford and Reedley). From the start, the network leadership made it clear that they were seeking meaningful integration that would reap tangible rewards for its patients.
 
The quickest benefits came from within the hospitals, as emergency physicians and hospitalists began collaborating at their respective sites. However, integration soon spread across the network as providers from all three hospitals came together to improve patient care.
 

In my next two posts, I'll explore the idea of system-wide integration using the CVN hospitalists as an exemplar. In today's post, we'll look at some of the ways that group has improved inpatient care across the network. In my next post, we'll explore the cultural foundation that makes this level of integration possible.

Integration: True or False?

 

“We had been given the task to really improve the patient experience and throughput. We felt that having a related hospitalist service could resolve the issues because they’re Partners in the same group and have the same goals.”
- Kendall Fults, RN, Senior Vice President of Network Operations, Adventist Health – Central Valley Network


Previously, the hospitalist programs at Selma, Hanford and Reedley were staffed by three different physician groups. CEP America brought these practices under a single umbrella — still locally independent, but aligned toward common goals.
 
The network leadership wanted to achieve "meaningful" integration across the system, but what exactly should that look like? To illustrate my own vision of integration, I like to compare it to the difference between American football and basketball.
 
In football, players are essentially "siloed." Each has a narrow skill set and a specific job to do. The quarterback never punts. After fourth down, the wide receiver doesn't stick around to play defense. The ball changes hands exactly once a play. And after that play is set, there's relatively little on-field communication.
 
Many hospitals and health systems operate like football teams. They say they are "integrated," but in reality, they are a collection of more-or-less functional silos. They never do the difficult work of breaking down those siloes so they can realize their full potential.
 
By contrast, a truly integrated health system is more like a basketball team. Players have positions, but those roles are more flexible. Everyone plays offense or defense as the situation demands. Everyone dribbles, shoots, passes and blocks. Handoffs and communication are fluid and constant throughout the game.
 
And what a difference this type of play makes to the patient. The integrated system moves faster. The players are constantly working together to plan and execute the next move. From the patient's point of view, this translates into being cared for by one cohesive team as they move between departments — and even hospitals.
 

Three Hospitals, One Vision

 

In order to achieve "meaningful" system-wide integration, providers from different hospitals must work as one team. To this end, the hospitalist medical directors from Selma, Reedley and Hanford meet monthly to engage in joint planning, review progress and troubleshoot issues. (The Central Valley Network leadership attends these meetings on a quarterly basis.)
 
A major victory for this group was a marked increase in in-network transfers. Previously, patients were often sent to other health systems for certain services or when inpatient beds were scarce. However, the hospitalists found that by working together, they could usually meet patients' needs within the network. So for example, when a Reedley patient needs critical care, the Reedley hospitalist contacts their colleague at Hanford (which has an ICU) to facilitate a handoff and transfer. Not only does this approach prevent financial losses, it's safer and more expedient for the patient and family.
 
Another victory for the hospitalists has been the use of network-wide "champions." A recent example is sepsis standard work. When the hospitalists reviewed their clinical data at a joint meeting, it became clear that the team at Hanford was "the best of breed" when it came to screening, early goal-directed therapy and mortality. They were clearly following a number of best practices that could benefit their sister hospitals. So the team developed one enthusiastic physician as the "sepsis champion." The champion then shared sepsis best practices with the Partners at Selma and Reedley.
 
The "network champion" model has also been used in areas like venous thromboembolism prophylaxis, patient experience and catheter-associated urinary tract infection. The champions take a multidisciplinary approach to process improvement involving medicine, nursing, case management, clinical care coordination and everyone at the hospital who touches the patient.

A Win-Win for Patients and Hospitals

 
The integrated CVN hospitalists have achieved some amazing results:
 
  • In-network transfers recaptured $1.4 million in revenue.
  • Average inpatient length of stay (ALOS) dropped for all hospitals (and by 25 percent at Hanford). The current network ALOS is 2.9 days.
  • Case mix index (CMI) is at an all-time high for the network.
  • All emergency departments saw a marked drop in turnaround times to admission (TAT-A).
 
So what made the difference? Aligning the three hospitalist teams toward common goals certainly helped. And the initiatives they designed were very clever. But there's more to the story. It wasn't until the organizational culture at these hospitals clicked that the numbers really took off.
 
What kind of culture do I mean? And how did we foster it? We'll explore that next time on Perspectives.


Comments
Rick Newell
Thanks for sharing Mu. What a great example of how true integration benefits both patients and hospitals.
2/5/2016 8:34:21 AM