Breaking Through to the New Healthcare

Greg Wise, M.D., vice president of medical affairs, Kettering Medical Center, Dayton, Oh.: We are an eight-hospital system; we have our own college with baccalaureate and graduate degrees. Three of our hospitals are teaching hospitals and affiliated with Ohio University and with Wright State University. My journey has principally been around quality. And we’ve really valued Premier Inc. as a partner in this journey. We were involved in QUEST 1.0, now QUEST 2.0, and in the Partnership for Patients, value-based purchasing, ACO readiness, etc.; Premier has been a critically valuable partner, because no single hospital or even system can address all the issues involved without a partnership with an organization like Premier.

Greg Wise, M.D.

So we’ve been presenting on our journey with regard to clinical documentation. As you know, all data in hospitals is collected by somebody, and sent to many different avenues; but in the basic quality metrics that hospitals are compared against, such as risk-adjusted mortality, complications, and length of stay, etc., that risk adjustment is done through physician documentation. And this is a highly regulated process through Medicare. Physician documentation in the chart determines risk-adjusted methodology and outcomes so you’re truly comparing McIntosh applies with McIntosh apples across the country. And we’ve built a physician-led physician documentation program, which also includes nurses, coders, finance, and we even have our corporate integrity officer on our committee to make sure we’re doing everything correctly. And we’ve been doing that for 10 years.

So we’ve been doing continuous work to optimize our physician documentation process. At the same time, we’ve been working with a Premier collaborative around mortality, end-of-life issues, and other related issues. And we’ve been using a physician-led process to build and approve the use of evidence-based order sets into our CPOE [computerized physician order entry] system.

What have been the results of all this work?

We have a third-party independent group that comes in to audit our documentation process. We look at the response rate by physicians to our queries; there’s  great compliance with our external audit. And the government has been doing RACs as well. And we’ve come out quite well on our RACs. We’ve been subject to five or six RAC audits so far in the last year or so. Some are around sepsis and other low-hanging fruit. The other aspect would be length of stay.

What have the key learnings been from this work?

Probably the major one is that it does take a village, in the sense that it requires a multidisciplinary approach. But we’ve built a unit-based process with our documentation specialists so that we build a relationship with our physicians. Meanwhile, all of these elements [clinical documentation, evidence-based ordering, clinical performance improvement] are related.

And the big-picture question now is, how can we turn data into information that can be actionable? And then we need to form a community to allow all employees in the hospitals to have access to the Premier database.

Dr. Bechard, I know that you and your colleagues have been involved in a quality journey, too.

Douglas L. Bechard, M.D., chief quality and safety officer, Adventist Health System, Altamonte Springs, Fla.: Over the last six years that I’ve been with the organization, the emphasis has been on creating, in terms of improving quality, the infrastructure and the content, and to demonstrate that it improves patient care. We’ve put in the infrastructure for paperless hospitals in all our institutions. For example, on April 23, we turned on 63 applications, including CPOE, at one of our largest facilities, converting them from their current systems which were not integrated to the AHS standard including CPOE. Doing these conversions on an enterprise-wide level has been a daunting task.

Douglas Bechard, M.D.

We have not been with Premier very long yet; we were concentrating on ‘putting the tracks down’ for sustainable improvement with enabling technology. Where we have spent our time is on trying to put into the workflow of nurses and doctors what the best practices are, with just-in-time information. So we’ve worked with Zynx and have developed 650 order sets. We then allow them to take a parent order set, and if they want to make a child out of it, there are certain measures, pieces of evidence-based care, that can’t be taken out. And while we have not been universally successful in that, we’ve been working on that. And with nurses, we’ve developed and deployed  interdisciplinary plans of care, or IPOCs.

We have had data comparing our hospitals before and after CPOE, to look at conditions and risk-adjust them.  Our data demonstrate that patients who have been on our CPOE order sets have 10-20 percent lower costs and length of stay, though in a few cases, costs have actually risen, for good reasons.  We focus on what’s best for patients. Our preliminary data also show improved outcome and process measures.

Listening to all these accounts of work being done in these innovative organizations, what are your perspectives, Dr. Bankowitz?