If the landscape of the new healthcare remains an uncertain and tricky one for most patient care organizations, at least the leaders at North Memorial HealthCare have a map of that terrain. Indeed, as hospitals, medical groups, and integrated health systems lurch forward towards the new healthcare—a U.S. healthcare system requiring of providers far higher care quality and patient safety, far greater cost-effectiveness, accountability, transparency, and patient and community satisfaction—indeed, overall, far greater value—provider leaders face a huge challenge in figuring out just how to prioritize their foundational work.
But at North Memorial, a two-community-hospital health system based in Robbinsdale, a suburb of Minneapolis-St. Paul, leaders have launched themselves on a path that will position their organization beautifully to adopt the principles of the new healthcare, and it is one that is already reaping rewards. At both the 300-bed North Memorial Medical center in Robbinsdale and the 100-bed Maple Grove Hospital in nearby Maple Grove, clinician, executive, and IT leaders have embraced the concept of comprehensive, data-driven, enterprise-wide quality improvement, and are moving as rapidly as possible to apply the concept to as many clinical processes and clinical service lines as possible. As Jeffrey Vespa, M.D., medical director for clinical quality for the system puts it, “A lot of it is centered around the value proposition that’s out there for healthcare. And when you consider that quality-cost equation, we’ve elected to pursue the quality part of it, assuming that we will gain the cost benefit.” Importantly, Vespa says, “The opportunity we saw was that, without good, real-time data, it was hard to show improvement and then provide the feedback to individuals and teams about their performance. People may try to implement change, but then the question is, did you really do it?” It is the sustained leveraging of clinical and operational data, harnessed to a long-term commitment to enterprise-wide quality improvement, that is the key to sustaining performance change, he emphasizes.
North Memorial Healthcare's innovative team, from left: Linda Engdahl, R.N., director of Maple Grove Hospital Women's and Children's Services, Maple Grove Hospital; Jon Nielsen, M.D., medical director, North Memorial Women and Children's Service; J. Kevin Croston, M.D., chief medical officer of North Memorial HealthCare and president of the Physician Organization; Greg Kern, measurement and reporting manager, North Memorial Healthcare; and Jeffrey Vespa, M.D., medical director of North Memorial Healthcare.
In pursuing this work, Vespa is part of a like-minded leadership group at North Memorial, including J. Kevin Croston, M.D., the health system’s chief medical officer; Jon Nielsen, M.D., a practicing gynecologist and the medical director of the system’s Women’s and Children’s Service; Linda Engdahl, R.N., M.S.N., director of Women’s and Children’s Services at Maple Grove Hospital, who is along with Dr. Nielsen co-chair of the Women’s and Children’s Guidance Team for the health system; and Greg Kern, manager, measurement and reporting, for the health system.
Begun in 2007, the enterprise-wide quality initiative is leveraging an electronic data warehouse platform (from the Salt Lake City-based HealthCatalyst) for the gathering, sharing, and storage of data, enterprise-wide; the use of advanced healthcare analytics applications to facilitate all aspects of the initiative; and permanent, multidisciplinary teams responsible for care improvement in specific clinical areas. Working with near-real-time data via easy-to-use dashboards, the teams are building evidence-based practices into clinicians’ workflows, and helping to eliminate variations in care practices unsubstantiated by evidence or consensus.
One of the first projects undertaken has been to reduce or eliminate unjustified inductions of child labor prior to 39 weeks’ fetal gestation, based on strongly replicated evidence in the clinical literature that such inductions, unless truly medically necessary, pose health risks to the fetus and mother, often leading to increased admission to the neonatal intensive care unit (NICU).
Jon Nielsen and Linda Engdahl have been leading that project, and have strong results to show for it, reducing elective pre-39-week inductions from 1.2 percent to 0.3 percent within a year. One of the key elements, as Nielsen and Engdahl note, was beginning by creating a more rigorous determination of fetal gestational age. Ensuring that estimated gestational age was entered correctly into the electronic health record (EHR) at the earliest possible moment was an initial hurdle to overcome. And then, as Nielsen notes, “The first substantive thing we had to do was to increase clinician awareness that it would probably have real impact to deliver at 38 weeks instead of 39 weeks.” In addition, bringing all the key clinician stakeholders, both physicians and nurses, including not only medical nursing and leadership, but also front-line obstetricians and obstetrical nurses, Engdahl and Nielsen report, was another key step.
Having put all those elements together, and then capping off the process with a protocol requiring that any obstetrician seeking to schedule a pre-39-week induction contact Dr. Nielsen for pre-approval, have been instrumental in bringing down an induction rate that, though lower than the national average in that area, had sometimes reflected physician and/or mother convenience preferences. What’s more, admissions to the NICU have dropped dramatically, because of improved baby outcomes.
All those involved agree that the strategic leveraging of clinical data, EHR- and clinical decision support-facilitated, at the point of care and clinical decision-making, has made all the difference, along with an enterprise-wide commitment to continuous quality improvement. Still, says Croston, the CMO, “It’s a little more complicated than continuous process improvement; that is the ultimate outcome. But what we were trying to get to was that we have a medical staff with 300 employed physicians and 1,200 affiliated doctors. And we were really trying to migrate to become a real healthcare delivery system, not just a hospital.” Marrying strong clinical information systems to executive management-backed continuous improvement and the reshaping of the physician culture in the organization, he concludes, has been the key to success so far on this journey.
While everyone at North Memorial HealthCare agrees that the organization is still early on in its journey towards clinical transformation, the leaders of the health system’s quality initiative also agree that they’ve got a good map for that journey going forward. And it’s one that organizations all around the U.S. could use and benefit from.