As the U.S. healthcare system shifts inexorably further away from fee-for-service payment and towards value-based reimbursement, one area of importance that is looming larger than ever before is that of variation in clinical practice and care delivery. Variation in the way that physicians, nurses, and other clinicians deliver care was largely unchallenged under fee-for-service reimbursement, because there was no need to standardize care patterns to produce better patient outcomes or to reduce or curb costs. That underlying landscape is changing now, and the leaders of more and more patient care organizations are expending the time and effort needed to uncover variation and standardize care practices.
Nancy Lakier, R.N. is the founder, CEO and managing principal of Novia Strategies, a San Diego-based healthcare consulting firm that advises hospitals and health systems on improving their operations, quality and financial strength. Lakier sat down recently with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss her and her colleagues’ work in the crucial area of uncovering and eliminating unnecessary clinical variation. Below are excerpts from their interview.
You’ve been in healthcare for a number of years, and have had a broad range of professional experiences. Please share with me some of the experiences that brought you into this type of consulting.
I was the CNO at Scripps Health, and over operations at Scripps-La Jolla, and was recruited down there when I was up in Los Angeles, as they were anticipating a major hit coming from managed care. They had called me back in 1989, and I worked there from 1990 to 1995. And they had been right—very shortly after I arrived, that organization was feeling the strong effects of managed care. It was something of a “perfect storm” of difficult challenges: the economy was in a slump, they were cutting back on military bases, and managed care was taking a big bite in order to save money.
And one thing that I ended up developing was what we called the Lakier Predictable Factor. Essentially, it was a methodology for understanding the trajectories of predictable patients. For example, if you’re 40-something years old and you go in for a total hip replacement, you’ll probably have a relatively smooth and predictable course of care, whereas, for example, the 85-year-old who’s diabetic and breaks their hip, will not have that same predictable trajectory.
Nancy Lakier, R.N.
And, without realizing it at the time, we were really breaking new ground with that approach. So I partnered with a physician, Dr. Bruce Campbell, and we developed a clinical redesign. We did this across the whole hospital, but started with certain populations, and worked our way through. We were working with a limited database in those days, but we used it and put together teams of physicians, nurses, therapists, etc., to say—for the predictable populations, what were the right protocols? What drugs, supplies, should we use? When you look at implants, instead of 30 vendors, can we reduce that number? So we started looking at changing practice—using lighter anesthetics, decreasing time on ventilator, getting patients up and moving faster—and all those elements were starting to bring down lengths of stay. And working forward in that direction led to a lot of questioning of previously unquestioned practices: for example, why are you ordering a chest x-ray every day? The reality was that physicians practiced based on how they had been trained at the particular medical schools that they had attended, rather than anyone adhering to best demonstrated practices.
So one of the things that we started seeing is that we were reducing the cost, and literally moving the mean line in terms of cost-effectiveness as well as in terms of clinical outcomes. At that time, we were getting one, two, three days’ reductions in lengths of stay—but also improvement in outcomes in every one of the patient populations we addressed. And also, we put in very robust case management to manage the unpredictable. So, for example, what needs to happen with this 84-year-old diabetic who’s broken their hip? We essentially were examining the practice patterns around the care of both predictable and unpredictable patients. And that inevitably led to us directing a team to look at labor issues, because if you’re reducing length of stay, then you also need to look at staffing. So we also ended up creating a productivity task force.
How long did it take to achieve a transformation of your processes at Scripps?
It really took about two years at Scripps-La Jolla, and then we refined the methodology and spread it to the other four hospitals.
Looking at the landscape right now in healthcare, what is your sense of the readiness of clinicians and administrators in hospitals nationwide to pursue the examination and reduction of clinical variation, in the current environment.
It’s still all over the gamut. Leadership is feeling it for sure, in terms of realizing that this kind of work is needed. The rank and file is still a mixed bag. Some physicians are like, ohmygosh, I need to do this; some haven’t even heard about it. Some have heard about it, but they’re planning to retire in five years and think they can just slip out. The younger physicians are ready for it and have been prepared psychologically for it.
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