In 2009 Robert Wood Johnson University Hospital (RWJUH), a 600-bed academic medical center in New Brunswick, N.J., embarked on an initiative to improve its clinical and economic performance. Using physician management software from the Austin, Texas-based Crimson, a division of The Advisory Board Company, RWJUH began a pilot program involving 50 physicians. As part of that program, Joshua Bershad, M.D., senior vice president, medical affairs and chief medical officer, and Lois Dornan, director of decision support systems, met one-on-one with physicians to review specific opportunities to reach an appropriate average length of stay. Bershad and Dornan then followed up with physicians individually and in groups with monthly trending and progress data.
This project yielded an 8 percent decrease in average length of stay and a $276 reduction in average cost per case. The program yielded such strong immediate improvements that RWJUH doubled the number of participating physicians within 12 months. Within its first year, the hospital saved $1.7 million, more than four times its initial $400,000 goal. In the future, performance monitoring will be tied to incentives, and RWJUH will add an outpatient module to its performance tool to better assess cost and quality across the continuum of care. Bershad spoke to HCI Associate Editor Jennifer Prestigiacomo about the performance initiative and how he went about changing the culture of his hospital. Here are excerpts from that interview.
What was the impetus for the performance initiative, and when did it start?
The overall impetus for us to get involved with Crimson was the drive for value in healthcare, in the economic definition of quality over cost. The most expensive healthcare costs are related to utilization of tests and services. The physicians have the control over that, but they don’t have access to their own clinical and economic performance data. Crimson is set up to influence the conversation that you have with the physician to show them their data so they can relate to it. [This project started] sometime in mid 2009, and we made the decision to implement in September or October. The piloting was till March 2010, and we went live with our effort in April 2010.
Joshua Bershad, M.D.
How were the 50 physicians chosen to participate in the pilot?
We wanted at least a 2-1 economic or quality return on the investment we were making in the system. So we looked at which physicians had the most opportunity to improve or who were the most influential among peers. The goal was for this not to be a punitive process; it was meant to make them aware of performance trends.
How did you unseat the common physician rationale that their patients are sicker than others that were benchmarked?
Most systems that look at physicians’ performance on economic and quality, look at physicians compared to others. And that leads to the argument, ‘well we don’t have the same patients.’ However, Crimson looks at the patients you take care of versus by patients taken care of by anyone in the control group. So it’s looking at patient to patient, instead of physician to physician. So the statement that I started all these meetings with physicians is, ‘your patients have a longer length of stay than those patients with the same severity of disease and the same disease processes taken care of by other physicians.’
It’s never the tool that gets you the results; it’s the partnering of the tool and the process. We took a very disciplined approach. [When I would meet with the physician] I would try to pull out a [patient] case to find an example to illustrate the points of where this physician could improve. So we used specific patient examples to get performance to change.
How does this help you on your road to meaningful use?
This isn’t truly part of the meaningful use criteria. But I think where this works is [to start] a discussion around info sharing to be the fundamentals behind accountable care and looking at outcomes. When you look at outcomes you need data and a system and everyone to have easy access to the outcome information. Crimson updates every month and is accessible over the Web, so you can look at it anywhere you want, any time you want.
What were the challenges during this project?
This is a very time-intensive process, as with any type of cultural change. It’s just a matter of coordinating, tracking, measuring, and project managing something like this to keep it moving. It’s one-on-one meetings and discussions about practice. Yesterday, I got a call from one of the physicians we work with who said, ‘hey I have a patient that’s in the hospital. The patient had a unique clinical condition, and I know that they’re going to be in here for longer than I expect. I know that my numbers didn’t look as good as it should have last month. What should I do?’ First, the fact that he saw the number we sent him, second, he recognized the challenge, and three he reached out for help. That’s a cultural change that occurred, and six or seven months ago they wouldn’t have cared at all. They would have cared about the eventual outcome and the patient, but they wouldn’t have cared on a performance basis.