One of the truly pioneering patient care organizations in the United States is the Billings Clinic, which, though founded in 1917 as a medical group, in 1993 became an integrated delivery system, ,when the existing Billings Clinic, then composed of about 95 physicians, came together under that same name with what was then Deaconess Hospital, located across the street from the clinic in Billings, Montana.
Today, the Billings Clinic organization encompasses the 280-bed inpatient hospital, 11 critical-access hospitals in rural areas surrounding the city of Billings, as well as about five rural clinics in the region; and nearly 300 physicians. What’s more, the organization became nationally known when it joined the Medicare Physician Group Practice Demonstration Project, participating from April 2005 through 2010, along with nine other medical groups. As an important July 2011 report on the demonstration project noted, all ten of the medical groups involved made considerable progress in increasing the efficiency, effectiveness, and care quality of their management of patients with diabetes, congestive heart failure, and coronary artery disease, and in their preventive care efforts.
Indeed, much of what was learned in the PGP demonstration project, says Billings Clinic CEO Nicholas Wolter, M.D., became foundational for the Medicare Shared Savings Program, which Billings Clinic joined as an accountable care organization (ACO) in 2012.
So how did Billings Clinic become a national leader among medical groups? Ultimately, the answer is tied to vision, mission, and culture, says Dr. Wolter. He will be sharing some of his thoughts on those subjects when he gives a keynote address entitled, “Culture, Safety, and Quality: Strategies to Enable IT,” at the Health IT Summit in Seattle, to be held August 19-20 at the Seattle Marriott Waterfront. The Summit is sponsored by the Institute for Health Technology Transformation, or iHT2 (since December 2013, Healthcare Informatics has been in partnership with iHT2 through HCI’s parent company, the Vendome Group, LLC). For further information on the Summit, please click here.
Nicholas Wolter, M.D.
As he prepares to speak at the Summit on August 19, Dr. Wolter spoke with HCI Editor-in-Chief Mark Hagland about the ongoing journey of the Billings Clinic as a pioneering organization in U.S. healthcare, and how culture, vision, and mission have been decisive factors in its success so far. Below are excerpts from that interview.
How did Billings Clinic become such an innovative organization?
Well, the organization in its current form came to be in 1993 when Billings Clinic and a hospital right across the street, Deaconess Hospital, merged. We decided we didn’t want to duplicate services; and that merger led into a several-years-long dialogue about what form the organization should take. So we felt on the board and in the senior leadership that moving in the direction of a Mayo Clinic, Cleveland Clinic, a Virginia Mason Medical Center, would be the direction we wanted to follow. The group practice dated back to 1917. And when I came to the clinic in 1982, there were 55 physicians; and at the time of the merger, we had about 95 physicians in our self-governing organization. Now we’re at just under 300.
For a physician organization, that’s quite large, particularly in your region.
Yes, and the hospital is about 280 beds; we also manage 11 critical access hospitals, and have about five rural clinics in addition to the critical-access hospitals we manage. And as we got through the merger and developed one culture, and had a community board overseeing both the hospital and clinic, we also developed some internal structures, including the leadership council, which is comprised of seven physicians who meet with the senior leadership every month. We take budget requests there, IT requests, and discuss measurements of quality and performance there; the council is very much like an internal board.
In any case, by spending time on culture and by finding ways to be sure that the structure did involve physician leaders in the group practice, that set us up in a good way for the challenges of tackling quality and safety issues, as well as how health IT needs to be applied and embedded—as well as quality, too, because we’re doing a lot of Six Sigma work.
How did you and your colleagues create a physician-led culture of change and transformation?
In about 2002 or 2003, we brought together a number of physician and administrative leaders, and came together around a project to draft a white paper on quality and safety, inspired by the 1999 IOM report [the “To Err Is Human” report by the federal Institute of Medicine, which estimated that at least 98,000 preventable deaths were occurring in U.S. patient care organizations every year because of avoidable patient safety lapses]. We didn’t have many of the current initiatives in place tying quality and safety to payment [the provisions under the Affordable Care Act mandating value-based purchasing, healthcare-acquired conditions reduction, and avoidable readmissions reduction, and providing for optional participation in ACO and bundled-payment development].
We launched our[ patient safety and care quality initiative] little by little, and as we got better results, that strengthened [that effort] in the organization. In 2005, we actually developed a vision in which we aspired to be the best [patient care organization] in the nation in quality, safety, and service. And you can imagine, here in Billings, Montana, that we had people questioning whether we could perform at the levels of organizations like Mayo or Cleveland Clinic. But we decided that if we really wanted to perform at that level, we needed to figure out a path, and figure out the resources. And over time, as we’ve met goals, we’ve received a variety of recognitions.
What made the physicians come to consensus on moving forward with such an ambitious vision?
There wasn’t really a turnkey thing that happened. I think it had more to do with charting the vision, developing a set of strategies and tactics, and then persistence and sticking with it; those were the most important things. And we’ve got nearly 300 physicians. And there is a lot raining down on physicians, including learning how to use the electronic health record [EHR], and many of the regulations around documentation, and many of the payment changes. And some physicians are losing the joy of practice. But we’ve tried to involve the physicians in all our decision-making; and if they have concerns over the EHR or anyone else, there are probably some legitimate concerns—so we’ve listened to their concerns all along, and addressed them.
In other words, you’ve created a kind of a consensus-driven governance?
Yes, largely, that’s why we have the leadership council. And it doesn’t mean we don’t have any complaints about administration; but most of our departments would agree that when there is discussion of any challenging issue, the physicians in practice are heard and listened to.
What does one need from healthcare IT leadership as an organization pursues these changes?
I’ll start by saying, you’ve got to have a CEO who believes that health IT will help make patient care better, is really critical, and one who’s willing to listen to physicians about the changes and frustrations, someone who believes in the resources needed for this. And there, the CFO comes into play. Does the organization have a CFO looking at the importance of IT to any of these initiatives? And then you need a CIO who really understands that bringing physician leaders to the table on health IT decisions, is very important. We have an excellent CIO who does engaged the physician leaders. We also have three physicians jointly sharing the CMIO role; one is a surgeon, one is an ED physician, and one is a primary care, physicians, and all practice about a quarter-time right now, and bring different, important, perspectives to our deliberations. For example, when it comes to medication reconciliation, think about an orthopedist who is preparing to do a hip or other surgical procedure on a patient with complicated medical problems. Is it fair to expect that an orthopedist could reconcile medications outside their area? That’s why it’s so beneficial that we have three different physicians filling the CMIO role, and able to offer those different types of perspectives because of their clinical practice experience and understanding.
What will you urge the audience to think about and do, in Seattle, next month?
When we began our conversation, you noted that we’re living in a revolutionary time in healthcare, and I think that’s pretty accurate. We’ve got so many things on top of us all at once, so I think that persistence of vision around quality and safety, during this time of intense change and activity, is critical. Also, I believe that at the end of the day, we will see these electronic health information systems improve. They’re pretty immature right now, and there’s plenty of frustration with them. But the continuously persistent view that these systems will be good for patients, and the need for the rolling up of sleeves and persistence of work [to improve patient safety and care quality], those will be elements in my message.