Note: MultiCare Health System’s Clinical Collaboratives project was named a semifinalist in the 2016 Healthcare Informatics Innovator Awards Program. Short descriptions of the projects of all of the semifinalists in this year’s program can be seen here.
At Tacoma, Wash.-based MultiCare Health System, a six-hospital integrated healthcare delivery system, physician-led, multidisciplinary teams, called Clinical Collaboratives, are developing and deploying system-wide improvement strategies that have resulted in some stunning clinical outcome improvements and measureable financial benefits. Even more impressive is the fact that MultiCare has successfully implemented a sustainable approach for standardizing best-practice, value-based care across not just a health system, but also across its commercial accountable care organization (ACO), called MultiCare Connected Care, and its clinically integrated network.
In 2011, MultiCare created the two initial Collaboratives focused on improving outcomes for sepsis and heart failure. There are now seven Collaboratives across the system focused on critical care, medicine, surgery, primary care, emergency services, women’s services and pediatrics. The Collaboratives were tasked with accomplishing the following—reduce clinical variation across the system and standardize care; improve and monitor clinical outcomes for high impact health conditions; reduce costs and improve documentation and collections.
Led by physicians, the Collaborative teams are multidisciplinary, including clinicians, operations, finance and data analyst. The Collaboratives are supported with dedicated resources—including clinical resources as well as technology and analytics experts who could work with frontline teams to interpret the data. Technology-enabled analytics were used to support the hardwiring of best practices, providing validated data to support decision-making and prioritization and near real-time feedback on performance transforming data into actionable information to drive results.
Healthcare Informatics’ Assistant Editor Heather Landi spoke with MultiCare leadership involved in the Clinical Collaboratives project. Taking part in the interview were: Florence Chang, executive vice president and chief operating officer, MultiCare Health System; Christopher Kodama, M.D., president, MultiCare Connected Care; Albert Marinez, director of information intelligence at MultiCare Health System; Christi McCarren, R.N., senior vice president, retail health and service lines, MultiCare Health System and Kate Mundell, program manager, Clinical Collaboratives, MultiCare Connected Care. Part one of the team’s interview with Landi from last week can be found here; part two excerpts can be seen below.
How did you set up the governance and structure for the Clinical Collaboratives and the adoption of best practices?
Kate Mundell: In the past 18 months, the biggest step forward, in addition to continuing to focus on matching the clinical quality work with the data analytics piece, has been packaging the Collaboratives as a more formal and methodology program. And we have put that program under the auspices of MultiCare Connected Care, which is MultiCare Health Systems’ relatively new ACO and clinically integrated network product. So, now we have the added alignment of not just the triple aim—experience, quality and the cost—but now you have the contract methodology and payment methodology from an ACO and a clinically integrated network perspective that we’ve aligned that same quality improvement with.
The other thing we’ve put into place and one of the other things that has propelled the work forward is that we have instituted a governance and a structure around the Collaborative that didn’t exist 18 months ago. So in addition to the formal staff and the informal staff that we have through the service line agreements, we also have leads on each of the seven Collaboratives and their subsequent work groups. So in addition to people’s day jobs, they provide anywhere from two to five hours a week, which for a provider or a nursing director is a substantial amount of time to invest, and that has helped to move the work forward.
Christopher Kodama, M.D.: Regarding the alignment with payment methodologies, and this is something that we’ve observed at the state level as well, where you have the development of the evidence-based care pathway standards. But the challenge has been with the state laws that it’s nice to have these standards, but how do you encourage people to adopt them and where does the accountability reside? And, I think we’ve answered both of those questions at least at the macro level, and the devil is going to be in the details over the coming years, in that the accountability now resides within this clinically integrated network of self-governing physicians who are going to hold each other accountable to adhering to the standards that are developed through the Clinical Collaboratives. And furthermore, we will align financial incentives over time in terms of the rewards associated with these risk-based reimbursement agreements that will, hopefully, reward and encourage people to comply and contribute to the evolution of the care pathway standards through the Collaboratives. And that’s where we start to get to the balance between the academic exercise and something that has a meaningful impact to the lives that we’re serving.
Christopher Kodama, M.D.
The Clinical Collaboratives has achieved some stunning clinical outcomes improvements, including a 65 percent reduction in the sepsis mortality rate. I’d like to drill down to the Women’s Services Collaborative and the 71 percent reduction in C-section deliveries with length of stay greater than six days. How did you achieve this reduction?
Mundell: I think those numbers tell a wonderful story about using data to drive decision-making and to drive standardized performance across a group of clinicians, which can be challenging at times. The Women’s Services Collaborative was one of our earliest Collaborative groups, and it was driven by a small handful of very engaged physicians who had an appreciation for data. That Collaborative has the benefit of some state-driven mandates and recommendations coming out of the state level, but our approach was to not re-create the wheel, but to take some state-driven best practices and recommendations and to “MultiCare-ize” them and really adapt them to the standards and the best practices here. I think at the heart of the work, it was physician-led and the group worked to standardize best practices to achieve those results, so it was physician imparting to physicians the importance of doing that work. Then, we were able to build and layer over the structure and the governance that we created in the past 18 months, and expand the presence to our clinically integrated network as we were able to grow that outreach. Albert’s team has been able to give to the physicians daily access, at their fingertips, to that data to help drive performance and drive gaps in that performance. And beyond that C section outcome metric, you also have a standardized delivery and C section note that is built into our electronic medical record that has 100 percent compliance across the physician network. So I think it’s that build up that led to those outcomes and probably those outcomes wouldn’t have been generated and sustained had that build up not taken place.
To share some other clinical outcome improvements, our Hospital Medicine Collaborative has done some amazing work around reducing pneumonia readmissions and improving quality of life there. And the Surgery Collaborative has done some outstanding work in the past 18 months as far as that’s the group that has generated the most pathways and best practices and has seen the highest adherence to as it, as well as keeping length of stay down and keeping readmissions down. We have a group that’s focused around elective colon outcomes and that group has experienced zero surgical site infections going on 18 months now.
How has health IT played a significant role in the success of this project?
Christi McCarren: The work to reduce the sepsis mortality rate is a great example. Early on, our information intelligence team created dashboards that looked at the process measures that were based on the evidence-based guidelines and so we could monitor those on a real time basis and view and sort by hospital. This enabled us to see where the process was derailing and we still use that dashboard to this day to look at our performance. The dashboard and metrics enable you to see the improvements that you’ve made but if you start to fall back a little, you’ve got it right here to help you know where to go. And that is what has guided us; it’s a whole continued improvement cycle and it takes constant visual. Without a dashboard or some kind of metric that you’re watching on an ongoing basis, the improvements wouldn’t be sustainable long-term. And each of our Collaboratives now have information intelligence ports with the idea that each is going to have a dashboard to reflect the practice improvements that they put in place.
Christi McCarren, R.N.
So looking ahead, what will you be focusing on this year for the Clinical Collaboratives project?
Kodama: In 2015, we focused on what’s our standard process around deployment and adoption and how do we actually get these standards socialized with the broader network of providers. 2016 is going to be building on that and taking what we’ve been designing from the providers’ side and really syncing those up more with what the purchaser environment has been telling us through the types of quality and cost performance measures that they put into their value-based contracts. They are not always complimentary to one another between what we have been focusing on in the Collaboratives and what’s in the contracts. Now we have a forum through the Accountable Care Organization for our contracting discussions with potential purchasers to start lining that up a little bit more.
McCarren: We’re moving into bundled payments and some of the Collaboratives are taking on that work. Going forward, it’s also about being intentional with transitions of care and involving our primary care physicians and our community physicians so that we’re looking at the entire continuum. So it’s a vehicle that, whatever changes in healthcare, we’ve got a place to take the issue or problem. Another development that came about with this structure is that we became involved at state level to larger extent. We can point to somebody in each of our Collaboratives who is responsible for being a liaison with whatever state level committee and that’s helpful to the organization.
Florence Chang: One of the most important things is that we have a lot of great best practices out there, and for us, the focus this year is the consistency across the organization—how do we share this best practices across the system and how do we consistently utilize the pathway that we have established so that every part of the organization can have the same outcomes and results? It’s important to any initiative to not only have the best practices, but that you are also able to make this a part of the DNA of your organization.
We’re excited and proud of what we have started and this is a journey that we’re going to continue to move forward on. But engaging physicians from day one was critical in this effort, and now a physician should own this work and the outcomes that they created, so I think that’s the most important piece.