Clear Case
Cover Story
Written by Jill Rose   
Tuesday, 01 June 2010
Clear Case
Providence Regional Medical Center’s healthy financials and satisfaction scores are proof that a little corporate know-how works wonders in healthcare.

Clear Case

Clear Case
There is some resistance in healthcare to standardization of care and process improvement. It’s understandable to a degree—healthcare is about people, after all, not assembly lines. But increasingly, when we hear about hospitals with high patient satisfaction scores and healthy financials, operational excellence is part of their mission.

Providence Regional Medical Center in Everett, Wash. may be the best example of this yet. The hospital is consistently ranked as one of the top in the country, with Press Ganey scores in the top decile in most areas and ranked for the last four years in the top 5% of all US hospitals for overall clinical performance by HealthGrades. And according to a BusinessWeek story earlier this year, Providence Regional is one of only a few health organizations in the country that does not lose money on Medicare patients.

As you’d expect, results like these do not come from making minor improvements. Rather, the five-campus hospital is run more like a corporation than a healthcare organization, using reams of data, monitoring performance with dashboards, implementing Six Sigma process-improvement methods, and employing its physicians.

“We use an incredible amount of dashboards and data here,” said Preston Simmons, COO. “We put that in front of our team and challenge ourselves every year—we compare  ourselves against others, talk about how we can get better, and discuss how we can use our operational excellence.”

Unlike a corporation, the goal at Providence Regional is not profit; it’s to provide the best clinical outcomes possible. Happily, improved clinical outcomes lead to substantial cost savings, creating a virtuous circle—those funds can be used to provide care to Medicare patients and improve programs such as palliative care.

Literally patient centric
For more than a decade, Providence Regional has had an award winning cardiac program, and in 2003, it began looking at making its care more patient-centric by having care literally revolve around the patient. Today, the hospital’s 15-bed cardiac single-stay unit has near-perfect patient satisfaction scores (99th percentile), and length of stay is lower by a day than the national average.

Rather than having the patient move from surgery to ICU, a step-down bed, and an acute-care bed, the patient remains in the same room after surgery, with staff and equipment moving in and out as needed. “The traditional model is harder on a patient and involves more handoffs, higher risks, and more chance of infection,” said Simmons.

At around the same time, the hospital set a goal to reduce blood transfusions for cardiac patients, another source of risk and infection. When the program began, 43% of cardiac surgical patients received transfusions; four years later, it was down to 18%. The program was rolled out to orthopedics, which lowered its rates to around 18% in only a year and a half.

The program involved creating protocols around equipment and surgical techniques, implementing pre-surgical anemia management, and hiring a blood management specialist. “Our next phase is to roll it out to all disciplines,” said Simmons, noting that the program is also a community benefit since blood is a precious resource.

In a similar vein, the hospital is using continuous improvement methods to lower its rate of hospital-acquired infections. Clinical pharmacists and infectious disease specialists worked together to look at every patient on an antibiotic protocol, then worked with physicians to set up substitutions to broad-spectrum drugs. “We designated a specific drug for each patient, reducing the creation of resistant bugs,”
said Simmons. “Over time, this reduced our C. diff costs by about $200,000.”

Hiring physicians
Although hospitalist programs are gaining popularity in the US, the traditional physician/hospital model is still prevalent. Providence Regional provides a strong case for making the change.

Simmons said the hospital, the community, area physicians, and the Everett Clinic reached a mutual decision that a hospitalist program would be the best way to deal with inpatient care. The program involves 42 medical hospitalists; a number of intensivists, nocturnists, and orthopedic hospitalists; and will soon include laborists to relieve area OBs from call duty.

Because so many of its physicians are employees, the hospital is able to more easily drive best practices through protocol standardization, said Simmons. Improvement programs, including the cardiac single-stay unit, are mainly physician-and staff-driven, he said.

“Any new clinical protocol that requires a capital investment or something like changing a type of implant goes in front of the Value Analysis committee,” Simmons explained. “There’s a literature review from a physician in front of his/her peers. They really challenge this person—will this create better outcomes for our patients, is it more costly, how will it affect our other programs.”

As in other hospitals, some of these roles are voluntary, but Simmons said Providence Regional has more paid roles than most hospitals. “We have full-time CMO and four chiefs that are almost all full time. We also have 40 positions that are partially paid. That helps further align goals, standardization, and process improvement.”

Project sponsors are typically those at a top level, such as the chief of medicine or chief of nursing, often together. Under them might be a work team consisting of the director of hospitalists and the nursing director with a number of operational improvement teams looking at various aspects of the project.

Reducing readmissions
Right now, the hospital is studying ways to reduce its readmission rate. One possibility is assigning transition coaches to work with patients considered at high risk for readmission. “How can we work with them when they are discharged to make sure they are staying on their treatment regimen?” explained Simmons.

“We are also looking at how hospitalists can be tied into ED consultations for certain patients,” he said. “We could look at admissions that may be the most problematic right from the beginning.”

Education must also be part of the mix, as reducing admissions in some cases means having patients admitted to a palliative care program rather than the hospital. Simmons said a group of 30 people recently met that included representatives from long-term care, home health, kidney dialysis, and more to talk about educating patients about the hospital’s robust palliative care program.

“Our medical community and our staff and the hospital leadership is intimately aligned around the passion to always be better,” said Simmons. “Instead of competing, we collaborate. There isn’t a lot of competition in this area, so we could have set making money as our objective—instead, we’re about the values, the mission, and the patient.” 
 
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