Leadership Foundation



Raising the Stakes in Healthcare

Cynthia Hagerty

Leading Change in Organizations 560/Southwestern College

Dr. Susan Sasiadek

May 8, 2013

Abstract

Hospital value-based purchasing is the link of payment systems to improving healthcare quality. In the past, the government’s philosophy has always been that hospitals are paid for providing services to the Medicare and Medicaid patient population, that philosophy is changing. Hospitals will be required to prove that the quality of care provided, as well as the patients’ perception of that care, meet or exceed the national standards. In the hospital setting, this will be accomplished through a multidimensional approach of tracking and measuring core measures, patient satisfaction (HCAHPS) data, and safety and quality processes. For many hospitals, this will necessitate evaluation of leadership, process teams, and infrastructures to align with the overall strategic plan to improve how they deliver high quality, efficient care, which will affect incentive payments. This national quality initiative of value-based purchasing, most likely will be one of the biggest transformational agents of change, in the history of healthcare.

Raising the Stakes in Healthcare

Value-based purchasing is the merging of quality and patient outcomes with data on the financial spending designated for health care. The focus is on management of each healthcare system to reduce inappropriate and unnecessary care, while rewarding the organizations with the best performance. The overall goal of value based purchasing in a healthcare system is based on the foundation of quality and value, with clear support of evidence-based practices.

Value-Based Purchasing Design

In April of 2011, the Centers for Medicare and Medicaid Services (CMS) released the Hospital Value-Based Purchasing Final Rule. This ruling has caused hospitals to frantically explore any advantages that can be identified that might help them to excel in this fast-paced, mandatory healthcare competition with millions of dollars on the line for each organization. This value based purchasing (VBP) program authorized by the Patient Protection and Accountable Care Act of 2010, gives CMS the power to base a portion of hospital payment on how well hospitals perform in twenty-five core measures (Nelson, 2013). Three aspects of patient care, called domains, will be measured in 2013 and 2014. These domains include Process of Care, Experience of Care, and Mortality or Outcomes. In 2013, Process of Care will have a weight of 70% and Experience of Care will be weighted at 30%. For 2014, CMS will shift the weighting system to Process of Care at 45%, Experience of Care at 30% and Mortality (Outcomes) at 25% (Miltenberger, Downs & Greene, 2012). The power that CMS will now have over hospital reimbursement, will change from their passive past involvement, to an active participant of defining what high-quality healthcare systems should look like.

Strategic Plan

As addressed by Gardner (2004), in Changing Minds, when discussing the dramatic turnaround by BP, they became a learning company. The executives began by spending time in strategy sessions, looking at current state and future state. This is what has occurred in the Via Christi Healthsystem. Vision 2020 is designed to engage all members of the Via Christi family in determining the focus on patient-centered, team-based, high quality, affordable care for our patients. This three-year strategic plan provides an opportunity to advance the organization to full integration and improved financial performance. This plan is critical to ensuring Via Christi’s long-term success at fulfilling our mission of serving as a healing presence to all, including the most vulnerable among us.

Process of Care Core Measures

A core measure is the percentage of patients that receive the appropriate care represented by a particular measure. For example: In the cardiac patient population, data will be collected on the percentage of Acute Myocardial Infarction (AMI) patients that receive aspirin upon arrival to the hospital. If seventy-eight out of one hundred patients admitted to the hospital with the diagnosis of AMI, receive aspirin upon arrival and it is documented in the patient’s medical record, the core measure is seventy-eight percent. The hospital will then develop an action plan, to reach a higher percentage, which the hospital will have established as their goal. Core measures are designed to be used as improvement tools. The results of this data collection will then be submitted quarterly to CMS, which is then publicly reported. Hospitals that are able to reach benchmarks set by CMS will then receive a higher reimbursement from Medicare and other payers (Nix, 2009).

The complete list of clinical process core measures are as follows:

1) Fibrolytic Therapy Received within 30 Minutes of Hospital Arrival

2) Primary Percutaneous Coronary Intervention (PCI) Received within 90 Minutes of Hospital Arrival

3) Discharge Instructions

4) Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

5) Initial Antibiotic Selection for Community-Acquired Pneumonia in Immunocompromised Patients

6) Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision

7) Prophylactic Antibiotic Selection for Surgical Patients

8) Prophylactic Antibiotics Discontinued within 24 Hours After Surgery

9) Cardiac Surgery Patients with Controlled 6:00 a.m. Post-operative Serum Glucose

10) Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period

11) Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered ( this includes aspirin upon arrival as cited in the example)

12) Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours

This data is typically collected after the patient is discharged from the hospital. Hospital staff is required to go back through the patient’s chart and determine if the patient was core measure eligible. If the documentation is accurate, and the appropriate care was delivered, the information is then reported to CMS in the appropriate software system. This tracking of data is a great deal of work and takes a lot of time. There is no funding provided by CMS, even though it is mandated. This number of core measures will continue to grow yearly, therefore leaving hospitals to decide how they will have the work force to extract the core measure data (“Hospital value-based purchasing,”2011).

What we have implemented at Via Christi is a more labor-intensive method. In the cardiac arena, we have decided to utilize professional staff to work with frontline care providers to improve their practice, use evidence-based interventions, and keep the core measures in front of the staff while working with every patient, every time. This plan is proving to be successful for the short-term, and we are in the process of developing a plan for long-term sustainability. The implementation of the Cerner computer documentation system throughout the Wichita hospitals will definitely help with long-term compliance.

Experience of Care

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey reflects the patients’ perspective of hospital care, and is the first national, publicly reported, and standardized survey of this kind. This survey is a random, 27-item questionnaire, based on eight different dimensions of care measures. The survey asks the patient their opinion on the hospital care, communication, responsiveness of hospital personnel, instruction regarding prescribed medications, pain management, discharge information, and cleanliness and quietness of the environment.

The hospital is rewarded points for performance related to achievement thresholds and national benchmarking. Three goals have helped to shape the HCAHPS . The standardized survey and implementation will produce data that will allow meaningful comparison of hospitals on topics that are important to all consumers. Second, the HCAHPS results are publicly reported, creating a drive to improve the quality of patient care being delivered. Third, this information being made available to the consumer will enhance healthcare accountability and transparency (Miltenberger, Downs & Greene, 2012).

Preparation for Value-Based Purchasing

Preparing for the arrival of value-based purchasing has been a challenge, but there are several tips that have helped Via Christi and other hospitals to be ready.

• Pick partners carefully. Understand the terms of any contractual agreements, and who will be their teammates for value-based purchasing.

• Accept personal accountability. Hospitals need to demand more responsibility from individual physicians, and be willing to post their performance on key measures.

• Educate the nurses and physicians about communication. Patients assume that the medical team, the nurse and physician are on the same page and regularly sharing information, they should represent as a team.

• Make eye contact with the patient. If physician’s sit down with patients, even if only for a few minutes, the patient feels like they are being heard.

• Establish upfront expectations. Discuss with patients what they should expect while they are in the hospital. This will keep the patients expectations to hospital standards.

• Pay attention to details and be adaptable. Focus on measures will shift, be adaptable and willing to change (Nelson, 2013).

Mock scorecards and quality dashboards are being designed as a communication tool for all stakeholders involved. At Via Christi, these dashboards are front and center at every leadership meeting, as well as unit based staff meetings, so that all staff is empowered to come up with new tactics while sustaining improvements that have already been made.

Process Improvement Teams

A critical piece of Vision 2020, the strategic plan for the Via Chrisiti Health Systems is a system-wide, specific goal, to improve the quality, safety and value of patient care delivery processes. Clinicians were asked to participate in training sessions to learn to utilize and apply these new concepts to practice: Process Improvement Methodologies, Evidence Based Practices and Lean Six Sigma statistical tools. These tools are instrumental in obtaining optimal patient care outcomes and satisfaction, increasing patient safety and decreasing costs. The patient is at the center of everything that we do as we developed four key PIT teams: AMI/CHF, Pneumonia, SCIP, and Hospital Acquired Infections.

Via Christi has hired trained black belts to help analyze our processes, utilizing the Japanese quality improvement methodologies of Lean and Six Sigma. These individuals have backgrounds in the aviation industry, and specialize in improving quality and safety processes. In the past, monitoring of quality and safety was the responsibility of the Quality Department within the hospital. The interaction and teamwork with the black belts, is requiring openness to change and the opportunity to look at processes and outcomes in a completely different way than before.

Leadership Changes

With all of the new and exciting changes for the vision of our organization, there was a need to evaluate leadership roles. Healthcare providers are very familiar with change and are continuously operating in a shifting environment. Technological advances, new standards of care, a growing population, and changing demographics have made it impossible to not embrace change. Regulations, cost pressures, ethical and legal issues, and healthcare reform add to the overall complexity of surviving as a healthcare institution. With all of these challenges, it is very difficult to continuously assess if an organization has the leadership talent in place that it needs. There must be leadership in place who are supportive of the vision, and have the ability to align with employees and physicians, while seeking to provide safe, high-quality patient care. Organizations must develop meaningful leader development strategies, and take the proper steps to build a foundation of capable individuals in key roles throughout the organization.

A restructure in nursing leadership took place more than one year ago. It will be necessary to continue the evaluation of leadership throughout the health system, to identify the appropriate leaders to implement change and new processes development. It is very important that leaders have the skills that they need to adapt to change, while being resourceful and meeting necessary business objectives and goals. Areas of opportunity have been identified for providing leaders additional education in participative leadership, confronting problem employees and building and mending relationships. It was also found that many leaders could benefit from further development of interpersonal and leadership skills to create alignment and commitment within the organization, as well as direction. This education would address skills such as coaching employees, delegating effectively, and hiring talented employees that are change leaders. It was identified that there was a need to have a stronger focus on strategic talent development and preparation of leaders for the future. These tools will be made available to all leaders throughout the entire healthcare network.

Change Management

Change is a fact of life in an organization and necessary in order to prosper. The vision of the organization will provide a corporate sense of being. An organization must be able to implement and manage change, as well as provide meaning for all stakeholders in both the present and the future. Change is much more that a vision, it involves continuously scanning the environment of the organization and in the case of Via Christi, the entire healthcare system. Via Christi has implemented the three different levels of planning, addressed by Beach (2006) in our text. A strategic plan has been designed to tie value-based purchasing into the vision, translating into a set of long- term goals to stay abreast of the CMS changes, which will be transitioning and expanding over the years to come. Within the operating plan, concrete medium-term goals have been established with actions designed in concert by the black belts and leadership. The dashboard is a tool that allows review of the data tied to goals with continuous evaluation of action steps. In addition, the task plan outlines those highly specific goals and the specific activities designed to attain short-term goals. One of the most important tools that we initiated immediately is what we call the blue sheet. This tool identifies all of the core measures, puts them in front of the caregiver, is part of every patient hand-off, and is reviewed on each shift for compliance.

There must be a constant assessment of situations and processes, deciding how to leverage the culture to help with the change, and then deciding what actions need to be taken to manage the change. For the organization to be successful, it is necessary to continuously evaluate the environment, make certain that the right leaders are in place, decide what the organization stands for, and reconcile the differences.

There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a new order of things- Niccolo Machiavelli

Conclusion

Value-based purchasing is intended to increase the level of accountability among providers. This increased accountability will bring about transformational total care delivery changes across entire healthcare systems. The overall anticipated outcome is to reduce Medicare spending per each beneficiary and improve patient care outcomes. Hospitals and healthcare systems need to embrace the change and be in a constant state of preparation for the CMS changes and updates. The hospitals that have the ability to thrive in this new healthcare era, will be the ones that have the right foundation and systems to excel. The ability to execute new tactics, while sustaining improvements that have already been made, keeping staff connected to the sense of purpose for what they are doing to serve others, and the ability to keep excellent patient care front and center, will be the tools to survival (Miltenberger, Downs & Greene, 2012).

Via Christi Health is the largest health care provider in Kansas, and Wichita’s second-largest employer behind Spirit. As companies and organizations continue to struggle in these very challenging times, Via Christi will remain viable with a continued vision of purpose, focused on putting the patient first, and empowered by leaders that have the ability to implement change.

References

Nelson, B. (2013, April 8). Value-based purchasing raises the stakes. Retrieved from

Miltenberger, B., Downs, S., & Greene, L. (2012, February). Value-based purchasing-what's ahead for healthcare providers. Retrieved from

Gardner, H. (2004). Changing minds: The art and science of changing our own and other people's minds. Boston: Harvard Business School Press.

Nix, E. (2009, April). Core measures 101. Retrieved from

Hospital value-based purchasing program. (2011, November). Retrieved from htp://Hospital-Value-Based-Purchasing

Beach, L. R. (2006). Leadership and the art of change: A practical guide to organizational transformation. Thousand Oaks: Sage Publications, Inc.

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