By Anne Constable
The Santa Fe New Mexican
(TNS)
Nov. 08—What if you could improve health care and save money at the same time?
Intermountain Healthcare, a nonprofit health system based in Salt Lake City with 22 hospitals and 185 clinics serving patients in Utah and southern Idaho, says it knows how to do that.
For example, it noticed that when a mother’s labor was induced prior to 40 weeks, the gestation of a full-term baby, women had longer and harder labors. More infants were admitted to the pediatric intensive care unit. And more than a quarter of those pre-term deliveries were not clinically appropriate.
In 2000, Intermountain, which is known for high quality and low prices, cut these inductions, often scheduled for convenience or comfort, from 28 percent (around the national average) to close to zero.
It saved women 145,000 minutes of labor each year.
It reduced newborn ICU admissions.
And Intermountain, where 34,000 babies are born annually, found it could deliver 1,500 more babies a year without a single additional hospital bed or nurse.
Its elective induction protocol is saving the people of Utah $50 million a year, according to Dr. Brent James, the chief quality officer of Intermountain Healthcare and the executive director of the Intermountain Institute for Health Care Delivery Research, where he is lead instructor for its Advanced Training Program.
Now New Mexico’s Christus St. Vincent Regional Medical Center, hoping to improve its quality of health care and increase patient satisfaction — and maybe also save some money — is trying out some of Intermountain’s ideas.
Lara Goitein, a specialist in critical care and pulmonary medicine, is leading the “clinician-directed performance improvement” project to give practicing physicians and nurses the time and support to improve the ways they provide care to patients.
“This is an unusual investment in quality for a hospital of this size,” Goitein said. “I am quite proud. This is very forward thinking. The hospital is showing it is serious about real quality improvements.”
Christus St. Vincent is one of the early adopters of the Intermountain idea positing that in health care, as in manufacturing, quality improves and costs drop when variations in procedures are reduced.
The effort comes as hospitals all over the country are facing huge cost pressures from Medicare, Medicaid and private insurance companies, and every day it gets a little tighter, James said. They need to show they offer both good care and good prices in what Christus St. Vincent’s hospitalist medical director, Joel Rosen, calls an “era of value-based health care.”
Christus St. Vincent is often maligned by members of the community who complain about staffing levels and long emergency room waits. And there was opposition from neighbors to its $44 million expansion project that will increase the number of private rooms and, the hospital hopes, reduce the infection rate and address other patient complaints. The project was approved unanimously by the City Council last month.
Despite the grumbling, the government’s Medicare site shows that Christus St. Vincent is about average according to many different measures. Its rate of unplanned readmission for patients suffering heart attacks, heart failure, pneumonia, stroke and chronic obstructive pulmonary disease, as well as patients who have undergone hip and knee surgeries, is about the same as the national rate. It actually has a better rate than the national average for overall readmission after a patient’s discharge from the hospital.
The death rate for heart attacks, heart failure and stroke at Christus St. Vincent is no different than the national rate, and in some cases the cost of care is less than the national average. Measures of appropriate care, such as giving aspirin at discharge to heart attack patients, are also about the same as at the average hospital in the U.S., although Christus St. Vincent patients spend much more time in the emergency department before being admitted as inpatients than at other high-volume hospitals.
One area where the hospital falls down, however, is in patient experience. Fifty-eight percent of patients said in a national survey on the federal Hospital Compare site that they would definitely recommend Christus St. Vincent, compared to 71 percent nationally who would recommend their hospital. It ranked below the New Mexico and national averages on measures such as whether doctors communicated well, whether patients received help as soon as they wanted, whether pain was well-controlled and whether rooms and bathrooms were always clean and quiet at night.
Christus St. Vincent is “not scoring as well as they would like on clinical performance measurements,” James said, “but that doesn’t mean they are bad. It just means they want to be excellent.” Looking down the health care road, however, “Excellent is going to be key to survival. But more than that, this is what they should be doing anyway,” he said.
James said 96 doctors, nurses, support staff and other executives at Intermountain have received the training, and the evidence-based protocols they have developed have cut $440 million from the system’s operating costs in the last three years.
One of the physicians at Intermountain put together a protocol for rapid detection and aggressive treatment of sepsis, the No. 1 cause of death in the hospital. The mortality rate dropped to 8.1 percent from 20.2 percent, saving 125 lives. The cardiologists developed a list of evidence-based indications for doctors to check before performing catheterization, stenting or implanting devices such as pacemakers. James said utilization rates dropped by more than 20 percent, clinical outcomes improved slightly and health care costs fell $30 million a year in Utah. Intermountain also has reduced the time it takes it to remove a clot from a patient with the most severe form of heart attack, where time is of the essence, James said.
There have been about 50 “sister” training programs, James said, including prestigious facilities such as MD Anderson Cancer Center in Texas and hospitals in Sweden, Australia and Argentina.
Intermountain provides digitized training materials that Christus St. Vincent can modify to suit its needs. The hospital is in the middle of seven-month training sessions led by James and others. Since August, it has launched 12 projects in 10 clinical areas led by doctors and nurses who receive paid time to plan them and collect and analyze the data.
“The doctors and nurses are really excited,” Goitein said. “They have a new sense of engagement and empowerment. What they are saying is, ‘It’s about time someone asked us.’ “
SVHsupport, a nonprofit that supports the hospital, provided initial funding.
Goitein, who is the former head of the hospital’s intensive care unit, said that in 2013, Christus St. Vincent piloted an ICU rounds checklist to “make sure that we’re covering the many small, important details of ICU care that can sometimes get lost in the workload,” and saw an improvement in the length of stay and ICU mortality.
Gina Robey, an ICU nurse and the nurse coordinator for the project, is working on preventing central line and urinary tract infections in the ICU. “This is the hospital’s effort to empower us to make a difference and improve patient care,” she said.
Theresa Ronan said the hospital is paying to set aside 20 percent of her time to improve quality of care. Her project involves collecting information on what medications patients are taking at the time they arrive at the hospital.
“It sounds easy,” she said, “but it’s actually kind of difficult. When people come to the hospital, they are often in a hurry and they don’t bring pill bottles or a medication list. Or they are ill and can’t recall.”
If the emergency room visit is after-hours, the hospital often can’t reach a primary-care provider. Her goal is to standardize the process for obtaining the information “so that we all do it the same way every time.”
Melanie Smith, a surgical nurse, said the training has helped her and others “learn how to observe and document clinical performance so we can identify ways to improve.”
Smith said, “I am so impressed the hospital has chosen to go forward with a program that promotes improvement and is teaching us how to go about it.” Teams also are addressing pain management for surgery patients and surgical site infections.
“This is one way I can help a large group of people who come to us and trust us with their care. We want it to be the best science and the best approach we know, and the best possible experience they can have,” she said.
In another project, the staff is working on actively screening for medication errors rather than waiting until they get a report.
James also approved of the projects selected by Christus St. Vincent, such as reducing adverse drug effects and infections. They matter, he said. And 1 in 4 or 5 of their projects “will turn into absolute solid gold,” he predicted. But, James added, “What I really like to see is a group willing to step up. That’s not true for a great many places in this country.”
Ronan said she believes that as a result of the clinician-directed performance improvement projects, the quality of health care delivered will be “even superior to now, patient satisfaction will improve, health care workers will have improved professional satisfaction and the level of trust will increase.”
According to Rosen, if those things happen and “the patient perceives that the care is better, it makes business sense. Patients will come here for their care. This is a big paradigm shift for the hospital.”
But Goitein stressed, “None of us have the goal of saving money. We all have the goal of improving the quality of the patient’s experience and the quality of care. If we approach it that way, cost reduction follows.”
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