How to Improve Clinical Programs by Breaking the Cycle of Waste in Healthcare

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Health systems interested in clinical program improvement—breaking the cycle of waste and improving the quality of care patients receive—often have trouble pinpointing where to start.

Because waste adds significant costs and doesn’t align with quality processes, it is a prime area for health systems to target for improvement initiatives. Finding the waste can be tricky, though. I’ve seen it happen again and again—providers are so focused on giving good care, it becomes difficult for them to know whether or not their processes are efficient or wasteful.

Identifying the 3 Types of Waste

There are typically three types of waste in healthcare. They are as follows:

  1. Ordering waste. Ordering waste includes tests, procedures, supplies, or medications ordered even if they may not add value for the care of the patient. Ordering unnecessary chest X-rays for patients with asthma because of an older order set, for example, was something an organization we worked with discovered and addressed in its process improvement programs.
  2. Workflow and operational variations. Workflow and operational variations happen when providers vary the care they deliver. This wastes time, materials, and money. For example, charge nurses in some organizations are still manually faxing a nightly list of patients with urinary catheters and central lines to their infection preventionist team. Other examples include slow operating room turnover or lengthy emergency care wait times. Workflow variation is an area of waste that typically offers the largest opportunity for improvements because of the significant variation in how or where care is delivered.
  3. Defect waste. Defect waste is care required to address patient safety issues, such as falls, pressure ulcers, transfusion reactions, wrong-site surgeries, central-line associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI). Defect waste is a particularly concerning form of waste for health systems. It increases patient stays, mortality rates, and cost of care. Defect waste can even potentially reduce reimbursements. A 2009 CDC report estimates that one CLABSI case costs about $16,550. Defect waste is also largely preventable.

clinical program improvementThree types of waste (ordering, workflow, and defect) indicate many areas for improvement opportunities.

Using Data to Prioritize Clinical Program Improvement Initiatives

The varying amounts of waste produced by health systems mean there are several opportunities for improvements. Identifying which improvement opportunities will provide the best return on investment starts with data collection at the patient’s bedside. For example, as a nurse assessing an appendectomy patient, I gather all of the patient’s data to understand his or her status and provide an accurate charting update. This includes both subjective data, such as responsiveness and appearance of pain, and objective data, such as temperature or dressing status.

Then to understand the outcomes of a group of appendectomy patients, I rely on an enterprise data warehouse (EDW) to analyze the group’s charts along with other relevant data. The EDW integrates data from many data sources (e.g., cost, outcomes, patient satisfaction) that may be beyond what I need to care for just one patient at the bedside. I can see the care provided not just for my appendectomy patient, but for every appendectomy patient in the hospital. Then by looking at multiple patient care records, I can find opportunities to improve the overall care for an entire group of patients.

Visualization for appendectomy patient Sample visualization showing appendectomy patient data, such as length of stay, readmission rate, and number of appendectomy patients by age.

The case for an enterprise data warehouse

The appendectomy example above shows why it’s important to have access to broad and varying data points when prioritizing clinical program improvement projects. Discovering areas to focus on requires more data than can be found in the EMR. Data from billing systems, patient satisfaction systems, lab systems, and many other source systems is necessary to locate areas with the best opportunities. When the health system’s data sources are gathered in a healthcare-specific EDW that supports the use of analytics applications, clinical programs can pinpoint areas of ordering waste to understand the implications of individual care decisions on cost and outcomes.

The case for sophisticated analytics solutions

My colleague, Bobbi Brown, wrote about the Health Catalyst Key Process Analysis (KPA) Application’s ability to integrate clinical and financial data. The KPA Application provides a quantitative analysis of how to prioritize programs based on case count, payment, length of stay, and variable direct cost opportunities. The application also identifies clinical processes with the highest variation and resource consumption.

Setting Up Success with Organizational Readiness Assessments

While the KPA Application is instrumental in determining where to start a quality improvement project from a quantitative perspective, the application isn’t able to guarantee success. Another key component to consider is organizational readiness. If the people, culture, or resources associated with the work processes aren’t ready to implement data-driven changes, the project most likely won’t be successful or sustainable.

Assessing the following key areas will help determine organizational readiness:

  • Clinical or operational leadership.Does the project have the support and oversight that will be required to guide the team to success? Is the commitment sustainable—will the project be viewed as a “one and done” versus a continuous process of ongoing improvement?
  • Data availability.Data from key systems (e.g., EMR system, financial for costing and claims data, and patient satisfaction) will be critical for success. Is this data available and useable?
  • Shared vision. Does the quality-improvement project align with the strategic direction of those involved in the delivery of care or the organization’s goals?
  • Administrative support. Will resources be made available from IT, quality, operations, and clinical leadership? Data managers, data analysts, data architects, clinical and operational subject matter experts, and other participants are essential to the success of the project.

Breaking the Cycle of Waste to Improve Clinical Programs

Waste in healthcare creates many opportunities for improvements within a health system’s clinical programs. Finding these areas, however, requires several solutions. First, an EDW integrates multiple data sources to make the data accessible to team members for the analysis and support of improvement projects. Next, the KPA Application shows areas where volume and variation opportunities exist. Then, the organizational readiness assessment uncovers environmental and organizational factors that will influence a project’s success. An EDW, the KPA Application, and an organizational readiness assessment combine to drive clinical program improvements and break the cycle of waste in healthcare.

What have you done to identify waste in your organization? Do you have the organizational support you need to carry out clinical program improvement projects?

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