The Healthcare Outcomes Improvement Engine: The Best Way to Ensure Sustainable, Scalable Change
Successful and sustainable healthcare transformation relies on an organizational culture with a systemic focus on healthcare outcomes improvement. Effective engagement from multiple disciplines coupled with standardized improvement processes will create a scalable and sustainable outcomes improvement environment. I call this the outcomes improvement engine—a system primed to generate improved outcomes at a consistent and scalable pace.
Four Components to Building an Outcomes Improvement Engine
An effective healthcare outcomes improvement engine requires four components:
- Engaging executives
- Prioritizing opportunities
- Adequately staffing initiatives
- Communicating success early and often
#1: Engaging Executives
The outcomes improvement engine begins with effective engagement—around which several stakeholders and teams work together. The executive leadership team launches the improvement work by developing a strategic vision. A clear strategic vision enables people to prioritize work and to allocate scarce resources appropriately. This team governs the prioritization of strategic goals and the work required to operationalize the strategic vision. Domain specific teams that report up through the executive leadership team are then responsible for executing to the strategic vision.
The executive leadership team should include board members, C-suite, and others with influence in improvement work and clinical operations (e.g., finance, operations, quality and safety, nursing, and physician roles). While titles may vary across healthcare systems, in any organization, this team must have good representation from system-level leaders who can foster a culture of data-driven quality improvement initiatives; they have decision rights for the entire organization, help to define the priorities, and ultimately own the enterprise-wide strategic vision.
The members of the executive leadership team can align incentives with outcomes improvement initiatives. This sends a powerful message to the organization: real and sustainable outcomes improvement is important and something everyone should focus on.
Effective engagement in outcomes improvement requires buy-in and support at the board and executive levels, as well as the clinical and operational levels across the system. Furthermore, close collaboration and consistent communication between key stakeholders ensures a process that prioritizes outcomes improvement and safeguards resources for high-priority improvement work. These key stakeholders typically represent data and analytics infrastructure, quality improvement, domain specific governing bodies (e.g. the women and newborn’s service line or a revenue cycle leadership cabinet), and executive leadership.
#2: Prioritizing Opportunities
An outcomes improvement engine runs best when targeting opportunities that are prioritized through a standardized objective process that is driven by analytics and is clearly understood. Developing a prioritization rubric acknowledges that resources are a scarce commodity and that initiatives that are selected demonstrate return for the investment of such resources. Prioritizing opportunities means that you are turning down other opportunities. When you tell people no, they will want to know why. If you can’t be objective when prioritizing the work, you will lose support, buy-in from key stakeholders, and ultimately, the energy needed to realize your strategic vision. Spend some time identifying what the rubric will be for selecting objectives.
The leadership team can use objective tools like the Key Process Analysis (KPA) to select the best prospects for improvement and cost reduction. The KPA tool combines clinical and financial data to highlight the best quality improvement and cost reduction opportunities by utilizing the 80/20 rule to identify cost-driving areas where large variation exists among processes. The 80/20 rule suggests that 80 percent of the opportunity can be found in the top 20 processes.
While objective criteria allow you to be consistent, include some subjective criteria as well. It is important to balance the objective data with subjective criteria to account for cultural or domain specific circumstances that may cause bottlenecks in the work. For example, if the objective data shows the most opportunity in reducing readmission rates among hypertensive newborn deliveries, but the healthcare system is not sufficiently organized with a team in the women and newborn clinical domain to focus on this work, it is probably not a promising opportunity for immediate improvement. The leadership team should choose another area for improvement while also looking at a strategy to build up the women and newborn’s team with innovative leaders that can lead the improvement opportunities
Reconciling Strategic Priorities and Resource Constraints
The rubric for prioritizing opportunities should also consider other strategic organizational priorities that may cause resourcing constraints. As the executive leadership team establishes a standardized rubric to assess improvement opportunities, they should consider the following six questions:
- Does this work align with other board and executive level strategic priorities?
- Are there regulatory pressures/penalties that need to be addressed?
- Will the organizational/departmental readiness and culture of improvement ownership support your prioritized initiatives?
- Do you have leaders/innovators ready to own the work?
- Is there data available to provide the analytical infrastructure necessary to measure improvement?
- Are there other improvement initiative requests from domain specific teams that align to higher level opportunities?
The EDW Is a Scarce Asset for the Outcomes Improvement Engine
The rubric will help the various teams driving the improvement initiatives stay focused on the strategic priorities and avoid unnecessarily allocating resources to other initiatives that come in from across the organization. A robust and effective enterprise data warehouse (EDW) operating system is critical to creating and scaling the outcomes improvement engine. The ability to bring disparate sources of data across the organization into one location gives the improvement teams a very powerful platform to create and measure best practices and, thus, quickly improve outcomes. The EDW’s ability to create a breadth of reports, however, makes it an attractive tool throughout the organization. Therefore, if not managed appropriately, a high volume of unfiltered requests for data will drive the EDW focus away from the prioritized strategic initiatives of improvement.
Too many EDWs evolve into an operational reporting shop, which in turn, takes away resources and focus from facilitating real outcomes improvement. This shift to basic reporting usually creates an environment where scarce data architecture and BI resources feel under-utilized and overworked, as they are spending much of their time and effort managing basic reports and processes—tasks that may not have a meaningful impact on improving healthcare quality and decreasing cost.
Effective Prioritization Comes from the Executive Level
The same can be said for other departments that are involved in facilitating improvement initiatives across the organization. Process improvement, marketing and education, clinical, financial, and operations, among others, need to understand how their work gets prioritized and how they work together to accomplish the executive leadership team’s strategic vision. If prioritization doesn’t happen at the executive level, any scarce resource will run into demand issues and will be forced to make unnecessary decisions.
These resources are essential assets in outcomes improvement work, and leadership needs to protect them as such. As the gatekeepers of the improvement initiatives, the leadership team should develop processes that clarify which types of projects can utilize the scarce resources. This entails restricting focus to projects that meet the following requirements:
- Have a clearly defined value proposition
- Help the organization build standardized processes to focus on improvement
- Deliver opportunities tied to strategic objectives
- Have organizational buy-in
- Produce meaningful and measurable outcomes
- Can be spread across the system
Domain-specific improvement teams at every level need to develop the muscle memory to articulate the ROI for projects that drive the goals set by the executive team. Improvement methodologies provide tools to facilitate this process (e.g., A3, outcomes improvement worksheet, etc.). While the type of process improvement methodology used isn’t important, standardizing on an approach that moves teams through the outcomes improvement journey relieves pressure on the scarce resources and, in turn, empowers them to partner with improvement teams to accelerate the work. Developing the muscle memory to clearly outline the quantifiable opportunity keeps the scarce resources from being pulled into non-essential projects and keeps the EDW operating system from transforming into an expensive report factory.
A systemwide cultural shift toward thinking of the EDW and scarce resources primarily as assets for outcomes improvement takes time and hard work. This starts with a clear strategic vision from the executive level that’s evangelized to each improvement team. Specific improvement opportunities that fit within the strategic vision can be communicated from the domain level improvement teams up to the executive teams or can be initiated by the executive teams and pushed to the improvement team.
Importantly, the work is prioritized and sanctioned by the executive team. This effective engagement communicates to the rest of the organization that outcomes improvement is a priority and that the teams doing the work will have the resources required to reach their goals. The culmination of having multiple domains improving processes and establishing best practices will have a big impact on the areas prioritized as opportunities for improvement.
#3: Adequately Staffing Initiatives
To complete steps one and two effectively—1) engage executives and 2) prioritize opportunities—organizations need to be resourced appropriately. This ensures that they not only have the workforce, but that have the right people that are properly trained around the standard improvement methodology. This allows for a clear and efficient path to standardizing outcomes improvement and earning organization-wide adoption.
The leadership team oversees the establishment of domain-specific permanent improvement teams with dedicated resources. They are organized for long-term improvement and consist of innovators and early adopters. Team members include: data architects, process improvement specialists, clinical leadership, and ad hoc members (finance, training, EHR subject matter experts, etc.). These teams will focus on improving outcomes through data-driven hypothesis testing, developing and iterating through processes that impact outcomes.
As standard knowledge assets are created and assimilated into the workflow, the domain team ensures that the organization adopts the process and then scales it throughout the system so that it becomes best practice. Once initial improvements are made, the same team continues to monitor and maintain the gains while beginning work on additional processes that drive improvement on the measured outcomes.
#4: Communicating Successes Early and Often
Success, large and small, excites the masses around improvement and turns skeptics into believers by showing value in focusing on outcomes improvement early on. Leaders who share early wins across the organization acknowledge teams for their hard work as they make progress—rather than waiting for the finish line. This sustains enthusiasm for the initiative. It can take several years to achieve bigger goals, so recognizing the smaller achievements along the way sustains morale and empowers the team to continue their improvement journey. Frequent and consistent communication also changes organizational culture to scale outcomes improvement efforts.
By acknowledging successes throughout the outcomes improvement process and sharing them across the organization, improvement teams create value in their process. As others see their success, they’re encouraged to buy into the initiative. For best results, standardize communication around successes using a repeatable process and format. Messaging should come from operational and strategic leadership levels to keep the focus on clinical and quality improvement.
Engagement Keeps the Outcomes Improvement Engine on Track
Changing a health system’s culture to focus on analytically driven outcomes improvement is challenging because culture isn’t measured. Improvement gains are often subtle and part of a larger process. Communicating wins—even small ones—often drives engagement, as improvement teams are proud to see how their work continuously impacts patient lives, and the organization clearly sees and understands the value of outcomes improvement work. In addition, a dedicated executive leadership team that prioritizes improvement and protects the resources needed to realize key initiatives—particularly the EDW operating system—will keep the outcomes improvement engine running consistently and efficiently.