Clinical Integration: A Value-Based Model for Better Care


[Holly Rimmasch]

Thanks Tyler. Thank you this morning for spending a few minutes talking about a really important subject about clinical integration. And again, I encourage, I’m looking forward to any questions and hopefully we’ll have some moments at the end. If there is time that we want to spend some time on questions, we’ll go ahead and do that.

Objectives [00:19]

So you know, just the objectives of thinking about today, you know, it’s really understanding the importance of having a clinically integrated organizational structure to support the systematic improvement and sustainability. And we want to talk a little about some of those key roles and processes. One thing, as you know, we’ve had the opportunity to work at many healthcare systems. The understanding is some of these principles are fairly simple but sometimes we’ve forgotten the busyness of trying to do all the work that we’re doing to try to support care for patients. And so, I want to just spend a few minutes on that.


Just to remind you a little bit about some thoughts, you can see these couple quotes from key people that many of you know. From Dr. Paul Batalden, that “Every system is perfectly designed to get the results it gets.” And another person that I thought about as we were doing this is thinking about Deming and that importance of organizing around processes. So as we’re thinking about our clinically integrated network, one thing we should be thinking about, we should be redesigning our system to get better results and get better outcomes for patients. And I think that’s really important.

Three Systems for Improvement [01:31]

As we’ve talked about some kind of key areas and if you’ve attended any of our other webinars, you probably have seen the concepts of – there are three systems that we see are really key. Now, there are other things that are important but these are really three key areas to get improvement outcomes as we think about organizing around those, clearly around best practices, analytics, and adoption. And in these three areas, analytics helps us understand how we’re doing, best practice is what we should be doing, and adoption is how do we really transform to get our outcomes improvement. And as we talk about it, the area that we’re going to talk about is clinical integration has really wanted these areas that supports the adoption and how we support change and clarify clear accountability of care processes.

Clinical Integration [02:26]

So, what is clinically integration? If we are in a classroom, I’d be asking you all what clinical integration is in your mind, and I’ve come up with a very simple definition of what it is, and maybe too simple. As you think about it, it’s a very complex process but it’s organizing around those clinical processes that facilitates clear accountabilities for care across the continuum. And this is probably a rhetorical question but why is it important? It’s because our core business is providing value through better clinical care. So that gives a little bit background.

Another emerging definition – [03:05]

One thing I wanted to mention, and many of you on the phone, I’m sure, are very familiar with the idea of a clinically integrated network, which here’s a definition from the Advisory Board. There is a specific type of legal arrangement that allows for hospitals and physicians to collaborate while improving care. Today, we’re not going to spend time talking about the legal arrangement. We’re going to talk about the organization around what we’re going to do.

Typical Healthcare System?

Just some examples… [03:32]

So, this next slide, this is just an example but this is really a typical healthcare system or a clinic where we have a CEO and maybe we have a variety of different titles as we look at that. We are segmented basically into traditional roles. And again, as we go through this, these organizations are important as we think about operations of hospitals. So it’s not a concept that you would tell then replace.

Budgeted Departments – examples [04:04]

And here’s kind of the budget examples which makes it difficult sometimes as we think of care across the continuum because we’re separating different budgetary areas. And so, my big question here for all of you in thinking about your organizations and where you are, is that enough to provide clinical care to organize around these departments? And I’m guessing most of you are thinking, no, it’s not enough.

Heart Failure Readmissions [04:28]

And as you think about this heart failure, you know, are you organized around the ability to get improvement outcomes, these are just some examples of reducing. You can see this one is readmits and this is looking out from the inpatient to the outpatient setting.

Reducing Sepsis Mortality [04:46]

These are results around primarily more of an inpatient setting around sepsis.

Improved ACO Care Coordination [04:52]

And this is another example about moving along the continuum of care and looking at collaboration, advanced care planning – are we organized around the ability to communicate and make decisions and accountability to do these.

Key Functions of a Clinically Integrated System [05:13]

So as we think about the key functions of a clinically integrated system, there are four areas that are emphasized. The first one is creating a shared vision. Regardless of how you organize and what you do, that is an important aspect of being able to achieve your outcomes of improving healthcare. Creating an integrated information system, again going back to understanding what are we doing and what is the impact of what we’re doing across the continuum. And this is the point we’re going to spend the most time today about integrating our clinical and operations management structures in order to support improving outcomes. And of course, the last one, we’re not going to spend a lot of time, which could be an entire another session, is integrating our incentives and our cost structures.

Poll Question

Please rate your organization. How integrated are your clinical and operational management structures? [06:03]

[Holly Rimmasch]

So Tyler, we’ve just wanted to talk about our first poll question. I’d love to hear from you about your perspective on this question.

[Tyler Morgan]

Alright. Let’s go ahead and launch our first poll question. Please rate your organization. How integrated are your clinical and operational management structures? We’ve got our 100% – we are there, 75% – you’re are getting there, 50% – we’re well on our way, or 25% – we’re not too far on the journey, or maybe don’t know.

So, we’ll leave this open for a few moments. We’ve gotten a few questions in asking about – I’d like to remind everyone that, yes, we will be providing the recorded webinar, as well as the slides after the webinar. And I think we’re grateful for those questions. I’ll remind everyone that if you do have questions or comments, you can type those in to the questions pane in the control panel.

Let’s go ahead and look at the results of our poll. We’ve got 2% say 100%, 11% at 75%, 33% at 50%, and 34% at 25%, with the 20% don’t know.

[Holly Rimmasch]

We that’s great to know. I think this is probably pretty representative of how most people are feeling and actually it would be really great to hear of them the two who are there because I think this is definitely a journey and I think what you also see in these results is that people see the importance of doing this. So, thank you.

Outcomes Improvement Organizational Structure [07:27]

Alright. That really helped us give a view of what people are thinking and where we are. So, as we think about it, this is really just an example of outcomes improvement organizational structure. And as you think about it, again, the names of these teams could be very different and your organization is very complex. But as you think about from the simplest format, this executive team that you look at the top, the clinical outcomes improvement leadership team, really who in the organization is providing overall governance, prioritization, and leadership to those clinical care aspects across the continuum. Now, as you think about your organization, you could be an acute-based hospital and think about the same structure. But you also could be an integrated network and be thinking about the same structure – because again it’s the importance of looking across the continuum in these areas and representing the appropriate people that are providing care and accountability in each one of your areas within the hospital, as well as area within a community network.

As you go down on the right-hand side and you think about guidance teams, we’re going to talk a little bit more about guidance teams. These are more domain oversight of areas like cardiovascular or Women’s and Newborns, which they really provide domain oversight. And then these next two teams than are in red, outcomes improvement teams and work groups are really under the guidance of this overall guidance team. We’re going to talk a little more detail on all of those. And then on the left-hand side of the screen, the other concept and principle is the importance of integrating your data governance into providing support of your overall system, clinical goals, and content and analytics teams that are doing that.

Clinical Outcomes Improvement Leadership Team

Accountabilities [09:31]

So let’s move on and talk a little bit about this clinical outcome improvement leadership team. Now, my guess is in most of your organizations, you have a team that is similar to this, doing similar roles. And part of I think the learning experience is how do you integrate these into your current structures to make these easier to implement and sustain. But as we talk about these teams to provide the overall governance and prioritization and one core component they do is helping culturally change your leadership and breakthrough barriers and make it possible for these teams to be successful.

Another key component is this team establishes the teams, like clinical programs or clinical support services, that are the teams that are accountable to do the work. And as they think about establishing these teams as we’ve mentioned earlier, they should represent the continuum of clinical services and recommend clinical board goals and review. We talked about review progress removing roadblocks.

Clinical Outcomes Improvement Leadership team

Membership should represent key stakeholders in system (e.g., acute, ambulatory,

MD division) [10:38]

One again important concept you should think about these teams, typically we have a variety of people who have led these teams. And one thing that we have seen over time is the importance of having kind of this triad of folks who are leading this team. One is your physician lead, your CMO or VP in Medical Affairs or however you’re organizing your organization, and having a chief nursing officer/executive or VP for nursing. But the one thing that we have learned with integrating both the clinical and operational roles is making sure that you have your administration or operational officers as part of the lead of this team. And then there are other key stakeholders that are obviously important, you know, IT, finance, patient quality, safety, population health. You may have your physician group who’s representative and you maybe even have community leaders as part of your network in there. And then the other important part is leadership representing the multiple services that you’re providing care with with your clinical services or programs and your clinical support services.

Clinical Programs: Ordering of Care [11:50]

Going on, as we talk about those clinical programs, and you may call them clinical services, these are the groupings that we’ve identified as you think about the groupings that would really order care. These are people that are driving care, driving the utilization of our services. So, these are groupings of people who would meaningfully work together around care processes to improve care across the continuum. We’re going to show a little more examples of that later on.

Clinical Support Services:

Delivery of Care Ordered [12:24]

And the other concept again that we talked about, the importance of representing in this executive team, are all of those that are delivering the care. So there are places like lab, like pharmacy, nursing units, care units that are important to integrate. And as we talk about clinical integration, this is one of the key concepts – is integrating those people who are ordering care and also driving it with people providing care and coordinating how we set goals across those areas.

One of the clear example in my past experience is as we sat around the table and we set these clinical goals about improving care, one area we had primary care who had set a goal to improve diabetes and in adolescence. It was an area where we saw a lot of variation, we saw a lot of opportunity. And one of the core ways that they looked at implementing it was having the dieticians actually provide education to these folks. Well, I happened to be over our food and nutrition area and our dieticians had set a whole another set of goals. And so, as we sat around the table in this executive leadership meeting, we recognized that we actually could not do both of those and we needed to prioritize one of those areas. So, the importance of having the groups who have key understanding of those care processes needs to integrate to make sure those are aligned with the goals of the people who are actually doing the work.

Care-Level Hierarchy [13:57]

Another concept to think about is in order to support that, and we talked about analytics in these teams, is that you need to clearly identify the accountability of each one of these teams. So, if you saw the cardiovascular or clinical program, one of the things that we’ve worked on a lot and many organizations have hierarchies. We call them care-level hierarchies or clinical program hierarchies that basically are rolling out those codes and providing data to these teams so they understand what care processes they’re involved in. So for instance, cardiovascular would be kind of for heart rhythm disorders, vascular disorders, ischemic heart disease and heart failure. And you can see again under that there’s multiple care processes and sub-care processes that these teams would be responsible to look at improving care across the continuum.

One thing to highlight here, you know, for instance, is ischemic heart disease is anywhere from the prevention of having ischemic heart disease to the intervention. So it includes things like open heart surgery and other procedures done by cardiology.

Clinical Implementation Teams [15:05]

So, I just wanted to overlay a little bit how this works out. So you saw the clinical programs before. This is just an example where we have cardiovascular. And the guidance team really is responsible for all of those care processes, the implementation team, which we’ll talk about in a minute is just responsible for leading the expertise and developing improvement across the continuum, and the work groups are really the ones who do the detailed work about developing protocols and supporting these care processes.

Care Process Pareto Analysis [15:38]

So, I just pulled out an example of the cardiovascular clinical program because that’s my background. So I know it best. But this happens to be a list, we pulled a very large data set to show the type of disease processes that these teams might focus on first. And you can see in kind of the dark green you can kind of see the spend as a way to look at it, but it starts to drive, you can see from an overall perspective. And I’m going to go to the next slide…

Pareto Analysis >> Prioritization [16:08]

…that as a leadership team having these tools is really important to support clinical integration – because as we think about it, this Pareto analysis, and again this varies a little bit by the population you are looking at, but we see very similar that this Pareto analysis, where there is a certain amount of care processes that really count for a large volume and account for variation in organizations. And we start to see again and there’s a certain number of care process. You can see the number here, 40 care processes account for about 62%.

Internal Variation versus Resource Consumption (Excel Example shown) [16:43]

And this is kind of the Pareto Analysis. We have 85 care processes that represent 80% of the opportunities. So as a leadership team, you start to look at how many of those care processes falls within cardiovascular or Women’s and Newborns or teams that you have already existing where you start to say, where should we put our resources as a system to improve care across the continuum. And I think one thing that is highlighted here too is that there are a lot of different care processes, but when you start to look at your opportunities, there is a good area to focus. And for instance, if you are an organization that has a very high oncology volume because you have a big outpatient volume, again, this might look different and you’ll say, we want to put our focus to integrate our resources around oncology first versus another group which have cardiovascular and that’s the importance of looking at this information.

This is just another look at looking in internal variation, which is another tool for this group to see. And again, this is broken down. You can see down to the care process level, we can see that, again, septicaemia is one of those bubbles that we see that has high variation, you can see on the Y axis. In the X axis, you can see it has a lot of resources consumed. And so, you generally see as a leadership team, you start to see, okay, how we got ourselves organized and how we resourced the key roles in this area to be successful over long periods of time.

Guidance team [18:15]

So now I want to kind of go down one step and talk about the guidance team. We showed the slide earlier that talked a little bit about the accountabilities of that guidance team, and the importance is understanding what is the accountability of this guidance team. So as I showed earlier, the CV team actually knew that they were assigned the accountability of these care processes. Now, let’s say you have something like heart failure and one organization decided to assign it to cardiovascular. But another organization decided to assign it to primary care. Is that okay? Absolutely. Because we know a lot of the heart failure is in the outpatient setting and taking care of that but the key concept here is that you’ve assigned the accountability to somebody to drive. Now, it does not take away the importance as we all know that you have the right people sitting around the table. And as you’re looking along the continuum, you’d always involve the right people. But the accountabilities really start to drive improving outcomes along the continuum.

And in addition to that, the key role in the guidance team, if there are areas that cross-function a lot, like for instance respiratory, and you’re dealing with very high respiratory issue, you would definitely probably want to consider bringing some of those people for (19:36) on the team.

So this team is really the one that provides the domain oversight we mentioned earlier, recommends the priorities within those areas, and they start to recommend those board and clinical program goals which rolls up to the executive teams we talked about earlier that actually moved that to a board goal. And they prioritize resources within their areas and they determine the order and timing of the creation of the team. So, we saw that one earlier slide in cardiovascular where we had a list of opportunities, and they would determine the timing about when the teams would be putting together. And again, that’s not only based on the cost but it’s also based on leadership availability, external pressures, marketing needs and those things. There’s a lot of things to consider in that but this team really does that and they have the accountability to do that. And they ensure that there is best practices that are diffused and sustained systemwide as the leadership team within that domain and continue to remove barriers, as necessary, within the group.

Guidance Team [20:39]

And as you see again, you’re going to see kind of some of the key triad here again. You’ve got key physician, nurse leadership, and an administrator from each of the areas you’re representing. So, just to give you an example, we could talk a lot more about the details of this, but let’s say you’re regionalized. And you don’t want this team to be hundreds of people. You don’t want your executive team to be hundreds of people either if you’re in a large system. So you want to try to figure out can I have a physician represent a region, can I have a nurse administrator, and an administrator represent the region, and look at more in kind of a cluster representing; or if we’re in an outpatient setting, do we look at clustering different types of clinics together.

And then another areas is each one of these teams needs some support and tools and processes. And we have identified this by looking at a knowledge manager and a data architect and an analyst. And you can see by looking at the data, one of the reasons it’s important is because it gives this team enough transparency to understand the work they’re doing and the impact of the work that they’re doing. And obviously, there are other key stakeholders, IT finance, patient quality, patient safety, sometimes we see people from the PI world in this at different aspects. And again, in these teams, there are assigned people that are accountable to this group to help bring together best practice.

Permanent Teams Characteristics [22:12]

So this is just a picture. We kind of laughed. We’ve done this in kind of multiple different ways. And you know, if you think about these teams, the guidance teams, the driver on the right-hand side, the physician and the clinical ops directors are really leading this team. And again, we talked about administrator, but from a clinical perspective, they’re driving and providing support to these clinical teams.

And you can see, this is Women’s and Children, but if I replaced it with cardiovascular, the pockets would be heart failure, ischemic heart disease, and they would identify leads in those teams, and you can see, again as you think about the integration, about the importance of identifying the early adopters and innovators to do that. And then along the bottom, you can see that the roles that we talked about, the knowledge manager, the data architect, and the application administrator, those are folks that when these teams start to work on improvement processes, they actually have people that are assigned to update your EMR. So if you had to change and we said we know this would actually improve care, we’ve got five places that we’re charting this, we need to change it in, one, in your EMR, these people are assigned to do that. So, these people can support multiple processes that are happening, but you’ll see again critical to that.

Critical Key Functions to Consider…[23:31]

This next one is, again, one of the reasons. So as people on the bottom of the truck are so important, and they aren’t being driven over. We do want to make sure they’re actually helping support – is that the importance of providing data and capturing data analysis for these teams is an ongoing permanent resource.

And I’m actually going to go back to the slide a little bit because I missed a couple things. There’s one thing different. If you think about a clinical integrated network, one of the concepts we have seen over and over again is the importance of permanence in these teams. Now, I think on the guidance level team or the clinical service level team, we often have permanent teams in our respect. But I think as you look at the teams below that, the outcomes improvements teams and the workgroup teams, they have the tendency to be very project-oriented, and it does have an impact on sustainability and the ability to implement. So, I think we’ve covered both of these areas.

Outcomes Improvement Team [24:32]

So we’re going to go to the next team, which is the outcomes improvement teams, that really I would say the key topic here is that they’re supporting implementation. And this is a concept and it would have been probably good to put a poll question here to talk about how we support implementation – because implementation is one of these really hard things to do in a clinically integrated network. As we know, it’s very complex and there’s a lot of people involved in it. But the idea and concept of identifying a team that is accountable for implementation is absolutely critical in this process. And doing that, as we’ll show a little bit later and say, work with the teams that are developing the protocols and developing the best practices, it allows that smaller group to come to a larger broader group who can give feedback who overtime actually support the implementation because you are culturally bought in to these processes.

So let me give you a very specific example. So, let’s say you’re looking at heart failure and you’re working with a lot of clinics and you’re developing protocols on how to better support these patients, and you’re talking about places where we may have a place where we’re going to develop a specialized heart failure clinic. That sounds really good but then we have a lot of people that they’re doing very similar work. And so, the opportunity for the smaller team to come back and be able to go to a broader set of clinics and get some feedback and interaction during that process actually allows for long-term better implementation and a better understanding of the issues and challenges of implementation.

So again, this membership of these teams, you can see that it’s primarily led by domain experts – so physician leads, nurse leads. And I will mention when we talk about the clinical services later, these teams are very important around the people who are implementing the work. So maybe it is a respiratory therapist and a physician, maybe it’s a pharmacist and a physician but that same concept is true across.

Workgroup Team [26:50]

So now I’m going to skip to the workgroup team, this is probably the easier concept for most of us to understand. They are assigned as very specific domain discovery and intervention design by the guidance team and the outcomes improvement team. And they really do the heavy lifting. They are meeting more frequently. They are developing the care process best practices. They are working with education. This one is really about getting the right people in the room together and looking at analytical and technical experts to support them in their journey of gaining transparency.

So as you think about integrated clinical network again, as you think about this, okay, so we have one group that’s doing an improvement process on a heart failure patient, we have another one that’s looking at normal newborn, we have another one that’s looking at palliative care. Another concept that’s important as you are thinking about clinically integrated network is do you have consistent processes across these teams and methodologies for them to go through these processes and improve care? Because the end of this is it goes to the patient and it goes to a provider who is trying to take information, maybe a primary care physician or a hospital who is trying to take information from multiple areas, there needs to be some consistency on how we go through the process, how they integrate and familiarity with what’s happening.

Improvement Cycle [28:22]

So again, this is just a PDSA cycle. We’ve integrated a little bit more of the data components of this but it is important to do that as we support the teams.

Identify Potential Improvements

Process AIMs and Outcome Goals [28:33]

And then understanding again, as a leadership team and as an integrated network, that through the transformation process, it takes multiple workings on improvement cycles to really start to see the needle move on getting this care.

So, generally we see that two-to-four process improvement AIMs should produce a significant outcome. Now, why is this important as we think about clinically integrated network system and looking at the organization around that? It’s important for the executive team to understand kind of the work effort that goes into that. It’s important for all of the teams to understand how to set a goal. So if you sit down and set a goal and say, we are going to improve the mortality by 20%, and you have no baseline and you have no idea about the core steps that we’ll get to there and commit that to the board, that is a really hard thing to do in one year. Usually we see these clinical board goals, they sometimes take a year to get this process kind of things fixed before they even understand what the real opportunity is to improve outcomes.

And so, I guess in summary, this is complex work. It takes a long time to do. There is a lot of integration that needs to happen between the people who are doing the work, the people who are driving the work. And so, don’t underestimate the culture change and the timing to commit to do these goals and not underestimating the resources that are needed in this process.

Actionable Visualizations [30:18]

So kind in the end for workgroup team, they come up with some very detailed work around actionable visualizations and start to continue to learn to drive. And one thing I just wanted to highlight is these tabs across the top of this, this happens to be heart failure, continues to grow. And the importance of these permanent teams, you’ll see teams that have been working on this for five years that have in multitude of tabs that continue to improve process, which we would have lost the opportunity if we would have said we’re just going to put this heart failure team together to develop best practices and think that it’s kind of at a time-limited basis because the opportunity goes overtime.

Team Structure Options [30:59]

I just wanted to highlight. We talked about the importance. This is just a high-level thinking about permanent and temporary teams. There are some pros to having a temporary team. It takes less time to start initially. It feels less expensive to start. But, you know, as you think about the pros of having a permanent team, that’s something that you really have to think about in this integrated network.

And the other thing about the pros, you know, it’s just expensive. I think the cost is it feels more expensive but if you look in the long run and you look at the outcomes you get, it truly probably is not more expensive over time. As we’ve looked at the data, it certainly has proven out to be one of those things where you want to install the fortitude to put these kind of resources in there, even though it’s really tough and it looks overwhelming.

And again, as you go back to that executive team, that’s why maybe you only start one or two of these, to start with, and you start to build your resources. And I think what you’ll find in most organizations is these roles are there in most organizations and it requires re-shifting those resources to get where you need all the way from the leadership team down to the workgroup team.

Data Governance Categories [32:14]

I just want to spend just a brief moment on this. As you think about data governance, and this is a whole another set of detail, we could spend a lot of time on that, there’s really kind of two major areas in data governance in the simplest forms. One is the priority management and the other one is the data stewardship. And in this clinically integrated model, the importance is that the priority management of those resources should be aligned with your clinically integrated network.

Content & Analytics Team [32:44]

And I would say the same is true for developing the content, developing the care process models and the analytics should also be aligned with the overall system goals.

Care Improvement Map

Sepsis and Septic Shock [32:57]

So this is just an example of some consistency. They create consistencies across these multiple programs. This just happens to be a care map around sepsis that supports the importance of content in the process.

Poll Question

Are your data governance and content & analytics resources aligned with your improvement outcome goals? [33:12]

But Tyler, I think, I would like to go to the poll question too and ask the audience about how well they think this is going in their organizations.

[Tyler Morgan]

Alright. Let’s go ahead and get our next poll launched. Are your data governance and content & analytic resources aligned with your improvement outcome goals? Yes, mostly, sometimes, no, or don’t know.

We’ll leave this open for a few moments. I would like to remind everyone that you can type in your questions into the questions pane of your control panel. We’ve got a couple questions. Yes, this is being recorded. We will provide the recording, as well as the slides after the event is over. There was also a question regarding can we get a certificate of attendance to use for continuing education purposes, and unfortunately that’s not something that is available with our webinars at this time. While we do focus on educational topics, in all transparency, because we are a vendor, it’s much more difficult for us to obtain continuing education credits for these webinars. But that’s something we continue to investigate and try. So if we are able to get them, we will certainly let you all know.

[Holly Rimmasch]

Yeah. And I’ll mention this, in our AP courses, we actually do have continuing education hours attached.

[Tyler Morgan]

That’s right. And we’ll mention those AP courses later on in this webinar. So let’s go ahead and close this poll and share our results.

Alright. So we have 6% that said yes, 14% said mostly, 44% with a sometimes, 18% no, and 18% don’t know.

[Holly Rimmasch]

That’s great. I think I would actually love, you know, to open up a conversation with your experiences in that and your understanding of the importance, and this is one thing, is, you know, to have the opportunity to reflect about how can we do this better. And again the idea is there is a lot of different ways to do this but how do we really integrate. You can see in a long-term success factor, we’ve got to figure out how to do this to be successful in healthcare.

Executive Leadership Team, Guidance Team, Broad Teams, and Small Teams [35:32]

Alright. I think I’m just going to summarize a couple of key concepts. And I put these slides together, I think, when we send out the slides, so that there is a visual way to look at this. But again, as we take over our organization, you know, the idea of the executive leadership and they are basically prioritizing the system, the guidance team, which is prioritizing innovations within the domain. And you can see we’ve got these cute little people on the side that represent a Women’s and Newborns team. Then we have these small teams that are really doing a lot of the work. They are iterating, they are billing the DRAFTs. And then we have these broad teams that support implementation across your system or across your hospital, depending on the scale of where you are going.

And I think the other thing – that this slide has a lot of detail actually. You can see we have actually tried to identify some of the key subject expertise in there. You can see we have subject matter expert, data capture, data provisioning, and data analysis that help support all these teams on all levels.

Key Success Factors/Lessons Learned [36:44]

And finally I just want to kind of just end with a slide about some of the things that we have learned as we have worked with multiple people across in different organizations. Again, some of these seem very simple but it is so complex that it is hard to remember and see the forest to the trees sometimes.

And one is key leadership. In order to do this, you really have to have your leadership. And you can see your clinical leadership aligned with your management leadership is critical. You have to have that shared vision, you have to have a process where we understand we are going to align our resources around what we are going to do, and it is hard because we are prioritizing, and there are a lot of things operational that will need to be done that cannot go through this team but we know the most important things we’re actually resourcing.

Next, that idea of integrating the technical, clinical, and operations. You can see the importance of that in the ability to have sustainability and long-term outcomes. And dedicated resources. We’ve talked about that, the importance.

And I’ll just mention, you know, the clinical leadership, how are your physicians or how are your nurses or how are your administrators incentivized to participate in this program? And I think, you know, again, you might actually go through the level of many organizations who have revised their job descriptions or the position summaries to require participation for key physicians, nurses, that they are actually measured on their participation in these types of teams, that you actually start thinking about pulling out physician time that is really focused on providing the leadership in these areas, not just as a side bar of you’ve got a really good position, you’ve got a really good nurse who can do this, but for the long-term sustainability, there needs to be dedicated time and resources into that.

We talked about the permanent structure and I would say that one of the challenges we tend to look at is changing from a “project” to “the way we live”. This is the process we look at. This is the things we live by. This is the way we set our goals. This is the way we prioritize the importance. And obviously, developing that culture of quality and improvement and consistent methodologies we talked about.

Transparency – everyone sees everyone else’s stuff. In this process, physicians see things that maybe we may have a variety of different comfort levels of seeing some of the data as we go along, but that transparency has been one with success factors as we go along.

Integrating your key concepts into current work teams or structures. We mentioned that earlier where if you’ve got a process that’s working and you have teams that are working that have a good representation, then change their charter. Change their accountability or clarify their accountabilities, that they really truly are accountable for these.

And finally, there are a lot of ways you can put this puzzle together. This is just one example. There are other teams. There’s other parties of the organizations that happen. So this is not the only organizational structure within healthcare system. But it is really a journey. And as you start to accept these accountabilities, you start to see opportunities and improvements that you never really imagined and it becomes easier and easier because you’ve set up structures and process to clinically integrate, again, what we’re going to work on and how we implement those processes.

So that’s really the wrap-up of the formal presentation, Tyler. And I don’t know if we have time for some questions or if there are any questions that people would like to ask, or comments.

[Tyler Morgan]

Well we do have some questions coming in, and some comments, and we’ll definitely get to those. Before we get to those, we have one last poll question that’s somewhat connected to something that Holly had alluded to, which is our Health Catalyst University.

So, our webinars are meant to be educational about various aspects affecting outcomes improvement in our industry. And our topic today is actually one of the many that we present in our Health Catalyst University, which is an accelerated practices program that prepares healthcare teams to accelerate outcomes improvement. So if you are interested in having someone from Health Catalyst reach out to you to talk to you more about our Health Catalyst University, please respond to this poll question. And we are going to go ahead and leave this up while we start with some of the questions. How about that?

[Holly Rimmasch]

Okay. Sounds great.

Where is the quality control to ensure data sets are reliable? [Holly Rimmasch]

That is a really good question, and we could probably spend a lot of time in that area. But I think generally, as we think about that’s the importance of the data governance, being attached to the overall goal. So I think when you think about the overall accountability of the data, that really falls under the data governance IT process. And those data managers that we shared with that are sitting on supporting the clinical teams in the domain in this model, those folks are accountable for the cleanliness of the data, they are accountable to make sure the data collection is happening the right way, they are the people who really understand the data, and they work with the data governance structure to support the overall group. So hopefully that answered your question.   That’s a pretty simple way to talk about it. But I’d say it’s integrated into those teams, but in the overall structure, from the accountability for the organization, it’s under the data governance component.

[Tyler Morgan]

It really sounds like one of the words that you used a lot today is accountability. Accountability. Accountability. Set accountability. Give accountability and make sure that’s a sign. That really seems like that’s a big part of this.

[Holly Rimmasch]

It is. And I think, as I mentioned before, accountability might be more important than, you know, if you’ve assigned the wrong accountability, it usually becomes apparent pretty quick if it’s not right. But what is good about it is people understand where they are focusing and they understand where they can make decisions and where they should be driving the process. And again, if it’s wrong, we learned that in a couple processes we did, I mentioned the one around heart failure. We did the same thing around kind of stroke. It was such a big process, we just started it from – I can’t remember where we started. We probably started from heart and then we realized that it ended up in some way totally different, but we started it. And I think that’s important. And I think, again, accountability for the data and the support, the accountability for the implementation, those are all things you want people to wake up in the morning and then think about, how do I do this better.

The clinical outcomes improvement team needs to be led by physicians with admin leader and more providers on this. Team providers have power of the orders and/or CPOE and the difficult group to get buy-in. What’s your take on that? Yeah, I would say, you know, when you look at that team, that the representations from each cluster region, or again if you’re hospital-based or if you’re community-based, really do need to be more of the clinical perspective because they are domain experts. So you would want to pull in physicians from key areas.

And again, just as I think the person who asked the question understands, it is harder to get buy-in. If they are a part of that process, then that works better.   For example, if you have a protocol that’s developed and you have this really great way you can implement your EMR and all that kind of stuff, and it was developed by the largest hospital grouping or the largest community grouping, there’s always a natural resistance to say, gosh, you know, is this right? And again, it may be totally evidence-based, but that ability to be part of that process is why these permanent teams are important – because it needs to happen consistently. And when we started doing this, we actually made that mistake where we developed and we had really key experts in these workgroups, they were doing phenomenal work, and we came up with really great protocols and processes, but we could not get it implemented because we had never had that concept of the implementation team, where we went back and said, “Hey, what do you think about this?” Because we actually had a better protocol and better processes when we had the implementation team because they sought from different perspectives and that really helped us in the long run. We were more successful implementing and it was something that people were bought in and we were able to sustain it.

Is oral healthcare excluded? Well that’s a good question. I think that oral healthcare is absolutely a part of, you know, as you look at care processes, is part of all of us. And we probably haven’t integrated those types of community resources as well into these communities. In particular, when you’re talking about certain populations of patients, you know, I think that would be a consideration. And so, I think that, again, it’s not excluded.   We haven’t done a very good piece and it’s not critical as much sometimes into the inpatient kind of setting but when we get to the outpatient setting. So I think that’s an opportunity to figure out how we integrate that. I’ll mention that at the same time I think in these teams, another good thing to be thinking about is how are you integrating patients or community members to these teams? And I think from a clinically integrated network, you’re starting to see around the country people taking risks and bringing people into some of these goal setting meetings and developing protocols. And so, I think that’s a little scary because we think about we’re showing a lot of our worth in processes through that, but some of the groups that we’ve seen do that have had an incredible support from their patients and community members.
To what extent do organizations utilize a department of evidence-based medicine or clinical effectiveness to establish or manage best practice utilization to accomplish the improvement goals across the enterprise?   Would that be equivalent to the clinical outcomes improvement leadership team? Well, I think, again, there’s multiple ways to take a look at this process. I think, first of all, as we talk about that content team, content analytics team, that’s one of the areas where you see evidence-based medicine. You may develop a team and we do see organizations around the country who have developed these evidence-based medicine teams who support the entire organization. So they developed processes around how to do it best, they have developed mechanisms and communication patterns. So there’s one way that we’ve seen it. And then also I’ve seen within these areas, let’s say for cardiovascular, where they have developed those teams within their own areas.   And I think that there’s probably a mix that is important but the challenge with developing that not in a systematic way is then you have 11 different ways to look at how we look at evidence-based medicine.

So I think there’s a really important role for that. One of the clients we worked with does a phenomenal job at having this evidence-based medicine group, developing protocols. And again, they are pulling in, the core work is done within the clinical area, but they are pulling together better processes and a systematic way to look at it, and I think it’s really quite effective.

What advice do you have for physicians that want to be more involved in this kind of work? What resources can we use to gain a better understanding of care processes and the process of process improvement? Well, first of all, it’s exciting because I think physicians are core to this work. And as you can see, as we’ve talked about it, I think there’s opportunities in providing leadership. There’s leadership in all levels of the team, from physicians who want to be involved in it. And you know, in the organization I was prior, first we (49:19) physicians to be part of it because they are so busy. Towards the end, when we had set up kind of the standard mechanism, we had 10 physicians involved and wanting to apply for this position. So we actually went through a very formal process in bringing them in.

So I think there’s a lot of opportunity for improvement for physicians that want to be more involved and learn about kind of actually doing that. It seems some of the tools, again, as I went through kind of the workgroup tool about bringing the data and have physicians being part of that process to actually drive the development of improvement process. I think if you want to have more information on learning how to do more about that, Tyler, I think, one of the things we have internally, but there are a lot of different opportunities across the country, where there are courses on improvement, processes and mechanisms.

I think the other thing is there are usually parts of the organization who are doing this really well. We’ve seen pockets of it in every organization.   And one other opportunity is actually to work with those pockets within your organization to learn more about that.

So there’s both formal, informal, and I hope I answered the question well enough on that. But I think it is critical and I think it’s actually really exciting that you would want to be more involved or physicians may want to be more involved in process because I think it can’t work unless they are involved.

How do you get your providers to buy into the concept of taking time to invest in meetings to establish process? Since they don’t want to take any time away from their patient care. You had said initially you had people who weren’t interested but then you had many people applying. I’m guessing time was part of the factor, but what else was it that really started to move that? [Holly Rimmasch]

I think there’s a couple of things. One is you’re starting this journey, one is identifying those people who are innovators, and there’s innovators in all different disciplines, people, you know, physicians, nurses, administrators, who are willing to do whatever needs to be done regardless of the personal price of their work-life balance because really people are really busy, and physicians, in particular, are extremely busy and they are doing really important things. So it’s taking away from care when we do that. I think that’s not a very good long-term strategy. I think it can work for a while and I think the other way is to really, and this is really hard, but to really set aside those resources and work within your organization to say, so on average on these guidance teams, we’d see about a physician taking about 20 hours a month to help lead these teams.

Now, the nurse operator positions generally are full-time when you get in a larger component. And if it was a really large area that was very broad-spectrum, again you might need more time. But we actually went through and said, okay, to lead the implementation team, it takes a physician around 10 hours a month. That’s what we had set aside. And for a workgroup, we set our 10 hours. I think we did about 5 hours a week, so it was more intensive, depending on the process. But to really set aside and say, this is part of the job description or the job summary of this physician’s role. So they are doing clinical work as much time and then they have 20 hours a month to actually do this work. We did not get a shift in our ability to really provide the physician leadership or the other leadership and those support roles until we actually set aside and said, this is part of your job and this is important part of your role.

And not only on the executive leadership but when we’re getting to the workgroup and we’re going to the implementation, when you’re saying, here’s a cluster of clinics or here’s a cluster of hospitals or here’s a region, those people need to have some time to do that work because they are the ones who are responsible to get this stuff to that bottom of the road there. When the rubber meets the road, they need to help facilitate that culture change.   So it’s a really hard concept, it feels really expensive, but in the long run, again, I think it’s less expensive.   It is much more satisfying for physicians and nurses and folks who are in those teams because that is part of their accountability.

[Tyler Morgan]

So with that accountability, you’re readjusting actual job roles, descriptions, payment structures, and things around all of that and their expectations and accountability towards the process improvement.

[Holly Rimmasch]

Yes. Right.

[Tyler Morgan]

That seems like it takes quite a commitment by the organization.

[Holly Rimmasch]

It does take a lot of commitment by the organization. And I think the other thing is in these teams, you should have a chart or you should have a clear accountability of those teams and you should take it to the step where you’ve actually written it down and talk about who is on that membership and then bring it down to the next level and say, okay, that membership that is on this team, making sure it’s integrated into their regional or their hospital or their clinic job description. So it is absolutely critical to the success of this.

How well do the models you have presented adapt to multiple cultures within the organization, both among the staff and patients? I’m trying to make sure I understand this question. I think there is a lot of different cultures in our organization. And actually when you go from hospital to hospital or clinic to clinic, you have multiple organizations, and I think that’s why it’s so important to have a systematic process, a systematic way that we’re doing things. And it’s important, I think, that these leaders that are doing this are really good at listening and really making sure that they are getting feedback, so that makes that transition a little bit easier with culture.
Where do you see pain management in this process? I see pain management is one of those horizontal clinical support services. In my previous (55:38), actually pain management was one of those things and I see them integrated into many teams across the continuum. But yet, they have a need to improve pain services, so they have their own separate team as well as being integrated across the continuum.
At what point should you bring patients directly into the discussions and decisions about process improvement? Well, like I said, it’s kind of a scary thing.   I think we see more and more organizations bringing them in early on as they start the teams. Generally kind of what happens is you get these teams together and you feel like your team is kind of gel first and then bringing in the patient and community members. You would just want to make sure you have kind of a functioning team. But once you start getting comfort level into putting these teams together, you see an earlier and earlier entrance into that.

Thank You [56:40]

[Tyler Morgan]

Alright. Well we would like to thank everyone for joining us today. Thank you so much, Holly, for sharing your expertise with us. I would like to let everybody know that shortly after this webinar, you will receive an email with links to the recording of this webinar, the presentation slides, and the poll question summary results. Also, please look forward to the transcript notification we will send you once that is ready.

So on behalf of Holly Rimmasch, as well as the rest of us here at Health Catalyst, than you so much for joining us today. This webinar is now concluded.