Outcomes Improvement Governance: The Quest to Achieve More with Less

Outcomes Improvement Governance:
The Quest to Achieve More with Less
November 22, 2016

Outcomes Improvement Governance:  The Quest to Achieve More with Less [00:01]

[Tom Burton]

Thanks, Tyler.  Glad to be with all of you today and I am excited to talk about this very important topic, the improvement governance, and how that works.

Poll Question #1

Which of the following symptoms of less-effective governance are present in your organization? (Check all that apply) [00:14]

So, I actually want to start out with a poll question, and we see these symptoms a lot as we work with healthcare systems across the country and I would like you to check all that apply.  I will read through them and then we will give you a chance to respond to this poll.  But let me know which of these symptoms apply to your organization.  So, you might have pockets of improvement occur but very few initiatives spread to every unit at every hospital or every clinic.  You have silos between departments and that is prevalent.  There is a lengthy process to fund or approve improvement initiatives.  You spend more time debating what to improve rather than the actual improving.  There are lots of top priorities or constantly changing priorities, or there is a big battle for resources at budget time, or your organization has trouble saying “no”.  In addition, you might have a light effort on a whole bunch of areas rather than a deep effort on a critical few.

So these are all symptoms we have seen before and we will now open the poll up to see which of those apply to your organization.

[Tyler Morgan]

Alright.  The poll is open right now to give everyone the opportunity to respond.  We have got a bunch of folks come in.  We do have a couple of questions.  There are questions regarding whether or not we will have the slides available.  Yes, we will make the slides available as well as the recording to this webinar after the event.

Poll Results [01:53]

[Tom Burton]

Alright.  Taking a look at our results here.  It looks like we have a lot of silos between departments and a lot of time debating rather than actually improving.  And so, we will talk about a lot of these symptoms today and what we feel are the resolution of those symptoms with some core principles around outcomes improvement governance.

Learning Objectives [02:18]

Okay.  So we have four main learning objectives today.  The first is to learn how to engage the right people around governance.  Second, understand how important it is that we have a shared understanding of the different improvement opportunities and what it is going to take from a resource and analytics perspective to achieve those improvements.  We will talk about how we align incentives and we will also talk about balancing polarities.  This is probably one of the hardest things to do.  And the fourth learning objective will be how do you optimally allocate scarce resources to the most important, the highest priority, highest yield improvement initiatives.

Well designed and executed governance optimally allocates scarce resources…[03:08]

So, at Health Catalyst, we fundamentally believe that well designed and executed governance optimally allocates scarce resources, and when that is done, that significantly accelerates the breadth and the depth of outcomes improvement.  And so, we will talk about what is required for outcomes improvement and how, if we get governance right, it really impacts outcomes improvements.

Why Governance? [03:33]

Some of you may have attended other webinars or come to our Healthcare Analytics Summit and we spent a lot of time talking about what are the key ingredients of outcomes improvement.  Now, we think about those in three major categories – best practice, analytics, and adoption.  Best practice is really what should we be doing, should this patient get a spine fusion or should they just have a physical therapy.  Then the question is how are they actually doing – that is where the analytics come into play.  Are we compliant with the best practice, are we following that, what percentage of the time are we following that.  And then finally, there is typically a gap between what we should be doing and what we are actually doing – so how do we change, how do we transform, and that is all about adoption.  When those three things work together, you get significant massive outcomes improvement.  Now, that could be in one key clinical or operational area.  For example, pregnancy or hearth failure or asthma.  Now, how do you get it to spread to all areas, all clinical and operational domains of the care delivery system?

Capabilities to SCALE Outcomes Improvement [04:51]

In order to do that, you have got to have great leadership culture and governance, and that will be our focus today, as well as you have got to have financial alignment.  So these are the core principles around scaling outcomes improvement.

And I want to turn the time over now to a good friend of mine, David Grauer and a little bit of background about David.  David spent many decades at Intermountain Healthcare and his most recent role before joining Health Catalyst in our professional service team as one of our key leaders, he was the CEO of Intermountain Medical Center, which is the largest hospital in the State of Utah and he had the opportunity there to just spend a lot of time with improvement work, governing that improvement work and seeing how all these pieces put together.  So I am very excited to share this webinar today with my good friend, David, and I will turn it to him now.

[David Grauer]

Thank you, Tom, and thank you all for joining us today and giving us the chance to talk with you about our experience and share some best practices that we have learned both in the industry and here at Health Catalyst.

And the way this webinar will be structured, we have a series of principles, there are four main principles that Tom has introduced, and each of the principles has several steps associated with them, and we will walk you through each of the principles and the steps associated with them.

Principle #1:  Stakeholder Engagement [06:30]

And let us start just with principle #1, which is about stakeholder engagement and the concept is really quite straightforward and it is starting at the top.  Be sure that we engage all the stakeholders around the common vision.

Principle #1:  Stakeholder Engagement [06:40]

And the questions to be thinking about here as you make sure the right people are at the table are on the slide here.  Which stakeholders control key resources and funding?  Which stakeholders have specific domain knowledge?  Who is the most qualified to make tradeoff decisions?  Who can influence others to adopt change?  Who can understand the root causes related to poor outcomes?  Who is best able to redesign more effective processes?  And who ultimately will be impacted by process changes?  Those are the questions to think about as you design your teams, as you set up executive governance and as you think about who ought to be included in the process and at various levels of the process.

Four Levels of Stakeholder Engagement [07:28]

We think about and talk about four key levels of stakeholder engagement here at Health Catalyst.  Those who control resources and make funding decisions at the executive level, those with domain expertise or specific expertise, and that can be in any of a number of areas – clinical, operational, financial, or others.  Those who have the ability and the expertise to influence the adoption – so at an implementation team level, those who can actually support and encourage change.  And those at a workgroup level, those who are innovative and who are able to address root causes, identify and address root causes, and drive the process toward better outcomes.

So ultimately as we think about this, we are talking about those who have the ability to drive change, to support change, to resource change, and to facilitate change, remembering that this is really both strategic and tactical, and a lot of this revolves around the organizational ability to facilitate cultural and adoptive change.  And so, that requires, in our opinion, expertise and engagement at all of these levels.

Step 1:  Call to Action [08:46]

So step 1 under principle #1 is a call to action and I like to think of this as the bugle call or the shoot for the moon statement by President Kennedy or the CEO of the organization saying the most important thing that we are going to focus on is safety as examples.  And the intention here is for a leader to create some momentum, to create some engagement, to give some authority and accountability to the team and make it clear that this will be an organizational priority and that will be resourced and that there will be commitment in order to move this process forward.  It is critical for this to come really from the highest level of the organization that is possible because those leaders are the ones who have the ability to drive and direct the strategic direction of the organization.  So it is the bugle call.  It is the call to action.

Step 2:  Form the Leadership Team [09:48]

Step #2 is about forming a leadership and let me just take you back to those questions that were on a couple of slides ago, where you think about who has the ability to influence, to resource, to support, to drive strategy, and so forth.  It is critical that this team is representative, in our opinion of many, if not all of the C suite level executives of the organization because of their ability to drive the things that we are talking about.  A principle here to think about though is balancing agility with representation.  It is important to be agile enough that the team can make decisions and be dynamic in its work but we also want to make sure that it is representative enough that those who are affected by the work and who can actually drive the work are there.

A Story of Missing Stakeholders [10:47]

Just a quick story and a quick example that is not a unique one to me and it is probably very common with all of you.  We have worked with a client.  In fact, multiple clients, who have multiple hospitals in multiple states and the one I am thinking of specifically was very passionate about outcomes improvement.  They identified lots of opportunity.  They formed a leadership and executive governance committee and they failed to include the chief financial officer.  They did a ton of work, they did a ton of great work prioritizing, identifying opportunities, planning, putting teams together, and when they were ready to pull the trigger and start down the path, the CFO, who ultimately had a funding authority, said, “I am sorry.  What are you talking about?”  And put a block on it.  And the point I think here is obvious.  You need to make sure you have, in this example, the CFO involved early, engaged, understanding the process because he or she in this example has the ability to stall the process.  And really the point is it could apply to nursing, it could apply to the physicians, it could apply to the informatics group.  The point is that the leadership has to be involved.  If you expect that your outcomes improvement effort will affect your positions, you have got to make sure that your chief medical officer is there.  You expect that it will affect your nursing or you should make sure the chief nursing officer is there.  In my experience, I always knew that I needed my executive team with me if we are going to move anything forward successfully.

Principle Review:  Stakeholder Engagement [12:29]

Okay.  Just a quick review on this principle.  And I should have make a query when we started.  We believe these are guiding principles at Health Catalyst.  Some of the details, some of the organizational reality that you all experience is different.  This can be flexible in terms of the actual tactical steps.  For example, you see how in this slide you may already have a team that is largely consistent with the principle that there may need to be some tweaks, your call to action may be slightly different.  The key is following the core principle, adapting it to your specific environment and more specific reality.  But remember, start at the top, engage all stakeholders around the common vision.

Principle #2: Shared Understanding [13:16]

Principle #2 is about shared understanding and making sure that the organization has a common understanding of organizational needs, capabilities, and readiness here.

Step 3: Identify High Level Opportunities [13:27]

One of the most important things that an executive governance committee can do in outcomes improvement is identify priorities.  And as we move through these steps, we are moving through a narrowing process.  And so, if you think about a very wide panel, ultimately we start high level and we narrow to just a few as the governance committee does that work.  And early on here, this is about identifying the very high level, the Pareto Principle, if you will, and understanding some of the basic opportunities, whether it is the most variation, whether it is the most cost, whether it is the most opportunity, to improve outcomes at a high level and beginning the narrowing process and understanding where the organization might focus.  Remembering that the data will tell you one thing, you have to apply the data and integrate it with your organizational reality.

Step 4:  Assess Organizational Capabilities & Readiness [14:27]

Step #4 again is narrowing the process and we are recommending a few steps here that help to inform the governance committee about how to choose those priorities, and this is about understanding the capability, the capacity and the willingness of the organization to move forward.  Again, if you do not understand these things in advance, you cannot plan, you cannot resource, you cannot prepare to begin this work in earnest.

There are a couple of tools that we have that we have used successfully.  The diagram that you see on the bottom right is a readiness assessment that we can help perform.  It is an online tool that looks at the five questions and the five capabilities that you see there – leadership, culture, and governance, these are the five that Tom talked about – Analytics, best practice, adoption, and financial alignment.  We can help with interviews of key people, key team leaders.  And ultimately the goal is to look at how ready are you, how capable are you, what resources do you need, where are the gaps, and how do you begin the process of narrowing those gaps to move forward.

Key Resources That Are Often Scarce: [15:37]

These are just a few areas that we are seeing repeatedly where there are often scarcities in our experience.  In the analytics and data area, data expertise, the ability to capture, provision, and actually interpret.  Also in the process and quality improvement areas of expertise, those who can facilitate change, management engineers, process engineers, and the subject matter experts, or SMEs as we call them, who really understand the fundamentals of each of these processes.  Communication experts, content experts, and then the clinical and operational leaders.  And we see parenthetically adaptive leaders.  Remembering here that much of this is around organizational and cultural change and the ability to adapt to the change.  And so, it is critical that the people who are in leadership roles understand how to change organizations and move forward.

Principle Review:  Shared Understanding [16:38]

A quick review again, the ‘How’ can be different, the key here is to make sure that you have a common understanding of the organizational needs, capabilities, and the readiness, so that you can plan, prioritize, and close the gaps on resources in order to move forward as successfully as possible.

[Tom Burton]

Just a comment, David, on that assessment.  There is a free version of that assessment that you could just go to our website and take the assessment as an individual, and that will give you a good sense of the types of capabilities that are really needed for broad and deep outcomes improvement.  And so, anyone is welcome to take that.  It is a free survey and it gives you a nice analysis of kind of your own personal assessment of how your organization is doing and that can be a great starting point.

Principle #3:  Alignment [17:30]

I am going to dive now into the third principle, which is alignment.  This is one of the most difficult principles to get working well in an organization.  I noticed on our early poll question that silos tended to be a big challenge and alignment is all about breaking down those silos.

So as we think about alignment, there are a couple of core principles.  One is coming together around how you do improvement; second, aligning incentives; and third and perhaps the most challenging is balancing polarities.

Step 5:  Adopt a Consistent Improvement Methodology [18:09]

So let us talk first about a consistent improvement methodology.  Oftentimes, we see almost religious battles over what improvement methodology should be used, and we see the Six Sigma Camp, the PDSA Cycle Camp, the Toyota Production System Camp, the Lean Camp, all of these different methodologies.  Well they all kind of have their roots in Deming and they all have the same underlying core principles.  And the core important concept here is to have a common language to talk about improvement work and be able to communicate the root cause problems, be able to understand what are the deep challenges to getting to improving outcomes for patients in the areas we are working on.  It is not really as important what the methodology is.  It is that you have a standard methodology that you can communicate through and that you have a systematic way of doing it.  So that is the core principle.  Many of the team may need to be trained in a new methodology once a standard is determined and making sure that the entire team from the top level executives down to frontline workers understands that improvement methodology is really important.

Step 6:  Align Incentives [19:37]

The second key principle is aligning incentives, and this includes not just goals for clinical or operational improvement but also financial bonuses and financial incentives, and having specific goals around clinical quality, financial objectives, operational or patient experience objectives, research objectives, and having those (20:05) can help to break down the silos that often exists.

One of the things back in the days when I was at Intermountain that we did and it felt like this was a huge change was we changed a lot of the administrators.  And David, maybe you remember when this happened, but we changed the administrators’ bonus plans from strictly being based on their financial performance to having clinical and patient experience goals.  I do not know.  Maybe you could just comment on what that change was like and what impact they had.

[David Grauer]

No, that is true.  And in fact, people were often stunned that the administrators’ compensation was based on measures for which he had, in my case, no expertise.  So I have no clinical expertise yet.  I was rewarded or penalized based on the clinical outcomes that we provided at the hospital, the patient experience, and so forth and it helped to align all of us around the common goals, which were in those areas of safety and experience and clinical outcomes, as well as financial.  So this is a big shift and this requires maybe members of the C suite to come in together to design those objectives and those compensation packages that will actually promote alignment and promote working together across departmental or row lines.  And so, this is a big change.  But, it can be very powerful.

Just a quick story.  When we have started Health Catalyst about eight years ago, Steve Barlow and I, we have been in the healthcare delivery system for many many years and we hated the way that vendors interacted with us.  We could smell a commission sales person a mile away and it bugged us.  We hated it because it was all about them hitting their quarterly number.  And so, when we started Health Catalyst and after the first three or four years, we finally had to hire our first salesperson, we wanted a different kind of compensation structure.  We did not want coin-operated salespeople because we had experienced how bad in experience that could be trying to work with someone who just focused on the number and we did not feel they really care about us as a delivery system.

A Story of Alignment Success: [22:51]

So we came up with an aligned incentive package for everybody at Health Catalyst.  And so, this is our – I will just share our bonus structure.  It is based on three aligned incentives.  And depending on your role, you may have less or more influence on a particular, one of these areas, but everybody’s bonus is exactly the same.  So a third of everyone’s bonus is based on our customers actually achieving outcomes improvement.  Whether that’s clinical or financial outcomes, it is helping them to achieve a measurable improvement in outcome.  So we track that.  We have a target number of outcomes improvement that we are going for each quarter and a third of the sales team, a third of the financial team.  Everyone’s bonus is based, a third on that metric.  A third of everyone’s bonus is based on staying within our operating budget and meeting the timelines that we commit to our customers.  And then finally a third of our bonus is based on us hitting our overall global sales targets as a company.  Well what this has done is it is amazing how just this bonus structure has changed a typical behavior.  So now, a salesperson is extremely interested in making sure that the contract that is written is fair, that its timelines are realistic, and that we could actually achieve an improvement in outcomes.

In the same way, a developing team member is really motivated to go help the sales team maybe with a demo to show in-depth vision of the product because their bonus is also based on the whole company hitting our sales target.  And it had this really positive effect of creating breaking down boundaries and are really creating a team kind of feeling across the entire organization.  So, we really believe this principle is important.  We have used this structure internally of having a single bonus structure based on core principles that we believe apply to everybody and it is how you jump back.

Indiana Jones and the Last Crusade [25:05]

Alright.  Now, I wanted at this point to show a clip of one of my favorite movies, Indiana Jones and the Last Crusade, but I have been informed that video clips and webinars tend to always have technical problems.  So I am just going to describe this to you.  So, many of you have probably seen Indiana Jones and the Last Crusade, and towards the end of the film, Indiana Jones has to go through this labyrinth of deadly traps in order to get to the Holy Grail and his father has been shot and they are yelling to Indiana to hurry, you have got to get the Holy Grail so that the healing powers of this mystical cup and water can heal the deadly wound that has been inflicted on his father.  And so, he comes to this point and it is a leap of faith.  There is this huge castle and it looks like there is no bridge across this.  And so, he has to take a step out into what looks like nothing.  He feels like he is going to fall off into this deep cavern.  And in reality, there is kind of this invisible bridge and he is able to then walk across this invisible bridge, which is just camouflaged that looks just like the walls of the deep cavern and he makes it across safely and then he throws some pebbles and dirt back over so you can see the invisible bridge and it is no longer invisible.  Well, this is very much like a polarity.

Problem or Polarity? [26:46]

And let me describe a polarity.  A lot of us confuse problems with polarities.  Now, a problem is much much easier than a polarity.  A problem is not ongoing, it has an endpoint, it is solvable, it is kind of like what is the solution here, figure out what the solution is and apply it.  A polarity is quite different.  A polarity is something that you have to manage over time.  It is ongoing.  There is no right answer.  And it is usually a balance between two good things.  And if you get too far extreme on either (27:24) can be bad.  And so, what you are trying to do is do both of the things simultaneously and kind of stay in the middle.

Polarity Example:  Data Protection AND Data Sharing [27:33]

So the analogy I want to draw is it is like this invisible bridge that Indiana Jones had to walk across.  And if he kind of geared to the right or the left, he would fall into the cavern, but if he stays balanced in the middle of that bridge, that will be a good thing and he would make it across.

So, let me give you an example of a polarity.  Data protection AND data sharing.  So if you think about data protection, some symptoms of falling off a cliff and going to the extreme would be your IT controls the final sign-off on all data access.  And so, it takes six months to get someone who has legitimate need for the access, the ability to actually log into an application with analytical capabilities and get access and be able to see that information.  Or some of those requests just get denied and it is all about I have got to protect the data.  So if that goes too far from the extreme, you are limiting your ability to improve outcomes because the right people are not getting access to the data.

Now, however, on the other extreme, if you are so much about data sharing, that you do not put safeguards in place, that you do not have a process for legitimately granting access, you could end up with a data breach.  Huge privacy issues that could bring your entire company down.  Or you could have inappropriate use of the data.  And so, that extreme is also bad.  So if you have either extreme data protection or data sharing, you could fall off into this (29:14), fall off this bridge into one of either side of the cliff.

Now, what is the evidence of a balanced approach?  While you have an appropriate and secure process for granting access and auditing if that access was appropriate, you would also have the ability to use data for improvement and you would be able to get to that data quickly so that you could make improvement decisions.  So, streamlined access process, consistent auditing, the appropriate use of data, and big data stewards.  So, clinicians or operation personnel would be the ones granting the access.  So, this is a great example of a polarity and one that we see people struggle with quite a bit.  So, let us talk a bit about the principle of managing these polarities.

Step 7:  Keep Polarities in Balance [30:12]

So the key is to keep polarities in balance.  Now, there are a lot of polarities that you will need to manage.  And so, you do not want to tackle all the polarities at once but identify your top five polarities that your organization struggles with and put some policies and processes around managing those polarities, so that you keep them in balance.  Similar to the example I gave with data perfection versus data sharing, you could have policies around what is a reasonable amount of time for the access to be granted, who grants that access, who has the stewardship to remove that access once a project is done, or is that continual access because of their permanent role.  Those are all things you can define with policies.  Now, let me just mention here that oftentimes people get started on data governance with these types of polarities at the problem they are trying to solve but they do not think about them as polarities.  They think about them just as one side of the polarity.  And what happens in those cases is you create the extreme policy that serves one of the good principles but ignores the other.  And so, data governance, outside of the context of the improvement governance, can become very problematic and frustrate the improvement efforts.  So, we are not going to talk in detail about data governance today but many of the data governance principles are polarities that need to be managed, but they need to be managed in the context of overall improvement governance because any analytic system that you are creating, the focus of it is to improve outcomes for your patients.  And if you apply rigorous policy for data governance outside the context of improvement governance, you will often be falling off the cliff into the deep cavern that Indiana Jones did not fall off of because you are not doing it in context.  So, find those top five polarities that are challenging for your organization and manage those polarities.

So I want to go and ask to show you some examples of some polarities and then we are going to have a poll question here to see which polarities your organization is struggling with the most.

Polarities Examples [32:43]

So here are just a few governance polarities that we see often as people struggle with both improvement governance and data governance, and then there are a lot of other polarities in healthcare.  So, you can see there is just a few data protection and data sharing (that is the example I gave), financial performance and improved care delivery, information transparency versus information privacy, data accuracy versus timely decision making, data for learning versus data for research, clinician and patient decision making.  You could see there is a whole lot of polarities and I just listed here.  I will not read through all of them.  What we have done is on this next poll question, we have put some of the most common polarities.

Poll Question #2:  What are the hardest 3 polarities to manage in your organization?  (check 3) [33:35]

So we will open this poll question up and what I would like you to do is identify which of the three polarities that your organization struggles with the most of these – and again, this is just a list of polarity challenges we see commonly.  So, data protection and data sharing, financial performance and improved care delivery, data accuracy versus timely decision making, data for learning versus data for research, spreading and sustaining improvements versus promoting new improvements, organizational goals and payer incentives, regulatory metrics and metrics that most correlate outcomes improvement.

So, Tyler, let us open up the poll and we will see how our audience rate these different polarities.  Which of the top three that you are struggling with at your organization.

[Tyler Morgan]

Well thank you, Tom.  We have the poll up right now.  And we would like to remind everyone, as you are filling this out, you can check up to three definitely.  Also, we would like to remind everyone, you can type in your questions and comments in the chat pane of your control panel.  A lot of the response is coming in.  let us take a look and see what we have got.

Poll Results [34:51]

[Tom Burton]

Very interesting.  So, a lot around financial and clinical outcomes, as well as learning data versus research data.  Okay.  Interesting.

I think a lot of these, everyone struggles with.  And so, coming up with policies around keeping them in balance is a real key.

Principle Review:  Alignment [35:17]

[David Grauer]

If I could just add, Tom.  I think the concept of being able to do both here is critical.  And when you think about, one of the highest going on here is the financial and clinical outcomes.  In the healthcare industry, when we think about how do you improve quality for years, the thinking was in order to improve quality, you had to spend more and there had been so many studies now that have shown really better quality is actually lower costs and we really can do both.  You can get higher quality and reduce cost and that is something we are really trying to work with clients across the country to try to facilitate.  And one of my favorite examples actually is in nursing, and so, the clinical folks on the line, and the argument was for a long time in order to get better patient satisfaction and patient engagement, you needed more nursing resource.  And that is not always the case.  You can actually get appropriate utilization of resources by driving out wastes and processes and improving things for the nurses who are providing care and improve patient outcomes and patient experience and patient satisfaction.  So it is this concept of doing both on both sides of the polarity.

[Tom Burton]

Yes.  Both and instead of either or.  Thanks, David.

So, just to review this principle of alignment, you have got to get aligned.  That includes aligning around the consistent improvement methodology, it includes aligning financial incentives and other incentives, and it includes balancing polarities.  So a core principle in outcomes improvement governance is alignment.

Principle #4: Focus [36:56]

The final principle we want to cover today is focus.  Practice disciplined decision-making to prioritize, fund, organize, and sustain improvements.  This is perhaps the hardest thing to do.  As we work with organizations, we will typically start by focusing on just one or two.  And inevitably, when we have incredible success in those first couple of areas, someone on the C level would say, well, let us do 30 of these next quarter.  And it is just not possible.  We cannot spread our resources that thinly.  It is much better to do some significant improvements deeply than to spread everybody really thinly and we make minimal progress in every area.

Step 8:  Analyze Opportunities and Determine Priorities [37:49]

So, how do you do that?  How do you decide which areas to put a significant amount of focus?  Well the first is to analyze the opportunities and determine where can we get the biggest bang for the buck.  It takes about the same amount of effort to improve a small process versus a large process.  So one of the things that we recommend doing is to keep process analysis.  Look at the variation in all of your processes clinically, operationally and find the large processes that have a lot of variation.  Those are probably your biggest opportunity areas.

Step 9:  Allocate Resources [38:29]

Next, you want to allocate resources to those large processes with a lot of variation and make it real.  Resources make it real.  When you assign people to go and work on that and form deep teams that have analytics team members, clinical and operational team members, financial team members, it becomes a focus for the organization.  It does not seem real until you have taken other things off of people’s place and ask them to focus on a specific improvement area.

Step 10:  Establish Prioritized Teams [39:01]

The third is establishing these teams.  Now, these teams should be in our disciplinary and there are multiple teams at which improvement should be established, and these map back to the teams that David covered in the stakeholder section.  So, you will want a leadership team, you will want guidance teams, you will want innovation or workgroups that come up with the improvements, and then you have got implementation teams that will spread them across the organization.  Several of the ways that we have seen to operationalize that is for these teams that are deliberately organized and then continuous.  They have daily cuddles or standups.  They have weekly iteration planning meetings where they are focused on how we can improve care this week.  They have monthly adoption meetings where they talk about the next intervention that has been designed, how are you going to roll that out to all the clinics, all the units.  And finally, quarterly guidance team meetings.

So what you are doing is you are systematizing improvement work.  You are making it part of your culture and you have a governance structure in place that supports ongoing improvement work.  We want to establish continuous improvement teams that do not ever run out of things to improve.  Some of the teams that were established at Intermountain have now been going for 20 years and they have not run out of things to improve.  And so, it is a commitment to invest in continuous improvement and continuous learning.

Step 11:  Extend and Sustain Improvement [40:48]

And the final step is extending and sustaining the improvements.  Oftentimes, we see organizations have a project mentality where they got written up by CMS on some core measure.  And so, they form a SWAT team to go in and work on that particular bad score they got.  And so, a team forms, they go work on it, they improve it, and then boom! the team dissipates and goes and works on the next burning platform issue.  Well, the challenge with that is you do not sustain the games.  You do not have the ability to continually measure and monitor the new improved process and you do not have an automated way of measuring that.  And so, what happens is as the team moves on and focuses on something else, you will write back to the old habits and we have seen that time and time again where it is challenging to sustain the gains.  So what you want to do is establish a consistent team that will own that particular improvement area long term.  Now, it is not a dedicated team.  It may just be a portion of many people’s time but it is a consistent team over time.  And so, you adopt and then sustain those gains, sustain those improvements.

So, I will turn it now to David for a story about how important this last key area and principle is on focus.

A Story of Focus [42:25]

[David Grauer]

Thank you.  So, Tom actually cued this one up perfectly and I think the example or the story that I want to share is a common one.  We have seen it many times and I have actually experienced and it is where a client gives improved outcomes on a very critical measure, and let us say CLABSI, Central Line Associated Bloodstream Infections, or CAUTI.  There are lots of these where we have seen it happened.  But they lose the game because they fail to focus or they end up having competing priorities.  And what we want to encourage you to do is to think long term and this is where the extending and sustaining step that Tom just described comes in.  It is important to be thinking about the next priority and to be lining up the resources and creating the skills within your organization to continue this.  I mean this is not the one project and then done mentality, as Tom suggested.  You want to be planning for the next initiative in your governance committee.  So as you identify one and you work on it and you begin to make progress, you should be preparing for the next, training your teams, creating the resources, and the gains that you get from improvement project #1 can allow you to invest in improvement project #2 and so on and so on, and what you do is you create not only a culture of continuous improvement but you create a resourcing and an investment approach that allows you to stay focused.  But before you actually move on, actually you do not ever really move on because what you want to make sure you are doing is building into the governance process the ability to monitor and measure so that you do not lose that focus, you do not lose that game that you achieved as you move to the next effort because these have to be additive, not unique improvement processes.

Poll Question #1 – Revisited [44:16]

So, I want to take you back not to redo this poll but only to think about this.  This slide has the same symptoms that Tom opens with.  We simply categorized them here along the lines of the four principles that we have just reviewed with you and I hope that it is evident that each of these symptoms falls pretty comfortably within one of the principles that we have just reviewed and the purpose of this is to draw that connection and to be thinking about, okay, where can you or where do you need to focus as an organization going forward.

Poll Question #3 [44:52]

Which leads us actually to our last poll question and it is, as you think about each of these principles and all of the steps that we have reviewed with you, where do you think your greatest opportunity is, and as you leave this and go back and think about what do you want to do next, where do you think the greatest opportunity is?

[Tyler Morgan]

Alright.  Well, we have got the poll question up.  You can check all that apply.  Which of these four principles do you feel your organization needs to improve?  Stakeholder engagement, shared understanding, alignment, or focus?

While we leave this up to give everyone a chance to respond, we have actually had quite a few requests for the link to the outcomes readiness assessment that we have on our website, and we will be sure to add that link to the email that we send out, along with the recording and the slides as well.  So we will make sure that everyone gets that link today.

Poll Results [45:44]

So as we look, it looks like alignment and focus in particular seem to be leading back.  So those are tough tough principles that we see a lot of organizations struggle, especially with alignment but you can achieve alignment as you follow the principles we have outlined today.

Lessons Learned [46:09]

[David Grauer]

So I think actually alignment is one of the most difficult.  I mean as we have talked to clients, they all understand conceptually and philosophically the importance of aligning incentives, as Tom described.  But actually moving an organization, particularly a large organization, to a single set of aligned incentives takes time and we recognize that and I thin in my experience, just looking at the results, alignment and focus, I think in my experience, focus is probably the area where I had struggled the most, staying focused and sustaining and holding the games that we have achieved is probably where I have struggled the most.

So we hope that these 4 principles and the 11 steps that we shared with you have been enlightening and have stimulated some thinking and perhaps some action for each of you in your organizations and our hope is that as you focus on these, you can improve and achieve the success and outcomes improvement that you hope.  We believe that everybody can no matter how dysfunctional the organization.

Governance Handbook [47:17]

And one tool that we have produced and published is a handbook, the Governance Handbook, that outlines all of the principles and steps that goes into much greater detail than we did today on this webinar and this is available to anybody who requested.  I will let Tyler explain how you can get one but this is a resource that we have produced and we have been sharing that has been in demand with our clients.  So we are happy to make it available.

[Tyler Morgan]

As a matter of fact, David, we did create one last poll question for everyone.

Poll Question

Would you like to have someone from Health Catalyst reach out to share with you the governance handbook? [47:50]

Would you like to have someone from Health Catalyst reach out to share with you the Governance Handbook.  Simply yes or no.

So we will leave this up to give everyone a chance to respond.  And while they are responding, we can actually go ahead and move it as time for our questions and answers time so we can move right into some of our questions.


The very first question that we have, I believe when we were talking about that, I think the question is are you saying here that the C suite is the team?

[David Grauer]

You know, it is a great question.  I do not think in all cases it should be the C suite.  I think depending on the size of the organization and the complexity of the organization. I  think in a smaller less complex organization, that may in fact be the executive governance team, but in a large organization, I think you need to think a little bit deeper as you think about the levels of engagement and the different teams and you incorporate some people with some very specific on the ground domain, expertise as well.  So I think my answer is it depends on the size and complexity of the organization.

[Tom Burton]

Yes, I would agree with that, David, and I think the key is to have the right stakeholders represented as you are thinking about outcomes improvement.  And so, there are clinical outcomes we are trying to improve, there are financial outcomes that we are trying to improve, there are operational outcomes and patient experience outcomes we are trying to improve, and then there is the technical infrastructure that supports all of those.

So, having representatives in those key areas is critical.  Now, not always it is at a C level person that is in charge of one of those areas.  And so, you may have a member of that governance team that is a vice president or a senior vice president, not a C suite person.  So it is more a representation at the highest level possible of those core areas – clinical, operational, financial, experience, and technical.

[David Grauer]

And I might add one other point.  We often see facilitator roles on that governance committee.  They may not be a C suite person but they may be a vice president of analytics or process improvement or system improvement and they had tremendous expertise and facilitation to the governance committee as well.  So you might think about adding somebody like that.

[Tom Burton]

So I see another question here, how do you apply these principles in a health system that is spread across a wide geography, and this can be a challenge.  When travel and face-to-face is difficult, these principles may be more challenging to apply.  Some of the ways, and we do have some of our clients that are very spread out as far as the geography goes, the principles still apply but sometimes there may be some added layers.  You may have a regional layer where teams come together.  And you may implement some of these at a mid-layer or a local layer, but then still have it roll up to the overarching layer.  Now, that typically may take a little longer to establish but we have seen it successfully apply across a large geography.

[David Grauer]

Agreed.  And the challenge is if we are working with a system that has nine different regions spread across several states, if we only had a centralized body that try to govern all the processes, we would be missing out on some of the unique organizational realities that occur at each hospital.  I mean multiple hospitals.  And so, as Tom said, best to have some regional teams with some local representatives as well that ultimately feed in and inform an executive level.

[Tyler Morgan]

Great.  Next question is, how can a small and mid-size health system avoid being overwhelmed by this.  They lack human and financial resources, unable to devote enough time due to other pressing demands.

[Tom Burton]

So this is a great question.  The small and mid-size systems may not be able to dedicate specific skilled resources to go after this.  I think the principles have to be adopted in those cases.  And so, you may have some people wearing multiple hats.  So, we have some of our customers that are a single small regional hospital in a rural location.  However, they still have the same challenges.  There are still silos even in a small hospital.  There are still misaligned incentives.  And so, you can apply the principles that adopt it and maybe you do not have every single layer of that executive domain adoption and innovation.  Some of those layers may be combined but they kind of switch hats or switch roles and play dual roles.  So they may be doing the root cause analysis on what needs to be improved and they may also be the one implementing it throughout the (53:25) unit.  So we have seen that it scaled down as well as up.

[David Grauer]

I think the question speaks to the importance of prioritization at the governance level because in a smaller organization with fewer resources, it is really important to get an early win because if you get an early win, you can generate savings, you can generate momentum, you can then capitalize on that and use this investment philosophy that I talked about earlier.  If you get an early win because you have chosen well, you can then plan the next one and resource the next one.  And so, that speaks to the importance of picking and choosing wisely.

[Tom Burton]

We have another question here, how does Health Catalyst help customers align and execute on these principles?  That is a great question.  And it kind of goes back to why we started Health Catalyst in the first place.  Back when I was at Intermountain, I had the privilege of going through Brent James’ course on outcomes improvement, and I would hear from all sorts of people across the country coming to his course, well yeah, you can do this at Intermountain, you do not have as much competition here, you have great leaders like Brent James that promotes this deeply across the organization, and they would make excuses, like, well we could never do it back home.  And I just fundamentally did not believe that.

And so, we actually pitched the idea to Intermountain of, well, what if we form the department that got in the trenches with organizations on the ground and really try to help them implement what took us years and years to do it at Intermountain.  And ultimately, Intermountain declined building that internally, a consulting professional services organization as well as a technology organization, but Steve and I got pretty excited about that and that is why we have formed Health Catalyst.  And so, what we try to do is be in the trenches with our customers, helping them through these really challenging, applying these really challenging principles.  And so, we have a professional services team that works with executives that actually sits down, walks you through step by step as we try to implement these best practice principles.

It looks like we have time for maybe a couple more questions.  I do not know if we have the electronic version but we will find that out.  There is a question on is the governance handbook electronic.  I think we probably can have a PDF version of that available.  We will include that in the email.

[David Grauer]

In the email that we will send out and make sure we have all the available link or something there, if necessary.

[Tom Burton]


[David Grauer]

There is a comment here.  It is not actually a question, and I agree with it.  The comment is, “better outcomes should improve financial performances.  They are not polarities.”  And perhaps I misspoke.  We do believe higher quality actually reduces the cost and improves financial performance.  And so, those are not obvious polarities but there is tension always in a healthcare organization between outcomes improvement and cost and efficiency.  And so, I think the comment here is right but there is a tension that always exists if you think about, okay, where do we invest, how do we most appropriately use our clinical resources, and we do believe that improving quality does reduce cost.

[Tyler Morgan]

Okay.  It looks like we have time for one more question.  So it was mentioned that quarterly health outcomes objectives can be set to incentivize success.  Could you please provide any examples of such quarterly health outcomes objectives?

[Tom Burton]

Yeah.  So, and it is not always quarterly.  Sometimes it is annual.  Sometimes these improvements take longer, but…So for example, at Intermountain, each clinical program set an outcome goal of either reducing the cost of care or improving the quality of care and then everyone’s bonuses were tied to those improvements.  And they would track actually daily and weekly progress on those initiatives, but every single clinical program had a board goal.  And Intermountain has set a great example there of actually having board level goals that are tied to quality.

Prior to Dr. James and Dr. Burton promoting those, most of the measures were financial at the board level.  And so, we really recommend establishing some goals annually at a board level and then breaking those down into meaningful chunks quarterly.  So for example, you may work on different aspects, different process metrics that tie into the outcome metric.  So if you are working on heart failure readmissions, you may work on medication reconciliation one quarter and the next quarter you may work on making sure of a follow-up visit schedule.  Then the next quarter, you may work on making sure that they have got a good time to their primary care physician.  And so, those process metrics that you look at and focus on quarterly can then tie into an overall outcome metric at reducing readmissions or reducing the cost of care significantly.

I think we are out of time, Tyler.

[Tyler Morgan]

I think we are out of time.  There was a very quick question.  Is the Governance Handbook free?

[Tom Burton]

Yes.  Yes, it is.

[Tyler Morgan]

Okay.  I want to make sure we cover before we close.  Thanks, Tom.  Thank you, David.  Shortly after this webinar, you will receive an email with links to the recording of the webinar, the presentation slides, and the audio download, as well as a link to our outcomes readiness assessment.  Also, please look forward to the transcript notification we will send you once it is ready.

Thank You [59:31]

On behalf of Tom Burton and David Grauer, as well as the rest of us here at Health Catalyst, thank you for joining us today.  This webinar is now concluded.