Since the late 1990s, with a base of physician leaders firmly in place among its member hospitals, VHA has proselytized for clinical quality improvement initiatives.
"Three or four years ago, we would have gotten blank stares" when mentioning the need for quality improvement, says Stuart Baker, M.D., executive vice president at VHA. "Now there is uniform acceptance. I've seen this sea change myself in just a few years, and that's encouraging."
Today, about 97% of the 471 shareholder and partner organizations that make up VHA participate in the Irving, Texas-based cooperative's clinical quality programs.
David Nash, M.D., director of the health policy office at the Jefferson Medical College of Thomas Jefferson University in Philadelphia, says the American College of Physician Executives, of which he is a member, "owns" the concept of physician business leadership.
But "VHA has adopted and implemented this strategy," Nash says.
"To be successful at the national level, an organization needs to promote physician leadership and support it appropriately," Nash says. "VHA, to their credit, has done that. VHA knows that good hospital-physician relationships are linked to better quality."
Relieving patient distrust
VHA supports its members' clinical improvement efforts with the Center for Research and Innovation, its in-house research arm that identifies and analyzes issues of concern for its member hospitals.
Their latest research points to an increase in patients' distrust of healthcare providers.
"This is a trend we've been seeing for the last four or five years" as the population has aged, says Ken Smithson, M.D., vice president for integration services at VHA. "Baby boomers are demanding more and want to be part of the decision process."
He says a VHA focus group found that 96% of those born between 1946 and 1964 are "very much aware of the medical error issue."
According to Baker, the healthcare system is disjointed. He says there needs to be more linkage between hospitals, physicians and consumers-a group that includes patients and their families.
One way VHA seeks to bring these disparate pieces together is through two technology ventures, LaurusHealth and HEALTHvision.
LaurusHealth is a consumer healthcare information Web portal as well as the publisher of consumer-centric content for the Web sites of 820 hospitals. HEALTHvision provides much of the technological infrastructure supporting LaurusHealth, including the operation of VHA hospital Web sites and online portals used by more than 15,000 physicians.
"Our strategic niche is to bring the clinical piece, the business side and consumer needs to kind of that `sweet spot,"' Baker says. "It's about the best care for the patient every day."
A little more than three years ago, VHA formally brought top hospital management in on quality improvement by forming the CEO Workgroup for Clinical Excellence-actually a number of workgroups, each concentrating on a specific clinical area, and open to others besides CEOs.
"These are collaborative groups that work over a period of three or four years," Smithson says.
Membership is controlled at around a dozen hospital executives per group "to maintain intimacy," Baker says. After the meetings, the leaders return to their own hospitals and team up with physician executives to implement the ideas they've discussed.
"Every time we work on one of these programs, we assemble an expert clinical panel that's primarily physician-driven," says Marc Edelman, vice president of the four-hospital Crozer-Keystone Health System, Upland, Pa., and a member of a CEO workgroup.
Crozer took home a national award for clinical effectiveness at the annual VHA Leadership Conference in Boston last month for its 2-year-old program in evidence-based medicine.
Current CEO workgroups are looking at adverse medical events, medical error prevention and infection reduction, areas now being emphasized by CMS and the Joint Commission on Accreditation of Healthcare Organizations.
"Why not be good at the things that you are going to have to report?" Baker says.
One part of a yearlong program of the CEO initiative on transforming intensive care units was pain management. The CEOs sought out data on clinical performance to communicate to physician leaders their desire to concentrate on this area.
"We found that many hospitals weren't even recording pain scores," says Smithson. "Starting to pay attention alone led to dramatic improvement in just a week."
VHA determined that following this and other protocols on treating patients in intensive care potentially can save 47 lives and $3.1 million per 1,000 ICU admissions at the hospitals it studied, Baker says.
"Two secrets (to a successful clinical improvement plan) are involving physicians and involving leaders," Baker says.
Even though the CEOs have ended their ICU focus, VHA leaders continue to monitor healthcare information technology and report their observations to members.
"We follow the vendors very closely to watch the efficacy of their products in our hospitals," Baker says.
For example, Smithson says physician leaders in the national office outside Dallas are tracking installations at VHA member hospitals of bar-coding technology for medication administration from Bridge Medical and the eICU virtual intensivist program offered by Baltimore-based vendor Visicu.
Community Hospitals, a five-hospital system in Indianapolis, worked with the CEO Workgroup for Clinical Excellence on the ICU program, but it also has taken advantage of its affiliation with VHA to network with other healthcare provider organizations it might not otherwise contact.
"We collaborate with other institutions around the country," says Glenn Bingle, M.D., Community Hospitals' senior vice president for medical affairs. "The docs get to talk with other docs whom they are not competing with."
When Community's physician leaders share strategies and stories with their counterparts in other markets, Community's staff performs better, Bingle says.
Involving physicians in quality planning has paid tangible dividends for the system, improving the care of diabetics and postoperative open-heart patients, two areas of disease management VHA has stressed, according to Bingle.
Community Hospitals also uses clinical quality data to develop standardized protocols to aid decisionmaking at the point of care, he says.
These programs, as well as current efforts at Community to adopt computerized physician order entry, bar coding and other technology to automate the clinical process, have firm roots in the VHA philosophy of empowering physicians to lead, Bingle says.
For Community, this empowerment goes back nearly 15 years, when the medical staff had a voluntary leadership that rotated annually and, thus, was ill-equipped to tackle long-term projects. One of them was a program to address "some surprises in the quality arena . . . issues of malpractice," recalls Bingle.
The Indianapolis system adopted a VHA model and gave Bingle more authority to act. He initiated a systematic review of each physician's claims history and incorporated it as part of the credentialing process. "Those initial (quality) problems resolved themselves over a couple of years," Bingle says.
According to Smithson, this demonstrates that healthcare organizations can indeed overcome the incentives not to provide quality-such as payments based on visits and procedures, not outcomes-that pollute the system today.
"Even in the face of this toxic environment, you can deliver quality care," Smithson says. "Times like these call for leadership."
We're interested in your feedback on this story. E-mail your opinions to [email protected] Comments will be reviewed and posted on ModernPhysician.com.