Carlson: Bill, did the effort involve at some point any changes in workforce either adding people or taking away any people from their units?
Leaver: I would say, generally not. It (unclear) had people working more productively within their unit. I don't think that I know that I can point to any massive change in terms of how people were used.
Carlson: So the extra cost was just having people's time spent on a project.
Leaver: That's what I mean by the extra cost was really the investment and people's time to focus on this. So we would take staff nurses and they would be observers, observe other nurses. We had people from a system level who were supporting that effort. And we had a rollout. We're doing this hospital by hospital, and we would take staff nurses from one hospital that had been through it would go to the next hospital. As it was going to start the process, they would become the trainers for the new hospital that was going through the process. So it really became a very iterative process, but it does take time—and it's an investment of time.
Carlson: OK, great. Well, I think next we are going to hear from Peter Knox. Peter, take it away.
Knox: Really great work. Very interesting work. What I wanted to do was spend a little time talking about some work that I've done through the institute, specifically using Bellin, applied to health systems in the U.S. and Canada. So let me, though, speak to Bellin and how we've applied these concepts there. So at Bellin we have a vision that the people in our reach will be able to help extend the country. We have four strategies around that: Population health, passionate team and patient, family-driven care, and the fourth strategy is growth and prosperity. Focus in there but understand this nestles within a broader picture.
So in our growth and prosperity strategy, one component of that is efficiency and becoming more efficient. By that we really mean by driving and reducing waste and rework, and increasing efficiency. We measure that across the system in a measure that we call ‘Cost to produce.' So at the system level, we have a formula for rolling out the clinic visits, the outpatient visits and the hospital visits into a single cost to produce number, the cost to produce a patient discharge. But that becomes a single measure or indicator for the system. That, of course, can be cascaded down through each division, each team or microsystem, and each individual ultimately. W really working on two dimensions here with the work. We're working on the microsystem level and we're working on the continuum level. At the microsystem level, we have a process we call ‘quality and daily work,' and it's a process that is a 11-step process to help microsystem teams understand their work, their processes, and how their work is currently performing and to drive the improvement and the change at the microsystem level, and really try and capture all of our employees and engage them and improve their work. The 11 steps at the microsystem level start with ‘What is your purpose? How do you contribute to the broader mission of the organization, and who are your customers? What do they need from you and expect from you? What are the products you produce? What are the core processes? Who are your suppliers? And what you need from them to do your work? How are your processes performing? What do you need to be improving? How do you communicate to your customers, and how to do you continue to build a positive program within the microsystem.
So we're really focused on, again, the work of the microsystem and how they contribute to the bigger hole. In terms of this specific strategy, productivity, let me drill down to an example. So in our organization, related now to about 90% of every job category in our organization, we drilled down the cost-to-produce indicator to individual performance and productivity measures. So just as an example, let's take therapy. Our goal is 24 units of patient care per day. When we started this a couple of years ago, we had variation from 15 to 26 patient-care units per day. Our goal is 24. So we began the analyze the variation and try and understand the processes and systems and competencies of people, and now through a lot of work, a lot of good work, we now average 24, and we've got good processes and systems in place and have people who have helped people overcome some of the barriers that they can add in achieving that productivity. Now we have that in place for about 90% of the job categories across the system.
We're working at variation—internal variation—trying to understand our processes and systems and improve those processes and systems and help people be successful. So that's worked at the microsystem level. The second dimension of this is across the continuum. We're related to what Bill was talking about. We have organized ourselves into brands—or some might call it a service line—and then at the service line level, the brand level, we defined our individual products so that we're organized around brand or service lines drilled down to a product level. Brand leaders are responsible for accountable for performance of that product across the continuum, and they're responsible for the cost, quality and experiences of that product, so we're looking both upstream at prevention through an acute-care episode, rehab or therapy if it is necessary. We have fitness centers through fitness and then a relationship with individuals over time to get them back to a level of the quality of life that they're seeking. So an example of this might be our orthopedic sports medicine brand with our healthy joints product. Our brand leader's responsible for screened prevention, trying to prevent people from needing replacement. Through the surgical procedure, they'll visit with a specialist surgical procedure rehab and then the ongoing relationship with that individual. And they're responsible for cost, quality and experience. Part of that cost equation, they're responsible for finding variation and training for consistency and looking for that common platform across that product. So we're looking at two dimensions of this, and when we think about productivity—the microsystem and then the broad, what we call, connected personal experience across the continuum—our results over the past five years related to this strategy and efficiency we have year-over-year-over the past five years reduced our cost by 1% to 3% on an annual basis on same business. We doubled in size in the past five years, and that was natural growth with through market share gain. So while what was doubled in our business volume in revenue, we've also been able to take out 1% to 3% of our cost year-over-year. So those are the results we've achieved through this, and that was just a little bit of background, Joe, on what we're doing.
Carlson: Peter, how does staff respond when you introduce concepts like trying to measure cost to produce and units of patient care per day? Are folks receptive to that?
Knox: They are, and I think that, again this is balanced with a strategy around developing a passionate team. We've found that people are—many times in healthcare today—frustrated with their work in with their work environment, the inefficiency of their work, with being able to really focus on what's important in the work, the patients or someone who is serving the patients. So when we engage, were engaging in a dialog around, again, the quality of work. We're engaging in a conversation that's much broader in trying to involve people in trying to understand work and create better solutions to the work. So we found that people are very receptive to creating a better work environment for themselves. I think to some degree it's like anything: It's how you approach it. So we don't lead with that; it's a part of the conversation.
Carlson: Next we're going to hear from Dave Regan, and Dave, I imagine, as somebody who has represented workers at numerous hospitals across California and the West Coast—you've probably heard a number of these conversations over the years. What are your thoughts?
Regan: You know I think you're right that no matter where healthcare workers are employed these days, you know everybody sees the same basic forces in the industry. There's a concern about shrinking reimbursement payment, hence the need for providers to deliver care on fewer dollars per patient. All of this triggers the types of initiatives that the previous two speakers talked about.
But what I wanted to focus on up in my remarks was we are obviously a healthcare workers union, and we represent in the state of California 85,000 hospital workers, 60,000 home care workers and about 10,000 nursing home workers. And the largest group of our members are employed by Kaiser Permanente. We represent 45,000 Kaiser employees across the state of California, and what's interesting is: I think about Kaiser, and obviously Kaiser is a closed system and is really a unique model in American healthcare. But we have, along with Kaiser, worked over the past 10 years or so to really build a partnership that I think is unique and different and attempts to get at all of the kinds of issues and solutions that have been mentioned here this morning. But coming at it from a little bit of a different place, I think it's important for us in SEIU in Kaiser is we spend a lot of time thinking about the organizational culture and the organizational values that we want to create, and values and how that culture forms of the work that we do. And I'd just like to share a bit about that. Within the context of the partnership between us and Kaiser is the notion of something called a ‘value compass.' And it's a very simple idea, and I think for a lot of people its one of those things that it's easy to miss, but I think fundamental and I think makes a huge difference.
The idea is a compass with the four basic directions, and in the context of partnership we talk about best quality, best service, most affordable, and then the fourth basic component being the best place to work. And within the notion of those four things: best service, best quality, most affordable up and best place to work there's the basic point the patients are always at the center of everything that we do. So that's something that we created intentionally. It was done consciously and informs all of the work of the partnership, and on a parallel track we talk a lot about this inside the union. We are a healthcare workers union. We believe strongly that people who work in healthcare or have come to that field because they want to make people's lives better. It's something that's really a: calling for people.
There's lots of jobs out there in the world, but we think that healthcare workers are different, and we try to take that into account in the work that we do. And inside of our union we talk a lot about what's the kind of culture that we want to have, and for us we think about how do we build a culture of a workers' organization and one where their leadership is the core thing that we try to promote and develop among our members. And, in my mind, when we think about the Kaiser partnership with the set that comprise the coalition of unions those two sets of values and organizational cultures really do match up well and give us the opportunity to create a different kind of work environment. So that's the first thing.
The second thing I want to emphasize is to think about how you organize and structure the delivery of healthcare for a premier healthcare organization like Kaiser Permanente to say that we have four basic things that are going to drive our work and one of them is the desire to be the best place to work in the context of American healthcare. I think that's an important and it's hard to overstate what that really means. And, in particular, what Kaiser has made a conscious decision to do is that part of their strategy is to pay market-leading wages and benefits. And I think so much of the conversation that takes place in healthcare today because of the shrinking number of dollars, because of the fiscal situations that so many states find themselves in, it is not common to find a major employer that says you know what we really want to lead the industry in terms of compensation for workers and to do it in a way where that compensation is determined with through the process of collective bargaining. So both a best place to work, market-leading wages and benefits and then collective bargaining at the center of the whole endeavor, and this is something obviously that's developed over time. We've been at this for 10 or 12 years. Our members who work for Kaiser recognize that these are the best jobs in the healthcare industry not just in California, but maybe anywhere in America. There are hundreds of applications for every job opening that exists and beyond the basic compensation issues and the fact that this is a unionized workforce and all of that, there is also a really a requirement that the union be willing to conduct its work in a certain sort of way, and I think is counterintuitive to a lot of what many people would assume is normal in terms of a unionized workforce at this point in time. And let me just give a couple of examples: You know, first of all, all of the work that we do with Kaiser is based on interest-based processes. We spent a lot of time—you know, there's a whole vocabulary that goes along with it about how we do things in partnership with, whether it's bargaining our contracts, whether that's how we conduct a labor management meeting, how we solve problems to deal with care issues in the delivery of services—everything is done in partnership and is done in an interest-based way.
There is an expectation that the union is intimately involved in all of the decisionmaking, and the core of that is something that we call ‘unit-based teams.' And these are an outgrowth of, again, the collective bargaining process and something that's been built into the contracts that we have with Kaiser. And in fact is tied to compensation levels for employees across the organization, and after a number of years working with on these things what we're now finding and learning is that over half the Kaiser employees across the country and right now that would be about 80,000 union-represented employees participate in something called ‘unit-based teams.' These are self-determined, self-organizing groups of people to try to find better ways to do the things, better ways to deliver care, ways to make work more efficient, more productive, all of that. And it is something that is uneven across the organization but has clearly taken root and creates the sort of decentralized decision-making and decentralized initiative that I think is critical, particularly in large organizations. The other thing that's interesting is that the highest-functioning unit-based teams are in places where you find the most satisfied employees. So there is a direct relationship between the affinity that workers have for participating in the self-directed groups and their satisfaction with their job I think makes sense to most people. But we now have a whole body of evidence that demonstrates that.
And last thing I'd like to share is just in terms of concrete outgrowth of something where we think a lot about the culture and the things we do. You know, values really mean something. There's two things that I'd point to. One is what we've seen over the years is patient-satisfaction scores through the work of the partnership, through the work of unit-based teams. We get regular, concrete data about our patients more satisfied with the work we're doing and what we're finding is that as unit-based teams take root, that the patient-satisfaction scores are really beginning to grow are correcting what we saw as lapses or failures in terms of the way we delivered services, the way we engaged Kaiser members of, Kaiser customers who come for healthcare.
And the other thing that I've liked to point to, and I know this is something that the organization overall is very, very proud of is the ability within Kaiser is to really drive the incidence of sepsis down to dramatically low rates, and this is a story that's talked about all of the time inside the organization. A decade or so ago, if somebody acquired a sepsis infection at a Kaiser hospital, like many places in America, the prognosis was pretty bad if that was not detected early. And what I think we all know now is that if you can detect the onset of sepsis within the first hour, you could really make an enormous difference in terms of the outcome that that patient will experience. And this is one that literally can be the difference between life and death. Over the past set of years, there've been a whole set of work teams that figured out everything from what has to be available on any of nursing unit so that we can intervene in the most appropriate way inside of the first hour to make sure that we stop people from getting one of these infections. How do we get lab results turned around very quickly in ways that would have taken hours previously, and can now be done in 15 or 20 minutes? And again make a critical difference in terms of the outcomes that patients experience. So when you look over the past of six to eight years, what we've seen is a reduction by almost three-quarters of the sepsis infections across Kaiser, and a recognition both on the part of the employees and here in the union that the way we do our work together has really made a profound difference for how these types of things are done.
Over time as the drive is toward more integrated, more coordinated care, the way teams of people function is going to make a huge difference—not just on efficiency, not just on productivity—but I think into the future in terms of how providers get reimbursed and paid by different payers. We are trying to build a culture that puts a premium on all of those things that we know really help create a better system. So I'd just like to stop there, but that's a little bit about the experience we've had with Kaiser and the partnership in the 10 years or so we've been creating it in California.
Carlson: Dave, do you have specific metrics that are used to measure nurse productivity and other measures related to that?
Regan: You know there's all kinds of metrics that are used, and you know one of the things that Kaiser is explicit about and we agree with is a part of the culture of most affordable and best service is a culture of continuous improvement and data on everything. Whether it's the housekeeping department and how much of an area has to be cleaned in a given day to how long it takes for nurses or other caregivers to respond to certain types of situations. There really is an amazing amount of data, and it's enhanced because of the nature of Kaiser's model that because it's a unique model with a closed system you get a set of longitudinal data that might not be available in other settings, so all kinds of things and just about any question that you want to consider. There is always a desire to know what the facts are, what's the data we have, how do we assemble it and how to we think about it?
Carlson: Bill, a similar question for you: Is there a standard industry of wide measure of hospital productivity or are there new measures that are being considered or that Iowa Health is looking at?
Leaver: Well, I think we try to look at how many hours is required to produce what every unit of service we're measuring, and those are pretty standard. You're looking at that across—whether it's a nursing unit, your pharmacy or your radiology—but I think our focus, much to Dave's point about his experience at Kaiser is really now about shifting toward looking at a broader if the care of the patient over a long period of time. And so the care of the patient over the stay in the hospital, but eventually we're going to migrate to looking at how well did we take of our diabetics over the year and did we keep them out of expensive settings like hospitals and so forth? So I think our measure of productivity is going to shift a pretty dramatically over time and what we focus on will shift as well.
Knox: One of the things that I'm involved with at IHI. I'm lead faculty for a program called Impact in Cost and Quality, and we have 42 organizations right now that are engaged with us in a yearlong initiative to really reduce costs—improve quality and reduce costs. And when you asked the question: Is there a standard indicator, measure across healthcare today along productivity, I think the answer would be no. Even, I think, health systems and hospitals are in different places in terms of their capability to measure things and when we try to come up with a single indicator in this if initiative, it was a very difficult. In fact, we couldn't do it. That would be the goal much like we have consistent, standardized quality measures that are well-recognized, but we're not there yet.
Carlson: Bill, I've got another related question from the audience for you. Bill, did you do a review of all the clinical processes because you were switching to a new IT system, and what IT system are you switching to?
Leaver: Well, we're moving to Epic, and what we did is basically the work of standardizing these core processes. Again it was the same group of chief nurse executives and others who were involved in the design of and building the system care processes under Epic, and we really utilized those same agreements around standardized care processes. That's what we built and agreed that we would use the same workflow through the Epic system in all of our hospitals. So we've been able to, I think, the number I saw the other day was probably a standardized about 85% of the work flow across the system. And had we not gone through the standardization process, we would have not gotten anywhere close to that version Epic.
Carlson: You know, I wonder, Dave, what's your perspective on the question of moving to a new IT system? Do you find that as a thing that's received well, and does it make a difference?
Regan: From a worker's perspective? In some ways, I just think this is reality that information is critical and this is the way the world is heading. And there's tensions around it. Again, just to use Kaiser as a focal point, this is an organization that's made a huge investment in electronic medical records, the way information is collected and deployed, and I think there are obviously people where there's lots of anxiety around what does that mean for the future of work? So, on the one hand, I don't think that there's any question that being able to collect information and measure results is a hugely important thing. On the other hand, the notion of change is a given in the delivery of healthcare and frankly we're in the most fluid moment that we're ever going to be in I think in terms of the way the American healthcare system is set up.
There's lots of anxiety about: ‘Will I still have my job next year? Will it be the same way? What does it mean for my personal future?' And I think it begs a whole set of questions about how do you deal with a workforce that is not static and that is going to need, you know, a constantly evolving set of skills and attributes? And how do you manage those problems so that people don't feel like they're on the chopping blocks so that anxiety is minimized and not a constant at work? All of those are really important questions, and you have to tackle those as they come, but I don't think there's any question that the trend towards increasing utilization and sophistication of information technology is here to stay.
Leaver: I would just add to Dave's comment, and I think back to his earlier comments about culture, is we are going to change, we're going to have to change as the world evolves. And leaders need to manage that change, and be cognizant that IT is something that most people now use every day in their work, and they get used to and understand how to make it work to make themselves productive and get their work done. And when you change that, as Dave said, that creates anxiety, and leaders need to pay attention to that and continually work on: Do you have the right training? And are you doing just-in-time training? Are you creating enough support system so people can feel comfortable with migrating to a different way of doing things? We often get hung up on making a very technical decision about this system or that system is the right one. That, to me, really misses the point.
Carlson: And actually, I was going to ask Pete a question along those lines. What technologies have had the biggest impacts do you think on productivity? And, relatedly, what technologies of you think have had least impact on productivity?
Knox: I think we have some serious concerns about information technology and how people are approaching it. I sincerely believe that it needs to start with redesign. Work and care redesign. And then we looked at how IT is supporting that and can support it. We're in the process as well of moving to Epic. We're spending a lot of time upfront just, as I think I'm hearing Bill say, looking at process flow and value stream redesign, and looking at how Epic can support that. I think the biggest advantage we've seen to technology is giving the people the information they need when they need it to make decisions. And that's both the care team and the patient exam team and the family. And I think that as we engage more the patient and family being important members of the care team driving really the care processes, they need information as well when they need it.
So those are the things that we are seeing as the most beneficial, and how do we get the information people need when they need it to make decisions? But we're in the midst of a major transition to Epic now with, and that's going to take us a couple of years.
Carlson: Are there any technologies that you've worked with that have not had an impact like hoped?
Knox:Certainly. I think we've implemented technology without good process design, and driven a lot of frustration with people. I think that, just in my opinion, it's not the solution. It's a tool to support us. So yeah we've done some things certainly with good intention but didn't give people what they needed when they needed it to make decisions.
Carlson: Question from the audience, and I think I would direct this one to Bill, although I'm interested in everyone's thoughts on this. The question is: Do any of the panel speakers have experience with productivity vendors like Premier or Thomson or HMC?
Leaver: Earlier in my career, I've had experience with those. But, I'd tell you, in this job I don't spend a lot of time with that. That is work that others do, so I'm not in a very good position to comment, Joe. I hear good things about Premier, but that's anecdotal.
Carlson: Any thoughts on that Pete or Dave?
Knox: We have not had any experience with those vendors.
Regan: I have no experience with any of them.
Carlson: This is sort of a wide-open question here, but I think it sort of gets to the heart of at least part of a philosophical question: If cost was not a factor, do you think it's possible for healthcare providers to have a perfect record on quality? And I think we should start with Dave on that one.
Regan: I think the answer is no just because you're just dealing with a huge universe of people, and I think the optimum thing is how do you reduce bad outcomes in every area to a very low rate? (unclear) … And frankly, I think we all know that the way our healthcare system in this country is set up, we build in bad outcomes for millions of people. There's just no question about that. And I think the job from all of us is: How do we design a system that delivers needed and appropriate care far earlier to everybody. We have a system that is up incredibly back-loaded and overreliant on technology and dramatic interventions. And, somehow, I think what we have to find a way to create in this country is a different momentum towards integrated, coordinated care that puts a lot more emphasis on preventive care and lowers the bad outcomes. So, that's my view.
Leaver: I would echo that and add that I really think we need to focus more on population health and think about our patience over a long period of time, become much more patient-centered. I think Kaiser in a lot of ways has been able to do that because of their closed economy and their integration. And we certainly, in our system, are trying to move to tighter integration between our physicians, home care and hospitals, but with the focus of keeping the patient really in the most appropriate setting with the least intervention. So, that requires a very different way of looking at what you consider a best outcome or a good outcome, and what your job is. And I think that's really the huge shift in culture, perception and envision that we have to have for our healthcare system if we're going to be able to provide better value for people who pay the bill and for the people who ultimately receive it.
Knox: In reality we really want to disconnect the two: cost and quality. And I really don't think we can nor should. In fact, the way to reduce cost is to improve the quality and that's really classic Dr. (W. Edwards) Deming, and so it is the focus on quality and trying to reduce error … and (unclear) work improve the quality that will ultimately reduce costs. So I think the tendency still I see many times and healthcare is to try to disconnect the two and they cannot, in my opinion, be disconnected.
Carlson: Let's see here. Dave, we have a follow-up question: Could you expand a little bit on what you mean by building in bad outcomes? Can you elaborate on that?
Regan: Beyond the reach of any single provider or for any single system. I mean we have a system in this country where everybody knows that six chronic conditions drive three-quarters of healthcare spending in America. And those six conditions are largely preventable. And our system is not designed to reduce the incidence of those conditions. It's designed to—far too often—intervene at the back-end of those whether it's diabetes, hypertension, heart disease, depression, what have you. And I think from where I sit, there's more and more talk these days about how do you think about the concept of total health or what is it that presents itself in the healthcare system, but I just think we have a design problem and we have a method of financing healthcare in this country that frankly tolerates a huge amount of late, expensive, reactive healthcare, and that's not a criticism of any single system or any single—you know, we have a systemic problem that we simply haven't summoned the will to deal with.
And hopefully, I happen to believe in this fiscal environment that there may be an opportunity—and not necessarily at the federal level but at perhaps different state levels—to try and make some fundamental reforms that take cost out of the system because the only thing I believe that is going to reduce cost enough is the reduction of those chronic disease drivers. We are all nibbling at the edges unless we get at the heart of that problem, and that's something that's going to take years and years but I think we can begin on.
Carlson: Pete, do you think it's possible to get at those conditions without having a capitated system like Kaiser has?
Knox: Yes I do, and with our population health rate, I think we're going to have to change the boundaries of the systems. We are now extensively involved at the employer setting with on-site primary-care services. We're in the public school systems every day looking as partners with public schools on improving the health of kids and parents and staff. We're working with the seniors population.
So I think that the challenge is to really look at the boundaries of our traditional system to get upstream and really begin dealing with what we're talking about here. But I don't think it will work if we continue to send our established environments and wait for things to come to us. I think we really have to push upstream and push the boundaries upstream. I think it's possible—reimbursement certainly isn't there today to do that. And is it well-aligned? But that's where the work, I think, needs to go.
Carlson: OK, great. I think we're going to have to wrap up the discussion there. This has been the Modern Healthcare webcast “Staying Productive: Best practices for reducing operating costs without jeopardizing clinical or financial performance.” This is Joe Carlson with Modern Healthcare, and I'd like to thank our three panelists. They were Bill Leaver with Iowa Health, Peter Knox with Bellin Health and with the IHI, and Dave Regan with the SEIU-United Healthcare Workers West. Thanks, gentlemen.
May: This concludes today's discussion on productivity issues at healthcare provider organizations. For those who want to view the webcast again, all attendees will receive a follow-up email with a link to the recording of the webcast available on modernhealthcare.com/webcasts. All slides presented during the webcast are also available at that address. Thank you.