Higher-value performance

Prominent hospital chief executives have called on their peers to endorse broad priorities for healthcare efficiency and effectiveness, invoking the framework of checklists promoted to catch clinical errors and improve quality of care.

“We are asking, we are pleading, we are challenging, calling out our fellow CEOs and senior leaders, saying these are things we should be doing in every organization,” said Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Health System and one of 11 executives who drafted the priorities as a checklist for high-value healthcare.

The authors touted the checklist, released last week as a discussion paper by the Institute of Medicine, as critical despite an approach that is looser than more detailed step-by-step checklists used by providers in clinical settings.

“In some ways, they represent more a credo of commitment than a simple checklist, but each checklist item is every bit as vital as the items on the checklists routinely used by pilots taking complicated aircraft into quickly changing conditions,” the discussion paper said.

The checklist includes evidence protocols, targeted services for resource-intensive patients, internal transparency, and board and executive support for effective and efficient medical care as among items critical to improving value.

Authors hope that by sharing their experiences, others could use the checklist to focus their efforts and accelerate the rate of progress, according to the report.

“I think all too often, over the past decade and more, we as an industry have been quick to point to factors outside of our control that have the healthcare system in the situation that it is,” Kaplan said. Common culprits include Medicare, Medicaid, healthcare's regulatory environment, a competitive marketplace and health plans.

“What I am saying is that there's things that we can do to change this for the better and create higher-value healthcare,” he said. “Rather than look outside for causes, let's look inside to for what we can do to make things better.”

The paper includes examples from the authors' organizations. Geisinger Health System saved $1.7 million once spent to pull patient charts by adopting healthcare information technology, the report said. The Cleveland Clinic saves $10,000 a month on laboratory tests after adding a “hard stop” for same-day duplicate tests in its physician ordering IT. HCA saved $68 million after adopting a standard bundle of evidence-based care for high-risk obstetric patients.

Dr. Robert Petzel, undersecretary for health at the U.S. Veterans Affairs Department, described the report's examples as powerful motivators for others seeking similar changes.

Examples, Petzel said, “are very powerful and much more powerful in many respects than talking in the abstract” about quality improvement.

The list addressed infrastructure, healthcare delivery and reliability and feedback in addition to what authors call “foundational elements,” such as board and executive support.

“The Checklist's 10 items reflect the strategies that, in our experiences and those of others, have proven effective and essential to improving quality and reducing costs,” the discussion paper said.

The authors' checklist does not target specific efforts to reduce individual services that “are often overused, unnecessary or otherwise wasteful,” according to the paper.

The group also chose to endorse common priorities, but opted not to dictate how to achieve those goals because every organization is different, said Dr. Brent James, executive director of the Intermountain Institute for Care Delivery Research. Each hospital will have its own culture, resources and organizational structure.

“We didn't want to over-prescribe,” he said. Local communities can devise strategies tailored to their needs.

Rather, the authors, who also include the undersecretary of health for CEOs of Kaiser Permanente, Partners HealthCare System and the Cleveland Clinic, hoped the checklist could help others avoid mistakes.

“We've learned in the school of hard knocks,” James said. “This is not just theory,” he said.

Kaplan said the group is also soliciting suggestions and ideas from other organizations that have experience to share. “We're inviting our colleagues to embrace the checklist and make it stronger,” he said.

The IOM is expected to release a report on building a learning healthcare system that will incorporate the checklist.

James said the paper invoked immediate interest, which he credits to a shift within healthcare to deliver higher-quality care at a lower cost.

“I think it's so timely,” James said. “It's hitting the tenor of the times.”