Shortly after becoming CEO of the Rehabilitation Institute of Chicago in 2006, Dr. Joanne Smith gathered her team of scientists, leaders and clinicians and challenged them to set the institution on a new path. It was a slightly unconventional move considering the institution was perennially ranked on various lists as the top rehabilitation hospital in the nation. Still, Smith said that the organization could not necessarily prove it was getting the right outcomes for patients. Flash forward 11 years. The newly branded Shirley Ryan AbilityLab opened the doors to its one-of-a-kind hospital in downtown Chicago in March. For the first time, clinicians and researchers work side-by-side addressing patient needs and studying new techniques to get them moving again. Smith talked with Modern Healthcare Managing Editor Matthew Weinstock about the AbilityLab's unique approach to patient care. The following is an edited transcript.
Modern Healthcare: What was the thought behind putting researchers and clinicians together?
Dr. Joanne Smith: We chose the word "ability" 10 years ago when nobody else was using it because it was a softer spin on disability; it was more positive for the patient, it was individual.
We created a new vision and what we are going after: measuring ourselves by how many people we attract and how much ability we create. And when I say people, I don't just mean patients, but also scientists and managers and great thinkers and supporters and nurses and clinicians and board members and philanthropists and governments and legislative people. We are creating something that nobody has ever done and that's that unique outcome.
Ability is our code word for recovery. It's even our code word for cure. Patients would come to me and say, "You know, Dr. Smith I am paralyzed, but if I could just move my thumb, I know that with today's technology, the world's my oyster. I could live by myself. I could communicate by myself. Just work on moving my thumb."
We didn't wait for this new building; the building was only a tool in our mind at that point in time. But we shifted our behaviors. We were going to embed science—all applied and human subject science—with our patients and our clinicians because we felt that if we surrounded the patient with scientists and clinicians, we would get that collision of thought and awareness and observation that would . . . raise all boats.
When we got into the design of the building, I had this word, this vision of advancing human ability, then I had this new behavioral motto where we were going to embed science around the clinicians and, in fact, the cultures were going to collide.
MH: What were the hurdles for clinicians and researchers to start working side-by-side? How did you address workflow and culture?
Smith: Two key things. Patients and clinicians and scientists needed front-stage time, which is where experiment and studies and observation and things could happen out in the open. And then they needed backstage time where they could think and analyze and quantify and design in a quieter, private space. So we designed the building to have flexibility for both.
When the architects came in, they started thinking about the patient experience because that's universal. I said, "I don't want you starting with patient experience."
They all looked at each other and said, "You don't care about the patient experience?"
"No, I care about the patient experience," I said, "but what patient wants to be in the hospital? You can give them nice bed linens and pretty ceilings and concierge support and good food, but none of us want to be in the hospital. Why are you there? You are there to get an outcome done and get out. So, I want you to design the outcome first and the outcome is the integration of science with clinical care . . . where patients are going to get more ability. And then, once we figured that out in the design, then we will back into a good patient experience."
MH: How has that transition been for you to start to focus on outcomes?
Smith: Our hiring decisions are crucial right now. We need to fill this beautiful building with the minds and the skilled hands that are going to create those better outcomes. As we do that, we are placing bets with insurers and starting to create opportunities to do some experimental relationships with certain patient populations.
You might guess that some of our patients are not high-incidence in any one locale in the country. Let's take pediatrics for example. Say there are 30 bad brain injuries for kids, but only two may happen in Illinois. There is a model that we conceived that says, "We are the destination for those kids. There isn't another place that has the tools, equipment, the science and capability that we do. Let's work together on an experimental process to study how we can jointly take care of these kids, get a better outcome at a more efficient and effective cost, and in the long run, a better outcome, less suffering and more ability for the patient."
MH: Who are you talking to?
Smith: It's early stage, so I can't say just yet. But, there is interest, and there is interest from workers' compensation companies and reinsurance companies, because those companies have the most catastrophic cases with the most lifetime risk. So now you take an insurance company with a lifetime risk and they've got a bad burn or a spinal cord injury or bad brain injury. They fly that patient across the country. They know that short-term gains lead to long-term gains resulting in lower overall life-care costs for the patient and, ultimately, a better outcome.
MH: Are you beginning to define your own outcomes metrics?
Smith: Yes, absolutely. The outcomes endeavor has two parts to it, one of which is called the ability quotient, which is another word for the entire database of metrics that will look at a patient from a functional standpoint, whether it be cognition, speech, balance, eating, swallowing, whatever, using validated tools, but only those that are statistically important to define the patient's progress and predicting the outcome.
The second part is a database we've created that includes every patient we have touched, both past and current—using the ability quotient for current patients. And then being able to query past patients, even though they are not here anymore, on similar metrics or similar points in time to understand patient progress.
We believe that we can actually predict where a patient should be with a certain injury or certain diagnosis at a certain point in time. And if they are not, understand why and understand what intervention we need to do in order to get them back on the curve. And then, soon after that, as we begin to predict where they should be, we are going to be able to predict what the cost is.
MH: How far away are you from being able to predict cost?
Smith: The cost piece is still further out, but predicting their progress is happening right now.
What I am looking for upfront is for progressive insurers to say, "Let's try it out together and learn and then share the benefits." Right now, I can't say I am going to go fully at risk because there is too much variability, particularly with some of the catastrophic cases that we care for, which by the way, are most expensive for them. What we are looking to do is create a model with payers and take a defined number of these patients, study them on this model, study where the cost troughs and peaks are, look at how we can intervene and then be able to apply that on a broader basis.
MH: How vital will this database be as you compete with skilled-nursing facilities?
Smith: Crucial. Our hypothesis right now is that the only thing that they are effective at competition on is cost and with the strata of the population that may be very geriatric with basic stroke and/or basic neurological conditions, and also, simple joint replacements.
Right now SNFs are doing well on those populations and saying, "Give us some of those harder populations." But it is all based on cost, and shame on us in rehabilitation because we haven't proven that our outcomes are better. We are, for the entire field, looking to prove that the outcomes are better.
MH: Going beyond that, if you can flash-forward a few years, what mark are you hoping the AbilityLab leaves?
Smith: Regrettably, rehabilitation has lost its power and its mojo in the domain of medicine. And, in part, it is because previously there was no science, and because acute-care hospitals were really focused on cure and when they couldn't cure, they dismiss patients to lower levels of care.
So one of the things I am hoping we have already done is carving almost a new space of medicine. If I look at what Netflix has done to TV, it's spun it on its head. It is not TV, it is an entirely different form of accessing entertainment.
We used to be a rehabilitation organization. I think we have now become something that is not even in that space any more. It is somewhere between acute care and step-down care. And with the science that we are harnessing in the clinical domain, the patients who can't be "cured" in the acute-care world actually have great hope and opportunity for a cure at this level.
So, I hope we are raising all boats. I believe we are carving a new niche in medicine and we can raise the standard for patients with stroke and tumors and injuries of the brain, spinal cord and nervous system, across the world.
