Trial and error: Learning from failure key to improving performance

When CEO Dr. Steve Narang arrived at Banner-University Medical Center Phoenix in 2013, the hospital was well-known for the way it cared for the most medically complex patients. But Narang found patient outcomes told a different story—one that did not reflect clinical excellence.

“We had a lot of silos,” Narang said. “We had the quality department siloed in one area, finance in another, we had operations, and then we had our physicians, and in the middle of this there’s the patient.”

 Narang said the hospital’s fragmented operations hindered care coordination and that negatively affected its quality and efficiency.

So in 2013 Banner formed “care transformation” teams that had data analysts and performance improvement experts working with clinicians to address three major issues: reducing patients’ length of stay, decreasing mortality rates, and lowering the average amount of supplies being used. 

“We didn’t go to our physicians and say, ‘Hey, we need to reduce our length of stay or cut costs,’ ” Narang said. Instead the hospital went to the physician heads of their various clinical units and asked them to use data to implement best practices based on patients’ diagnoses.

The physician leaders’ input is compared with best practices found in literature. New clinical pathways, which are followed by the rest of the clinical staff, then are added to the electronic health record system.

Narang said the process significantly reduced both the average length of stay and the overuse of resources over the past three years. That happened by focusing on the top 20% of DRGs that were responsible for 80% of longer stays.

Banner’s length-of-stay rate was 2,871 days better than the expected length of stay in 2018. The system saved $2.1 million.

“That number is never brought to the docs,” Narang said of the financial benefits. “The physicians there are just taking care of patients and trying to get the best practices there; and behind the scenes, we’re working with them to translate that into a financial and operational model that makes sense.”

Narang said Banner’s success comes from a yearslong process of trial and error that continues to this day. He said it’s important to develop and commit to a strategy and to be patient when it’s not producing immediate results.

“We have failed, we have failed quickly, and then we scaled the best practices,” Narang said. “And we continue to fail quickly, and then try to learn and scale.”

Establishing a long-term commitment to improving is a goal for many hospitals on the 2019 100 Top Hospitals list published by IBM Watson Health.

At Advocate Sherman Hospital in suburban Chicago, the road to becoming a 100 Top Hospital in 2018 and 2019 began around five years ago after the one-time independent healthcare provider joined what is now Advocate Aurora Health.

Sherman President Lisa Deering Dean said the hospital identified physician leaders who could monitor, train, coach and encourage clinicians to follow proper protocols and report potentially harmful events. The result has been a continued increase in reporting near misses, while actual adverse safety events have dropped by 85% over the past five years.

“It’s so easy to say ‘Just do this and we’re going to get where we want to go’—well that won’t work,” Deering Dean said.

Over the last year, Sherman significantly reduced its rate of hospital-acquired infections through a number of initiatives including holding daily audits of care units across the organization and replacing central-line dressings on patients every Wednesday. The hospital’s current ratio for HAIs is about 21% lower than the median in 2019 for the 100 Top Hospitals and about 37% lower than the average among hospitals not making the list.

“I would call it a disciplined process,” Deering Dean said. “We can’t cross our fingers and hope that everyone is going to do the right thing well because they won’t, and they don’t.”

Though Sherman had performed well on certain measures for years, Deering Dean doubted the hospital would have succeeded had it not joined Advocate.
 

“The reality is there’s power in scale,” she said. “When you’re an independent hospital and you have no sister hospital to call, you’re doing your best—but when we joined (then Advocate Health Care) suddenly we had nine other hospitals that we could learn from and share from, and they could learn from us.”

Advocate Aurora Health, formed in 2018, has 27 hospitals in Illinois and Wisconsin.

Like many of the 100 Top, Parkview Noble Hospital, a 31-bed, short-term acute-care center in Kendallville, Ind., implemented a strategy several years ago and only recently saw a return on investment. 

In 2015, the hospital charged a transitional care navigator with addressing post-operative care in an effort to reduce the hospital’s rate of 30-day readmissions.

One of the most common risks for many post-op recovering patients is falling. So when clinicians flag a patient for risk of falling, the navigator coordinates with a member of the emergency medical services department to visit a patient at home. That staffer identifies potential trip hazards and connects them to community services that can provide ramps or handrails.

The navigator also tracks clinical outcomes and helps clinical staff develop strategies for improvement.

“We had felt we were pretty hard-coated in that area and what we learned was that we needed some additional manpower,” said Gary Adkins, president of Parkview Noble. 

Adkins said the investment drove the hospital’s rapid five-year rate of improvement for 30-day readmissions, which ranked in the 63.4 percentile when compared with its peers nationally last year. Parkview had an even faster rate of improvement in the same period when it came to its performance on complications, which was ranked in the 98.1 percentile by the survey in 2018.

“I think we created better connectivity with our patients by helping them with their needs even past their discharge,” Adkins said.

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