Top health systems focus on alignment of quality across facilities post-merger

As health systems get larger, quality leaders are faced with the tough task of making sure outcomes are similar no matter where a patient receives care. 

“Once you start adding more hospitals, it becomes very challenging to figure out how to align across the system,” said Ekta Punwani, leader of the 100 Top Hospitals Program at IBM Watson Health. “It’s not just about technology, it’s about strategies. How do you lead the organization? That is a newer challenge in healthcare.” 

Consolidation continues across the industry, including the recently announced proposed merger of Atrium Health, Wake Forest Baptist Health and Wake Forest University that would create a 49-hospital system. 

Mergers are usually touted by executives as a way to improve quality of care through expanded service lines and better efficiency, but there’s little research showing that actually happens. In fact, most literature illustrates that prices are lower and quality is better when there is more competition in the market.

Some of the organizations recognized this year on IBM Watson Health’s 15 Top Health Systems list for their better-than-average performance on certain CMS quality measures have also recently engaged in M&A activity. Four of the systems outlined strategies they have implemented to ensure quality of care is aligned across their operations, particularly exploring approaches when a new facility joins the organization and an entirely new entity is created post-merger.

When Avera Health in Sioux Falls, S.D., acquires a new facility, the organization is immediately presented with the system’s annual quality plan. This plan lays out Avera’s four main priorities for quality improvement for the year. It’s created at the system level with input from clinical leaders across the system and then approved by the board of directors.

The system, which has 34 hospitals, then distributes that action plan to each of the facilities. For new hospitals, it usually takes about a year until the plan is fully adopted, said Stacey Erickson, vice president of quality and data integration at Avera, which was recognized by IBM Watson for the first time as a top health system. 

“When we onboard it’s important that they begin to feel like they can align with the quality strategy,” she said. 

Avera’s plan is also provided to outpatient centers. Avera most recently acquired Carris Health Marshall, which includes a clinic and surgery center. 

The plan usually includes best practices and order sets to achieve each of the priorities, but the facilities have the freedom to innovate. This year, the four main focus areas for the plan are reducing avoidable readmissions; preventing healthcare-acquired infections with an emphasis on hand hygiene; addressing opioid-related adverse events; and improving the use of depression screening tools to identify persons at risk for suicidal ideation. 

“Given our vast geography there has to be some of the flexibility in the quality plan for every entity,” she said. “They take the plan and make it their own.” 

At new hospitals, a lot of time is spent familiarizing the clinical staff with the data now at their disposal. Each month, every facility is provided with a quality insight report that lays out how they are performing in relation to their peers. They’re also offered dashboards on a weekly basis that show how they are doing on certain process measures. 

“We help them understand that the data is solid and dependable so they can move from data abstraction to performance improvement,” Erickson said. “You want people to use that robust integrated electronic medical record.”

There was an intentional effort to unify services and the patient experience at Edward Hospital and Health Services and Elmhurst Memorial Healthcare shortly after the two merged in 2013 to form Edward-Elmhurst Health based in Naperville, Ill.

“What we wanted to do was create consistent processes and have the same experience of care throughout the system,” said Sherri Hill, vice president of quality and patient safety at the system, which is on the 15 Top Health Systems list for the first time. 

In addition to creating a leadership team from Edward Hospital and Elmhurst Memorial to guide quality work shortly after the merger, Edward-Elmhurst also worked to consolidate supply chain and payer contracts. 

When the system formed six years ago, supplies used between the two hospitals were “about as different operationally as they can be,” said Matt Hess, system director of supply chain. 

Both hospitals had different vendors and group purchasing organizations. To begin aligning the supplies, the supply teams from both hospitals were unified under one system department. 

The decision “accelerated a lot of the standardization,” Hess said. The system quickly moved to a single group purchasing organization post-merger and many supplies have since been standardized, such as Foley catheters. 

Hess said he is diligent about ensuring consensus is reached among the nurses and physicians across the system before changes in supplies are made. 

“I’m big on transparency,” he said. “When we work through these situations, it’s about making sure the clinical staff has the same information we do. If everyone has the same information, they will generally make the same decisions or fully respect the decision that is made.” 

Regarding payer contracts, Edward-Elmhurst has worked with insurers over the last few years to consolidate agreements. Usually, when a contract is about to expire, the system begins negotiations to see if it can be integrated with an existing contract to reduce administrative burden, said Shawn Roark, system vice president of payer strategy. 

Ongoing negotiations with insurers also take place to align the existing contracts, so they have the same rates for the same services no matter where a patient receives care in the system.

“It’s about making the pricing friendlier to consumers. They know they are going to be charged a single rate,” Roark said. 

Physicians from Elmhurst Memorial were also encouraged to voluntarily transition to Illinois Health Partners, a physician-hospital organization formed in part by Edward Hospital doctors prior to the merger.

Not long after Colorado’s UCHealth acquired Yampa Valley Medical Center in September 2017, efforts began to engage the new physicians in the order sets they wanted to use as they implemented a new electronic health record system.

UCHealth appointed Dr. Gary Breen, a hospitalist at Yampa Valley, to spearhead the work. 

At the time, UCHealth—which this year was named to the 15 Top Health Systems list for the fourth time and operates 10 hospitals in Colorado—had about 1,200 order sets in its Epic EHR that it wanted to consolidate. Epic recommended the system go down to 160 order sets. That gave Breen a unique opportunity to speak with his physician colleagues at Yampa about what they wanted to use when they were integrated to the new EHR system. Before the merger, Yampa was using an EHR platform from Meditech.

“I recruited physicians from each department to find out what they really wanted and didn’t want, and in the end, after all the effort, there were very few of the Meditech order sets that were actually converted into Epic,” Breen said. 

Yampa Valley went live with Epic eight months after the merger was finalized with few hiccups and with many of UCHealth’s order sets. “Even though it looked different, most of the physicians really liked the order sets,” Breen said. Getting input from the doctors helped tremendously in achieving that, he added. 

Engaging the physicians in decisionmaking is an important part of UCHealth’s strategy when it acquires new facilities, said Steve Hess, UCHealth’s chief information officer. It can be overwhelming to get used to a new EHR post-merger, so asking front-line staff for their input in decision support helps ease the transition, he said. 

“Making them feel welcome and including them in the process and decisionmaking is really critical,” he added.

Spectrum Health was familiar with Lakeland Health before the two merged last year. 

Up until about four years ago, both organizations were part of a quality collaboration in which they shared clinical data and quality-improvement work. 

“We have a long history of being transparent with each other around performance and learning from each other before this integration,” said Dr. Loren Hamel, who heads what’s now Spectrum Health Lakeland, a division of Spectrum Health.

This year, St. Joseph, Mich.-based Spectrum Health Lakeland is on the 15 Top Health Systems list for the second time. Before the merger, Spectrum Health, based in Grand Rapids, Mich., was recognized by IBM Watson for several years. The not-for-profit has a total of 14 hospitals.

Given their shared history, Spectrum approached the merger with Lakeland like a partnership, said Tina Freese Decker, CEO of Spectrum. 

“We are purposely embedding this collaborative approach where we learn from each other and we will be better because of that,” she said. 

Spectrum is now comparing quality outcomes with Spectrum Health Lakeland to find opportunities for shared learning. “We are going to be careful that the activities are adding value and don’t in any way erode performance that is already occurring,” Hamel said.

DATA: IBM Watson Health's 15 Top Health Systems