By Joyce Pulcini, PhD, RN, FAAN, Policy and Politics contributing editor, AJN
The ECRI Institute’s 19th annual conference (November 28–29) looked at system-level innovation and quality in the health care system. It brought together experts from many fields, including medicine, nursing, hospital or health system administration, informatics, health care quality, policy makers, journalists, and academics. ECRI Institute is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care. The goals of the conference were to address the following:
- What is “systemness”?
- Which elements within mature health care systems result in the best clinical outcomes?
- Are approaches taken by long-established systems transferable to smaller, newer, or less integrated systems?
- Are financial incentives enough to drive change?
- How can electronic health records (EHRs) help improve “systemness”?
- Do transformation units within health care systems produce results?
The conference essentially tried to attack in a creative way the issues around the creation of systems that function optimally. Truly changing culture and providing optimal care delivery should always result in putting the patient at the center of care. The conversation was open and the conference succeeded in fostering important dialogue among the speakers and the audience. A major focus was on creating systems, looking at technological or financial solutions, and measuring outcomes.
The session on team care (“Creating teams to improve inter- and intra-health care systems: Does evidence show a benefit?”) highlighted the vexing issues around how to truly foster optimal teams. Lisa Schilling, RN, MPH, VP National HC Performance Improvement, Director, Center for Health Care Systems Performance, was one of the speakers. She started in her role in 2008 and by 2010 published the results of her efforts, which led to a 30-day readmission rate after hospitalization reduction of 9% (Schilling et al, 2010) and a dramatic reduction of mortality from severe sepsis, which saved 1,100 lives. The solution, she says, was to focus on culture, with leaders and teams working together from the ground up to create learning organizations with clearly measured outcomes. She emphasized that while leaders manage variation, change culture, and manage team-based improvement, change begins at the front lines and alignment in health systems is a key factor in systemness.
Patient perspective. Another speaker, Jesse Gruman, a patient and consumer advocate, asked some heartfelt questions about who teams benefit. She answered quite honestly that patients do not really understand how teams will benefit them. Patients want to have a relationship with their “doctors,” not with teams. They are not really interested in being the leader of the teams either, as some of the rhetoric suggests. When they are sick, patients need people who can help them get better and the patient cannot lead this aspect of care.
She challenged us to think about what happens when teams do not work together well. She was concerned about the large “cast of characters” patients must often face while hospitalized. One solution, which was proposed by Children’s Hospital Boston, was a patient app called “My Passport App,” which had pictures of staff who were on their team (as an alternative to the old whiteboard solution). Family as well as patients could see who was on the care team, know what to do at home, and actually see their own plan of care.
Who really benefits from teams? One speaker asked who teams really benefit. In the end, the perception of the value of teams did not always reach the consumer. If the patient does not see the value of team care, we have a long way to go if this concept is to succeed. Patients should not have to receive the mixed messages and experience the poor communication often inherent in modern health care.
Population health. An important discussion took place in one session around the meaning of “population health.” The answers were diverse and difficult, as our delivery and payment systems are still primarily individually focused. There was much nostalgia on the separation of public health from individual health over the years. Many questioned if we need to go back to a public health focus.
The reimbursement question. In the final session, we heard from Sharon Levine, CEO, Kaiser Permanente Medical Group and Gail Wilensky, economist, Project Hope and former HCFA Director. Reimbursement has to support the move to systemness. Financial incentives are key, and we have the system that we have due to incentives created through reimbursement and systemic regulations. Patient-centeredness continues to be an important future driver.
The real question is how to really get the transformations needed for true patient-centeredness. Medicare is still financing care with the old fee-for-service methods, an old broken system with perverse incentives. Gail Wilensky emphasized the need to change how we reimburse clinicians and to remove perverse incentives that are rampant in the system. She also asked if we will be able to sustain change. We have seen a lot of innovation, especially in the private sector, but with subsequent cuts in funding over the years. She felt that we should consider innovative approaches with some skepticism based on past experience, noting that “innovation without disciplined implementation is wasted energy.” Finally, Sharon Levine stated that the important question to ask is, “Can we keep the promises we make with the patients?”
NPs and PAs as part of the solution. An NP asked about the use of nurse practitioners and physician assistants. The responses were interesting. One speaker said that there is an “inevitability” in use of these providers and that there was a need to push through expansions of scope of practice. Another said that too much care is being provided by highly trained providers, who should “work at the top of their license” and allow other clinicians to do more of the work. Another said that use of NPs and PAs is not just a scope-of-practice issue, but an economic issue. I later spoke with this NP conference participant, Jordan Hopchik*, MSN, FNP-BC, CGRN, who was a gastrointestinal nurse practitioner and endoscopist. He said, “When nurse practitioners have innovative ideas to improve health care quality and lower costs, they need to align themselves with those key stakeholders who will help them make it a reality. Be persistent and never give up! Being passionate about something alone is not enough to become the driver of change. . . ”
Schilling, Lisa; Chase, Alide; Kehrli, Sommer; Liu, Amy Y.; Stiefel, Matt; Brentari, Ruth. (2010). Joint Commission Journal on Quality and Patient Safety, 36, (11),. 484-498(15).