This year's Presidential Lecture at the 2016 American Academy of Neurology annual meeting in Vancouver, BC, was delivered by Brent C. James, MD, MStat, Executive Director and Quality Officer, Intermountain Healthcare Leadership Institute, Salt Lake City, UT.
Clinicians at Intermountain Healthcare Leadership Institute are saving lives and millions of dollars by applying rigorous measurement tools to routine patient care. They are showing that the future of medicine, and neurology, may be driven more by the science of implementation than by technical innovation.
“We count our successes in lives. Each year, I can document well more than 2000 Intermountain patients who would have died, but did not,” said Dr James. “Moreover, from a purely financial perspective, this has a more financial upside than developing and applying new technologies.”
Shared Baseline Protocols
Dr James reported that there are several problems with “best care” protocols, including that level 1, 2, or 3 evidence is only available a small percentage of the time; expert consensus is unreliable; and that guidelines do not guide practice, because no 2 patients are the same.
Conversely, shared baseline protocols use data-driven process management to deliver better patient care. Dr James recommends the following steps to implement the shared baseline protocol:
- Identify a high-priority clinical process (eg, for sepsis)
- Build an evidence-based best practice protocol. This is always imperfect because of poor evidence and unreliable consensus, but the model is essential for what follows
- Blend this protocol into clinical workflow, which provides clinical decision support. Dr James stressed the importance of not relying on human memory, noting “Make ‘best care’ the lowest energy state, the default choice that happens automatically, unless someone must modify”
- Embed data systems to track protocol variations and the short-term and long-term patient results, including clinical, cost, and satisfaction outcomes. “Anytime somebody varies from protocol, you need to know that a variance has occurred. Side by side with the workflow, track what happens with your patients”
- Demand that clinicians vary care based on the needs of patients. “We don't just encourage this, we demand it. I can never get a guideline that fits every patient. That's why we have doctors; I need a thinking-minded interface,” Dr James remarked
- Feed data back in a lean learning loop and continuously update and improve the protocol. Because theory is always an abstraction, the last step may be the most important; validation data are needed to show where the model really produces. “It's important to tune one's theory to reality,” noted Dr James.
The result is to take a complex environment and to “allow the human mind to focus on a relatively narrow band of factors, where you can be maximally effective,” he advised.
New Standard for Sepsis Care Saves Lives
According to the Centers for Disease Control and Prevention, one of the leading causes of hospital deaths is sepsis, and the rate of inpatient deaths resulting from septicemia is rising. Before implementing the shared baseline protocol at Intermountain, the mortality rate for sepsis resulting from emergency department transfers to the intensive care unit was approximately 20%.
“This rate was one of the best in the nation. We now average 8.1%, which is a new standard for sepsis care,” Dr James reported.
The sepsis bundle alone has translated to more than 125 additional lives saved annually. When combined with other protocols, the data-driven, clinical management approach is responsible for more than 2000 lives annually.
“Mortality is just the tip of the iceberg. We've also seen a dramatically bigger impact in terms of function restored and suffering averted,” he said.
Clinical Outcomes Drive Cost Outcomes
In addition to the improvement in clinical outcomes, the sepsis bundle has also reduced the cost of care at Intermountain by $1.3 million annually and has lowered its actual operating margins by $720,000. This approach has also led to unorthodox organizational goals, such as reducing revenues.
“If you're reducing revenues by delivering better, more cost-effective care, it makes perfect sense. Our operating margins are the strongest we've ever seen,” said Dr James.
“We're showing that better care is cheaper care. Better clinical results nearly always produce lower costs,” Dr James added.
More than 50% of all those cost-savings will take the form of unused capacity, such as fixed costs (eg, empty hospital beds), empty clinical patient appointments, and reduced procedure, imaging, and testing rates. This, in turn, is balanced by dramatically growing demand.
“We're creating the capacity for that extra demand without building more hospitals or scanners. Our current physician and nurse workforce can meet those needs. It's called increased productivity…balanced by increasing demand,” Dr James explained.
However, this methodology implies a partnership between the medical and nursing staff and administration, and it is not about putting administrators in control, he emphasized.
“The only way we're going to survive is for physicians and nurses to step out and create a new future that works for all of us in close partnership with our administrative colleagues,” Dr James said.
Considerable work remains, but despite the challenge, Dr James's optimism is unwavering. In his vision, a new healthcare delivery model involves the right care, delivered at the right time, at the lowest necessary cost, and under each patient's full knowledge and control. Accomplish this, and the results will be nothing short of transformative, he said.
“Medicine is still the best profession the world has ever seen,...and we have not yet begun to understand how good we can be for our patients,” he concluded.