Intermountain Healthcare's McKay-Dee Hospital Center .

4 T he C ommonwealth F undConversation with Brent James, M.D., Executive Directorof Intermountain’s Institute for Health Care Delivery ResearchIntermountain Healthcare system established the Institutefor Health Care Delivery Research in 1990, though theInstitute’s leaders had been conducting studies in clinicalquality, cost, and efficiency at Intermountain since the mid1980s. The Institute integrates and analyzes administrativeand clinical data from Intermountain facilities and supportsquality improvements throughout the system. It alsoconducts quality training and leadership programs forIntermountain medical directors and other clinical staff.“We learned early on that narrowing variationimproves clinical outcomes,” said Brent James, M.D.,executive director of the Institute. “And we demonstrated that quality drives savings.”Intermountain’s researchers and clinicians developed an outcomes tracking and reporting system toidentify and collect data in each of its nine clinical programs. The data system measures medical outcomes,cost, satisfaction, and other performance indicators. Based on these data, the researchers identify priority areasfor improvement. Fourteen Development Teams, each focusing on a different condition and comprising frontlineprofessionals and a physician leader, develop “care process models” and test protocols with clinical staff to promotebuy-in and ownership. If the protocols are successful, the teams help deploy them throughout the Intermountainsystem. The teams track variances in processes and outcomes, and check regularly to see whether further changesto the protocols are needed. “Care process models change every month,” said James.Looking ahead, James and his colleagues will be testing the concept of accountable care organizations.Through pilot programs in which Intermountain is partnering with health plans and labor unions, they will implementand evaluate “bundled payments” for certain episodes of care (e.g., the entire pregnancy/labor/delivery/postpartumperiod). James said these pilots will “test the ability of the system to manage quality and cost.”Source: Interview with Brent James, March 4, 2010.records. Also, having its own home health networkimproves coordination between Intermountain hospitals and home health providers.All Intermountain hospitals share the philosophy that clinical excellence drives decision-making—an understanding that it’s best to “do the right thing”to improve quality, even if it adds costs or reduces revenues. For example, McKay-Dee built an outpatientheart clinic (discussed below), despite the likely reduction in downstream revenue for the hospital, andIntermountain started its own home health network,requiring significant investment. Similarly, afterreviewing data showing increased mortality ratesamong babies born before 39 weeks of gestation,Intermountain ceased performing elective pretermbirths, even though this resulted in reduced NICU utilization and its associated revenue.1According to McKay-Dee’s leaders, strategicfinancial management is handled primarily at theIntermountain system level, enabling individualhospital boards to focus on quality, safety, and medicalstaff issues.1See Reducing Inappropriate Induction of Labor: CaseStudy of Intermountain Health Care (New York: TheCommonwealth Fund, Oct. 2004).

I ntermountain H ealthcare ’ s M c K ay -D ee H ospital C enterIntermountain also has regional quality committees, with members drawn from all system hospitals.The committees discuss quality issues and share bestpractices, with support from 14 systemwideDevelopment Teams as well as research/data expertisefrom the Institute for Health Care Delivery Research.The RegionUtah is the lowest-cost state in the nation in terms ofhealth spending per capita and also has the lowest percent of avoidable hospital costs.2 James suggests thatthis is in part because of Intermountain’s long recordof quality and cost measurement and initiatives, whichhas influenced its competitors to reduce costs as well.Another factor may be the very low rate of tobaccoand alcohol consumption among Utahns. Health careproviders in Utah undoubtedly benefit from a higherthan average median income, lower than average costof living, and a rate of employer-sponsored insurancewell above the national average.McKay-Dee has about 46 percent market sharein its region. Its biggest competitor is Ogden RegionalHospital, which is owned by the Hospital Corporationof America.PRIMARY FOCUS ON CLINICAL EXCELLENCEWhile many hospitals focus their quality improvementefforts on raising their scores on the CMS core measures, McKay-Dee leaders think these are the wrongtarget. “Here, we target the problem itself. We focuson treating the whole patient. If we do things correctly,then the scores will take care of themselves,” saidGarry MacKenzie, M.D., medical director of cardiology services at McKay-Dee. The hospital did not setout to reduce readmissions; instead, leaders view itslow readmission rates as an outgrowth of its commitment to improving quality and taking care of thepatient. “We do the right thing while people are here,”said McKay-Dee CEO Timothy Pehrson.2www.statehealthfacts.org and The Commonwealth Fund2009 State Scorecard.5Improvement Processes andStandardized CareMuch of McKay-Dee’s quality improvement work isinitiated by system-level Quality Councils. Fourregional councils set priorities and standards, oftenbased on research and practice findings spearheadedby the Institute. Quality Councils also translate theirfindings into clinical protocols, which are then tested,adapted, and spread by Development Teams made upof frontline staff from across the system. Furtherrefinements occur as the protocols are implemented.Standardization is a tenet of McKay-Dee’simprovement work. The hospital standardizes processes, monitors practices and outcomes, and seeks toreduce variation in both. In particular, it has focusedon processes that reduce complications and infections,thereby reducing readmissions. For example, new evidence on five classes of medications for heart diseasepatients led to nurse discharge protocols that include amedication checklist. Appropriate medication compliance increased from 57 percent to 98 percent, and bothmortality and readmission rates declined among thesepatients, according to James.Here, we target the problem itself. We focus ontreating the whole patient. If we do things correctly,then the scores will take care of themselves.Garry McKenzie, M.D., medical director ofCardiology ServicesMcKay-Dee’s use of hospitalists also promotesstandardization. Hospital leaders find it easier to trainand influence the behavior of a small group of fulltime physician employees than large numbers of community physicians. McKay-Dee employs 14 hospitalists, who together manage the care of about 33 percentof the medical/surgical population. Medical staff leaders would like to expand the use of hospitalists, butfeel they need to do so in an incremental way; theyacknowledge that not all patients want to give up theircommunity doctor while in the hospital, and some

6 T he C ommonwealth F unddoctors like to retain control of their patients whenthey are admitted.McKay-Dee makes its mission to deliver highquality, patient-centered care operational by givingdepartment chiefs and nurse managers responsibilityfor the quality of care within their clinical areas andpromoting strong nurse–physician relations, wherebynurses know they are partners with physicians andhave their support.Since 2008, McKay-Dee has been working tointegrate the principles of Lean manufacturing tohealth care.3 It is using process improvement tools toeliminate waste as well as a management system thathardwires improvement activities into the daily workof administrators and staff. Each unit of the hospital isinvolved in focused improvement projects, facilitatedby one of five management engineers. Each unit alsohas an Idea Board, to which employees can submitprocess improvement suggestions. To participate, anemployee identifies a problem and recommends asolution; if given approval by their manager, theemployee does the work necessary to implement thesolution. Over 1,900 employee ideas have been implemented in the past two years.Measurement and AccountabilityAt McKay-Dee, transparency is a cornerstone ofimprovement strategies. Administrative and clinicalleaders describe the hospital’s efforts to become moretransparent as “a journey.” Extensive internal datareporting started in the mid-1990s. Each hospital unitgets a monthly report summarizing its performance onmany indicators over time, compared with benchmarksand goals. It shows where practices deviate from standards and expectations, in some cases providing startling news to clinicians who were unaware of the discrepancies. In addition, each quarter some physicians(including those who work in general medicine, theemergency department, hospitalists, and soon intensivists) receive report cards showing a range of indicators3Lean, first used in the Japanese automotive industry andnow translated for use by the U.S. health care sector,focuses on increasing value and decreasing waste inadministrative and clinical processes.related to their patients, compared with goals andIntermountain system averages. Exhibit 2 shows partof a physician’s report card related to readmissionrates at 30/60/90/360 days after discharge.At first, physicians questioned the accuracy ofthe performance data that Intermountain data analystscollected from the system and presented to them. Overtwo to three years, they came to accept and trust thenumbers, and now some medical chiefs post the reportcards in their departments. Leaders say that early successes helped promote this shift. For example, simplechanges in infection reduction strategies led to reducednumbers of infections, and people began to believe inthe data.McKay-Dee also compiles a report card for hospitalists, which is shared with them each month. Itcompares hospitalists as a group to McKay-Dee physicians overall, and to Intermountain’s goals for numerous measures related to service (e.g., doctor explainedthings well to patient), clinical targets (e.g., readmission rates, appropriate screenings and vaccinations),and operational effectiveness (e.g., average daily billedencounters).Department chiefs have a “chat” with any physician who has failed to fulfill a certain care protocolor is an outlier in any particular measure. In addition,all readmissions within 30 days are reviewed by a hospital quality consultant and then in a peer review.Clinical and administrative leaders say that the reportcards have been very successful at modifying physicians’ behaviors over time. However, not all physicians have been responsive. McKay-Dee wants toexpand the information provided to surgeons in orderto address some lagging surgical care measures.For some conditions, information is compiledand shared very quickly. For example, the “time totreatment” for acute myocardial infarction patients isreported to managers and passed on to the rest of thestaff within 72 hours. This enables staff to make timelychanges to the care process. Then, quarterly roll-ups ofthe data help them to see the patterns.For certain measures, registered nurses acting asquality consultants abstract data from patients’ charts

I ntermountain H ealthcare ’ s M c K ay -D ee H ospital C entershortly after they are discharged, instead of waiting formonthly or quarterly performance reports. For example, they review charts for all heart failure patients tosee whether all steps related to medications, activity,weight, diet, and symptoms were addressed during thehospital stay. When they discover failures in adherenceto protocols, they drill down to determine causes.McKay-Dee is the only hospital in the system that useshighly trained registered nurses in this role; theybelieve doing so is worthwhile because registerednurses are better able than clerical staff (i.e., nonnurses) to interpret and analyze what went wrong.7Moving from accepting data to being accountable for improving their performance is the next phasefor McKay-Dee’s clinicians. Medical leaders say thatthis culture shift has just begun. As an important step,McKay-Dee recently introduced financial incentives—equivalent to 5 percent to 10 percent of salary—foremployed physicians who meet two clinical goals. Thehospital has found that, after physicians reach thegoals, they tend to maintain that higher level of performance because behaviors and systems are changed inthe process. Physicians report that the hospital supports their ability to earn their bonuses by providingdata and guidance.Exhibit 2. McKay-Dee Physician Report Card: Readmission RatesSource: McKay-Dee Hospital, March 2010.

8 T he C ommonwealth F undExhibit 3. Sample Personalized Medication assiumElectrolytes10meqTwicedailyXX22- .5mgSeebelowXOtherinstructions:1. Metolazone2.5mgMon&Thursonlyasof2/25Source: McKay-Dee Hospital, 2010.CARE TRANSITION STRATEGIESInterdisciplinary Care Coordination andDischarge PlanningMcKay-Dee employs a number of strategies to promote smooth transitions from the hospital to post-acutecare and thereby reduce avoidable readmissions. Onthe day of admission, every patient is assigned a nursecase manager and social worker to assess his or herneeds and plan for discharge. They examine what triggered the admission, available family supports, finances,and medical history. If a patient cannot afford his orher medications, one of the outpatient pharmacistshelps register him or her with a pharmaceutical manufacturer’s free or low-cost medication program. Thecase manager coordinates with the patient’s insurancecompany to create a plan for discharge, taking intoaccount the support that will be required. If patientsare members of Intermountain’s insurance plan, theinsurer has access to their electronic medical records.The case manager closely coordinates follow-upcare with home health agencies when necessary.Intermountain created its own home health network toimprove coordination between the hospital and homehealth providers; inadequate support or attention tochanges in condition can land someone back in thehospital. After starting their home health service in1963, Intermountain experienced a significant declinein admissions and readmissions.Seeking to better coordinate care and identifyat-risk patients, McKay-Dee began daily, interdisciplinary care coordination meetings in late 2009. Casemanagers, floor nurses, social workers, hospitalists(who stay only during review of their own patients),and sometimes pharmacy staff meet to discuss eachpatient on their unit. Participants review when patientsare going home, their needs, discharge issues needingattention such as home care, and whether patients haveheart failure, which would trigger heart failure education and care protocols.In addition, nurses write the estimated dischargedate and goals for discharge on white boards inpatients’ rooms, to help prepare patients and their families for the transition.Hospitalists schedule post-discharge follow-upappointments for their patients. For nonhospitalistpatients, the case manager, social worker, or nursingstaff facilitates follow-up appointments as needed. AllIntermountain-employed, nonsurgical community physicians are required to see discharged patients within a

I ntermountain H ealthcare ’ s M c K ay -D ee H ospital C enterweek of discharge. The discharge plan includes referral to the outpatient heart failure clinic (describedbelow) when appropriate, although participation is voluntary.For patients who do not have a regular sourceof care in the community, the hospitalist or case manager can leverage McKay-Dee’s membership in ahighly integrated system to link patients to communityproviders. Referring to its network of physician practices and clinics, one of the health system’s leadersnoted, “We can find a [medical] home for anyone.Without this system alignment, some patients could bedifficult to place.”Finally, nurses call all heart failure, catheter,and hospitalist patients after discharge to identify andaddress problems before they are serious enough torequire readmissions. If they are unable to contact aheart failure patient, they send him or her a letterreviewing follow-up and discharge instructions andproviding telephone numbers to use to contact someone with concerns or questions.9niques, including how to take into account patients’unique learning styles and needs. For example, nurseslearn how to assess patients’ readiness to learn and usewords they are likely to understand. They conductmedication education and give each patient a customized list describing the purpose and timing of each ofhis or her medications (Exhibit 3).Identification and Management of HeartDisease InpatientsWhile consistently providing the right care helpsachieve low readmission rates, McKay-Dee has foundthat heart failure patients require more extensive interventions than either pneumonia or heart attackpatients.Over the past 20 years, McKay-Dee has workedto standardize its approach to heart failure care, addingone component after another until it has achievedstrong results. First, staff seek to identify and educateevery patient with heart disease—the underlying condition behind a large portion of avoidable readmissionsnationwide. Its computer system flags patients whohave a history of heart failure, even if is not their current primary diagnosis or the condition is inactive.Previously, coders had missed patients if heart failurePatient Education and EngagementA patient education expert on the heart failure clinicstaff trains McKay-Dee nurses on educational tech-Exhibit 4. The MAWDS Heart Failure Patient Education MnemonicSELF-MANAGEMENT WITHMAWDSSelf-management is key to heart failure treatment. Teach Intermountain’s MAWDSmnemonic to help promote compliance with these important self-care steps:HEART FAILURE PREVENTION& TREATMENT PROGRAM (HFPTP)PROVIdER sUPPORT HOTLINE and cONsULTATION cLINIc:(801) 507-4000(801) 507-4811PHONE:FAx:WEb: intermountainhealthcare.org/heartfailureor use the referral form in clinical Workstation (cW) hot textFOR MORE INFORMATION:Intermountain heart failure patient educationmaterials:nnClinicians can view and order materials fromintermountainphysician.org/PEN or call (801) 442-2963.Send patients to intermountainhealthcare.org/healthOther helpful websites:nnnMEDICATIONS: “Take your MEDICATIONS”Make sure your patients understand the importance of medications in their heartfailure management. Tell them which medications they are taking and why. Mostimportantly, make sure they understand the necessity of taking their medicationsevery day, even when they are feeling well.ACTIVITY: “Stay ACTIVE each day”Many patients with heart failure are afraid to be active. For others, it just seems liketoo much of an effort. Encourage your patients to participate in some form of physicalactivity every day. Participation in a supervised cardiac rehabilitation program is agood way to help patients overcome their fears and understand their limits.WEIGHT: “WEIGH yourself each day”It is critical that your patients understand the importance of weighing themselvesdaily. Patients will be more likely to comply with daily weighing if they understandthat you are concerned about fluid retention as it relates to heart failure. Patientsshould notify their provider when they gain more than 2 pounds in one day or 5pounds from their usual/target weight.44D444?IET: “Follow your DIET”Heart Failure Society of America (HFSA):provider: www.hfsa.orgpatient: abouthf.orgAmerican College of Cardiology: www.acc.orgAmerican Heart Association: www.americanheart.org?A good diet—especially sodium restriction—is critical to heart failure management.Helping patients understand how to restrict their sodium and learn otherimportant diet elements can be time co

McKay-Dee Hospital Center in Ogden, Utah, part of the Intermountain Healthcare System, had readmission rates in the lowest 3 percent of hospitals across the nation for all three clinical areas reported to the Centers for Medicare and Medicaid Services (CMS)