Editor’s Note: This is an Invited Commentary on Coleman DL, Wardrop RM III, Levinson WS, Zeidel ML, Parsons PE. Strategies for developing and recognizing faculty working in quality improvement and patient safety. Acad Med. 2017;92:52–57.
In this issue of Academic Medicine, Coleman and colleagues1 propose an ambitious strategic action framework for academic health center (AHC) department chairs seeking to expand faculty expertise in quality improvement and patient safety (QI/PS). The authors courageously attest to several inconvenient truths. First, in comparison with single-mission community hospitals focused solely on patient care, AHCs are notably “late to the party” when it comes to QI/PS. Indeed, quality may represent the sole domain in modern medicine in which “town leads gown,” given the impressive gains in quality at mission-driven private hospitals and integrated delivery systems that have often outpaced similar efforts at AHCs. Perhaps some fundamental incompatibility exists between the widely heralded “triple aim” of improving care, enhancing population health, and controlling costs and AHCs’ tripartite mission of research, education, and patient care. In the current complex work environment of AHCs, adding a core QI/PS responsibility represents a heavy lift for faculty at all levels. To their credit, however, Coleman and his coauthors press boldly ahead and, with the backing of the Board of Directors of the Alliance for Academic Internal Medicine, lay out a strategy for closing the gap in QI/PS between community hospitals and AHCs by fostering deliberate, proactive faculty development. Well reasoned and clearly articulated, the path proposed by Coleman and colleagues will demand sustained effort over a substantial time frame to achieve the fundamental culture change at AHCs that is needed to achieve their goals.
In this Invited Commentary, I discuss the same challenges identified by Coleman and colleagues, but I approach them from a different angle. Instead of proposing a new strategic framework, I offer a range of less ambitious tactical actions that department chairs could take, which may yield substantive short-term gains in faculty QI/PS effectiveness and expertise. I stress leveraging each AHC’s existing QI/PS, analytic, and innovation resources to mitigate, rather than overcome, the long-standing barriers to achieving the fundamental institutional culture changes needed to elevate QI/PS to an equal status with research, education, and patient care at AHCs.
In the sections that follow, I summarize five important challenges identified by Coleman and his coauthors as confronting academic chairs seeking to grow faculty QI/PS expertise within their departments. As remedies for the first four challenges, I propose straightforward tactical initiatives that can be undertaken on the chair’s authority (with the dean’s support) within a single budget cycle; these initiatives could yield substantial gains in QI/PS and buy time while more ambitious strategic projects get under way. My final “tactic” departs from this model and crosses the line into strategic territory. I propose a fundamental shift away from the care process and payer-mandated pay-for-performance measures that currently consume most AHC quality resources to comprehensive, longitudinal patient health status and outcome tracking. AHCs’ core strengths, especially their complex data acquisition and analysis capabilities, uniquely position them to undertake this ambitious, game-changing transition. Comprehensive health status and outcome tracking would allow AHCs to regain the lead in QI/PS and create a new value-based marketplace. Each of the necessary elements for an outcome-driven model exist and have been tested and validated, but, lofty mission statements notwithstanding, they have yet to be combined as a delivery system’s central value proposition and business model. This transformation awaits only an institution with courageous leadership and an appetite for disruptive innovation to unlock its potential.
Challenges and Tactics
The first challenge is mitigating the mentorship gap or the paucity of senior faculty who can pass on QI/PS expertise to rising junior colleagues.
Department chairs should encourage junior faculty interested in QI/PS to take part in existing, non-physician-led quality initiatives that are already under way at their institution. Most successful QI/PS initiatives in health care begin at the microsystem level,2 when a small, multidisciplinary team spots an opportunity to reduce waste or errors or improve outcomes and decides to test a different approach to see if it yields better results. Although one team member may drive these “insurgent” improvement projects, their success requires contributions from all team members and often support from management, information technology, and additional resources to “hold the gains” and generalize them to other services. A typical AHC might have a dozen or more of these team-based “tests of change” under way at any given time; often, they are led by nursing administration or quality improvement staff under charters from senior management and with help from data analysts and staff trained in QI/PS methods, such as Lean or rapid-cycle continuous improvement. Faculty, both junior and senior, are often unaware of these projects or only peripherally involved. Department chairs can identify these opportunities, protect faculty members’ time, and help them gain access as team participants. The faculty joining these projects can contribute valuable clinical perspectives while learning, from more experienced team members, sufficient QI/PS vocabulary and methodology to eventually lead similar initiatives within their own departments. Having faculty learn from nonphysicians who are already experts in QI/PS methods accelerates the development of a cadre of “QI/PS faculty” without the long delays associated with waiting for expert QI/PS faculty to be promoted to senior academic ranks.
The second challenge is mitigating data and analytic bottlenecks. Clean, valid, aggregated information on patient care processes and outcomes constitutes the lifeblood of most QI/PS initiatives. However, most enterprise electronic health record systems function as transactional tools without the relational database capabilities needed to analyze system-level results or outcomes. These complex record systems are generally supported by an information services team that, in addition to keeping the production environments up and running, must respond to many internal customer requests for analytic reports. These overworked teams rarely have the resources or bandwidth to respond to all custom information requests in a timely fashion. As a result, information requests to support QI/PS projects often enter long, backlogged queues of prioritized queries from other departments and are pushed to the back of the line, effectively halting progress on QI/PS projects.
In their annual budgets, chairs should set aside funding for a dedicated QI/PS analyst who can work with the information services department. The specific position title, description, qualifications, and salary likely will vary depending on the clinical department’s needs. To be most effective, the analyst position should reside within the existing information services department, so she can have full access to all data systems. The analyst’s primary responsibility should be to support departmental QI/PS projects with data and analytics. She should join QI/PS teams during the planning phase of any project to help shape the queries and reports needed to accomplish the project’s goals. With a dedicated analyst, QI/PS teams can receive timely information to assess the impact of the changes they are testing, accelerating improvement cycles without disrupting ongoing daily information technology operations. Relieving the data/information outflow obstruction will allow existing teams to thrive and will encourage new teams to form. Of the tactics I propose here, this one may have the greatest near-term return on investment.
The third challenge is mitigating the misalignment between existing reimbursement mechanisms and QI/PS. Despite the hype and saber rattling about changing reimbursement systems to reward value rather than volume, fee-for-service remains the dominant payment model for both physicians and facilities. Even with prospective payment models for hospital stays, AHCs are under intense pressure to reduce lengths of stay and increase the number of patients admitted who require complex procedures. Bluntly stated, current reimbursement mechanisms drive high utilization of costly interventions and can financially penalize organizations that keep patients well and avoid complications. “Upstream” prevention glows with incandescent appeal, but rescue medicine still keeps the lights on at most AHCs.
Departments can blunt the negative impact of existing reimbursement models by working more closely with individual payers to align quality incentives and improve care. For example, internal medicine department hospitalists care for most medically complex patients who are frequently hospitalized for decompensated chronic conditions. These admissions generally represent low-value events for all parties. To improve care coordination for these complex patients, chairs can approach high-volume payer organizations (see Commonwealth Care Alliance below) and ask them to fund a dedicated hospitalist service to care for their plan members requiring emergency department or inpatient admission. These hospitalists are fully privileged members of the medical staff and can be employed either by the AHC’s existing hospitalist group using plan funds or directly by the health plan. When optimally deployed, this arrangement enables tight coordination of clinical and “wraparound” social services that can prevent or shorten inpatient stays. The health plan has access to all of its members’ ambulatory records, and case managers can help guide goal-appropriate care, avoid “social” admissions due to housing or placement challenges, and integrate behavioral and medical care.
One such initiative is under way at Boston Medical Center, in collaboration with Commonwealth Care Alliance (CCA), a nonprofit health plan for high-risk, dual-eligible Medicare/Medicaid beneficiaries. CCA funds a hospitalist service at Boston Medical Center to manage their members who require hospital services. Despite multiple psychiatric and medical comorbidities, CCA members experience low hospitalization rates as a result of intensive multidisciplinary care management and coordination. “In-sourcing” quality through strategic payer alliances that benefit all parties is a highly effective but underused QI/PS strategy. AHC residents and junior faculty could rotate onto these specialized services to learn a new model of highly coordinated, patient-centered care, in which patients, hospitals, and payers all enjoy improved cost and health outcomes.
The fourth challenge is mitigating limited recognition for QI/PS achievement in academic advancement decisions.
Working through the dean’s office, chairs should ask promotions committees to add a new section to the academic advancement dossier templates requiring each faculty member under consideration for advancement to list all his/her QI/PS activities since the prior review. This dossier section would provide a place for faculty to document their effort level and achievements in QI/PS, just as they do now for research, teaching, and clinical service. QI/PS is inherently team based, so this dossier section should ask candidates to list their QI/PS teams, their roles and level of effort, and the results achieved. Receiving advancement credit for participating on a successful QI/PS team should not differ fundamentally from receiving credit for participating on a successful research or education team, and advancement committees can decide how they want to weight QI/PS achievements in their overall academic advancement determination.
The fifth challenge is inventing, testing, and implementing alternative business models that reward value and results rather than the volume and pricing of services provided, and that align payer, provider, and patient incentives around high-value care, defined as improvement in outcomes divided by costs.
This final tactic entails the greatest effort and risk, but it also offers the greatest potential gains and therefore crosses the line from tactic to strategy. I include it here because action in this arena lies well within the reach of AHC department chairs in the near term, and those who choose to lead the way in this domain will likely chart the path to our next delivery system. Tactically, deans must ask each department chair to submit annually a plan for weaning his/her department from its current dependency on relative value unit procedures and other fee-for-service reimbursement methodologies. This plan also should include steps to replace this model with payment mechanisms that reward clinical outcomes that matter to patients and families and therefore to purchasers and payers. Opportunities to secure substantial extramural support for this planning exist from public and private agencies, notably the billion dollars set aside by the Centers for Medicare and Medicaid Services to fund alternative reimbursement projects. Successful examples of this shift exist: Geisinger Health System led the way by bundling cardiac surgery services for a single price. In addition, numerous Medicare accountable care organization pilot programs have yielded valuable information on risk- and gain-sharing arrangements.
The next step is to globally capture health status and functional outcomes using standardized, validated outcome tools and to create a market between payers and providers in which patient health status and outcomes, rather than treatments, form the basis for reimbursement. Despite its “blue-sky” sound, all of the theory, methodology, and technology tools necessary to advance to this next level currently exist and have undergone rigorous validation. The path forward toward quantitative longitudinal tracking of patient-reported health status has been eloquently charted.3
Although other short-term tactics can spur the growth of QI/PS work at AHCs, taking responsibility for a defined patient population and achieving rigorous, comprehensive longitudinal capture of valid patient-centered outcomes, including patient-reported measures of functional status and well-being, represents the fundamental system transformation that all major stakeholders seek but that has eluded us to date. As patients, we seek care to feel and function better, or at least not much worse, as we age. Theory, tools, and methods now exist to deliver on this vision of creating a competitive market structured around results. Building it will place heavy demands on innovation, cross-departmental collaboration, data management, analysis, and reporting. Each of these features is in much greater supply at university-based AHCs than at single-mission hospital systems. An enticing opportunity exists for AHCs to leapfrog back into a leadership position in QI/PS. I look forward to seeing which institution first finds the courage, leadership, partners, and determination to make this leap into the future.
Acknowledgments: The author wishes to acknowledge Drs. John Loughnane and Toyin Ajayi of Commonwealth Care Alliance in Boston for sharing information on their innovative hospitalist collaboration with Boston Medical Center.