Breaking Down Internal Silos

As hospitals initiate new strategies to transition from fee-for- service to population health, many times the programs are established in a vacuum.  Managers in one are unaware of what the managers of another are working on – sound familiar.  That age old problem of “silo mentality”.  This may be due to a number of 

reasons but often silos are “a result of a conflicted management team” (Gleeson & Rozo, 2013). So how do you mesh your ACO strategy with your clinical integration strategy with your population strategy?  Does it fit with a Bundled Payment for Care Initiative (BPCI) or gainsharing strategy?

Most importantly, everyone from the top down must be engaged and knowledgeable about the goals of the organization, not just their individual program.  Understanding how one initiative can integrate with others is vital.  Often, measuring the effectiveness of one can be used to measure the success of others.

Recently I spoke with April Venable, the Director of Population Health Decision Support at Inspira Health Network in New Jersey.

April Venable discusses Inspira’s gainsharing successes with Jo Surpin

She is also the Program Coordinator of the Bundled Payment of Care Initiative (BPCI) Model 1 Gainsharing Program for two of the system’s hospitals.  Their approach was to merge the activities of a number of committees, involving a host of individuals representing all levels of the organization, into the BPCI Steering or Oversight Committee.

Why did your organization decide to pursue gainsharing?

April Venable (AV): The organization has three ultimate goals, consistent with the Institute for Health Improvement’s Triple Aim.  They are: improve the patient experience and quality of care; improve the health of populations; and reduce the per capita cost of healthcare provided.  We chose the Model 1 Gainsharing Program as a means to help achieve these goals.

 How did you organize the Steering Committee for the BPCI initiative?

AV: We have voting members comprised of physicians, hospital administration, and a community member.  Physicians represent various disciplines such as internal medicine, cardiology, pulmonology, infectious disease, surgery, emergency medicine, and medical education.  We included non-voting members from key hospital departments like Case Management, Performance Improvement / Quality, Business Development, and nursing leadership.

The gainsharing steering committee also functions as our Utilization Review committee as well as our Clinical Integration Committee, which is charged with developing care paths (evidence-based protocols).  We meet each month for 90 minutes.  Gainsharing initiatives are covered every month, UR and CIC rotate.  Often many of the initiatives impact the goals of the various committee functions – for example, a protocol implemented by CIC would be followed for gainsharing purposes to see if the specific Medicare cases for which it applies have reduced variation and result in cost reduction.

How did your Steering Committee decide what to focus on?

AV: I would say “low hanging fruit” was the first pass – attribution was a concern from the start and a simple order allowing the physician to choose the person providing the majority of patient care was put in place.  We tossed around lots of ideas but made our focus items for which data was available and reliable.

 How did you communicate the program to physicians and get their interest?

AV: We did a number of things, from posters in the medical staff office, to email blasts to the medical staff and  presentations at various departmental meetings.  We also met with the practice administrators to educate them on the initiative.  In addition, we put out a quarterly newsletter to keep them informed and to offer “food for thought” in terms of clinical management.  For instance, in the Fall 2014 newsletter, we highlighted cost and quality considerations in pulmonary and cardiology, two areas of opportunity for cost reduction.  A number of ideas were outlined, such as whether daily blood gases are necessary on stable, long term ventilator patients, and whether telemetry is still needed.  These are not prescriptive, merely items to consider when managing patients.

Were there other items discussed?  If so, what were they?

AV: Yes – some “out of the box” thinking was done around how the patient experience impacts cost of care.  Our committee has made a targeted effort around training physicians on communication models that will impact HCAHPS scores in the physician domain – being listened to, treated with courtesy and respect, and having physicians explain things in an understandable manner.  I once read that patient satisfaction does not mean “happy”, it means “informed”.  And clinical outcomes, for example readmission rates, have been linked to patient experience scores. It makes sense to me – the more patients feel prepared to deal with their diseases, the more empowered they are to take an active role in self-management, and good will come!  As part of our efforts, our residents developed a video that showed various communication do’s and don’ts – simple things like sitting to talk to a patient, which puts the physician at eye level.  We will be using this to educate other physicians.

Have the items been communicated to other professionals such as nurses or respiratory therapists?  Have any educational efforts been undertaken to bring them up to speed?

AV: Again, since we are still in the early phases, we have not gotten to this point.  However, we intend to avoid silos and make sure all impacted parties are brought into the loop.

Do you measure the effectiveness of your program and if so, how?

AV: Yes, we do have metrics in place.  As part of the CMS BPCI Model 1 Program gainsharing, we have to monitor care redesign protocols and report these.  But we tried to incorporate existing metrics so that multiple projects were assessing the same factors.  We look at 30 day readmission rates (CMS), pneumonia care (IQR), sepsis care (VBP) among others.  .  This is an example of how we can tie gainsharing to other initiatives that have financial consequences to the organization.

Are you seeing any success?

AV: We are only finishing up a year in the program but we have seen  positive results.  Length of stay has dropped over 4% against expected and we have achieved about 26% of the cost reduction opportunities that were identified.  Orthopedic surgery has been a real winner for us, with over a half million dollars in savings.  We still have work to do but we are pleased at this point.

So to re-cap, this organization embraced a new program from top to bottom; communicated the organizational goals and programs in an inclusive manner, implemented the project while meshing it with existing initiatives, and developed a coordinated system to measure the impact.  This is how you avoid the silo mentality and get your organization moving in one direction.  It is also a critical step to successful engagement of physicians.

References

Gleeson, B., & Rozo, M. (2013, October 02). The Silo Mentality: How to Break Down the Barriers. Forbes, p. online. Retrieved from Forbes.