A transparency initiative launched in 2008 by Premier healthcare alliance has helped more than 300 hospitals deliver more evidence-based care, decrease preventable mortality rates and save an estimated $9 billion in costs.
Executives and participants in Premier’s QUEST program shared a four-year update on the initiative, which encourages hospitals to share, test and scale new ways of delivering care with the goal of improving quality, safety and cost effectiveness. The initial pool of 157 participating hospitals has expanded to include 333 organizations that share data with and benchmark performance against one another.
QUEST measures performance across six dimensions: cost of care, mortality, patient experience, readmission, harm and evidence-based care.
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Of course, most hospitals are working on improving these areas, too. But Premier President and CEO Susan DeVore said participating hospitals have exceeded national trends, for example, in reduced mortality rates. They’ve also held inpatient hospital costs to an increase of 11 percent over four years, compared to a 28 percent increase nationally.
“If you were to extrapolate this kind of improvement over five years to all hospitals in the U.S., the numbers get really big, like 950,000 acute care deaths avoided, evidence-based care to an additional million patients and a savings of $93 billion,” she said
The ultimate goal of QUEST, in fact, is to decrease the performance gaps between participating hospitals and hospitals nationally. “One of the objectives that we have […] is to be very transparent about the learnings and the results and to share it broadly with not only the rest of the Premier membership but broadly across all hospitals,” she said.
Mortality
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At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
What has really helped Tennessee-based Mountain States Health Alliance in reducing preventable mortalities, according to VP of Quality and Patient Safety Tamera Parsons, has been the ability to see how the system stacks up – or in her system’s case, wasn’t stacking up – against top performers in QUEST. In looking at comparisons of mortality data, the system saw that not only was one of its small community hospitals the worst performer in the QUEST database, but there was plenty of room for improvement in its other hospitals as well.
So the system went to work identifying primary drivers of mortality and found the biggest opportunity in how it was addressing sepsis. “Where we were falling short was in identifying patients with sepsis early enough to intervene with the evidence-based care needed to prevent their death,” Parsons said. “We were aware of criteria to identify patients that may be septic called SIRS, but our processes were not equipping us to do this rapidly,” she said. So MSHA began exploring best practices shared by other facilities within quest, and as it’s been implementing them, has seen improvements in some of its hospitals.
Over four and a half years, QUEST hospitals all together have seen a 36 percent reduction in observed-to-expected mortality.
Cost
In-patient hospital costs have increased slower among QUEST hospitals than among a similar sample of hospitals nationwide and have actually remained flat over the last three quarters. “We’ve been isolating, with our collaborative members, how they got there, and we’re seeing a lot of things,” DeVore said. Among them are the implementation of EHRs and Meaningful Use standards, adhering to evidence-based protocols, using case managers to reduce length of stay and using resource float pools so that staff can be moved around as needed without hiring temporary labor.
Readmissions
DeVore admitted only modest improvements in readmission rates, but said that as hospitals put more focus on this area, she expects improvements to pick up.
One measure that seems to be working among participating hospitals is more comprehensive discharge planning that includes “teach back” strategies and ensuring that patients know where to go for post-discharge services. Post-discharge follow up, including follow-up phone calls within 48 hours, has also helped.
Dr. Thomas Macaluso, chief quality officer at Memorial Healthcare System in Florida, said that his system started efforts in reducing readmissions among congestive heart failure patients by preventing unnecessary admissions. Memorial began placing case managers in the emergency department to evaluate patients as they come into the hospital, to prevent patients from being admitted unnecessarily to begin with.
It’s also increased the use of pharmacists and pharmacy techs to clarify the medication reconciliation process at all points of transition of care, and to teach patients and their families about their medications while they’re still at the hospital. Another strategy has been working with local home health agencies to ensure that they meet expected quality criteria.
At its flagship regional hospital, the system wanted to reduce CHS readmissions by 20 percent this year, and based on data from the first two quarters it’s on track to do that, Macaluso said.
All of these things, though, of course cost money, and that’s been a huge challenge for Memorial in sustaining some of these activities. “We’ve scrambled to identify those grants that are available for this type of care coordination work,” Macaluso said. It’s also reallocating people within its organization, making sure it’s being efficient in its other processes. “We recently combined our social work department and our quality and case management department, recognizing that you don’t need three people and a chart when you can have one person and a chart. That frees up the other people to do other types of work.”
It’s also beginning to look at risk assessment tools to identify patients that you may need to target for case management.
DeVore noted that there are still factors that need to be addressed in readmissions, particularly related to socioeconomic disparities, a lack of primary care in the community and various issues that get in the way of patient engagement and lead to non-adherence. Premier is also considering other ways to continue improving the initiative, like potentially adding community health as a seventh dimension of performance.
“(QUEST) is a terrific example of how proper design of healthcare delivery is a way to get the results we’re after,” said Donald Berwick, a senior fellow at the Center for American Progress and former CMS administrator. “The alternative to the design approach is not a good one; that is saving money by just cutting and cutting and cutting and taking things away from people.”
A presentation of the four-year data and case studies are posted here.
