PatientsChartingCourse

•Measures of success—outcome metrics, compliance with guide- lines, patient satisfaction, cost of services

•Result—improved outcomes and cost of services (Table 9-1)

Chronic Disease Care Optimization:

•Population—primary care office patients with chronic diseases

•Care model innovation—evidence-based care pathways and EHR- based registries and reminders for patients with diabetes, high blood pressure, and hyperlipidemia

•Business model innovation—pay-for-performance incentives

•Measures of success—bundled metrics for diabetes, hypertension, cholesterol and preventive services, patient satisfaction

•Results—marked improvement in all metrics (Table 9-2)

ProvenHealth Navigator:

•Population—all Medicare beneficiaries seen in primary care offices

•Care innovation—value-driven medical home model based on part- nership between primary care providers and GHP

•Business model innovation—fee for service supplemented with sti- pends and a quality-driven shared savings model

•Measures of success—triple aim outcome metrics for health status, patient experience of care, cost of care

•Results—improvements in Healthcare Effectiveness Data and Infor­ mation Set, patient satisfaction, and cost metrics (Table 9 3)

Patient-Centered Value Learning

This patient-centered value business model focuses learning on systems to improve outcomes. This is best seen in our ProvenHealth Navigator medical home model. The measures of success for this model are improvements in the dimensions of health status, patient experience of care, and total­ cost of care. Physicians are rewarded explicitly for improvements along these dimensions. As a result, the practices and GHP are tightly focused on monitoring outcomes together. The entire practice team, including GHP in-office case managers, reviews outcome results at monthly meetings. The practice managers produce monthly reports demonstrating the results of chronic disease care and patient satisfaction for each physician. GHP staff report on patients admitted to the hospital, all readmissions, and the total cost of care. Admissions, readmissions, and concerns for specific patients or care systems are discussed with the entire staff. The whole team, including office staff and GHP payer staff, is engaged in conversations about what could be done

Innovation: Evidence-based best practice surgical case redesign Evidence Development: Process and outcome metrics for surgical care Incentive: 90 global payment, including complications

TABLE 9-2  Value Learning: Chronic Disease Care Optimization

Innovation: EHR-driven registries and reminders

Evidence Development: Physician-specific monthly Healthcare Effectiveness Data and Information Set (HEDIS) metrics

Incentive: Straight pay for performance

TABLE 9-3  Value Learning: ProvenHealth Navigator

Innovation: Medical home with population management built into the primary care office Evidence Development: Process and outcome metrics for surgical care

Incentive: Fee for service, pay for performance, stipends and shared savings paid based on quality outcomes

better. Examples of best practices from other offices are diffused rapidly. In this environment, the team members can see the impact they are having across an entire population. Every member knows that good outcomes will be celebrated and poor outcomes scrutinized to learn important lessons.

In the ProvenHealth Navigator model, outcome measurement flows directly and naturally from the delivery of care. Understanding the patient

experience, quality outcomes, and the cost of care is a central management function of the practice. Learning to improve these outcomes is built directly­ into the operations of the practice.

Lessons Learned

We have made mistakes and learned important lessons over the past 5 years. The most significant lessons learned are as follows:

•It is possible to improve delivery systems to optimize the quality, patient experience, and efficiency of care simultaneously.

•Change is difficult to accomplish in the context of daily practice; it requires ongoing attention, additional dedicated staff, and a good motivation.

•Financial support and rewards are essential to make the business case, but:

—individuals respond to multiple drivers, not just payment; and

—transparency, constant feedback, and celebration of success drive staff engagement.

•Clinical and business leadership are critical.

•The provider–payer partnership is central.

•Transparency works: sharing results within and across practices drives improvement.

•Engagement and accountability work best in small units—groups of four to five physicians.

•Clinical transformation is hard work—focusing on initiatives with broad impact delivers the most added value.

•Timely analysis of results is essential to rapid-cycle innovation.

•Innovations affecting small numbers of patients provide limited data for analysis and learning.

The innovations described in this paper impact a relatively small portion of the overall clinical activity of our system. Other parts of the system operate with a more traditional volume-based model, albeit within the culture of a not-for-profit multispecialty group practice. The results demonstrate what is possible within an organization operating two business models. How much more value could be produced in an environment where every operational area was working to optimize patient-centered value? Given the synergistic effects among initiatives that we have seen, we believe it would be possible to produce much more value in a simplified business environment.

Implications for Health Systems

Our experience leads to the following suggestions for organizations, providers, and payers that make a strategic commitment to delivering higher-value care to their communities:

•Make patient-centered value an explicit strategic commitment, and communicate it clearly to the organization.

•Make patient-centered value innovation objectives important ­drivers of senior leaders’ incentive plans.

•Include the innovation goal in all employee incentive plans.

•Build population registries and other tools with which to manage a population, not just those in the hospital.

•Form payer partnerships to align reimbursement and agree on joint initiatives and R&D investments.

•Explicitly identify the source of added value before selecting a particular initiative.

•Maximize the leverage of care redesign and reimbursement changes to drive the broadest clinical impact with the least administrative work.

•Shorten the learning cycle time:

—build evidence-based guidelines into the flow of care;

—build data capture into standard care processes; and

—measure and feed back results frequently.

•Extend initiatives to as many patients as possible to create mass and momentum for change, as well as meaningful data.

•Establish analytical resources close to the innovation activities to provide rapid evaluation and feedback.

•Celebrate success.

Public Policy Implications

The most significant public policy opportunity to improve value inno­ vation and learning is to create the will for healthcare organizations to deliver high-value outcomes. The reimbursement innovations for providers­ and MA plans in the recent healthcare reform legislation will drive movement in that direction. The greatest impact would result if public and private payers developed a common approach that gave providers an unambiguous context in which to deliver higher-value care. Other suggestions include the following:

•Begin a public campaign to legitimize patient-centered value as an explicit aim.

•View CMS and the Center for Innovation as payer partners work- ing with providers to deliver patient-centered value.

•Make outcome data rapidly available to providers operating under value-based contracts.

•Increase transparency and stimulate learning by providing claims data to third parties for provider profiling.

•Challenge payers and providers to step up to accountability.

•Develop partnerships with private payers to provide greater patient mass for care transformation efforts by providers.

•Build a rapid learning network; use the EHR capabilities of mul- tiple integrated systems to establish a learning web that can mine current and future data to evaluate treatment impacts.

•Be cautious about evaluating initiatives that occur in provider sys- tems with mixed business models.

Conclusion

Opportunities to improve the value of health care abound, even with the limited knowledge we have today. As the healthcare system becomes digitized, shorter learning and innovation cycles become desirable and inevitable. We will learn from other industries that use refined data management capabilities to adjust their operations in real time. Whether innovation will drive higher value for patients or more revenue and volume for producers is unclear. The most significant step we can take to ensure that innovation serves patients is to reward higher-value outcomes. Public–private payer initiatives with specific providers committed to an unambiguous patientcentered value business model would provide the most robust learning envi­ ronment. This is the model that can teach us what is possible when every employee wakes up every day committed to learning how to better deliver high-value care for patients and the community.

CREATING A LEARNING CULTURE

Anne F. Weiss, M.P.P., and Bianca M. Freda, M.P.H.

The Robert Wood Johnson Foundation

The American healthcare system faces critical challenges, including poor quality, skyrocketing costs, and troubling racial and ethnic disparities. The ACA of 2010 arguably should provide tools to address many of these challenges. But it is unrealistic to expect that the nation’s healthcare system need only undergo a one-time transformation. Rather, the healthcare system will need the ability to identify problems proactively, develop solutions for those problems quickly, and create a culture that rewards

solutions and promotes the ongoing search for problems and their respective solutions. Essentially, real reform requires that health care become an ongoing learning enterprise. Unfortunately, health care currently is not that sort of system. In fact, American health care offers few incentives for, and indeed poses formidable barriers to, learning and problem solving. There is, however, hope. Work supported by The Robert Wood Johnson Foundation (RWJF) is helping the field understand some of the important necessary next steps toward such a learning system. Many observers have noted that the current system of paying for health care in the United States creates dis­ incentives for high-quality care: it encourages wasteful and fragmented care and does not reward providers who struggle to deliver good care (Miller, 2009). RWJF’s work to improve healthcare quality suggests that there are, however, powerful nonfinancial incentives that can be used to influence behavior and shape a learning culture.

RWJF launched its Quality/Equality strategy and its signature initiative, Aligning Forces for Quality (AF4Q), in 2008. RWJF’s board of directors has made a $300 million commitment to the strategy through 2015. The strategy was designed around two principles: first, that while quality is a national problem, health care is delivered locally, and fixing it requires local action; second, that those who receive, give, and pay for care—consumers, providers, and purchasers—need to team up and align their efforts to create lasting change (Painter and Lavizzo-Mourey, 2008).

AF4Q is being implemented in 17 targeted regions. Three are states (Minnesota, Wisconsin, and Maine); one is a rural county in California; and most of the rest are multicounty or metropolitan areas. In each region, a multistakeholder team of healthcare leaders, physicians, nurses, con­sumers, health plans, business, and others carry out three key activities: they issue public performance reports on hospitals and physicians, develop a sustainable capacity or infrastructure to help physicians improve, and work to engage consumers in using healthcare information.

For this strategy to succeed, different stakeholder groups need to reach fundamental agreement on difficult tasks, such as defining and measuring good care, engaging professionals in efforts to improve care, and getting patients and consumers more involved in different aspects of their care. And they have to accomplish these tasks in the absence of any meaningful policy, social, or economic incentives. Although there is certainly overwhelming evidence of various kinds of healthcare quality problems, different groups generally understand those problems differently (AHRQ, 2009).

The challenge of getting different stakeholders aligned around common goals in AF4Q is very much like the challenges to creating a learning health system. RWJF and its partners have addressed these challenges by using strategic communications, engaging health system leaders, and engaging consumers.

Using Strategic Communications

During 2007–2009, RWJF, in partnership with several strategic communications firms, embarked on a series of message research projects with the general public, physicians, consumers, and employers. In general, these projects involved a review of existing research, individual interviews, focus groups, and telephone or online surveys. The firms developed evidencebased messages, which were extensively sourced to ensure that they would be credible. Messages were distributed widely to AF4Q community teams and other grantees, who were trained in using the messages and were given interactive tools, such as a slide builder. The messages, training, and tools have been extremely well received by the AF4Q communities. There are lessons to be learned about each audience for these communications and ways to reach them effectively, which should also prove useful in efforts to create a learning culture.

Research on the general public was conducted in part by a firm, Olson­ Zaltman Associates, with a unique methodology based on theories of cognitive learning: that people learn and perceive the world according to a few universal frames or metaphors, and these metaphors help them derive meaning from a wide range of related concepts. Therefore, the firm’s approach is to identify these universal emotional metaphors and use them as the foundation for messaging and engagement efforts. In the case of health care, Olson Zaltman­ Associates’ research reveals that people view health care as a journey from a state of confusion and complexity to one of relief and simplicity, and they see quality health care as a patient–provider relationship that takes them to their goal, around multiple barriers, and results in comfort and peace of mind. The essence of quality health care from patients’ perspective is having a close relationship with their medical provider that is based on trust.

Subsequent message research with a physician audience emphasized AF4Q’s focus on measuring and publicly reporting on the quality of care. This research revealed that physicians are understandably focused on how performance data are collected, adjusted, and analyzed and how the data will be used; they expressed the greatest confidence in initiatives led by their peers. Physicians were interested in how they compared with their colleagues but did not want this information made public. They did not expect their patients to use public performance information. The results of this research were used to develop messages that acknowledge problems with previous efforts to measure and report quality and physicians’ frustration with the healthcare system. These messages give physicians reasons to participate in the project and ask them to contribute their leadership, expertise, and influence to help improve care and make their patients better partners in care. It is also important to link the process of measuring and reporting on quality with payment reform.

Messages were developed for employers as well, based on insights provided by AF4Q communities. These insights revealed the need to communicate very basic reasons why employers should take an interest in poor healthcare quality and offer specific ways they can contribute. Major messages used with the employer audience include both the direct and hidden, indirect costs of poor health care; the added premium costs of wasteful, poor-value care; and examples of companies that have made a difference.

Engaging Health System Leaders

Health system leaders, such as hospital board members, do not always make quality a strategic priority (Jha and Epstein, 2010). Fewer than half of hospital board members rate quality of care as a top priority, and only a minority have been trained in quality. A number of quality improvement initiatives sponsored by RWJF have explored ways to engage board members and senior executives in efforts to measure and improve quality (RWJF, 2008). Based on those experiences, a number of recommendations can be made for engaging health system leaders in a learning community:

•Make the case based on both mission and margin: build evidence for how learning is “the right thing to do” but also is good for the bottom line.

•Use a trusted intermediary, not a consultant, to reach hospital leaders.

•Make learning activities a standing agenda item, with dashboard metrics that align with other institutional goals.

•Ask health system leaders to play a role in publicly showcasing and communicating about results, as well as in motivating staff.

Engaging Consumers

Consumer engagement is a critical strategic component of AF4Q, as it should be in a learning healthcare system. RWJF’s goal is for consumers to access and use health and performance information to make healthcare decisions at key points. Consumer representation in all aspects of a learning organization, including governance and decision making, is critical to achieving the goal of patient-centered care (Regenstein and Andres, 2010). Consumer representatives may require ongoing training and support to play a meaningful role.

Authentic consumer representation involves individuals who do not have a financial stake in the healthcare system. They may represent a specific constituency, be it faith-based, disease-based, or population-based (NPWF, 2009). Individuals who are current or retired employees of a

healthcare organization and their spouses are often tagged as “consumer” representatives but may not be able to play that role convincingly.

Too often, healthcare improvement initiatives focus on what is technically and politically feasible rather than what is of greatest importance to patients and families. This is due, in part, to the relative absence of information on meaningful outcomes that capture patients’ experience over time and in different settings, compared with an abundance of information on specific clinical processes and transactions. For example, while it is costly to collect information on patient experience, these measures provide direct information about the patient-centeredness of care at both the practice and provider levels, and positively correlate with processes of care for both prevention and disease management (Shaller et al., 2010). AF4Q sites are working to make the results of patient experience surveys more widely available, despite the difficulty of finding a sustainable business model for doing so. A learning health system should focus on and promote the issues that matter to patients and families.

Creating a Learning Culture: Some Conclusions

Although not backed by rigorous research results at this point, some insights about how to create a learning culture within the healthcare system have emerged from RWJF’s experience in promoting social change and AF4Q’s experience to date:

•Test change in local markets—Although healthcare quality is obviously driven by federal and state policy, as well as private market developments at every level, health care is delivered locally, and it is important to gain experience in different market environments around the country.

•Invest in message research and adhere rigorously to tested ­messages—

Strategic communication is a proven critical component for achieving social change (Hurley et al., 2009).

•Insist on participation by multiple stakeholders (Sequist et al., 2008).

•Engage authentic consumer participation.

•Measure and focus on what matters.

•Value transparency.

•Do not neglect financial incentives—Although this paper has ­focused on nonfinancial ways to create a learning culture, creating such a culture is difficult in the face of payment systems that often punish, rather than reward, learning and improvement (RWJF, 2010).

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