Case Study Organized Health Care Delivery System • January 2010 Scott & White Healthcare: Opening Up and Embracing Change to Improve Performance D ouglas M c C arthy and K imberly M ueller I ssues R esearch , I nc . The mission of The Commonwealth ABSTRACT: Founded in 1897 in Temple, Texas, Scott & White is the largest multispe- Fund is to promote a high performance cialty health care system in the state, and delivers a comprehensive continuum of care to health care system. The Fund carries its health plan members and constituents. Along with a tradition of supporting scholarship out this mandate by supporting in medicine, the system’s mission includes contributing professionally to advancements independent research on health care issues and making grants to improve in the domains of medical research and education. Evolving network composition and health care practice and policy. Support provider reimbursement strategies have been associated with reported improvements in for this research was provided by productivity as well as quality and patient satisfaction outcomes. These quality improve- The Commonwealth Fund. The views ments are linked to greater system efficiency through oversight by physician and admin- presented here are those of the authors istrator leadership teams. Scott & White espouses a shared culture and values, character- and not necessarily those of The ized by the vision and expectation of continuous quality improvement, collaboration and Commonwealth Fund or its directors, officers, or staff. peer accountability, the ability to look at the totality of patient care, and a willingness to embrace systemic change when necessary to help the organization achieve success.      For more information about this study, please contact: OVERVIEW Douglas McCarthy, M.B.A. In August 2008, The Commonwealth Fund Commission on a High Performance Issues Research, Inc. dmccarthy@issuesresearch.com Health System released a report, Organizing the U.S. Health Care Delivery System for High Performance, that examined problems engendered by fragmenta- tion in the health care system and offered policy recommendations to stimulate greater organization for high performance.1 In formulating its recommendations, the commission identified six attributes of an ideal health care delivery system (Exhibit 1). To learn more about new publications Scott & White is one of 15 case-study sites that the commission exam- when they become available, visit the ined to illustrate these six attributes in diverse organizational settings. Exhibit Fund's Web site and register to receive Fund email alerts. 2 summarizes findings for Scott & White. Information was gathered from Scott Commonwealth Fund pub. 1365 & White health system leaders and from a review of supporting documents.2 Vol. 37 The case-study sites exhibited the six attributes in different ways and to varying 2T he  C ommonwealth F und Exhibit 1. Six Attributes of an Ideal Health Care Delivery System • Information Continuity Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record (EHR) systems. • Care Coordination and Transitions Patient care is coordinated among multiple providers, and transitions across care settings are actively managed. • System Accountability There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination, since one supports the other.) • Peer Review and Teamwork for High-Value Care Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and col- laborate to reliably deliver high-quality, high-value care. • Continuous Innovation The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery. • Easy Access to Appropriate Care Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs. degrees. All offered ideas and lessons that may be Because Texas law prohibits the corporate helpful to other organizations seeking to improve practice of medicine, Scott & White was organized their capabilities for achieving higher levels of as three distinct legal entities: the clinic, the hospital performance.3 and foundation, and the health plan, each with its own physician-leader and chief administrative officer, all of ORGANIZATIONAL BACKGROUND whom met weekly in committee to promote “integra- Scott & White, based in central Texas, is the largest tion through cooperation.” In 2000, Texas law changed, multispecialty health care system in the state, with permitting a merger of the hospital and the clinic. At three hospitals that admit 30,000 inpatients annually, the same time, a single chief executive was appointed nearly 50 regional primary and specialty care clinics to lead the entire system (the health plan remains a receiving 1.7 million annual outpatient visits, and a separate nonprofit legal entity under his leadership). 200,000-member health plan (Exhibits 3 and 4). It also The system functioned much like a group model serves as the clinical residency site for the Texas A&M health maintenance organization until recent years, Health Science Center College of Medicine. Founded when, in response to increasing market competition in Temple, Texas, in 1897, the physician-led nonprofit and purchaser demands, it moved from a closed capi- system employs more than 7,000 staff, including more tated model to an open fee-for-service network model. than 700 physicians and scientists. A major growth Nearly simultaneously, the health system began pursu- initiative culminated in 2007 with the replacement, in ing contracts with national health insurance providers, Temple, of the Scott & White Memorial Hospital by the health plan began to contract with independent pro- the new 500-bed Center for Advanced Medicine, and viders, and salary-based compensation for physicians the openings of a new long-term acute-care hospital, evolved to include productivity expectations along also in Temple, and a new 70-bed multispecialty hos- with their patient care, teaching, research, community pital in Round Rock. Scott & White enjoys a market service, and professional contributions. Referrals to the share of approximately 70 percent in the Temple area. system increased 22 percent during 2008, according Supported by double-digit relative growth in the vol- to the organization’s annual report. Currently, Scott & ume of inpatient and outpatient services, Scott & White White Clinic physicians render about 75 percent of ser- reported over $1 billion in revenue in 2008.4 vices provided under the Scott & White Health Plan. S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 3 Exhibit 2. Case-Study Highlights Overview: Scott & White is the largest integrated multispecialty health care system in Texas, employing more than 700 physicians who prac- tice in three hospitals, including a new long-term acute care facility, and in almost 50 regional primary and specialty care clinics in central Texas, providing 1.7 million outpatient visits and more than 30,000 inpatient admissions annually. Scott & White Health Plan enrolls 200,000 members in group, individual, and Medicare coverage programs and contracts with both Scott & White and independent providers. Scott & White also serves as a clinical educational site for Texas A&M Health Science Center College of Medicine. Attribute Examples from Scott & White Information Continuity An EHR links main hospital and community clinics, facilitating communication across the care continuum. Hospital nurses use mobile com­ uters for electronic medication administration at bedside. p Primary care physicians receive e-mail notifications of specialist consultations for their patients and e-mails to reconcile medication following hospital discharge. An online portal allows patients to find a doctor, schedule ap­ ointments, request prescription refills, make p payments, and learn about health topics. Care Coordination Nurse care managers are em­ edded in two large clinics to work with primary care physi­ ians on patient b c and Transitions; chronic disease management. System Accountability* Health plan–sponsored nurse care managers provide telephon­c support for chronic disease education, i monitoring, and follow-up after hospital discharge, and refer patients for clinic appointments as needed. New mothers receive phone follow-up and transitional support following birth. Anticoagulation clinics staffed by pharmacists or nurses monitor patients outside the hospital us­ng stan- i dardized protocols. Peer Review and Teamwork Physicians are evaluated through annual credentialing and performance reviews including patient care, for High-Value Care teaching, research, and community service. The EHR facilitates informal peer review and feedback. Some de­ artments perform formal blinded peer p review with feedback to physicians. Divisions/departments can earn a 20 percent bonus by scoring 90 percent or higher on quality targets and goals. The Patient Panels program invites patients to share personal stories of negative experiences; lessons learned are shared across the organization to im­ rove quality and service. p Continuous Innovation Every major facility has a director of quality and a Quality and Pa­ient Safety Council; the System Quality t and Pa­ient Safety Council monitors systemwide quality measures; any core measure not achieving a 90 t percent score becomes an organization-wide quality improvement initiative with a formally chartered team led by a physician and an operational leader. The Clinical Simulation Center designs and tests new processes and promotes con­inuous learning for t human error prevention. Easy Access to Clinic “ambassadors” greet pa­ients at the door, direct them to appointments, and generally facilitate t Appropriate Care patient comfort and access. The Office of International Affairs serves non–English-speaking pa­ients (primarily from Mexico and t Korea) with 24-hour interpreta­ion and bilingual providers. t A telemedicine program for select specialties reduces geographic barriers for patients in remote areas. HealthExpress clinic offers walk-in urgent-care access seven days a week. Group visits are offered for chronic disease education. * System accountability is grouped with care coordination and transitions, since these attributes are closely related. 4T he  C ommonwealth F und Exhibit 3. Scott & White Service Area by County Primary service area Secondary service area Dallas • El Paso • Austin � Houston • San Antonio • Brownsville • Note: Geographic boundaries represent counties. Source: Scott & White. INFORMATION CONTINUITY patient bedside for electronic medication management, Scott & White’s internally developed electronic health scanning a drug and the patient’s identification bracelet record (EHR) system, called Sequoia, has evolved to ensure that the right patient receives the right medi- over the past 13 years into a unified clinical informa- cation and dose at the right time. tion system linking the main hospital and outpatient The Scott & White Web site offers patients clinics (Scott & White physicians also have access to the opportunity to find a doctor or clinic, schedule an the system from their homes) and is accessible both appointment, request a prescription refill, make a pay- by computer and mobile device. Clinical guidelines ment, and learn about health-related topics, support embedded in the EHR promote evidence-based treat- groups, and clinical research trials in which they may ment at the point of care. The EHR enables a standard- be eligible to participate. ized medication reconciliation process across care set- tings within the system. Scott & White is implementing CARE COORDINATION AND TRANSITIONS: third-party software, called NextGen, to complement TOWARD GREATER ACCOUNTABILITY FOR its legacy systems with additional functionality includ- TOTAL CARE OF THE PATIENT ing appointment scheduling, patient communication, The EHR, enhanced by next-generation technology, workflow management, medication management, and promotes coordination of care among Scott & White referral tracking. facilities and clinicians. For example, a primary care The new Center for Advanced Medicine (the provider or referring physician will automatically main replacement hospital) features state-of-the-art receive an e-mail notification within two days of a digital imaging and technology to facilitate communi- patient’s clinic visit or hospital dismissal, advising of cation between patients and providers and to enhance changes to the patient’s medication regimen, plans of patient safety. Inpatients can immediately reach their care, and recommendations from other providers. personal nurse through a digital call system. Physicians Scott & White offers several forms of care man- can access real-time clinical data on their patients agement that follow evidence-based clinical guidelines through wireless devices from anywhere in the hospi- and protocols to help improve the care and outcomes of tal. Nurses use wireless “computers on wheels” at the patients in need of monitoring, education, and support. S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 5 Exhibit 4. Scott & White Facilities Note: Geographic boundaries represent counties. Source: Scott & White. • Nurses employed by the Scott & White Health and pharmacists who use physician-approved Plan are embedded in some of the system’s standardized protocols to monitor patients on larger primary care clinics to assist in the man- warfarin (a blood thinner), make needed dosing agement of patients with diabetes and heart dis- adjustments, and maintain close communication ease. Nurses work with physicians to communi- with primary care providers. cate with, educate, and (through a computerized • New mothers receive telephone follow-up registry) monitor patients. An evaluation found from MOMS (Maternal Options Maintenance this program was associated with 32 percent to Support) nurses, who check on the status of 35 percent lower hospital use (days per 1,000) both mother and baby after discharge, facilitate and 15 percent to 17 percent lower total costs insurance enrollment for the newborn, and make per member among patients with diabetes at referrals for follow-up care as recommended pilot sites compared with other practice sites.5 or needed. The program has, however, proven to be a chal- lenge to sustain from a staffing perspective. Specialty clinics offer patients with conditions such as heart failure, diabetes, and cleft palate an • Nurses employed by a third-party vendor staff opportunity to see multiple specialists who work as a “HealthConnect” care management programs team to provide comprehensive and coordinated care for health plan members with chronic condi- in a single setting. For example, a patient in the heart- tions such as asthma, diabetes, heart disease, failure clinic may see a cardiologist, cardiac nurse and chronic obstructive pulmonary disease. Care specialist, dietitian, and exercise physiologist at the managers contact patients by telephone to check same visit. The diabetes clinic has begun to test group on their status after hospital discharge, monitor appointments in which 10 to 12 patients see an endo- their medication adherence, provide self-care crinologist, a diabetes nurse specialist, and a dietician education and resources, and make referrals to to learn how to better control their diabetes and reduce the clinic for follow-up care as needed. complications. Care is coordinated with the primary • Anticoagulation clinics in operation at several care physician and communicated via the integrated Scott & White facilities are staffed by nurses EHR. Specialist providers in these clinics are also 6T he  C ommonwealth F und available by secure e-mail to primary care providers To cultivate the spirit of teamwork, nearly all across the system. These types of communications Scott & White physician-administrators maintain active facilitate access to formal and informal consultation practices with patient care responsibilities. Dr. James services, regardless of location. Rohack describes the rationale this way: “In a multi- The Cancer Treatment Center at Scott & White specialty group everyone starts out pulling the wagon brings together eight multidisciplinary care teams of together. When you are assigned to administration, you oncologists, surgeons, pathologists, and other hospital get up on the wagon and take the reins and everyone staff who meet on a regular basis to plan and deliver else is pulling you. So at least if you can get off the a coordinated program of care to patients with cancer. wagon once in a while and help pull a bit, it makes A nurse coordinator assists with referrals and schedul- the horses feel better.” In addition, outpatient primary ing, facilitates communication between providers, and and specialty care providers have the opportunity to serves as a point of contact for patients. Patients receive serve a scheduled inpatient hospital in rotation. The “bio-cards” containing background information and pic- organization has found that having physicians rotate as tures of the providers who will be working as part of hospitalists keeps everyone’s skills current, helps with their care team. Planned renovation of the treatment continuity of care, and improves efficiency. center will centralize the multispecialty teams and Scott & White researchers recently implemented update facilities to promote an easily accessible and a pilot intervention targeting medication reconcilia- more comfortable treatment experience for patients. tion and physician feedback in four of their outpatient clinics. In this pilot, participants age 65 years and PEER REVIEW AND TEAMWORK FOR older were queried about their medication use at home, HIGH-VALUE CARE and the information was compared with their medi- Scott & White employs multiple mechanisms to pro- cal record. Any discrepancies were documented and mote high-value care: reported to the patient’s physician in writing, along with an adhesive label of patient-reported medications • A multifaceted evaluative process for physi- for easy inclusion in the medical record. Documented cians includes the granting of hospital admit- discrepancies included not taking medications as ting privileges and credentialing for health plan prescribed, taking medications not documented in participation, annual performance reviews, and the patient chart, and a difference in dosage and/or ongoing informal peer review facilitated by schedule. Physician response to this intervention was group practice and information-sharing through overwhelmingly positive, with over 90 percent of par- the EHR. The radiology and family medicine ticipating physicians surveyed reporting the written departments are pilot-testing a formal “blinded” feedback and the labels as helpful.6 (confidential) peer review process with feedback Each quarter, the Patient Panels program iden- to physicians. tifies three of the patients who have experienced the most Scott & White services—such as inpatient and • Compensation is linked to quality improvement outpatient care, radiology, and the ER—and who have efforts by a bonus program whereby an entire had either a positive care experience or a negative division or department can earn a 20 percent experience (such as an adverse event). These patients bonus in pay if they score 90 percent or higher are given an opportunity to tell their stories to physi- on core measures and 90 percent or higher on cian and nurse leaders in the system. Resident physi- tracer measures based on national patient safety cians also attend these feedback sessions, reinforcing goals and on the Scott & White quality improve- their competency in listening to what their patients tell ment initiatives. them. (This pedagogical approach has been recognized S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 7 for educational innovation by the Association of The chairperson of each quality initiative team, Program Directors in Internal Medicine.) After each together with the Quality and Patient Safety Council panel presentation, the providers debrief and dis- leader and quality program director, participates in cuss how that patient’s experience could have been the System Quality and Patient Safety Council, which improved. Each patient panel is videotaped and key includes the system’s CEO, the chief medical officer, excerpts are shared at staff meetings in each facility to the chief of hospital operations, and three members promote systemwide learning and change. of the Board of Trustees. During monthly systemwide quality improvement accountability meetings, three CONTINUOUS INNOVATION chartered quality improvement initiatives are discussed Every Scott & White facility names a Director of on a rotating basis. Each initiative process results in the Quality who is assigned to one of 10 primary Quality development of a new action plan and timeline if the and Patient Safety Councils that oversee quality measure is still below the 90th percentile. Occasionally, improvement efforts in the system. These councils are when no improvement has been shown over time, a responsible for monitoring standard quality measures team’s leadership will be changed. The council struc- such as HEDIS (Healthcare Effectiveness Data and ture provides consistent improvement strategies and Information Set) that are widely used among man- results in practice-sharing between providers as well aged care plans. Any core measure not achieving a as “friendly” competition between facilities to improve level of 90 percent or higher becomes the subject of quality and patient safety (Exhibit 5). an organization-wide quality improvement initiative that is assigned a physician leader, an operational • Quality “tracers” on each unit are monitored leader, a chairperson, and a team. Each initiative is once every quarter. Facilities are evaluated then formally chartered to include expected outcomes, through direct observation by trained qual- resources, care bundles used, a timeline, and decision- ity management nurses on such core measures making authority. as hand hygiene and “crash cart” checking. Clinic managers are informed of the results the Exhibit 5. Scott & White Quality and Patient Safety Program Operational Communication and Support Infrastructure Strategies People Strategies Strategies Quality improvement goals Effective communication Resources Examples: National Surgical Quality Examples: structured and Examples: data and staff Improvement Program, critical language Organizational culture Five Million Lives Campaign, Problem analysis tools Examples: engaged leadership, preventing patient falls Examples: human error and fair and just policy and practice Action model reliability, team dynamics Examples: implementation tools Frontline involvement such as rapid improvement process Examples: root cause analysis, teams, quality management safety culture survey, senior programs such as medical staff staff rounds peer review Patient involvement Examples: Patients as Partners program, patient panels Source: Excerpted and adapted from Scott & White internal documents. 8T he  C ommonwealth F und same day and given a suggested action plan for vaccination, nurse response time, and medication rec- improvement. onciliation. Externally driven initiatives are developed in response to mandates arising from accreditation and • A quarterly Quality and Patient Safety Day has regulatory requirements. Examples of such mandates recently been added to the quality improvement include Medicare hospital quality indicators, recent process. Council members, together with any Texas legislation requiring public reporting of hospital- staff they would like to invite, participate in acquired infections, and Medicare’s new policy of educational presentations, open discussion, and disallowing payment for “never events” in which best-practice sharing on each of that year’s qual- one of the selected conditions was not present ity initiatives. upon admission. • The Quality and Patient Safety Councils also Scott & White has made the Joint Commission’s help determine systemwide process improve- core performance measures a feature of its continu- ments to standardize equipment purchases, ous quality improvement efforts. A dedicated qual- leverage economies of scale, and improve qual- ity coordinator oversees each major hospital service ity of care. The organization has adopted the line to facilitate compliance with core measures for Toyota “lean” philosophy to reduce waste and heart attack, heart failure, pneumonia, prevention of redundancy in the system, with a patient safety surgical infection, and pregnancy-related conditions. focus. Scott & White sponsored training in lean Coordinators work in conjunction with physician-led methodologies for physician leaders to facilitate multidisciplinary teams to monitor and abstract data, engagement in quality improvement processes. then report and disseminate information on opportuni- Scott & White’s executive director of safety ties for improvement. As a result of these efforts, the and quality, Gail VanZyl, distinguishes the system’s pneumococcal vaccination rate, for example, rose from quality improvement initiatives as either internally 20 percent to 95 percent in just over two years (Exhibit or externally driven. Internally driven initiatives 6). Scott & White captures additional data elements are selected by Scott & White’s Quality and Patient within each domain to improve internal performance Safety Councils. Recent examples include pneumonia and to participate in voluntary external measurement Exhibit 6. Scott & White: Quality Improvement for Pneumococcal Screening and Vaccination Percentage of appropriate inpatients receiving service 100 80 60 40 20 0 4 5 04 05 04 4 05 05 04 05 04 00 00 00 20 20 20 20 20 20 20 20 .2 .2 2 ar. ar. v. ay ay n. pt pt ly ly n. No Ju Ju Ja Se Se M M M M Ja Note: Data represent pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. Source: Adapted from Healthcare Financial Management Association, “Core Measures Drive Change,” Managing the Margin, Mar. 2006. S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 9 initiatives. This allows the system to make process time for receiving test results from 72 hours to two improvements before public data reporting is required. hours. Subsequent isolation procedures are instituted Scott & White manages the Clinical Simulation as indicated to prevent the spread of infections. The Center (located on its Temple campus) in partnership system is spending close to $1 million annually on its with Temple Community College and Texas A&M MRSA prevention efforts, which were associated with University. The center includes four high-fidelity a 25 percent reduction in positive MRSA cultures dur- simulation rooms: two intensive-care rooms, a labor ing 2008. Similar improvement efforts are under way and delivery room, and an operating room. All feature to reduce rates of ventilator-associated pneumonia in high-technology manikins with simulated veins, arter- critical care units across the Scott & White system ies, heart beat, pulse, breathing, and speech controlled (Exhibit 7). remotely. Scott & White uses the simulation center to In September 2007, Scott & White Health Plan train residents, to design new processes and test them partnered with American Imaging Management (AIM) before they are implemented with patients, and to to implement a Radiology Quality Initiative Program, promote continuous learning and human error preven- which evaluates outpatient radiology orders for appro- tion for physicians and other providers. The Agency priateness and timeliness. The system uses a call center for Healthcare Research and Quality recently funded a and an Internet-based patient portal, where referring simulation project to determine whether a curriculum physicians enter orders for imaging services. A tiered for training multidisciplinary rapid-response teams system reviews the orders for compliance with nation- in better communication methods using high-fidelity ally recognized clinical guidelines. If necessary, the simulations will improve safety in a rural tertiary-care ordering provider can speak with a nurse or physician hospital. reviewer to provide additional information to guide the In an effort to reduce hospital-acquired infec- utilization review process. AIM also works with Scott tions from methicillin-resistant Staphylococcus aureus & White Health Plan to design and implement provider (MRSA), every patient admitted to a Scott & White education and communication programs and to pro- hospital receives a nasal swab MRSA screening using mote adherence to the guidelines. rapid DNA testing, which has reduced the turnaround Exhibit 7. Scott & White Memorial Hospital: Ventilator-Associated Pneumonia Rates, January to June 2008 Number of cases per 1,000 ventilator days CTCU MICU NICU 15 10 5 0 M 08 08 08 08 8 8 8 8 08 00 00 00 00 20 20 20 20 20 2 2 2 2 ar. ar. ar. ay ay ay n. n. n. Ja Ja Ja M M M M M Note: The Pediatric Intensive Care Unit recorded no cases of VAP from January to June 2008. CTCU = Cardiothoracic Care Unit; MICU = Medical Intensive Care Unit; NICU = Neonatal Intensive Care Unit. Source: Scott & White. 10T he  C ommonwealth F und Exhibit 8. Scott & White: Pilot Study on Effect of PDA Use on Diabetes Outcomes Mean glycosylated hemoglobin (HbA1c) measure 9.7 10 8.0 8 6 4 2 0 Baseline Six-month visit Note: PDA=personal digital assistant; 18 subjects completed the six-month intervention. Source: S. N. Forjuoh, M. D. Reis, G. R. Couchman et al., “Improving Diabetes Self-Care with a PDA in Ambulatory Care,” Telemedicine and e-Health, Apr. 2008, 14(3):273–9. Scott & White’s Department of Family and PDA more frequently. Although limited in size, the Community Medicine conducts research to improve study appears to confirm the potential benefit of per- patient care and prevent disease. For example, it sonalized health information technology in improving coordinates the Central Texas Primary Care Research self-care activities among motivated individuals.7 Network, a practice-based research consortium funded by the Agency for Healthcare Research and Quality EASY ACCESS TO APPROPRIATE CARE that conducts research in primary care settings and Scott & White patients needing after-hours or urgent translates findings into practice. Other research has care are accommodated through such mechanisms as examined the benefits of a migraine disease manage- a HealthExpress Clinic, a walk-in urgent-care clinic ment program, the use of e-mail communications with open every day of the week. Scott & White Clinic also physicians, and the effects of “open-access” scheduling offers specialized clinics to handle seasonal needs, on appointment availability. such as Saturday vaccination clinics for children need- A recent pilot study from the Department of ing immunizations in advance of the new school year. Family and Community Medicine looked at the effect The Department of Family Medicine has championed of a personal digital assistant (PDA) on self-care activi- the “open access” approach to appointment schedul- ties by patients with diabetes. In that study, 43 patients ing, which seeks to reduce waits for appointments with type 2 diabetes and a most recent hemoglobin A1c by matching daily supply to demand. However, this measure of at least 8.0% were furnished with training approach is challenged by physician absences during and the use of a PDA loaded with software designed to inpatient rotations and has met with mixed acceptance. improve and enhance diabetes monitoring by providing Clinic “ambassadors” greet patients at the door, reminders and by recording and trending information direct them to clinic, lab, or radiology services, get on glucose measurements, medication administra- them tea or coffee and otherwise act to make their tion, food intake, and other self-care activities. The 18 visit as stress-free and comfortable as possible. Patient subjects who completed the six-month intervention “navigators” facilitate access to care for patients with achieved a 17.5 percent decrease in their mean hemo- cancer and act as a liaison with multidisciplinary globin A1c measurement, from 9.7% to 8.0% (Exhibit cancer care teams. The navigators help guide the 8), with greater reductions seen in those who used the patient through the health care system while providing S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 11 emotional, informational, and technical support. At its patients, the Scott & White Health Plan reviews the four of Scott & White’s busiest outpatient clinics, an use of interpreting services periodically to guide the automated kiosk enables patients to check themselves development of patient materials in languages other in, update their contact and insurance information, than English. The Scott & White Web site lists bilin- and even process a credit card payment for insurance gual providers. copays. The first system was installed in September Scott & White provides medical services 2007, and additional kiosks may be installed at other throughout its local and extended communities. For clinic sites. Although the kiosks do not replace the example, the system provided medical care to individu- regular check-in desk, many patients find it convenient als evacuated to Central Texas after a hurricane, offers to use the automated system.8 a free heart disease risk assessment, and conducts vac- The Office of International Affairs serves non– cination clinics for schoolchildren and health clinics English-speaking patients (primarily from Mexico and for people who are homeless and those with chronic Korea) with 24-hour access to medical interpretation conditions who lack health insurance. services. In an effort to monitor the ongoing needs of Exhibit 9. Selected Externally Reported Results and Recognition* Inpatient Care Quality10 Four-topic clinical composite (24 measures): Scott & White Memorial Hospital (CMS Hospital Compare ranked in the top quartile of U.S. hospitals evaluated. Jan.–Dec. 2007) Heart attack treatment (8 measures): Scott & White Memorial Hospital ranked in the top quartile of U.S. hospitals evaluated. Heart failure treatment (4 measures): Scott & White Memorial Hospital ranked in the top decile of U.S. hospitals evaluated. Surgical care improvement (5 measures): Scott & White Memorial Hospital ranked in the top quartile of U.S. hospitals evaluated. Ambulatory Care Quality Clinical quality (33 measures): Scott & White Health Plan ranked in the top quartile (NCQA Quality Compass of commercial health plans nationally or regionally on 11 measures, and in the top 2008) decile on 5 of those measures. Patient experience (9 measures): Scott & White Health Plan ranked in the top quartile of commercial health plans nationally or regionally on 5 measures, and in the top decile on 4 of those measures. National Recognition Verispan Top 100 Integrated Health Networks (2006–2008). and Ratings Thomson/Solucient 100 Top Hospitals: National Benchmarks for Success (Scott & White Memorial Hospital, 2003–2008). HealthGrades Distinguished Hospital for Clinical Excellence (Scott & White Memorial Hospital in 2006). National Research Corporation’s Consumer Choice Award (Scott & White Memorial Hospital in 2004/2005–2007/2008). National Committee for Quality Assurance: Commercial and Medicare Health Plan Excellent Accreditation. US News & World Report Best Health Plans: Scott & White ranked among the top 25 Medicare plans in 2005 and 2006. * Note: These data reflect a time period used across all case studies in the series. See the Series Overview, Findings, and Methods for analytic methodology and explanation of performance recognition. CMS = Centers for Medicare and Medicaid Services; NCQA = National Committee for Quality Assurance (Quality Compass 2008 represents the 2007 measurement year). 12T he  C ommonwealth F und Nurses employed by a third-party vendor staff 2001 to 2005 had relatively lower Medicare spending the 24-hour HealthConnect answer line, offering infor- per person (83% of the U.S. average) and fewer hospi- mation on self-care needs and advice on whether a doc- tal days (68%) and physician visits (64%) as compared tor’s appointment, urgent care, or ER visit is appropri- with the U.S. average. Among 93 academic medical ate. Scott & White Health Plan members have access to centers, Scott & White had the lowest Medicare inpa- wellness programs (provided by a third-party vendor) tient costs (reimbursements) per person during this that evaluate members’ health needs and create a per- time period.9 sonal health improvement plan with tools for stress The identification of areas of excellence does management, nutrition and weight, smoking cessation, not mean that Scott & White has achieved perfection, and depression management. The programs include however. Like the other organizations in this case- financial incentives for participation. study series, Scott & White has room for improvement Telemedicine technology enables specialties in several areas of care. Scott & White’s track record of such as cardiology, mental health, plastic surgery, and improvement suggests that the organization will learn pediatric neurology to reach patients who live in out- from such deficiencies and continue to innovate so as lying communities. Telemedicine facilitates specialty to achieve higher performance. consultations by overcoming barriers such as provider shortages and significant travel distances. The Sleep INSIGHTS AND LESSONS LEARNED Disorders Center, for example, uses telemedicine tech- Scott & White is a thriving, integrated multispecialty nology to diagnose and treat patients who are located system in a state known for independence and auton- more than 100 miles away, while permitting visual omy. While it once enjoyed the market share and cost contact and open communication between the patient insulation benefits afforded by a capitated and closed- and the provider. network model, its recent change to an open-network The Center for Diagnostic Medicine facility was model is increasing community trust and resulting in designed “with an eye focused on patient care.” The unexpected improvements in productivity, quality, building promotes a pleasant experience for patients and patient satisfaction in addition to greater financial and staff, with accessible waiting areas, conference stability and organizational self-awareness, accord- rooms for support groups and continuing medical edu- ing to its leaders. Various system functions, such as cation, a deli and garden patio, and a pharmacy. It also specialty consults, have had to adapt within the new incorporates “green” strategies for energy efficiency reimbursement structure, but are facilitated by a shared and patient-centered design aspects, such as rheumatol- EHR and electronic communication tools. As James ogy and geriatric clinics located on the first floor. Rohack, M.D., director of Scott & White’s Center for Healthcare Policy, puts it, “We moved from a closed- RECOGNITION OF PERFORMANCE group ‘push’ model to an open ‘pull’ concept where In addition to the results of the specific interventions the patients now have a choice, and that has provided described above, Scott & White has achieved notable increased incentive to improve service.” results on selected externally reported performance Within this culture of independence, systemic indicators and has received recognition for its perfor- dynamics in the Scott & White organization over the mance in several national benchmarking or award pro- last decade have had an impact on policies related grams (Exhibit 9). In terms of efficiency, data from the to provider management. While not without its chal- Dartmouth Atlas of Health Care, which examined care lenges, moving from a salary-based physician compen- at the end of life for Medicare patients with chronic sation system to one tied to productivity- and quality- illness, indicate that those who received the majority based outcomes has increased productivity. Developing of their care at Scott & White Memorial Hospital from and implementing uniform, evidence-based standards S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 13 and a more formal and systemwide peer review process CEO of Scott & White. For example, physicians lead aim to reduce practice variation and improve quality every key quality initiative, and regularly review qual- and, ultimately, outcomes. Furthermore, implementing ity data at Scott & White facilities. Under physician an open-access model to promote improved access to leadership, interdisciplinary teams plan and monitor providers becomes complicated when physicians spend progress toward quality goals. The CEO, several board weeks out of their clinics serving an inpatient rotation members, and a lay individual participate in the System in the hospital setting. The implementation of these Quality and Patient Safety Council, and even when processes was facilitated by the integrated nature of rates are approaching their targets, leadership “keep[s] Scott & White. As Dr. Rohack notes, “The best system us challenged to not be satisfied” with the status quo, is a system. And if we’re going to improve quality and according to Gail VanZyl, R.N., executive director of safety and reduce costs, having everyone in the system safety and quality. aligned to do the right thing, so there’s no incentives to A shared vision and expectation of continuous do wasteful things or things that don’t add value to the quality improvement, a culture of collaboration and system, then that’s going to…allow American health- peer accountability, the ability to look at the totality care to evolve.” of patient care, and a willingness to embrace organi- zational change when circumstances require it have I think there are tremendous opportunities for helped the organization achieve its success, its leaders process improvement in evidence-based medicine, say. Potential recruits undergo a rigorous screening decreasing variation, all the things we all know about process to ensure that they are a good fit for the group- that we as a very complex industry basically ignore. practice model and organizational mission. Physicians We have tremendous opportunity at every level to do are not bound by contract, allowing graceful exits things better. when appropriate. Quality and Patient Safety Councils, Alfred Knight, M.D. at both the unit and the system level, create a formal president and CEO of Scott & White charter for internally and externally driven initiatives. Physician and administrator leadership teams func- With a robust culture of organizational improve- tion to ensure that quality improvements are linked to ment, Scott & White is developing and testing vari- greater system efficiency. That philosophical founda- ous quality improvement strategies. The organization tion has helped Scott & White to achieve substantial is physician-led, and physicians are integral to its improvements in quality and efficiency, but, as Dr. functioning, not on an “ownership” basis but through Knight points out, “I think there are tremendous oppor- active, collegial involvement with shared responsibil- tunities for process improvement in evidence-based ity and accountability. “It’s incorporating physicians medicine, decreasing variation, all the things we all throughout every level of governance and leadership know about that we as a very complex industry basi- and every committee. It is a fundamentally different cally ignore. We have tremendous opportunity at every structure,” says Alfred Knight, M.D., president and level to do things better.” For a complete list of case studies in this series, along with an introduction and description of methods, see Organizing for Higher Performance: Case Studies of Organized Health Care Delivery Systems— Series Overview, Findings, and Methods, available at www.commonwealthfund.org. 14T he  C ommonwealth F und N otes 6 S. N. Forjuoh, M. D. Reis, G. R. Couchman et al., “Physician Response to Written Feedback on a 1 A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, Medication Discrepancy Found with Their Elderly R. Nuzum, and D. McCarthy, Organizing the U.S. Ambulatory Patients,” Journal of the American Health Care Delivery System for High Performance Geriatrics Society, Dec. 2005 53(12):2173–77. (New York: The Commonwealth Fund Commission on a High Performance Health System, Aug. 2008). 7 S. N. Forjuoh, M. D. Reis, G. R. Couchman et al., “Improving Diabetes Self-Care with a PDA in 2 Information on Scott & White was obtained from Ambulatory Care,” Telemedicine and e-Health, Apr. interviews with Alfred Knight, M.D., president and 2008 14(3):273–79. CEO; James Rohack, M.D., director of the Center for Healthcare Policy and medical director for sys- 8 C. V. Culp, “Local Clinic Has Installed Automated tem integration at Scott & White Health Plan; and Kiosk to Speed Check-In,” Waco Tribune-Herald, Gail VanZyl, R.N., executive director of safety and Nov. 25, 2008. quality. Background information was obtained from 9 J. E. Wennberg, E. S. Fisher, D. C. Goodman et internal documents, the organization’s Web site al., Tracking the Care of Patients with Severe (www.sw.org), and other sources noted below. Chronic Illness: The Dartmouth Atlas of Health 3 A summary of findings from all case studies in the Care 2008 (Hanover, N.H.: The Dartmouth Institute series can be found in D. McCarthy and K. Mueller, for Health Care Policy & Clinical Practice, 2008). Organizing for Higher Performance: Case Studies The analysis focused on the last two years of life of Organized Health Care Delivery Systems—Series among Medicare patients with one of nine chronic Overview, Findings, and Methods (New York: The conditions who died between 2001 and 2005, Commonwealth Fund, 2009). controlling for differences in patients’ age, sex, race, and primary chronic diagnosis. Data on Scott 4 Scott & White announced on Nov. 23, 2009, that it & White Memorial Hospital are available online at had signed a letter of intent to merge with Trinity www.dartmouthatlas.org. Health Services Corporation, based in Brenham, Texas. Under the agreement, “Scott &White Health- 10 Rankings for CMS Hospital Compare clinical topics care would become the sole corporate member of (heart attack, heart failure, pneumonia treatment, the newly formed health system,” according to a and surgical care improvement) included hospitals press release. Trinity Health Services Corporation that reported on all measures and recorded at least serves an eight-county area with facilities consisting 30 patients in each topic (only results in the top of a 60-bed acute care hospital, a 128-bed long-term quartile are noted). Scott & White Hospital was care facility and a Foundation (http://www.sw.org/ evaluated and reported on the four clinical topics, web/patientsAndVisitors/iwcontent/public/news- but did not rank in the top quartile on the Hospital room/en_us/html/newsroom_PRTrinityAnnounce- Consumer Assessment of Healthcare Providers and ment20091123.html). Systems (HCAHPS) overall patient rating of care measure (patient rating of 9 or 10 on a 10-point 5 L. Gamm, J. Nelson, and B. A. Kash, “Organiza- scale). tional Technologies of Chronic Disease Manage- ment Programs in Large Rural Multispecialty Group Practice Systems,” Journal of Ambulatory Care Management, July/Sept. 2005 28(3):210–21; J. N. Bolin, L. D. Gamm, M. A. Zuniga et al., Chronic Disease Management in Rural and Underserved Areas: Patient Responses and Outcomes (College Station, Texas: The Texas A&M University Sys- tem Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center, Nov. 2003). S cott & W hite H ealthcare : O pening U p and E mbracing C hange to I mprove P erformance 15 A bout the A uthors Douglas McCarthy, M.B.A., president of Issues Research, Inc., in Durango, Colorado, is senior research adviser to The Commonwealth Fund. He supports the Commonwealth Fund Commission on a High Performance Health System’s scorecard project, conducts case studies on high-performing health care organizations, and is a contributing editor to the bimonthly newsletter Quality Matters. He has more than 20 years of experience working and consulting for government, corporate, academic, and philanthropic organizations in research, policy, and operational roles, and has au­ hored or coauthored reports and peer-reviewed articles on a range of health t care–related topics. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. During 1996–1997, he was a public policy fellow at the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. Kimberly Mueller, M.S., is a former research assistant for Issues Research, Inc., in Durango, Colorado. She earned an M.S. in social administration from the Mandel School of Applied Social Sciences at Case Western Reserve University and an M.S. in public health from the University of Utah. A licensed clinical social worker, she has over 10 years’ experience in end-of-life and tertiary health care settings. She was most recently a project coordinator for the Association for Utah Community Health, where she supported the implementation of chronic care and quality improvement models in community-based primary care clinics. A cknowledgments The authors gratefully acknowledge the following individuals who kindly provided information for the case study: Alfred Knight, M.D., president and CEO of Scott & White Healthcare; James Rohack, M.D., director of the Scott & White Center for Healthcare Policy and medical director for system improvement at Scott & White Health Plan; and Gail VanZyl, R.N., executive director of safety and quality at Scott & White Healthcare. The authors also thank the staff at The Commonwealth Fund for advice on and assistance with case-study preparation. Editorial support was provided by Joris Stuyck. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.