Reinventing Health Care Delivery: C A L I FOR N I A H EALTH C ARE Innovation and Improvement Behind the Scenes F OU NDATION H ospitals and health systems are “Innovation frequently emerges from worst-case creating new entities to explore and exploit scenarios, and we’re really getting into worse case non-traditional solutions to a wide range of scenarios now,” says Lyle Berkowitz, MD, founder systemic health care delivery challenges. Known as of the Szollosi Healthcare Innovation Program, an innovation centers, the organizations are modeled innovation initiative associated with Northwestern Issue Brief on similar entities from non-health care sectors Memorial Hospital in Chicago. and focus largely on quality, access, and cost issues. The California HealthCare Foundation “The current system is not sustainable. We’re interviewed leaders at health care innovation spending too much and getting too little. That’s organizations nationwide to learn more about why I think it’s critical that we try to make how the centers operate, the objectives they are changes now rather than wait until the system pursuing, and some of the challenges they face. essentially collapses.” Hamstrung by an increasingly complex, costly, The sense of urgency surrounding health care’s and disorganized system of care, health care current state is being amplified by the ongoing organizations are following the lead of the economic crisis. With total health care costs corporate world and embracing innovation as approaching 16 percent of the Gross Domestic a way to overcome the seemingly intractable Product and the population of uninsured at about problems that have undermined U.S. health care 47 million and growing, providers are scrambling delivery for decades. to identify any opportunity to rationalize and streamline their delivery mechanisms. Today’s innovation centers — most of which are affiliated with large hospitals or health Corporate Forerunners systems — range in scope from modest internal The concept of dedicated innovation centers in programs to large, formalized organizations health care began migrating from the corporate with dedicated physical space, sizable staffs, and sector in the 1990s, according to Chris McCarthy, external clients. Key areas of emphasis include an innovation specialist with Kaiser Permanente facility design, operational efficiency, optimized and director of the Innovation Learning Network. information technologies, improvements in the Companies like McDonald’s, Bank of America, patient experience, and care quality. and Proctor & Gamble established the centers to test new production techniques, work Participants say the innovation efforts have sprung processes, physical spaces, and customer service from a growing consensus that health care’s status improvements. quo is no longer tenable and that fundamental, rapid change is necessary if the system is to In an earlier era, innovation centers likely would stabilize and prosper in the years ahead. have been termed research and development S eptember 2009 arms. But unlike those predecessors from the world of is vital for success, innovation experts say. But by the manufacturing and consumer goods — which typically same token, entities must enjoy unqualified support from focused on product improvement — health care the hospital or system administration and buy-in from innovation today largely is concentrated on strengthening the organization’s medical staff and rank-and-file to be the delivery of services. effective. Common Objectives Innovation ideas themselves frequently bubble up from Within a framework of delivery improvement, much of clinicians on the patient floor. Other times, centers are the work is aimed at eliminating barriers between the tasked with broad strategic objectives, such as developing silos of service and information that have long dominated process and design improvements in preparation for health care to create a seamless, human-centered, and major facility construction or renovation projects. more cost-effective care process. Most innovation experts agree that it is essential to “In health care, everybody has their own perspective establish and adhere to a rigorous, empirical methodology on what innovation is, and it’s a very difficult thing to for advancing a concept from inception through testing, nail down,” McCarthy says. “But I think what many simulation, and finally implementation. Given the often of us mean by innovation is most clearly defined as amorphous nature of the work, it is similarly important design thinking, or using design methodologies to create to develop the tools and skills necessary to measure the spaces, tools, processes, and techniques that meet the success of an innovation. Indeed, the relative absence needs of the humans in the system, both the clinicians of precise methods for determining the value of a and the patients, while controlling costs and improving particular concept or innovation is seen by some as one efficiency.” of the central shortcomings in the present innovation movement. Specific solutions involve the reinvention of primary care with a greater emphasis on virtual physician “I think there is a certain amount of faddishness visits and telemetry in disease management; improved associated with innovation right now,” says David interdisciplinary communications; better patient Osborn, Ph.D., founding director of the Vanderbilt engagement; wellness and prevention strategies; and Center for Better Health in Nashville. “There is the idea refining information technology to meet clinician needs that if we build a cool-looking place with cool technology more effectively. and hold some meetings there, then we’re doing what we need to do. But an innovation center needs to be Defining Characteristics more than just a Montessori School for adults. The Although models vary, innovation centers typically key question is: How much of the work is actually are created as quasi-independent entities within operationalized?” multi-hospital systems and may be funded through a combination of hospital revenue, endowment funds, and An examination of nine innovation centers reveals a broad charitable contributions. array of projects, approaches, and objectives; advanced methodologies for developing and testing ideas; and a Because the nature of innovation necessarily entails consistent emphasis on producing practical results. rethinking and sometimes overturning the status quo, developing some measure of organizational independence 2  |  California HealthCare Foundation The Idea Lab of the projects, but function as a tool and a resource for Converting ideas into working solutions — particularly in Kaiser Permanente to innovate.” the area of facility design — was and remains the central goal behind Kaiser Permanente’s Sidney R. Garfield Although the groundwork for two significant innovation Health Care Innovation Center. Kaiser launched the successes predated creation of the Garfield Center, the sprawling, 37,000-square-foot warehouse-like facility in concepts were tested and fine-tuned at the facility. The an industrial district near Oakland, California, in 2006. first, known as the Nurse Knowledge Exchange, is an easy-to-follow bedside protocol that ensures that vital The center initially was developed to optimize information is transferred between clinicians during shift technologies and design configurations in support of a change. The process — which engages the patient, the massive, $30 billion hospital construction investment family, and clinicians — was developed and engineered and system-wide deployment of an electronic health by Kaiser Permanente clinicians and today has been record. Staffed by six, full-time equivalents and equipped implemented across all 32 Kaiser hospitals and even has with a range of simulated care environments, including spread to facilities outside the organization. an entire mocked-up medical-surgical unit, the Garfield Center today continues to serve as a test bed for workflow A second major innovation success, known as the KP improvements, floor plan designs, and new technologies, MedRite, was similarly developed by clinicians under the according to director Jennifer Liebermann. auspices of a broad innovation mandate. In this case, the objective was a safer, more rigorous and more systematic “Our goal is to road-test how a new technology, process for administering medications in hospitals. workflow, or architectural design actually functions, The resulting process is being rolled out across Kaiser. because it’s important to understand how something Significantly, on patient floors where the system already is works before we replicate it a thousand times across the in place, compliance with accepted meds administration system,” Liebermann says. “It can be very difficult, for protocols has jumped from 30 percent to approximately example, for people to read an architectural plan and 90 percent, McCarthy says. know just what 85 square feet really feels like.” McCarthy, Liebermann, and others are quick to point out Beyond testing new workspaces and workflows, the that for every success in the innovation arena, multiple center also does what Liebermann calls “bake-off ” disappointments can be expected. But Liebermann says work: comparative analyses and live demonstrations the benefits of failure can be just as valuable as the lessons of competing technologies and equipment that of success. Kaiser is considering acquiring. Business units within Kaiser — chiefly the National Facilities Group, One case in point: In its efforts to improve medication Information Technology Group, and Patient Care Services distribution, clinicians working with the Garfield Organization — are the main users of the facility. Center decided to try carrying patient medications aboard their mobile workstations, or wireless carts, to “The internal clients tee up projects that meet a set of improve efficiency by reducing trips to the medication defined criteria and that are important to them. Then room. Prototype carts were ordered and simulations we help them execute,” Liebermann says. “The Garfield got underway. But problems quickly emerged. For one Center views itself like Switzerland. We don’t own any thing, the carts were heavier with the newly installed medication drawers and thus more difficult to maneuver. Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  3 Second, security concerns arose when the carts were left elements — facility design, operational efficiency, unattended. There also was confusion about which cart information technologies, patient experience, and care was being used by whom, given that the carts previously quality — as a singular objective. Ronald Paulus, the chief were interchangeable. innovation and technology officer for Geisinger, says the approach is necessary to get at the overarching problem in “The idea solved some problems but introduced a whole health care: discontinuity of care and the resulting costs, set of new ones that we hadn’t anticipated,” Liebermann quality shortcomings, and missed opportunities it creates. says. As a result, the mobile-medication cart concept was dropped. Interestingly, when representatives of a large, “Clinicians are seeing the patient — one facet of that for-profit health care system in the southeast visited individual at one point in time — and they’re doing this the Garfield Center some months later, Liebermann as they run on a ‘hamster wheel’ of incentives that says shared the experience of the aborted medication carts. we’re going to pay you for one of two things: either for Liebermann says the executives explained how their seeing lots of patients per unit of time or for performing organization had purchased several thousand carts for a procedures,” Paulus says. similar purpose. Unfortunately, the project proved to be challenging and costly for the same reasons identified in To realign incentives, minimize variance, and reduce the Kaiser simulation. costs, the largely rural Geisinger system has embraced the medical home concept, a care model that focuses “They evidently spent millions on these carts to use across on personal care coordination by shifting from episodic their system and ended up abandoning them,” she says. acute care to a continuous, comprehensive, team approach. Geisinger has two campuses with three According to Liebermann, the greatest challenge facing hospitals, as well as 40 community medical practices the Garfield Center at its inception was finding ways across 41 of Pennsylvania’s 67 counties. Although the to define and document the value produced through system doesn’t operate an innovation entity per-se, the innovation. With subsequent successes, however, that task entire organization could be considered an innovation became easier and she says that today, the center is viewed center, given its fundamentally different approach to care internally as an important asset for conducting safe, delivery. low-cost tests on ideas, applications, and care solutions. Central to Geisinger’s medical home approach, which “In a sense, we don’t get credit for a good idea unless it it calls ProvenHealth Navigator, is providing financial gets implemented,” Liebermann says. “A great innovation incentives for primary care physicians. Payments are is just a `bunt’ unless you can implement it. But it made for a variety of actions that contribute to a more becomes a home run when it is operationalized on a coherent treatment process, including seeing individual widespread basis. With a few of those early on, the patients more frequently, seeing them during off-hours, pressure and scrutiny were reduced.” and generally playing a more direct and involved role in coordinating their care through the system. New Models of Care Although many innovation centers focus primarily on Under the ProvenHealth program, internists likewise are one or two aspects of the delivery process, Danville, paid for adherence to evidence-based guidelines in the Pennsylvania-based Geisinger Health System is treatment of chronic disease and other illnesses. Surgeons pursuing improvement across the range of delivery and specialists similarly benefit from financial incentives 4  |  California HealthCare Foundation designed to support adherence to evidence-based care, that is being attacked on multiple fronts. In Boston, Paulus says. In addition, physicians are rewarded for Massachusetts General Hospital, the nation’s third oldest collecting and managing patient data, allowing trends to hospital, has created an organization that is focused be identified and analyzed. exclusively on revitalizing and redesigning primary care. The John D. Stoeckle Center for Primary Care “If treatment parameters are not met, then we try to work Innovation was launched in 2000 and named for one of through why it happened so we can fix the process, fix the the hospital’s primary care pioneers. technology, educate the doctor, the nurse or the patient, or learn something new,” Paulus says. From the start, the center has concentrated on developing improvements that can be tested and implemented across Along with altering the delivery side, Geisinger also is Mass General’s 22 primary care practices, according making major changes in the way it charges payers. For a to Susan Edgman-Levitan, a physician assistant who number of surgeries, for example, costs are bundled into a has run the center since 2003. The diversity of that single flat fee. If the patient experiences complications or provider base — groups range from small, private- requires follow-up treatment within 90 days, the system practice-like entities to large, hospital-based, teaching covers the cost. groups — provides an ideal laboratory for testing ideas that may be applicable nationwide. Paulus says Geisinger’s various innovation efforts all build on what he terms the organization’s innovation “We see our role as helping support primary care doctors architecture. “The technologies and the lessons from each as they deliver complex care to an aging population and project are harnessed in support of the next step. It’s a to try to help them manage their responsibilities — in continuously evolving improvement paradigm.” ways that allow them to go home and sleep at night,” Edgman-Levitan says. “The fact is, most primary care The benefits have been substantial since Geisinger’s doctors are overwhelmed. They don’t have enough time medical home program was launched more than three and they don’t get paid to do the job they’re expected to years ago. The system’s average length of stay has been do.” reduced from 6.2 to 5.7 days (albeit still above the California average of 4.7 days) hospital readmissions have To ease the burden, the Stoeckle Center has developed dropped by 44 percent, and overall treatment costs are a relatively simple but highly effective tool to provide down. help in one of the most important areas of primary care medicine: patient engagement and decision support. Over “Inferior quality and high costs are two sides of the same the past five years, the center has worked with a Boston- coin,” Paulus says. “That means you’ve got to solve both based organization, the Foundation for Informed Medical problems together, because the emphasis on volume is Decision-Making, to provide Mass General patients with what drives the costs and also produces the inefficiencies short DVDs explaining the pros and cons of various and less-than-optimal outcomes.” treatment options. Assisting Primary Care Physicians To initiate the service, physicians select an icon on the Geisinger’s attempts to reinvent the delivery of electronic medical record and the video, along with a primary care go to the heart of what many see as a brief patient questionnaire, is shipped Netflix-style to key shortcoming in the present system. It is a problem the patient. Currently, more than 30 titles are available, Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  5 covering a full spectrum of medical issues, ranging Meeting Human Needs from prostate cancer and colorectal cancer screenings Innovation centers don’t necessarily need to be large to to menopause treatments, hip and knee replacements, be successful. Several years ago, Chicago internist Lyle cardiac issues, and a variety of gynecological problems. Berkowitz found himself treating Peter Szollosi, a local Importantly, the videos are created around rigorously executive who worked as a creative director with Chicago vetted evidence-based guidelines. billionaire investor Sam Zell. Szollosi’s illness was serious and his care complex. Over the course of many months, “It’s a wonderful tool for the patient, because they the businessman and physician spent considerable time become so much better informed and engaged, and it’s together and frequently found themselves discussing also great for physicians, because it saves them time. Plus, and lamenting the shortcomings of the delivery it’s a source they can trust,” Edgman-Levitan says. “We system — deficiencies which Szollosi often experienced showed one physician the video on colorectal screening first-hand. and he basically said, ‘If I had two weeks to spend with a patient, I would never be able to explain the procedures “We had a great meeting of the minds and we talked and the pros and cons of each as well as this video does in about doing something; creating some kind of funded 20 minutes.” program that could focus on innovation and problem- solving in ways that were not typical or routine in health Yet another initiative involves finding ways to expand the care,” Berkowitz says. use of — and knowledge about — patient advanced care directives. Given the disproportionate costs associated The illness took Szollosi’s life in the fall of 2007. But with late-in-life care, and given that most people are in because the businessman’s friends and family were no position to make judgments about that care when they aware of his ongoing discussions with Berkowitz, they need it, ensuring more widespread adoption of advanced approached the doctor about creating and funding just care directives is essential, Edgman-Levitan says. the kind of entity the two men had envisioned. Thus was born the Szollosi Healthcare Innovation Program. The center also played a role in creating what Mass Affiliated with Northwestern Memorial Hospital, the General is calling the Ambulatory Practice of the Future. organization’s mission is straightforward: Use creative Like Geisinger’s medical home approach, the concept thinking and diverse technologies to produce a better involves realigning incentives for primary care physicians health care experience for patients, physicians, and others and shifting to a more coordinated, patient-focused associated with the care process. care model. The idea will rely heavily on virtual doctor- patient visits through email and video conferences and “We aren’t trying to improve quality in the standard way,” initially will be made available to Mass General’s 23,000 Berkowitz says. “Instead, the focus is on improving the employees. Although the new center is not expected to overall care experience because we recognize that when be operational until early 2010, many of the hospital’s patients are involved in a significant health issue, it can be employees already have expressed interest in receiving a very scary and confusing time, and how they interpret their care from the new entity, Edgman-Levitan says. She the experience can play an important part in the healing adds that the new approach is expected to reduce costs process. Improving the experience for physicians can by cutting the number of emergency room visits and be just as important, since they won’t use new systems hospitalizations. unless those systems are shown to be both efficient and effective.” 6  |  California HealthCare Foundation Berkowitz’s innovation initiative is more virtual than the Healthcare Information and Management Systems physical and is staffed with only one full-time employee. Society (HIMSS) conference last spring and is starting to Berkowitz himself continues to see patients half-time blog about the topic at his Change Doctor blog (http:// and also remains director of clinical information systems drlyle.blogspot.com). for his physician group. Both roles, he says, continually stimulate and inform his innovation efforts. “Most EMRs present data in either a spreadsheet or Word document-type format,” he says. “But why does it have Much of that work so far has focused on developing to look like that? Maybe it could look like a video game improvements around what Berkowitz calls inflection or maybe like Facebook. Maybe the EMR could look like points, or junctures in the care continuum where nothing we’ve ever seen before. “This is an area that is not significant events transpire but where friction or funded normally, so it’s exciting to be able to spend some inefficiency often undermine the process. time working on an issue like this.” One example: Berkowitz partnered with Northwestern Like Liebermann at Kaiser, Berkowitz is quick emergency medicine and primary care physicians to to acknowledge that pursuing innovation doesn’t develop a Web-based template that can be used by automatically result in success. In fact, converting a internists to convey pertinent patient information to unique idea from concept to reality generally is the the emergency room in a more effective manner, where exception, not the rule. Yet the low conversion rate of the notes can then be downloaded and reviewed. The ideas should not dissuade organizations from embracing information exchange has improved the continuity of innovation efforts, he says. care — particularly for complex cases seen by the hospital’s primary care group — and has been incorporated into “There has to be a balance between receiving funding the electronic medical record application now in use by and having the freedom to pursue a wide range of the ER. possibilities,” he says. “There is no guarantee that anything I’m going to do is going to work every time, “We were able to develop this in a matter of weeks for a but we have to try a lot of different things before we can few thousand dollars and get it deployed pretty quickly,” come up with a big winner.” Berkowitz says. “I think it shows the kinds of relatively simple things you can do when you work together to The Human/IT Interface solve significant problems.” Like many health care organizations, Vanderbilt University Medical Center’s commitment to improving A related area of interest involves what Berkowitz terms care delivery was accelerated by the seminal 1999 and “information visualization,” or the ability to quickly grasp 2001 Institutes of Medicine Reports, To Err is Human and act on key data points amid a fast-moving river of and Crossing the Quality Chasm. The studies, which information. “Physicians are truly overwhelmed with data deconstructed the myth of U.S. health care supremacy and we don’t really have very good tools to weed through and advocated a fundamental transformation in the care it all to determine what is important,” he says. process, prompted the Nashville-based medical center to create the Vanderbilt Center for Better Health in 2002. To change that, Berkowitz has been working with graphic designers to develop more effective electronic medical David Osborn, Ph.D., the center’s founding director record interfaces. He debuted several of these designs at who now heads up an affiliated health policy arm, says Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  7 Vanderbilt’s pioneering adoption in the early 1990s of Breaking down the human side of the technology an electronic medical record and physician order entry equation is made easier at Vanderbilt, thanks to the large system — both now supported by evidence-based clinical number of computer scientists on staff who are also guidelines — helped jumpstart the center. clinicians, Osborn says. One recent example of the type of tasks the center tackles: Technology currently exists to In the years since its formation, the center has evolved implant wireless micro-devices in the chest walls of at-risk into a large, multi-faceted organization operating two, cardiac patients to provide early warning of potential 18,000-square foot facilities and employing 15 people. heart attacks. The hard part, Osborn says, is figuring out The center provides a range of tools and capabilities for who is responsible for monitoring the device. Is it the developing, testing, and implementing new health care primary care physician, the cardiologist, or both? And is methodologies, systems and strategies. the monitoring a stand-alone service or part of a larger care continuum? And what are the responsibilities of About half the work is done for the medical center and the patient? Excessive drinking or drug use likely would medical school; the rest is done for external clients, trigger false positives. What would happen then? including other health systems, payers, government agencies and life science companies. Given Vanderbilt’s “It’s a good example of how the technological hurdle information technology track record, IT continues to be a can be pretty small compared to hurdles that need to be primary focus of the work, Osborn says. overcome in terms of human behavior and the business processes necessary to operationalize the technology.” “I don’t know if I would call informatics the centerpiece of health care innovation and reform, but I do think Like Kaiser’s Garfield Center, the Center for Better it is essential because it allows you to change processes Health frequently relies on simulated scenarios to and make patient care decisions that would be extremely understand innovative concepts more clearly. In one difficult, if not impossible, in a paper world,” he says. instance, a 16-hospital system was replicated using various areas of the innovation center to represent different One of the central lessons learned at the center has been hospitals, outpatient centers, and corporate offices. The that while developing new technologies is important, objective was to help the system determine how best to the real challenge lies in adapting them to human fast-track the implementation of 11 major IT projects in behavior — and vice versa — in order to maximize a two-year period. the technology’s potential. Too often, Osborn says, organizations invest “a ton of money” into IT systems Through the years, the Vanderbilt center has developed and not only don’t see a return, but actually witness a and codified a rigorous process to move quickly from diminution in productivity. problem to solution, Osborn says. The design-build- use approach relies on intensive, multi-day workshops, “Organizations try to force-fit an IT solution without separate groups simultaneously attacking different aspects designing the technology around better work processes of the problem, and an iterative approach to solution or around what the clinicians really need,” he says. development. “Essentially, they’re asking clinicians to move from paper to electrons without giving a lot of thought to making the “Speed is a big deal for us,” Osborn says. “Our experience clinician’s jobs easier or improving care quality.” has shown that if we can produce a first iteration quickly and then focus on improving it, that usually gets us 8  |  California HealthCare Foundation a better answer faster than if we took all the time we Gianrico Farrugia, a member of the center’s steering needed to come up with the ‘perfect’ solution.” committee, a practicing gastroenterologist, and head of the Culture & Competency of Innovation platform, Osborn and others believe that innovation centers cannot says the center was born from a recognition that rapid succeed without a significant degree of independence changes in care delivery and patient needs required more from their sponsoring organization. Innovators need formalized processes for adapting to — and helping to be free of the political and social pressures that exist shape — those changes. within the typical leadership hierarchy, he says. And bringing in the front-line clinicians who will actually be “What the center offers is a unique space to develop and implementing the new ideas is equally important. nurture new ideas, allow them to grow in a protected environment, and mature and evolve until they’re ready to “Some innovation centers will cherry-pick the people reach the clinical setting,” he says. who’ve always demonstrated an ability to think outside of the box and they’ll come up with the idea,” he says. “But Each platform includes a multi-disciplinary team made then nothing ever comes of it, because the folks that are up of physicians, nurses, designers, systems and procedure integral to that part of the organization weren’t involved experts, finance personnel, and IT specialists, Farrugia in the effort.” says. A patient advisory group also plays an integral role. While each platform’s activities are, by definition, A Comprehensive Approach somewhat unstructured, a rigorous methodology — as is As befits its role as the oldest and largest not-for-profit the case at Vanderbilt and Kaiser — has been created to group practice, the Mayo Clinic has embraced the drive and direct the work. innovation movement with a comprehensive, multi- pronged strategy aimed at advancing the care delivery That methodology involves identifying trends, defining process on a number of fronts. Created in late 2007, opportunities, declaring a focus, framing the topic, the Mayo Clinic Center for Innovation today consists designing concepts and prototypes, testing the pilot, and of five “platforms.” transferring the solution. Mayo Clinic Connection is concerned with pursuing the Although the center is new, several solutions already medical home concept and extending electronic delivery have emerged. One involves using Internet-based video of health care via the Internet for patient visits that don’t conferencing to connect patients and physicians for require a physical examination. Prediction & Prevention specialty consultations and second opinions regarding Experience aims to improve chronic disease outcomes procedures and treatments. Like Mass General, the service through early detection, exposure modification, and initially was offered to employees but has now been rolled preclinical intervention, including predictive genomics. out to all patients. Farrugia notes that within a month of Wellness Experience focuses on engaging individuals to its availability, 20 percent of employees chose the virtual develop a more effective and comprehensive approach consult option as their preferred method of consultation. to prevention. Destination Mayo Clinic Experience works to enhance and integrate outpatient care at Mayo. A second application — the use of graphical, red-and- Culture & Competency of Innovation is charged with green computer screen charts to convey relative heart instilling a culture of innovation into the daily work attack risk for cardiac patients considering the use of routines of Mayo. statins — also has proven highly successful, he says. Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  9 “It’s very effective in helping people conceptualize degrees part on incremental enhancements to the delivery of risk and as a result, it helps them make their own process — Ascension is also concerned with identifying informed decisions about whether taking statins is right and anticipating larger paradigm shifts that may affect the for them. entire health care sector. Accordingly, the tactical focus of much of its innovation work is directed not inward but “Something as simple as that can have a profound effect out, toward improving health beyond the hospital walls. on how engaged patients are in their own care,” Farrugia adds. “And it’s something that ordinarily wouldn’t “Internal, incremental innovation is something we’ve have emerged without the innovation center and its already been doing for a while at Ascension,” says Hyung mechanisms for listening to what patients are telling us.” Kim, M.D., Ascension’s vice president of research and managing partner of the Transformational Development One of the risks of innovation work is what Farrugia (TD) team. “So the idea was to vest a group that could terms the “greenhouse” effect, or the danger that creative both identify significant changes occurring in health care but not necessarily practical ideas are developed without a and pursue non-traditional approaches to meeting health tangible connection to real-world patients, caregivers, or needs externally.” events. To guard against that possibility, Mayo has made sure that each of its innovation platforms is headed by a Ascension is the largest nonprofit and also the practicing physician. largest Catholic health system in the country, with 67 hospitals and more than 500 total health care facilities “That was a deliberate decision to ensure that the there operating in 20 states and the District of Columbia. was a reality check built into the system,” he says. “When Its Transformational Development unit was created in you’re continuing to see patients, I think it provides an late 2007 and is funded independently from operating important grounding to the innovation efforts.” revenue. According to Kim, the TD team spends a considerable amount of time scanning a variety of Beyond ensuring that innovation work is joined at the hip business and industrial sectors to identify ideas, solutions, with an organization’s day-to-day practice of medicine, and techniques that may be applicable in extending care Farrugia concurs that creating formal structures to guide beyond the hospital or physician’s office. and assess innovation is essential. Like most other centers, Ascension has codified a “There is a perception that innovation is just a scattered, process for testing and implementing innovation ideas. non-focused, and un-measurable process, but that is not Ascension’s so-called “funnel” approach borrows from the case,” he says. “There are people who have devoted techniques used in the world of high-tech start-ups and their lives to describing the process of innovation and the venture capital, Kim says. In simplest terms, resources are ways it can be measured. Consequently, creating structure incrementally allocated and progressively increased as an and metrics can make it much more likely that the center idea moves ahead through specific stages of development, will succeed.” validation, and testing. Paradigm Shift Although relatively new, Ascension’s group already has Like Mayo, St. Louis-based Ascension Health has generated four very different initiatives, including one adopted a far-reaching approach to innovation. But that represents a dramatic departure from the types unlike many centers — which concentrate for the most 10  |  California HealthCare Foundation of activities traditionally associated with health care Ascension also is prototyping online consults — real-time organizations. interaction with doctors or advanced practitioners on specific health issues — to improve customer service and Known as Enterprising Health, the effort in Flint, streamline the provision of some non-acute care. Like Michigan, is designed to attack root causes of inadequate the remote disease management effort, Kim says an health care in underserved communities by working overarching goal is to create a service that is so compelling closely with local individuals to both identify barriers to and valuable that consumers willingly pay for it out-of- better health and to develop sustainable small businesses. pocket. Since late 2008, a group of five Ascension staffers have One final area of exploration at Ascension involves the lived and worked in a low-income neighborhood in Flint use of ethnographics, or anthropological field methods, under the leadership of Marcy Buren, Director at Genesys to better understand and address health care challenges Health System, Ascension’s local Health Ministry there. facing various socio-economic and cultural groups. The As part of the project, Ascension has sponsored business initiative includes intensive “immersion” studies aimed education sessions designed to foster entrepreneurial skills at uncovering unique social and cultural barriers to care. within the community. The ultimate objective, according Researchers then debrief and brainstorm about possible to Buren, is to create a financially self-sustaining solutions. enterprise that can provide income to individuals and a range of services to the community. Exactly what shape In one recent two-day exercise in Austin, Texas, that business may take remains to be seen. But part of researchers focused on health records acquisition, the project’s benefit is in the journey itself, Buren says. maintenance, and sharing, and how record-keeping More than a dozen local residents from widely varying processes affect the patient experience. From this effort, backgrounds --from unemployed individuals to those eight potential improvements were identified and two holding two jobs to make ends meet — already have from the list are currently being explored, Kim says. signed on as “business partners” in the effort. Listening to Customers “The idea is that self-sustaining business enterprises, will, The ability to thoroughly understand patient needs in in and of themselves, have a positive impact on the health order to improve delivery mechanisms has been advanced of the community,” Kim says. to a science at Alegent Health, a seven-hospital, 50-plus clinic system serving the Omaha metropolitan area. On a separate front, the Transformational Development group is preparing to roll out a next-generation care In 2005, Alegent launched an extensive customer management initiative for diabetics. The approach is information gathering initiative in anticipation of a being developed in partnership with an undisclosed planned, $400 million multi-hospital renovation project. retailer and will incorporate telemetry to monitor blood The objective was to incorporate patient feedback into pressure, blood sugar, and weight for diabetic patients the renovation design. Alegent partnered with a customer remotely. Kim says the service will test individuals’ research firm and began field work around each hospital willingness to pay out-of-pocket for state-of-the-art care. service line. The first iteration is expected to be tested in the Detroit and Indianapolis metropolitan areas by autumn of 2009. “We recruited patients, went to their homes, went to their treatments and doctors’ appointments,” says Larry Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  11 Niemann, Alegent’s Operations Leader for Change “Moms love it, and clinicians like it too, because it gives Management. “Basically, we followed them around, them time to catch up on some of the paper work they interviewed them, video and audio-taped them, and need to do,” he says. asked them what they liked and what they didn’t. It was observation in its rawest form.” Niemann says the decision to terminate the patient experience program reflected a change in organizational The collected information, which reached hundreds of leadership, the departure of Alegent’s chief innovation transcribed pages and hundreds of hours of video tape, officer, and the challenge of demonstrating the project’s was then painstakingly culled to identify reoccurring hard-dollar, return-on-investment. themes from which “buckets of needs” were developed. Those needs were subjected to a “decision accelerator “Clearly, determining ROI for something like this process” wherein cross-functional teams were assembled can be difficult,” Niemann says. “It’s hard to quantify, to develop solutions — primarily involving space upfront, the benefits of improving the experience of configurations and work processes — around the the patient, the physician, and the staff members. And identified deficiencies or desires. that’s particularly true given the nature of the work, since where you start and where you end can be very different The process was completed for oncology, behavioral, places. So that was one factor, given the current economic maternity medical/surgical inpatient services, and environment.” ambulatory services before budget constraints, new executive leadership, and a shift in strategic priorities led But Niemann adds that the primary rationale for administrators to discontinue the effort, Niemann says. terminating the effort in his view was a desire by the new leadership to pursue improvements in the “We didn’t change the world or invent the new iPod, but patient experience from a different angle. The new we were able to incorporate a thousand little things that administration, he says, is confident that shifting the will incrementally change the way our customers receive model to one driven by evidence-based care and relying and perceive their care,” he says. on quantitative performance improvement metrics will improve the patient experience. Niemann says that throughout the process, innovation team members became adapt at spotting “the low “Previously, we had the philosophy that failure was a hanging fruit,” or opportunities that could be easily part of innovation, that you in effect, ‘fail forward’ but and immediately addressed even before completion of that you’ve got to be willing to try different things. What the construction work. One example: In the maternity changed was the appetite to experiment with new and department, interviews and observation led the Alegent to unproven models. So the decision was made to go with initiate a “quiet time,” or two hours out of each day when concepts that were safer and more proven. Basically, our clinicians would not interrupt new mothers. new strategy is that if we provide a high-quality, low-cost product through evidence-based care models, that will, in “We could see that it was just a whirlwind of activity and of itself, generate a positive patient experience,” he around the moms; no downtime, no rest in the whole says. process,” he says, adding that the policy has been well-received by both patients and clinicians alike. 12  |  California HealthCare Foundation In Flexner’s Footsteps “The thing about health care is that we have an Nearly 100 years ago, educator Abraham Flexner exceedingly inefficient knowledge market. In other words, produced a book-length report that illuminated the the ideas are out there, we just do a really poor job of often deplorable state of medical education nationwide. sharing them. In many respects, health care is still very Flexner’s study recommended a number of changes; most much a mom-and-pop industry. And I think it’s critical were adopted to create the foundation of the modern that we find ways to change that.” health care system. Today, clinicians at John Hopkins School of Medicine are working through the innovation As an example of what he sees as unnecessary duplication, process to uncover a “new Flexner model” that can have a Pronovost points to the development of evidence-based similar impact in the 21st century. clinical measures required to meet Joint Commission goals. It is painstaking work and something Johns Peter Pronovost, M.D., Ph.D. and a professor with Hopkins has spent literally thousands of man-hours on. the John Hopkins School of Medicine, heads up an Yet it is work being replicated at many other provider innovation center created in 2003 to spearhead the effort. organizations nationwide. The center is organized around the Institute of Medicine’s six transformation aims, namely, that care should be safe, “When you stop to think about it, that’s just foolish,” effective, patient-centered, efficient, equitable, and timely. he says. For the most part, the center pursues what Pronovost calls “Little I” innovation: Small, incremental changes It’s a sentiment shared by others. Says Niemann of that improve quality, strengthen processes, and save Alegent Health: “I think what health care needs more of money. But “Big I” innovation — large, systemic changes is the ability to pull groups together that have common in areas like pharmacy and medication distribution, for needs and themes and to work on strategies and solutions example — also is on the agenda. collectively, rather than trying to recreate the wheel 20 different times and coming up with 20 different Duplication of Effort? solutions, some of which work, some of which don’t.” Pronovost has emerged in recent years as one of the country’s major proponents of innovation and Beyond the duplication of effort, Pronovost sees a related is a prominent voice in the field. Yet he admits he’s weakness in the current innovation milieu: Effectively increasingly troubled by what he sees as the duplication of measuring the relative value or contribution of a effort taking place as health care organizations scramble particular idea or improvement frequently is problematic. to reinvent and improve the care process. Without a more unified approach and greater cross-pollination between Most health care organizations, he says, simply are not innovation entities, he warns, much energy, time, and equipped to evaluate, for example, clinical guidelines for resources will be lost. a particular disease state. Likewise, there is a dearth of follow-up studies to determine which work processes and “I think the questions that need to be asked are, ‘which delivery innovations are proving most effective. pieces of this work are more effectively done through a centralized process and which pieces make more sense “I think we’ve been naive to think that organizations when pursued through an individualized, free-market- can both innovate and evaluate effectively without a type approach?,’ “ Pronovost says. substantial investment,” he says. Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes  |  13 Pronovost believes that what is needed is a centralized kind of universal system,” McCarthy says. “But I do think organization that could coordinate private-sector the approach we’re taking now has the ability to make innovation efforts around specific delivery and safety a significant difference, because we’re thinking far more challenges. While it’s not immediately clear what that critically about the relationship between clinicians and entity would look like, he points to the Human Genome patients than we ever have in the past. Project as an example of a coordinated, problem-solving initiative that included multiple, diverse entities across “We’re trying to create the best spaces and best tools and health care. best processes to meet the needs of all involved. We’re in the early stages of using this approach. But my gut says “NIH coordinates gene research,” he notes. “Why not we’re definitely going down the right path.” create an institute for health systems delivery?” For innovation to truly work, though, virtually all experts Time will tell whether, and to what extent, innovation and participants agree that well-conceived methodologies centers can or should coalesce into a more integrated must be developed to test ideas and ultimately transform whole capable of systematically addressing the system’s the most promising ones into viable, sustainable solutions. many choke points. Some sharing between non-profit- Likewise, skills and tools must be created to better assess based innovation centers already is taking place under the the impact of innovation work, both in terms of quality auspices of the Innovation Learning Network, an ad-hoc improvement and cost-effectiveness. consortium established by Kaiser Permanente. “It’s easy to go an inch deep and a mile wide in The network, created in 2006, includes nine systems that innovation, instead of a mile deep and an inch wide,” meet several times a year and converse monthly via video says Hopkins’ Pronovost. “And that can be self-defeating, conference to exchange ideas on topics such as the future especially if you lack the training to truly assess the extent of remote primary care. and nature of the improvements you’re making.” Kaiser’s McCarthy, the center’s director, says that the network — the only one of its kind — is limited in membership to non-competing, not-for-profit Author Bonar Menninger is a freelance health care writer based in organizations. “I think that if there was a for-profit or a Kansas City He can be reached at bonar@nstarcom.net. competitor involved, it would probably hinder the deep sharing we have among our members. And it’s critical that we maintain that openness.” About the F o u n d at i o n The California HealthCare Foundation is an independent Tomorrow’s Tools philanthropy committed to improving the way health care It seems likely that the future of health care delivery is is delivered and financed in California. By promoting being shaped by the innovation efforts underway today, innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they regardless of whether organizations find ways to unite and need, when they need it, at a price they can afford. For more amplify some of their innovation successes. information, visit www.chcf.org. “I honestly don’t think we’ll have a big bang in health care unless or until we have payment reform and some 14  |  California HealthCare Foundation