In order to survive and thrive, practices must measure their outcomes and seek to implement improvements.
Decisions must be data driven to negotiate with managed care.
The world of medicine has changed and physicians must become well versed in a new set of skills in order to survive and prosper. Despite the growing interest in outcomes, relatively few organizations have become involved in developing outcomes initiatives to improve quality and cost effectiveness. The reasons cited for this lack of involvement vary, however, moving from the conceptual to implementation is clearly a challenge shared by all.
Following are some compelling reasons for surgeons to implement outcomes initiatives into their practice:
- Achieve improved clinical outcome;
- Reduce costs and improve cash flow;
- Increase patient satisfaction and patient retention;
- Improve efficiency;
- Collect data to support negotiations with managed care; and
- Improve management skills through the collection and analysis of data.
Challenges in Implementation and Facilitating Change
Physicians were trained to practice medicine. They have not been trained in total quality management, and implementing an outcomes initiative requires new skills. Internal resources within practices are already stretched. The perception that implementing an outcomes initiative is too burdensome must be overcome.
Most significantly, the development and implementation of a broad outcomes initiative represents change and requires commitment. The causes for the failure in implementation can most often be found in a lack of commitment by the leadership and a failure to manage the change process. Although an in-depth analysis of leadership and change go outside the scope of this discussion, the following basic concepts should be kept in mind:
Organizational commitment must be present.
Regardless of the size of your practice, commitment by the leadership for implementation of an outcomes initiative is crucial.
Identify champions at all levels.
Without the support and input from physicians, an outcomes initiative is impossible. Likewise, without the support and involvement of key non-physician staff (i.e., nurses, administrators, etc.) any data collected will be, at best, incomplete. Identifying both physician and non-physician champions will assist in motivating others and provide momentum to move the process along.
Establish a sense of urgency.
Everyone resists change. A major factor in overcoming resistance is to create a sense of urgency. Organizations that fail to implement systems to assess and improve outcomes will not be able to remain profitable, survive and prosper.
Develop a vision and strategy.
There are a number of reasons to collect outcome data. The vision developed for the outcomes initiative should include as many reasons as possible for its implementation. The strategies created should directly link to that vision. Lastly, and most importantly, the vision and strategies must be communicated frequently to all staff, at all levels of your practice.
Remove obstacles.
Even with the most motivated clinical staff, there are obstacles to implementing outcomes initiatives in every practice. For example, the sign-in process might not support distributing patient reported outcome instruments. Financial data may not be linked electronically to patient records. Whenever possible, review those obstacles and find ways to remove them. The processes within your practice must be recreated to support the ssystematic collection of outcomes data.
Generate short-term successes.
Select projects at the beginning of the implementation process that will yield meaningful data in a relatively short period of time. For example, implementing a report card for selected outcome indicators or a patient satisfaction survey can produce an early success that yields useful data.
The implementation of an outcomes initiative, in any setting, represents a continuum. Each step along the continuum must be carefully planned for and developed prior to implementation. Beginning an outcomes initiative also requires both a significant planning process and a willingness to change. Although the process seems daunting, it is possible to develop an outcomes initiative that yields valid data in a cost-effective, efficient manner.
Phase I: Planning
Developing an effective plan is the most critical segment of imple-menting an outcomes improvement system. Key elements of the planning phase include:
Assessing your practice and your health care marketplace.
In order to effectuate meaningful improvement and to keep your efforts small and simple, look at your practice and the marketplace you are practicing within. Review the following questions: 1) Is there a disease process or procedure for which we see significant variance in outcome? 2) Do we know whether our patients are satisfied with the care they are receiving? 3) Are we being faced with negotiating capitating contracts? If so, do we have the data that will allow us to have an accurate picture of our patients and the cost of their treatment? 4) Are we required to obtain approval from managed care plans prior to implementing treatment? Would the collection and presentation of data circumvent that process? 5) How will looking at the process of care within our practice increase profitability? 6) Are there variations in the treatment process among the physicians in our practice which lead to difficulty in the care process and/or variances in outcome?
Create a team to create goals and objectives, as well as overall strategies.
Make certain that members include representatives of the leadership within the practice. Once the team is created, begin to develop a written plan that clearly sets out the approach being used; the reasons for implementing an outcomes initiative; the assignment of responsibility for various tasks; and how you will measure success. An important part of the plan will be the development of goals and objectives that answer the following questions: 1) What are we trying to measure? 2) What process are we trying to improve? 3) How will we measure change? 4)How will we improve the process once the data is collected? 5) What will we do with the data once it is collected?
Reducing these concepts into a written plan will enable you to continuously evaluate the effectiveness of your plan and keep the team on track during the implementation process.
Phase II: Implementation
During this phase, the team will finalize what data will be collected, what measures will be used, and how the collection of data will be integrated into the clinic routine. It is suggested that the final implementation design be tested on a small group of patients (10-15) to see how the process works and if there are modifications that will streamline the process. Typical issues dealt with during this phase include: 1) Do we need outside help in designing this plan and analyzing the data; 2) What outcome measures will be collected; 3) Which instruments or measures will we use; 4) Which patients will we collect the data from and over what period of time; and 5) Once we have the data, how will we analyze it?
<Phase III: Analysis
Data analysis is a key factor in achieving utility. If you have collected simple, useful measures, analysis should lead to answering the questions posed during your planning phase. Typical questions include: 1) Does the patient population differ so that risk stratification is required? 2) How can the data be analyzed in a way that answers the questions we have posed? 3) How can the analysis be displayed in a way that leads to a prompt understanding of the results? 4) What does the data analysis reveal about areas requiring improvement or change within our practice?
Phase IV: Feeding the Data Back
Once the data analysis is complete, the data should be distributed to all members of the practice in an effort to decide what areas require improvement. Implement changes to improve the areas targeted and continue to measure the outcomes overtime to assess the effectiveness of the changes.
In addition, developing a reporting mechanism to payers is often valuable. For example, if one of the managed care plans is critical of your length of stay, a report showing length of stay information will be beneficial in challenging their position.
Practices often view the collection of outcomes data and the implementation of an outcomes initiative as an overwhelming burden. The truth is that it does take time and resources; however, it can be done effectively and lead to receiving invaluable information. In order to survive and thrive, practices must measure their outcomes and seek to implement improvements. Decisions must be data driven in order to successfully negotiate with managed care.
The growing demand for data and the increasing level of accountability will continue. Practices that proactively begin to implement outcome improvement systems will be able to prosper in a competitive health care marketplace. Practices that fail to address the need to collect outcome data will find themselves continually reacting — a time consuming and ineffective response.
Megan Morgan is the Project Manager for the AANS/CNS Outcomes Initiative — a team convened to provide tools to AANS/CNS members for use within their practice to measure, monitor, and manage selected outcomes; and provide the capacity to store outcomes data on a national level through a data repository which will allow for aggregation of data and individual comparison against a national benchmark.