Showing a Commitment to Cost Savings and High-Value Patient Care

Staff meet to discuss the appropriate use of accommodations project. From left: ARPITA PATEL, RN; ROSDY PAMATIAN, RN; LISA SHIEH, MD, PHD; DAVID SVEC, MD, MBA; PAUL GEORGANTES, MSN, RN, CNL.

As Stanford Health Care strives to be increasingly innovative and efficient, front-line providers develop and implement collaborative initiatives aimed at saving money and increasing high-value care. Two such programs illustrate those efforts.

The Cost Savings Reinvestment Program

Leaders at Stanford Hospital expend a fair amount of time and energy figuring out how to improve the delivery of high-value care and patient outcomes and, when possible, to reduce costs. One such effort is the Cost Savings Reinvestment Program (CSRP), which Paul Heidenreich, MD, professor of cardiovascular medicine and vice chair for quality in the Department of Medicine, describes as a “Stanford Health Care–led initiative which asks faculty to come up with a cost-saving idea or intervention, and if it is approved and put in place, rewards those who carry it out with a 25 to 50 percent share of the savings in the first year.”

The funds cannot be used as any form of salary support or compensation for physicians, but they can be used at the discretion of the departments for supplies, research-related expenses, and continuing education.

The Appropriate Use of Accommodations Project

One project under the CSRP addressed a significant source of inpatient costs: the level of in-hospital care to which patients are assigned. A patient occupying an intensive care unit bed who does not require specialized personnel and equipment associated with such accommodations is mismatched. Lisa Shieh, MD, PhD, clinical professor of hospital medicine, and David Svec, MD, MBA, assistant professor of hospital medicine, saw mismatching as expensive and wasteful. Besides simply saving money, says Svec, “We believed that using these extremely expensive resources appropriately would improve the value of the care patients receive.”

After exhaustively gathering data about accommodation costs and the distribution of patients in different levels of accommodation, Shieh and Svec estimated that assigning patients to more intensive levels of care than necessary was costing Stanford Hospital millions every year. They designed a project that would ensure appropriate levels of care for all patients by engaging physicians responsible for patients’ levels of care.

To effect meaningful change, they first had to get buy-in from all departments that assign accommodations, which meant meeting with the chairpeople of those departments and convincing them to delegate a faculty member to drive their part of the project.

Shieh and Svec’s next step was to create a set of alerts to increase awareness about levels of care. The first alert they created asks — every day — whether a patient who is on cardiac monitoring still needs it. A response from a caregiver is required, causing that caregiver to think about whether the use is appropriate according to Stanford and national guidelines. A second alert reminds caregivers that their patient’s level of care is the intermediate intensive care unit, a fact sometimes missed because rooms on different levels look the same.

The results are positive so far. The CSRP project is likely to save the millions Shieh and Svec estimated, and they look forward to working on additional projects to provide higher value care for Stanford patients.

WINNIE TEUTEBERG, MD (left), and STEPHANIE HARMAN, MD, discuss the difficult conversations project.

The Improvement Capability Development Program

The Improvement Capability Development Program (ICDP) is a joint venture between the Department of Quality for Stanford Health Care and the School of Medicine. Its premise: Stanford Health Care commits to returning 1 to 2 percent of a department’s clinical revenue to help develop and execute far-reaching quality improvement (QI) projects, depending on its level of commitment and outcomes or deliverables. Although these funds cannot be distributed as a bonus to department faculty, they can support faculty conducting improvement work, including research and education related to quality.

According to Stephanie Harman, MD, clinical associate professor of primary care and population health, it has been a challenge for clinical departments to fund QI initiatives “because clinicians are bootstrapping projects with unfunded time and no project management support. With ICDP, Stanford Health Care is funding the time and project management it takes to lift up a new project that aims to improve the care we give.”

Difficult Conversations with Seriously Ill Patients

One ICDP project has to do with seriously ill patients. After learning that there are many patients with serious illness who have no advanced directives or other documentation of what matters most to them, Harman realized that important conversations with patients were not happening. “These are conversations that many physicians see as challenging and time-intensive, but the system wasn’t built for them to happen in busy clinic settings,” she says. The serious illness conversation project was developed to bring advance care planning to more patients and families and to integrate it into the standard work of the clinic.

To get the project off the ground, its leaders entered into a partnership with Ariadne Labs — a joint health system innovation center of Brigham & Women’s Hospital and the Harvard T. H. Chan School of Public Health — founded by Atul Gawande, MD, to help with training and workflow redesign. Harman explains the need for such help: “Left to our own devices, we would have been reinventing the wheel. We didn’t know what resources it would take to carry out the project on a large scale, for instance. The ICDP project funding has paid a fee to join, which covers team training and coaching, the implementation of workflow redesign, and our membership in a collaborative national group. Those funds also support part of a physician leader’s time as well as true project management support.”

Harman says that while the program is still in the early stages, “it’s going well. The emphasis on implementation and workflow redesign ensures that physicians aren’t the sole holders of these conversations and ensures that they happen. Everything else we do in the clinic is team-based, and so should this be. The feedback from several groups of physicians, nurses, social workers, and clinic managers who underwent training is that they are 100 percent likely to recommend it.”

The physician leader of the project is Winnie Teuteberg, MD, clinical associate professor of primary care and population health. Her responsibility entails partnering with the project manager to implement the program. The hardest part, she believes, “is selling the program. We’re asking doctors to change a part of their job that deals with an emotionally-charged subject.”

The project uses a guide developed by Ariadne Labs, which Teuteberg describes as “having a list of about 10 questions that go through information sharing and patient preferences. It includes ways for providers to share a prognosis if that’s appropriate. Then it talks about hopes and goals, fears and worries. The ultimate wrap-up is the physician pulling the information together and making a recommendation about where to go next.”

Ann Weinacker, MD, senior vice chair of medicine for clinical affairs, reflects on the fundamental value of programs such as the CSRP and ICDP: “What is really exciting about these programs is that they actively engage physicians and School of Medicine clinical departments in improvement work that aligns with the goals of Stanford Medicine, an alliance between the School of Medicine and the hospitals. The development of ICDP and CSRP was born of the recognition that the commitment of physicians to this work is essential to increasing the value of the care we deliver.”