The Cost Savings Reinvestment Program (CSRP): Engaging physicians, aligning goals
"We like CSRP as it harvests good ideas from the front line,” says clinical professor of medicine Lisa Shieh, MD, PhD, from the Division of Hospital Medicine.
Like many healthcare organizations, Stanford Hospital expends a fair amount of time and energy figuring out how to improve the delivery of high-value care; improving patient outcomes; and – where possible - reducing costs. “This requires an understanding of both the clinical and economic impact of the technologies, drugs, and medical devices that we use to treat our patients,” states Paul Maggio, MD, MBA, associate professor of surgery and associate chief medical officer of operational effectiveness for Stanford University Hospital. “Although physicians’ choices determine a significant portion of hospital expenses, historically physicians have been less engaged in managing the costs of care.”
As we move to a more value-based healthcare environment, says Maggio, “we’ve been trying to understand how we can encourage physicians to partner with hospital leadership in reducing costs.” One such effort is the Cost Savings Reinvestment Program (CSRP). CSRP is a program that benefits both the School of Medicine and Stanford Health Care by sharing some of the realized cost savings from physician-led improvements. Although these funds cannot be used as any form of salary support or compensation for physicians, they can be used at the discretion of the departments to fund the purchase of supplies, research, or continuing education.
Maggio continues: “When we began the program, we thought it would be limited to physician preference items, i.e., devices and implants used at Stanford that reflect a physician’s choice. Once we set up the program, however, we found that physicians throughout the organization were identifying opportunities that we would not have come up with.”
A case in point: The Appropriate Use of Accommodations Project led by Shieh and clinical assistant professor of medicine David Svec, MD, MBA.
Svec explains the premise of the project he and Shieh initiated with the help of the Residency Safety Council, represented by Justin Slade, MD: “Accommodation costs [the price associated with the level of in-hospital care a patient is assigned to] drive about 50 percent of patient costs per day. If we can use these extremely expensive resources appropriately, then we can improve the value of the care patients receive.”
“If we can use these extremely expensive resources appropriately, then we can improve the value of the care patients receive.
After gathering data about accommodation costs and the current distribution of patients across levels of accommodation, Shieh and Svec estimated that assigning patients to levels of care more intensive than their conditions warranted was costing Stanford Hospital millions per year. Their goal was to assure appropriate levels of care for all patients all the time by engaging all the physicians who played a role in assigning and maintaining their levels of care.
To effect meaningful change, they were first going to have to get buy-in from all departments that have a role in assigning accommodations, which alone meant meeting with all involved chairmen. It was critical to convince them of the worthiness of the project and to have them delegate a faculty member to drive their part of the project.
They did this with the support of Renee Box, Program Manager – CSRP, Hannah Wetmore, Consultant-Performance Excellence, Celeste Connolly, Consultant – Performance Excellence and various other team members from Clinical Business Analytic. In addition, Chris McMurdo, Director – Decision Support Services and Roslind Wiley, Finance Program Manager – Decision Support Services were key partners in finalizing the calculation method to find the data on appropriateness of care level. “It’s a great example of a physician-led initiative,” says Maggio.
Once they had gathered faculty members to lead each department’s part of the initiative, Shieh and Svec’s next step was to create a set of alerts to provide more awareness and standard work around cardiac monitoring and level of care. They first asked – every day – whether a given patient who was on cardiac monitoring still needed it. A response was required, causing thought about whether the use of the resource was appropriate based on Stanford and national guidelines. The second alert increased transparency on the use of the intermediate intensive care unit (IICU). This was needed because, since patient rooms all looked the same, patients were sometimes kept at a certain level of care unintentionally, when they could easily have been stepped down to a less resource-intensive level.
At any given time, up to 20 CSRP projects are underway, creating a variety of ways that the hospital and physicians can work together to contain costs and improve the value of patients’ care.