Pilot Testing

John Commins, for HealthLeaders Magazine , October 13, 2008
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A partnership with six physician practices helps a Missouri hospital test a care delivery model one patient at a time.

On March 30, 2009, SSM Health Care in suburban St. Louis will open the $236 million, 154-bed St. Clare Health Center, a full-service, acute-care hospital that will offer a patient-centered, team approach to care delivery. The system hopes the new facility's operating philosophy will enhance patient satisfaction, reduce medical errors, and improve outcomes by encouraging interaction among physicians, patients, and support staff.

It's a big move, but one that came about through small steps—specifically, through a joint venture with physicians. Hospital administrators, doctors, and staff have worked out the kinks of the new hospital's care delivery model through incremental steps and careful coordination, one patient at a time, in a pilot unit at SSM St. Joseph Hospital in Kirkwood, MO, the 54-year-old hospital that will be shuttered when St. Clare opens next spring. St. Joseph and six physician practices representing about 80 primary care physicians formed SJHK Medicine Co-Management Co., LLC, an independent entity that in February opened the ward to see if SSM's care delivery ideas could work on a small scale.

"We needed to develop processes to take to the whole hospital, but if we tried to do that across the whole hospital, it is much more difficult to create change," says Sherry Hausmann, president of St. Joseph and president-designate at St. Clare. "So we involved the physicians in hiring the staff for the pilot unit. We told the staff if they wanted to participate in something very different and if they were the kind of person who could accommodate rapid-cycle change, then this would be for them."

Hiring staff that was energized by such an environment—and maintaining a unified vision by creating a closed floor where only those certain physicians and staffers worked—was critical, Hausmann says. Physicians own 75% of SJHK, and St. Joseph owns 25%. Physicians are paid a base management fee with defined incentives based on quality measures like patient satisfaction. If thresholds are met, SJHK is paid, with the 75-25 split in the incentive payouts, as well. So far, with an average daily census of 16 patients, the pilot ward is reporting outcomes higher than the 95th percentile in Press Ganey patient satisfaction scores.

Timothy Pratt, MD, chairman of SJHK and a physician at Kirkwood Medical Group, says starting with a small group of receptive participants has helped the unit as it works to change not only processes, but relationships. "To do that, you need the same people involved with each other day after day to find out where the flaws are," Pratt says.

Communication receives heavy emphasis in the pilot unit. Rounding physicians are met by attending nurses who walk with them as they meet with patients and discuss their progress, goals, and course of care for the day. Physicians communicate directly with each other, or with support services like radiology and cardiology to improve performance. "It has really worked in terms of the physicians defining what they need as customers from our support staff," Hausmann says. "It is so much more efficient than them having to work with administrative leadership. Physician to physician is a more direct channel that we find creates results for physicians."

If there were skeptics who doubted the emphasis on mutual respect and input from everyone on the ward, that ended in March when SJHK revoked the privileges of a physician who'd been rude to support staff in front of a patient. After undergoing counseling, the physician's admitting privileges to the pilot floor were eventually reinstated. But the action was noted. "That one act was amazing," Pratt says. "You could see the difference in the nurses and support staff after the physicians disciplined one of their own."

The unit has already created more efficient processes. Overnight nurses on the unit now coordinate blood drawings at various times when patients are already awake, which eases the usual 5 a.m. crush for blood tests and ensures that physicians have the information they need for their morning rounds. Each day, a new physician walks the unit—not to confer on patients, but to ensure that the unit is working, tests are getting done promptly, processes are being followed, and coordination of care is in place. "If there is a delay in testing, we try to figure out why," Pratt says. "It's more of an overview—not of the medical treatment, but of the whole process." And thanks in part to input from staff, when St. Clare opens March 30, all the medications for each patient will be in that patient's room. The move is expected to save time and reduce the chance that patients will receive the wrong medications.

Hausmann says the pilot unit's costs per adjusted patient day are about the same as in the regular hospital. "Any investment we have made in the company has come back to us in efficiency and effective care and designing our processes for the future," she says. "We could have gone out and hired expensive consultants to help us design St. Clare, but that wouldn't have been as effective as finding a vehicle that allowed us to sit around the table with our own physicians."

John Commins is an editor with HealthLeaders magazine. He can be reached at jcommins@healthleadersmedia.com.

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