What we do at Geisinger is probably something like what Kaiser does--a multi-modality approach.1. We are physician led, which makes a real difference in all of the following. At least when the CEO says, "Make it perfect for the patient--and meet your budget." and means it.
2. We are committed to the belief that quality and efficiency must be worked for and achieved together, if either is to be achieved in any significant way. (A truism of process engineering, as I understand it.)
3. Every business unit is led by a physician-administrator pair, reinforcing 1.
4. Improvement initiatives begin with the definition of (evidence-based) Geisinger standard of care. (E.g., when we re-designed elective CABG, the cardiac surgeons identified 38 sub-processes that they believed were demonstrated to decrease the risk of complications.)
5. Next we design the measures and automated electronic reports. At the outset of CABG, we found we were providing the 38 to patients at a rate of 69%. Within 3 months of project initiation, we were at 95%. Our run rate is over 98% for the last 3 or so years.
6. Next we assemble the entire care team for the given problem--GPs, cardiologists, surgeons, PACU, ICU, hospital wards, cardiac rehab, etc.--and agree on the processes we will use and the roles everyone will play to achieve 100% performance.
7. Next we configure the health IT to provide information, tools, and reminders to the right person (including the patient) at the right time in easily actionable form. (In this context, "alert fatigue" largely dissipates, since the alerts are reminders of how we have agreed to work together.) Part of this is agreeing on what the definitions of all the data elements are, who will receive each, and what decisions they will make using the data.
8. Often, incentives are designed. They are rarely directed to individuals, but rather to teams or facilities.
(If an individual does not perform, they are educated and then referred to their (clinician) supervisor. Of course, if they identify a flaw in the process or health IT, we fix them.)
One way to characterize this would be to say that we don't teach EBHC, we build it into care processes and the information systems that support them.
And we have a very low physician turnover rate, less than 4% the last time I knew the number. The near-universal sense is that docs are freed from worrying about administrative detail, giving them more time to diagnose problems, educate and plan with patients, perform procedures, etc.
Jim
James M. Walker, MD, FACP
Chief Medical Information Officer
Geisinger Health System
The best way to predict the future is to invent it.
- Alan Kay
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