Dedication to Quality Improvement Delivers on the Triple Aim: Saves Tens of Millions Annually

Unwarranted variation in clinical care is costly: representing as much as $30 million of actionable savings opportunity for a typical organization. Addressing clinical care at Allina Health, however, was challenging—as a large system with limited resources, the organization struggled to standardize work to impact outcomes and reduce costs.

Allina Health’s executive team understood that, due to market and system demands, it needed sharper focus on increasing clinical value to improve financial margins. In response, the organization launched its Clinical Value Program, a systemwide effort to measure and improve clinical value. The program quantifies the value of clinical change work to improve outcomes, while reducing costs and increasing revenue for reinvestment in care.

REDUCING UNWANTED CLINICAL VARIATION: AN IMPERATIVE IN VALUE-BASED CARE

保健服务的支付已从基于数量的支付转向基于价值的支付，越来越多的支付者基于护理质量的偿还。¹临床差异仍然是公平和有效提供医疗保健的一个普遍公认的障碍。有些变化是合理的，反映了患者个体临床症状和偏好的多样性，但也有不合理的变化，导致稀缺的医疗资源使用效率低下。²

对于一个典型的组织来说，每10亿美元的收入中就有2000万到3000万美元的临床护理不合理的变化。³Improving quality requires executive and board leadership to foster an organizational culture that’s dedicated to improvement and directs resources toward the structures, processes, and monitoring systems that ensure patients receive needed care without risk of harm.⁴

A not-for-profit health system, Allina Health is dedicated to the prevention and treatment of illness, and enhancing the greater health of individuals, families, and communities throughout Minnesota and western Wisconsin. Allina Health’s strategic framework focuses on improving clinical value to achieve the Triple Aim: improving the health of populations, while also improving patient care/experience, and lowering the per capita cost of care for populations.

LIMITED INSIGHTS INTO COST AND OUTCOMES

With healthcare increasingly moving toward reimbursement for value, Allina Health recognized the need to focus more sharply on ways to fund its mission. As a large health system with limited resources, the health system was challenged to standardize work to improve outcomes and reduce costs.

Allina Health发现，缺乏对价值(成本和结果)的洞察力是造成无根据的临床变异的原因。以往提高临床价值的努力能见度极低，导致最佳实践的传播不一致。组织没有将整个系统的改进工作优先化，需要一个全面的计划来优化结果、成本和临床过程的适当性。

A SYSTEMWIDE, TEAM-BASED EFFORT TO MEASURE AND IMPROVE CLINICAL VALUE

Allina Health’s executive team understood that, due to market and system demands, it needed a sharper focus on increasing clinical value to improve financial margins. In response, the organization launched its Clinical Value Program, a systemwide, team-based effort to measure and improve clinical value. The program quantifies the value of clinical change work to improve outcomes, while reducing costs and increasing revenue for reinvestment in care.

The Clinical Value Program focuses on several objectives:

• 通过将组织利益相关者聚集在一起，确定、优先排序和实施项目，在降低成本的同时，实现并管理驱动护理提供价值的范式转变。
• Enable consistent, accurate, and reproducible identification and reduction of unwarranted clinical variation across Allina Health, while maintaining or improving patient care outcomes.
• Develop and apply a prioritization approach by determining projects’ value, which enables appropriate resource assignments and implementation timing.
• Identify and build evidence-based opportunities to address unwarranted care variation.

The Clinical Value Program enlists the entire organization through collaboration and resource coordination, supporting clinically driven work to reduce unwarranted clinical variation and optimize outcomes, cost, and appropriateness of clinical processes. It identifies and validates improvement opportunities and implements practice and workflow changes.

Five factors for identifying and validating opportunities

Allina Heath identifies and shapes opportunities using five critical factors:

1. Focus on high-cost, high-variation clinical conditions.
2. Identify the drivers of variable cost.
3. Examine variation by facility and/or provider.
4. Drill down to homogeneous patient populations by segmenting on severity, diagnoses, and procedures.
5. Analyze the impact of other factors, such as LOS, potentially preventable readmissions, and potentially preventable conditions.

Allina Health’s initial step, conducted on a quarterly basis, is to identifyopportunity through analyticsand collaboration across finance, payer relations, and clinical leader functions. The health system used the Health Catalyst^®Analytics Platform and broad suite of analytics applications as its primary source for managing and mining data. To identify opportunities for improving clinical value, data analysts used the rich data in the analytics platform to find undesirable variation in high-cost, high-volume clinical care processes. In addition to leveraging the data available in the analytics platform, the organization solicits opportunities for improvement from various stakeholders—physicians, pharmacists, telehealth, providers, nursing, and laboratory staff.

A team-based approach to improving clinical value

The organization created three teams to carry out its clinical value initiative:

• The assessment team weighs achievable clinical improvements.Armed with meaningful data, the clinical value committee created an assessment team, which includes a clinical data analyst, financial analyst, primary investigator, and program manager. This team completes an initial assessment of achievable clinical improvements and the associated financial value to the organization.
• The development team creates the business case and charter.团队定义项目范围，制定目标声明，确定度量标准和涉众，并制定包含关键里程碑的时间表。在实施之前，章程要提交给执行团队进行审查和批准。
• The implementation team put clinical value into practice.Once the charter is finalized, the clinical value committee develops and documents a change management plan, and resources from hospital and information systems are assigned to the implementation team. Implementation begins with the development of a timeline including the specific tasks required to meet the timeline. The team develops a communication and training plan for stakeholders. Following training, the team implements changes, which often involve workflow, roles and responsibilities, and the EHR.

Sustaining progress

Allina Health每周进行状态检查，向实施团队询问有关实施时间表的进度更新。问题、风险和阻碍成功的障碍被跟踪，以及对组织的财务影响，以及相关的质量度量和平衡度量。这将持续12个月，在此期间，改进将成为常规实践的一部分。然后，团队资源被重新分配给新的改进项目。

The Clinical Value Program’s multidisciplinary, team-based approach, which included physicians, clinicians, pharmacy, imaging, lab, supply chain, finance, and clinical analytics, effectively engaged stakeholders from hospitals, clinics, clinical service lines, home care services, and other departments.

RESULTS

With a data-driven, multidisciplinary team effort, Allina Health’s Clinical Value Program has improved care and delivered on the Triple Aim—achieving more than $33 million positive margin impacted by expense reduction and additional hospital in/outpatient revenue:

• $32.7 million savings validated by implementing 71 projects within the first two years of the program.
• $1.1 million savings in less than one year by adopting a minimalist approach to transcatheter aortic valve replacement. This change also reduced LOS by 31 percent and achieved a17.4 percent relative reduction in median procedure time.
• $210,000 in increased revenue due to improved access in the women’s health clinic. The redesigned workflow also reduced the no-showrate增加了20.8%，增加了20%的超声波预约。
• 通过减少专科医生和住院医生之间护理差异带来的房间费用，已确定节省了37.8万美元，这影响了癫痫患者的住院时间。

“在安利纳健康，临床价值是通过降低成本、增加收入和/或获得绩效支付，同时监测质量和财政结果，来理解我们工作的价值的整个系统的努力。”

– Timothy Sielaff, MD, PhD, FACS
Chief Medical Officer

WHAT’S NEXT

阿利纳健康公司正在通过开发绩效跟踪工具，提高临床价值计划的透明度和参与度。这个简单的资源包括来自章程的质量和财务指标，以帮助监控和控制项目结果。

Allina Health plans to continue to use a data-driven, multidisciplinary team effort to strengthen the clinical value process, establishing it as routine practice across the system. In 2017, teams are on track to achieve a $12 million positive margin impact, due to expense reduction and added hospital inpatient and outpatient revenue—all accomplished by addressing clinical variation to improve and standardize care processes. Allina Health has budgeted $13 million in improvement opportunities for 2018.

参考文献

1. Lee, T. H, & Kaiser, L. S. (2016). Turning Value-Based Health Care into a Real Business Model.NEJM Catalyst.
2. Partington, A., Chew, D. P., Ben-Tovim, D., Horsfall, M., Hakendorf, P., & Karnon, J. (2016)Screening for important unwarranted variation in clinical practice: A triple-test of processes of care, costs and patient outcomes.Australian Health Review, 41, 104 - 110。
3. Advisory Board. (2017).Unwarranted variations in care – Origins and approaches to reduction.
4. 美国医疗保健管理学院。(2012)。The healthcare executive’s role in ensuring quality and patient safety.