UT Medical Center CEO Joe Landsman: Standardization is the answer to some of healthcare's biggest problems

The delivery and payment of healthcare in this country is fragmented among multiple players operating in individual silos. The disconnect between various clinicians  involved in a health episode results in patients navigating a complicated and inefficient industry. These same issues also result in tremendous variation in the experience, cost and outcomes for our patients.

Our patients ultimately fall into these 'cracks' which plague our industry, and we can learn from organizations that are considered high performers in other industries in order to address our own fundamental deficiencies.  Using established principles of standardization and alignment, we can improve the value of the services we offer to our patients. This approach can also improve coordination and communication between providers and patients across the continuum of care. Healthcare leaders must bridge these gaps to create value for their patients.

For decades, payers have made attempts to force sustainable change in the delivery system by using the same lever, the volume-based payment model which has added chaos to an already complicated problem. Though some payment models, such as value-based care, have proven results, hospitals and health systems are still largely paid based on volume. Providers must step up to encourage innovation that ensures success no matter the reimbursement structure.

At The University of Tennessee Medical Center in Knoxville, Tenn., our physician and health system leadership came together to examine variation throughout the continuum of care. Electronic medical records have provided hospitals and health systems the ability to improve the coordination of care and communication throughout a patient's care process. EMRs also provide a wealth of data that is the underpinning of a truly clinically integrated delivery model. 

In Knoxville, access to patient information is enhanced by a community-wide health information exchange that was built and supported by most of our local hospital providers. Our overarching goal is to transform our delivery system through clinical integration. Clinical integration is best defined as the delivery of an episode of care based upon a disease-specific, evidence-based, patient-centric plan of care that spans the entire episode regardless of where the episode begins or ends. Wrapping around these pathways are centralized chronic illness management programs that engage directly with the patients to provide education and clinical assistance related to their illness. Each interaction is documented in the EMR and is readily available to other clinicians caring for that patient. 

UTMC began its journey to help reform the healthcare delivery system by focusing on the inpatient component of care. The development of disease-specific pathways brings together physicians, nurses, pharmacists, respiratory therapists and others involved in the care of our patients. Lean methodology experts guide collaborative, multidisciplinary meetings to create evidence-based plans of care that begin with inpatient admission and follow the patient through any subsequent post-acute care. These clinical pathways are hardwired into the patient's EMR. Clinicians can access the same information and plan accordingly, thereby ensuring patient care does not succumb to the inefficiencies inherent to variation during an episode of care.

As of today, approximately 500 pathways and order sets have been developed that cover approximately 95% of our inpatient admissions. The efficacy of the pathways is measured by the compliance rate coupled with mortality, complications, readmissions and length of stay improvements. The pathways were expanded to include the post-acute providers as well with similar metrics of performance. Our medical center is in the process of incorporating the pathways into the outpatient arena with an emphasis on pre-and post-hospitalization care standardization.  The next evolution of our transformation will be to engage the patient in the care process by converting the pathways into comprehensive patient education materials that will be electronically available to educate and engage patients in their care process.

The pathways are reviewed and updated as new studies and treatment data become available to ensure that each and every patient who passes through our doors receives the best possible care.

Our clinical pathways also address another of healthcare's most important issues - and one that few leaders are willing to discuss - namely end-of-life care. Depending on the study, many estimate that 10 – 13 percent of the medical spend in the U.S. occurs shortly before a patient dies.  

End-of-life consults are incorporated into our pathways to help patients and their family members understand the challenges they face during this difficult time. UTMC provides multiple resources for our patients and their families which include hospice and palliative care specialists, medical ethicists and our pastoral services department. This program does not seek to change anyone's mind or convince them to pursue a particular path. It educates our patients and their families about their options and empowers them to make informed decisions instead of treatment options that do not have the ability to make a meaningful difference on outcomes.

UTMC continues to analyze the results of our delivery system transformation journey using standardization as a foundation. To date, mortality and complications have dropped dramatically as well as reductions in readmissions and length of stay. Additionally, as our value proposition has improved, so have volumes. 

The only constant in healthcare is change. Our duty as leaders is to ignore all the distractions that surround us and focus on providing high quality safe care and a good experience at low costs for our patients, their employers and their health insurance payers. Speaking from our experience with the clinical pathways program, care standardization may be one of the most effective ways to achieve these goals.

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