Town Hall Meeting

Remarks by Jeffrey Rich, M.D.

Town Hall Meeting at the AHRQ 2007 Annual Meeting

September 27, 2007

Good morning. Thanks everyone. Thanks, Carolyn, for inviting me, and I'm honored to be here. I'm going to take this a little bit differently. I've been hearing a lot of broad spectrum, touching on millions of lives, and I'm going to focus down a little bit and more specifically on patients of coronary disease and other heart disease, and tell you a story—a story about not only my institution, but about the State and how providers that really come together in a State to effect change, not only clinical, change in quality improvement, but change in financial outcomes for health care. And I hope that, at the end, I will impress on you that, unlike politics, where all politics is local, all quality improvement is not local—that there is incredible value in regional collaborations for quality improvement purposes, because you can greatly accelerate change within your region and your own institution.

And I'll do so by starting with Sentara Healthcare, where I am. It's a hospital health care system. We provide 2,000 open-heart surgeries a year, 5,000 CATS a year, which is the behemoth in the Southeast and Northern Virginia Beach, and we have heart transplants and a lot of high-tech things. I've been involved in your quality improvement process for a decade, maybe even longer, and the Chair of the Quality Improvement, and I accepted that position with the knowledge that I could have oversight not only over surgeons, but anesthesiologists, cardiologists, the nurses that touch my patients and all patients, and administrators. They have report cards, as well. And we've done very well. And this is a story that all of you probably can tell about your own institutions—quality improvement, target areas for improvement, and create unique situations for patients; identifying, for instance for us, we not only look at the patients coming in, look at their acuity scores going into surgery, but we look at discharge and give patients three levels of acuity to create safety nets for them. If you're a higher acuity, we have nurse practitioners in the clinic to see these patients. If you're living alone, we send them home with scales and blood pressure monitors and call them to make sure they're not going into heart failure. So, we've done a good job. And I think the fact is that, you know, we've been in U.S. News and World Report, "Top 50 Hospitals," for the last six years, and this year, yours truly was on the front cover. And it was a big story about Sentara, but you know, is that really enough? I think that it's been a great story and a great story to tell, but for several reasons, it's really not enough. Because through years, I found that we were re-inventing the wheel. We'd identify an issue, and then we'd go out and get all the evidence and try to figure out how do we create quality improvement in processes to, you know, improve that one metric and if that, you know, people around the State were already excelling in that particular area.

And it seemed to me that there was, number one, value in sharing—sharing the best practices. And number two, I felt that personally I had a moral professional obligation to sort of share the knowledge with other people, because this shouldn't be a competitive environment. You know, we should have open and inclusive collaboration and really work together, and we started working with the University of Virginia in Charlottesville and INOVA in sharing things. We realized that we're all really good, but they did some things better, and there was a lot of variation in costs, and we just felt that we needed to make this a regional effort. So we organized the State of Virginia through the Virginia Cardiac Surgery Quality Initiative 10 years ago, and that was self funded; each Hospital that wanted to participate with $50,000, each surgeon was $5,000, and we raised almost $1 million and, you know, we created all the infrastructure that we needed. We hired an executive director, we had a memorandum of understanding, a board of directors, and a chair, and a balanced board. It was really a true hospital/physician collaboration, because its administrators, as well as surgeons and other physicians, nurse practitioners, PAs, and clinical nurse specialists, who worked our quality improvement arm in each individual institution. And we had monthly conference calls, quarterly meetings. It's a really robust group. And we share a lot and do a lot, but we had another goal. We wanted to not only improve quality, but we saw in the State a large variation in costs, and we felt the pressure already that health care felt, that we needed to do something to contain costs. So, we decided that, like at Sentara, every member would have to join the Society of Thoracic Surgeons database—20 years in the making; you get reports back on your performance; you can compare yourself to your peer groups. So as a national benchmark, and through that continuous feedback, you can get some real meaningful data. And we have over 900 participants in the Society of Thoracic Surgeons database across the country. I'm sure many of you are.

But we wanted something else. We needed a clinical financial tool, and we took the UB-92 database, the MedStar database, and looked at all the revenue shown for cardiac surgery, put them into revenue buckets, and blended the two databases, so now that we can do quality improvement and look at the cost. And we looked at cost containment exercises while focusing on quality and making sure we were not impacting quality. And through the uses we did that and it's a Web-based tool, it's a wonderful tool. And with it, we demonstrated and had some fairly good results, and I'll show you those quickly, because I know this day's getting long.

First of all, we decided that the National Quality Forum for Cardiac Surgeon Consensus Project, those measures would be our focus. So we would look at, within the State, areas that needed improvement with any of those particular measures. So we report those—we sit down with blinded data. We share the data. We share financial data as well as clinical data, but we wanted to do—the first thing that everybody wants to focus on is mortality. So, we shared best practices. And mortality in this State is significantly lower. Our risk of mortality trails the national average, probably by almost a percentage point. In the four years that we've been doing, the last four calendar years, I won't go back to the other six years, but by our estimate, we saved 120 lives. These patients were expected to die, and through sort of revved up clinical protocols and attention and through some of the things we did, our estimate was that there were 120 lives saved.

We looked at atrial fibrillation, a common complication after surgery, because with our database we were able to identify not only areas of quality improvement, we could identify the incremental costs of complications, and we saw atrial fibrillation costs $2,500 more per patient, and infections in your chest is a $50,000 complication. So let's take atrial fib and look at the best practice in the State, and we wrote a statewide protocol. We implemented the protocol 3 or 4 years ago. We've driven down our atrial fib rate from the STS average of 21 percent to 13 percent, with probably about 5,000 fewer patients having the atrial fib. Of course, as doctors we had an estimated savings of $2.5 million dollars in institutions and obviously a higher quality for the patients. Mediastinitis. We had some problems with that and every hospital, as far as infections, is a big issue. My hospital had the best practice. We sort of deployed that within the State. The mediastinitis rate went down 70 percent. We had gone from four hospitals having no mediastinitis in their inpatients in a calendar year to nine. And we've saved an estimated 140 cases of mediastinitis at $7 million.

So, it's been very positive because we started to use this tool. We've done this with some of the process measures and MPF measure set, the perioperative meds that are necessary to, you know, when you're discharged, you get your anti-lipid agent, your aspirins. Each of those measures has just skyrocketed in use as we've been collaborating, and that measure set has come out.

We currently have work to do. We have prolonged ventilation, and we're looking at efficiencies and costs. We're actually starting to look and see some relationships between high quality and low costs within institutions. So we find and create cost-savings models based on the evidence of the State using our database and using the evidence-based medicine and obviously focusing on quality first and putting the patient first.

We work now with WellPoint Anthem on pay-for-performance, and we've done this using our composite measures that I've worked with the STS to develop this measure. I think it's sort of the latest and greatest. Its components are mortality, use of internal mammary artery, the medications, and the absence of complications. So when you look at this measure, every hospital in the United States who are getting this report, they'll get a numerical report. It will tell consumers what the chances that they'll go to Sentara, have an operation, survive, leave the hospital without any complications, and leave the hospital with all the right medications, and descriptions in hand.

That should roll out this last quarter. It's been fun doing it. We're using that within the State, and the paper performance with WellPoint Anthem to generate, even accelerate, change more. So, I guess in closing, the message is that QI—you can do it locally, but we can move it faster and you can find out that you're maybe not doing everything as well as you think you are, but regional collaborations have been phenomenal in the State of Virginia—sharing of best practices, some of the peer pressure you feel when you see yourself out there, you want to make yourself better. There, you know, it's been great the trust-building that goes on in collaboration. The group before, I used to have to pull them together. And now there's just, you know, it has its own energy. It's got great energy. It's got incredible synergy and wonderful chemistry and, you know, I actually like some of the administrators more, I like the surgeons more (laughter). Well, that was a big switch for me. And we're trying to create change now. We've looked fairly closely at ways to save money, reduce costs by reducing complications, but how about let's go after just the regular operation, and we'll get resource utilization and see where we can sort of start trimming the fat without impacting quality and create, you know, good cost savings models that are patient-centered and focused. And I think we're going to expand, as well, as we have already been approached by seven or eight hospitals in North Carolina, so it may become a different main entity at some point in time. Thanks.

Current as of July 2008