Improving Processes for Outpatient Care

By Linda Leckman M D

One of the greatest challenges facing the health care field is the need to provide better care at a lower cost. At Intermountain Healthcare the largest nonprofit health care system in Utah — we've proven that it can be done in clinical primary care through a strong, coordinated focus on quality improvement. We've also learned some valuable lessons.​ ​

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Our primary care clinical program has improved outpatient care processes for conditions including asthma (an increased use of controllers and a decrease in emergency department visits among patients), diabetes (decreased HbA1c levels among diabetes patients) and depression(increased satisfaction among physicians and patients and decreased costs). These results suggest that broader application of this approach holds benefits for health care on a larger scale — both in the number of care processes and the geographical scope.

Our own health care system is sizable. Our medical group operates as part of an integrated health care delivery system that includes 22 hospitals in Utah and southern Idaho and a health plan that insures 500,000 members. It is a multispecialty group with 900 employed physicians, 200 advanced practice clinicians and 3,500 employees providing patient care in facilities spread throughout Utah.

Program for Systemwide Improvement

From our organization's inception, our leaders were attracted to continuous quality improvement pioneers who proposed that higher quality would result in reduced costs. Adding cost outcomes to our traditional clinical activities validated this hypothesis. Efforts to measure the cost of clinical care laid the groundwork for the expanded efforts that followed.

After analyzing more than 600 clinical work processes, we found that 62 processes accounted for 93 percent of our inpatient clinical volume and about 30 processes comprised about 85 percent of outpatient clinical volume. We then grouped these work processes into "clinical programs," an initiative to unite our resources and the many quality improvement efforts within the organization along clinical program lines. The primary care clinical program was developed to address the 30 conditions most commonly managed in outpatient primary care.

In developing this program, we incorporated the Institute of Medicine's Six Aims for Improvement, as well as the six attributes of an ideal health delivery system, as identified by the Commonwealth Fund's Commission on a High Performance Health System: an electronic health record system, coordinated patient care, accountability, easy access to appropriate care, accountability for the total care of patients and continuously innovating and learning.

Despite all of these organizational commitments, however, we needed to change the way we approached clinical quality improvement. Instead of having projects occur regionally or in isolated instances, we needed systemwide improvement efforts. We had to move from a traditional management structure focused on managing facilities to one oriented toward clinical quality and clinical processes. This entailed building a clinical administrative structure as a counterpart to the management administrative structure.

The Primary Care Clinical Program Guidance Council is the corollary to the management administrative structure. The guidance council is led by a medical director and clinical operations director. Together they lead the guidance council, which comprises medical directors along with nurse consultants from each of the eight medical group regions. Additional support staff include data analysts and representatives from our health plan. This team assists in determining strategic direction for clinical quality and improvement processes.

Program Goals and Champions

Crucial to our success in this effort has been the involvement of senior leaders at the highest levels. Senior managers spearheaded the development of the primary care clinical program, and the medical group's senior leadership team works closely with the clinical programs to ensure that these initiatives are an integral part of our work.

Program goals are a major priority for our corporate management team as well as our corporate board of trustees. Each year the program establishes one goal that is reviewed and approved by the corporate board and becomes part of the board's annual goals, which are significant drivers of the organization's activities. In addition, part of our senior leadership team's compensation is tied to meeting program goals.

With limited available resources, we had to study carefully our patient data and focus our efforts on those areas that would yield the greatest results, using three measures of success: outcomes of quality, cost and patient satisfaction. We also had to get the right people involved, develop the physician leadership, and determine how to engage the clinicians, whose support was essential.

One critical aspect to having the right people involved was enlisting the support of champions — both among physicians and administrators. It was imperative to have systemwide, regional and local champions. They were the cheerleaders and organizers and helped to keep things going. We also needed a structure to move things forward. The development of the primary care clinical program was part of that, and the aforementioned guidance council was also key to our progress.

Along with the champions, we needed effective physician leadership. Our organization believes in developing physician leaders, investing in talent management activities and, consequently, spending significant time engaging key physicians in team-building, envisioning activities and leadership training. Engaging clinicians is an ongoing, long-term effort.

Addressing the Challenges

There were, of course, major challenges to implementing the program:

  • Organizational culture. Engaging physicians in the program's implementation was (and is) a significant challenge. Key to this is physician leadership and physician champions. We also set up brown bag lunch discussions, and the medical directors work with physicians who have not responded, establishing appropriate incentives to engage them.
  • Financial incentives. We developed financial incentives in collaboration with the health plan, or performance on quality indicators. The financial incentives had a very positive impact.
  • Information technology. Needs and issues concerning information technology had to be improved when we found we did not consistently have the data elements we needed.
  • Personnel and workforce. Our biggest challenges were ensuring that training got to the "end of the row" and that we were not adding undue burdens to our workforce. We took a multipronged approach with different avenues to accomplish this. One solution was to add care managers in the clinics as part of the medical home effort.
  • Other challenges included engaging patients, ensuring compliance and keeping staff motivated.

Seeing the Results

The primary care clinical program has experienced significant results for all of our care processes, as exemplified by the following:
  • Asthma. Since we started tracking asthma patients in 1999, we have seen greater compliance among patients using controllers (from 78 percent to more than 90 percent compliance) and a decrease in ED visits (from nearly 9 percent to slightly more than 5 percent) — providing better outcomes for patients and lower costs to the system.
  • Diabetes. For 2011, we set a goal to improve the average HbA1c for diabetes patients age 18 and older who have had a glycohemoglobin at or above 8.0 for at least 12 months. At the beginning of the measuring period — Oct. 1, 2010, to Sept. 20, 2011 — 9.76 percent of patients had high HbA1c levels as indicated. By the end of the period, we reduced the number of diabetes patients with an HbA1c at or above 8.0 to just 9.1 percent.
  • Depression (as part of the mental health integration). The mental health integration (MHI) care process gives providers tools and resources to manage patients with depression in the primary care setting. Physician satisfaction improved, because the MHI care process requires more of a team approach to managing patients; patient satisfaction increased as well. Those clinics that have incorporated MHI have decreased costs associated with their overall care, in part because they're using fewer ED and inpatient resources.
Achieving better care at a lower cost is not easy, but the lessons we've learned make the scaling of the program easier and provide real optimism that its benefits can be expanded dramatically.