Mark Briesacher, MD: I'm Dr. Mark Briesacher the Chief Physician Executive at Intermountain Healthcare. Today we have a guest host, Dr. Shannon Phillips, who's our Chief Patient Experience Officer and she's talking with some of our caregivers about this very important topic.

Shannon Phillips, MD: Well, good afternoon. This is Dr. Shannon Phillips, I'm the Chief Patient Experience Officer at Intermountain Healthcare. I'm talking this afternoon with three of the members of our leadership team in the Office of Patient Experience who are working with our front line care givers and our health system in the realm of quality.

I’d like to have you take just a moment to introduce yourselves.

Donna Barhorst, MD: I'm Donna Barhorst. I'm a pediatrician and I'm the Community Care Medical Director for Quality in the Office of Patient Experience.

Milli West: And I'm Milli West. I am the System Director for Quality for Intermountain Healthcare within the Office of Patient Experience. And, I have almost 15 years of quality experience, and prior to that, I started my career in the medical laboratory.

Denitza Blagev, MD: Dr. Denitza Blagev, I'm a Pulmonary Critical Care Physician and the Medical Director for Quality Specialty Based Care. I’m sort of focused on the end patient side of it within the Office of Patient Experience.

Shannon Phillips, MD: So, quality's a big word. A lot of things get thrown in the basket of quality. What's quality for you? What's quality in the space you're working in? And, they may be one and the same, or you may see differences. Who wants to start? Go, Denitza.

Denitza Blagev, MD: So, I think there are very specific ways of defining quality in terms of how we're being measured in publicly reported metrics. And then there's also the long view of quality, where we ultimately really want to be able to provide the best care for every patient every time, and what we're trying to do is keep our eye on both of those things. So, within the specific metrics, we have made a lot of progress within specific areas like cardiovascular, congestive heart failure, and pneumonia or COPD, total knees and hips and joint programs. And, focused on disease conditions. But then also part of having both the hospital side and the community or outpatient side is trying to link up across the continuum so that we can think about people as more than just their one disease that we're tracking, but the entire patient with their comorbidities.

Donna Barhorst, MD: And, in the ambulatory setting, I think we're looking at quality as how we can really start focusing on how do we improve the quality of our communities and of a population. And a lot of that is around what preventive services do we need to make sure we have patients able to get, reminded to get, so we can track and follow that. For example, a patient who turns 50 should have a colonoscopy at age 50.

I have a dear friend who delayed her colonoscopy by three years, and if there had been some way of triggering that, maybe she would have gone in at 50 to go in and have her colonoscopy, and she ended up with stage four colon cancer, and after a valiant effort, succumbed to it. And, so, what we can do in an ambulatory setting that allows us to have those reminders and tools face up, to help support the process so that we're able to improve the overall community health through preventative services, wellness activities, and other things like that. So quality on a big population sort of spectrum that then is the continuum that Denitza talked about as well.

Milli West: Well, I would just add, I'm often asked by people outside our profession, “What does that mean? What do you do?” And, I basically tell them it's my job to make sure we get it right the first time every time. And, it is my job to do the work behind the scenes to help those providing the care set them up to succeed. To fix our processes to a point where it's really, really hard for them to fail. And, that's something that we're focusing very heavily on: becoming highly reliable, using the tools that we have at our disposal, and tools that we can develop within our organization to help our providers succeed in providing the absolute best care, to help people live the healthiest life possible. Because that's our mission.

Shannon Phillips, MD: We are, in the Office of Patient Experience, trying to think across ... put ourselves into the shoes of the patient's journey. So, very often somebody listening to this might be very used to having a hospital Quality Director and a Chief Quality Officer or whoever they are that are accountable for these things, and now we're trying to think about ...That's set up really for our bricks and mortar, right? But if we say the patient has a journey, the patient spends time maybe in the hospital, maybe I'm very well and quality to me is about staying well, or I have a chronic disease that's managed and my goal is to stay out of the hospital or is to walk around the block...

Tell me how you think healthcare and Intermountain specifically can rethink quality to align in the journey of the patient. Or if you've seen really good examples of that, too, but I think for convenience we've built things around us, right? A little bit provider centered. How can we rethink that in a way that's meaningful?

Denitza Blagev, MD: I think one of the helpful things that we've found within the Office of Patient Experience is having different representations within the same group. So when we start to think about what happens to the patient, and if I'm really really focused on readmissions, there's a lot happening with the patient, and to the patient that influences that, that's outside of the hospital scope. And if we start to envision that this patient has a primary relationship that guides them through their health and their interaction with the healthcare, then that really facilitates sort of prioritizing with them what they need to worry about. Helping to prioritize, whether it's their outpatient colonoscopy, or their inhaler use, or COPD action plan, to try and help them stay healthy.

Milli West: I think we also, we're trying to actively listen to our patients. We're actually asking them questions about medication reconciliation and what matters most to them with regard to that. What should an end of life conversation be like for them and for their family? And we actually have these patient and family advisory councils, and we regularly take questions to those individuals and say, “What does it look like for you? How do we get it right for you?”

You know, one of the things we were recently talking, were having conversations around end of life, palliative care, these discussions to help these patients that have these severe chronic illnesses that we really kind of know how it's eventually going to end. And trying to help them make the decisions that will help them leave this life with the most dignity and the best quality of life. And you know, there are all kinds of different things out there. Like we've heard some places will actually show a video of what a resuscitation looks like. Like an actual resuscitation. They'll show these to patients and their families and say, “This is what we're talking about when we mean Full Code.”

And so we're taking things like that to our Patient and Family Advisory Councils and saying, “What do you think of this? Is this disturbing to you? Is this something we should do?” And really listening to them, because we can sit behind a desk or around a board room and come up with all kinds of wonderful ideas of what we think it should look like, but the people experiencing it are the ones who really know what it should look like. And if we're not looping them in on the conversation, we're going to miss probably the most important pieces of it.

Donna Barhorst, MD: And then I think, also in the ambulatory setting, asking the patients what are their barriers to care? Around, for example, my example of the colonoscopy, what's the barrier to getting that done? And what other options do we have, like the fit testing and those kinds of things that we could then use that allow to get the screening without necessarily having the procedure. Or just simply, what's the most frustrating when you call into the office, you know we want folks in for these annual wellness visits and all these other things, but we're never really asking them, “Why don't you want to come in for an annual on this visit?” After we've called them three times.

But actually saying, “What's the barrier? What's the issue?” And typically it's because they don't really understand why we're wanting to do what we're doing and getting their input into that. So we've been trying to work on that as we try to improve the metrics that we're tracking right now. You know, that's sort of a crude measure for what we're doing, but at the same time it's really getting back and figuring out what's the root cause of why people don't get their screening or don't do their preventative care or don't manage their hypertension or their diabetes? What else is in play there that's impairing them?

Shannon Phillips, MD: So you all are touching on this a bit. How can we better get the voice of the patient in the quality of care that we deliver? We make a lot of presumptions. I think medicine is naturally very paternalistic. “I know what you need. I’ve got this for you.” And we haven't done ... You know, I heard Milli say, “What matters most? What matters to the patient?” Are we doing that well enough and where could we do that better?

Denitza Blagev, MD:I think one of the ways that I think about it is, we try to incorporate the voices of different people and different areas. Just to keep in mind that it's not one patient, and what we really want is the diversity of patient opinions. And I think the strategy for incorporating that is very similar to the way we think about how do you bring diverse opinions, for example, of women in medicine or underrepresented groups, and the way you do that is you don't just have the one token person sitting in on your board meeting and representing ...

Shannon Phillips, MD: An entire gender.

Denitza Blagev, MD: ...speaking for a whole cohort. Exactly. So I think the way that we need to think about incorporating the voice of the patient is to incorporate it often at a variety of levels with a variety of different people. So some structural things like the P-Fax where there are really clear lines of, we have a specific question and we ask this group, but also I think one of the really valuable things to me about being within the Office of Patient Experience is the fact that we have patient experience colleagues that are really leading the patient voice.

And we can reach out to them and say, “We are interested in figuring out why nobody knows what medications they're on, why they're not taking their medications and they're coming back into the hospital, what are these things? Can you help us figure out what the appropriate ... You know, is it this meeting? Do we need to try to get a focus group of patients around this issue? What are the issues?” So I think it's just more than one thing where we have a meeting, and we've invited a patient to all of our meetings, but continuing to think in all the things we do, how do we incorporate the patient voice? And that's not one answer in my mind.

Donna Barhorst, MD: And I think I would just add too, by talking to our caregivers who are providing the care on a regular basis, patients tell them what's frustrating to them. And if we look at our comments on our surveys, and we really looks at them and say, “What's the thread that runs through this?” Is it access? Is it getting an appointment in a timely manner? What is the thread? Because those are sort of broad categories I think we can look at, but also, for example, have a family come in. There's five kids in that family and they're getting five surveys a month if they happen to go see five different providers, so just that little tweak of, okay, how can we fix that? Because we have one office thinking about those things together, how do we take that feedback and really act on it and then loop back, let the clinician know what we've done, or the caregiver know what we've done, but also really change what we do. And not just say, “Oh, isn't that nice,” while they would rather not get five surveys to their house.

Do you see what I'm saying? So I think really listening to, as we're around and out with our teams, to hear what they're saying around the pebbles in their shoes and the frustrations, because those are the same pain points often times for patients. So I think we need to get both sides of it.

Milli West: Yeah, Donna mentions our experience surveys, and that probably is, right now, our richest source of information from a diverse group of our patients. And we actually can apply some heat mapping methodologies to the comments that are given to us on the surveys, not just the questions. The comments. We're looking at heat mapping to figure out, well how could a certain issue that maybe isn't addressed by a question be affecting a question? But could we also heat map our comments to see what are just the common threads? What are the things we are not getting right?

And whether they impact a question or not, let's work on those. So I think we need to pay more attention to the additional information that our patients are giving us in their responses to our surveys.

Shannon Phillips, MD: I will make a ridiculous confession that I have on my desktop and I carry around to open, I have the first quarter of all the verbatims of our patients across the system in all care settings. And I will open it and read a couple pages at a time and highlight, and you're right. It is incredible the richness of that. And I think people too often maybe dismiss that as, it's about customer service stuff, and I'll say that, sure, there's that, but there's so much more. It's absolutely a fascinating read, and I think hits on many, or all, of our fundamentals of care here at Intermountain. Safety, quality, experience, access, and stewardship. They are telling us exactly what we need to know.

So I agree with you. It's probably untapped.

Donna Barhorst, MD: And I think in my role as a geographic medical director, when I'd been meeting with physicians, and this is before we went to Press Ganey or using other vendors, but maybe they weren't doing as well and they'd come and we'd meet and we'd talk about it. And they said, “What can I do?” I said, “Well, the first thing you need to do is you need to look at the comments and you need to say, 'What are they trying to tell me here?' This is their perception of your care. Not your own perception of your care but their perception of your care.” And that's really key, because that's what it's about. That's where we're not meeting their expectations. And it gives you kind of the starting point to address issues. Not just bad things, but good things, and celebrate.

Shannon Phillips, MD: Do more of the ...

Donna Barhorst, MD: Yeah, do more of the, “Wow, she actually called me back about my labs and actually talked to me about my labs.”

Shannon Phillips, MD: Right.

Donna Barhorst, MD: Those little things that we think are kind of a no-brainer, [00:17:00] but they're critical. And it's really about treating people like you want to be treated. I mean, if you've ever been a patient in the healthcare system, you know how incredibly frustrating it is. Or if any of your family members have, and you just sit and wait for those lab results or for that phone call or for that person to round. And those are where we can influence that, and that, to me, is what quality is about. You know, it all supports the same thing: the best care for the patient [00:17:30] as they need it with their needs in mind. We'll get there, but anyway.

Shannon Phillips, MD: So, healthcare is a very interesting place to work right now. I sort of pinch myself and say, “Wow. I will have in my professional career lived through, I think, a transformative time in healthcare.” As we near 20% of the GDP and value is top of mind, there've been legislative attempts at fixing it, which we won't have a political conversation. It's not right yet. I mean, it's just not.

The concept of getting into risk relationships about patients, that you're not just there to put widgets out and do one thing at a time, but you're there to keep that population as healthy as they can be is a very new, strange, but new thing in healthcare. If I asked you what are you excited about in healthcare quality going forward? Knowing the bit of a tsunami we've been in, what speaks to you in what we have the opportunity to do in this time of change?

Milli West: Well, for me it's being able to take an approach to treating the whole patient. You know, sometimes we've got public reporting, and we've got value-based purchasing, and we've got helping people live the healthiest ... We have a lot of competing priorities, and we're robbing Peter to pay Paul, and we don't even notice Joe over here. And then we maybe experience an event of preventable harm, because that's all going on at one time.

But treating the entire patient rather than just the chief complaint, shifting that focus in our culture to where we're covering all of the bases ... When we drill down within our quality function to events that have occurred looking for what we could have done better or what we could have prevented, we often find that, that we were so focused on the chief complaint, we didn't notice what was going on with this comorbidity over here.

I talk to a lot of patients just in my community, because they know that I work for Intermountain. And sometimes I hear, in fact I just heard recently, “They listened so well. They connected with me. They did such a great job and they listened, but I don't feel like they heard me.” And we have to hear, we have to hear them, and we have to take it into account when we're planning their care. So that's huge for me.

The other thing for me that we're seeing from a public reporting perspective is more of a focus on all payers and all causes within our outcomes. So we're not just dwelling on our heart attack patients or our total joint patients. We're thinking about all of our patients. Every patient that is readmitted counts. Every patient that experiences a preventable death counts. Every patient that gets a hospital-acquired infection counts. It doesn't matter who their payer is or how old they are. And so I'm liking seeing this shift to everybody matters, population health. We're going to take care of the whole patient.

And I also like what I'm seeing around opioids and some of the things that are coming forward around the opioid crisis to better incentivize us and make us aware of what's happening with that. So those are the things I personally am excited about right now.

Donna Barhorst, MD: Then I think for me, it's really getting upstream of the disease process, and part of that maybe has to do more with my pediatric training where it's all about prevention. A big part of it is keeping kids well and healthy throughout their life. And I think to be able to transfer that into the adult population is about getting ahead of the disease process. So if we have people with prediabetes, if we can get them to lose five percent of their body weight, we can normalize their hemoglobin A1C and delay the onset of diabetes.

So how can we build teams and processes within our clinics to be able to identify those patients, get them plugged in, and have those community events that maybe aren't even in our clinics or our hospitals but are at a community center or something like that to help folks understand the importance of these behaviors? So, I think for me, it's aligning that quality on the community side or the ambulatory side where we take in to live well, the home care, the outpatient clinics of Intermountain, and the medical group. And we do that across an integrated system, so it's not just the medical group, but it's also all of our affiliated providers that are working together on the same goal. So I think that in itself is going to raise the standards and really improve the preventative quality. 10 years down the road from now, we won't ever know what we prevented by doing some of the work that we're doing. So, that's what's most exciting for me.

Denitza Blagev, MD: So basically one of the things that seems to finally be coming is data. I think we've all suffered with the electronic health record, and we keep hearing about how it's going to have payoffs, but really in the last several years a team is like defacto there is becoming, just a standardization of, there's only so many medical records. Fewer and fewer places have a legacy record. And with that standardization, there comes the ability to extract data from the electronic health record among institutions and within an institution. And I think that gives us an opportunity to rethink care based on actual objective data that we have access to that we can look at.

So when I look ahead at medicine and I think, okay, so I'll use my own field as an example. I'm a lung doctor, so the national lung screening trial showed that lung cancer screening CT had a 20% reduction in lung cancer mortality. And so you can say, "Well I should have a lung cancer screening metric, and I should make sure everyone is getting referred." But if you look at that broadly, more than half of the patients both within our program and in that trial who went for a lung cancer screening scan were actually active smokers. And so as a health system and as a country, we can look and say, okay, I can focus on this. Like how often did you talk to your patient about lung cancer screening? But maybe the broader focus going to Donna's point is how about we implement tobacco cessation.

And if you look again at the NLST trial, in fact more people in the lung cancer screening trial died of coronary artery disease than they died of lung cancer. And so you can look and say, "I should grade you." This is a USPSTF recommended measure. It's as good as breast cancer screening. But maybe we have an opportunity to look back and say, "It's not rocket science. Smoking is common risk factor for both COPD, lung cancer, and coronary artery disease."

So we really have the opportunity to inform in a much more specific way, there's a subgroup here that really needs to prioritize lung cancer screening and there's a subgroup here that really needs to prioritize tobacco cessation. And I'm going to lay off on these 50 other metrics that I'm grading their doctor on so that their doctor can really work on tobacco cessation as more as, "I handed you a booklet, and by the way, you should stop smoking while you lose weight and you go for a sleep study."

Shannon Phillips, MD: Wow. Laying down the gauntlet, yes. You know, I heard a theme of getting upstream, the opportunity to ... In quality, we ask the whys: Why did that happen? Why did that happen? Right? You're not going to have lung cancer most of the time if you haven't smoked. So, a good point. And I think when you look at value, if we can get upstream and keep people healthy, we've delivered on quality at a great cost. I'm not going to let you get away, Denitza, without your 60 seconds on the other value stream, which is the work that you just did on COPD where we can provide value to patients, we can improve quality and reduce costs by stratifying patients and applying the right care to the right risk. Great for patients, great for the cost of care. Go.

Denitza Blagev, MD: So, we are really excited for our work with the LIVE score, which we validated and developed at Intermountain and actually validated into National Veterans Affairs data. The question we asked is essentially if Facebook can know who I'm going to vote for based on my likes, why can't my health record know something important about me and my COPD based on the data that's contained within the health record? And traditionally, most of the COPD risk stratification has centered around how severe is your COPD. And what we see on the ground is that you might not have very severe COPD, but if you also have heart failure and renal failure and untreated sleep apnea and you're on opiates for your chronic back pain, that person has a much higher risk of negative outcomes compared to someone with really bad lung function who does not have those comorbidities.

And so the LIVE score was a way of empirically deriving what variables are most important, and we were able to find that just five commonly checked lab values will risk stratify. We validated this at Intermountain on about 50,000 patients on mortality and COPD admission, and we validated in over 80,000 patients of the National VA Health System and about 3,000 patients at the University of Chicago, and we're working on looking at that and the Kaiser data. So really exciting and important work, and our thoughts with this is that this provides people on the ground a way of focusing on who needs that extra support at what level.

Shannon Phillips, MD: And value, right? That's controlling costs. You can't put everything at everybody, nor should we. I think that's a really important example, so congratulations on that work. So, the Institute of Medicine, back a while ago, defined quality as safe, timely, effective, equitable, efficient, and patient-centered. And I think you all of have brought up pretty much all of that. We've got big work ahead of us in healthcare in the U.S. and here at Intermountain. I think we've got a crack team to get this done, so we'll get back at it. And I appreciate your time today.

Denitza Blagev, MD: Thank you.

Donna Barhorst, MD: Thank you.

Milli West: Thank you.