csc WORLD WORLD HEALTHCARE: A Performance Improvement Maturity Model for the Healthcare Industry at Virgin Money AN ARTICLE FROM

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1 csc AN ARTICLE FROM WORLD HEALTHCARE: A Performance Improvement Maturity Model for the Healthcare Industry The Green IT Issue WORLD Building a Better Business June 2008 at Virgin Money JUNE 2008

2 A Performance Improvement Maturity Model for the Healthcare Industry 1 By LYNETTE FERRARA, DAN FOLTZ & DONALD BIALEK, MD, MASTER OF PUBLIC HEALTH The U.S. healthcare market has discovered the link between quality and performance improvement. Health plans and government are linking reimbursement to quality: rewarding adherence to quality guidelines and refusing to pay for complications due to medical errors. Even life sciences companies have jumped on the quality bandwagon, offering money-back guarantees if medicines do not result in promised patient outcomes and cost reductions. 1 The frameworks in this document reflect the contributions of many members of the CSC Health Informatics practice including Lily Fink, Don Griffin and Abhay Nihalani. LYNETTE FERRARA is a partner in CSC s Health Informatics practice. DAN FOLTZ is the director of CSC s Health Informatics practice. DONALD BIALEK is a physician with CSC s Health Informatics practice. 24 JUNE 2008

3 Healthcare Provider organizations (hospitals and physician networks) share the commitment to quality improvement but often lag behind government and health plans in their capabilities to measure and manage quality. In several regions of the United States, industry stakeholders have created collaborative programs to measure and manage the quality of care and to improve the performance of the healthcare system as a whole. These efforts have been hampered by the absence of a common language to assess the ability of industry stakeholders to measure and manage quality. The Capability Maturity Model for Performance Improvement that we introduce here will enable industry stakeholders to work together using an industry-validated roadmap for achieving organizational performance improvement. 2 This maturity model provides a shared vision for what an organization needs to do to attain a specified level of quality. Organizations that adopt this shared maturity model have a place to start when redesigning their processes, a common language and vision, and accepted benchmarks against which to assess their progress. There are also six lessons learned from other industries that can reduce risk and speed implementation. The Healthcare Performance Improvement Maturity Model Healthcare organizations that adopt performance improvement programs evolve through three distinct phases of organizational development (see Figure 1): Foundational Level: They begin by measuring conformity with quality standards established by an accrediting organization, a regulatory body and/or a key customer. They are defining how they will measure the quality and efficiency of their processes, establishing process improvement objectives and determining the baseline measures of their operations. Advanced Level: Organizations proactively manage quality improvement. They have well-articulated quality improvement goals and a defined methodology for setting and achieving quality improvement objectives. Process redesign is embedded in the organizational DNA through information-driven care processes and health information systems. Distinctive Level: Organizations will have sufficiently rich and timely information to ensure that each individual receives personalized care based upon Figure 1 such factors as genetic makeup, specific health history and specific environmental factors. This can take the form of personalized health coaching and/or highly tailored care management processes. In the next three to five years, health plans expect to enhance their ability to manage the quality of care provided though their provider networks. They are launching technology assessment programs that limit reimbursement to medical technologies and new procedures with a track record of improving patient outcomes and reducing the cost of care. They are also implementing a new generation of health management programs that provide both physicians and patients with timely, evidence-based suggestions to improve the safety or quality or to reduce the cost of care. Providers struggling to measure quality The provider organizations in this study are academic medical centers and the flagship research hospitals of proprietary hospital networks (see Research Methods sidebar, page 26). They have at their disposal more resources to measure and manage quality than the average community hospital in the U.S. market. However, this survey found that even these leading-edge providers were struggling to gather the data needed to generate the many quality reports demanded by regulators, payors and governments. While the leaders of the quality programs have ambitious goals for redesigning their processes to improve outcomes and reduce cost, they believe progress will be slow due to lack of resources, the difficulty of coordinating care across organizational boundaries, and resistance from physicians and other key stakeholders. They were even less optimistic about their ability to influence consumer and physician behavior and design effective interventions. The Healthcare Performance Improvement Maturity Model RICHNESS AND TIMELINESS OF INFORMATION Health plans are moving from measurement to management U.S. health plans are investing in data and processes that will enable them to improve clinical outcomes while controlling costs. Ninety percent of all health plans report the Healthcare Effectiveness Data and Information Set (HEDIS) measures used to assess compliance with standards for managing patients with common chronic diseases. Even the smallest and least well-funded plans provide the measures their customers demand. 2 The value of a capability model to manage the evolution and value of data and analytic processes was identified by Alexander Black and Jacquelyn Thomas, in Analytics Rising: How Companies Are Responding to Demands for More Meaningful Customers Insights (CSC 2006). MEASUREMENT (Quality, Safety, Outcomes, Cost & Value) FOUNDATIONAL Building Blocks To Success REPORTING MANAGEMENT (Physicians, Consumers & Health Professionals) ADVANCED Market Advantage ANALYSIS PROCESS MANAGEMENT PERSONALIZED MEDICINE DISTINCTIVE Competitive Advantage PREDICTIVE MODELING EVOLUTION OF EVIDENCE-BASED MEDICINE JUNE

4 A Performance Improvement Maturity Model for the Healthcare Industry Lessons learned from other industries The U.S. healthcare industry is adopting process performance methods and technologies that have been vetted for over 20 years in other industries, ranging from heavy manufacturing and consumer goods to software development. While leaders of healthcare organizations tend to believe their industry is unique, heeding the following six lessons learned in other industries will help to avoid common missteps that delay the performance improvement of individual organizations and the healthcare system as a whole: 1. Invest the time and resources needed to define process performance objectives. IT organizations and technology vendors can help, but only if they know an organization s performance objectives and the necessary time and energy are invested to redesign processes. Core processes that impact cost, and patient safety and well-being, cut across departmental and organizational boundaries. Creating patient-centric, efficient and effective care requires a change in roles and responsibilities, rewards and management systems, as well as in processes and IT systems. 2. Getting Health Information Technology (HIT) right is everyone s job. HIT provides the platform that reduces cost by automating work that adds little value. It also improves quality by providing the information needed to ensure that health guidelines are followed. However, these benefits require an active partnership between clinicians and IT departments throughout the software deployment lifecycle. Health plans report that many of their legacy systems were not designed to capture and store information contained on medical and pharmacy claims relevant for measuring quality and efficiency. These systems must be retooled or replaced to avoid stripping valuable information when claims are adjudicated. Similarly, many provider organizations implement electronic medical record (EMR), lab and diagnostic systems without first defining the information that must be collected to measure quality or outcomes and to monitor and improve organizational performance. 3. Explore the use of innovative, service-based business and IT architectures and business models. Hundreds of organizations now offer technology-enabled business services to support quality management. Health plans can buy data integration services from one or more vendors and then rapidly deploy organizational performance improvement initiatives. Provider organizations face a less mature market but can find service and technology partners to rapidly provide clinical and analytic capabilities. However, these services are utilized best in the context of a health informatics framework that orchestrates the integration of patient data and business processes. Without a well-articulated business and service architecture, organizations risk squandering scarce resources on duplicative and overlapping services. 4. Invest in analytic capabilities. Do this at the same time you deploy electronic transaction systems so they will be optimized to support medical claims, data used in patient visits and other work flows. Technical design rarely supports reporting or analysis. As importantly, much of the data needed to measure and manage quality is generated by other systems within the organization and in partner organizations. Until recently, the only option was to develop a proprietary data warehouse. Today, health services companies like CSC provide health informatics based on a common Health Informatics Framework (see sidebar page 27) reducing the time and cost needed to develop process measurement and management capabilities. 5. Consider regional process improvement solutions that provide visibility and facilitate collaboration and process improvement over the entire continuum of care. Few consumers receive healthcare from an integrated delivery network that establishes care guidelines and offers providers, patients and their families coordinated care. Instead, patients shuffle among primary care physicians, specialists and other providers in both inpatient and outpatient settings. Without common guidelines and shared information systems, duplicative services drive up costs and errors due to incomplete information that puts patients at risk. When health plans and providers form regional quality improvement collaboratives, they can focus available resources on joint objectives and measures. For example, in Massachusetts, the major health plans and independent provider networks have adopted common standards for managing patients with five major chronic diseases. These standards are used to provide patient care, helping to ensure continuity of treatment as patients move among providers. 6. Conserve your resources for the really difficult challenges: forging consensus on political and economic policy and changing deep-seated behaviors of clinicians and patients. Be prepared to invest in change management. Healthcare performance improvement requires industry stakeholders and consumers to develop a shared vision of how healthcare systems will function. This touches the sensitive issue of what services will be covered and at what prices, where services will be provided, how end-of-life decisions will be made and how health care professionals and consumers will be accountable for outcomes and for choices and payment for treatment. Join organizations that encourage industry stakeholder collaboration at the regional and local level. Build processes and a culture that engage diverse community groups in discussions of best practices for maintaining health, preventing disease and seeking and complying with proven treatment, when sick. O Download an in-depth version of this article at Research Methods This research was conducted through interviews and panel discussions with medical and pharmacy directors of 31 U.S. health plans and CEOs, medical directors and chief quality officers of 10 provider institutions. The participants in this research were asked to validate the Performance Improvement Maturity Model. They were then asked to use the model to assess their organizations maturity today and describe their plans for enhancing their capabilities over the next three to five years. The health plans provided the full range of health insurance programs including privately funded health insurance as well as Medicare Advantage and Medicaid HMO programs. They ranged in size from three of the largest national plans covering over 20 million lives and large regional plans (three to 20 million lives), to smaller regional plans covering 600,000 to three million covered lives and local plans (less than 300,000 lives). The provider organizations were academic medical centers or the flagship research hospitals of national or regional hospital groups. These institutions are not representative of U.S. hospitals since they are likely to be better funded and have medical informatics teams on staff. 26 JUNE 2008

5 Healthcare OVERALL SOLUTION STEWARDSHIP Strategy Process Intelligence Governance ` PROVIDER-CENTRIC HEALTH INFORMATICS Primary Uses of Information Secondary Uses of Information Quality and Safety Measures Clinical Decision Support Resource Use Healthcare Planning Credentialing Public Health Clinical Auditing Personalized Medicine Efficiency Measures Customer Intelligence Benchmarking Performance Improvement Epidemiology and Research Clinical Governance CORE BUSINESS INTELLIGENCE SERVICES Queries Reports/ Dashboards OLAP, ROLAP MOLAP, HOLAP Process Models Statistical Analysis and Validation Business Rules/ Predictive Models Optimization Reception and Profiling Culling and Cleansing Verification to Specification Staging for Integration FOUNDATIONAL DATA SERVICES Data Collection Data Integration Data Management Probalistic Matching Master Person Indexing Augmentation Controlled Medical Data Architecture Inventory and Tracking Master/Reference Data Maintenance Database Management Systems Data Models Metadata Privacy, Security and Compliance Logging and Auditing SUPPORTING SERVICES Business Integration Services Presentation and Portal Services Systems Management Services TRANSACTIONAL SYSTEMS Clinical Information Systems Administrative and Financial Systems Claims Systems CSC s Health Intelligence Framework CSC s Health Intelligence Framework is designed to allow customers to integrate and standardize their data once, and to orchestrate the transaction and analytic services needed to measure and manage performance improvement. Examples of this framework in action include: Developing efficiency and effectiveness measures for doctors and hospitals serving six health plans and over 30 employers Enabling a multi-hospital chain to measure operational efficiency, quality and customer satisfaction despite wide variation in clinical systems and processes Enabling physicians and hospitals in a regional network to share information on quality and effectiveness Enabling a life sciences company to reduce the time and cost of clinical trials by refining patient selection criteria and selecting investigators in geographic areas rich in eligible patients Designing use cases to reduce the time and effort to track infection in a hospital setting freeing infection control managers to prevent rather than simply track infection JUNE

6 Contact CSC World: Visit: Worldwide CSC Headquarters The Americas 3170 Fairview Park Drive Falls Church, Virginia United States Europe, Middle East, Africa Royal Pavilion Wellesley Road Aldershot, Hampshire GU11 1PZ United Kingdom +44(0) Australia 26 Talavera Road Macquarie Park, NSW 2113 Australia +61(0) Asia 139 Cecil Street #06-00 Cecil House Singapore Republic of Singapore About CSC The mission of CSC is to be a global leader in providing technology enabled business solutions and services. With the broadest range of capabilities, CSC offers clients the solutions they need to manage complexity, focus on core businesses, collaborate with partners and clients, and improve operations. CSC makes a special point of understanding its clients and provides experts with real-world experience to work with them. CSC is vendor-independent, delivering solutions that best meet each client s unique requirements. For more than 45 years, clients in industries and governments worldwide have trusted CSC with their business process and information systems outsourcing, systems integration and consulting needs. The company trades on the New York Stock Exchange under the symbol CSC. Copyright 2008 Computer Sciences Corporation. All rights reserved. Printed in USA