On farms, each crop (e.g., corn, soybeans) is a commodity that must be stored separately from the others. To accomplish this, farmers build silos that stand side by side holding one crop each. This approach may work well for the farming industry but delivers less-than-satisfactory results in a healthcare setting.
What Are Clinical Silos?
Silos have become an analogy for our fragmented healthcare system. Too often, hospital departments, medical specialties, and community-based services operate side by side but remain isolated from one another.
"Siloed" providers diagnose and treat patients according to their expertise but rarely involve other disciplines or specialties. This singular focus persists even when collaboration is clearly in the patient's best interests (as in the case of comorbidities, for example).
Why Break Silos Down?
Two decades ago, when most medical care was reimbursed on a fee-for-service basis, providers had little incentive to collaborate. However, the economics of healthcare are changing. New reimbursement structures like global and bundled payments reward providers who deliver value, which can be defined as quality and safety at minimal cost.
To succeed in this new environment, health systems must align their providers toward shared goals of care coordination, quality, and customer service. In other words, they must transform their provider-centric silos into multidisciplinary patient-centered teams.
The process of "silo busting" can be highly disruptive. Silos usually form over a period of years or even decades. The culture of independence is deeply ingrained in siloed providers, who resist changing their practice behaviors.
That being said, many health systems have successfully transitioned their silos to flexible, engaged teams that deliver great outcomes for patients. Here are three strategies that have worked for our client health systems:
1. Process Codesign
Hospitalists and emergency physicians "share" many patients but don't necessarily work well together.
Traditionally, emergency physicians have focused on disposition as an endpoint: "I need to stabilize this patient and get them to med-surg or ICU."
Meanwhile, the hospitalist's goal is diagnosis: "I need as much data as possible on this patient so I can start treatment as soon as possible."
By contrast, in a truly integrated culture, each specialty takes on the cares of the other. Emergency physicians think about diagnosis, and hospitalists consider disposition. Both constantly ask themselves: How can we work together to accomplish these shared goals?
Healthcare leaders often try to "integrate" clinical services by issuing top-down directives. But a better approach is to invite stakeholders to codesign new processes and workflows. While this method certainly takes longer, it's more likely to succeed, because it reflects the needs and work styles of both teams. What's more, the codesign process itself provides an opportunity for the specialties to build relationships and learn about one another.
Emergency Medicine and Hospital Medicine, Adventist Health – Central Valley Network
Adventist Health – Central Valley Network, a three-hospital system in California, decided to charge its Vituity hospitalists and emergency physicians with codesigning a better handoff process for patients admitted from the ED. The medical directors of both departments agreed to focus on improving patient satisfaction, then asked one another, "How do we get there?"
This discussion led them to codesign several shared processes that they further refined in the field with their teams:
- Integrated care pathways. ED workflow was retooled to provide patients with the right treatment and right therapy, right away. ED physicians now place preliminary orders to help hospitalists hit their core measures (e.g., VTE risk assessment). Hospitalists then "catch" the patient and adjust the orders as needed. The teams also created several condition-specific pathways for patients with congestive heart failure, chest pain, and pneumonia. As a result, quality metrics have improved, and length of stay has decreased.
- New practice patterns. Emergency physicians have begun providing more comprehensive care in the ED, often in consultation with the hospitalist. This means admitted patients reach the inpatient floor in more stable condition and with more diagnostic information. It also means discharged patients are less likely to return to the hospital.
This ED-hospitalist collaboration helped to break down other silos across the hospital. Once the two medical directors had a basic plan in place, they invited leaders from other clinical areas like nursing, cardiology, and surgery to further refine the process. This strengthened relationships and sparked closer collaboration among departments.
2. Integrated Clinical Pathways
Emergency Medicine – Anesthesia, Good Samaritan Hospital
Administrators at Good Samaritan Hospital in San Jose, Calif., wanted to improve pain management and decrease length of stay for hip fracture patients. To address the issue, several departments (including emergency medicine, anesthesiology, surgical services, case management, and rehabilitation) created a multidisciplinary hip fracture committee. Its purpose was to get experts with different backgrounds and training aligned toward these shared goals.
Through a series of discussions, providers set aside their service line-specific goals and challenged ingrained ideas that their departmental processes couldn’t be modified. They took ownership of their role in the big picture of hip fracture care. Agreeing to collaborate meant shifting from isolated practice to shared responsibility for patient outcomes and experiences.
Vituity had managed Good Samaritan's ED for many years, and the project gained momentum when the anesthesiology group also joined Vituity. Going forward, the two specialties teamed up to provide leadership and structure for the initiative. Their efforts made it much easier for other departments to engage in the process and brought great energy to the project.
Together, the teams reviewed the data, discussed strategy, and began designing an integrated hip fracture clinical pathway:
- Today when a hip fracture patient arrives at the ED, the emergency physician alerts the anesthesia department. The on-call anesthesiologist consults with the surgeon on pain management options.
- The anesthesiologist then sees the patient in the ED. When appropriate, he or she administers a nerve block, which is very effective at controlling pain and reduces the need for opioid medication.
- The anesthesiologist also coordinates communication with the admitting hospitalist, facilitates scheduling with the OR, and orders post-surgical therapies. This allows the patient to move more quickly from the ED to the hospital floor — and ultimately onward through surgery and therapy.
The new hip fracture pathway has been quite successful. Length of stay for this population dropped from 133 hours to 95 within the first 12 months. Use of opioid medications also declined. And anecdotal evidence suggested that patients and families felt reassured by the camaraderie and teamwork they saw.
3. Community Partnerships
Emergency Medicine – County Mental Health Services, Rideout Memorial Hospital
As funding for local mental health services declined, Rideout Memorial Hospital in Marysville, Calif., found itself treating more and more behavioral health emergencies. Between 2015 and 2017, the number of mental health- and substance abuse-related ED visits rose from 40 per month to 145.
Often, these patients would endure long waits for a psychiatric evaluation. Those who were ultimately admitted to inpatient facilities spent a median 25–27 hours in the ED, often under the care of a paid "sitter." "Psychiatric boarding" was costing the hospital an estimated $3 million a year while sorely exacerbating ED crowding.
The sad thing about all of this waiting was that it was often unnecessary. Patients who present to the ED in psychiatric crisis are twice as likely to be admitted compared to those with purely physical complaints. But research suggests that 70–80 percent of this population can be stabilized, discharged, and treated in the community.
The ED team, the hospital, and the county behavioral health department all agreed that things needed to change. So in 2016, they launched the Mental Health Emergency Collaborative. One of its overarching goals is to reduce the need for inpatient admissions by stabilizing patients in the ED.
Today when a patient presents to Rideout's ED with a mental health emergency, the collaborative team swings immediately into action.
- The emergency physician conducts a rapid screening on arrival and alerts the mental health team as appropriate.
- A county crisis worker conducts an initial assessment and recommends a tentative clinical path (admit to an inpatient facility, evaluate further, discharge with support).
- The ED team works to medically assess and clear the patient.
- An emergency nurse, county crisis worker, and Vituity telepsychiatrist evaluate the patient.
- When a patient requires inpatient admission, the crisis worker secures the necessary clearances, completes the paperwork, and arranges admission and transportation.
- If the patient will be discharged, the crisis worker consults with the ED charge nurse to finalize a support and safety plan.
- The county psychiatrist consults with the team as needed regarding final disposition. He or she also lifts involuntary psychiatric holds when appropriate.
Within six months, the collaborative was producing some amazing benefits for the patients, department, and hospital.
- Median ED length of stay dropped from about 25 hours to 18 (for admitted patients) and 14 hours to 9 (for discharged patients).
- The number of sitter hours required to manage boarded patients decreased — even as the total number of patients with mental health complaints rose.
- Use of restraints due to violent or disruptive behavior was cut by more than half (10 percent of patients to 4 percent).
Above all, the collaborative was the right thing to do for patients. It helped to reduce unnecessary admissions, keep patients comfortably at home, and connect them with community resources.
Tips for Getting Started
Are there some silos in your health system that need breaking down? Here are some helpful tips from the three hospitals listed above:
- Consider outsourcing. Contracting with a multispecialty group to run multiple departments (for example, emergency medicine and hospital medicine) can help to align providers toward common goals.
- Form a multidisciplinary committee. Bring together leadership from a variety of departments, specialties, and services to discuss a key issue and design solutions.
- Remember that innovation goes hand in hand with disruption. Build an organizational culture that welcomes risk-taking and failure as essential parts of growth.
- Give integration time. Remember, it takes years and even decades to build silos. So it will also take some time to dismantle them.
- Finally, when you encounter resistance, always refocus the issue around patients. While change is hard, many providers genuinely want to improve outcomes and experiences for their patients. Appeal to their compassion and sense of personal mission.
To learn more about how Vituity can transform your hospital's emergency care, visit our website.
Originally published July 17, 2018.