A Bold Experiment
A little about my background: I previously served as emergency department (ED) medical director for Adventist Medical Center-Selma and Adventist Medical Center-Hanford in California's Central Valley. Based on Vituity's success in the emergency room, Adventist Health approached us about expanding our partnership. Vituity now staffs the EDs and hospitalist programs at three Adventist Health hospitals as well as an urgent care center and skilled nursing facility.
Adventist Health's administration hoped that staffing all of these services with a single multispecialty group would help to improve patient satisfaction, reduce readmissions and improve throughput across the system. They also hoped to achieve closer integration of their clinical services, better positioning them to succeed in the coming era of value-based reimbursement.
I think the Adventist Health administration was quite forward thinking in that they wanted to take "integration" beyond its buzzword status. They wanted their patients to feel like they were being cared for not by the emergency physician and then the hospitalist and then the SNFist, but by one unified group — harking back to the old-time family doctor days when one physician coordinated all of your care.
They also hoped a single group would be more effective in bringing about systemic change. Previously, if they'd wanted to improve throughput or patient satisfaction, they had to go through a process of wooing multiple medical directors. Under the new arrangement, they would have one point of contact for issues and suggestions.
On paper, it looked like a fantastic plan. But could we pull it off?
Barriers to Integration
It's one thing to staff multiple service lines at one hospital. Lots of groups can do that. It's quite another thing to get them to work together.
The primary reason for this: integration requires a fundamental change in the way physicians have been trained and conditioned to practice. Rather than focusing on "what we do" ("we" being hospitalists, emergency physicians and so on), we need to think flexibly and focus on what's best for the patient.
In other words, providers of all specialties need to come out of isolation and embrace goals and processes that have previously "belonged" to other service lines. This requires them to let go of their egos and open themselves to tasks they may not be "experts" at.
Emergency physicians and hospitalists are great examples. These two service lines share patients, but they haven't always worked 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, emergency physicians think about diagnosis and the 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, in my opinion, 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.
At Adventist Health, the hospitalist and emergency medicine medical directors began with the endpoint of high 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. Our emergency physicians now provide more comprehensive care in the ED, often in consultation with the hospitalist. This means admitted patients reach the floor in more stable condition and with more diagnostic information. It also means discharged patients are less likely to return to the hospital.
- Patient-centered handoffs. The emergency physician uses a care card with the hospitalists' pictures to prepare admitted patients for the transition. The emergency physician sets expectations: "This is Dr. Smith, and she's a great doctor. She's going to see you tomorrow." He or she also reassures the patient that the two departments are a team: "If any issues come up tonight, let your nurse know, and they'll call Dr. Smith or me."
A Success Story
To reiterate, codesign takes longer than more directive approaches to change. The tradeoff is greater ownership and engagement by the participants. They actually have fun using the processes they helped build and enjoy seeing their ideas brought to life.
Codesign also fosters integration across the hospital. The care pathways are a good example. Once the ED and hospitalist 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.
So was Adventist Health's integration experiment a success? To be fair, both the EDs and inpatient programs still have strengths and weaknesses. On a positive note, quality metrics are improving across the board. What's more, the culture has deepened to the point that the hospitalists and emergency physicians really do think of themselves as one team with shared goals.
A final caveat: I've focused this post on a situation where one physician group staffs multiple service lines. However, it's worth noting that physician leaders from different groups can apply the same principles to improve integration. The best way to start is to put the patient at the center of the process. Then ask one another: how do we want to improve their care? And how can we work together to get there?
Originally published July 7, 2015. Updated Feb. 7, 2018.