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Pharmacy Executive Forum
How Clinical Standardization Can
Transform Your Organization
Braden Lang
Senior Consultant
©2014 The Advisory Board Company • advisory.com
6
2
3
1
Road Map
Beyond Evidence-Based Practice
Case Study: Banner Health’s Clinical Transformation
Applying the Banner Model at a Single Hospital
©2014 The Advisory Board Company • advisory.com • 30126F
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Amidst Many Critical Priorities, Cost-Consciousness Rises to the Top
Source: Physician Executive Council Topic Poll,
2014; Physician Executive Council analysis.
Consensus: We Need Cost-Conscious Physicians
1) In response to the question, “How much of a priority is this topic likely to be for
you in 2014?”: A-This is one of my top priorities, B-This is a secondary priority
for me, C-This is not a priority for me, F-I will spend no time at all on this topic.
3.18
3.29
3.30
3.37
3.42
3.50
3.55 Cultivating a Cost-
Conscious Medical Staff
Effective Communication with
the Mixed Medical Staff
Engaging Physicians in the
Shift to Population Health
Leading Cross Continuum
Clinical Transformation
Keeping Up with
Industry Transformation
The Integrated
Quality Function
Overhauling Physician
Leadership Roles
Top Ranking by Priority, as Graded by System and Facility CMOs1
n=38
Out of 4.0
©2014 The Advisory Board Company • advisory.com • 30126F
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“Right Care” Engages Physicians in Tackling Clinical Overuse
Source: Physician Executive Council interviews and analysis.
1) Evidence-based practice.
A Cost-Conscious Role that Resonates with Physicians
Evidence-Based
Practice Right Care
Shared
Decision-Making
Self-Directed
Medicine
Physicians practice
according to own
training and
knowledge, yielding
dramatic variations
in care
Physicians practice
according to the most
up-to-date clinical
evidence, yielding
greater
standardization where
evidence exists
Physicians practice
EBP1, and even where
the evidence is unclear,
physicians identify and
weed out unwarranted
variation and excess
costs of care
Physicians
incorporate costs of
care into shared
decision-making
conversations with
patients
Cost-conscious physicians
practice at this end of
the spectrum
Desired Evolution of Physician Practice
©2014 The Advisory Board Company • advisory.com • 30126F
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Source: Yancy, Clyde, et al., “2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines,” 2013, available at: https://circ.ahajournals.org/content/128/16/e240.full.pdf;
“Heart Failure Fact Sheet,” American Heart Association, available at: http://www.heart.org/idc/groups/heart-
public/@wcm/@private/@hcm/@gwtg/documents/downloadable/ucm_310967.pdf; Physician Executive Council interviews and analysis.
1) Left ventricular systolic dysfunction.
2) Angiotensin-converting enzyme inhibitor.
3) Angiotensin II receptor blockers.
Distinguishing Between EBP and Right Care
Evidence-Based
Practice Right Care
• Prescribe HF patients with
LVSD1 an ACEI2 or ARB3
• Prescribe patients evidence-
based specific beta blockers
Order an echocardiogram to
measure left ventricular function
and ejection fraction. Repeat
measurement only
recommended for patients with
significant change in clinical
status or device therapy.
Unclear guidelines
yield significant
variation
Clear guidelines yield
adherence to appropriate
standard of care
Group of cardiologists identifies
and addresses drivers of care
variability (e.g., ordering habits,
different definitions of “significant
change”); provides medical staff
with appropriateness criteria for
repeat echoes
Example 1
Example 2
Example Guidelines for
Heart Failure Patients
©2014 The Advisory Board Company • advisory.com • 30126F
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Source: Physician Executive Council interviews and analysis.
The Push to Right Care Requires Ample Investment
z
Sample Investments Along “Right Care” Development Workflow
Opportunity Assessment
Regularly assess cost,
outcome data to identify
variation, pinpoint greatest
opportunities
1
Consensus Groups
Physician-led groups
set care standards to
optimize quality and
resource stewardship
2
Roll-Out Communication
Leaders explain rationale
for new standards to
physicians, highlight their
role in adoption
3
z
Ongoing Monitoring
Track outcomes to
assess efficacy of
standards and identify
opportunities to improve
6
Accountability
Mechanisms
Set resource stewardship
goals; share performance
data with physicians
5
Practice Change Support
Use education, workflow
prompts and tools to
support adoption of clinical
standards
4
Iterative
process
repeated
to address
new
variation
hotspots
©2014 The Advisory Board Company • advisory.com • 30126F
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In Need of a Medical Staff Culture Shift
Does not view innovation as solely
additive services—helps figure out
when providing less care is optimal
Considers the impact of costs
on the affordability of
healthcare for patients
Aware of market imperative to increase
“value” of healthcare; embraces physician
role of reducing excess utilization
Uses data to identify opportunities to
reduce variation and compare the
effectiveness of different care paths
Resource Stewardship Not a Significant Departure from Core Values
Source: Physician Executive Council interviews and analysis.
Innovative
Patient Advocate
Data-Driven
Committed to
Health Care
Delivery
Core Physician Values Attributes of a Physician
Steward of Resources
©2014 The Advisory Board Company • advisory.com • 30126F
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Source: Chatman, Jennifer, “Leading by Leveraging Culture” California Management Review,
2003, available at:
http://faculty.haas.berkeley.edu/chatman/papers/18_LeadingLeveragingCulture.pdf
Talent Development, The Advisory Board Company; Physician Executive Council analysis.
Making an Amorphous Concept Concrete
Vision
Leadership
Commitment
Talent
Management Infrastructure
Four Tactical Elements of Cultural Change
Defining Culture
“Culture is a system of shared
values (defining what is important)
and norms (defining appropriate
attitudes and behaviors).”
Jennifer Chatman, PhD
Haas School of Business
UC Berkeley
©2014 The Advisory Board Company • advisory.com
13
2
3
1
Road Map
Beyond Evidence-Based Practice
Case Study: Banner Health’s Clinical Transformation
Applying the Banner Model at a Single Hospital
©2014 The Advisory Board Company • advisory.com • 30126F
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1) Through a merger between Lutheran Health Systems and
Samaritan Health System.
Case Study: Banner Health
Case in Brief: Banner Health
• 25-hospital, not-for-profit system headquartered
in Phoenix, Arizona, with facilities in Arizona,
Alaska, California, Colorado, Nevada, Nebraska,
and Wyoming
• Approximately 1,000 employed and 8,000
affiliated physicians system-wide
• Banner Health was created in 19991; in the early
2000s Banner committed to system-wide clinical
standardization as a means to improve quality
and reduce unnecessary care utilization
• To support this endeavor, Banner built “Care
Management,” an infrastructure with strong
clinical leadership committed to developing and
implementing system-wide standards of care
• This approach has contributed to improved
quality outcomes and financial growth (from $2B
to $5B in annual revenue) over the past 15 years
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
IMA
GE
CR
ED
IT: B
AN
NE
R H
EA
LT
H
©2014 The Advisory Board Company • advisory.com • 30126F
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Commitment to Reducing Variation Yields Returns
• As of 2012, 17 of 25 hospitals
achieved Stage 7 EMR Adoption
(HIMSS Analytics)
• 2013 Top 5 Large Health System for
Clinical Quality (Thomson Reuters)
Clinical Accolades Financial Growth
• Increased revenue from $2B in
1999 to $5B in 2014
• 2013: $13.7M reduction in
supply costs from strategic
initiative
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
A Sampling of Banner’s Achievements Across the Past Decade
Hallmarks of a Maturing Delivery System
Growth of Physician Leadership Team
• 1999: Three FTE physician leaders, 1 facility with a CMO
• 2014: 28 FTE physician leaders, 24 facilities with CMOs
Increased Reliability of Care
• System has matured to support monthly rollouts of multiple
system-wide clinical standards (e.g. six in September 2014)
©2014 The Advisory Board Company • advisory.com • 30126F
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Physicians Feel Empowered as Clinical Innovators
“I am into utilitarian health care—providing the best care to the
largest group of patients. After practicing at Banner you can very
clearly see it’s the best thing for the patient.”
“I feel obligated to save the nation money. We can do that and
improve quality through standardization.”
“Is it a perfect system? Of course not. But it’s pretty good, and I
want to be a part of the solution—you’ve got to try, right?”
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Quotes from Practicing Physicians at Banner Health
“I believe in the system—I am a big proponent of standardization.
It just works. Care Management saves lives and reduces costs.”
“Somebody, the government, the system, will make cuts based
on cost. At Banner that somebody can be us, the physicians. If we
want to advocate for the best patient care, we need to be involved.”
©2014 The Advisory Board Company • advisory.com • 30126F
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How Banner Rolls Out Care Standards System-wide
Care
Management
Council
A Quick Look at the Banner Model
25 Acute
Care Facilities
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
17 Clinical
Consensus Groups
Care Management Council consists
of clinical executives and retains
oversight of all care standard creation
and deployment
Clinical Consensus Groups include
multidisciplinary participants who
develop system-wide care standards
within a given clinical area
All 25 facilities “go live” with new care
standards on the same day, with the
help of system implementation experts
©2014 The Advisory Board Company • advisory.com • 30126F
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Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
A Journey of a Thousand Miles…and Counting
Major Milestones in Banner Health’s Clinical Journey
1999
Merger between Samaritan
Health System and
Lutheran Health System
forms Banner Health
2001
CEO sets vision to become
a “clinical quality” company;
system CMO adopts
clinical standardization as
central tenet of that effort
2003
First Clinical
Consensus Group
develops system-wide
CV1 care standards
2004
Banner invests in
implementation
experts2 to support
local rollout of care
standards
2009
Expansion from six to
twelve CCGs3, led by
facility CMOs
Cultural and Clinical Transformation Does Not Happen Overnight
2013
Expansion to
17 CCGs
2014
Creating post-acute
care CCG to support
population health
strategy
1) Cardiovascular
2) Includes industrial process engineers, clinical informatics staff, and clinical educators.
3) Clinical Consensus Groups
“This is a journey that is not complete. You don’t make progress in six months.”
Dr. John Hensing, System CMO, Banner Health
©2014 The Advisory Board Company • advisory.com • 30126F
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Facing Real-World Challenges
System overseen by single
operating board; heavily
centralized leadership and
operating structure
Banner Health’s Starting Advantages Banner Health’s Headwinds
System financially strained
and culturally fragmented
post-merger
Multiple facilities widely
geographically dispersed
System CEO champions clinical
quality as organization’s primary
focus; committed to growing
bench of physician leaders
No shared culture among
physicians post-merger; even
now, only 15% of the medical
staff is employed
Early investment in system-wide
EMR supports standardized data
collection, order sets, and
electronic workflows across
the system
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
©2014 The Advisory Board Company • advisory.com • 30126F
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Towards the Practice and Culture of Reliable Care
1. A Defined Vision of
Reliable Care
2. Physician Value-
Vision Alignment
Adopting Care Reliability as
the Central Clinical Strategy
3. Clinician Defined
System-wide Standards
of Care
4. Physician Support
Structure
Building a Clinician-
Centered Infrastructure
5. Cultural Fit
Assessment
6. Physician Leader
Pipeline Development
7. Accountability for
Clinical Standard
Adoption
Aligning Medical Staff
Management
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Seven Elements of Transformation at Banner Health
©2014 The Advisory Board Company • advisory.com • 30126F
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Defining What the Vision Means for Clinical Care
Evidence-Based
Practice (EBP):
Care standards based
on evidence from the
scientific literature • Most care variation is not addressed
by published clinical evidence
• Published evidence typically does not
account for variation in resource use,
costs of care
• Standardized care provides the ability
to monitor and assess the efficacy of
new care standards
Rationale for supplementing EBP
with “practice-based evidence”:
One, or both, of these methodologies underlie all of Banner’s care standards.
• In absence of published
evidence, clinicians
agree on care standards
• Standards implemented
and monitored to confirm
efficacy and identify any
needed changes
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Banner Embraces Care Standardization, Even in Absence of Evidence
Practice-Based
Evidence:
Care standards based
on evidence from
Banner’s own practice
“Standardization is more important than evidence.”
Dr. John Hensing, System CMO, Banner Health
• When possible,
clinicians create and
implement standards
that reflect universally-
accepted clinical
evidence
1. A Defined Vision of Reliable Care
©2014 The Advisory Board Company • advisory.com • 30126F
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Clinical Strategy Appeals to Physician Motivators
Primary Components of the Reliable Care Strategy
Fix the System,
Not Physicians
Banner’s focus on
system design shifts
the “blame” away from
individual physician
performance
Grounded in Science
and Logic
The creation and
implementation of
clinical standards are
grounded in scientific
principles, specifically
the science of reliability
and outcomes
monitoring
Physicians at the
Center
Practicing physicians
are at the forefront of
developing system-
wide clinical strategy
and care standards
Commitment to
All Patients
Physicians embrace
concept of ensuring
every patient, even
those they do not see,
receive the best care
possible everywhere in
the system
To secure physician engagement, Banner ensures all efforts focus on
improving the quality of care. Cost reduction is NOT a goal of Banner’s
approach to clinical standardization, but it is a positive externality.
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
2. Physician Value-Vision Alignment
!
©2014 The Advisory Board Company • advisory.com • 30126F
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Towards the Practice and Culture of Reliable Care
1. A Defined Vision of
Reliable Care
2. Physician Value-
Vision Alignment
3. Clinician Defined
System-wide Standards
of Care
4. Physician Support
Structure
5. Cultural Fit
Assessment
6. Physician Leader
Pipeline Development
7. Accountability for
Clinical Standard
Adoption
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Seven Elements of Transformation at Banner Health
Adopting Care Reliability as
the Central Clinical Strategy
Building a Clinician-
Centered Infrastructure
Aligning Medical Staff
Management
©2014 The Advisory Board Company • advisory.com • 30126F
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Who’s Responsible for Quality?
Oversee peer review,
credentialing, medical
staff by-laws
Medical Executive Committee
Responsibilities
Central “Care Management”1
Responsibilities
Banner and MEC Redefine Respective Quality Responsibilities
Manage system-wide
clinical data systems,
collection, and sharing
Define, design, and
implement system-wide
care standards
Identify areas of greatest
clinical variation across the
system; set quality agenda
Manage recalcitrant
physicians, medical
staff relations
Track qualifications and
provide recommendations
for department chair positions
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
3. Clinician Defined System-wide Standards of Care
1) At Banner, Care Management is the division that provides leadership for excellence in clinical
care and patient safety across the system. It is led by the Chief Medical Officer and includes
the physician leadership structure as well as the functions of clinical quality, informatics,
research, analytics, education, innovation, and health management.
©2014 The Advisory Board Company • advisory.com • 30126F
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Clinician-Centered Infrastructure Delivers the Vision
Banner’s Care Management Structure
Care Management Council
17 Clinical Consensus Groups
25 Acute Care Facilities
Care Management
Leadership
Clinical Consensus Groups:
• 17 CCGs2 (e.g., Critical Care,
Orthopedics, Oncology)
• Each co-led by physician and non-
physician (typically a nurse)
• Multidisciplinary membership3
representing the entire Banner system
• Define and lead implementation of
system-wide care standards
Care Management Council:
• Led by System CMO
• Includes all CCG1 leaders, CMOs,
and CNOs
• Sets quality strategy for system
• Approves all care standards
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1) Clinical Consensus Group.
2) 17 CCGs: Perioperative, Behavioral Health, Critical Care, Cardiovascular Surgery, Women’s Health,
Neuroscience, Emergency Department, Pediatrics, Pharmacy and Therapeutics, Nephrology, Medical
Imaging, Cardiology, Hospital Medicine, Infectious Disease, Primary Care, Orthopedics, and Oncology.
3) Includes physicians, bedside nurses, clinical informatics, pharmacy, supply chain, and therapy
(occupational, respiratory, physical).
©2014 The Advisory Board Company • advisory.com • 30126F
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Clinical Structure Evolves with Strategic Priorities
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Changes within Existing Structure Additions to Existing Structure
Need for Specialized Expertise,
Small-Group Efficiency
Support for Population Health
Management Strategy
Perioperative CCG1
Surgery CCG
1) Clinical Consensus Group.
2) In development as of August, 2014.
3) Post-acute care.
Anesthesia CCG
Identified need for
Post-Acute Care
CCG
Developing Post-
Acute Care CCG
Charter2
Challenges of Ambulatory Expansion
• CCG work largely limited to inpatient setting
• Do not own most PAC3 facilities
• Mostly non-employed physicians practice in
PAC facilities
!
©2014 The Advisory Board Company • advisory.com • 30126F
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1) Clinical Consensus Group.
2) Chief Medical Officer/Chief Nursing Officer.
3) If a standard is deemed “optional” due to lack of
evidence, the CCGs will not roll it out system-wide.
System Only Adopts High-Quality Standards
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Adoption Expectation Built
Into Guidelines
Guideline Vetting Process
Cert
ain
ty o
f E
vid
ence
Lik
elih
ood o
f M
ajo
r R
evis
ion
Expected
Recommended
Optional3
CCG1 Workgroup
Other CCGs with Relevant Expertise
Care Management Council
Each Care Standard Assigned
A Level of Adoption:
CCGs largely work on
expected guidelines
Clinical Consensus Group
CMO/CNO2 Committees
1
2
3
©2014 The Advisory Board Company • advisory.com • 30126F
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Without System Support, Facilities Hit Implementation Hurdles
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1) Cardiovascular.
2) Clinical Consensus Group.
But…Vetted, Trusted Standards Not a Silver Bullet
8-Month Implementation Period
CV CCG develops
clinical standard for
entire system
Facility leaders receive
standard and
independently manage
implementation
System provides
CV1 CCG2 with
data highlighting
clinical variation
opportunities
Facility Feedback:
“It’s really hard to do
this—we don’t have the
expertise or resources.”
“Can’t we figure this out
once, together, for the
whole system?”
Banner’s Initial System-Wide Clinical Standard Rollout
“The success of a clinical standard is based 30% on the
excellence of the product, and 70% on implementation.”
Dr. Marjorie Bessel
Regional Chief Medical Officer, Banner Health
©2014 The Advisory Board Company • advisory.com • 30126F
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Workflow Experts Ensure Usable Clinical Standards
• Dedicated to specific CCGs3
• Provide project management support:
craft meeting agendas, organize CCG
workgroups, circulate relevant
materials to CCG members, track
meeting attendance
Program Managers Industrial Process Engineers
• Work across multiple CCGs
• Integrate CCG clinical standards
into existing workflows with goal
of “zero defect” practice
Robust Team Helps Translate Standards into Practice
Program managers exclusively
dedicated to Care Management
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1) Clinical Performance Assessment and Improvement Staff are largely involved in monitoring the adoption of
clinical standards at the facility-level. The other staff outlined in the box are largely involved at the system-
level, designing how the standards will be integrated into the frontline workflow.
2) This amounts to .6 FTEs per hospital, although they are a centralized resource rather than a facility resource.
3) Clinical consensus groups.
Industrial process engineers
across system2 6 15
Clinical
Informatics
Staff
Clinical
Educators
Clinical Performance
Assessment and
Improvement Staff1
4. Physician Support Structure
©2014 The Advisory Board Company • advisory.com • 30126F
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1) Computerized Physician Order Entry.
2) Includes checklists, criteria for medical necessity, etc.
Constellation of Supports Ease Clinician Adoption
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
CPOE1 Order Sets
EMR Prompts
Clinical Decision-Making Tools2
Education and Training
Talking Points for Leaders
Outcomes and Adherence Data
Supports to Facilitate Local Adoption of System-wide Clinical Standards
Clinician
©2014 The Advisory Board Company • advisory.com • 30126F
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Role of Implementation Experts3
Role of CCG1 Clinicians
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1) Clinical Consensus Group.
2) Care Management Council.
3) Includes program managers, industrial process engineers, clinical informatics staff, and clinical educators.
Enabling Top-of-License Clinician Contributions
• Identify opportunities to
standardize practice, or update
a current standard
• Assess the evidence, define
standards
• Present standards for approval
from other CCGs, CMC2
• Incorporate new standards into
clinical workflow and develop plan
to monitor results, compliance
• Design facility support tools (e.g.,
talking points, EMR prompts,
clinician training, order sets)
• During system-wide “go live,”
act as local champions for
new standards
• Report colleague feedback to
CCG and decide on any
follow-up action
Banner’s Three-Step Process for Implementing Clinical Standards
Design Implement Define
• Provide input to implementation
experts on clinical workflow,
tools
• Conduct ongoing monitoring
to assess efficacy of
standards and identify
adoption barriers
• Provide project management
support (e.g., schedule
meetings and create agenda,
organize CCG working groups,
track attendance, etc.)
©2014 The Advisory Board Company • advisory.com • 30126F
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Towards the Practice and Culture of Reliable Care
1. A Defined Vision of
Reliable Care
2. Physician Value-
Vision Alignment
3. Clinician Defined
System-wide Standards
of Care
4. Physician Support
Structure
5. Cultural Fit
Assessment
6. Physician Leader
Pipeline Development
7. Accountability for
Clinical Standard
Adoption
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Seven Elements of Transformation at Banner Health
Adopting Care Reliability as
the Central Clinical Strategy
Building a Clinician-
Centered Infrastructure
Aligning Medical Staff
Management
©2014 The Advisory Board Company • advisory.com • 30126F
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Physicians Only Hired if Compatible with the Banner Philosophy
5. Cultural Fit Assessment
Ensuring the Right Fit
Multiple stakeholders
interview physician
candidates and screen
for the “three Cs”
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1
2
3
Is the candidate CRITICAL to achieving
Banner’s mission?
Is the candidate CAPABLE of practicing at
the Banner standard of performance?
Is the candidate culturally COMPATIBLE?
• Assess how this physician will
contribute to Banner’s population
health management strategy
• Review physician’s patient charts to
assess quality of care
• Identify any legal issues
• Assess physician’s opinion towards
Banner’s philosophy of developing and
adopting system-wide care standards
Banner Medical Group’s Interview Process
©2014 The Advisory Board Company • advisory.com • 30126F
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1) Clinical Consensus Groups.
CCGs1 an Incubator for New Leaders
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
Benefit from support
of project
management,
informatics, workflow
experts
Take leadership
courses focused on
stakeholder
management,
teamwork, analytic
problem-solving
High-Potential
Practicing Physicians
Senior Physician
Leaders
“Engage physicians around their value system, which is based in science, not in money.
As it turns out, money doesn’t matter—which is good, because there isn’t any.”
Dr. John Hensing, System Chief Medical Officer, Banner Health
Physician Participation on CCG
Intellectually engage
with care
standardization and
resource stewardship
principles
See the direct
impact of their
efforts on improving
patient care
©2014 The Advisory Board Company • advisory.com • 30126F
35 7. Accountability for Clinical Standard Adoption
1) Ongoing Professional Practice Evaluation.
2) Varies by medical staff at local facilities.
Expecting a Commitment to Clinical Standards
Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
• Take part in performance
conversation with regional or
system CMO
• May not get preferred block
scheduling or other privileges
• Adoption of clinical standards
included in OPPE1 and/or
peer review process2
• Medical group is starting
annual professional reviews,
including discussion of quality
• Take part in performance
conversation with physician
peer from Clinical Consensus
Group or facility leader
All Physicians
Outlier Physicians
Repeat Outlier Physicians
Tiered Approach to Accountability
©2014 The Advisory Board Company • advisory.com
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2
3
1
Road Map
Beyond Evidence-Based Practice
Case Study: Banner Health’s Clinical Transformation
Applying the Banner Model at a Single Hospital
©2014 The Advisory Board Company • advisory.com • 30126F
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Empowering Physicians to Pursue “Right Care”
Source: Western Connecticut Health Network, Danbury, CT;
Physician Executive Council interviews and analysis.
Western Connecticut Health Network
IMA
GE
CR
ED
IT: D
AN
BU
RY
HO
SP
ITA
L.
Institution in Brief: Western
Connecticut Health Network
• Three-hospital system comprised of
Danbury Hospital, New Milford
Hospital, and Norwalk Hospital
• Based in Western Connecticut
• Medical staff comprised of 1,300
physicians, with 400 employed
• Physician-led Right Care initiative
reduces unwarranted clinical
variation and overutilization;
initiative started at Danbury and is
being scaled across the system
• Achieved $2.9 million in charge
reductions from FY 2009-2010
©2014 The Advisory Board Company • advisory.com • 30126F
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From Promoting Order Set Adoption to Rightsizing Utilization
Source: Western Connecticut Health Network, Danbury, CT;
Physician Executive Council interviews and analysis.
A Maturing “Right Care” Strategy
Reduce Unnecessary
Utilization by DRG
Reduce Unnecessary
Utilization by Cost Driver
Standardize Order Sets
and Pathways
• In 2004, Danbury
completes CPOE
implementation
• Clinical executives focus
on promoting adherence
to evidence-based order
sets and care pathways
Three Phases to “Right Care” at Danbury
• In 2006, executives shift
attention to reducing
unnecessary utilization
• Physician-led initiatives
focus on reducing
unnecessary utilization
within specific DRGs—
these are classified as
“vertical” opportunities
• In 2009, Danbury leaders
complement DRG-focused
initiatives with initiatives
focused on cost drivers
(e.g., lab, imaging)—these
are classified as
“horizontal” opportunities
• In 2013, CMO classifies all
efforts to reduce
unnecessary variation as
“Right Care”
2004-Present
Like Banner, Danbury’s
transformation has been
a decade-long journey,
championed by the CMO
Focusing efforts on “right
care” delivery secures
physician support
©2014 The Advisory Board Company • advisory.com • 30126F
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Source: Western Connecticut Health Network, Danbury, CT;
Physician Executive Council interviews and analysis.
1) Diagnosis Related Group.`
Physician-Led Groups Work Toward “Right Care”
• Now chaired by CMIO
(formerly CMO)
• Meets monthly with content team
leaders to assess progress
Steering Committee for Right Care
Dedicated Content Teams
• Led by physician leaders
• Each team dedicated to DRG1 or cost driver
(e.g., lab, imaging, pharmacy, etc.)
• Teams analyze data (e.g., contribution
margin, volumes, charges) to flag
unnecessary utilization and demonstrate
the negative patient impact of excess tests
“Right Care” Goals
Quantifiable Targets: Content teams
set annual utilization targets based on
medical literature and chart reviews
(e.g., reduce echo utilization for CHF
patients by 30%)
Financial Incentives: Department
Chairs are incented on relevant
utilization goals which account for
one-fifth of a 30% base pay
incentive potential
“Right Care” Structure
Responsive to Practice: Teams track
utilization throughout the year—if the
annual target over- or underestimates
appropriate utilization, they will alter
the target
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Dedicated Content Teams Design and Implement Prompts
Source: Western Connecticut Health Network, Danbury, CT;
Physician Executive Council interviews and analysis.
1) Computerized physician order entry.
Physician Choice Informed by Workflow Prompts
Education
Spectrum of Clinical Decision Supports
• “More is not better”
education
encourages, but
does not mandate
practice change
• Ex: explaining to
physicians why
they should curb
use of calcium tests
“Check the Box”
• Automated prompts in
CPOE1 require
physicians to select
pre-populated
indication for why
particular order is
clinically necessary
• Ex: physicians must
respond to dropdown
questions when
ordering a CT scan
Permission
• Hardwired hard-stops
require physicians to
request permission
before making certain
orders
• Ex: residents cannot
order high-cost tests
without attending
approval
Elimination
• Restrictions eliminate
certain orders
altogether when clear
evidence indicates
intervention offers no
additional value
• Ex: hospital removed a
continuous passive
motion machine for
orthopedic inpatients,
and eliminated multiple
inpatient lab tests
Underlying Evidence, and Necessity for Opt-Outs, Informs Degree of Prescription
Least Prescriptive Most Prescriptive
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Adopting “Right Care” Strategy at a Single Hospital
Source: Western Connecticut Health Network, Danbury, CT;
Physician Executive Council interviews and analysis.
Challenges Danbury Workarounds
Lack system executive mandate and/or
support to focus on reigning in unnecessary
variation
Hospital CMO and other respected physician leaders
champion this work and are the “face” of the initiative
Single facility does not have as large a pool
of potential physician participants as a
system
Encourage broad participation from department chairs
and other physician leaders by including utilization goals
as part of leader incentive
Lacks support from centralized engineering,
IT, and project management resources
Pair physician leaders with facility data analysts who
help unearth variation opportunities; secure support from
hospital IT to implement CPOE order sets, prompts
Do not have as large and diverse a patient
base to assess effectiveness of new care
standards
Rely heavily on published evidence for standards;
physicians also regularly conduct chart reviews to
ensure the impact of each initiative is to provide patients
with the right level of care
As facilities join or grow into systems, the
clinical variation work at one facility is
mismatched to that at another
Leaders identify best practices within the system and
consider replication across sites; leaders should also
consider incorporating representatives from the new site
into existing content teams
Lessons from Danbury
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Source: Banner Health, Phoenix, AZ; Physician Executive Council interviews and analysis.
1) Dr. John Hensing, Banner’s System CMO, attributes the
organization’s success to the balance of these four elements.
Greater Than the Sum of Its Parts
Physician
Leadership
Physician
Engagement
Clinical IT
Investment
The Science
of Reliability
Banner Health’s
Four Keys
to Success1
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November 7, Washington, DC
2016 Pharmacy Executive Forum Fall Meeting
A Unique Opportunity to…
Reflect on the future of health care and
pharmacy services
Pressure-test ideas for forward-looking
pharmacy strategy
Develop leadership and change
management skills
Exchange ideas and best practices
Network with other pharmacy leaders
Communicating Pharmacy’s
Strategic Value
Pharmacy System Strategy
Playbook
Advancing Retail Pharmacy
The New Era of Health Care
Reform
Tentative Agenda