Intermountain's Brent James: Patient-centeredness drives quality, savings

When 11 top healthcare executives shared best practices for reducing costs while improving outcomes, a prominent theme emerged--the importance of patient engagement.

Brent James, chief quality officer and executive director of the Institute for Health Care Delivery Research at Utah's Intermountain Healthcare was among the 11 execs to contribute to the CEO Checklist for High-Value Health Care.

FierceHealthcare caught up with James (pictured right) to discuss how hospitals can use patient engagement to create high-quality, low-cost systems of care, as well as learn about how Intermountain put the focus on patient-centeredness, not revenue enhancement, to improve the bottom line and outcomes.

FierceHealthcare: How has the industry's approach to patient engagement evolved over the years?

Brent James: Patient-centeredness has a number of different meanings: One is "nothing about me without me"--which means that patients ought to be in control of their own lives, especially in a healthcare setting; that we do nothing to them without their explicit permission and understanding.

Another definition comes from the idea that care is organized around the patient and his or her needs. Rather than building a care delivery system around the building or specific piece of technology or service or superstar physician, imagine that you organize the whole care delivery system around the patient.

Now most of healthcare delivery is disease treatment--when you do it that way you start to build around care delivery processes. That's the work of Dr. W. Edwards Deming, called quality improvement theory.

At its core, quality improvement theory is the science of process management. We used to call it continuum of care. The idea is that you track a patient before the disease process, as it starts to take place in their body or life, all the way down to its treatment until some sort of conclusion, hopefully when it's resolved and gone. That continuum of care idea is a natural extension of process science.

Here's the funny thing that happens: If you start to focus on care delivery processes and quality improvement, it forces you to that form of organizational patient-centered care.

Usually the more superficial view that is a bit easier to understand, is that view centered around the idea of nothing about me without me. But when you're building systems of care, that second definition of continuum, boy it turns out to be important but it's far more subtle.

FH: What are some barriers to fostering patient-centeredness, and how can hospitals overcome them?

James: Most hospitals focused on revenue enhancement, which means you try to increase the numbers of services you supply. In a very real sense, the people who really consume those services are the physicians. So you have physicians who, with a stroke of their pen, can make or break a hospital.

We tended to build our organizations and think about them in terms of a superstar physician, a new program, a new heart hospital, marketing more services for imaging or lab--those are all top-line revenue enhancers. For many hospitals, that's the tradition. That's how it's done, so others did it too.

It was a pretty easy approach to take. It was what everyone else in the industry was doing, so the biggest barrier is tradition.

The fact is, that's not what patients need moving ahead. We need care that's designed around them, not around the big revenue generators.

FH: How did Intermountain move the focus away from revenue?

James: The first thing you have to know about Intermountain is we are massively mission-driven. The short version of our mission is "best medical result at lowest necessary cost." We're a charitable not-for-profit and we actually behave that way--in most ways.

So we realized that when we keep the cost of our services low, people can afford to come and take advantage of those services.

We proved William Edwards Deming's idea that better quality outcomes, in almost all circumstances, should reduce cost of operations. This happened back in the 1980s for Intermountain and we were the first group in the world to show that principle applied in clinical medicine.

FH: How did Intermountain prove Deming's quality improvement theory?

James: Around 1987 or 1988, I came home from a meeting with Dr. Deming when he shared those principles. Up at LDS Hospital in Salt Lake City, we had a big trial running around improving clinical outcomes. John Burke, chief of infectious disease at LDS, had developed evidence that suggested there was an ideal time at which to give prophylactic antibiotics to prevent post-operative wound infection.

We used a two-hour time window before surgical incision and when we did this our wound infection rates fell from 1.8 percent to 0.4 percent.

At the time, we had thought quality meant spare no expense. We thought quality meant pull out all the stops; you can't put a price on human life.

But what if we track costs as one more outcome, side by side with our clinical outcomes?

So we threw costs in and what we discovered is that as the infection rate fell from 1.8 percent to 0.4 percent, our cost of treating the infections went away. It saved the hospital a little bit more than $1 million a year in operating costs.

Now, it's not always the case--about 15 percent of the time, delivering a higher quality outcome requires more resources and it increases costs. But a lot of the time you can reduce the cost of healthcare by improving your patients' medical outcomes. At the time, this was completely antithetical to what everybody believed in healthcare.

Well, Intermountain got hooked on that. The way we get costs under control is not by rationing care but by actually doing better for our patients. That was an addictive drug for leadership at Intermountain.

And so we started to promote it heavily, ran a whole series of products on it and eventually started to organize our whole system around it.

At the core lies process management theory. If you start with process management, that forces you to that continuum of care, which  drives you to patient-centered care.

FH: How did Intermountain use process management to lower costs?

James: The jargon we use in quality improvement is "move upstream" in a process. The idea is you move up stream and prevent problems before they happen, and when you do you avoid the costs of dealing with the problem after the fact and it's usually massive cost savings.

All of the savings came back to insurers as windfall savings, and they were potentially financially deadly to the care delivery crew. So we started to try to use it for contracting.

If I move to some form of a capitated system (shared savings models, bundled payment at a hospital level), in that payment setting all of the savings come back to care delivery group, as opposed to going to the insurers.

Then, you want to move even further upstream, it forces you to population level care and a whole new health system organized around patient needs as opposed to organized round revenue generation in the form of a superstar physician or a special program to try to promote more heart care.

I happen to fall into an organization at Intermountain where because its mission centers on patients, that strategy was acceptable. Intermountain was willing to invest in the future of our patients. Most places in healthcare would struggle with this kind of strategy.

In truth, we fight about it. And the reason is you're asking the people in your system to do really hard things that appear to damage their success from a financial perspective. And then you've got to be willing to work your way through it.

FH:  What advice would you give to other hospitals looking to empower patients at their organizations to improve care and lower costs?

James: First, consider including patients directly on your strategic planning teams--the teams that build and manage the processes. Get that voice in there.

The second item goes hand in glove with that. As you move upstream, the first caregiver is the patient. And from them, you'll get insights in how you can involve patients more fully in their own care, give them more personal control.

So the simple organizational thing to do is move to process management and put patients on your process teams--and then listen to them and follow their advice.

It'll have reach and impact far beyond what that simple step seems to imply. It's not so much an end in itself as a means to the secondary impacts it'll have down the road.

A big part of it will still involve the experts; their voice will continue to be important. But make the patient part of the conversation to a degree that you haven't in the past. Do it in a substantive way, not a superficial way.

For diabetes patients--what if I can get far enough upstream and get them to control their weight (better diet and better exercise) so that they never became Type 2 diabetics? What if I can empower them and teach them so they can be far more effective in managing their own disease in its early phases, when that's quite realistic.

So manage the onset of the condition, manage the early disease, and you're whole aim is they never have to deal with late-stage disease. And I would get that by understanding how patients interact with my process of care. The best way to understand how patients interact with my process of care is to get some good thoughtful patients and stick them on my teams that are designing my processes.

Editor's note: This interview has been condensed and edited for clarity.