How to Improve Quality Across a Newly Formed Health System

Andrew M. Ibrahim MD, MSc is the Maud T. Lane Research Professor of Surgery, Architecture and Urban Planning and Vice Chair of Surgery at the University of Michigan. He previously spent 6 years as the Chief Medical Officer and Senior Principal of the global design and architecture firm, HOK.

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A friend of mine recently became as the Chief Quality Officer of their health system. Like many health systems across the country, they recently went through a merger and are now with twice as many sites of care, providers and resources then before. So, they curiously asked, “How do you take advantage of these accumulated resources to improve clinical quality? It seems like a missed opportunity to just keep doing things the same way as we did before the merger, right?”

? Interestingly, I have also been receiving the corollary question from my architecture colleagues. “So many of our clients are accumulating more and more physical assets through mergers – how should we optimize these built resources? If we know they are going to keep growing, should we design differently? Or be re-designing what they already have?”

? I have been studying the optimization of growing health care systems for about a decade. This has included in-depth ethnographies of high-performing systems, leveraging large administrative claims datasets to evaluate who has been able to better deliver care after accumulating more resources and by working with architects to master plan growing health systems. ?

? Here are three of the quality improvement strategies I have found in my work that I believe every health system should at least consider after forming into a larger network. Each directly informs how the lens of clinical quality improvement can help health systems leaders strategize around hospital mergers and how architecture firms can better align system master-planning with clinical care delivery.

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Leverage Volume-Outcome Relationships for Complex Procedures

One of the most important inpatient functions of a hospital is to deliver complex procedural care. Examples include complex surgery to remove part of the pancreas or reconstructing the gastrointestinal tract after removing the esophagus.

These complex procedures have some important common features that make them a prime target for quality improve in a newly formed health system. First, they are often the only definitive treatment for their condition that will result in a cure. As such, there is real emphasis on getting it right the first time. Second, they are high-risk and known to have relatively high-levels of post-procedure complications, even in the best of hands. Third, they have well known volume-outcome relationships. More so than other procedures, these complex operations have a clear, “you should be performing at least X number of these per year” to have high quality outcomes. (See an example list of volume thresholds here and here .) Finally, each of these procedures, when a complication occurs, require intensive resources to prevent a cascade resulting in death.

Prior to a network formation, hospitals may be performing these procedures at lower annual volumes per hospital. But after a merger, when more hospitals are banded together, they can centralize the procedures to fewer sites of care and get each hospital further-up on the volume-outcome curve. For example , health systems that have centralized pancreas surgery (e.g. pancreaticoduodenectomy) have demonstrated lower rates of death after surgery.

Centralizing complex procedures to few sites within a newly formed health systems is not without tradeoffs. Doing so may face some important cultural and workforce differences by moving providers and patients to a different site of care. In addition, it may be additional travel burden on patients. However, recent work (just out last month ) has demonstrated that a majority of patients (80%) undergoing high-risk surgery at low-volume hospital had a high-volume hospital within the same system <30 miles away.

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Optimize Access for Common Procedures

On the opposite extreme of complex surgery, are the common procedures that millions of Americans undergo all of the time. These included things like repair of hernias or removal of the appendix.

Our research about these common procedures has identified a few important features that also make them great opportunities for quality improvement. First, these procedures can be safely performed at small, low-volume hospitals. In our initial work on critical access hospitals (small rural hospitals with <25 beds), we found that these procedures can be performed at the same quality and lower costs than their larger hospital counterparts. Second, these procedures have the best outcomes when access is optimal. For example, a planned hernia repair at a nearby hospital has far lower complication and readmission rates of the same procedure when done in the emergency setting.

How then can newly formed health systems improve access for these common procedures? Offer them at more sites of care and specifically in communities with higher social vulnerability. Multiple studies (here , here , here ) have demonstrated that communities with worse infrastructure (e.g. housing, transportation) are less likely to get timely care for these conditions, and instead, present when they need a far-higher risk emergency procedure.

? Optimizing access by decentralizing common procedures to more sites of care has another advantage; it opens up capacity to centralize complex procedures. The two strategies listed so far are intentionally complementary such that both can be achieved within a newly formed health systems using the existing infrastructure.

Distribute Content Expertise across the Health System

When I visited Carolinas Cancer Center to study their health system, I was struck by their motto: “Universal, high-quality care, anywhere in the system.” This struck me because I knew from my research that even though newly formed health systems often rebrand to carry the same name and logo, they still have high variability in quality across their network. In fact, many of the our country’s best ranked health systems demonstrate 4-fold variation in outcomes across sites within their own network.

How did Carolinas distribute universal, high-quality care, across their health system? They leveraged their experts. For several of their common and complex care pathways (e.g. newly diagnosed cancer), the topic experts in their network created evidence-based order sets that auto-populated within the electronic medical record. In doing so, patients at any site had access to a standardized initial evaluation, equitable opportunities to enroll in trials and clear follow-up plans including evidence-based surveillance. By putting these into the electronic medical record by specific condition, the top experts within the health systems were making their expertise more broadly available, even for patients they had never met. This was further realized by a robust, telehealth infastructure (long before COVID) that allowed for virtual tumor boards and provider-to-provider virtual consultations.

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These three strategies – centralize complex procedures, decentralize high-demand procedures, and distribute system expertise—are a helpful start for growing health systems to improve their care delivery. Successful execution of these strategies will require alignment between c-suite leaders, facilities, architects and front-line workers to realize the true potential of a group of hospitals after they merge into a larger system.