Achieving long lasting Healthcare Value implies a balance between the excellence in patients’ clinical outcomes and the sustained profitability of the provision of care.

Succeeding at the major undertaking that is a long term plan to achieve the balance of these two distinct objectives requires active collaboration between multiple functions within the healthcare value chain. Healthcare Value can be seen as the convergence of four forces:

• Patient Experience
• Operational Performance
• Clinical Excellence and
• Technology Maturity

We examine below two of these forces (Operational Performance and Clinical Excellence), as a guideline to embrace the transformation and identify the key areas of improvement. Each case is unique, and any hospital, clinical or clinical care center would display variances to the model on what they do better or worse. Still, most might find that these suggested efforts resonate with their experience at transforming healthcare within a rapidly evolving regulatory, clinical and operational landscape.

Operational Performance

Operational performance is a key element in the management of hospitals and clinics: unless a care center is consistently profitable, all other concerns become quickly secondary. The growing trend of mergers and acquisitions, combined with the creation by ACOs of narrow networks moves the profitability index as an imperative. Like any business, care centers are looking at how they accrue revenue, how much they are spending and what is the balance of cash flow, equity and liabilities.

Below are some key areas of improvement to explore.

Billing

Prompt and accurate billing as pillars for rapid payment for services. Both rely on precise and timely exchange of information within the Care Center, with all units and departments using standard forms and tools to exchange and enrich the records. All data acquisition should be done by the time outpatients leave the premises or events and milestones have been met for inpatients.

Late and imprecise billing leave room for challenges, as patients and payers build their own expectations or struggle to take in the statements or trust the validity of erroneous declarations. Following up on potential issues is much easier when the patient is in the premises, and when all acts, services and costs have been already shared and explained.

Erroneous codification of procedures for instance can routinely wreak havoc in the billing and cash flow, while they can be more easily identified and auto-flagged using systems and electronic records.

With the rapid changes in the regulatory space, to the plans and the rules for coverage, the billing communication includes training and explaining. A positive exchange can turn a possibly controversial debate into a constructive discussion.

Electronic Records

Electronic records are more than a component of Meaningful Use of Technology for Healthcare. It is a back-office tool which has evolved into a full fledge environment, both clinical and non-clinical; now the reach of technology includes the patients and 3rd party providers, in a continuous connectivity which is changing how patients experience care and how care is being delivered.

Using electronic records increases the quality of the data as information can be gathered directly from the clinical or patient management systems, and core information on the patient is only captured once.

Electronic data reduces the potential for errors and typos, and allow doctors, pharmacists, nurses and staff to replace reporting and writing time with patient care or training, both of higher value.

Surprisingly for a profession which has been under change for a long time, especially with the introduction of information management technology and clinical equipment, the enduring use of paper trails combines archaic performances with an error-prone work model.

Departmental Performance

Analyzing departmental and practitioners’ performances increases individual accountability on costs, especially when federal and regulatory costs containment measures are decided that impact the practice. Clinical care centers are businesses, and they need to remain profitable to remain open to the patients. Finding ways to contain costs without compromising the quality of care involves more than an administrative view of the financials. Looking at optimized pathways however requires clinicians to work with business and financial analysts to ensure that efforts are targeting the right cost burdens and that solution actually solve the problem.

Optimal use of an expensive equipment like a LINAC for instance suggests a high rate of utilization. This rate might only be possible through increasing the patient group size, hence optimizing the management of referrals. Keeping existing equipment or acquiring new tools might require such large scale collaboration to be viable. Clinical care, financial performance and patient access to treatment are tightly linked in building a successful and sustainable practice.

Accountability

Clinicians cannot neglect the financial viability of their practice, including the utilization of the floor space they occupy, in the same way hospital managers and CFOs cannot ignore the patient-outcomes focus of clinicians, narrowly defined by ethical, clinical and regulatory boundaries. Clinicians are as much accountable for value as the CFO, and the CFO is ultimately sharing accountability for the quality of care provided by the Center.

Increasing the individual accountability of all clinical agents in the healthcare workflows is more than a declaration of intent. This is a true cultural change, making all rethink how they contribute to the “Greater Good”.

Cash Flow

The management of cash flow is a third concern for care centers, especially when profitability is getting tighter. Proper electronic exchange to get payments from payers or CMS requires precise codification using codes that have become complex with ICD10 and HIPAA compliant X12 standards. From eligibility to claims submission to claims status inquiry and response to Fee-for-Service claims, records and processes must absolutely adhere to formats and process cycles. The rejection of a payment in response to a claim must be re-submitted within 90 days or incur denial, for instance; since the rejection details must be checked by the submitter, it can be easy to let a claim slip through and incur a revenue loss. Following on receivable to accelerate the collection is also important, as this becomes a growing source of revenue as healthcare plans shift more out of pocket payments to patients.

Waste Management

The management of waste can be a significant burden for administrators, and can only be effective if the clinical staff is engaged into the effort. Comparing teams and departments can help identify waste “bubbles”, but shifts in uses and practices in order to reduce unnecessary spending or consumption can only happen with the knowledge and understanding of the relevant practitioner. Disposal of unused, recalled and expired products for instance, can be labor and cost optimized with sourcing the problem to a specialized organization.

Waste is more than openly wasteful practices, which can be rooted out easily. Here again, mindsets have to be changed so staff, administrators and clinicians look at the cost of care from a cost perspective. Standard practices should be

examined critically to find out how much of the medicines, products and services a patient really utilizes, and if they were all necessary. The goal here is not to take away beneficial treatment and care, but to make sure that the patient gets all he or she needs, nothing more. It might be counter-intuitive, but an extra pill or an extra day in specialized care might prevent many days of extended stay or re-admission time. Waste can also be the care that could have been avoided.

Digitalize yourself

Finally, hospital managers and leaders should consider integrating Telemedicine and e-Consult practices into their coverage of care. These become more mainstream and they offer solutions for basic care that appeals to many patients and MCOs alike. Blending a version of Telemedicine into the regular practice could expand the reach of the care center, while preventing patients with simple care issues to either check into Emergency Care or engage into an in-person appointment which might not generate sufficient value for both the care center enter and the patient.

Although this might not come first in the priorities of care managers, e-Consulting practices are slowly gaining ground. The case could be made that clinical centers are best suited for delivering such services in a streamlined and dependable fashion. An added benefit being that the patient who needs admission or a visit would find a consistent experience and possibly the same clinician who took care of the early assessment.

For hospital managers, the choice could be that it is better to be part of the movement than be left out of it when it gains momentum. In a landscape where Continuous Care becomes a standard, clinical centers will not be able to ignore or discount emerging care practices.

Follow the money

Following up on payments and reimbursements can be a full time job, but this is critical to the financial strength of the care center. Lingering payments by patients can turn into a contentious argument unless they are handled swiftly. Even if the claims becomes an issue, it is better to know the problem than assume erroneously that this will be a straight receivable. Same with the reimbursement process; even though the CMS process has been greatly improved with electronic interchange, process interruptions exist whether linked to a claim rejected or to a third party or service company interfacing the process and taking additional steps, putting a hold etc. Such discrete events can rapidly become large amounts uncollected, which often end up being written off. A diligent tracking and management of the claims and receivable maintains the profitability of the Center and ensures all practitioners that their payments will be managed effectively.

Clinical Excellence

Improving clinical care is an ongoing goal for all clinical organizations, but each facility or department presents a unique situation. The issues are however in most instances comparable between organizations, based on our experience with clinical facilities.

Clinical Excellence themes have been grouped in 5 broad categories:

1. Care workflows and processes are often discontinued, inconsistent and in some cases rely on distinct architectures and technologies. Standardizing the processes makes the analysis of records easier and streamline the deployment of process improvements, as there is only one version of each track. Standard processes also create a single way to measure the outcomes, in turn providing more usable information on strengths and weaknesses or optimization efforts. Standardized metric and outcomes can also simplify the administrative and payment processes, reducing cycle time and decreasing payment defaults.
2. Historical records provide precious input on things that work (or not), optimal ways to execute the workflow, typical shortcomings and (not the least) cycle time and cost information. Collecting and analyzing historical data can help identify issues (e.g.: Readmission rate, High Risk patient care, discrepancies in Dx and Tx workflows) and reduce or prevent their re-occurrence. Departmental performance comparison can be viewed sometimes as a challenge, although the best performers becoming the new baseline help improve the overall practice over time.
3. Information exchange and inter-operability of equipment and systems creates a continuous care model, removing manual or translated exchanges which are a considerable source for errors or misinterpretation. Enabling inter-operability also removes the need to store data in a given format, convert it and store it into another format. With the reduction of copies with various formats, the security of the patient information is greater, while operating and infrastructure costs are reduced with the elimination of intermediate data stores. A practical case is to move patient outcomes from a free text field to a standard field, ensuring all data is retrievable easily.
4. Training and Learning can be a burden for many organizations. This however is key to proper use of complex equipment, reducing operators’ errors, equipment maintenance and improving patient experience and care. Treatment dosage for instance, can be improved with better calibration of systems, an acquired skill, which benefits all. Learning can be for softer know-how as well, such as a better workflow, a novel dosage approach or other improvements made by peer teams which have been proven to be better. In such case, the original team becomes the source of the teaching.
5. Process Optimization efforts can reduce cycle time, patient experience and reduce waste. It can improve the pathway of frequent procedures, generates systemic screening or certain conditions, or reduce the cycle time to Dx or Tx. In each case, the patient outcome and clinical performance improve while costs decrease. Optimization efforts can also focus on transition protocols, discharge process, inter-departmental communication. Some ideas such as alcohol rub apparatus in the patient rooms or air quality management can help reduce HAI such as preventable nosocomial infections, if they are tied to other protocols (e.g.: hand hygiene, sterilization, etc.) that the clinical staff is best fit to identify and optimize.

Improvements and innovations proposed by clinicians must include other dimensions such as the financial benefit and the improvement in the patient experience, in addition to the clinical benefits. The practice of healthcare is patient centered and therefore requires collaboration between specialties and other functions touching the patient at any step of the workflow.

If the case is a true innovation, an additional benefit could be the increased perception of value by patients, as they are selecting a care facility in an increasingly competitive landscape.

Two sides of the same coin

Clinical Excellence and Operational Performance are both contributing to the creation of healthcare value, for both patient and care center.

The connection goes deeper that a simple collaboration, as the clinical performance is seen as a differentiator by the patient, helped with a growing number of scoring and ranking tools comparing medical centers.

Clinicians and operational managers are also together responsible for the best possible cost of care, balancing the quality of care and outcomes with their cost, making the care and its quality sustainable. Operational constraints limiting the provision of the best possible care can hurt the clinical performance. Clinical costs that trigger a department or equipment shutdown because the performance is not financially viable not only hurts the overall financial performance, but also deprive the patient from access to the best care.

Long term healthcare value is the balance between clinical and operational performances, working together to continuously achieve excellence.