As front-line physicians at Yale New Haven Health embarked on a dedicated program of Clinical Redesign in 2015, they leaned heavily on Choosing Wisely recommendations, viewing the seed work of national specialty societies as a great seal of approval.
“When talking about change management across a health system, it is really helpful to start where there is already consensus. We didn’t have to prove to people that this was the right thing to do. We already had national recommendations as the basis for those early projects,” said Scott Sussman, MD, Physician Executive Director of Clinical Redesign at Yale New Haven Health.
Their early projects involved optimizing order sets to reduce the use of telemetry and prevent duplicate lab tests, optimizing C. diff testing, and daily blood draws for hospitalized patients. Since that time, their efforts have blossomed to over 200 quality improvement initiatives – fueled by a novel rapid-cycle approach to change management.
“One of the keys to our success is that we use a 90-day timeline, which has been really important to keeping engaged teams,” said Maribeth Cabie, PharmD, BCPS, Director of Clinical Redesign, adding that their Clinical Redesign methodology employs fairly rigid processes in order to complete tasks between weekly meetings. “In that 90 days, we not only come to consensus, but we implement the solutions and create a dashboard to help us to monitor progress.”
The redesign teams, which consists of a core group of nine physicians and nine project managers buttressed by local clinical subject matter experts, then uses a 30-60-90 day review model following project completion to continue monitoring outcomes. Cabie said getting a senior leader to sponsor a project also was critical to success, and can help with ongoing sustainability.
More recently, the teams include patients too, said Cabie, adding that the partnership with the Patient and Family Advisory Council has been critical to the redesign work. “The patients remind us why we are doing these projects. We need to hear their voices as we are thinking about how solutions might impact the care that patients receive,” she said.
Forty projects have been instituted across the entire health system, which provides more than 2.4 million outpatient encounters and 124,668 inpatient admissions per year. Approximately half of the projects have been initiated at Yale New Haven Hospital, and the remainder have been dispersed throughout four other hospitals in the network.
Every department has been involved, with multiple projects from the following areas: hospital medicine, blood bank, digestive disease, geriatrics, gynecology, oncology, surgery, urology and psychiatry. Project foci have been broad as well, from opioid utilization, laboratory test ordering and outpatient parenteral antimicrobial therapy to COPD/PNA care, surgical trays, abnormal Pap smear tracking, addressing in hospital hypoglycemia, reducing post-operative pneumonia, use of particular medications for labor induction, and launching virtual hospice.
Approximately 70 percent of the redesign projects have been successful. Those that were not initially effective allowed the teams to rethink the project and spin-off in new directions.
“We have a questioning attitude that keeps patients at the center and addresses clinician pain points,” said Sussman, noting that the redesign work at YNHH is unique in that it has been so all-encompassing, focusing on all aspects of clinical care from admission through discharge and more recently includes ambulatory optimizations. Clinical Redesign at YNHH has reached a scope and scale that has enabled them to drive high-value care and impact nearly every patient in some way, he said.
Sussman said that in the early days, the team calculated clinical and financial impacts for each project, which equaled over $25 million in each of the first two years of Clinical Redesign; over time each patient was being impacted by multiple projects and it became challenging to attribute savings for distinct projects. So they continued to look at patient-centric metrics such as length of stay, readmission rates, and the amount of blood saved by not ordering daily routine labs, and moved to cost per case at the service line level instead of the financial impact of individual cases.
“People have trained to do a certain thing and that’s what they are comfortable with,” said Sussman, adding that by using a light touch questioning attitude with deference to local experts, the rapid cycle redesign process engages clinicians in change management and healthcare innovation. Clinical Redesign makes it easier to do the right thing for patients and drives value across Yale New Haven Health.