Geisinger: Making health care right
When Abigail Geisinger envisioned the George F. Geisinger Memorial Hospital in 1913, she told her chief of medicine: “Make my hospital right. Make it the best.”
More than a century later, Geisinger Health System has become renowned for innovations that are improving the health of its populations and the patient experience while also reducing the overall cost of care.
“Today Geisinger Health System has a national — even international — reputation for innovation,” says Kevin Lanciotti, CFO and VP of finance for Geisinger Medical Center and Geisinger-Bloomsburg Hospital. “This earned reputation and confidence by the industry — and more importantly, by our patients — are our biggest financial returns.”
At the heart of Geisinger’s process improvement efforts is “getting the right people to do the right work,” says Dr. Thomas Graf, Geisinger’s chief medical officer for population health and longitudinal care services lines. “We look at what the care process should look like, and then we simplify it as much as possible.”
When Geisinger teams re-engineer a process, they have five key objectives:
- Eliminate any activity that doesn’t add value to the patient.
- Delegate work to non-physician staff whenever possible.
- Automate work that does not require a human.
- Incorporate, or “hardwire,” reminders and alerts into electronic health records to make the new way the standard way.
- Activate patients in their own care.
Often, process improvement translates into better care for the patient. For example, rather than drawing blood on the day of the physician visit and waiting three days for the results, Geisinger primary care physicians now have patients come in for bloodwork three days before the physician visit. Not only did this new process eliminate the need for a letter or phone call about those results, but the physicians can discuss those results in person and make timely treatment changes. As a result, Graf says, the “chance of moving from data to action is much higher.”
One of the keys to Geisinger’s success has been keeping people focused on the big picture, Graf says.
“Having your cholesterol under control — most folks will say, ‘Yeah, that’s a good thing.’ But it doesn’t have the same impact as saying, ‘…and they will have fewer heart attacks,’” he says. “By showing them that higher sense of purpose — ‘we’re creating health and stamping out disease’ — they’re committed to making these things work. If you have better people and better engagement of your people, you’re going to get better results.”
Lanciotti and Graf shared their perspectives on the opportunities, challenges and best practices of process improvement.
What have been the most significant findings in terms of how to improve efficiency and patient outcomes?
Graf: We need to simplify medicine so people can succeed and we can create health for our patients, communities, and members of our health plans. If you simplify the process of creating health, then you have more reliable systems, happier staff, and happier and healthier patients. If you do that, all the rest of the issues, including the financial ones, solve themselves.
What are the important factors that have allowed you to realize financial returns from your process improvement efforts?
Graf: The way to reliably execute well is to have better medical professionals—doctors, nurses, front desk staff, and anyone who touches the patient. If you focus on taking the best care of those professionals, providing them with the best support, and focusing them on the parts where they can use their training and experience maximally, then you are going to execute better. That is the trick to ensuring the elements of the triple aim: To really focus the energy of the organization on improving the knowledge, the tools, and the processes, and thereby ensuring you have the best possible team members working with you and for you.
Also, by matching the need of the patient and the complexity of the task to the ability of the person, we create a higher sense of professionalism. People are spending more of their time doing things that are maximally challenging for them. They feel empowered, so they actually get more work done.
Lanciotti: Geisinger’s greatest investment is in its human capital. Geisinger is organized into clinical service lines across the system as opposed to the “platform” top-down approach found at the typical hospital. These service lines—for example, cardiology, and pediatrics—have a physician leader teamed with an administrative leader, and they’re organized as business units with all the appropriate support staff (such as quality, nursing, marketing, finance, and human resources). This interdisciplinary organizational style—where everyone is working together and sharing ideas in one room—fosters a higher level innovative thinking.
How do you measure process improvements?
Lanciotti: Here at Geisinger we focus on the total cost of care when measuring our process improvement efforts. This focus includes areas such as over utilization of testing, supply consumption, patient flow efficiencies, readmission rates, and so on. Many organizations focus primarily on labor costs, but focusing solely on labor reduction without addressing process improvement can negatively affect the quality of care being provided to their patients, along with employee morale, which leads to high turnover costs. At Geisinger, we find that staff are generally very busy. To reduce their workforce without reengineering their processes can leave serious gaps in the continuum of care and ultimately increase the cost of care.
How do you encourage a culture of innovation?
Lanciotti: Healthcare leaders must foster innovative thinking to change the way we’ve provided patient care in the past and move into a more efficient and cost-effective model for the future while still increasing the quality of care we’re providing. Geisinger’s culture rewards individuals for thinking outside of the box and trying something new, whether the idea develops into a successful model or not. The normal process is for a pilot innovation project to be financed, which then, based on the ability to show value to our patients, moves into full implementation. Our team members don’t avoid innovation due to the fear of failure; rather, they’re encouraged to set new boundaries for effective patient care.
Graf: We don’t wait until we get a perfect solution. We get a good solution, pilot it, and then we go fast to fix it. It allows you to go a lot faster if you have a little bit of tolerance for imperfection. Clearly you can’t fail 50 percent of the time, but if you’re not failing some small percentage of the time, then you’re probably not going fast enough.
Lanciotti: A great example of this was that we recognized a problem with the variation and paucity of care provided to patients that were in nursing homes. We focused clinical care on this, developing best practices for the care of these fragile patients and also devoting full-time advanced practitioners dedicated to the specific facilities. While the quality improved significantly, the impact on readmissions was variable and the number of patients each advanced practitioner was able to touch was too small to really improve the financial picture. So we improved this by supporting them with some back-office staff functions (such as scheduling, time management, and training), along with improving processes and procedures to help them accelerate the provision of care. Now more patients are getting measurably better care and we are generating both increased fee for service revenue by the advanced practitioner and positively impacting re-admission rates.
What can other business leaders learn from your process improvement efforts?
Lanciotti: Efforts that solely focus on an immediate financial return, such as aggressive labor reduction efforts, are short-lived and not sustainable in the long run. We still utilize tools such as benchmarks to ensure we are proportionately allocating resources, but we don’t let resource management interfere with our process improvement and innovation efforts. Benchmarks are an accumulation of data from organizations that are all trying to follow a norm. If you’re a high-performing organization trying to set new boundaries, you may have to overlook what a benchmark is telling you in order to achieve success. As an example, Geisinger has made a huge investment in clinical pharmacy staff over what the benchmarks were telling us, and the outcome on patient care and cost supports our decision. Because we’ve made the investment in clinical pharmacists and have integrated them into the daily care of our patients, we’ve experienced an improvement in readmission rates, medical errors, antibiotic stewardship, length of stay, and ultimately the total cost of care has decreased. So we broke from the traditional benchmark and made an investment that paid off for us.
Graf: Having the right leaders engaged in the process is important. They have to have a passion for it, and they have to take data and translate it into something that is meaningful. Also, look at the rollout process as a separate and discrete item as opposed to an afterthought. Finally, make sure you have a feedback loop so that everyone understands what is happening and you have the ability to adjust the innovation in a rapid-cycle fashion, quickly iterating for the best results.