Main Line Health improves its bottom line by creating a collaborative culture

A health system in the Northeast pursued an operations improvement initiative that yielded more than $120 million in savings — half of which came from clinical enhancements — in over a period of two years.

In 2017, Main Line Health, a not-for-profit health system serving areas of Philadelphia and its western suburbs, launched an initiative, called “Performance Excellence 2020,” aimed at achieving breakthrough organizational performance on population health and clinical outcomes, to help pave the way for financial success under value-based payment models.

Main Line recognized it needed to take proactive measures to ensure expenses under such models would not grow faster than revenues. Such a trend would erode the health system’s ability to maintain financial health through standard approaches to reducing costs, such as leaving vacant positions unfilled, postponing IT upgrades and freezing capital spending.

The health system also understood its financial and performance-quality goals would be out of reach if clinicians and other stakeholders were not engaged in the effort. Success would depend on shared commitment to transforming processes, with a focus on improving quality and revenue performance while avoiding excess cost. Thus, to build the needed collaborative culture, Main Line Health embarked on an initiative of transformational engagement, called “Performance Excellence 2020.”

The primary objective of the initiative was to foster organization-wide commitment to:

• Eliminating disparities and preventable harm while achieving top-decile results around quality and performance
• Reducing costs through more informed operational decisions
• Improving the patient and employee experience

Case example: Reducing care variation in the ICU

One of the first areas of focus for Performance Excellence 2020 was on reducing variation in Main Line Health’s four intensive care units (ICUs). The health system’s success in this area exemplifies the approach it used across the larger initiative.

Main Line Health’s clinical leaders knew variations in care existed among the four ICUs, but like their counterparts in many health systems, they could neither define nor quantify it. The health system therefore began by developing an internal methodology for tracking ICU variations in care that gave administrators and clinicians line of sight into care patterns.

The resulting analysis disclosed the following challenges:

• The length of stay (LOS) in the ICU was variable for the same diagnosis and severity across facilities.
• The likelihood of admission to the ICU also was variable for the same diagnosis and severity of illness across facilities.

Being able to visualize the extent to which the ICUs’ processes were not standardized mobilized leaders and highlighted the need for immediate action.

The first step was to engage ICU medical directors in the effort to make changes. Yet it presented several challenges:

• The medical directors operated independently of each other, and the concept of collaboration among the ICU teams was new to physicians and nurses alike.
• When the data initially was shared with the ICU medical teams, physicians pushed back, questioning the validity of the analysis.
• Physicians’ individual interests were multifaceted — and these interests were not always aligned with the organization’s priorities.
• Some clinical leaders openly questioned whether true alignment could be achieved.

Steps for promoting physician engagement

Main Line Health knew it would need to gain physician leaders’ trust to effectively engage them in transforming processes to eliminate unnecessary variations in care. The health system therefore took several steps to overcome these obstacles.

One-on-one meetings with medical directors. Over several months in 2018, leaders met one-on-one with medical directors to describe the potential for strong gains in performance that existed if the organization’s ICUs were to standardize care processes across the system. The health system’s leaders elicited medical directors’ perspectives on improvement opportunities, explained the “why” in support of changes and innovation and listened to concerns about risks and potential negative impacts.   A primary goal of the one-on-one sessions was to assure the medical directors that the initiative to transform ICU care was not a nameless and faceless cost-cutting activity.

Group discussion forum. The one-on-one sessions were instrumental in generating interest among the medical directors to work together to improve performance. The directors then participated in a group discussion forum designed to help them coordinate their efforts with each other and with other clinicians and administrators. Through these key interventions, Main Line Health launched a collaborative process for redesigning key aspects of ICU care with direct and ongoing input from physicians.

Governance framework. At the same time, the health system established a governance framework to oversee this initiative, as well all other clinical initiatives, to advance the organization’s approach to holding leaders and teams accountable for performance improvement. Putting a clinical oversight structure in place fueled proactive and collaborative engagement among the ICU medical directors and teams. Similarly, creating a multidisciplinary design team — which included medical and nursing directors as well as other key stakeholders — ensured broad clinical representation and united efforts to make a deep difference in the quality of care provided. All these steps were informed by the guiding principles that Main Line Health’s leaders adopted to provide a conceptual framework for the initiative. (See the sidebar, “IMPACT: A key success factor for transformation engagement.”)

The results were extraordinary. Within 17 months, with physician input to help standardize processes across the four ICUs and eliminate unnecessary high-cost variations in care, Main Line Health was able to save $1.4 million by reducing ICU days. Much of this improvement came even though patients admitted to the ICUs during the initiative were found to be sicker, on average, than those admitted over a similar time frame prior to the initiative. Even as the ICU case mix index increased at all campuses, the average LOS for ICU patients improved for every level of patient severity at each campus.

Today, Main Line Health is nationally recognized for excellence in ICU care. Its Paoli Hospital ICU received a Gold Beacon Award from the American Association of Critical-Care Nurses, while Silver Beacon Awards were presented to Lankenau Medical Center’s cardiac and cardiothoracic ICUs, Bryn Mawr Hospital’s ICU and neuro-cardiac ICU, and Paoli Hospital’s progressive care unit. In 2018, the health system also received a regional award for excellence from the Mid-Atlantic Alliance for Performance Excellence Baldrige program for the quality of care and service it provides.

Overall Results of Performance Excellence 2020, to date

On its journey to becoming a high-performing organization, Main Line Health focused on quality, safety, financial performance and equitable care delivery by systematically using the Institute of Medicine’s STEEEP (Safe-Timely-Effective-Efficient-Equitable-Patient-Centered) framework in all projects.

Over a two-year period, Main Line Health’s clinical, physician and administrative leadership teams collaborated on initiatives with various objectives, including:

• Clinical transformation
• Improvements in corporate services
• Physician enterprise contracting and operational improvements
• Workforce transformation, including improving productivity

As a result, the health system was able to improve financial operations by $121 million, with $59 million resulting from clinical enhancements. An additional $17 million impact is projected for FY 2020.

Main Line Health’s experience in driving transformational care improvement, particularly in the ICU, is a powerful example of how a health system can benefit from reimagining its approach to engaging physicians. The principles and approaches it applied in its Performance Excellence 2020 initiative could prove helpful to executive teams of other health systems facing similar challenges.