By Erin Cristales, Vizient
When Vizient Chief Medical Officer David Levine studies high-performing healthcare institutions, he finds a deceptively simple question often serves as the guidepost to success: Who comprises our community?
"That question should always be your starting point," said Levine, who along with Julie Cerese, Vizient senior vice president, performance management and national networks, has studied healthcare top performance for the past two decades. "It's how you decide if you should focus more on outpatient versus inpatient or virtual care versus brick and mortar. It really is the key to better patient access and outcomes."
In fact, the five top executives who recently shared their own high-performance journeys in our recent report "CEO Spotlight: How healthcare leaders can harness high-performance principles," use that very question as the backbone of their efforts around high-performance principles including benchmarking, systemness, innovation, health equity and culture. After all, they pointed out, true high performance means never straying from your No. 1 mission.
"Different variables are introduced every year," Johnese Spisso, president of UCLA Health and CEO of UCLA Hospital System, said in the report. "Stay true to the plan that you know will provide the best outcomes for patients."
Here, Levine outlines some strategies for how healthcare organizations should think about high performance moving forward — and how that mindset will benefit the communities they serve.
In thinking about the concept of "high performance," how is it different from top performance as measured by Vizient's Quality and Accountability scorecard?
Top performance is a measurement. It's your score within a certain level, usually top decile. Many organizations that are high performers also rank as top performers. Top performance is important, but ultimately, it's a metric. You need to consistently monitor and aim for top performance to be a high performer. But high performance in its truest sense is outstanding, consistent performance — it really is the "whole package" that encompasses patient-centered, equitable care through quality, safety and operational efficiencies.
In our recent high-performance report, each of the five CEOs discussed guiding principles including benchmarking, systemness, innovation, health equity and culture. Are there additional areas health systems should think about in terms of being a high-performing institution?
I would say community — certainly, it's implied in culture and health equity. But I think it's important to explicitly call out service to your mission.
So, if you're telling an institution that they need to focus on their community to be high performing, what does that look like? What do they need to specifically think about to achieve that?
It's understanding that your patients are customers — and being as laser focused at providing the right services as the best companies in other industries. You have to ensure you're providing the right care in places that are convenient to the populations you serve. It's also important to address the social determinants of health that affect your community in the right ways, which is likely a combination of direct interventions that your organization has in place, as well as strong cooperation with other nonprofits and governmental agencies in your area. You have to reach out to key groups who not only know the patients but also the employers in your community and ask for regular feedback about how you're doing in addressing their needs.
Many health systems operate across state lines and serve vastly different types of communities. Thinking in terms of systemness, when you're talking about targeting communities, is that something that should happen at the system level? Or is it something each individual location needs to take ownership of?
I think it's a hybrid. There's a system approach to how you're going to receive community input around your mission. But even for systems that are close geographically, you can go a few miles in one direction and that community will be very different than a community in the other direction. So, the strategy also needs to be local, but filtered through a larger lens of what your health system is trying to accomplish for that specific community.
What are the opportunities for virtual care to meet community needs, especially when looking at expansive geographic regions?
I'm excited to see how much virtual care has accelerated, especially post-pandemic. The more successful systems are increasingly offering virtual care because it makes them more accessible to pockets of the community that have a harder time making it to brick-and-mortar locations. In fact, I just read an example of a system that uses virtual care for the ICU. Those kinds of solutions really do provide opportunities to better meet your community's needs.
Of course, systems should be cognizant of community challenges around broadband such as access or with elderly populations who may struggle with using the technology. So, to be clear, it's not a one-size-fits-all solution. It's about looking for those opportunities where they exist and make sense.
We all know health systems are facing challenges in many different areas. So, as they're strategizing how to become — or maintain their status as — a high-performing institution, how should they prioritize what to focus on among all these different issues they're trying to tackle?
Set up a dashboard of key metrics early on — whether it's the Vizient Q&A or a subset of the Q&A with other metrics attached — with a baseline and sensible goals that are focused on where you want to be long term. Those metrics should come from your mission and what you're trying to achieve. For example, you might not be able to address mortality and length of stay simultaneously. To prioritize, decide where you can gain ground first. Personally, I would look at inpatient or 30-day mortality as a priority area, along with safety opportunities to prevent hospital harm. And in nearly every case, I always advocate for quality over cost. So, start with areas where you know you can affect change and that are measurable on a regular basis.
Are there areas that could help in achieving high performance that healthcare organizations aren't focusing on enough?
Addressing healthcare costs and driving out unnecessary variation of care are huge areas of opportunity. One of the biggest is access, especially access to outpatient primary care and specialty care. A number of institutions are monitoring it but definitely haven't solved that problem yet. But there are some strategies around access:
- Are you maximizing mid-levels at the top of top of their license?
- Are you maximizing clinic and appointment times?
- Do you have the ability to flex into evening and weekend hours that are more convenient for patients?
- Are you using telemedicine for consults? A patient may think they need to see an orthopedic surgeon, but do they really?
- Are you maximizing the right level of provider and are the right pretests being done so when a patient goes to see a specialist, it's not a wasted visit?
Looking at all the opportunities that exist around high performance, what role does governance play?
Governance is incredibly important in this. There has to be accountability, especially around the right metrics being available to the right people. Employees need to understand their role in trying to hit those goals. When you look at top performers [as defined by the Q&A ranking] or overall high performers, they all have some sort of mantra that encompasses their mission and vision. I can pick anyone in that institution, and they can tell me what that mantra means and how their individual role contributes to it.
As an example, a few years ago I was studying a top-performing hospital and I ran into one of their patient transporters on the elevator. When I got off the elevator, he said, "Sir, you need to go to one of the gel stations and sanitize your hands." I looked at him a little quizzically – I wasn't questioning him; I was just intrigued he had pointed that out. He told me, "It's my responsibility to help decrease infections that can spread from patient to patient when people don't wash their hands." Later, I found out that even the patient transporters at that institution got their C. diff infection ranking, which was one of their key metrics. In fact, bonuses were even tied to that metric.
At high-performing institutions, every employee knows exactly how they contribute to the patient experience. Central governance is incredibly important, but it has to be mixed with personal responsibility, accountability and empowerment.
That's an interesting point, because often it seems like discussions around high performance center more on the C-suite and clinicians. But it's clear that every internal stakeholder plays a distinct role in achieving high performance.
That's true, and it's also true that administration and physician leaders are the ones who can really build empowerment across the organization. Another quality of high performers is that they have a true dyad structure of physicians and nurses that is based on mutual respect. Everyone feels free to speak up on behalf of the patient. Even better is a triad where you have an administrative partner. It's so important for those in the C-suite to commit to being visible within their hospital or system.
So, thinking about the C-suite and just the sheer number of commitments they have to juggle, how can leaders strategize being more visible? How can they free up that time?
The best strategy is to make it part of your schedule. The executives who have been most successful at this have asked their executive assistants to make that time a priority on their calendars. They schedule a block of time — it could be a half or full hour once a week or biweekly. You're not going to hit every unit every time, but you can rotate or even go in groups, like having the chief medical officer and chief nursing officer round together.
Remember that it's about more than being visible — when you're there, you have to be present and open to listening. You don't need to have all the answers; it could be, "I'm going to look into that, thank you for letting me know." And if you commit to looking into something, you must follow up. But quite honestly, the administrators who do this say it's the best part of their job.
You've talked a lot about the importance of community, whether it involves leaders building a collaborative internal culture or pinpointing how to best serve patients. So, I'd like to end with a question about community. In terms of high performance, how can providers balance the needs of their internal communities with those of their external communities?
You know, one thing hospitals often forget is that the majority of their staff live in the communities they serve. So, if you're setting goals around doing your absolute best for your community, you're also going to be doing the best for your employees. That increases retention and engagement and leads to higher quality, all of which help you achieve high performance.
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