In seeking to improve care value, a central challenge that most health care delivery organizations face is their limited capacity to measure and analyze health care value, particularly around costs. In 2012, University of Utah Health Care, under the leadership of Dr. Vivian Lee, initiated a large-scale effort to create a “value-driven outcomes” (VDO) tool that would provide clinicians and managers the ability to analyze actual system costs and patient measures.1
As we examine the following case, think about how to measurably improve value at the scale of an entire health care system and how to use data to help identify potential sources for improvement.
The University of Utah Health Care system, as of November 2015, included 4 hospitals, 11 community clinics, 15 regional partners, and 1,380 physicians, and saw approximately 1.4 million patients each year. First, The University of Utah had to determine measures for their patient outcomes, processes of care, patient experience, and costs. Each of these metrics can be difficult to precisely define, and we will explore them in more depth later in this course. For now, let’s focus on the bigger picture of how defining, measuring, and evaluating aspects of care delivery is critical to improving value.
To define outcomes, clinical teams consisting of physicians, nurses, administrators, and quality improvement staff collaborated to identify clinically relevant outcomes that consider patient priorities. These included risk-adjusted mortality, patient safety measures such as hospital-acquired infections, clinical process measures, and unplanned hospital readmission or emergency department visits. They also collected patient satisfaction data.
The care team for each specialty selected key quality and outcome variables that they felt were most important to the care of their specific patients. These were combined into a single binary measure that they called “perfect care.” To achieve perfect care, the care team had to accomplish ALL of the key elements.
Next, the University of Utah Health Care system had to determine how much everything in the hospital actually cost. All hospitals have a “charge master,” which lists the charges for each item or procedure that they provide. Few, however, have a list that shows what these items actually COST. An important concept to note is that the price does NOT equal the actual cost. The University of Utah dedicated significant resources to study and define how much processes and items within their hospitals cost, and they referred to their database of these costs as a “cost master.”
After teams defined the key metrics for perfect care, multidisciplinary value improvement teams that included clinicians, administrative leaders, and process engineers, used web-based visualization tools to view and monitor care costs and quality metrics. These data provided feedback to individual clinicians and were aggregated at the service-line level to identify areas with broad variations in cost and/or quality.
In 2016, The University of Utah Health Care system published results in JAMA from three selected clinical projects that resulted from the VDO program. These clinical projects focused on total joint replacement, lab testing costs, and sepsis. For total joint replacement, the quality of care improved, with surgeons achieving a “perfect care” score for their patients 54% of the time at baseline compared to 80% at one year into implementation. The costs for total joint replacement also dropped 11% compared to baseline. Hospitalists decreased the costs of lab testing per day from a mean of 138atbaselineto 123 in the evaluation period, saving an estimated $250,000 each year for the hospital. The pilot sepsis project improved care quality by shortening the mean time to antibiotic administration following the first clinical signs of sepsis from 7.8 hours to 3.6 hours.
If you are interested in the methods behind the University of Utah VDO Tool, this manuscript details the analytical and IT infrastructure of the tool.
Kawamoto K, Martin CJ, Williams K, Tu M-C, et al.
Journal of the American Medical Informatics Association
2015;22(1),223-235.
This video features the University of Utah Medical Center and their efforts to reduce costs and improve outcomes that matter to patients.
NBC Nightly News with Lester Holt.
November 27, 2016.
This article details the story behind the development of the VDO tool at the University of Utah and includes more information on the people who made it happen.
Algorithms for Innovation.
University of Utah Health Sciences. 2016.