Reengineering of care: Surgical leadership


WASHINGTON – Years of research have taught us that when it comes to heath care delivery, there is no relationship between cost and quality, according to Dr. Glenn D. Steele, the president and CEO of Geisinger Health System. Dr. Steele delivered the 2013 Commission on Cancer Oncology Lecture at the annual clinical congress of the American College of Surgeons.

Geisinger Health System, based in Danville, Pa., is a renowned leader in transforming health care delivery through innovative multi-institution collaboration and an emphasis on consistent use of best practices and evidence-based medicine, he said. The goal over the past decade has been to reengineer complex medical care to improve quality and reduce costs. Dr. Steele asserted that these two goals are not mutually exclusive.

Dr. Glenn Steele

"We now believe that if you look at a patient cohort – whether it is hospital based or whether it’s ambulatory care – for folks with three, four, or five chronic diseases, you find that the population with the highest costs has also the least-quality health care ... more often than not, high cost equals a less-than-optimal outcome," he said.

At the heart of the reengineering concept is the recognition that many patients in conventional treatment situations end up with what Dr. Steele referred to as "unjustified variation" in the execution of the treatment. A noted study by Little et al. showed that only half of patients treated for lung cancer, for example, receive the recommended care (Ann. Thorac. Surg. 2005;80:2051-6). The Geisinger Health System tackled the problem of unwarranted variation in treatment and "road tested" a wide range of innovations involving standardization of treatment, electronic data gathering and tracking, and institutional culture change.

The ProvenCare model was developed to incorporate all the initiatives that had been researched and tested at Geisinger, and the model was first applied in 2005 to coronary artery bypass grafting (CABG). This application of ProvenCare showed that "an improvement model that embeds evidence-based medicine into the workflow, applies the principles of reliability science (standardization, error proofing, and failure mode redesign) to the care redesign process, employs effective data feedback strategies, and engages patients in their care results in the right care delivered 100% of the time with better patient outcomes" (CA: A Cancer Journal for Clinicians 2011;61:382-96). The model has since been applied to hip replacement surgery, percutaneous coronary intervention, and cataract surgery.

Dr. Steele gave an update on a recent ProvenCare project, a model for treatment of resectable non–small cell lung cancer. The project is a collaboration between Geisinger and the American College of Surgeons Commission on Cancer. The initial survey of lung cancer care revealed substantial room for improvement. The ProvenCare goals initially were to standardize care; build in redundancy to make sure all tasks are done; bundle related tasks; build teams, feedback protocols, and training models; move toward a multi-institutional collaboration; and achieve widespread change in institutional practices, protocol, and culture of care. The project involved an 18-month period of training and testing in the participating institutions.

Engagement of patients and a "very well-articulated set of expectations" were a critical part of the ProvenCare model. The challenge involved achieving 100% compliance across the many institutions

Geisinger has created an insurance company that has some role in controlling costs. Dr. Steele estimated that many resources spent in health care are wasted. "If we could figure out how to extract much of that 25%-30% of needless cost, we can redistribute it. ... Some of that redistribution would go to our bottom line and allow us to grow programs and make our balance sheet comfortable. ... Some of that value would go back to our insurance company and to the middle-size and small businesses that are buying our insurance premiums." This is where cost savings are reducing the cost of premiums and "giving some of that value back to consumers."

Dr. Steele said, "In most industries where you have reengineered whatever it is you are doing, you’ve got better outcomes on both the quality side and the cost side, and you are in heavy-duty competition in the consolidating market. What do you do? You lower your price. And you maintain your contribution margin. And you run your competition out of business. We don’t think that way in health care. But my bet is, in 5 years, we will think that way."

Ultimately, the drive to lower costs goes hand in hand with improving quality of care, he said. "If you believe that, and you are a professional driven to help your patients, you are much more enthusiastic about reengineering than simply working to keep costs down."

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