Why do you care about improving value?

starts with my pride in the work that we do here at the university, and especially in joint replacement. I know that our work is as good as it gets in the country. It’s frustrating to see ratings like US News and other scorecards rank us behind places like Mayo, knowing full well that the work we do is as good or maybe better. Part of my motivation is to be able to prove that our work is of national caliber and get those rankings. I went into academic medicine because I wanted to be on the cutting edge. We strive to be better; we invent new processes, techniques and implants to make care better for patients. We are the guys sharing results at national meetings, teaching other doctors how to be better.

The value world is the next level. In my early career, it was the area that most interested me because it is so actively changing. It was an area where we (Utah) were poised to make a difference both in cost and outcomes. I thought I could lead the way institutionally and nationally by getting involved in value.

How did you get started in Value?

It started with my relationship with Bob (Pendleton). He and I had a long relationship working together on joint replacement and thrombosis. When he became CMQO, it was natural to start collaborating on value improvement. Secondly, I’m drawn to process improvement because joint replacement is so regimented and protocolized. The connection to improvement is natural. Third, I knew there was opportunity to get better. Other organizations were doing things differently from us, and we could get better outcomes. We were really comfortable with the way we were doing things, but many of our processes were ingrained in culture and status quo. Lastly, the University was driving forward with this idea of lean process improvement and value driven outcomes (VDO). I saw VDO as way for us to start getting data. Armed with the right data, we could build the case for change, and show if the changes we were making were moving us toward improvement. These four pieces laid the foundation for my work.

How did VDO help you and your team improve?

Doctors in the trenches are tired of being told what to do by administrators. Physicians are empowered when they can drive improvements from within as opposed to being told what to do. We all know that the care we provide is excellent, but how do we continue to show that? Armed with real-time, accurate data, our surgeons are motivated to improve because we want to continually make it better. If we try something, we can show if it leads to improvement with VDO. If we can show the improvement in quality or a decrease in overall cost, people get excited. They are motivated to do more. Everyone that’s in medicine was a great student. They loved getting straight A’s and they want to excel in everything they do. This is a report card that shows them that their efforts are paying off and that they are getting an A.

"Physicians are empowered when they can drive improvements from within as opposed to being told what to do."

The other thing that the university helped us with was the resources of Value Engineering. It was important to have someone with a background in improvement to help drive the project and improvement forward. Even while I was in the operating room, we had an expert working to get the detailed data to answer the clinically relevant questions that the physicians were asking. He helped us to meet on a regular basis, get the right people in the room and facilitated our progress.

What was difference between redesigning care with VDO and in the bundled care environment?

The BPCI program is just focused on CMS Medicare patients but we decided early on that we would design changes and processes for all our patients, not just the CMS Medicare patients. The bundle (BPCI) forces you to look outside your own institution’s walls. With VDO, care process improvements tend to be more focused on things that happen within our organization: reducing cost of implants, getting patients ready to leave the hospital in a timely fashion, reducing in-hospital complications. The bundle extended that view to a 90 day outcome, it forces you to look at a bigger scale. We couldn’t enter the bundle and keep caring for our patient the same way we had been, even with the quality measures we had developed with VDO.

We were very high utilizers of post-acute care. We believed or perceived that post-acute care was worth the cost, because more resources should equal better care for our patients. The bundle forced us to reassess this assumption, looking at the high cost and the potential impact on quality. What we learned by reducing our use of post-acute care is that our readmissions rates, emergency room visits and infection rates have all gone down. It is exciting. We have actually improved the quality outcomes of the patient which is what this is really about in the end.

"Improving value is not just about saving money for CMS or the financial return to the organization for taking risk."

Improving value is not just about saving money for CMS or the financial return to the organization for taking risk. It’s about my ability to tell a patient, “I don’t want to send you to rehab but instead I can help you find ways to go home, whether that’s having a neighbor come by a couple of times a day if your family is unavailable, or having family take a week off of work. What is most important is that by going home you are at lower risk for infection, complication, readmission or reoperation. Your outcomes are likely to be better and we know that because of the data we have.” This is the next scholarly publication to come from our efforts. We published our VDO efforts in a peer review publication. We will be presenting our findings from the bundle at our professional society’s annual meeting in November.

What made it easier was the institutional support and administrative leaders like Ryan (VanderWerff). Ryan is a very special type of manager. He gets engaged and interested and then really steps up. We have many people like Ryan in our organization. That’s the way this work is done. We can try to teach human behavioral changes, but unless you have a partner it is very hard to get things done. Hospital leadership like Ryan and Bart (Adams) supported this idea. Expanding our care from the 3 days patients are in the hospital to 90 days following surgery required investment by the hospital and our department, mostly in personnel and resources. We are only two quarters into bundle payment with a current return of about $450,000, which is 4 to 5 fold return in investment. It shows that the right investment of money, effort, people and time can result in major changes and improvement.

How has your CVO role changed your perspective?

It’s my opinion that physicians in the trenches who are busting butt to take the best care of patients don’t like top down directives from administration. They don’t like directives like improve Press Ganey scores, see new patients in 7 days, offering after-hours clinic appointments. Even physician leaders, as soon as they move to full time administration work, quickly lose street cred. Front-line physicians accuse them of losing touch with the challenges, of misunderstanding our plight, and discounting what they say. The CVO role is an intermediary position. I can still be a doctor in the trenches, but have an ear to important administrative directives and health care reform. Healthcare reform is not going away. A lot of our doctors don’t see that. They don’t see what our administration or even the CVOs are exposed to.

Being a CVO has made me a better liaison to my colleagues. I’m better able explain to those who are skeptical and leery of change. I’ve heard both sides and try to provide the data to help others understand the issue. I’ve also been able to empower them with access to resources to help with change. I can say, “You got a red dot on your report card. If you want to learn to understand your cost and outcome variation, I can call people who can help you.” That has been a valuable part of being CVO.

How is value work contributing your professional goals as an academic physician?

My focus on value improvement enhances my ability to be a physician scholar in academic medicine. The majority my scholastic body of work now revolves around value improvement . My abstracts and publications are about care process, quality and value improvement. You can build a Curriculum Vitae around the value work you do. That’s the greatest thing.

Chris Pelt is an assistant professor and serves as the inaugural Chief Value Officer for the department of Orthopaedic Surgery at the University of Utah School of Medicine, Salt Lake City, UT.