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Top 10 Critical Success Factors for Care Model Redesign

Posted by Matthew Smith on Jun 24, 2015 12:33:27 PM

As the healthcare landscape shifts from volume-based fee-for-service reimbursement toward value-based risk sharing payments and penalties, organizations must develop new and innovative strategies across all care delivery channels. In order to move to true value-based care, financial models must be aligned, and the quality and overall patient health and outcomes must be addressed. Care model redesign is a necessary solution to achieve success and long-term sustainability.

The process of care redesign entails a systemic shift in the way care is delivered across the continuum with input from leadership, acute and post-acute clinical and administrative staff, and community partners and stakeholders. To ensure effective and efficient integration and strategic alignment, a governing steering committee should be established, and their vision and recommendations implemented by working groups that focus on distinct components. The following represents the top 10 considerations needed to implement transformative care.

1. Use an interdisciplinary care team approach supported by plans of care. Focusing on the accountability and improvement of the care delivered across settings for all dimensions of health and associated costs is a collaborative approach. It includes different disciplines working together to share knowledge and skills to guide and impact patient care. A physician drives the clinical care but collaborates with the entire team, with the ambulatory care manager as the consistent thread who follows the patient throughout the continuum of care. The patient and his/her family or caregiver is an integral part of the care plan development. The developed goals are patient-centric and focused on the patient’s preferences and wishes, taking into account specific cultural and linguistic needs. Each provider and/or discipline contributes to and aligns care with the patient’s plan and goals.

2. Target care from both a medical condition(s) and social determinant perspective. In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum, with a focus not only on the clinical aspects of care, but of equal importance, and at times more important, the social determinants of health. This includes access to care, caregiver support, behavioral health, social economic status, health literacy, adequate food and shelter, addiction, etc. Key components of a “whol-istic” approach include: patient/family engagement, tools for effective self-management of chronic conditions, an individualized comprehensive treatment and continuum-based care plan, health education for disease and medication management, primary care, and care management follow up – all supported with appropriate community-based resources.

3. Facilitate new patient identification, and identify high-risk population(s) to address barriers to care (e.g., poverty, behavioral health, health literacy, social support, etc.). The use of risk stratification is necessary to manage patient populations and identify high risk and risk rising patients who need proactive and careful management. The development of interventions to address individual clinical and social needs is recommended to improve the success rate of transitioning the delivery of care across settings. Risk stratification methods enable the prioritization of clinical workflows by cohorting patients for population health and disease and chronic care management programs. Additionally, they help ensure patients receive an assessment and inclusion into the appropriate case management programs. Homegrown and proprietary platforms exist, but all stratification models should include the critical components of comorbidities as well as (but not limited to) age, poor pain control, and low functional status or cognitive deficits to calculate a risk score.

4. Expand utilization management (“UM”) focus from episodic to complex chronic care, post-acute care or community-based care delivery needs. UM is increasingly important to manage healthcare costs and services across the continuum. Traditional UM is episodic and driven by point-of-care medical necessity and appropriateness of ongoing provision of care. As alternative payment and service delivery models are developed and tested by The Centers for Medicare and Medicaid Services and adopted by private payers, the care delivered will need to be considered across the continuum. The delivery of the right care at the right time in the right setting is evolving the role of UM. It requires considering a longitudinal approach to care provided outside of the four walls of the hospital, moving away from acute episodes to proactive delivery of complex, chronic care that maintains a patient’s health in a community-based setting.

5. Align primary care physicians (“PCPs”) incentive compensation to encourage coordination and access to all care team members. As the care delivery model for PCPs continues to move toward patient-centered models by organizing as a medical home or medical neighborhood, compensation models need to promote health outcomes and the coordination of care team members across the continuum. PCPs are tasked with driving care through a proactive, collaborative approach with patients and specialists with a focus on chronic disease management. New models of care delivered by PCPs will improve the health of populations and value for patients and compensation plans need to support the evolution of care delivery.

6. Develop new provider contracting models to address care across the continuum and engage new physicians and provider networks. As alternative payment models reward and penalize organizations for the quality of care provided, there is a corresponding need to evolve physician compensation models from a production/Relative Value Unit focus to one of value. Contracts need to clearly define the organizational strategy and goals as well as the expectations and accountabilities of the contracted providers. When designing compensation models, key factors to consider include aligning organizational and system goals with physician goals, identifying the appropriate quality benchmarks, and determining the proportions of compensation tied to risk, productivity goals, and quality.

7. Include value-based incentives and key performance metrics to provide appropriate and accountable care. Reporting quality measures is a familiar practice for providers who have participated in pay-for-performance programs such as Physician Quality Reporting System or the Hospital Inpatient and Outpatient Quality Reporting Systems. To promote appropriate and accountable care, existing and new value-based model metrics are now tied to incentives and penalties for providers to prove they are not only decreasing the overall cost of care delivered but are meeting quality standards. As payers continue to expand patient populations required for reporting financial and quality metrics, effective management and alignment of contract incentives is needed to ensure that care is delivered efficiently to lower costs but also improve the quality of the care delivered.

8. Create clinical data analytic functions and integrate relevant data sources (e.g., practice management, claims, financial, pharmacy, etc.) to support clinically data-driven efforts with real-time data. A robust data analytics infrastructure is necessary to integrate varying tools and data sources and to manage the vast amount of data to support real time, point of care decision-making. Health information exchanges or data warehouses are platforms to provide a solution to improve data integration functionality, aggregating data so staff spends its time analyzing data (not integrating data) and meeting organizational performance goals. The capabilities of the system should include all data sources related to clinical and patient experience, financial and cost performance, and quality data.

9. Develop robust communication, feedback, and reporting systems. The development of the most sophisticated data analytics infrastructure and the clinical information derived from the care of the patients is of little use if that knowledge is not communicated in a timely, meaningful way to the appropriate providers or systems across the continuum. If these gaps in communication of healthcare information are not addressed with the same effort as the development of information systems, the gap will continue to grow as networks expand and population panels increase. Greater consideration needs to be placed on communication enhancements to improve the quality and safety of clinical services. It is critical to view the communication needs from multiple directions – within and outside of the organization, with PCPs and community-based organizations, and between providers and their patients.

10. Develop system-wide tracking, reporting and accountability plan(s) to drive to population health-based outcomes and to compare internal and external peer group benchmarks and trends. Long-term success and intervention sustainability cannot be achieved without the continuous performance improvement and continuum based key performance indicators. Data reported in real time dashboards fosters close monitoring and analyzing both the financial and clinical data. Tracking, review, and actionability of the results will target the successes, areas of needed improvement, and the gaps in care for continued care delivery improvements.

Topics: Care Model, Care Team, Care Redesign, Transfomative Care

10 Emerging Characteristics of High-Performing Hospitals

Posted by Matthew Smith on Jun 8, 2015 9:01:02 AM

For decades, hospitals across the United States have operated within a challenging, rapidly changing, and fragmented healthcare system. Today, this environment is even more complex as healthcare reform and market forces transform the way healthcare is delivered and managed, shifting focus from fee-for-service to value-based care models. While healthcare providers are increasingly pressured to improve clinical quality at a lesser price, many have a long path of improvement to achieve sustainability in this post-healthcare reform era. Here are 10 emerging characteristics of high-performing hospitals in the value-based care environment.

1. Defined Strategic Vision

According to a 2014 global survey commissioned by the American Management Association and administered by the Institute for Corporate Productivity, the single largest gap between high-performing and low-performing organizations is whether organization-wide performance measures matched the overall strategy. The second largest gap between high- and low-performing organizations was due to whether organizations had clear and well thought out strategies to support the strategic plan1.

High-performing healthcare organizations have a strategic plan that sets a clear direction for the organization, and there is proper alignment between the strategies set forth and the organization’s goals, tactics, and measurable outcomes. Further, the strategic plan is hard-wired throughout the organization across all departments, engaging physicians, nurses, and staff in the process and making them accountable for achieving the organization’s overall goals.

2. Consistent Leadership

Leaders in high-performing healthcare organizations consistently demonstrate the mission, vision, and values, and ultimately drive the direction of the organization. These leaders are responsible for thinking strategically, allocating appropriate resources, building engagement, driving accountability, and achieving results – all in collaboration with very different stakeholders (physicians, nurses, staff, board members, and vendors).

Given that the healthcare industry overall faces an aging workforce, high-performing healthcare organizations have developed a pipeline of future leaders whose skills match their future needs. These organizations identify potential leaders, both clinical and non-clinical, and develop skills and competencies needed for the future. According to a survey of more than 5,000 executives conducted by The Boston Consulting Group and the World Federation of People Management Associations, high-performance companies fill 60 percent of top management roles with internal candidates, while low-performance companies fill only 13 percent internally2.

Lastly, high-performing healthcare organizations directly link leadership strategy to the organization’s overall strategic direction. Regardless of who the C-suite may be, operational execution takes place at the mid-level and supervisory levels of the organization, and involves engagement from physicians, nurses, and staff. High-performing healthcare organizations invest in their success, and actively monitor and work to strengthen their engagement and skills3.

3. Talent Management (don’t tolerate the low performers)

High-performing healthcare organizations focus on the development of their talent, managing people in the challenges of healthcare reform, strategic initiatives, and operational and performance improvement initiatives. These organizations are proactive in managing their talent and are quick to identify individuals that are not meeting performance targets, implementing necessary measures (e.g., talent replacement, mentoring, among others) to ensure that the organization’s performance remains on the projected path. According to a 2014 report published by the Project Management Institute (“PMI”), only nine percent of organizations surveyed rated themselves as excellent on successfully executing initiatives to deliver strategic results. Further, the PMI found that high-performing organizations successfully complete 89 percent of their projects, while low performers complete only 36 percent; high-performing organizations wasted nearly 12 times fewer resources than low performers4. Thus, high-performing healthcare organizations have more successful operations and waste fewer resources because they effectively align talent management to strategy.

4. Culture of Accountability

High-performing healthcare organizations are constantly looking for ways to improve the quality of care provided in order to achieve the Institute for Healthcare Improvement’s (“IHI”) Triple AimTM of: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; and 3) reducing the per capita cost of healthcare. In order to achieve these objectives, high-performing healthcare organizations have adopted and hard-wired a culture of accountability throughout the organization. A culture of accountability serves as a vehicle to reduce inappropriate utilization of healthcare resources; increase utilization of, and adherence to, clinical practice guidelines and evidence-based medicine; improve patient care outcomes; and ultimately create a continuous learning environment. As healthcare organizations seek to create a culture of accountability, it is critical that the following key factors become integral to the organization’s culture:

  • Provide consistent leadership and involve physicians
  • Focus on quality and the underlying processes required to sustain high levels of performance
  • Ensure customer service and patient satisfaction are forefront priorities across the organization
  • Regularly measure and monitor performance
  • Adopt and implement an infrastructure to support achievement of the organization’s objectives

5. Change Management and Adaptability

In this era of healthcare reform, high-performing healthcare organizations have the ability to rapidly adapt to changes in the marketplace and engage key stakeholders in the process. These changes include shifts in demographics, health status, and patient care needs; technological advancements; reimbursement changes; and transitions to emerging value-based care models. Not only are these organizations able to quickly adapt, but they have a disciplined approach to drive shifts in focus, strategy, direction, structure, and culture throughout the organization through innovation and by developing alternative approaches that maximize impact – usually through more cost-effective, higher quality of care. Further, high-performing healthcare organizations are prepared to respond to failures, and continually find new solutions, and their resilience and quick problem-solving prevents disasters.

6. Transparency

High-performing healthcare organizations drive organizational awareness and quality performance through improved communication and data sharing. These organizations provide sufficient, easy-to-access information to the right person at the right time for the right patient, facilitating evidence-based decision-making, and appropriate and timely measurement of quality and key performance indicators. Further, high-performing healthcare organizations are able to successfully align governance with the use of data and information to drive performance improvement. Comprehensive sharing of information and best practices means alignment between leadership and physicians, nurses, other clinicians and staff around strategic goals, data-driven decisions, transparent metric analysis, and timely reporting. This helps to ensure that patients receive consistent care while improving overall quality outcomes at lower costs.

7. Outcomes

The healthcare industry is becoming increasingly consumer-driven. Patients have greater decision-making power in managing their healthcare budgets, and the increased transparency of healthcare outcomes data allows patients to compare and select providers based on published reports. As competition intensifies, patient satisfaction, service quality, and efficient resource management have become the basis to measure patient, clinician, and organizational outcomes. High-performing healthcare organizations have developed a strategic quality plan that sets the direction for quality improvement by creating a strong patient focus and demonstrate continuous commitment to achieving the organization’s quality improvement goals. Further, these organizations have hard-wired evidence-based practices throughout the organization to ensure performance targets are met, and have engaged physicians, nurses, and staff in this process. This is particularly important, as shifts in payment models link reimbursement to quality outcomes. Thus, the benefits of high-performance are recognized in multiple areas:

  • Financial outcomes, through higher revenues and lower costs
  • Clinical outcomes, through higher quality of care and more efficient clinical resource utilization
  • Operational outcomes, through healthier patients at reduced costs and improved processes and workflows to manage information and enhance patient experience

8. Alignment with Physicians Through Clinical Integration

Healthcare reform initiatives are forcing all providers to reevaluate current partnership models in light of future accountability mandates. As reimbursement systems evolve, hospitals and physicians will share an increasing amount of joint accountability for the care they deliver, which will require a defined infrastructure to evaluate costs while delivering higher quality care. High-performing healthcare organizations have adopted a clinical integration strategy that allows both the hospital and its physicians to achieve these goals by jointly participating in value-based contracting models. This provides opportunities for both parties to collaborate through coordinated patient interventions, management of quality across the continuum of care, movement towards population health management, and pursuit of value-based contracting – all of which are key critical success factors in today’s age of healthcare reform.  

9. Patient Engagement

To build and maintain patient loyalty and engagement during a time when consumers can shop for the best value, healthcare organizations must not only provide quality care but also exceed patient expectations. Patient experience and emotional engagement have become critical factors to achieve improved health outcomes and lower costs, and research conducted by Gallup suggests that high levels of engagement among physicians, nurses, and staff are key to developing and maintaining these critical patient relationships. For example, engaged employees are enthusiastic and willing to go above and beyond the basic standards of performance, which makes them more likely to anticipate patients’ needs and create a positive patient experience5. High-performing healthcare organizations cultivate provider-patient relationships and apply strategies to build patient engagement, allowing patients to become more active participants in their care. These strategies include empowering employees to problem-solve down to the front-line levels, as well as deploying behavioral interviewing techniques to hire the right people for the right positions.

10. Innovation and Care Redesign

High-performing healthcare organizations adapting to transformational payment systems and payment reform have determined it is not business as usual. Many organizations cannot afford sophisticated benchmarking or best practice comparisons. A beginning strategy in care redesign for bundled payment and other payment reform initiatives includes comparisons to internal best practices in both cost and quality. Additionally, high-performing healthcare organizations have implemented systems such as Lean and Six Sigma to involve frontline staff and physicians in identifying unnecessary, non-value added testing and processes.  Competency in care redesign is a critical skill in an organization’s efforts to reduce costs, eliminate variation, and streamline transitions in care. High-performing healthcare organizations have learned how to enhance care transitions and move outside the walls of acute care hospitals and into post-acute settings to reduce readmission rates and potential complications.


  1.  American Management Association. “The Essentials of High Performance Organizations.” October 6, 2014. http://www.amanet.org/training/articles/The-Essentials-of-High-Performance-Organizations.aspx
  2. The Boston Consulting Group. “High-Performance Organizations: The Secrets of Their Success.” September 2011.
  3. The Boston Consulting Group. “High-Performance Organizations: The Secrets of Their Success.” September 2011.
  4. Project Management Institute. “The High Cost of Low Performance.” February 2014.
  5. Burger, Jeff. “Why Hospitals Must Surpass Patient Expectations.” Gallup Business Journal. May 1, 2014.

Topics: Clinical Integration, Hospitals, Patient Engagement, Strategy, Care Redesign, Hospital Pricing Transparency, Hospital Performance, Performance Improvement

Population Health Alliances: The Value of True Care Redesign

Posted by Matthew Smith on May 6, 2015 4:26:28 PM

By Tara Tesch, MHSA, Senior Manager, The Camden Group

This is second of three articles in the Population Health Alliances series. The first article examined physician engagement strategies and detailed specific strategies that have proven successful for alliances.

Healthcare systems are increasingly choosing to partner with other provider organizations to pursue population health initiatives on a more regional and sometimes statewide basis. These “alliances” are often viewed as alternatives to more traditional mergers and acquisitions, and are created through the collaboration of more than one health system, hospital, or physician group. This emerging collaboration model provides opportunities to share common infrastructure, expand geographic reach, and increase access to additional clinical and support resources. These alliances also face additional challenges associated with sponsorship by multiple organizations that in some cases have historically been competitors.

Care Redesign

Value-based care management is a physician-led, patient centered, interdisciplinary approach to integrating healthcare across the care continuum, with the goals of improving patient health status while reducing the cost of care. Many value-based delivery networks have components in place, but to be successful in the movement toward population health, true care redesign is essential. Here are a few interesting facts to consider:

  • It takes 17 years to go from a proven breakthrough to use in every day practice1.
  • Only 55 percent of physicians are using/following evidence-based guidelines2.
  • Most dramatic change in the physician workforce is the movement from independent to employed practice. In 2014, 53 percent of physicians were employed by a hospital or medical group. Ninety percent of newly hired physicians are electing employment over private practice or partnerships3.

So what does this mean then for population health alliances? Physician leadership should drive the clinical transformation and care team development. The healthcare environment is changing at a rapid pace and population health alliances must continually educate their physicians and staff on these changes. Rigorous training programs focused on standards of practice should occur regularly, and care management staffs will need significant training to ensure they are providing adequate support to providers, and are working at the top of their license.

The role of the alliance, then, is in establishing the clinical standards, guidelines, and best practices and providing the information back to members regarding adherence to the clinical standards. Providers will also look for alliance-level resources to assist with tools and process change, including ongoing training and education. In order to educate members of the network on their performance, the network will need to have the capability to conduct analytics and reporting for both patient and population management. Clinical integration relies on transformation of the clinical care model; clinical transformation can only occur with enough data to produce information that will drive this change.

Alligned Incentives

Care is local, so actual redesign should occur at the local level to reflect the specific needs of the populations served. This will require different economic models to align incentives as well as multiple levels of care management resource needs. The growth of accountable communities is creating a burning platform for change. Care redesign must be approached at the continuum level and focus redesign efforts to impact total cost of care at the process/workflow level. While the most dramatic change will occur at the individual physician practice level, there is also increased pressure on networks to integrate in-home care in the continuum of providers. Care transitions and community-based resources become increasingly critical to both network and care model development for the alliance members.

Thus, the member provider networks will look to the alliance to provide actionable and real time information on their clinical outcomes, adherence to protocols, and value-based metrics. Transparency in these reports, including financial results, is critical to physician behavior change.

Coming soon: Watch for the final installment of our Population Health Alliances series examining Data Governance.

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine 2011;104(12):510-520. doi:10.1258/jrsm.2011.110180.

Elizabeth A. McGlynn, Ph.D., Steven M. Asch, M.D., M.P.H., John Adams, Ph.D., Joan Keesey, B.A., Jennifer Hicks, M.P.H., Ph.D., Alison DeCristofaro, M.P.H., and Eve A. Kerr, M.D., M.P.H. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003; 348:2635-2645. June 26, 2003. DOI: 10.1056/NEJMsa022615.

2014 Survey of America’s Physicians. Survey conducted on behalf of The Physicians Foundation by Merritt Hawkins. Completed September 2014. Copyright 2014, The Physicians Foundation.


tara.pngMs. Tesch is a senior manager with GE Healthcare Camden Group with more than 20 years of experience as a healthcare leader and strategist. Ms. Tesch specializes in value-based care delivery strategic planning, CIN development and implementation for commercial, Medicare, and Medicaid populations, health information technology data governance and analytics strategy, as well as care management strategy, design, and implementation. She has worked with a variety of healthcare providers, including integrated delivery networks, academic health centers, regional referral centers, rural community providers, and national non-profit and faith-based health systems. She may be reached at tara.tesch@ge.com.

Topics: Population Health, Population Health Alliance, Tara Tesch, Care Redesign

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