February 20, 2014

Rounds: A message from the Vice Chancellor for Health Affairs

A message from the Vice Chancellor for Health Affairs

Dear Colleagues,

Last month, I wrote about perspective.

Again in December and January, U.S. hospitals lost jobs. In our region, Kentucky’s largest health system, KentuckyOne, which includes the University of Louisville Hospital, announced it will reduce operating expenses by $218 million before the end of fiscal 2015, signaling staffing reductions. Everywhere we look we still see falling reimbursement for research and health care services.

While called upon to be ever more cost-effective and productive, I don’t believe we will succeed by simply pedaling faster. We must tap our capacity for innovation — a fundamental advantage we have at Vanderbilt as a world-leading destination for discovery.

Many would say, “VUMC has always led innovation.” True enough, but the palpable difference is that “innovation for the future” is no longer sufficient.

If you are watching the Olympics, think of the last century of innovation at Vanderbilt as our warm-up period. Changes — from how we are paid to how our performance is measured — are happening at a breathtaking pace. To succeed, we must become even more accustomed to innovating in real time. We must innovate NOW.

Admittedly, sweeping change in a system so large and complex as ours creates excitement and opportunity, but at the same time it’s anxiety provoking. It sometimes feels to me like we are fixing the airplane while still in mid-air.

In circumstances like these, I think it helps to consider the waves of change one at a time, rather than as one big frothy sea of change.

So let me take you back to the “rooms of the house.” Last month, we examined the kitchen — where the money is made that sustains our efforts. We examined a host of strategies VUMC is undertaking to increase available funds. Among those strategies was a commitment to “work smarter,” not just “harder.”

If we are going to work smarter, how do we make those improvements visible? And how will we measure success? Most importantly, how can we ensure that as we become more cost-effective, we fundamentally improve the care, education and research we are delivering to patients, students and the public?

The answer, I believe, is to measure every change we make using higher quality as our core standard. Everything we do, from education to patient care, must be held up against a standard that isn’t simply the “status quo,” but real improvement. Sounds simple, but quality is a tricky business, because a true commitment to quality requires a willingness at every level to be transparent — including admitting our mistakes — to ourselves, to our peers and even to the public.

When I last wrote to you, I suggested we make quality a ground floor issue and that we put it in the “living room” because of the picture window — our efforts, including areas where we either excel or need to improve, must be visible. All studies of quality improvement find that organizations with a culture that can admit its mistakes are by far the best performing. The reason — nearly everything we do requires not a single individual, but a complicated system of support involving many people. System failures are identified and fixed far more quickly in a culture that lifts up and supports those with the insight and courage to reveal its weaknesses.

And if you think about it, just the fact that we are dedicated to training in all areas puts us in the spotlight. We routinely have an audience of bright, caring students asking us tough questions during our day-to-day activities: “why do we do it that way?” Improved quality and innovation are born in such an atmosphere.

Truth be told, the picture window in our living room really needs to become a glass wall. Even today, anyone with Internet access can quickly see a host of outcome measures on most U.S. hospitals, from how many patients acquire surgical site infections to how noisy patients felt it was outside their hospital rooms. Just to make the point, Modern Healthcare recently featured a cover story titled “Performance Target,” with a bull’s-eye target superimposed over a peer academic medical center’s photo.

And the doorway between the kitchen and the living room has opened wide (think open-concept kitchen — family room combination!). Through provisions in federal health care legislation, hospitals like ours are now being rewarded (or penalized) on the basis of quality. Already, nearly all hospitals including ours are receiving a portion of Medicare payment based on performance on an array of quality measures, from rates of hospital readmission, to 30-day survival rates for patients admitted with heart conditions and pneumonia, to the quality of communication our patients experience with hospital staff, including nurses and physicians.

The ingredients to succeed in quality improvement in large organizations like ours are well established. Foremost among them are 1) a capacity to innovate and 2) a culture of civility and cooperation. What medical center — in our region or frankly in America — is in a stronger position to lead in these efforts than Vanderbilt?

In case you may wonder if I’m exaggerating, here’s some proof.

The Department for Health and Human Services Agency for Healthcare Research and Quality (AHRQ) uses a series of 11 Patient Safety Indicators (PSIs) to evaluate hospital safety, including measures ranging from bleeding during surgery to hospital infections. For the most recent quarter reported, VUMC’s Patient Safety Index was ranked in the top five in the University Health Consortium, an alliance of the 120 academic medical centers across the U.S. and 299 of their affiliated hospitals.

When it comes to quality, the little things are really the big things. Since 2009, we have embraced hand hygiene so totally that our compliance rate is a remarkable 96 percent for the current fiscal year. What is the impact? One example is our Pediatric Intensive Care Unit went more than an entire year without a single case of central line-associated infection, catheter-associated urinary tract infection or ventilator-associated pneumonia. Similar extraordinarily low infection rates are now seen throughout VUMC.

And yes, even hand-washing at VUMC lends itself to innovation — our physicians, nurses and IT specialists collaborated to create a wireless software application to document hand hygiene compliance in real time. We now use hand hygiene compliance apps for iPhones, iPads and iPod touch devices.

Our strength in innovation has yielded us huge gains in quality. But how will it serve us as we undergo the next wave of changes to make our care easier to access and more cost-effective for patients? Let’s use an example — pressure ulcers. We want to make sure that patients at VUMC have the lowest possible risk of these complications when under our care. At the same time, doing “everything” that we suspect might reduce these complications — throwing the so-called “kitchen sink” at the problem — can be inordinately expensive and in fact, might even cause complications for particular patients. To address this, we are testing a new tool known as “Cornelius,” designed by our own faculty to assess a patient’s risk for pressure ulcers and a host of other known risks during hospitalization — importantly, the moment they are admitted.

Cornelius taps the demographic and clinical factors already documented into the patient’s electronic medical record, and allows us to target extra treatments to those patients who are likely to experience a problem (such as a pressure ulcer), and avoid both the waste and the risk of complications with unnecessary treatments for those where the risk is truly low.

Along these lines, we are intensively developing new research-based methods to improve the safety of patient transitions from the hospital to either their homes or to rehabilitation facilities. And we are piloting telemedicine and point-of-care decision support to further improve the experience of our inpatients and the quality of life for our outpatients with chronic diseases like diabetes and heart failure.

Like many of you, I’ve been staying up too late watching the Winter Olympics. Beyond the intensity of the competition, what is just as striking is the ever-changing baseline for excellence. In 2010, the 500M speed skating men’s champion, a South Korean, finished in 69.82 seconds. This year’s winner from the Netherlands had a gold medal time of 69.31 seconds — more than a half-second improvement. But here’s the real kicker — the bronze medal time was 69.46 seconds. So the 2010 winning time would not even get you to the podium in 2014! Likewise, Meryl Davis and Charlie White had to achieve the highest score ever recorded in order to win the gold medal in ice dancing.

It’s the same in health care. Success is all about “upping our game” and working smarter. And the definition of excellence is ever changing.


Jeff Balser, M.D., Ph.D.
Vice Chancellor for Health Affairs
Dean, Vanderbilt University School of Medicine