Changing Someone's World with a Cup of Lemon Ice

Improving value in the care we provide

UH Clinical Update | June 2019

By Peter Pronovost, MD, PhD
Chief Clinical Transformation Officer

At UH, we’re on a journey to provide every patient with the highest-value healthcare. By value, we mean the highest-quality care, the best patient experience at the lowest annual cost of care. The ultimate goal is to keep more people healthy at home, taking the steps necessary to stay well or manage their health condition, rather than healing in the hospital.

This is a paradigm shift for healthcare, requiring us to adopt a new narrative and vision of success. But our team at UH is working together to make it happen – and in some new ways. Consider the following:

• Organizing Care Around Patient Needs First: Jill Dietz, MD, Director of Breast Center Operations at UH Seidman Cancer Center, has mapped a patient’s journey from the time she first feels a mass or has a positive mammogram, paying special attention to the time it takes to progress from one step of care to the next. When you are waiting for a diagnosis or to start therapy for cancer, time is suffering.  After finding that some wait times were long, Dr. Dietz and her team are working to reduce them. 
  
• Anchoring Our Care in Primary Care: Providing the highest-value care means that every patient has a primary care physician and gets an annual wellness exam – a tall order. This is especially important for people with chronic illness or multiple visits to the ED. To help improve outcomes, UH primary care physicians are seeing people on our employee plan who have multiple hospitalizations or ED visits every two weeks. In addition, Guilherme Oliveira, MD, Director of the Advanced Heart Failure and Transplant Center at UH Cleveland Medical Center, is doing a pilot project in which he sees patients just every two weeks, with UH Home Care visits and calls from an ACO nurse interspersed to provide patient support.
• Hardwiring Connections Between Upstream and Downstream Providers: Too often patients don’t get high-value healthcare because care is not coordinated within the system. For example, prior to our recent efforts, only 2 percent of patients were discharged from the hospital or the ED with a follow-up appointment scheduled with a primary care provider. Now we have increased this to 30 percent, and several hospitals are over 70 percent with a goal to hit 80 percent.   We are breaking silos and working together to improve care for our patients. Doctors, nurses, transition care coordinators, IT, physical therapy and the concierge team are meeting regularly, working collaboratively and improving weekly. There’s also a massive Point-of-Service scheduling initiative under way to schedule referral appointments with UH specialists before patients ever leave the primary care office. This takes some of the burden off patients, making it more likely that they’ll get the care they need.
  
• Engaging All UH Employees in the Mission of Providing High-Value Care: No matter their role, every UH employee should be engaged in improving the value of the care we provide. Take the example of nephrologist Aparna Padiyar, MD. She noticed that few dialysis patients seemed interested in the prospect of kidney transplantation – and also that these patients spend hours with dialysis technicians each week and patients often trust them.  Since March, when Dr. Padiyar standardized a script for nephrologists to have discussions with patients about the benefits of transplantation, referrals are up 45 percent. Imagine what would be possible if all employees were engaged in improving value.
  
• Reducing Mindless Variation and Increasing Mindful Variation:  Health care is full of variation, and some of this variation is harmful. Much of the mindless variation occurs because we have not created a pathway or because some people want to do things their way.  We need to reduce mindless variation though pathways. At the same time, we need to augment mindful variation.  This is intentional variation because you have a hunch or hypothesis that this patient is different. Yet mindful variation imparts an obligation to learn if your hunch was correct. Through our high-reliability medicine efforts led by Abi Sundaramoorthy, MD, the Organizational Effectiveness team and many clinicians, UH is seeking to reduce variation by creating pathways for care that try to avoid admission when possible, ensure appropriate ICU use, reduce hospital length of stay, ensure patients are discharged to home when possible and have a follow-up appointment with a primary care provider scheduled. The results are paying off. The percent of patients being discharged to home has increased from 68 percent to 78 percent, and both 30-day and 90-day readmissions are down. That is real harm-prevention for patients and real cost savings for all.       

Realizing the “Art of Compassion” with Micromoments of Connection and Love 

What is fueling these changes at UH? I believe the secret of high-value care is love, those micromoments of connection between patients and providers.  These moments are a win-win – a source of joy for clinicians and a great experience for patients.

We can all make micromoments every day.

Consider the impact Adrian Simpson, a Sr. Patient Access Representative at UH Seidman Cancer Center, had on Cheryl, a 45-year-old woman with metastatic rectal cancer. Cheryl learned that her disease had continued to progress and that she’d no longer be able to participate in the Phase 1 clinical trial that was her last option. Cheryl’s friend Sarah Mihalik, a Director with UH Ventures, accompanied her to her appointment with David Bajor, MD, to determine where to go next.

After the visit, Sarah asked Cheryl if she could get her anything. The answer? Lemon ice. “So of course, I went on a quest,” Sarah says. After a few failed attempts, Sarah asked Adrian at the check-in desk if she knew where to find some.  It was lunchtime.  About 25 minutes later, Adrian walked up with a pint of lemon ice from Corbo’s.  Adrian handed it to Sarah. “I could see and feel that Cheryl was having a rough day and that if I could get her that lemon ice, it might make a small difference,” Adrian says.

Sarah did not have to accompany her friend, yet she chose to.  Adrian did not have to use her precious lunch break to get the lemon ice for a patient, yet she chose to. We can all choose to create a micromoment every day.

The journey to providing high-value care may sound daunting. Yet this change is fueled scores of small changes, and every one is facilitated by micromoments.

Let’s each of us apply these principles of high-value care to the work we do every day at UH, with an eye to creating micromoments.

And let’s start today with a micromoment.