In the first part of this two-part series, ABILITY Magazine examined a unique collaboration among Anthem Blue Cross, California’s hospital associations, and the National Health Foundation (NHF). This alliance, called the Patient Safety First partnership, involves a three-year effort in the following areas:
1. Perinatal Care: Reduction of elective deliveries prior to 39 weeks
2. Sepsis: Reduction of incidence and morbidity
3. Hospital-Acquired Infections in the Intensive Care Unit (ICU): Reduction of instances of ventilator-associated pneumonia (VAP), central line bloodstream infections (CLBSI), and catheterassociated urinary tract infections (CAUTI).
Our first article focused on Anthem Blue Cross, its role in forming this unique partnership, and its commitment to saving lives while reducing health care costs for Californians.
In part two, ABILITY’s Lauren Becker interviews the other integral players in this collaboration: Art Sponseller, President and CEO of the Hospital Council of Northern and Central California; Gene Grigsby, President of NHF; Leslie Kowalewski, Associate State Director, California Chapter and Director, Big 5 State Prematurity Initiatives for March of Dimes (MOD); and Joanna Horsfall, an independent consultant tasked by Anthem with providing direction, oversight and coordination to the effort.
This article examines the contributions of each of these individuals in forwarding the goals of the initiative. It also investigates the coordination of efforts toward the project’s success and its implications on the future.
THE CALIFORNIA HOSPITAL ASSOCIATIONS: PUTTING PATIENTS FIRST
California’s hospital associations include the Hospital Council of Northern and Central California, the Hospital Association of San Diego and Imperial Counties, and the Hospital Association of Southern California. The not-for-profit regional trade associations represent 95% of all hospitals in the state. Their mission is to serve the political, economic, informational and educational needs of their member hospitals, and to improve the quality and accessibility of health care services in an effort to create healthier communities.
The Hospital Council of Northern and Central California is the lead organization for the initiative’s three regional associations. In the following interview, Art Sponseller, President and CEO of the Council, describes the initiative from the perspective of hospital associations, and discusses their roles and expectations.
Lauren Becker: What prompted this collaboration? Art Sponseller: In 2005, the Hospital Council, with funding from the Gordon and Betty Moore Foundation, and clinical leadership from Dr. Bruce Spurlock of Convergence Health Consulting, established the first large scale, hospital-based patient safety collaborative in the San Francisco Bay Area. Our initial focus was on the 100,000 Lives Campaign, a nationwide initiative to significantly reduce morbidity and mortality in American health care. Subsequently, a similar effort was established in Southern California. From day one, we had a vision that every hospital in California could participate in this initiative, and our real challenge was a matter of funding.
In 2008, we began discussions with Anthem Blue Cross about a partnership in which they would provide funding and public outreach to expand our collaborative activities so that our vision of all California hospitals participating could be achieved. That vision was realized in Patient Safety First…a California Partnership for Health, which was launched in January of 2010. Blue Cross envisioned that the state’s largest health insurer and the hospitals of California could come together in a unique and unprecedented way to save lives, and this led to the creation of the collaborative.
Becker: Why did the hospital associations decide to collaborate with these particular partners?
Sponseller: I know some of your readers are asking this question with skepticism. Hospitals and health plans are strange bedfellows, sure, but they really don’t need to be that way. In essence, we share a common hope and vision: we both want to save lives. So, realistically, this is a natural fit. Getting this initiative started under this collaborative model is the right thing at the right time.
Our partnership builds upon established peer-to-peer learning networks like the Bay Area Patient Safety Collaborative (BEACON) and the Southern California Patient Safety Collaborative. It also compliments the work of the March of Dimes, zeroing in on the area of perinatal care, and on issues of prematurity and education about why the last weeks of pregnancy can be critical to the health of the mother and baby.
Becker: Why did you feel this union presented a good opportunity for the hospitals?
Sponseller: We have found great success in the collaborative model. Our BEACON Collaborative in the Bay Area has had great results, with tremendous participation and enthusiasm. BEACON has accelerated the adoption of evidence-based and innovative practices, and has created a learning network among organizations who share a commitment to building healthier communities. The collaborative has also educated organizations about the importance of the initiative’s work.
Through quarter four of 2009, an estimated 1,593 lives have been saved: 375 from ventilator-associated pneumonia (VAP), 219 from central line blood stream infections (CLBSI), and 999 from sepsis. There have been 2,388 fewer hospital acquired infections: 941 from VAP and 1222 from CLBSI, and 463 fewer patients acquired pressure ulcers while hospitalized. What we’re doing is important work that ultimately translates to people being able to be up and walking around, people who three years ago would have died.
A number of hospitals in inland counties within our membership had previously expressed interest in creating similar collaborations in their areas. This project was a natural vehicle to use to facilitate this important work.
Becker: What is the role of the hospital associations in the partnership?
Sponseller: Our role as a member association is to convene our hospitals to discuss ways of improving patient safety in the areas defined by this initiative. We bring together hospitals in regions throughout Northern California to share best practices and to focus on measures that will assure improvements in areas targeted by the initiative. We provide a neutral ground on which hospitals can discuss their concerns and questions openly, without divulging proprietary details of their operations. The best practices highlighted by member hospitals can then be used by other hospitals. Our motto in these collaboratives is, “steal shamelessly.” It really works!
Becker: Did you seek approval from your membership prior to engaging in the collaboration? What was the general feeling toward the effort?
Sponseller: We always brief our hospital leadership teams about initiatives such as this one to get their counsel and support. Nearly all of our hospitals have patient safety measures underway to minimize errors. We were somewhat concerned about introducing another patient safety initiative because hospitals were already engaged in their own processes. The hospitals were particularly interested in this opportunity because the participation of the largest health plan in California created a stronger partnership that was focused on just three main initiatives.
Becker: Did you experience any pushback from the hospitals?
Sponseller: There was some concern that this initiative would simply create extra work for hospitals. However, it turned out that most of the hospitals were already engaged in patient safety efforts in the three areas of focus in the initiative. Pulling this effort together with other hospitals in various regions provided opportunities to see greater results with unilateral focus.
Becker: What is the relationship between the hospital associations and Anthem Blue Cross?
Sponseller: We’re committed to a collaborative working relationship to benefit the citizens and patients of California. This has brought us together in a productive relationship in which we share a common mission, goals, and objective, and has led to the development of a very exciting partnership.
Becker: Another partner in the initiative is the NHF. How do you interact with them?
Sponseller: The National Health Foundation helps us to independently document our progress. We are very fortunate to have their expertise in data collection and their experience in evaluating large-scale projects. Becker: Is there any one entity that is taking the lead on coordinating these overall efforts?
Sponseller: A leadership council, made up of the president and senior executives of all five organizations, meets on a regular basis to ensure that we are fulfilling our mission and meeting strategic goals. We decided from the beginning of this effort that we needed to bring the principal elements of this collaborative together through detailed planning and communication. There have been numerous in-person meetings, conference calls and emails sharing the evolution of the product. Regular updates are also provided to participating hospitals.
Becker: Tell me about the areas of focus for the initiative. Why are these the priorities of the hospitals that the associations represent?
Sponseller: As you know, the initial focus for Patient Safety First…A California Partnership for Health comes down to three primary areas: perinatal care, sepsis, and hospital-acquired infections in the ICU. We wanted to focus on issues on which hospitals were already working—we wanted to help them accelerate change and learn stronger reliability strategies.
In addition, these three issues have had huge impacts on the lives of our patients in our communities. Hospitalacquired infections must be reported to the California Department of Public Health, and have high visibility. If we can help more of our hospitals get to the “zero zone”, eliminating these infections, it makes sense to focus there. The perinatal initiative makes sense, too, as there are multiple entities focused on it today, including the Joint Commission (TJC), the Institute for Healthcare Improvement (IHI), and the California Hospital Assessment and Reporting Taskforce (CHART).
The maternal mortality rate in California is higher than the national average, and many practices, such as elective deliveries prior to 39 weeks gestational age, are based on convenience and on changes in societal demands, rather than on evidence-based practice. In fact, elective delivery, whether by induction or by Csection, should be undertaken only after 39 weeks of gestation. The American College of Obstetricians and Gynecologists, the California Quality Maternal Care Coalition, and the March of Dimes have been working together on a toolkit that will help spur this change.
Becker: What models are you using for this project?
Sponseller: Models for this project have a different presentation in each regional association. In San Diego, the hospitals have a long history of working on projects directed towards standardization of policies and processes, so they are taking a topic-by-topic approach to determining strategies to reach their objectives.
The Southern California Region has two regional collaboratives with a stable hospital population that are adding and refining the initiatives to include in their current programming. In the Hospital Council Region, we are soliciting and encouraging hospitals to participate. We are engaging hospitals that have not previously had this level of engagement offered to them. The idea here is to replicate the BEACON Bay Area collaborative, which involves in-person meetings, as well as web-based education and presentations during the intervening months.
Becker: What are the expected outcomes for the hospitals?
Sponseller: We hope to reduce mortality from sepsis by 25% statewide over three years. We also want to eliminate hospital-acquired infections, with a target of zero for central line blood stream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections.
Becker: Have you encountered any challenges with this effort? If so, how have you addressed them?
Sponseller: In the council region, the biggest challenge is the recruitment process. This is not new, as we experienced it previously with the BEACON project. There are many competing priorities in hospitals, as well as numerous opportunities to engage in quality and patient safety efforts through entities including physicians’ professional associations, the IHI, and others. With this effort, we are trying to emphasize the importance of regional collaboration and its positive impact on accelerating change.
Becker: What is most exciting to you about the initiative?
Sponseller: With health care reform having arrived on the scene over these past months, we see this initiative as a prime opportunity to try a different approach to solving challenging problems in patient safety. We’ve joined in this new partnership with the aim of saving lives and improving quality of care in a cost-effective manner. These are goals our partners share, and this mutual alignment creates a unique opportunity to positively impact the lives of the patients we all serve. “Patient Safety First” means just that. They are our customers and we have found a better way to safeguard them while they are in our care.
Becker: Where do you foresee this effort moving in the future?
Our hope is that the first three initiatives will ignite a firestorm that will burn for a long time among the partnership. We share common goals. Zero tolerance for error has been achieved by other industries, so why can’t health care be held to the same standard? With the strength, dedication, and focus of this new partnership, we can do better and sustain this improvement our over time. The success of these initiatives will naturally lead us to other areas of focus that need attention.
THE NATIONAL HEALTH FOUNDATION: KEEPING AN EYE ON THE DASHBOARD
A Los Angeles-based non-profit organization, the National Health Foundation (NHF) is dedicated to improving and enhancing the health care of the underserved by developing and supporting innovative programs that may become independently viable, provide systemic solutions to gaps in health care access and delivery, and hold the potential to be replicated nationwide. As its president, Gene Grigsby represents the NHF in its partnership efforts.
Lauren Becker: What is the role of the NHF within this project?
Gene Grigsby: We serve something of a dual role. One of our key responsibilities is that we house the database for all of the participating hospitals statewide. We enter the information relative to the target areas on which we’re focusing, and then we prepare reports that are made available to each hospital.
Becker: And where are you in that process?
Grigsby: We have just created the connecting website for the database and will be holding webinars very soon for all the participating hospitals. We will also begin entering data.
Becker: So you’ve created the database that you’ll give to each hospital and they’ll enter their own data? Grigsby: That’s correct. And this is a role that we played previously in the Patient Safety Collaborative in Southern California. We have the prototype of a database and a website that will allow individual hospitals access on a very secure web system, so that we can allow hospitals to look at their data and then contribute data for the other hospitals.
Becker: And that’s helping with this initiative?
Grigsby: We’re just starting the effort for this initiative, and we’re using the prototype for Southern California. We have been doing patient safety collaboratives in Southern California for the past two years. So we have expanded the project statewide and expanded the focus, with perinatal as one of the targets for safety improvement. That was not part of the original project we had.
Becker: And have there been any kind of lessons learned that have helped in streamlining this process or have made it easier for you?
Grigsby: The biggest lessons were not necessarily learned, but were certainly validations of the notion that when hospitals collaborate and focus on a problem area, they experience measurable improvement. So the whole purpose here is to identify problems that particular hospitals may be having with issues of sepsis or central line blood stream infections or ventilator-associated pneumonia, and get them working with hospitals that have overcome problems in those areas. Then, through a peer-to-peer learning process, you can get hospitals that are having difficulty overcoming these problems to make progress rather quickly.
Becker: Are you having any issues with hospitals being unwilling to share their information with others?
Grigsby: No, because once they see the value of the learning process and the safety improvement that occurs, they become true believers. It is fair to say that every hospital wants to be a safe hospital, but not every hospital understands the variation in safety data that exists across the state. With shared data, you begin to see that, even though you believe you are doing everything possible to deal with safety issues in your hospital, there are others that have better safety track records than you do. And that gets your attention.
Becker: That’s great. So, you’re not having any issues with competition?
Grigsby: This is not about competition. This is really about how can you provide the safest environment for patients. The emerging focus on patient safety and transparency is on changing the name of the game in terms of how hospitals function.
Becker: You’ve seen that happen over just the past couple of years?
Grigsby: Yes. That’s why we’re confident that we can, on a statewide basis now, move the needle even further and more quickly.
Becker: How long do you foresee this project taking?
Grigsby: We built this on a three-year time schedule, with the understanding that if we can show measurable improvement in the first year, based upon goals that we are establishing, then Anthem will add an additional year of funding at the end of the three years. This will allow the project to continually identify patient safety issues every year. If we begin to address the issues systematically and show substantial improvement, our partner Anthem is quite willing to continue to work with us.
Becker: You mentioned a second role you play. Tell me about that. Grigsby: The second role we play, in addition to the data-housing role, is that we serve as sort of the statewide coordinator of management information for Anthem—so we produce the quarterly reports based upon the fiscal overview of the project, including tracking of expenses. We’ve also created a dashboard that shows how well the project is moving across all of its phases, and how we’re doing in terms of achieving the goals and objectives that the project has set up.
Becker: What exactly is a dashboard?
Grigsby: It’s where we list all of the activities in whichwe’re involved, and includes a monthly calendar. The dashboard features a green bar that indicates we’re on track, a blue bar that indicates we’ve completed that task, a yellow bar that indicates this area needs attention because it’s not moving like we think it should be, and then there’s a red bar that says we’re behind schedule and may need help.
Becker: And I’m sure you don’t have many of those red bars.
Grigsby: So far, we have one, but we just produced the dashboard in earnest for this quarter, so now we’ll be doing it on a month-by-month basis, and reporting it to the overall management team quarterly.
Becker: So for the most part you’re right on schedule and feel like you can complete what you said you’d do on time?
Grigsby: Yes. But what people don’t realize is that this is a big project. The state of California is no small entity, so it’s taken a good three months for us to get all the startup and players in place. Thankfully, the project is really unfolding the way we envisioned. We have about six months in the first year to try to hit our mark, which is going to be a little bit challenging, but the dashboard lets us know where we need to focus our energies and our efforts.
Becker: And what are you seeing as the biggest challenge? The size of the state?
Grigsby: Look at it by regions. In Southern California we have had a number of hospitals that have been doing this sort of thing for the last two years, so we don’t have a lot of organizational challenges in terms of making hospitals aware of patient safety collaboratives. San Diego has never done this before, so it’s been somewhat of an educational process for them, introducing the patient safety collaborative and to getting their hospitals to understand why it’s important to work together on these initiatives. So San Diego has been a little bit slower to roll out of the box.
Up in Northern California, they’re dealing with the challenge of being one of the largest rural areas. They have hospitals that have been totally disconnected from any sort of collaborative participation, so they really have a challenge in terms of convincing these hospitals, which are largely isolated from other hospitals and are also having financial challenges, that this kind of collaborative is key to success. Patient safety, while important, may not necessarily have the highest priority for these rural hospitals.
Becker: How is the coordination of efforts going?
Grigsby: We have teams. We have our public relations team, our data outcomes team, our return-on-investment team, each of which meets regularly. We also have our leadership group, which includes the presidents of each of the associations, myself and a representative from Anthem. That group meets quarterly to review the dashboard. We also have bi-monthly phone calls among the hospital leadership teams. There’s lots of coordination that’s going on.
That sort of communication is good, but you also have to realize that you’re dealing with a bunch of partners who have never partnered before, so sometimes you have to learn to speak each other’s language. You have to learn each other’s communication and management styles, and that’s been a part of the startup learning process as this project moves forward.
Becker: What do you find most exciting about the partnership?
Grigsby: This is the largest partnership involving a health plan and hospitals that exists in any state in the nation at the moment. So I think the most exciting part will be when we are actually able to demonstrate a significant improvement in patient safety in those target areas. That’ll be a huge statement.
Becker: Do you foresee using this as a model in other states?
Grigsby: Clearly if this is successful, as we anticipate it will be, Anthem would like to see how it can capture value added here, and in other regions in which they work. As the reports and publicity about the success of this project get out, it is not inconceivable that other health plans in other states may want to emulate this model.
MARCH OF DIMES:
WHAT A DIFFERENCE A WEEK MAKES
The March of Dimes is the leading nonprofit organization for pregnancy and baby health. Leslie Kowalewski works diligently combating the issue of prematurity. Specifically, she connects multiple partners and stakeholders in California, including clinicians, public health departments, hospitals and the State of California Department of Health, in order to eliminate non-medically indicated deliveries before 39 weeks gestational age.
Lauren Becker: How did March of Dimes become involved in the initiative?
Leslie Kowalewski: March of Dimes has partnered with the California Maternal Quality Care Collaborative and the California Department of Public Health to address early elective deliveries by developing a toolkit that supports hospitals in changing policies and practices to eliminate non-medically indicated deliveries before 39 weeks of gestation. We are working with the Patient Safety First collaborative on rolling out the toolkit in California and across the country.
Becker: What are some of the problems commonly associated with early delivery?
Kowalewski: Babies born early are more likely to have feeding, breathing and sleeping difficulties and have more learning and behavior problems in childhood than babies who are born at 40 weeks. In the last six weeks of pregnancy, the size of a baby’s brain almost doubles. Many pregnant women do not know these facts: a survey of insured women who recently gave birth found that only 25.2% of women defined “full-term” as 39-40 weeks. More importantly, 92.4% of women believed that giving birth before 39 weeks was safe.
Through our outreach and education, March of Dimes is hoping to change these misconceptions. March of Dimes has also been working to educate women about the potential negative outcomes of early elective deliveries and the critical fetal development that occurs during the last weeks of pregnancy.
Becker: What are you doing at present with regard to the initiative?
Kowalewski: The Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Toolkit will be posted on the national March of Dimes website, in hopes that it will be used by all hospitals. The March of Dimes California Chapter will pilot and evaluate the toolkit in eight hospitals from August 2010- December 2011.
Becker: What do you hope will result from this work?
By eliminating non-medically indicated deliveries before 39 weeks gestation, we hope to reduce late preterm birth rates. We want to educate consumers about the importance of a full forty-week pregnancy by showing that every day counts.
ANTHEM BLUE CROSS:
PROVIDING VISION AND OVERSIGHT
Joanna Horsfall is an independent consultant working with Anthem Blue Cross on the initiative. She specializes in developing and implementing strategies to transform the delivery, financing and management of health care.
Lauren Becker: What part do you play in the Patient Safety First initiative?
Joanna Horsfall: I have been supporting Anthem Blue Cross President Leslie Margolin in bringing the idea of a cross-industry collaborative to drive patient safety to reality. Over the past year, I have supported Leslie in analyzing and articulating the potential value of the patient safety collaborative, in coordinating its launch, and in supporting the leaders of the partnership in the overall work of the Patient Safety First program.
Becker: What kind of work do you do on a day-to-day basis?
Horsfall: One of the hospital leaders described my role as being “the glue”. Specifically, I help the key leaders of the Patient Safety First initiative: Leslie Margolin, Art Sponseller, Jim Barber, Steve Escoboza and Gene Grigsby. I work with them to define the mission and goals of the partnership, to establish a way of working that balances the independence of each partner with the need to work together to deliver results, and to explore the contributions that each partner can make in shaping the sort of collaborative work they can do together.
I also work with the National Health Foundation to set up a day-to-day program management capability and to maintain a focus on the good of the whole. I help the leadership group identify and resolve substantive issues that could get in the way of its progress.
Becker: Have you encountered any challenges in your work with the partnership?
Horsfall: The challenges we face in pulling this effort together are typical of complex organizations in which there are no direct lines of authority. Each of the three hospital associations—Anthem Blue Cross, the National Health Foundation and the March of Dimes—is an independent entity with its own priorities. Day-to-day priorities create a natural, centrifugal force that can pull each organization away from the center.
The keys to maintaining momentum are the commitment and energy of the leaders as they stay focused on the goal. Leslie Margolin is extremely experienced and skilled in working collaboratively across organizational barriers, and her influence is very clear in this partnership. But each one of the leaders is exceptional in his or her ability to think strategically, work collaboratively, and operate in ways that fall outside of a comfort zone.
Becker: What is the significance of this project to Anthem?
Kowalewski: It represents an opportunity to play an important role in connecting parties to drive change that will eliminate avoidable medical errors, improve care, reduce costs, and save lives.
My personal opinion is that this work is of great importance because the challenges we face represent the challenges of the United States health care system overall. Recognizing and overcoming obstacles to working across organizational boundaries is in the interest of the consumer. One of the biggest obstacles these days is trust. I am extremely impressed with the progress that has been made by our leaders to build trust and to work together to do the right thing for the people of California. I hope that this work will provide real, tangible hope to other organizations that endeavor to work together to overcome obstacles to improvements in health care cost and quality.
NEW CHALLENGES, CONTINUED HOPE
Since this interview, Leslie Margolin has resigned her position as Anthem Blue Cross President. Margolin says she is now training her focus on developing a coalition called Transforming Healthcare, which aims to cut health care costs in California.
A spokesperson for WellPoint, Anthem’s parent company, acknowledged Margolin’s commitment to Patient Safety First, stating, “During her tenure at Anthem Blue Cross, Ms. Margolin played an integral role in collaborating with hospitals and providers across the state and has been a champion of innovative initiatives that improve patient safety.”
Mark Morgan, Anthem’s vice president of small group sales, has assumed Margolin’s role at Anthem on an interim basis. There has been no indication that Anthem will change course with regard to the initiative, and its partners remain committed to their objective of keeping Californians healthy. Art Sponseller, spokesperson for the hospital associations, said: “Our partnership is with Anthem Blue Cross. We thank Leslie for her leadership and commitment to Patient Safety First, and we wish her well in her future endeavors. We do not anticipate any program changes as a result of Leslie leaving and we look forward to the continued success and advancement of these very important patient safety initiatives.”