From Hub and Spoke to Hubs of Innovation: Delivering Care Transformations from Acquired to Flagship Hospital

From the 2019 HVPAA National Conference

Dr. Erwin Yang (NYU Langone Health), Dr. Frank Volpicelli (NYU Langone Health), Ms. Sonia Arnold (NYU Langone Health), Dr. Joseph Weisstuch (NYU Langone Health), Dr. Bret Rudy (NYU Langone Health)

Background
Numerous studies suggest that hospital consolidations usually have negative consequences on quality. Researchers find many consolidations are executed solely to achieve greater market power and do not involve true integration of care, defined as meaningful data sharing, systems for effective communication, and culture assimilation.

Objective
To demonstrate transferability of multispecialty best clinical practices grounded in multi-hospital integration, knowledge sharing, and culture change

Methods
In 2016, NYU Langone Health acquired our hospital, NYU Langone Hospital – Brooklyn (NYULHB). Accompanying a transition in leadership at our hospital across service lines, there was full integration through a single electronic medical record (EMR), cost accounting system, quality dashboard, etc., with shared institutional goals and other care delivery infrastructure components. Baseline performance was noted in key metrics for quality, e.g., mortality or hospital-acquired conditions (HACs), and efficiency, e.g., length of stay (LOS) and cost.
Our Value Based Management (VBM) team transitioned initiatives from our flagship hospital that spanned across service lines, including reduction of inappropriate utilization of blood products, prompt transition from intravenous to enteral medications, and reduction of commonly overprescribed medications, e.g., proton-pump inhibitors. As a culture of value was established, further areas of improvement unique to NYULHB were identified and addressed:

  • A small proportion of patients were long LOS outliers due to complex dispositions or challenging medical conditions, e.g., underinsured, catastrophically ill patients with significant post-acute care needs. We created a consultative team to assist primary medical and surgical teams devise solutions for a safe discharge.
  • We deployed several initiatives to reduce the incidence of HACs:We formed a group of physicians across service lines to review all requests to place peripherally inserted central catheters (PICCs), recognizing an opportunity to prevent central line associated blood stream infections (CLABSIs). This consortium reinforced best practices about central lines and appropriate use of intravenous catheters.
  • We developed a staged, multi-pronged, multi-specialty approach to reduce catheter associated urinary tract infections (CAUTIs). There was first educational outreach to front-line providers focusing on urinary catheter indications and appropriate specimen collection. We instituted clinical decision support reinforcing best practices.
  • We implemented an alcohol withdrawal program with: education of physicians and nurses; establishment of escalation protocols, including triggers for rapid response teams; and EMR flowsheet additions for data visualization optimization.
  • Building on our heart failure clinical Epic pathway, we led development of a COPD pathway focusing on reducing variation in steroid dosing, reinforcing updated evidence based practices for discharge medications, and promoting multidisciplinary patient education.

Results
Through our complex dispositions and discharges team, we observed a 38% reduction in the proportion long LOS outliers. By improving LOS, we created capacity for an additional 3,700 patients annually.

The incidence of HACs were significantly reduced. The rate of CLABSIs dropped by 40% year-over-year; the rate of CAUTIs fell by 72%. Central line use decreased by 25%; urinary catheter use dropped by 28% over the same time period.

Our cost-neutral alcohol withdrawal program expedited recovery time for patients, decreased ICU utilization, and eliminated mortalities due to alcohol withdrawal.

Conclusions
Our NYULHB leadership and VBM team successfully transitioned value-based projects from our flagship hospital and even innovated our own initiatives now instituted system-wide, e.g., HAC reduction strategies.

Clinical Implications
With leadership support, creating a culture of value across service lines can foster meaningful change and improve performance in quality and efficiency measures.

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