Integrating care to make it safer

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Integrating care to make it safer

Order from Chaos: Accelerating Integration of Care, a ­report of the Lucian Leape Institute (LLI) Roundtable on Care Integration, was released on the National Patient Safety Foundation's website in October. The LLI was created in 2007 and focuses on identifying new approaches to patient safety.

LLI has identified five major ideas as a framework for the future of patient safety:

  • Medical education reform
  • Active consumer engagement
  • Transparency
  • Reinstituting joy and meaning of work for healthcare professionals, as well as their safety
  • Integration of care within and across care delivery systems


This last concept-care integration-was the focus of Order from Chaos, which describes what health systems need to do to fix potentially harmful patient-related events from happening because of integration issues, from communication issues to information management to reducing unnecessary and potentially harmful redundancies. It defines care ­integration as "the planned, thoughtful design of the care process for the benefit and protection of the patient."

The report sought to answer the following questions:

  • Why has care integration been so difficult to achieve?
  • What are the chief obstacles to accelerating care ­integration at the level of individual care systems as well as at the national level, as a matter of public policy?
  • What levers can accelerate the formation of integrated care solutions and move the nation to a system ­capable of delivering consistently high levels of safety, effectiveness, and efficiency?


"I think the most important thing that the study helped to make the case for is that there is no excuse. There's no reason not to do this. The only excuse would have to do with lack of courage, lack of will," says David M. Lawrence, MD, retired chairman and CEO of Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals, who also served as chair of the Leape Institute Roundtable on Care ­Integration. A founding member of the Leape Institute, ­Lawrence also led the effort to produce the report.

"There is evidence now on making these changes. People know how to do it, they know what the methods are in terms of safer care, more effective care-and by the way, less expensive care," says Lawrence. "What I think is important to know from the study is that there's no reason not to do it; we know why and how. I think that's one of the key lessons from the study."


The situation at hand

Increase in the use of specialists and a more diverse and clinically complicated patient population both add to the potential for missing pieces of information as patients move, either from unit to unit, primary care provider to specialist, or from acute care to long-term care.

The study also cites the lack of real-time communication as another current issue, as this can lead to different treatment designs that counteract each other, drug interactions, and confusing directions for patients.

It's understood that a lack of primary care physicians adds to the problem of poor care integration, but the ­authors of Order from Chaos urge healthcare organizations to create a system around this shortage, as it won't be fixed anytime in the near future, and patients can't wait.

New devices and service delivery further complicate the problem. The study emphasizes that care delivery and integration is dependent on certain circumstances that surround the patient; specifically, how many sites in which the patient is cared for (i.e., one or multiple), time frame of care (i.e., one visit or years of visits), and predictability of a patient's condition (i.e., a complex chronic illness or an acute illness with well-designed evidence-based care methods in effect). The more sites, more time, and more complex and unpredictable a patient's condition is, the less automated the process will be and the more challenging the integration of care.

The report also warns that organizations' structural changes of healthcare systems that put multiple entities under one vertical structure (i.e., putting hospitals under the same corporate name) does not make for better care integration because it is the training of people and creation of pathways across care that matter most, not whether administrative and financial tasks are integrated. Putting hospitals all under one name as a healthcare system does not affect care integration as much as administrative integration, the report found. Usually, individual care centers are allowed to keep the same care models.


The challenge

Unfortunately, there are many barriers to creating ­better care integration.

"We talked to people in workshops and we tried to figure out what stands in the way," says Lawrence. "And I don't think there were many surprises. It's important to know what those barriers are and figure out how we can work around them. For example, obviously the reimbursement system is often cited as a barrier."

The barriers found included:

"It's a shift from acting independently as an autonomous professional to a collaborative system. And that's the fundamental part of this shift," says Lawrence. "The other thing is the collaboration between the doctors and their patients in active collaborative partnership. You don't get great care without doing that."

What we know about illness has changed-particularly how complex many widespread chronic illnesses are, and now the average patient with a chronic condition will be cared for by an average of six to nine physicians at multiple sites over a long period of time, according to the report. This statistic shows how the autonomy of one physician is not conducive to the average patient's care. This idea of the physician as an autonomous leader also affects the way system design is built-decisions are often made to support the physician, at the expense of the longer-term success of the system and sometimes even the best interests of the patient.

"I think you have some of the legacy problems of the fee-for-service models that are really a stumbling block if you're trying to do these things," says Lawrence. "If you're reducing the number of times patients have to come back through the ER, you're decreasing your revenue."

However, Lawrence emphasizes that this is not an obstacle that can't be surpassed.

"There are ways of addressing this [as] we've seen in successful institutions. But for many organizations it's a significant problem, but it's not a showstopper," he says.


Six starting points

Order from Chaos identifies six concepts that the ­authors believe are a starting point for organizations to act on. They include:

  • Shared understanding. Healthcare organizations and the public need to understand the ways in which better integration of care improves safety and increases efficiency.
  • Patient engagement. Organizations need to ensure that patients are active participants in their care. But it doesn't end at the bedside; organizations need to include patients in design of care. Patients should be on committees that help reduce patient harm as well as help make strategic organizational decisions for the future of the organization. See "Patient engagement on four levels" on p. 7 for more information on the study's recommendations for patient engagement.
  • Measures. Care integration must be measured. The study's authors suggest implementing such measures in the same vein as the public reporting measures that already exist. According to the study, "one step in this direction will be the addition in 2013 of the Care Transition Measure to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) standard survey required by the Centers for Medicare & Medicaid Services."
  • Evaluation. Measures don't matter unless the ­data is reviewed to create best practices for integrated clinical care.
  • Education and training. Organizations need to ­create partnerships (for funding) to train boards and leadership about patient safety and care integration. ­Professional schools, such as medical and nursing schools, need to teach these skills as well.
  • National spread. Organizations must be open to sharing and creating integrated systems, including ­investing in the technologic infrastructure needed to aid this integration.


In the end, Lawrence emphasizes that the study took a close look at healthcare systems believed to be on the road to success in care integration. He says some systems are already doing this, and that proves care integration can be achieved.

Hospital leaders of all kinds already have the knowledge they need to pursue integration, he says.

"The reasons for doing this are very compelling. The methods for getting there are very clear. But the time involved is very long," says Lawrence. "And that's what's standing in the way for people to do it. But that's an execution concern that stands in the way, rather than anything conceptual or moral."


Patient engagement on four levels

David M. Lawrence, MD, is the retired chairman and CEO of Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals, and served as chair of the Leape Institute Roundtable on Care Integration. A founding member of the Leape Institute, Lawrence led the ­effort to produce the ­October 2012 report, Order from Chaos: ­Accelerating Integration of Care.

According to Lawrence, there are four necessary levels of patient involvement:

1.Physician/healthcare provider and patient. "The more doctors involved, the more specialists involved, the more patients, the more opportunity for information to get lost, to have drug interactions, etc.," says Lawrence. "The first level of patient involvement is in the care process itself; making sure patients are involved in their own care. That's crucially important."

2.Design of care. "What we're seeing in some of the ­exemplary organizations is that patients are involved in the design of care, so that it is designed for their benefit as well as for the doctors," says Lawrence. "That, too, helps make it safer because it removes some of the silliness and redundancies and the extra work that gets done today in western healthcare. The patients are engaged in that process and ask why that is there, why that is happening. It kind of calls into question some of the old ­assumptions of how we care for people."

3.Evaluation of care. "This means stepping back after the care and have the families and patients involved in assessing whether or not the system and the doctors are providing the way they promised to do, the way they would like to see it done," says Lawrence. This piece is important for healthcare organizations to create a new standard of care that is in part designed by the public, not those who may have lower standards because they've been in the ­business too long.

4.Strategic planning efforts. "This means patient and ­patient representative involvement in what services are ­going to be provided, where are they going to be ­provided, how much to invest. That, too, helps with safety," says ­Lawrence. "What patients want is safe care that's effective. They want it designed in a way that doesn't waste their time, treats them in an honest, open, and respectful way. And they don't want a lot of care that is irrelevant to them, that seems to be done for the specialist and not the patient."