ProvenCare

by Glenn D Steele

  External affirmation also was important, and we insisted that whatever we did strategically needed to create national excitement in order to recruit and retain the kind of Geisinger family members necessary for long-term growth. Some of the external affirmation was the more typical muted academic publication and presentation of truly remarkable results, and some was beyond anything possible in the academic or professional venue. Increasing quality and lowering cost by diminishing unjustified variation was old hat in most industries, but revolutionary in healthcare, and it caught the attention of Reed Abelson of the New York Times. When her article on heart care at Geisinger5 appeared above the fold on the front page, it produced a tidal wave of recognition and affirmation. Subsequent positive articles and commentary emphasized many of our other value reengineering efforts, and a growing number of peer-reviewed publications began spreading the word among academics about our successful attack on total cost of care and the real benefit of better outcomes for patients.

  Such peer-reviewed and popular press articles built significant momentum. The timing of this attention was propitious since it coincided with the two-year run-up to the ACA. The Geisinger model began to be touted as one possible template that could succeed in the non-fee-for-service world proposed in the provider reform parts of the ACA. During the end of the ACA run-up, U.S. President Barack Obama mentioned Geisinger and our remarkable value reengineering innovations in his 2010 State of the Union address. Although he mispronounced our name the first time (he got better after that), the attention from the White House added significantly to our brand-building story.

  Geisinger also became a source of leadership for other organizations aspiring to be innovative or attempting the transformation from volume-based to value-based or population-risk-sharing reimbursement. What we achieved were real-world road tests of fundamental care redesign and change in the payer/provider interaction, not just conceptualizations. What was happening at Geisinger in the 2004–08 period was not happening most anywhere else, and candidates at all levels of experience began to seek us out. This momentum from both our internal and external buzz enabled early success in beta tests to lead to enthusiastic expansion of the innovation portfolio within the Geisinger family. Externally, it led others, and ultimately it led us, into asking and then beginning to answer the more important question. Could our results be scaled and generalized outside of Geisinger?

  We were extraordinarily blessed to recruit and retain remarkably articulate and substantive colleagues who could both do the work of innovation and tell the story internally and externally. In addition to the CEO providing congressional testimony, Geisinger speakers commonly were found at various national meetings of professional healthcare associations and societies, where we let our road tests and results lead, not our opinions. Subsequently, interesting early evidence of scalability and generalizability in non-Geisinger markets such as Delaware, Maine, New Jersey, northern Virginia, and West Virginia became a larger part of our external narrative.

  Without our Geisinger family of totally committed, incredibly productive men and women sharing a compelling vision and making it real, there would have been no story to tell.

  LESSONS LEARNED

  • Start with a compelling shared vision.

  • Fit the vision to the structure, culture, and unique capabilities of the organization.

  • Allow workers to decide how to make their own contributions to the vision.

  • Link success in achieving the vision to everyone’s well-being (both compensation and pride of purpose).

  • Start with the highest likelihood of success.

  • Get good results quickly and learn from mistakes.

  • Utilize clinical leaders.

  • Keep refining, but repeating, internal and external narratives.

  • Make patient benefit the key goal.

  • Accept the good luck that comes along.

  6

  Enabling Change

  The operations were humming, and the financial trajectory was positive. Leadership and key employee recruiting had recovered well from Geisinger’s demerger malaise. And the strategic discussion was coalescing nicely around how optimal healthcare could be delivered and paid for, which was uniquely testable in our structure, sociology, and market context.

  But how could strategic commitment to continuous innovation be enabled throughout Geisinger at the front lines of caregiving to ensure broad success? Simple, repetitive communication of the strategic goal was key, but not enough. Neither was the obvious Geisinger advantage of a systemwide, standardized electronic health record (EHR).

  We created an infrastructure to serve as a bridge between aspiration and continuous innovation, one that was pragmatic, instructive, and efficient and would eliminate the need for reinvention every time we scaled and generalized ProvenCare. This infrastructure has evolved over the years as we took Geisinger value reengineering into new markets within our own expanding health system as well as into new non-Geisinger markets.

  DRIVING DESIGN PRINCIPLES

  In almost every aspect of the Geisinger story of the past 16 years, our focus on desired patient outcomes was the driving force. Without the energizing professional pride of purpose, improving patient outcomes would not have happened. Our priority was to target the hearts first, then the minds, and finally the wallets of the entire Geisinger family. Without all three, and without sequential focus on the first two motivators, the compensation plan alone would not be an effective lever.

  In addition, we believed that top leadership should not interpose itself between clinicians and their patients, but rather should motivate, coalesce, cheerlead, and empower caregivers themselves to establish improvement targets and best practice defaults. Leadership’s job was to enable, not to showboat.

  Leadership’s enabling started by choosing areas most likely to create recognizable quality improvement quickly. Our choices ranged from programs with documented good outcomes and good clinical care leadership in place to programs with relatively bad outcomes and no reasonable clinical leadership in place. Despite the latter appearing to be the obvious improvement candidates, we always chose to go from good to great, assuming that with internal and external affirmation, we could more easily recruit better leaders into the clinical problem areas.

  Clinical leadership was always key. No one was going to change anything at Geisinger without a respected clinician at the head of the transformation effort. Even at the CEO level, clinical credibility enabled questioning why and how things were done and exploring how they could be changed without losing the troops in either hospital-associated treatment areas or the ambulatory setting.

  We also realized that most successful, busy clinicians were not competent financial or operational experts. So we included in our design principles a dyad or triad approach to clinical service-line and discipline-based leadership roles, with the clinical leader, operational leader, and/or financial leader working together. We did not wish to dilute a great clinician’s credibility and productivity by asking him or her to obtain additional operational or financial training. However, we did require that our clinical leaders agree to equal input from coleaders with specific financial and/or operational expertise. While this may sound straightforward, we often found that a clinical leader simply could not or would not acknowledge the necessary added expertise, nor celebrate the visible coleadership of the other members of the dyad or triad. In these cases, we replaced the clinical leader. We were also willing to replace the nonclinical partners if they viewed themselves simply as suppliers of data rather than key members of the accountable leadership duo or trio.

  Another major design principle became obvious early on as we simultaneously grew our geographic reach and market share and began to transact the innovation strategy. At issue was what we came to call the dominance of the day-to-day operational crisis. In both for-profit and nonprofit settings, increasing growth, complexity, and stringency of the payer and provider markets created so many
legitimate operational and even existential challenges that leaders became completely reactive to the momentary crisis or the particular stimulus at the time. The confluence of these factors became a catalyst for leaders to shift their focus away from strategy to almost exclusively operational emergencies.

  Advances in communication technology compounded the problem, as thought was supplanted by action, thoughtful action was replaced by motion, and discussion was replaced by transaction. Human interactions were interrupted by the telephone; the telephone was replaced by e-mail, then text messaging and tweeting. Writing with punctuation disappeared, and thinking was diluted by multitasking. Thinking and discussion with others was replaced by chaotic social media. It was imperative to slow this decline into chaotic activity, which we did through intentional structural design.

  ELEMENTS OF OUR STRUCTURAL DESIGN

  Most important was leadership recruitment, in our case an executive vice president for strategy and strategic program development. Interestingly, at the time none of our benchmarking data contained any such job category. This individual focused exclusively on helping to establish, maintain, update, and transact the strategic plan and became the most important colleague of the CEO and the chief medical officer (CMO). The position maintained the CEO’s critical process map, ensuring that the journey reached its desired endpoint.

  A second part of our intentional structural design was to force overall institutional attention to strategic accomplishment and to mitigate the operational dyads or triads being too focused on operational issues when allocating their limited time and energy, even with 20 percent of total compensation based on achievement of strategic goals.

  We took inspiration from three models of innovation in other industries during some extraordinarily progressive transformational eras: the Institute for Advanced Study, associated with Princeton during the era when computational data analysis was combined with nuclear physics; Bell Telephone Laboratories and the old AT&T when communication, physics, and mathematics were producing the first high-tech revolution; and the Skunk Works at Lockheed Martin Corporation that combined breakthrough science and engineering to develop magnificent new products.

  To foster continuous innovation, we committed space and resources that permitted people to think about new ways of doing things and new scalable enabling ideas and products without the continuous distraction of running an operating unit in our hospital, provider group, or insurance company. We called this Geisinger Innovations and recruited the second-most-critical colleague in our top leadership team, our chief of innovation, who reported to the strategy EVP. At the outset, the chief of innovation position also had no basis in benchmark data.

  During the next five years, Geisinger Innovations built up key staffing that helped design, transact, and update the Geisinger continuous innovation process and expand our healthcare value reengineering into the ProvenCare Acute and ProvenCare Chronic portfolios. The group included key nurse leaders on both the provider and payer sides of Geisinger. We also recruited and expanded the physician assistant leadership crucial in ensuring that real-time data was collected and initially fed back manually to clinicians through parallel non-EHR systems. The group also included IT experts seconded from other parts of our system to design best practice templates to be embedded into our EHR. Finally, Geisinger Innovations enabled interaction with key health economists whose input was critical to analyzing and eventually publishing the patient outcome benefits, as well as the cost consequences, of our value reengineering efforts.

  This innovation structure justified a separate budgeting process for the start-up costs, which had two distinct advantages. First, we could define the costs. Second, we didn’t have to make individual return on investment arguments at the operating-unit level to prioritize resources that would be in competition with more immediate and operationally pressing clinical operating needs. The innovation budget was determined by the CEO and the EVP for strategy, managed by the chief of innovation, and justified to the Geisinger board of directors by the CEO, who could tout innovation as the main enabler of the strategic plan’s top priority.

  OPERATIONALIZING THE INNOVATION FUNCTION

  Here’s how our innovation process worked. The CEO and/or the strategy EVP began a discussion with the leadership duo or trio in a clinical service line or discipline, for example, cardiovascular, which was a single combined surgical and medical service line at Geisinger. The objective was to obtain baseline data regarding indications for a particular procedure and to inventory the occurrence of unjustified variation in each aspect of routine practice for an episode of care. The leaders of the caregiving disciplines or interdisciplinary service lines simply needed to lead the effort to inventory the baseline data and then to help socialize whatever became the default best practice. All of the data accumulation, best practice template building, transaction detailing, and updating of the rapidly changing knowledge base was done by Geisinger Innovations. Our innovations function was the key driver of increased efficiency and decreased cost in our overall transformation effort.

  The clinical leadership narrative, the goal-setting tasks, and the transaction of key innovations were critical and difficult. For instance, almost all of the CEO’s initial ProvenCare Acute proposals were modified significantly from their original high-impact concepts to become more practical, but still substantive and attention-capturing. Similarly, almost all of the initial clinical leadership commitments to default best practice and standardized outcome metrics were modified. Initial bottom-up proposals were identified either as sandbagged or as unlikely to make a real difference in increased quality or decreased cost, or at least not easily perceived by the outside world as making a real difference.

  There were basic lessons that, at least in retrospect, seem intuitive. The first was the difficulty of managing a growing budget with the yet-to-be-realized economic return. Second, as the results of ProvenCare accrued and affirmation increased both within the system and externally, many of our best medical and surgical acute care nurses, acute care physician assistants, and insurance company care managers began to prefer the professional trajectory of innovations compared to their core caregiving commitment. Managing this inflow without stripping our clinical leadership was a balancing act.

  In addition, every successful non-P&L budget could easily justify infinite growth after several years of expanding our ProvenCare portfolio. So we quickly grew to see the need for a more generalizable and less costly approach to systematic clinical value reengineering, and Geisinger Transformation, a sister non-P&L group, was established. Its mission, first under the Geisinger Accelerated Performance Program and later under the acronym PRIDE, for Proven Innovation Drive for Excellence, was to increase efficiency across our system and extract 15 to 20 percent of our cost structure over three years. This was a scaling effort related to, but not quite the same as, the innovation group’s original mission, and initially the head of Geisinger Transformation reported to our chief of innovation.

  Another basic lesson learned was the continuing pull of operations, particularly as individual senior leaders contemplated what most likely would be helpful in advancing their own careers. Dr. Steele, a resolute contrarian who put the Skunk Works idea into practice at Geisinger, always maintained that the most difficult job was one in which there was no easy definition of schedule, metrics, or outcome; hence the need to recruit the strongest probable leadership into these usually nonoperational, often nonbenchmarkable jobs. For individuals who could tolerate the uncertainty and ambiguity inherent in the new, highly matrixed positions, there always was the siren song of big operational leadership opportunities, either within Geisinger or outside.

  A key evolution in our start-up infrastructure was the consolidation of transformation and innovation and the evolution of innovation into three separate units. One is under the direction of a single leader who is both chief medical informatics officer and chief information officer. This seemed logical given that value reengineering
continues to be dependent upon either embedding innovation into transactional EHRs or bolting innovation onto functional applications.

  A second innovation center is under the direction of our chief scientific officer, who is responsible for our basic science portfolio, health services research, and a remarkable new effort in population genomics, our version of individualized medicine.

  The third innovation component is embedded in a center called the Institute for Advanced Application, focused on bedrock bench-to-bedside translational medicine, doable at Geisinger with an immediacy unavailable in almost any other academic medical center.

  SCALING OUTSIDE OF GEISINGER

  We established three scaling and generalizing engines at Geisinger, all formulated with the understanding that scaling was quite different from innovating. The first test of our ProvenCare portability was simply the growth of our own payer/provider markets into Harrisburg, Scranton, and Wilkes-Barre, Pennsylvania, and most recently into Atlantic City, New Jersey. We knew that what had been successfully tested and grown in the sweet spot of the Geisinger Central Susquehanna, Pennsylvania, market might not be easily translatable into the quite different sociology of those other markets. In northeast Pennsylvania, for instance, even though 50 percent of the payer market was Geisinger Health Plan, almost 90 percent of the clinical care that occurred in the Geisinger hospital in Scranton was provided by non-Geisinger, nonemployed physicians. Our value reengineering was applied when many of the levers and enablers available among our own doctors were not applicable to our nonemployed caregiving partners.