Clinical microsystems, Part 4. Building innovative population-specific mesosystems.

BACKGROUND: In 2005, the Geisinger Health System (Danville, Pennsylvania) developed ProvenCare, first applied to coronary artery bypass graft (CABG), as an innovative provider-driven quality improvement program to promote reliable delivery of evidence-based best practices. A new mesosystem is created for each ProvenCare model, integrating the care delivery process between contributing microsystems and defining new mesosystem leadership. The approach has been expanded to many patient populations, including percutaneous coronary intervention (PCI). A NEW PCI MESOSYSTEM: In 2007 clinical microsystem thinking was applied to PCI: understanding the current processes and patterns, assembling the frontline professionals to redesign the processes, and using a beta-test phase to measure the changes and adjust accordingly, until the best process was established. A new mesosystem team was created to ensure that the right care is delivered at the tight time. REFINING IMPLEMENTATION: In the course of developing the CABG initiative, Geisinger established role definitions to keep teams on track; a comprehensive plan from design through execution and follow-up; and guiding principles established for the teams engaged in designing, developing, and implementing ProvenCare programs. PRELIMINARY EXPERIENCE: For the 40 measurable process elements in the PCI mesosystem pathway, as of month seven (July 2008) of the beta-test phase, 55% of the patients received 100% of the identified process elements. CONCLUSION: Geisinger Health System has joined different microsystems to form an innovative mesosystem capable of producing reliable, evidence-based care for patient subpopulations. This approach to embedding evidence-based care into routine care delivery can be adapted by others.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.

OBJECTIVE: To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. METHODS: The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). RESULTS: Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) CONCLUSION: A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.