Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

BACKGROUND: Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients. OBJECTIVE: To determine whether such informal clinical integration relates to a health system's performance in an ACO. RESEARCH DESIGN: We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration. SUBJECTS: Beneficiaries age 66 and older undergoing CABG. MEASURES: Ninety-day CABG mortality. RESULTS: Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01). CONCLUSIONS: Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.

Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center.

BACKGROUND: Turnover time (TOT) is one of the classic measures of operating room (OR) efficiency. There have been numerous efforts to reduce TOTs, sometimes through the employment of a process improvement framework. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change. METHODS: TOT data for general and gastrointestinal surgery were collected retrospectively over a 26-mo period at a large multispecialty academic institution. We calculated mean and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were canceled. Data were retrieved from the perioperative nursing data entry system. RESULTS: Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area. CONCLUSIONS: There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are "organizationally compatible."