As Robert Ebert, dean of Harvard Medical School, wrote in 1965, “The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Anthony M. DiGioia
“In the more than 50 years between [Ebert’s] statement and this moment,” wrote Gene Lindsey, MD,
chief executive officer emeritus of Atrius Health, “we have been on a frustrating journey, searching for an operating system and finance mechanism that could ‘provide optimally for the health needs’ of the nation.”
Continuous performance improvement
The Patient Centered Value System (PCVS) is just such an operating system — a continuous performance improvement methodology that is practical, easily implementable, and couples clinical and financial performance. PCVS delivers value-driven outcomes and experiences.
According to Lindsey, PCVS focuses explicitly on the patient and family as “the core concern” and engages them as partners in health care co-design. Furthermore, PCVS addresses the needs of everyone involved in delivering care, including providers, hospitals and insurance companies.
In the words of Donald M. Berwick, MD, MPP, president emeritus and senior fellow at Institute for Healthcare Improvement and a past CMS administrator, “…if we listen carefully and with open minds to what patients and families tell us, we can find the best compass toward improving our delivery of care and their care experience. Relationships with patients and families … come first, but the spiraling costs of health care also need to be understood and brought under control for the benefit of patients, families, communities, providers, and organizations.”
These are among the benefits of PCVS, and the steps to achieve these can be found in The Patient Centered Value System: Transforming Care Through Co-Design.
Co-designing care with patients, family, front-line providers
Value-driven care is quality care delivered efficiently; that is, outcomes achieved per dollars spent. Quality care is rooted in co-designing care with patients and families. However, financial realities, such as the bundled payment model, mean providers and organizations must deliver high-quality care and know the true costs to deliver it. PCVS addresses quality and cost as a way of succeeding in bundled payment and other value-driven models.
PCVS combines three tools into one comprehensive approach designed to improve patient experiences and outcomes while decreasing costs. The tools for implementing the PCVS include shadowing, patient-centered process improvement and team building, and time-driven activity-based costing (TDABC), which was developed by Robert S. Kaplan and Steven R. Anderson in 2007 and applied to health care by Kaplan and Michael Porter in 2011.
Shadowing is the direct, real-time observation of patients and families as they move through each step of the care process. Shadowing enables providers to observe the current state of care and engage patients and families in real-time co-design. After shadowing, patient-centered process improvement teams work to close the gaps between the current state and the ideal state. Using shadowing plus TDABC then enables providers to determine the true cost of care for the full cycle of care, such as for a 4-month bundle. Following this stepwise effort improves outcomes and experiences while reducing costs, which prepares providers for bundled payment models.
Total joint replacement example
For example, the Bone and Joint Center at Magee-Womens Hospital of UPMC used PCVS to identify the true cost of primary total hip and knee replacement surgery by resource type (personnel, space, equipment and consumables) during the full cycle of care (30 days pre-surgery to 90 days post-surgery) and by segment of care (pre-hospital, hospital and post-hospital). The OR accounted for the largest portion of the overall cost at 58% and 51% for total hip replacement and total knee replacement, respectively. Implants and personnel accounted for the second largest portion of the overall cost at 53% and 44% for total hip and total knee implants, respectively; and personnel accounted for 44% and 50% of the overall cost for THR and TKR, respectively. The cost of space and equipment for the 4-month bundle accounted for only 3% and 5% of the overall cost of THR and TKR, respectively.
The Bone and Joint Center has also used PCVS to compare the total joint replacement bundles for five surgeons at two urban hospitals and one community hospital, as well as outpatient vs. inpatient hip replacement. The analysis showed large variations in the care pathways, resource costs and total costs. PCVS showed preoperative testing protocols, time in the OR, types of personnel used, protocols for follow-up visits, discharge disposition (to home vs. to nursing facilities or rehabilitation centers) and the number of outpatient therapy sessions were also highly variable. This study shows high-impact opportunities for reducing total costs and variation across bundles tightly couples clinical and financial performance, and highlights areas for process improvement and exporting best practices.
Using PCVS as its operating system has prepared the Bone and Joint Center to be a pilot site for the CMS bundling program and positioned it to participate in any new care delivery models in the future.
“Health care professionals,” Lindsey said, “have often been unable to connect the industrial methodologies of process improvement to their work without a sense that they are losing the essence of why they became clinicians in the first place … [This book] offers clinicians and medical institutions a continuous performance improvement methodology that has its roots in the values of good clinical practice.”
According to a comment by orthopedic surgeon Steve F. Schutzer, MD, who is medical director of Connecticut Joint Replacement Institute, in The Patient Centered Value System: Transforming Care Through Co-Design, “The spiraling costs of health care and diminishing value for organizations, patients and families requires a new, transformative approach to health care delivery. PCVS is the answer to lowering costs, improving clinical outcomes, and increasing the patient and family care experience ...”
DiGioia AM, Shapiro E. The Patient-Centered Value System: Transforming Healthcare Through Co-Design. Boca Raton, FL: Taylor and Francis/CRC Press; 2018.
Anthony M DiGioia III, MD, is the medical director of the Bone and Joint Center and The Innovation Center at Magee-Womens Hospital of the University of Pittsburgh Medical Center. He developed the patient centered value system, a comprehensive relationship-based approach that combines shadowing, a patient-centered process improvement and team building tool, and a true cost tool based on Time Driven Activity Based Costing. He can be reached at email: firstname.lastname@example.org.
Eve Shapiro, is principal at Eve Shapiro Medical Writing Inc. She writes on topics of patient safety, patient-centered care, physician-patient partnership, medical ethics, and medical error prevention and disclosure for audiences ranging from researchers and clinicians to patients and families. She can be reached at email: email@example.com.
Disclosures: DiGioia and Shapiro report no relevant financial disclosures.