patient safety

A Century of Patient Safety

The history of patient safety as an organized movement has been a century in the making, beginning with the American College of Surgeons hospital standardization campaigned, launched at a Chicago conference on October 19, 1917.  A narrated video presentation on the movement’s early years is available above and the transcript follows below.  

In the 1990s, errors in health care had patients dying at a rate equal to a jumbo jet crash a day, according to a Harvard study.  Giving these patients real names and compelling stories, high profile media coverage of particularly tragic errors made the human cost and the need to act unavoidable.  The American Medical Association responded by launching the National Patient Safety Foundation. There was a sense of urgency and it may have seemed new, but it really wasn’t new at all. Rather, it was a renaissance.

The fact is, patient safety as an organized movement began a century ago in 1917.  That October, the American College of Surgeons launched its effort to standardize the nation’s hospitals for greater efficiency.  For them, hospital efficiency meant losing fewer lives to inaccurate diagnoses and incompetent surgeries.  They called on the nation’s hospitals to institute patient record systems, follow up on results, organize physician staffs, and establish laboratories.  The surgeons would check up on hospitals annually, publishing lists of hospitals meeting their standards.

The story begins on October 19, 1917.

Opening the pages of the Cincinnati Enquirer, we find a short article about the superintendent of Cincinnati’s General Hospital Dr. Arthur C. Bachmeyer.  He had left the previous evening for Chicago and a conference convened by the American College of Surgeons to make operations safer.   Inspectors would later fan out across the country, “checking up” on hospitals to see if they met minimum standards.

Also attending the conference was Amory Codman, the Boston surgeon considered by many the father of patient safety. He had developed an innovative record system, one card to a patient, documenting the end result of each case.   Using the cards, he summarized errors and failures.  He asked:  “was it the fault of the surgeon, the disease or the patient.  What can we do to prevent similar failures in the future.

Codman believed patients were put at risk by a rigged promotion system that overlooked the best surgeons.  Based instead on seniority, advancement came to those who built careers on connections and personal reputations, not on results.  In a very undiplomatic move, Codman made his point with a large cartoon drawn by an artist friend – fully in the style of a muckraker exposing corruption — which he unveiled at a public medical society meeting with reporters present.  As result, Boston society ostracized him while, across the nation, many heralded him as a patient safety pioneer.  In fact, the Joint Commission until recently presented an annual Codman award.

Meanwhile, patient safety borrowed from other movements, including Teddy Roosevelt’s conservation movement. Conservation came to mean more than protecting nature.  It also meant protecting human life.  In Atlanta, the newspaper reported that conservation of human life would be the focus of a public meeting on hospital standardization sponsored by the American College of Surgeons.  It urged its readers to attend.

Efficiency was another, “borrowed-from” movement. The most famous of the efficiency experts, Frederick Taylor, focused on factories.  But, Amory Codman’s friends, Frank and Lillian Gilbreth – of Cheaper by the Dozen — concentrated on bringing scientific management to the operating room.  In fact, Frank Gilbreth spoke at the same meeting where Codman presented his controversial cartoon.  Codman said “There’s a general movement, which the public is beginning to demand, toward increasing the efficiency of hospitals.”  Greater efficiency meant better safety.

The surgeons weren’t alone in promoting standardization. Henry Ford got in the act too. You could have your Model T in any color so long as it was black!  For the surgeons, efficiency was the standard. They said hospital standards “are as figures of a barometer which indicate the degree of efficiency of a hospital or the degree of safety of a hospital to patients.”

Correct diagnosis was Richard Cabot’s passion. He and Codman were friends and, like Codman, he was a reformer.  He published controversial studies reporting diagnoses were more than half-wrong. In partnership with Ida Cannon, pictured here, sent social workers from Mass General into the community, to improve conditions and to follow up on the results of care.

As far as Codman was concerned, surgeon efficiency reports were like batting averages. An amateur baseball player, he believed medicine needed rules and umpires.    Quite to the contrary, Arthur Bachmeyer, the Cincinnati hospital administrator believed great teams won championships even without any star players.  What mattered most was the organization, not the individual.

Teamwork was a constant refrain, like standardization and efficiency. To be up to standard, hospitals had to conduct monthly hospital staff meetings dedicated to reviewing and preventing errors. Pictured here is the St. Louis Children’s Hospital staff of the time.

Hospitals also had to keep records. The editor of Modern Hospital, John Hornsby wrote, if good records are kept, good work will be done, but 75% of hospital records had no value.  When Bachmeyer presented a set of recommended forms at the American Hospital Association, his report was hailed.

Speaking for nurses was Carolyn Gray from, as she said, “the applied common sense department or safety first division. Writing or printing orders spells safety for the patient and after all that is the acid test.”

Catholic hospital sisters got their written orders, quote “with a sister in charge having full authority to demand the careful cooperation of doctors, interns and nurses.”

When the nation entered World War I, many top physicians, surgeons, nurses, and administrators joined the army or navy. Patient medical records and monthly hospital reports, including documentation of errors and mistakes, were mandatory.  In this photo we have – in uniform – the Mayo brothers, Albert Ochsner of New Orleans and George Crile of the Cleveland Clinic.

Organizing and staffing their own battlefield hospitals were America’s leading medical schools and hospitals. Here is the Washington University base hospital in France.  The American College of Surgeons executive director John Bowman, wrote in the New York Times,  “Military hospitals are now standardized for soldiers so is the best surgery too good for the humblest patient? Are mistakes due to carelessness not repeated?”

About half the men examined for Army induction were rejected for defects. The surgeons saw standardization as a solution.  In fact, it was a test of medical patriotism.

Hospital fund raisers promoted the standardized safety of their new hospitals. Between 1925 and 1929 nearly a billion dollars was spent on new hospital construction, a third of all hospital capital investment by the end of the decade.

By 1928, the American College of Surgeons declared their hospital standardization campaign a great success.  Hospitals were safer.  Hospital mortality had been cut by half to 5%, from about 10% a decade earlier.

Meanwhile, auto crashes were sending drivers, passengers, pedestrians and an alarming number of children to the hospital. Cars were the fifth leading cause of fatalities. The surgeons and the auto club joined forces in a new campaign:  Safety first (when driving)/Safety afterwards (if you have to go to the hospital) The auto club provided lists of approved hospitals to its members.

Sadly, optimism over safer care came crashing down in 1929 when x-ray film at the Cleveland Clinic caught fire, costing 123 lives. It turns out that the Cleveland Clinic was not considered a hospital and thus not part of the surgeon’s safety program.  Responding to newspaper reporters, the American College of Surgeons said it had warned about the dangers of improperly storing x-ray film.

During the depression, the big issue for health care became how to pay for it.  Then came a brutal global war in the 40’s.  In the 50’s, an Ohio court decision stripped charitable hospitals of legal immunity.  Thereafter, lawsuit crises thereafter routinely boiled over.

Fortunately, during these dark ages, the health care equivalent of monks and monasteries labored on.  The Joint Commission took over from the American College of Surgeons.  The American Hospital Association and the National Safety Council collaborated on safety initiatives.  In 1962, the University of Michigan School of Public Health convened a remarkable conference, a beacon in the darkness, alerting hospitals to the hazards of poor safety practices.

Turning on the lights, for good, was the Anesthesiology Patient Safety Foundation with its founding in 1984.  Soon after, the Harvard Medical Practice Study got underway, using patient records from 1984.  By 1997, the National Patient Safety Foundation appeared, launched by the American Medical Association and inspired by Lucian Leape’s revealing research on the high number of deaths caused by medical error.  The patient safety renaissance had begun.

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care
Scale has its limits, as the nation’s two largest pharmacy benefit managers (PBM) are discovering.  Express Scripts and CVS Caremark each process more than a billion prescriptions a year.   That is not enough for big customers Anthem and Aetna.  Both are likely to alter dramatically or not renew long-term contracts set to end in 2019 with the PBM behemoths.

PBM Optionality for Anthem, Aetna

Anthem and Aetna say they now have “optionality” because Cigna and Humana, which they are respectively acquiring, both have PBMs.  That optionality goes well beyond the scale Aetna would enjoy as the fourth largest PBM.  It can put the pharmacy benefit, integrated within each organization, on the path to value-based health care.

Both the Humana and Cigna PBMs align well with the quality and outcomes focus of value-based health care.  Humana’s PBM primarily supports the company’s Medicare Advantage (MA) and Part D programs, with MA accountable care arrangements delivering better outcomes than traditional Medicare.

Meanwhile, Cigna has pioneered outcomes-based reimbursement arrangements with pharmaceutical manufacturers.  Previously overseeing Cigna’s PBM was none other than Aetna CEO Mark Bertolini; Cigna CEO David Cordani will serve as chief operating officer of the new Anthem.

In their sights is UnitedHealth Group (UHG), which brought its PBM business inside from Medco at the start of 2013, trigging Express Scripts’ anticipatory acquisition of Medco in 2012.    UHG says its OptumRx PBM focuses “on connecting total condition spend and pharmacy’s impact across benefits,” a process it calls “synchronization.”

More explicitly than Anthem, Aetna has said it will integrate Humana’s PBM, along with its “growing health care services business,” even characterizing it as an “Optum-like business.”

Value beyond Scale

UHG’s Catamaran acquisition earlier this year, while adding scale, also significantly included Catamaran’s RxClaim processing platform.  OptumRx plans to integrate the adjudication platform with its medical and pharmacy claims synchronization.  UHG promises to create value “beyond the scale … resulting from integration,” by linking “demographic, lab, pharmaceutical, behavioral and medical treatment data” to encourage healthy decisions and improve compliance with pharmaceutical use and care protocols.”

In fact, the very tools used to leverage scale to get lower prices, such as formulary exclusions, can potentially work against reducing total costs.  In securing a substantial discount from AbbVie for Viekira Pak, Express Scripts excluded Gilead’s Harvoni from its 2015 formulary.  Viekira Pak is a four pill a day regimen to Harvoni’s adherence-friendly one pill for curing hepatitis C.

Not surprisingly, given their focus on overall costs, Aetna, Anthem, UHG and Cigna all included Harvoni on their formularies and do not publish exclusion lists like Express Scripts and CVS Caremark.  Instead, they typically establish clinically based prior authorization criteria.

For the latest high-cost drugs to hit the market, Express Scripts is following the health plans on their value path.  Instead of excluding one of two new anti-cholesterol drugs, known as PCSK9 inhibitors and list priced at $14,000 per year, it announced coverage for both this week.

As the health plans did with Harvoni, Express Scripts will implement rigorous prior authorization procedures.  The company says it negotiated good pricing with Amgen for Repatha and with Sanofi and Regeneron Pharmaceuticals for Praluent, enabling it to cover both drugs.  Perhaps it also heard from customers unhappy with price-driven drug exclusions.

Wanting More, Customers Become Competitors

Clearly, some very big customers – Aetna, Anthem and UHG – want something more than scale from traditional PBMs like Express Scripts and CVS Caremark.  Beyond scale, they want a pharmacy benefit that contributes to reducing total costs through better outcomes, consistent with achieving overall value-based payment goals.

Building PBM paths to value-based health care for themselves, Anthem, Aetna and UHG will also sell against volume-based models like those of Express Scripts and CVS Caremark, and against health plans that fail to integrate pharmacy and medical claims for actionable intelligence.

Employers and the Limits of Scale

Their strategy blueprint could easily have come from the Harvard Business Review article “The Limits of Scale.”  Hanna Halaburda and Felix Oberholzer-Gee argue that, when rapidly scaling companies neglect to take into account differences among their customers, performance declines.  On that premise, they suggest how challengers and incumbents can take advantage of customer differences.

Among PBM customers with differences are employers, which provide health coverage for 147 million Americans.   The National Business Coalition on Health is uneasy with the growing use of exclusionary formularies.  It advises members to “base selection criteria for formularies on clinical outcomes to ensure that pharmaceutical costs do not decrease at the expense of rising medical costs.”

Employers are becoming more actively engaged in managing the pharmacy benefit, even developing their own formularies and negotiating directly with pharmacy retailers.  Caterpillar’s Daren Hinderman told an NBCH panel last year, “I don’t want to have a conversation [with PBMs] on rebates; I want to have a conversation on how I can keep my employees more compliant with medications they need to stay healthy. We decide what’s best for our employees. It’s a transparent process.”

NBCH also urges members to “verify that pharmacy and medical benefits are aligned, and link data between the two in order to evaluate cost and outcomes across both types of benefits and the entire health-care spectrum, not just through the lens of pharmacy.”  As Dr. Mark Fendrick of the University of Michigan Center for Value-Based Insurance Design told the NBCH panel, “I’d prefer to spend more on statins than on stents.”

Obstacles on PBM Value Path

Mapping the PBM path to value-based health care is one thing, building it is another.  Aetna and Anthem still must face a gauntlet of government and legal reviews before they can complete their acquisitions and commence integrating the Humana and Cigna PBMs.

OptumRx must complete its integration of Catamaran, which in turn is still integrating the data platforms of its acquisitions.  Furthermore, OptumRx and Catamaran both use different versions of the RxClaim platform and, for Catamaran, medical claims synchronization remains down the road (or path).

Meanwhile, the Catamaran acquisition has roiled a PBM industry where many participants use Catamaran’s RxClaim platform – including Cigna!  They were content to compete with Catamaran, despite using its technology.  However, will they be similarly comfortable with OptumRx and UHG in the technology driver’s seat?

Much like UHG’s acquisition of Catamaran and its technology, Rite-Aid did the same when it acquired EnvisionRx.  The PBM had previously acquired Laker Software, also a claims platform supplier for many PBMs.  Again, the comfort question arises, in this case over Envision and Rite Aid as the drug retailer pursues its path to value-based health care via innovative alliances with health care providers.

Making the Laker and RxClaim platforms particularly valuable has been the PBM industry’s reliance on a hodge podge of decades-old, antiquated platform technologies.  With each acquisition, scaling PBMs have patched together instead of invested in their platforms to maximize short-term synergies, at the cost of limited flexibility and lower efficiency.

PBMs Miss Technology Revolutions

Meanwhile, multiple revolutions have coursed through the systems development world since the PBM industry acquired its mainframes and data centers in the late 1980’ – early 1990’s.   When relational databases followed soon thereafter, PBMs adopted them for after-the-fact data analysis, but not broadly for real time use with claims processing platforms, which now are antiquated and fragmented.

More recently, graphical user interfaces have greatly streamlined the programming of business intelligence applications.  It is now easier for more people, more efficiently to translate their expertise into innovative systems.  No longer must visionaries exclusively funnel their solutions through highly specialized programmers and coders.  Now, the visionaries’ can become coders, their hands on the programming controls, unleashing new applications across the entire economy, including the PBM industry.

PBM Platform for Value-Based Health Care

One such visionary has developed a PBM solution for value-based health care.  His name is Ravi Ika.  “The solution is holistic, unlike that of any other existing PBM.  It reduces overall pharmacy cost, converts specialty from ‘buy & bill’ to ‘authorize and manage,’ and lowers avoidable drug-impacted medical costs,” explains Ika.

Before turning his attention to the PBM industry, he created a comprehensive, integrated payer platform now provided by ikaSystems, which he founded to transform the payer operating model.  Spanning all payer departments and business lines, it decreased administrative costs for health insurers by as much as 50% and reduced avoidable medical costs.

In 2013, Ika launched RxAdvance, a full service PBM, which similarly operates on an integrated, end-to-end platform – one designed specifically for value-based health care.   Combining pharmacy, medical, and lab data, the platform – called PBM Collaborative Cloud– enables real-time engagement.  This engagement occurs with physicians at the point of care, pharmacists at the point of sale, and patients via mobile cloud.  It also engages payers clinical and pharmacy staff through their workflows.

Better decisions by these stakeholders – driven by platform-generated, actionable intelligence – can reduce avoidable drug-impacted medical costs, optimize utilization, facilitate better specialty drug management, and decrease overall pharmacy costs.

PBM Processes Reimagined

“We started with a clean slate,” observes Ika, who says he and his team reimagined PBM processes to streamline workflow before building the platform.  Redefining the human role, they automated as much as possible while, on the other hand, increasing opportunities for engagement, what-if modeling, and informed decision-making.  The platform also enables market and regulatory changes configurable by the business user, as well as system-driven compliance management.

Ika built the platform from the ground up using a unified data model.  In information technology parlance, that means the platform’s standards are universal enough to encompass a large scope of data and types of data with high scalability.

In PBM language, the platform includes everything from pharmacy claim adjudication, formulary management, benefit design, enterprise reporting and analytics, to pharmacy network and rebate contracting, medication adherence and therapy management, specialty management, transparency, compliance, and adverse drug event management.

From Existing to Ideal Formularies

For example, the platform includes algorithm-driven artificial intelligence to manipulate, with plan sponsor engagement, the complex and interdependent variables associated with formulary management.  Incorporating habitual member and prescriber utilization patterns, in addition to other data, it derives an ideal formulary with optimal financial and clinical outcomes.  The system then maps a transition plan from an existing formulary.  The platform also accommodates an unlimited number of formularies and supports real time dynamic modeling and changes coupled with full transparency.

Better Medication Therapy, Adherence Outcomes

For medication therapy management (MTM), the platform taps patient medical claims and disease conditions, against which the system overlays a prescription listing for easy use by prescribers.  In addition, each new prescription triggers a dynamic analysis to determine patient eligibility for a comprehensive medication review (CMR), which the system prepopulates for efficient prescriber use.

After the CMR, RxAdvance advisors rely on system alerts to intervene with patients to ensure medication adherence.  For high-risk patients, RxAdvance will install an electronic, patent-pending pill station at their residences and resupply it with disposable pre-filled pill trays.

Integrated with and wirelessly connected to the company’s platform, the device assists with monitoring adherence and vital signs.   The company says the device has improved adherence to more than 93%, including patients with multiple chronic conditions who are taking an average of 15 medications a day.

The Centers for Medicaid and Medicare Services (CMS) recently underscored the PBM need for physician-led, point-of-care MTM capability when it announced a new Medicare Part D MTM model.  Currently, highly fragmented PBM MTM relies on pharmacists “chasing” patients without closing the loop with prescribers, thus failing to secure meaningful health outcomes, according to Ika.

Ika points to the RxAdvance specialty management program as another example of his platform’s capabilities.  As it does for MTM, the platform integrates prescriptions, medical claims and disease conditions to create an action plan for all stakeholders.  Case managers use a dashboard to prioritize their outreach to patients, prescribers and pharmacists.  Because the platform integrates medical, pharmacy and lab information, it helps facilitate appropriate utilization.

Risk Sharing

One of the hallmarks of an organization configured for value-based health care is its ability to share risk.  The RxAdvance unified data model platform enables it to share risk for both pharmacy and avoidable drug-impacted medical costs.  For pharmacy, it is prepared to assume both up and down side risk based on its cost management performance against a risk cap set below a national benchmark projected increase.

The company can also compute a baseline trend for avoidable drug-impacted medical costs using prior years’ medical claims data.  RxAdvance and its client then set a target and, if the PBM lowers actual avoidable drug-impacted medical costs, it will share in the savings.  According to Ika, this sort of risk sharing is unique in the PBM market.

Ika reports that RxAdvance is currently implementing full PBM services for three clients, replacing national PBMs.  “The Collaborative PBM Cloud platform is making for a very smooth launch,” he notes.

RxAdvance has gotten a head start along the PBM path to value-based health care, scaling the limits of scale.

As Insurers Merge, What’s Next for Healthcare? Watch Gretzky!

Gretzky

Remember that quote from hockey great Wayne Gretzky, “I skate to where the puck is going to be, not where it has been.”  To see where healthcare is going, watch Gretzky.  Watch the successful organizations that always seem to be in the right place at the right time. Watch Ascension Health.

The nation’s largest not-for-profit health system, Ascension popped up in a recent New York Times story on health insurer consolidation.  It had become an insurer, too, when it acquired Michigan-based U.S. Health and Life Insurance in February.

Ascension Health as Insurer

Ascension plans to continue the small insurer’s focus on serving small, self-insured employers, according to a filing with Michigan regulators.  Although 20 states have licensed the insurer, Ascension plans to concentrate on Michigan, where the health system’s footprint is biggest, as well as in Illinois, Indiana and Wisconsin.

Longer range, the system has the much more ambitious vision of coupling its new insurance asset with a newly formed Ascension Care Management subsidiary to provide employers with population health services. Ascension then can take provider direct contracting with employers to a new level.

Generally, organizations like the Mayo Clinic and the Cleveland Clinic have contracted with national employers for single-price orthopedic and cardiac surgeries.  Ascension, on the other hand, is ready to provide capitated care arrangements directly to employers for all their employees, not just surgical patients. Modern Healthcare reports that risk based contracts, including capitated arrangements with payers, already cover about 1.9 million Ascension patients.

Being a Healthcare Gretzky

To be a Gretzky, a healthcare provider must be able to assume risk. However, not every provider capable of assuming risk will be as good as Gretzky.  There is more to being a Gretzky, including focused scale, powerful information technology and clinical leadership.

Focused Scale

Surely, Ascension’s size is its most striking characteristic.  However, size alone does not make Ascension a Gretzky.  Instead, Ascension brings a distinguishing focus to its size, one that recognizes healthcare in the U.S. as a confederation of 50 state markets plus the District of Columbia.

For example, in Michigan, Ascension has allied with CHE Trinity Health Michigan to form Together Health Network for joint managed care contracting and, potentially, offering narrow network coverage products on the state’s public insurance exchange.

The network, which does not involve an asset merger, covers nearly all of the state, with 75% of the population no more than 20 minutes from a participating hospital or physician practice. Reinforcing that coverage, Ascension has also agreed to acquire Crittenton Hospital Medical Center in Southeast Michigan.

On the other hand, Ascension has scaled back in Arizona, where it has entered into a joint venture with Tenet and Dignity Health, resulting in Tenet operating Ascension’s Carondelet Health Network.  Ascension had not been a major presence in the market.

Ascension is also configuring horizontally for the nation’s diverse healthcare payment models.  In a recent article, CEO Tony Tersigni observed that Medicare resembles Canada, our under-65 model is closer to France, Germany or Japan, veterans, military and Native American healthcare is a lot like the British National Health Service and, for the uninsured, rural India or Cambodia provide the best comparison.

Consistent with this mental map, Ascension last year announced establishment of Ascension Health Senior Care, now the nation’s second largest not-for-profit long-term care provider in the nation.  Consisting of 34 facilities serving more than 5,500 patients, the unit shares best practices and establishes consistent standards.

Once again, like Gretzky, Ascension has positioned itself well. At this week’s White House Conference on Aging, the Obama Administration announced a proposed rule updating, for the first time in nearly 25 years, the quality and safety requirements for nursing homes and skilled nursing facilities.

Powerful Information Technology

Ascension is not waiting for national data to achieve “drastically reduced hospital readmissions.”  Instead, in almost real time, it spots patterns in 30-day readmissions using admission, discharge and transfer (ADT) data across the care continuum. The immediacy enables Ascension to evaluate and adjust interventions on a local level.

“We are highly engaged with supporting the technology that would enable rapid identification and management of those conditions, so we are working very hand-in-glove with our clinical leaders,” Ascension Information Services (AIS) vice president Mary Paul recently explained to HealthITAnalytics.

The system has identified three key risk factors for readmissions – medication management, access to primary care and socio-economic factors.  ““We can predict fairly well which patient is likely to get in trouble from their clinical situation, but their social determinants are just as important,” Chief Quality and Nursing Officer Ann Hendrich told the publication.

Meanwhile, 2,500 AIS employees are also working to standardize and consolidate across 1,900 sites of care in 23 states, according to CIO Mark Barner.  They are shrinking more than 4,000 software applications to a much smaller number and consolidating 37 disparate interface engines into one.  Ascension is using the Athenahealth ambulatory electronic health record application and cloud based applications for ambulatory physician practice management.

Clinical Leadership

Ascension Health has been at the forefront of the patient safety movement for more than 20 years.  In connection with a 2002 commitment to 100% access to safe, effective care, Ascension adopted a goal of clinically excellent care with no preventable injuries or deaths by July 2008.  The Joint Commission Journal on Quality and Patient Safety published a series of articles charting the system’s journey toward clinical transformation.

Ascension continues its leadership through its Hospital Engagement Network (HEN).  Selected by and with funding from CMS, Ascension’s HEN is developing advances in ten areas, including sepsis, hospital acquired infections, patient safety culture, home healthcare models, hospital acquired kidney failure, and safe patient handling.  Ascension will share the advances with hospitals throughout the nation.

The Ascension HEN has already identified, documented, refined and shared best practices in ten additional areas, including urinary tract infections, adverse drug events, pressure ulcers, fall injuries and central line associated blood stream infections. For example, Ascension developed a protocol for reducing catheter induced urinary tract infections, which account for 30% of hospital-acquired infections, by limiting catheter use.

In another example, Ascension has dramatically reduced induced or C-section deliveries before 36 weeks, which often result in higher complications for babies and mothers.  In February 2012, Ascension’s early-elective delivery rate was about 3.5%, already substantially lower than the national average of 10% to 15%.  Now, it is even lower, at 0.6% after shared data with physicians and stepped up patient education efforts.  (For additional advances in obstetrical care, see three Ascension-authored articles in the January 2014 edition of Health Affairs.)

Last month, Ascension told the White House Forum on Antibiotic Stewardship that it wants to “set the pace for the nation in antimicrobial stewardship.” It has pledged to establish facility-based antimicrobial stewardship programs in all Ascension hospitals that will include both a pharmacist and a physician with antimicrobial expertise.  The system also said it would reduce the use of three broad-spectrum or niche antimicrobials by at least 10% reduction during the first 12-18 months.

What’s Next for Ascension?

One of the best ways to project where a Gretzky organization will be next is to watch the Gretzky’s within it.  In Ascension’s case, that would include Chief Quality and Nursing Officer Ann Hendrich, who joined Ascension in 2003, after leading the development of an innovative coronary care unit at Methodist Hospital in Indianapolis.

That she would be a Gretzky to watch at Ascension was clear from an observation she made in her application to be a Robert Wood Johnson Executive Nurse Fellow in 1998.  Hendrich wrote, “The opportunity to take shell space and not replicate the present and familiar but integrate environmental design, technology and a new care delivery model is imperative.”

In her dozen years at Ascension, Hendrich has played a key role in cementing Ascension’s clinical leadership.  Given the system’s accomplishments, especially in clinical quality and patient safety, Ascension merits the recognition usually afforded the great healthcare brand names like Mayo, Cleveland Clinic, MD Anderson and Kaiser.

Establishing a strong national brand is “what’s next” for Ascension.  The need and the opportunity are clear and, to track how Ascension intends to build its brand, look to the recent arrival of another Ascension Gretzky, Nick Ragone.  A lawyer and author, Ragone most recently led the Washington office of Ketchum, a global public relations agency.

As Ascension’s chief communications officer, he will “enhance the strategic identity of Ascension,” according to the 2014 announcement of his arrival. His initial focus has been internal, engaging 153,000 employees, as it should be for any brand-building exercise.  Ragone is supporting an enterprise-wide “One Ascension” initiative, which is integrating and establishing best practices throughout the once highly decentralized system.

Meanwhile, Ragone is preparing to take his branding initiative on the road:  He is looking for a brand strategy director to “lead work around the definition and development of the Ascension brand, both internally and externally.  The Director will be responsible for developing the value of the Ascension brand and driving strategies to build brand equity for Ascension, its Subsidiaries and Health Ministries.”

Epilogue as Prologue

Earlier this month, Modern Healthcare editor Merrill Goozner interviewed Ascension CEO Anthony Tersigni.  He asked Tersigni about Aetna buying Humana and Anthem pursuing Cigna.  Tersigni shrugged off the big deals, saying, “Ascension is preparing to take on risk itself for self-insured employers as the system strives to manage population health while encountering an increasing number of patients in high-deductible plans.”

Spoken like a true healthcare Gretzky.