A recently completed project at Dartmouth-Hitchcock (D-H) has shown how process improvement techniques normally seen in areas outside of medicine can result in better outcomes, improved patient experience, and significant decrease in cost – potentially leading the way as Americans look for ways to reduce the cost of health care.
The project, undertaken by a multidisciplinary team at D-H, has improved the way endovascular repair (EVAR) for abdominal aortic aneurysm is performed, saving hundreds of thousands of dollars annually.
In analyzing the project, “we identified three key areas where we saw opportunities for improvement—in the clinic, the operating room (OR), and in our finance and purchasing activities,” says A.J. Horvath, practice manager of Vascular Surgery at Dartmouth-Hitchcock. “In the clinic, we learned that 55 percent of patients who were referred to us did not have the right imaging for our surgeons to evaluate as part of their visit. We found that referring providers and our staff weren’t sure what was needed for clinical decision making. So we developed a new protocol, and as a result expect to save 50 unnecessary appointments per year.”
In the OR area of the project, D-H vascular surgeon David Stone, MD, and his colleagues looked at the instrument usage required for EVAR. “We found that we opened 184 instruments every time we did a procedure, even though we didn’t use all of them. The reason given was, ‘we’d always done it that way,'” says Stone. “We worked with our OR team to pilot and implement a new instrument tray that led to a 32 percent reduction in instrument use. That not only reduces work for OR personnel, it saves on sterilization costs. Making those modifications to our OR equipment will save us $50,000 per year.”
Finally, the project team focused on the main driver of EVAR costs: stent grafts and supplies from manufacturers. “Traditionally, no cost considerations were given to these cases,” Horvath says. “We worked with our finance and purchasing folks and found that in order to maximize savings, we needed to use lower cost devices and also negotiate with vendors to improve pricing.”
The team went through a comprehensive RFP process, sitting down with each vendor and sharing its data and goals for providing the best care to D-H patients. “They appreciated our transparency and were impressed that surgeons were at the table talking about price,” says Horvath. “We anticipate saving a minimum of $325,000 per year.”
Historically, patients who had an abdominal aortic aneurysm—a degeneration in the wall of the aorta (the main artery in the body) that was in danger of rupturing—had to undergo a major, open operation.
“Our technology has evolved to a point where, using x-ray guidance, we can go through the femoral artery in the groin and insert a device, a stent graft, which serves as a bridge across the aneurysm,” explains Stone. EVAR has significantly reduced deaths, complication rates, and lengths of stay in the hospital for these patients nationally.
Addressing Rising Costs
“Endovascular techniques have significant associated costs, and EVAR is the most expensive procedure we do,” says Richard Powell, MD, Section Chief of Vascular Surgery. “With increasing patient demand and declining reimbursements from Medicare, it’s become an issue as to whether we can afford to do very many of these procedures in the future.”
In this light, Powell’s section began a “care path” project about a year ago to improve efficiency of care and maintain excellent outcomes for its EVAR patients. “A care path defines the steps of care that patients experience as they flow through our system, using the best evidence available to support the steps taken,” explains Department of Surgery Chair Richard Freeman, MD.
Dr. Freeman introduced the process to his department two years ago to help bring standardization and measurement to surgical care at D-H. “The overall idea is to improve both quality and efficiency of care over time,” he says. The EVAR project work was done by a cross-functional team with representatives from Vascular Surgery, Perioperative Services, Finance, Purchasing, and the Dartmouth-Hitchcock Value Institute.
“This is exactly the work we have to do to create the sustainable health system we are striving for,” said Dartmouth-Hitchcock CEO and President Dr. James Weinstein.”What I love about this is that the process was driven by the care teams at the department level. It wasn’t an edict from the top, it was a groundswell from those on the front lines.”
Established in late 2011, the Value Institute is “using proven process improvement methodologies from industry to provide the education, coaching, and infrastructure required to improve quality and reduce costs throughout D-H,” explains Susan McGrath, PhD, Director ofPerformance Improvement in the Division of Quality, Safety, and Value. She is also an adjunct professor at The Dartmouth Institute for Health Policy and Clinical Practice.
McGrath heads up a team of certified specialists trained in “lean” (eliminating waste) and “six sigma” (reducing error) principles. They conduct a series of quarterly training classes for both individuals and teams, guide them through selected improvement projects, and help lead other quality improvement work as needed. “Year one was about getting people to understand the methodology and how to use it,” says McGrath. “This year will be about providing the infrastructure to support project execution and sustaining that competency development.”
Stone and Horvath presented results from the EVAR care path project recently at D-H’s Value Grand Rounds, where multidisciplinary teams demonstrate and celebrate efforts that produce results. Notably, Horvath was the first Value Institute student—trained internally to be a project leader—to present at Value Grand Rounds.
Leading the Way
The project was recently submitted for presentation at the Society for Vascular Surgery’s annual meeting in San Francisco. “We’re excited to share our results,” says Stone, “and these savings can be significantly amplified when we apply much of this work to the remainder of our practice. This is a real opportunity to take a proactive leadership role, not only locally here at D-H, but regionally and nationally.”