Becker's Spine Review

Practice Management 24 Spotlight on Innovative Spine Care Delivery: Geisinger Neuroscience Institute's Dr. Jonathan Slotkin By Laura Miller G dence in the spine field made defining standards more challenging. Jonathan Slotkin, MD, is the Director of Spinal Surgery at the Geisinger Health System Neurosciences Institute and Director of Spinal Cord Injury Research for Geisinger Health System. He and his colleagues have spent around 50 weeks applying Geisinger's patented ProvenCare methodology to the acute episodic care of elective lumbar spine fusion surgery. More than two dozen providers, administrators, process improvement experts and information technology engineers have been working to reengineer care in a program called ProvenCare Lumbar Spine. There have been significant contributions from neurosurgery, orthopedics, medicine, and many other service lines. "Geisinger has demonstrated that when best practices elements are hardwired into the care delivery flow, you can for sustained periods cause 100 percent of the providers to make 100 percent correct medical decisions in every patient encounter," says Dr. Slotkin. "That's a lofty goal, but one we want to obtain. We always strive to obtain 100 percent compliance with best practices measures — all-or-none bundling." eisinger Health System is known for leading the curve in healthcare innovation by implementing evidencebased medicine and risk sharing programs early to truly lead the charge for change in healthcare delivery. Now, the health system is focusing on innovating in spine care. "It is safe to say that the overarching themes surrounding the Geisinger spine efforts are increasing the value of care delivery and performing analytics on the work we do," he says. "Finally, we are also decreasing unwarranted variation in care delivery. Those themes are intertwined. What we tried to do from the top down and bottom up is to infuse the design of our care delivery system with those themes." Evidence-based medicine The ProvenCare model — first applied to cardiac surgery at Geisinger — generally includes six main steps to create the system: engage champions, compile evidence, establish best practice measures, process redesign, go-live beta and finally go-live production. The core of Geisinger's ProvenCare model is process improvement to reengineer acute episodic and chronic care delivery through: •    Decreasing unwarranted variability •    Error proofing •    Failure mode redesign •    Patient engagement •    Improving work flow •    Building consensus •    Effect analysis While the amount of strong level 1 and 2 data for cardiac surgery was instrumental in developing those standards, the lack of similar strong evi- Dr. Jonathan Slotkin Best practice development When a particular treatment or procedure in spine didn't have strong evidence to support one pathway over another, the physicians and specialists at Geisinger consolidated their experience and expertise in the form of local expert consensus to agree upon the appropriate treatment pathway. The team first compiled all the level 1 and 2A evidence, which takes 10 to 12 weeks and then decided on best practices as a group. Consensus among surgical and non-surgical providers on every element of the best practices is essential to build a successful program. "As you establish best practices, the system has observed that the very act of defining these best practices is one of the key drivers of the observed benefits — all providers review them and become refreshed in the literature," he says. "Achieving consensus among all the specialists isn't always easy, especially with around three-dozen best practices that span preoperative, perioperative and postoperative care. Once they are defined the system goes through re-engineering workflows to incorporate the best practices into workflows." Workflow improvement The team aims to decrease duplication of efforts, unwarranted tests and instances where necessary tests aren't performed to revamp the process. After these areas are identified and best practices are put in place, a "soft go-live" period allows the group to enroll a small number of patients — currently the spine project has close to 40 patients enrolled — to carefully scrutinize and measure how the best practices are performing. "We will identify failures and figure out how to remedy those failures in our data collection phase," says Dr. Slotkin. "We always perform an analysis so we are measuring what we do and get continuous feedback in the form of data and provider observations.  Failure mode redesign techniques allow for rapid reworking of elements that are not yet quite right." Re-engineering an entire workflow process is time consuming, especially at a time when many providers are feeling squeezed for time and unmotivated to work beyond clinical responsibilities. Geisinger developed an innovative payment structure to encourage physicians to take ownership over this process. "Around 20 percent of the physician compensation at Geisinger is variable and dependent on participation and involvement in the process improvement, workflow redesign and other quality projects," says Dr. Slotkin. "It's not that productivity is unimportant, but that 20 percent is variable and much more weighted toward participation in non-clinical and quality improvement initiatives. Geisinger encourages hard work, but not extreme or unwarranted levels of productivity.  Drs. Lee, Bothe and Steele recently reviewed Geisinger's compensation model in an article in Health Affairs, and that article is instructive as to some of the ways to encourage provider participation in initiatives like these."   Future preparation In 2014, the group anticipates releasing the best practices along with a financial bundle that would cover the price for all pre-, peri- and postoperative care associated with lumbar spinal fusion. "We are designing the bundled payments in association with Geisinger Health Plan," Dr. Slotkin says. "We anticipate announcing a very novel and constructively disruptive pricing paradigm associated with this initiative."

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