Roundtables

complications and other parameters, it is not easy to know when care is suboptimal. More standardization of care in the proce- dural areas is our best bet to learn how to track quality and then to improve it. Dr. Mossallam: I don't know if there's one that's tougher than the others. Ob- viously, the emergency depart- ment has always been a tough area to maintain because of the rapid turnover of patients and the unknowns with which the patients present. e ability to manage surges and provide the highest quality care when you're being squeezed in several areas is important. As we are all running lean opera- tions, we might not have the excess to handle increases in volume readily [in the ED] — that's always been one of the challenges in maintaining quality. e [Patient Protection and Afford- able Care Act], based on the lessons learned from Massachusetts, will likely result in an increased number of pa- tients seeking care in our ED as well as requiring inpatient care. Dr. Orr: e Achilles' heel is patient behavior. We have a fair amount of con- trol over how the hospital or sys- tem is organized and we can incentiv- ize doc- tors. But if the patient doesn't go along or adhere to recommenda- tions and treatments it will all fail. We have guidelines on diabetes and hos- pital acquired infections, but we don't know how to get patients to change their behavior. e other is herding the doctors. ey're like cats; the only way is by using a lot of tuna. e tuna is the incentive for the doctors. Trans- parency is also an important piece of the puzzle. When you publish doctors' data side by side, they're professional and will respond accordingly. Dr. Shabot: Anything in which the emphasis is on patient-centered care is in conflict with traditional care. ose can be very difficult to change. We've seen some of these challenges, and we're doing well, but they're not easy. All of us on the CMO side, we love technical challenges, where we can just pro- gram something differently. ose are the easy changes — the dif- ficult ones are the ones that cut across culture. But as CMOs, that's our job, to change culture. Dr. Slonim: e biggest challenge at the moment is in the ambulatory en- vironment. Up to this point, we have had large volumes of data to assist us in improving inpatient care, but we have not had the data available to un- derstand the ambulatory environment. Now, through our accountable care or- ganization, we are finally tapping into data about physician performance in the outpatient arena. With that comes a realization of all of the improvement opportunities that exist in ambulatory healthcare to fulfill the triple aim. Q: what are your thoughts on the current federal quality report- ing requirements and reimbursement reductions for readmis- sions? How has your job changed in the past few years because of these changes? Dr. Arredondo: e quality reporting requirements are a fact of life, and we cannot escape them. As an integrat- ed system with hospitals, a medical group, a health plan, homecare, etc., the sheer volume of required measures to report upon is daunting — more than 200 — and the resources required to develop the capacity to report these and improve upon them is costly. Our organiza- tion has devoted significant resources to understanding these requirements and has committed to succeeding with these measures. We find ourselves spending much more time understanding and prioritizing the requirements. We then have to engage our providers and support staff in executing on pro- cesses that have been designed to meet requirements. Dr. Mossallam: e federal quality reporting requirements and initiatives are well-intentioned. Obviously, a lot of work goes into compiling the data and the metrics and that changes some of our processes, but it's oen change for the better. As painful as they are, they have led to process improvements for us and other [hospitals]. As for the readmission issue, it's been something we've been working on for the past couple of years. Here in Detroit, it's a socioeconomical- ly depressed area, and a lot of what prevents readmissions isn't about healthcare. It's about ensuring patients get home safely, that they have trans- portation to their fol- low-up appoint- ments and are able to keep them. It is about ensuring that they do not have to choose between spending money on medications versus food and shelter. It's made us rethink the 'episode of care' — it doesn't end at discharge, but at the safe handoff of the patient to the next care team. We can argue about whether or not that's fair on us, but it has shied our focus and caused us to engage more with our community partners. Dr. Orr: ere are benefits from this, and that's standardization of what is "Most standardization of care in the procedural areas is our best bet to learn how to track quality and then to improve it." -Dr. H. David Arredondo, CMO, Presbyterian Health Services Five CMOs Discuss Challenges, Changes and Advice 3

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