CVSL Leaders Address Avoidable Utilization

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AVOIDABLE UTILIZATION:
WHERE TO START

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Gordon B. Wesley,
DBA, FACHE

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Avoidable utilization is much more than the latest health management buzz phrase. It is a concept that is central to CV service line strategic plans all over the country.

Gordon B. Wesley, DBA, FACHE, is the Cardiovascular Service Line Administrative Director at St. Vincent’s Health System in Alabama. When it comes to addressing avoidable utilization, Gordon is ahead of the curve. He has been leading initiatives in this important area for years and has important insights that can benefit CV service line leaders as they take on this emerging issue.

What is avoidable utilization?

There are many definitions and explanations, but Gordon prefers to define it in its most basic form: “Avoidable utilization is the use of anything that doesn’t provide value.” It is where a CV service line is not running as efficiently as possible.

A key responsibility of the CV service line leader is to identify and eliminate areas of avoidable utilization in their department.

Approaching this task can feel quite daunting, so Gordon recommends starting by asking 3 simple questions:

What areas present an appropriate starting place?

For practically every procedure or protocol in the CV service line, guidelines and best practices exist.

Adverse event rates, device utilization rates, post-operative mortality rates, and lengths of stay are examples of metrics that are helpful benchmarks. Metrics like these provide essential guidance on where to start looking for opportunities to eliminate avoidable utilization.

Some valuable sources for industry guidelines and appropriate use criteria Hospital Registries: ACTION Registry—STEMI/PCI CathPCI Registry—PCI LAAO Registry—Left Atrial Appendage Occlusion PVI Registry—Peripheral Vascular STS/ACC TVT Registry—TAVR, Mitral Valve Repair EP Registry Suite: ICD Registry—ICD AFib Ablation Registry—EP STS: Adult Cardiac Surgery

Step 2: Compare your metrics against the benchmarks

With benchmarks in hand, compare those to the metrics of your CV service line and identify disparities. A CV service line that is delivering results better than industry benchmarks is an indication of effective utilization. However, those areas where the performance metrics are well below industry standards are where avoidable utilization is likely to be present.

These low-performance areas are the starting point for addressing avoidable utilization.

“If you don’t have a physician champion, that is a big red flag,” cautions Gordon. “It is important to have internal champions that are behind the idea.”

An initiative that creates change in a CV service line is a difficult undertaking. Before selecting an area to focus on, recognize that it will require a team effort. It is good practice to “shop around” ideas about where avoidable utilization could be reduced. Share numbers, talk tactics, ask for ideas—and have a physician champion. This is an essential part of success.

The right champions in the right seats will make all the difference. A physician champion is critical, but considering the influence of the larger team, having champions on the tech level, nurse level, and more are all factors that are required for success.

Now that the initiative has been selected—based on examining metrics and identifying champions—propose the initiative to leadership. Prepare a presentation that shares all the important data, shows the cost, and demonstrates the impact of making the proposed improvement. Also, bring along the physician who has chosen to champion the initiative to answer any questions leadership may have and to demonstrate their rt.

With benchmarks in hand and champions in the right seats, roll out the initiative to the CV service line. Clearly define a process so staff can follow along, but it is also important to communicate the “why” behind the initiative.

“You want to make sure the motivation is there from the start,” says Gordon. It is not enough to just educate the staff about how to follow the new procedures—it is equally important that they know why the new procedure is being put into place.

Examples of initiatives that address avoidable utilization

For Gordon at St. Vincent’s, outcome metrics and cost associated with coronary artery bypass grafting (CABG) were key areas to address avoidable utilization. They targeted the way in which they evaluated which patients were reasonable candidates for surgery.

They used an established, predictive model like the Society of Thoracic Surgeons' calculator as a tool to understand the risks of surgery.

Comparing the results of these calculations against predetermined values led them to change how they determined which patients were candidates for surgical intervention vs a watchful waiting approach. The results have been extremely effective at reducing unnecessary CABG procedures in high-risk patients who may benefit from medical management or protected PCI.

Another fruitful initiative at St. Vincent’s was examining the use of anticoagulants during PCI procedures. Across their service line, they found great variability in the number of clinicians prescribing high-cost anticoagulants vs heparin—and determined that improved assessment of patients at risk for bleeding may be an area where avoidable utilization could be addressed for appropriate patients.

Gordon worked with physicians as part of a national pilot program to develop a calculator to standardize the use of higher-priced anticoagulant medications. By getting physician input on the parameters, working to get their feedback on its functionality, and showing comparative data of their peers, Gordon was able to work with physicians to better stratify patients and reduce overall healthcare costs in PCI patients while still providing quality outcomes.

Carefully watch progress as the initiative is rolled out. These metrics will be essential to tracking the impact and refining the initiative as it progresses.

3 distinct types of metrics that should be monitored

Compliance – Is the staff following through with the new procedures? This does not give you an idea of whether the initiative is working, but it tells you if people believe in the new process and are working to make it a success.

Lead measures – The first official data the initiative produces. These measurements will be seen more immediately. These measure short-term outcomes and will produce the first real data to indicate the effectiveness of the initiative. An examples of a lead measure is tracking and measuring contrast usage (acute kidney injury), door-to-EKG (door-to-balloon time), or documentation compliance (appropriate use criteria).

Lag measures – These metrics can take months to report. They are often the most impactful and powerful metrics, and it is essential that they are included. However, these are not often the metrics that will provide insight during the initiative’s rollout—these provide validation of the greater value of the initiative.

No initiative is perfect from the start. Recognize this and build refinements into the expectations so course-correction is already part of the plan.

Examine metrics, especially compliance with the new procedures. Talk to people. Get feedback and suggestions. Discover the things that are creating issues and holding the staff back from pulling the initiative through.

“It’s more than transparency. It’s proactive transparency. Put the results everywhere. The stuff should be on the walls, in the procedural areas, and in the physician reading room.”

Gordon B. Wesley, DBA, FACHE
Cardiovascular Service Line — Administrative Director
St. Vincent’s Health System

The staff is working hard and changing behaviors. Hopefully, they know the why behind the initiative. They believe in the initiative’s value and are working to make it a success. Do not lose the momentum and commitment. Be sure you are sharing the results of the initiative every step of the way.

Sharing results—even mediocre results—will help sustain people’s investment in the initiative. It brings more ideas for solutions and improvements. It rewards them for putting in the effort of making changes to how they do things. It builds a sense of team. Share your results with “proactive transparency.”

Put avoidable utilization at the top of your list

In a healthcare environment where CV service line leaders are being asked to take on more tasks, avoidable utilization may seem like yet another priority on a list that is already too long.

Gordon sums it up perfectly: “If I have a patient and they're occupying a bed 1 day longer than they could have, it means a different patient can’t get that bed. Our work touches the community in an important way—and addressing avoidable utilization allows us to do that more effectively.”