Innovating to Problem-Solve: 7 Takeaways from a Conversation with Dr. Peter Pronovost

Steering innovation with a vision for enhancing both quality and patient safety continues to be of paramount importance even as the healthcare industry increasingly faces a myriad of challenges. In a recent study about the Top 10 Safety Concerns, staffing shortages and other obstacles reflected some of the care delivery challenges that have emerged in these two aspects of healthcare during the pandemic.

Organizations across the continuum of care, therefore, continue to work towards tackling these and becoming high-reliability care systems to better serve their patient population. That means identifying gaps and issues, and solving them, proactively and in novel ways as needed. 

In a recent conversation, Dr. Peter Pronovost, a world-renowned patient safety champion, critical care physician, and a prolific researcher with over a thousand peer-reviewed publications, outlined his journey into patient safety. He dived into his shift in approach towards problem-solving, designing systems to eliminate value defects, focusing on patient experience and outcomes, enabling transdisciplinary research to synthesize diverse knowledge to reduce risks, developing strategies to address the current labor constraints, and more.

Dr. Pronovost’s transformative work leveraging checklists to reduce central line-associated bloodstream infections has saved thousands of lives and earned him national acclaim, including being named one of Time Magazine's 100 Most Influential People and a recipient of the prestigious MacArthur Foundation Genius Grant, and he continues to lead groundbreaking initiatives.

Today, he serves as the Chief Quality and Clinical Transformation Officer and the Veale Distinguished Chair in Leadership and Clinical Transformation at University Hospitals (UH). He also serves on the President's Council for Science and Technology Patient Safety Working Group, advises the World Health Organization's World Alliance for Patient Safety, and regularly addresses Congress on patient safety issues. He's a strategic advisor for several healthcare technology and venture capital companies, has founded several technology companies including VisICU and Doctella, and is known as one of the top 25 innovators and most influential executives and physician leaders in healthcare. 

Here are 7 key strategies and lessons from Dr. Pronovost for building efficient health systems that empower care teams and patients alike.

1. “Leading with Love” to drive innovation

Dr. Pronovost shares that considering a lot of healthcare is still primarily fee-for-service, and clinicians are often more focused on their patients only, the fusion of evangelism and science is vital. It creates a culture that gets care teams to think about the quality of care at a system level and implement successful large-scale changes. 

When he first joined UH, there was a lot of focus on meeting the budget. Dr. Pronovost’s goal was to create a model of value in healthcare, and doing that by “leading with love … That is accelerant. Get that culture right for innovation, because innovation occurs when diverse ideas meet and connect with each other.” 

In fact, Dr. Pronovost’s podcast, titled Micro Moments with Peter also focuses on "micro moments" of collaboration and resonance that have a profound impact on clinical transformation and quality improvement. This includes empathetic patient interactions, supportive conversations with colleagues, and collaborative problem-solving sessions.

In concrete terms, that meant identifying known defects in value in care delivery - be it in preventative care or chronic disease management - and eliminating them. And then transforming care at a system level by leveraging technology.  

2. Keeping people healthy at home

For UH, one of the biggest focuses remains to keep people healthy at home. Considering the budget and health system margin restraints, Dr. Pronovost implemented a “Believe, Belong, Build” model that was used to transform UH - its success measured by improved outcomes, financial stability, and enhanced access to care.

1. Belief – Getting “every employee to believe that value is their responsibility and that they are powerful to do something about it” and ensuring managers evolve from “command and control management” towards “inspiring people.”
2. Belong – Creating a structure and culture that supports all individuals involved. “Our simple rule for any project is that every higher level of the organization needs to create a table where every lower level has a seat because that allows them to co-create goals,” shares Dr. Pronovost. ”It allows horizontal sharing of information and vertical sharing for accountability.”
3. Build – For UH, this meant developing a fractal management system. It's a checklist having clear goals and roles, an enabling infrastructure to achieve these goals, an effective communication system to share ideas and best practices, a peer learning community, and ensuring the ability to report transparently and have a shared accountability system.

The focus is on cultivating a “self-enforced” culture that empowers the team and the system to be efficient, autonomous, and able to autocorrect when it comes to improving quality and safety. The success of a system lies in its ability to run itself without micro-management, according to Dr. Pronovost.

This model is what led UH to win the American Hospital Association Quest for Quality Award and “It's the only model that we've seen that now allows us to have a strategy that wins in fee for service, which we're still mostly paid, wins in value, and improves access in our community, our population's health needs,” shares Dr. Pronovost. 

Also, the model has enabled UH to keep people healthy at home, rigorously reducing length of stay for surgical patients by giving them different access points for better care in the community, be it providing access to same-day specialists from primary care, doing hospital at home, setting up a virtual clinic from the ED, etc. 

Reducing the labor costs and being able to free up units in the health system to create more surgical units, while empowering patient care outside of a hospital setting, helped UH “win in our ECO contracts and our fee-for-service and free up capacity to meet the unmet demand for things that need care in the hospital. It's this virtuous cycle - we turned our finances around from losing a whole lot last year to now being ahead of budget through this integrated approach.”

3. Connecting digital health to value transformation

In a recent publication with Dr. Brian D'Anza at UH, Dr. Pronovost outlined a digital health framework to help system leaders better connect digital health to value transformation.

It names 3 categories of digital health: telehealth or direct care delivery, digital access tools, and digital monitoring. For Dr. Pronovost, adopting a problem-focused framework for connecting digital health to value in healthcare helps prioritize solving problems rather than getting distracted by trendy technologies. 

He also emphasizes that health systems need to start thinking of innovation in terms of problems that need to be solved. For instance, Dr. Pronovost outlines a four-part strategy being implemented at UH to address the challenges of current labor constraints, the resulting costs, and the potential increase in safety risks. It includes identifying work that can be stopped, automated, outsourced, or kept sacred at the bedside.

1. Stop: For instance, working with a large group of UH nurses to ask which policies lead to more burden than a benefit, which led to a revision of almost 80 policies and taking them out of the 1500 order sets they were embedded in. Or using asset-tracking technology to ensure nurses don’t have to spend 1/4th of their time hunting for supplies. 
2. Automate: Dr. Pronovost suggests this could be using remote patient monitoring or identifying which part of the discharge process can be automated.
3. Outsource: Identifying “what could either be outsourced more productively or allocated to another caregiver that is maybe less expensive or more available.” For instance, a bedside nurse has a role in discharge but every patient is seen by a care coordinator nurse to do the discharge as well. Reducing duplication can raise the fear of more strain on one role. However, if an outsourced nurse is brought in, you can “combine the work at 50% labor savings,” he shares.
4. Sacred at bedside: Tasks or processes that are essential, and need to remain as is. 

4. Creating scalable projects

Dr. Pronovost shares that “there's a lot of beliefs around the digital piece that we have to rethink” and challenge. This includes the overemphasis on technology rather than focusing on the problem, the notion that technology alone can succeed without rigorous usability testing, and the idea that pilots are enough without a clear plan of scaling. 

He challenges the academic mindset that is often focused on grants and publications. The focus, he emphasizes, should be instead on the ultimate goal of bringing the benefits of learning to patients, which requires scalability.

“Health systems are riddled with pilots that work that never go anywhere and that’s because it's too often owned by the ventures or the innovators rather than operators,” he states. Instead, UH has a model that combines the two - innovators have a role in problem definition, diligence, and running the pilot, but operators have to commit to solving these big problems. Post pilot, there’s an ROI analysis, and operators are then entrusted to scale it. 

He reiterates how “Every pilot that I do, every project, I think scale from the very beginning and why that's so helpful, it forces me to simplify. So many of these complex projects that you do in a pilot, they're either way too expensive to scale or they're not practical enough given the complexities. Then why do it? If it's not going to be a model you can scale, you're wasting your time. Let's focus on something that is scalable.” 

It is aligned with the concept of having a problem-solving framework - whether that is understanding how it fits into the frontline care team’s workflow, whether it will drive revenue, does it solve a problem - all components that have to be solved for at scale, from the very beginning. 

5. Successful implementation of ERAS

With a vision to shorten length of stay and thereby increase surgical throughput, Dr. Pronovost and his team at UH did a system-wide roll-out of Enhanced Recovery After Surgery (ERAS) programs. Even as COVID-19 hit during the planning stage, turning a crisis into an opportunity, Dr. Pronovost worked with the team to roll out ERAS across 15 service lines.

Utilizing a fractal structure for coordination across levels - where each service line had its own team and a lead, and each hospital had its own lead as well - the implementation was done in cohorts of 5 service lines. This fractal system allowed for rapid scaling. 

Since implementation, the system has achieved impressive adherence rates, increasing adoption from ~25% to ~80%; reduced surgical length of stay from 6.2 days to 1.8 days; and significantly lowered complications, costs, and mortality across various service lines.

Dr. Pronovost emphasizes that even though setting a target of 15 service lines, vs starting with just one as health systems usually do, is a big ask, what enabled the success is the “shared accountability because it's not like I walk away and wash my hands. I say, ‘okay, here's how we're going to make this feasible’. Start with one to get the prototype and then get leaders for these other ones and they could use that [prototype] to go create it [service line plans].” 

It enables sharing of best practices around protocols to implement, how to best engage people, etc. - and creates an iterative process where learnings, and consequent improvements, can be applied from one cohort to the next. It helps foster a “culture of learning and improving” that reduces the cycle times and builds a “management system that is then self-sustaining.”

6. Navigating healthcare consumerism

As big tech companies such as Amazon and CVS enter the healthcare landscape, Dr. Pronovost outlines four key priorities to strategically navigate this competitive environment.

1. Reduce bloated cost structures by targeting overhead, improving productivity and clinical outcomes like readmissions, length of stay, and complications, and eliminating waste and inefficiencies.
2. Evolve care models from “reactive and transactional to proactive and relational.” For instance, he reiterates that currently all quality and safety efforts are focused on being transactional and individual - when a patient shows up in ED, the department does its part, moves them to the next specialist or surgeon, and so on. The question to be asked is “How do we connect across the care continuum in hardwired ways?”
3. Enhance access and patient experience by addressing the current challenges and inefficiencies in scheduling and appointment processes.
4. Maximize value by focusing on high-quality care that delivers superior outcomes and experiences is a crucial aspect in establishing competitive advantage, considering that “CVSs and others had carved out a place because most health delivery systems didn't have good value,” shares Dr. Pronovost.

As more physicians are increasingly taking the leap to get into launching health tech startups, Dr. Pronovost advises the key to producing technology that adds value and stands out are:

• Focusing on the problem relevant to patients and creating solutions that impact health delivery systems.
• Having clarity about the problem you’re solving and fitting it into a clinician’s workflow.

7. Creating Centers of Excellence to drive value

With a mission to develop a patient-centered, high-value integrated program, Dr. Pronovost created the Centres of Excellence (CoE) at UH. Taking ERAS a step further, these CoEs look to optimize protocols, promote best practice guidelines, and eliminate unnecessary treatments and procedures.

At CoEs, comprehensive navigation, appropriateness criteria, and transparency in outcomes sharing result in enhanced value, appealing to both employers and payers. For instance, “within 48 hours of you getting scheduled, a nurse is on a call or on a digital call with you answering your questions, making sure you have your papers. They stay with you every step of the way of having appropriateness criteria because we know 30% of every procedure is not needed, but nobody does appropriateness where we say, no, that's a defect in value if you have an operation that you don't need.”

The overwhelmingly positive outcomes have since resulted in selling to commercial payers, private employers, and direct-to-employer contracting, which enables fulfilling cost margins from commercial payers. 

For more insights from Dr. Pronovost, listen to the full interview here.

And if you’d like to learn more about the ERAS program at University Hospitals, watch our Best Practices for Deploying an ERAS Program webinar with Dr. Heather McFarland, Vice Chairman, Operations at UH, and Dr. Kevin Elias, President, ERAS USA and Gynecology ERAS Leader at Brigham & Women’s Hospital.