Northwestern Memorial Hospital is the only hospital in the United States to have achieved exceptional high-quality outcomes at the lowest-possible costs in two of the country’s biggest public health threats, heart failure (HF) and myocardial infarction (MI) according to recently released data from the CMS.
R. Kannan Mutharasan, MD discusses how Northwestern Medicine is a leader in providing the safest, highest quality care at the lowest cost. He shares how they accomplish this and what multiple process improvement initiatives in place at Northwestern Medicine helped to achieve these results.
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The Holy Grail of Healthcare: Providing the Safest, Highest Quality Care at the Lowest Cost
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Learn more about R. Kannan Mutharasan, MD
R. Kannan Mutharasan, MD
R. Kannan Mutharasan, MD is a cardiologist at Northwestern Memorial Hospital. His clinical areas of interest include sports cardiology and the transitional care of heart failure patients. He directs the Heart Failure Bridge and Transition (BAT) Team, a multidisciplinary team focused on improving outcomes for hospitalized heart failure patients. He is also medical co-director of the Sports Cardiology program. Dr. Mutharasan is an assistant professor at Northwestern University Feinberg School of Medicine.Learn more about R. Kannan Mutharasan, MD
Transcription:
Melanie Cole (Host): Welcome. Here to discuss how Northwestern Medicine is a leader in providing the safest, highest quality care at the lowest cost and how they are accomplishing this, is my guest, Dr. R. Kannan Mutharasan. He’s the Medical Director of the Bridge and Transition Team and an Assistant Professor of Medicine in Cardiology at Northwestern Medicine. Dr. Mutharasan, I’m so glad to have you with us today. Start off by telling us a little bit about your high level thoughts on the state of healthcare costs today. What are you seeing in the trends?
R. Kannan Mutharasan, MD (Guest): Thanks so Melanie. I’m delighted to be here. It’s a very interesting time in healthcare in the United States because we have a lot of technology that’s now coming online. Patients are living longer, living with more comorbidities. All of this points towards more and more expensive healthcare which is really pointing providers and the general public as well as healthcare institutions like our; how do we control these costs. How do we make it such that we are able to bring these costs in line with what we can all afford?
Host: Well then define quality for us. What’s considered high quality patient care?
Dr. Mutharasan: Yeah, it’s a great question. High quality patient care has a lot of different dimensions to it. It’s got to be effective care. It’s got to be good care for the right patient. It’s got to be timely care. It’s got to be care that’s there for the patient at the right time. It’s got to be care that is equitable, that is it’s fair to all people, all people in the community. These are just some of the many dimensions that we consider for high quality care.
Host: Really such an important topic we are talking about today Doctor. According to recently released data, by the CMS, Northwestern Memorial Hospital is the only hospital in the United States that has achieved exceptional high quality outcomes at the lowest possible costs in two of the countries biggest public health threats. That would be heart failure and myocardial infarction. Tell us a little bit about what that means.
Dr. Mutharasan: Yeah, thanks Melanie. We’re really proud of this achievement. What it really means is, CMS, which is the main payor for Medicare claims for people who are mostly over age 65 in this country; really drove down into the data for the patients for whom it’s paying healthcare for. And what it looks at is mortality. What percentage of patients after leaving the hospital with one of these two very life threatening conditions, heart failure or myocardial infarction within 30 days; what percent of patients suffer mortality? That’s the quality component of that metric and then the other component of that metric is the cost or how much money does it cost for the healthcare system in question, in our instance, Northwestern Memorial Hospital; how much money does it cost for them to provide that care in that same 30 day window?
And so what this metric really looks at is value. Which is what we define as quality divided by cost. So, it’s not just how high quality of care you are delivering or what the costs but the combination of the two and that’s value. And what they identified was that Northwestern Memorial Hospital is the only hospital in the country with significantly better than expected costs and quality for both heart failure and myocardial infarction.
Host: Doctor, to help achieve the results you are discussing, I know Northwestern Memorial Hospital has multiple process improvement initiatives in place. Tell us a little bit about some of these and how they have helped you to achieve these results.
Dr. Mutharasan: Yeah, so the first thing kind of for us is that we look at heart failure and myocardial infarction when patients have this, it’s not just a medical condition they are suffering from. It’s the social environment that we want to address. We want to help address psychiatric comorbidities. We want to help patients be successful not just from the pure biology of a disease, but also in everything else that defines the disease context. So, to that end, for example for heart failure; we’ve built a multidisciplinary team called the Heart Failure Bridge and Transition Team or BATT team, which is physicians, nurse practitioners, dieticians, pharmacists, social workers who all work together to really identify the core drivers of what is driving someone’s illness. Whether it be for example, a valve that’s leaking severely or it’s because they don’t have a transportation card to be able to get to their hospital appointments. We want to address all of those barriers.
Host: It’s so comprehensive. And how about the heart failure Data Mart? How is that resource being utilized across all ten of the hospitals in the Northwestern Health System?
Dr. Mutharasan: Yeah, so for us, we think of things as kind of the air game and the ground game. So, what I just described to you is sort of the ground game. What’s happening on the ground, in our hospitals, in our clinics, with our patients and their communities. How are we addressing their problems one by one, patient by patient? But we also kind of think about the air game. What are we doing across the system to really monitor at a high level what our quality metrics are and how we are doing? So, as an example, you brought up the heart failure Data Mart. What that is, is a dashboard where anyone whether you are a nurse educator at one of our community hospitals or you are a pharmacist downtown; you can go into the Data Mart and look at what your quality metrics are doing. So, you could look by month, heh, how many people got heart failure education from my team or how many people did we miss and is there a pattern to the patients that we are missing connecting with and how do we then develop better processes in order to get to these patients?
So, that’s the way we can monitor quality at a high level to make sure we’re delivering on these process metrics that then really drive the outcomes that we are looking for.
Host: Well and while we are talking about outcomes, an important aspect to patients and to physicians is wait time. Tell us how working with the Northwestern University Kellogg School of Management is optimizing wait time in your heart failure clinics.
Dr. Mutharasan: Yeah, so one of the really fun things about being a hospital in a university setting is that we have all sorts of academic collaborators coming from all sorts of backgrounds who can bring all sorts of different lessons to bare for patient care. So, we reached out to DR. Van Mieghem at the Kellogg School of Management up in Evanston who is an operations management professor and he brought to our attention this concept called Queuing Theory and it’s a very elegant set of mathematics but it really boils down to the same math that drives for example if you are getting your morning cup of coffee and that coffee company is trying to figure out how many baristas to have in order to accommodate the morning rush, those peaks and valleys in terms of consumer demand.
There’s a math to that and that’s called queuing theory. And so, what we recognized is that when people are discharged from the hospital, it’s not like every single day there’s four or five people discharging from the hospital. There’s a big variability anywhere from zero to 20 patients and to accommodate that variability, you have to model it mathematically. And so what we did was we collaborated with the Kellogg School of Management and modelled what our discharge clinic needed to look like, how many slots we needed, what kind of buffer capacity we needed and put that into practice in order to reduce the wait times in our clinic.
Host: Wow. Thank you for that. So, we’re talking about all of these positives. What are some of the barriers or challenges to reducing healthcare costs Doctor, while providing that high quality care. What else do you feel that you can improve as far as the quality of patient care and how – you mentioned the multidisciplinary approach and comprehensive look at all these aspects, and it is so comprehensive. There’s nursing schedules and appointments and emergency department staffing. There’s so much that goes into this. Tell us about some of the barriers and what you see are some of the challenges and the way that you are overcoming them.
Dr. Mutharasan: That’s a great question. So, one of the fun things about doing this is that it’s a relentless pursuit. We are never finished. And so as soon as we put into place one improvement, we find the next thing to work on. So, there are kind of two things I wanted to highlight. So, one is we’re thinking a lot about how to send patients home on absolutely the right medications for their cardiac conditions and how to insure that they are getting the medications and taking them as instructed so that they can stay well because a lot of the cardiac medications for both heart failure and myocardial infarction really can save lives especially if patients are taking them properly even in the first week or tw after leaving the hospital.
So, we are really focused on how do we take that four to five day hospital visit for heart failure and MI and how do we make that a platform for learning, so patients know exactly what to do when they go home? We have found that while we are pretty good at this, we could get even better. So, medication adherence is one thing that we are really focused on.
The other thing that we are really focused on is really thinking about in the future, how do we take that heart failure Data Mart and take it to the next level? And we are really excited about the Center for Artificial Intelligence that’s been launched within the Bluhm Cardiovascular Institute to really take all the data that our healthcare system is collecting and be able to identify the patients in our network who are at the highest risk for developing cardiovascular conditions like heart failure and myocardial infarction. So, as an example, to make it really granular; the echocardiogram data that might be collected in the office, that might point to a patient who is at risk for developing heart failure in the future and are these people who need to be plugged in or connected to or at least offered specialty care.
Host: Well certainly adherence and follow up and continuum of care are so important aspects. And as we wrap up, it’s my understanding that you have a mantra that you use that sums up what we’ve been talking about today, how to reduce healthcare costs while maintaining quality. Tell us a little bit about that mantra. Explain it to us, Doctor.
Dr. Mutharasan: Yeah so, we think about the right therapy for the right patient for the right diagnosis at the right time. And to us, all four of these elements are really critical. So, we want to make sure that as soon as a patient steps foot in our hospital or one of the hospitals at Northwestern Medicine; that we are really figuring out exactly what that patient needs, and we are narrowed down on exactly what diagnosis we are treating. That quest for really figuring out the diagnosis we think lies at the heart of healthcare quality and we’re pretty focused on that.
And what I want to mention is when we think about diagnosis, we’re not just thinking about medical diagnoses, we’re also thinking about social diagnoses or other things that are contributing to barriers to care. So, the example I used having a bus pass to be able to come down to our office. Well, to us, that’s a diagnosis. That’s a diagnosis of not having the right social infrastructure to be able to access healthcare.
Host: Wow, I mean certainly is such a big picture. And very complicated. Do you have any final thoughts you’d like to leave the listeners with about the high quality of patient care that’s required today as you said at the beginning as we’re living longer but there’s comorbid conditions and wrap it up for us with your best advice.
Dr. Mutharasan: I guess my best advice would be to start somewhere. Find a quality problem that has kind of been bothering you or you feel gee, I could do this better or we could do this better as a team and just start tackling it. Start somewhere. Start with something small. Start with something where you have an idea as to what might work. Put it into place and see if it worked or not and what that does, it does two things. One is it fixes a problem no matter how small but the other thing it really does is it starts to build that teamwork. One of the things that we’ve learned is there’s nothing like a project to bring a team together. And even if it isn’t the exact right place to start, if you start somewhere, then you start to build that momentum, you start to put energy into that flywheel that really starts to build individual as well as organizational excellence.
Host: Absolutely. Wow. Great information. What a great topic. Thank you so much Doctor for joining us today and sharing your expertise for other providers. And that wraps up this episode of Better Edge a Northwester Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine; please visit our website at www.Heart.NM.Org to get connected with one of our providers. If you found this podcast informative and educational as I did, please share with other providers, share with your team, share with your patients and on social media and be sure not to miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.
Melanie Cole (Host): Welcome. Here to discuss how Northwestern Medicine is a leader in providing the safest, highest quality care at the lowest cost and how they are accomplishing this, is my guest, Dr. R. Kannan Mutharasan. He’s the Medical Director of the Bridge and Transition Team and an Assistant Professor of Medicine in Cardiology at Northwestern Medicine. Dr. Mutharasan, I’m so glad to have you with us today. Start off by telling us a little bit about your high level thoughts on the state of healthcare costs today. What are you seeing in the trends?
R. Kannan Mutharasan, MD (Guest): Thanks so Melanie. I’m delighted to be here. It’s a very interesting time in healthcare in the United States because we have a lot of technology that’s now coming online. Patients are living longer, living with more comorbidities. All of this points towards more and more expensive healthcare which is really pointing providers and the general public as well as healthcare institutions like our; how do we control these costs. How do we make it such that we are able to bring these costs in line with what we can all afford?
Host: Well then define quality for us. What’s considered high quality patient care?
Dr. Mutharasan: Yeah, it’s a great question. High quality patient care has a lot of different dimensions to it. It’s got to be effective care. It’s got to be good care for the right patient. It’s got to be timely care. It’s got to be care that’s there for the patient at the right time. It’s got to be care that is equitable, that is it’s fair to all people, all people in the community. These are just some of the many dimensions that we consider for high quality care.
Host: Really such an important topic we are talking about today Doctor. According to recently released data, by the CMS, Northwestern Memorial Hospital is the only hospital in the United States that has achieved exceptional high quality outcomes at the lowest possible costs in two of the countries biggest public health threats. That would be heart failure and myocardial infarction. Tell us a little bit about what that means.
Dr. Mutharasan: Yeah, thanks Melanie. We’re really proud of this achievement. What it really means is, CMS, which is the main payor for Medicare claims for people who are mostly over age 65 in this country; really drove down into the data for the patients for whom it’s paying healthcare for. And what it looks at is mortality. What percentage of patients after leaving the hospital with one of these two very life threatening conditions, heart failure or myocardial infarction within 30 days; what percent of patients suffer mortality? That’s the quality component of that metric and then the other component of that metric is the cost or how much money does it cost for the healthcare system in question, in our instance, Northwestern Memorial Hospital; how much money does it cost for them to provide that care in that same 30 day window?
And so what this metric really looks at is value. Which is what we define as quality divided by cost. So, it’s not just how high quality of care you are delivering or what the costs but the combination of the two and that’s value. And what they identified was that Northwestern Memorial Hospital is the only hospital in the country with significantly better than expected costs and quality for both heart failure and myocardial infarction.
Host: Doctor, to help achieve the results you are discussing, I know Northwestern Memorial Hospital has multiple process improvement initiatives in place. Tell us a little bit about some of these and how they have helped you to achieve these results.
Dr. Mutharasan: Yeah, so the first thing kind of for us is that we look at heart failure and myocardial infarction when patients have this, it’s not just a medical condition they are suffering from. It’s the social environment that we want to address. We want to help address psychiatric comorbidities. We want to help patients be successful not just from the pure biology of a disease, but also in everything else that defines the disease context. So, to that end, for example for heart failure; we’ve built a multidisciplinary team called the Heart Failure Bridge and Transition Team or BATT team, which is physicians, nurse practitioners, dieticians, pharmacists, social workers who all work together to really identify the core drivers of what is driving someone’s illness. Whether it be for example, a valve that’s leaking severely or it’s because they don’t have a transportation card to be able to get to their hospital appointments. We want to address all of those barriers.
Host: It’s so comprehensive. And how about the heart failure Data Mart? How is that resource being utilized across all ten of the hospitals in the Northwestern Health System?
Dr. Mutharasan: Yeah, so for us, we think of things as kind of the air game and the ground game. So, what I just described to you is sort of the ground game. What’s happening on the ground, in our hospitals, in our clinics, with our patients and their communities. How are we addressing their problems one by one, patient by patient? But we also kind of think about the air game. What are we doing across the system to really monitor at a high level what our quality metrics are and how we are doing? So, as an example, you brought up the heart failure Data Mart. What that is, is a dashboard where anyone whether you are a nurse educator at one of our community hospitals or you are a pharmacist downtown; you can go into the Data Mart and look at what your quality metrics are doing. So, you could look by month, heh, how many people got heart failure education from my team or how many people did we miss and is there a pattern to the patients that we are missing connecting with and how do we then develop better processes in order to get to these patients?
So, that’s the way we can monitor quality at a high level to make sure we’re delivering on these process metrics that then really drive the outcomes that we are looking for.
Host: Well and while we are talking about outcomes, an important aspect to patients and to physicians is wait time. Tell us how working with the Northwestern University Kellogg School of Management is optimizing wait time in your heart failure clinics.
Dr. Mutharasan: Yeah, so one of the really fun things about being a hospital in a university setting is that we have all sorts of academic collaborators coming from all sorts of backgrounds who can bring all sorts of different lessons to bare for patient care. So, we reached out to DR. Van Mieghem at the Kellogg School of Management up in Evanston who is an operations management professor and he brought to our attention this concept called Queuing Theory and it’s a very elegant set of mathematics but it really boils down to the same math that drives for example if you are getting your morning cup of coffee and that coffee company is trying to figure out how many baristas to have in order to accommodate the morning rush, those peaks and valleys in terms of consumer demand.
There’s a math to that and that’s called queuing theory. And so, what we recognized is that when people are discharged from the hospital, it’s not like every single day there’s four or five people discharging from the hospital. There’s a big variability anywhere from zero to 20 patients and to accommodate that variability, you have to model it mathematically. And so what we did was we collaborated with the Kellogg School of Management and modelled what our discharge clinic needed to look like, how many slots we needed, what kind of buffer capacity we needed and put that into practice in order to reduce the wait times in our clinic.
Host: Wow. Thank you for that. So, we’re talking about all of these positives. What are some of the barriers or challenges to reducing healthcare costs Doctor, while providing that high quality care. What else do you feel that you can improve as far as the quality of patient care and how – you mentioned the multidisciplinary approach and comprehensive look at all these aspects, and it is so comprehensive. There’s nursing schedules and appointments and emergency department staffing. There’s so much that goes into this. Tell us about some of the barriers and what you see are some of the challenges and the way that you are overcoming them.
Dr. Mutharasan: That’s a great question. So, one of the fun things about doing this is that it’s a relentless pursuit. We are never finished. And so as soon as we put into place one improvement, we find the next thing to work on. So, there are kind of two things I wanted to highlight. So, one is we’re thinking a lot about how to send patients home on absolutely the right medications for their cardiac conditions and how to insure that they are getting the medications and taking them as instructed so that they can stay well because a lot of the cardiac medications for both heart failure and myocardial infarction really can save lives especially if patients are taking them properly even in the first week or tw after leaving the hospital.
So, we are really focused on how do we take that four to five day hospital visit for heart failure and MI and how do we make that a platform for learning, so patients know exactly what to do when they go home? We have found that while we are pretty good at this, we could get even better. So, medication adherence is one thing that we are really focused on.
The other thing that we are really focused on is really thinking about in the future, how do we take that heart failure Data Mart and take it to the next level? And we are really excited about the Center for Artificial Intelligence that’s been launched within the Bluhm Cardiovascular Institute to really take all the data that our healthcare system is collecting and be able to identify the patients in our network who are at the highest risk for developing cardiovascular conditions like heart failure and myocardial infarction. So, as an example, to make it really granular; the echocardiogram data that might be collected in the office, that might point to a patient who is at risk for developing heart failure in the future and are these people who need to be plugged in or connected to or at least offered specialty care.
Host: Well certainly adherence and follow up and continuum of care are so important aspects. And as we wrap up, it’s my understanding that you have a mantra that you use that sums up what we’ve been talking about today, how to reduce healthcare costs while maintaining quality. Tell us a little bit about that mantra. Explain it to us, Doctor.
Dr. Mutharasan: Yeah so, we think about the right therapy for the right patient for the right diagnosis at the right time. And to us, all four of these elements are really critical. So, we want to make sure that as soon as a patient steps foot in our hospital or one of the hospitals at Northwestern Medicine; that we are really figuring out exactly what that patient needs, and we are narrowed down on exactly what diagnosis we are treating. That quest for really figuring out the diagnosis we think lies at the heart of healthcare quality and we’re pretty focused on that.
And what I want to mention is when we think about diagnosis, we’re not just thinking about medical diagnoses, we’re also thinking about social diagnoses or other things that are contributing to barriers to care. So, the example I used having a bus pass to be able to come down to our office. Well, to us, that’s a diagnosis. That’s a diagnosis of not having the right social infrastructure to be able to access healthcare.
Host: Wow, I mean certainly is such a big picture. And very complicated. Do you have any final thoughts you’d like to leave the listeners with about the high quality of patient care that’s required today as you said at the beginning as we’re living longer but there’s comorbid conditions and wrap it up for us with your best advice.
Dr. Mutharasan: I guess my best advice would be to start somewhere. Find a quality problem that has kind of been bothering you or you feel gee, I could do this better or we could do this better as a team and just start tackling it. Start somewhere. Start with something small. Start with something where you have an idea as to what might work. Put it into place and see if it worked or not and what that does, it does two things. One is it fixes a problem no matter how small but the other thing it really does is it starts to build that teamwork. One of the things that we’ve learned is there’s nothing like a project to bring a team together. And even if it isn’t the exact right place to start, if you start somewhere, then you start to build that momentum, you start to put energy into that flywheel that really starts to build individual as well as organizational excellence.
Host: Absolutely. Wow. Great information. What a great topic. Thank you so much Doctor for joining us today and sharing your expertise for other providers. And that wraps up this episode of Better Edge a Northwester Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine; please visit our website at www.Heart.NM.Org to get connected with one of our providers. If you found this podcast informative and educational as I did, please share with other providers, share with your team, share with your patients and on social media and be sure not to miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.