Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes

ABSTRACT Objective To develop expeditiously a pragmatic, modular, and extensible software framework for understanding and improving healthcare value (costs relative to outcomes). Materials and methods In 2012, a multidisciplinary team was assembled by the leadership of the University of Utah Health Sciences Center and charged with rapidly developing a pragmatic and actionable analytics framework for understanding and enhancing healthcare value. Based on an analysis of relevant prior work, a value analytics framework known as Value Driven Outcomes (VDO) was developed using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement. Results A modular, extensible framework was developed to allocate clinical care costs to individual patient encounters. For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. Conclusions The framework described can be expeditiously implemented to provide a pragmatic, modular, and extensible approach to understanding and improving healthcare value. BACKGROUND AND SIGNIFICANC

A Quantitative Review of Costs: Heart Failure Patients Before and After Implementation of an Integrated Practice Unit Model at University of Utah Health

Knowing the cost of delivering patient care is a mandatory first step as health care leaders are tasked with reducing the cost of US health care. The Integrated Practice Unit (IPU) model espoused by Michal Porter is a patient centered organizational framework whose tenets support value driven care. University of Utah Health has developed a proprietary costing model that gives them the ability to measure both costs and outcomes at the patient, provider, or in this research case, IPU program level. An interrupted time series (ITS) study design methodology is used to evaluate whether there has been an immediate effect on HF patient costs and related indicators post implementation of the HF IPU. The ITS pre/post analyses show an overall declining trend in total HF costs, total HF technical costs, total HF professional costs, HF costs (total, surgical and non-surgical), admissions, ED visits, and mean LOS. While VAD costs dropped initially, they began to increase in the post intervention period. HF readmissions remained flat across the pre- and post periods. Statistically significant and declining trends were observed in HF surgical, and non-surgical cost trends. While not all trends were statistically significant, they may be deemed financially or clinically significant and worth further study

Connecting Healthcare – Leveraging Technology to Promote Value-Based Care in the Emergency Department

The emergency department is a fast-paced and complex environment that serves hundreds of thousands of people a day across the state of Georgia. The establishment of a culture of value-based care in the emergency department is attainable but often falls short when the staff cannot properly leverage the technology available to them. Framed by the Complex Adaptive Theory and The Input/Throughput/Output Model of ED Patient Flow, the purpose of this qualitative case study was to explore how emergency department leaders and staff could better leverage technology to develop and sustain a culture of value-based care. The 30 participants in this study were members of the executive suite, as well as members of the emergency department staff in Georgia. The data were collected through online surveys consisting of open-ended questions. Thematic analysis of the data yielded 5 key themes, including (1) training, (2) time, (3) access to information, (4) troubleshooting, and (5) vendor selection. A key recommendation from this study includes researching the effectiveness of post-implementation health information technology in the emergency department, as it relates to sustaining a culture of value-based care

Facilitadores, barreiras e fatores moderadores na implementação de intervenções baseadas no valor em hospitais

Resumo - Introdução: Valor (eficiência) pode constituir-se como ponto de convergência entre os interesses dos profissionais e os interesses globais da organização. A transição do volume para o valor implicará uma abordagem contingencial, diagnóstico situacional e a congruência entre os elementos do sistema organizacional. A contratualização interna é construto de alinhamento organizativo para a melhoria do valor. Desconhecem-se estudos que sistematizem o conhecimento sobre os elementos que afetam, positiva ou negativamente, a transformação do modelo. Objetivo geral: Descrever e analisar facilitadores, barreiras e fatores moderadores na implementação de intervenções baseadas no valor em hospitais Metodologia: Para identificar facilitadores e barreiras na implementação de intervenções baseadas no valor em hospitais (objetivo 1), desenvolveu-se uma Revisão Sistemática e respetiva síntese narrativa. Para sintetizar concetualmente facilitadores e barreiras na implementação de intervenções baseadas no valor em hospitais (objetivo 1.A), recorreu-se à metodologia Gioia, produzindo-se uma síntese baseada no modelo de congruência. Para analisar fatores moderadores na implementação da contratualização interna orientada pelo valor num centro hospitalar (objetivo 2) e construir um modelo concetual de intervenções baseadas no valor em hospitais portugueses (objetivo 2.A), desenvolveu-se uma grounded theory, com recurso à metodologia Gioia. Resultados: O Estudo 1 (objetivos 1 e 1.A) teve como resultado teórico a Síntese de uma Revisão Sistemática sobre a Implementação de Intervenções Baseadas no Valor em Hospitais: Dinâmicas Tensionais. São facilitadores: gestão do conhecimento e evolução (recursos); confiança mútua (história); cooperação para além do hospital (ambiente); desenvolvimento da inovação (trabalho); gerar e desenvolver lideranças (pessoas); partilha e aprendizagem (estrutura e processos informais); gerir talento e articulação dentro do hospital (estrutura formal); sentido de serviço ao doente (output organizacional); otimização partilhada dos processos e soluções (output grupal); ou engagement e empoderamento dos profissionais (output individual). São barreiras: falta de apoio à decisão (recursos); profissionais não comprometidos (história); barreiras nos cuidados de saúde primários (ambiente); priorização pelo urgente imediato (trabalho); domínio das velhas linhas de poder (pessoas); fronteiras internas (estrutura formal); ou ineficiência sistémica (output organizacional). O Estudo 2 (objetivos 2 e 2.A) teve como resultado teórico a Anatomia de Intervenções Baseadas no Valor em Hospitais Portugueses. A identidade organizacional explica os fenómenos observados na componente (tendencialmente) informal: buy-in, apropriação e disengagement das lideranças intermédias e operacionais (os primeiros constituindo comportamentos estratégicos autónomos); descrédito da estratégia e das lideranças. A cooperação interna explica o conjunto de fenómenos observados na componente (tendencialmente) formal: preparação, desperdício de gestão e unidades territoriais. Discussão e conclusões: A Síntese de Dinâmicas Tensionais apresenta facilitadores e barreiras que influenciam a congruência de uma organização sob a intenção de valor, enquanto a Anatomia de Intervenções Baseadas no Valor apresenta fatores moderadores positivos e negativos na implementação de intervenções baseadas no valor em hospitais. A identificação de influências internas sugere que as organizações de saúde tendentes ao valor atentem na congruência dos seus subsistemas e focos tensionais, ainda que num ambiente favorável. A dinâmica dessas interações, relacionada com a complexidade das organizações de saúde e de cada organização em particular, poderá proporcionar novos modelos, melhorados ou, pelo contrário, limitados ou possíveis. Implicações práticas: Relacionando-se com o caráter social e organizacional da investigação, e procurando acionar os modelos concetuais decorrentes dos Estudos desenvolvidos, propõe-se uma modificação do modelo clássico de contratualização designada Contratualização Interna Baseada no Valor e o Balanced Scorecard (BSC) de Cinco Perspetivas, uma adaptação do BSC às organizações integradas no Serviço Nacional de Saúde.Abstract - Introduction: Value (efficiency) can be established as a point of convergence between both the interests of professionals and the overall interests of the organization. The transition from volume to value will imply a contingent approach, situational diagnosis, and the congruence between the several elements of the organizational system. Internal contractualization is an organizational alignment construct aimed at value improvement. Studies that systematize knowledge about the elements that affect, positively or negatively, the transformation of the model, are unknown. General objective: Describe and analyze facilitators, barriers and moderating factors in implementing value-based interventions in hospitals. Methodology: In order to identify facilitators and barriers in implementing value-based interventions in hospitals (objective 1), a systematic review and respective narrative synthesis was developed. In order to conceptually synthesize facilitators and barriers in implementing value-based interventions in hospitals (objective 1.A), the Gioia methodology was used, producing a synthesis based on the congruence model. In order to analyze moderating factors in implementing value-driven internal contracting in a hospital center (objective 2) and build a conceptual model of value-based interventions in Portuguese hospitals (objective 2.A), a grounded theory was developed, using the Gioia methodology. Results: Study 1 (objectives 1 and 1.A) had the Synthesis of a Systematic Review on the Implementation of Value-Based Interventions in Hospitals: Tensional Dynamics as a theory result. Facilitators are: knowledge management and evolution (resources); mutual trust (history); cooperation beyond the hospital (environment); innovation development (work); leadership generation and development (people); sharing and learning (informal structure and processes); talent management and articulation within the hospital (formal structure); sense of service to the patient (organizational output); shared optimization of processes and solutions (group output); and worker engagement and empowerment (individual output). Barriers are: lack of decision support (resources); non-committed workers (history); barriers in primary health care (environment); prioritization to what is urgent and immediate (work); dominance of old power lines (people); internal borders (formal structure); and systemic inefficiency (organizational output). Study 2 (objectives 2 and 2.A) had the Anatomy of Value-Based Interventions in Portuguese Hospitals as a theory result. Organizational identity explains the phenomena observed in the (tendentiously) informal component: buy-in, appropriation and disengagement of intermediate and operational leaderships (the former constituting autonomous strategic behaviours); and strategy and leadership discredit. Internal cooperation explains the set of the phenomena observed in the (tendentiously) formal component: preparation, management waste, and territorial units. Discussion and conclusions: The Synthesis of Tensional Dynamics presents facilitators and barriers that influence the congruence of an organization under the intention of value, while the Anatomy of Value-Based Interventions presents positive and negative moderating factors of the implementation of value-based interventions in hospitals. The identification of internal influences suggests that value-oriented health organizations are aware of the congruence of their subsystems and tensional focuses, albeit in a favourable environment. The dynamics of these interactions, related to the complexity of health organizations and of each individual organization, may provide new models either improved or, on the contrary, limited or possible. Practical implications: Relating to the social and organizational character of this research, and seeking to activate the conceptual models resulting from the studies developed, a modification of the classical contractualization model is proposed, which we call Value-Based Internal Contractualization and the Five Perspectives Balanced Scorecard (BSC), a BSC adaptation to the Portuguese National Health Service