Children’s Hospital of The King’s Daughters, Norfolk, Virginia
Children’s Hospital of The King’s Daughters (CHKD), a 200 bed freestanding children’s hospital, the only such facility in Virginia, was facing a series of challenges increasingly common among children’s hospitals. Standard & Poor’s1 reported that changes on the horizon, including those stemming from healthcare reform, could affect children’s hospitals traditional “niche” role and identified the importance of physician integration due to commercial and Medicaid payment contracts being increasingly tied to cost and quality. To address these challenges, CHKD implemented a co-management model in the operating room. Employed, contracted, and independent community physicians were engaged as partners with the hospital to align their interests in improving patient care.
Co-management is a collaborative approach to engaging physicians and hospital staff to identify and prioritize work. It enables physicians’ active participation and leadership in providing expertise and support to improve quality, safety, efficiency, patient experience, access, and strategic development. Physicians, administrators, and hospital staff work together to achieve data-driven, evidence-based management performance improvement goals with an emphasis on accountability and measurable results. A formal structure was created to establish, measure, and closely manage the desired performance improvement outcomes, providing pay-for-performance compensation incentives for achieving set goals.
Among the numerous benefits for the hospital is engaging physicians by offering them a seat at the table to make or influence hospital decisions affecting their patients. An important byproduct is transparency, collecting and reporting valid and reliable data to enable timely and effective decisions. Structured appropriately, clinical co-management arrangements meet all federal and state regulations and guidelines.
To address these challenges, CHKD implemented a co-management model within its perioperative service line to engage its employed, contracted, and independent community physicians as strategic partners in collaboration with the hospital to create better financial alignment and clinical integration. The first Perioperative Co-management Cycle included 60 participating physicians, representing a mixed medical staff, including employed, contracted, and independent community physicians within 11 pediatric surgical sub-specialties and anesthesiology. All preoperative, OR, and post anesthesia care nurses (RN and LPN), surgical technicians, sterile processing, janitorial, and other staff, 150 in all, worked together with the physicians over a four-month period. Physician participants were eligible for participation if they completed 100 cases in the preceding 12 months, or were in a low-volume specialty tied to the hospital such as pediatric neurosurgery. All hospital staff participants, whether clinical or administrative, were full-time employees.
The results of the first four-month cycle are summarized in Figure 1. Real improvements in important measures were obtained. In the quality and safety category, for example, infection prevention measures for patients with spine and ventriculoperitoneal shunt operations were dramatically increased. Infections in these patients, with implanted hardware, not only cause suffering, but create need for reoperations and prolonged hospitalization. Efficiency, as measured by release time compliance, on-time starts for the first case of the day, and cost per case for tonsillectomy and adenoidectomy, a high-volume case, also improved markedly. The patient satisfaction measure went up on a national survey measure. Through the first year after implementing the co-management model, CHKD has achieved a net $4.5 million return from reducing unnecessary utilization and operating expense while improving clinical outcomes, access, and the patient experience.