Paramedics used to routinely ignore do-not-resuscitate (DNR) orders for seriously ill or dying patients despite the protestations of family members. Even though end-of-life directives had been in place since the 1970s, they fell into a grey area outside hospital settings. In fact, a lack of legal clarity surrounding DNRs actually prevented, by each state’s policy, emergency medical services (EMS) professionals from honoring them. This ethical dilemma, in part driven by a flaw in the system of care, did not serve either patient or care provider well.
So in 1992, James Adams, MD, current professor and chair of the Department of Emergency Medicine at Northwestern University Feinberg School of Medicine, conducted a state-by-state study investigating the application of DNRs in nonhospital environments. This work helped clarify the national picture, improve quality of care by expanding the scope of DNRs through legislation, and gave him keen insight into the power of enhancing systems to achieve the best patient outcomes. This early-career experience set him on a course to focus on healthcare systems to improve quality. It has also made him uniquely qualified as the newly appointed chief medical officer (CMO) for Northwestern Medicine®. His goal: To do everything better to ensure the highest quality of care.
“We can trust that the current standard of care delivered at Northwestern is the best that has ever been provided, but that’s not good enough,” says Dr. Adams, who has headed emergency medicine since 2000 and led its transformation from a division to a department of medicine in 2004. “This is an exciting time. We have the rare opportunity to create a high-quality, patient-centered, science-driven enterprise—Northwestern Medicine. Few institutions in the world are equipped to make the next research discoveries leading to improved therapies and apply them in one coherent healthcare organization, and we will be one of them.”
All together now
On September 1, 2013, the Northwestern Medicine partnership that was forged in 2009 between the Feinberg School of Medicine and Northwestern Memorial HealthCare (NMHC) took an important step forward. On that day, an aligned health system, called Northwestern Medical Group (NMG), was formed when the school-affiliated Northwestern Medical Faculty Foundation (NMFF) joined the Northwestern Memorial Physicians Group. With this union, NMG counts itself among one of Chicago’s largest medical practices, with more than 1,000 physicians and other healthcare professionals. As Northwestern Medicine CMO, Adams and other leaders will put in place cohesive systems and structure to ensure that this aligned organization provides optimal care, from the outpatient to the acute-care settings
While cultural clashes might seem inevitable when bringing together what were once longstanding independent practice groups, Dr. Adams has no worries. “The health system formation is not about a trade-off of values,” he says. “The culture is really already here to amplify and prioritize what we want and need to do to provide better patient experiences.”
Combining the clinical enterprise into one system follows the Northwestern Medicine strategic plan that was unveiled four years ago. The melding of the practice groups only further solidifies the common vision of the medical school and its affiliates moving forward. “The alignment is about becoming greater than we were as separate entities by improving quality, reducing inefficiency, and expanding the care we provide,” says Peter McCanna, named executive vice president and chief operating officer of Northwestern Medicine in September. “By forming a single health system, we truly believe one plus one can equal three, four, or even five.”
Formerly Northwestern Memorial’s chief financial officer, McCanna will now help to ensure that all divisions and affiliates operate at optimal performance: achieving patient satisfaction, employee engagement, reliability, and efficiency goals; and that Northwestern Medicine meets the challenges and opportunities of healthcare reform and other future trends.
Sitting room always
Deeply entrenched in the high-adrenaline environment of the emergency department (ED), Dr. Adams doesn’t need to theorize about the pressures of those who provide and receive care. He’s seen the chaos that can ensue when staff is short on time and patients wait in sometimes noisy and crowded conditions. At the frontlines of care, he has also benefited from process improvements. It’s this perspective that energizes other Northwestern Medicine leaders involved in the clinical formation.
“He’s not just an ivory tower thinker―he knows how to get the job done,” says Julie Creamer, senior vice president, Northwestern Memorial HealthCare. “And that’s a rare combination of skills.”
Leading a number of transition activities for the new clinical enterprise, Creamer will work closely with Adams as the alignment process initially zeroes in on quality, culture and technology implementation. In October, Northwestern Medicine created 12 formation teams that will get to the nuts and bolts of becoming a coordinated system. Key content areas range from the ambulatory patient experience and clinical growth to communications and finance. Corporate-level functions have also been combined to create consistency across the entire health system; for example, Creamer will oversee a Business and Corporate Development group.
Creamer has significant experience managing complex initiatives for Northwestern Medicine. She co-led the development of the strategic plan and its implementation through annual shared goals between the medical school and NMHC. “Tapping into diverse expertise across campus has been key to our success,” she says. “Hundreds of individuals have participated in the strategies and goals, and we will replicate this approach as we form the health system. The talent and energy of the Northwestern community is an incredible asset, and together we will continue to achieve important outcomes.”
In his own sphere of influence, Dr. Adams has looked for ways to change processes to deliver excellent care. For him and those who follow his lead in the ED, listening to patients is essential to that mission. “Listening can improve the diagnosis, which can help us, for example, avoid unnecessary testing,” he explains. “Also, informed patients are happier patients who know what to expect and are better able to participate in their own care.”
However, giving patients the opportunity to speak requires a system that allows time for physicians to have this type of interaction. If achieving productivity levels gets in the way of delivering patient-centered care, then perhaps efficiencies need to be adopted, according to Adams.
“It’s important to make sure the right tools are in place to achieve what you value as an organization,” he says. “In the ED, we make it a priority to listen to our patients by physically sitting down in the exam room. At the most basic level that may mean making sure there is a chair to sit on.”
In practice, quantifying quality that drives patient outcomes will result from collecting lots of data. Adams plans to use national care metrics, scientific evidence-based findings, and internal processes to develop standards to raise the quality bar. The ongoing feedback of patients, nurses, physicians and others involved in the clinical enterprise will provide reality checks.
A primary care physician receives the results of a patient’s test: blood in the urine. Is it a contaminant? Repeat the test? Order a CAT scan? Involve an urologist? Which one? Today, these questions may arise for doctors practicing within the recently formed Northwestern Medical Group. In the future, as the health system alignment ramps up, quality systems will be implemented that will yield a much more efficient, best-of-care scenario. Based on quality models, that same physician might be advised to order a CAT scan and refer the patient to a specific clinic where a urologist who subspecializes in such abnormalities can quickly address the problem. At least, that’s what David Mahvi, MD, James R. Hines Professor of Surgery and chief of gastrointestinal and oncologic surgery, envisions in his new role as NMG president.
“Throughout all the practice groups, there was a bit of dis-coordination of services. It wasn’t always easy to figure out who at NMFF, for example, might be the perfect specialist for your patient’s situation or which hospital you should send your patient to for treatment,” says Dr. Mahvi. “The clinical alignment will allow us to better coordinate care and grow our entire enterprise.”
His passion for healthcare system development as well active leadership with NMFF made Mahvi the right candidate to lead the NMG. Now with one practice group on the same “best patient experience page,” the work begins for him and other system leaders to encourage everyone to think about quality. From his experience helping to integrate Lake Forest Hospital’s surgeons and surgical services into the Northwestern Medicine family in 2010, Mahvi learned an important lesson. “As long as our missions are aligned, everything works out great. “
At the end of the day, being at the top of industry performance will offer patients the latest diagnostic and treatment options. Examining inefficiencies and duplicated services will lead to more cost-effective, value-based care. (Already the wheels are in motion to implement one electronic medical records system, EPIC, in the ambulatory setting, which will allow for patients to receive one bill and facilitate communication among clinical care teams.) And truly listening to those who seek health services—from the routine checkup to the latest therapy for a complicated condition—will focus all clinical efforts toward patient-centered care.
But Dr. Adams wants to takes this vision even further, delivering service to patients and humankind. “At Northwestern Medicine, we need to go beyond how we see ourselves in the everyday care of our patients, which is still vitally important and valued,” he says, “to becoming a place where individuals with complicated diseases turn to for hope that is real and accessible.”