For This Health System, Less Is More

Kimberly Skelding, a physician at Geisinger Health System in Danville, Pa., jokes with Clark English, 75, a cardiac patient of hers who has had several stents. (Ricky Carioti - The Washington Post)

For heart bypass surgery, Geisinger guarantees that every patient will receive 40 action items it has identified as best practices. The list includes, for example, properly administering antibiotics within 30 minutes of the operation. The wrong dose increases the likelihood of infection, and infection can lead to a second surgery, prolonged hospitalization and greater risk of death.

Surgeons can opt out of doing any element if they give a reason, and an operation is canceled if a single step is missed in the preparations. Electronic medical records contain built-in reminders for the surgical team and track the results.

"No one thing on the list is magic," Casale said. "It's the reliability of knowing that every single one is going to get done on every single patient. That is the magic."

Cutting Out the Quirks

Just a few years ago, when a patient showed up in the cardiac unit at one of Geisinger's hospitals, the first question nurses asked was "Whose patient is he?" -- referring to the six surgeons on staff.

"What they did next depended more on who the doctor was than on what was going on with the patient," Casale said. It was not that one surgeon was better or smarter than the others, but that each had his own quirks and habits.

"We couldn't even agree on which side of the room the bed should be on," he said with a laugh.

The Geisinger program, marketed as ProvenCare, eliminates the guesswork, or "variability," by requiring every employee to follow an agreed-upon set of best practices. For heart surgery, many of the steps came from guidelines developed by the American Heart Association and the American College of Cardiology.

"They have been really smart about not reinventing the wheel," Berwick said.

Geisinger doctors initially recoiled at the idea of "cookbook medicine," believing they already followed best practices, Casale said.

Far from it, they soon discovered. At the start, three years ago, only 59 percent of patients received all 40 critical elements.

Within three months, the cardiac team hit the 100 percent mark, but three months later it fell to 86 percent. Since then, it has held at 100 percent, and Geisinger patients spend less time in intensive care, go home sooner and experience fewer complications. The in-hospital death rate on elective heart surgeries has dropped from 1.5 percent to zero.

Standardizing bypass surgery has saved Geisinger money on ventilators, blood products and staff time. Readmissions, which can be more expensive than the original surgery, have fallen 44 percent, according to Geisinger's data.