Reducing Pharmacy Costs Through Improved Utilization

hfm healthcare financial management association

Reducing Pharmacy Costs Through Improved Utilization

Feature: Cinda Bates, Barton S. Richards

By identifying unnecessary spend and changing expensive clinical practice patterns, a four-hospital system achieved nearly $2 million in pharmacy cost savings.

In 2011, faced with steadily increasing costs, Trinity Regional Health System in Rock Island, Ill., began a comprehensive assessment of its pharmacy operations, looking for opportunities to reduce pharmacy spend and optimize payment.The assessment uncovered an opportunity for Trinity to save $1.5 million to $2 million by changing practices related to medication utilization. Trinity’s broad goal for achieving these savings was to use less expensive medications and lower quantities of medications, where possible. To accomplish this goal, Trinity used data derived from benchmarking analyses to raise physician’s awareness of inefficient utilization practices, such as prescribing high-cost medications, and persuade them to refrain from such practices. As a result of this effort, the physicians began using loser-cost drugs and making changes in drug administration and dosage practices, enabling Trinity to save $1.9 million in 2012, or 14 percent of its pharmacy budget. Today, the health system is developing additional pharmacy improvement initiatives to reduce pharmacy costs by another $1.2 million in 2013.

Analyzing Opportunities for Cost Reduction.

Trinity Regional Health System is a four-hospital system that is part of West Des Moines-based UnityPoint Health. Trinity had historically experienced annual increases of 3 percent in its pharmacy department. However, changes in patient mix and acuity levels in high-cost areas, such as oncology, were expected to increase costs by 6 percent in 2012.

The assessment of Trinity’s pharmacy department included a review of inventory, organizational structure, and processes. Again, the focus was on identifying opportunities for savings that could be achieved by improving medication utilization practices across clinical departments. The analysis benchmarked drug expenditures per adjusted inpatient day for each of Trinity’s clinical areas against the same expenditures for a peer group of hospitals. Analyses of areas such as cardiology and oncology, in particular, disclosed significant opportunities for savings.
A medication utilization team was tasked with pinpointing the case of the higher-than-average costs in the clinical areas identifying ways to reduce costs. The team included two pharmacists, who were responsible for identifying the opportunities and performing the majority of the project work. Representatives from the finance and revenue cycle departments tracked and measured the results of initiatives and addressed questions about payment.

The medication utilization team also worked with clinical administrators, such as the chief medical and nursing officers, to designate physician champions and key stakeholders who could use their influence with their colleagues to win support for implementing cost-saving strategies.

Implementing Changes

The utilization team found that an expensive chemotherapy drug, costing $2,665 per dose, could be replaced with a less expensive, but clinically equivalent drug that cost just $249 per dose. Trinity’s chief medical officer, Paul McLoone, MD, and associate chief medical officer, Ahmed Okba, MD, recommended an oncologist who might be willing to be the champion for the initiative. McLoone and the utilization team engaged the physician in a discussion of the benefits of switching to the less expensive medication, supporting their position with third-party benchmarking data showing positive clinical experience with the lower-cost medication.

Persuaded by the data, the oncologist helped to develop protocols for using the less expensive medication. As a result, utilization of the more expensive agent decreased for an annualized savings of more than $100,000.

Other initiatives focused on drug administration and dosage. For example, Trinity had been using standard industry practice for a particular antibiotic, which involves infusing the product into a patient for one hour every six hours. Studies have shown, however, that infusing the antibiotic over a four-hour period every eight hours results in less product used and improved outcomes. The utilization team presented proposed changes in the use of this antibiotic to its Pharmacy and Therapeutics Committee for approval and then worked to educate Trinity nurses on the benefits of and steps involved in changing the infusion process (such as changing the type of bags that held the medication). The new infusion process reduced use of the antibiotic and achieved an annualized savings of $165,000.

In addition to changing from a regular to an extended infusion of the antibiotic, Trinity switched to mixing the antibiotic with a solution onsite at the pharmacy, rather than buying the premixed medication in frozen form, a more expensive process that increased costs by 50 percent.
Over the course of a year, the Trinity team implemented 58 medication utilization initiatives, beginning in November 2011. Trinity saved $600,000 in the first six months of 2012; total real savings reached $1.9 million by the end of the year, with annualized savings adding up to $2.2 million.

Building Momentum with Physician Stakeholders

Once cost savings opportunities and solutions were identified, focus shifted to working with physicians whose support was critical to achieving cost savings. Any barriers presented by physicians could impede success.

Data obtained from benchmarking analyses and published medical studies were presented in different ways. Physicians who were known to be receptive to new ideas were approached first and armed with data they could then take to their wider group of colleagues for discussion. McLoone was instrumental in identifying both physician champions and those who might be less receptive to change. The physician he recommended to champion oncology initiatives, for example, had completed a training program for physician leaders offered through Trinity.
An environment of cooperation already existed between physicians and Trinity because of the medical groups’ prior experience with incentive programs negotiated through co-management and management agreements. Consequently, physicians were open to understanding the need for cost reductions. Nonetheless, their real interest rested in the clinical efficacy of the proposed changes in medication utilization.
Initially, the utilization team’s project leader met with clinical department heads to explain proposed changes in the formulary and prescribing patterns. Meanwhile, McLoone reviewed and vetted research used to support proposed changes and then took part in follow-up clinical discussions with physician groups.

A key factor in gaining buy-in was the way data were presented- with recommendations open to give-and-take discussion that centered on how a medication change would affect the way physicians practice.

Physicians readily adopted initiatives that were well-supported by data and made sense clinically. They also sometimes offered their own suggestions for improvement beyond the recommendations of the utilization team. For example, after learning that an expensive blood thinning agent was being used even in cases where a less expensive agent was clinically appropriate, cardiologists developed guidelines for medication use in the cardiac catheterization lab, specifically noting when the more expensive agents should be used. This initiative led to an annual savings of $95,000.

Working with Suppliers to Reduce Costs

The challenged that surfaced within the medication utilization project were not solely clinical. Contractual issues also threatened to impede progress or stop it altogether.

Because a majority of Trinity’s contracting is conducted at the system level, cost reduction initiatives within the contracting arena affect not only Trinity hospitals, but also hospitals throughout UnityPoint Health. Gaining organizationwide approval for such initiatives and renegotiating contracts have therefore presented additional challenges.

For example, in the case of the premixed antibiotic, Trinity was contractually required to purchase the mixture in frozen form. To be released from this obligation, Trinity had to agree to purchase other products from the supplier in place of the premixed solution. This compromise still resulted in net annual savings of $94,000 for the remaining term of the contract.

Much the way gaining buy-in from physicians requires data, gaining systemwide buy-in of a proposed change requires a coordinated communication plan to inform pharmacy staff and physicians across the organization of the cost savings opportunities and persuade them to accept the change. Presenting the results of Trinity’s successful initiatives has helped to garner support. A pharmacy affinity team. Comprising representative pharmacist members from across UnityPoint Health, collaborates on various issues, including contracting decisions.
The introduction of more generic medications into the market has provided additional opportunities for savings. In one instance, Trinity would have benefited from a change from a branded agent within an antibiotic class to a generic antibiotic with comparable efficacy within the same therapeutic class, but the change would have threatened other affiliated hospitals within UnityPoint Health with the loss of volume discounts made possible through use of the branded product. So the introduction of the less costly generic antibiotic presented the organization’s hospitals with a difficult choice between opportunities for savings: whether to adopt the generic antibiotic or go with the previously contracted brand-name product.

The cost advantage needed to be reevaluated in the face of the introduction of the lower-priced generic product to provide all affiliate hospitals with the opportunity to evaluate savings if they decided to make the change. The cost savings that Trinity reaped as a result of this particular initiative were $166,000 for 2012.

Additional Improvement Opportunities

Since implementing these cost reduction initiatives, Trinity has embarked upon additional pharmacy improvement projects focusing on such areas as utilization, contracting, and payment. Initiatives include the following.

Patient assistance program.
Trinity is developing a structured program, staffed by an FTE, for providing medications to qualified indigent patients to be replenished by the manufacturer at no cost. Using software to identify eligible patients, the patient assistance advocate will work with clinicians and various departments, such as finance and case management, to complete the application required for patients to be accepted into the program. The targeted implementation date is July 1, 2012. The program is to be disseminated throughout the system wherever there is benefit for patients.

Contracting discounts with manufacturers.
In addition to contracting discounts provided through the group purchasing organization, Trinity has been able to receive discounts and avoid annual price increases by complying with additional manufacturer terms, such as purchasing products in bulk based on previous purchasing historical volumes. These contracting discounts, where identified, are coordinated with the group purchasing organization and offered to other affiliates throughout the system for additional value.

Fast-tracking chemotherapy agents.
Trinity is developing a subcommittee of Pharmacy and Therapeutics Committee representatives to address physician requests for chemotherapy agents that are new on the market. The subcommittee will assess payment for the new agents, help to educate pharmacy and nursing staff, and give patients a better indication of their costs for the new agents. This program is targeted for implementation on July 1, 2013. The program will greatly assist the reimbursement and revenue cycle, especially for the infusion center with increasing patient volume in that setting.

Such initiatives are projected to save Trinity an additional $1.2 million in 2013, based on annualized figures. In addition, Trinity has saved $780,000 on the existing initiatives in the first quarter and an additional $169,000 on initiatives like the above which were targeted for 2012. This projection is in addition to the sustained savings from the initial medication utilization project.

Coordinated Efforts

The sum of multiple initiatives in pharmacy can have a substantial impact on the bottom line. However, managing so many opportunities requires a coordinated effort that begins with getting key stakeholders, including administrative and clinical, to understand the cost implications of pharmacy and their roles in driving and sustaining change.

In Trinity’s initiative, finance and revenue cycle also have played key roles in sustaining results. Each month, the finance department provides the medication utilization team with savings reports on each initiative so the team can track progress and quickly address backward trends. For example, if a report shows that a high-cost drug that was at one time replaced has been repurchased, the utilization team can investigate the reason for the repurchase and take any steps deemed necessary to ensure compliance with the new utilization protocols.

Although pharmacy presents ample ongoing opportunities for savings, these opportunities will differ significantly for each hospital and health system. That said, for all organizations, there is ongoing opportunity to evaluate high-cost drugs and treatments and explore the potential for lower-cost alternatives. These initiatives prove to be well worth the effort.

How Orlando Health Improved its Bottom Line by Optimizing Observation Services

healthcare financial management association logo

How Orlando Health Improved its Bottom Line by Optimizing Observation Services

Feature: Richard Basaly, MD, Larry Volkmar, Barton Richards, Poonam Patel

Bringing together clinician “huddles” for quick reviews of the status of patients under observation was just one step that enabled the Florida health system to substantially reduce length of stay among observation patients, thereby reducing costs and increasing revenues by tens of millions of dollar.

Effective management of patients in observation status is important for ensuring a health system’s profitability. By optimizing length of stay (LOS) among patients in observation, a health system can free up capacity for care of patients with higher-acuity conditions. These benefits will remain elusive, however, if the organization lacks a clear strategy and approach for addressing observation management inefficiencies.

Orlando Health in central Florida offers a case example of how one health system has successfully pursued such an effort. As a private, not-for-profit healthcare system comprising eight community and specialty hospitals with over 1,800 beds, Orlando Health was struggling with rising observation rates and associated capacity constraints. The executive team was challenged to reduce observation rates by optimizing the process for determining patient status and shortening LOS for these patients.

To achieve these goals, they designed and launched a multifaceted initiative aimed at improving management of their observation patient population at each of its hospitals.

7 Ways to Ensure Optimal Observation Rates are Established and Observed

Broadly, the initiative encompassed the following seven areas of focus deemed essential to the health system’s efforts to establish and maintain optimal observation rates.

1. Create dedicated observation units.

A lack of bed availability to move patients from the emergency department (ED) created throughput issues for observation patients, with the result that they ended up scattered throughout the hospital. By developing dedicated observation units, a hospital could create cohorts of observation patients while opening up inpatient beds for higher-acuity patients.

The specifics of each observation unit vary by hospital, depending on the space available. Dedicated units range from 15 to 25 beds. Some facilities use clinical decision units that interacted closely with ED staff to help patient placement or the decision to discharge.

Initially, only patients who met selective criteria were placed in observation units. Such criteria applied, in particular, to patients experiencing cardiac-related symptoms. This approach allowed hospitals to pilot the functioning of the observation units and address common barriers before expanding to the entire observation patient population.

With dedicated units, the system achieved synergies in treating patients. The units helped create a culture where it was understood that observation patients had relatively low acuity and should have a short LOS. As such, the care teams were better able to prioritize observation patients for ancillary testing, thereby contributing to a decrease in the LOS. Hospitals were also able to vacate beds on a higher level of care units, including intensive care units.

2. Implement observation huddles.

Observation patients who were not placed in the dedicated observation units also required attention. Taking a lesson from its success in managing inpatients through multidisciplinary rounds, the organization implemented daily observation huddles in an effort to achieve similar results with the lower-acuity population.

The huddles are 15-minute calls in which the care management leader, the utilization review team and physician advisors discuss each observation patient. The huddles have two goals:

  • Assign and communicate follow-up tasks.
  • Convert or discharge observation patients.

Participation of physician advisors in the huddles was key to their success. (The role of physician advisors is discussed in greater detail at step six below). A physician advisor can directly indicate whether to convert a patient or schedule follow-ups with physicians who might have disagreed with the outcome of the secondary level review.

To be effective, huddles also require a strong facilitator who can bring clarity around assignment of follow-ups and reiterate the plan of care for the patient.

Orlando Health saw the observation rate decline immediately after it implemented the huddles, with a 15% percent decline in the number of observation patients staying greater than 48 hours, and a 25% decline in Medicare patients with long LOS.

3. Educate staff on effective observation patient management.

To sustain results achieved, Orlando Health needed to ensure all members of the care team were knowledgeable of observation patient management. The health system developed and delivered specific education to the care management team and bedside nursing, in particular, because these departments were identified as critical to the success of the process changes.

Bedside nurses typically have the most frequent interaction with patients and often are most attuned to when patients are ready for discharge. These staff members were presented with an overview of:

  • The meaning of observation status
  • Documentation requirements for billing
  • Circumstances when inpatient status may be appropriate
  • The role of care management
  • The need for collaboration to improve patient satisfaction, achieve the correct admission status, and reduce LOS
  • In addition to these topics, education for the care management team focused on:
    • Application of the Two-Midnight Rule
    • Observation billing rules
    • When observation is appropriate after a procedure
    • Status implications for the patient

4. Redesign the care management function.

A review of the organization’s care management department disclosed an opportunity to combine the role of care managers and utilization review nurses and establish care management teams to manage caseloads of similar units. Shifting to an integrated dyad model improved collaboration across the continuum of care while serving patient needs in a quality and timely manner.

Orlando Health implemented the integrated dyad model, which combines the roles of care managers and utilization review, to improve collaboration across the continuum of care.

This redesign reduced silos and redundancy of efforts while improving patient flow by centralizing teams responsible for cohorts of patient populations. Care management teams consisting of registered nurses (RNs), social workers and technicians now cover similar units. Staffing for each team is determined based on projected daily census by unit.

A new role, the utilization review liaison, was created to manage denial prevention and ensure timely compliance. Freed of these responsibilities, RN care managers can focus on utilization review and simple discharge planning. Social workers focus on complex discharge planning and coordination of care. The team leverages technicians to support clerical and post-acute care coordination efforts.
Education and hands-on cross-training also were required to clarify new roles and responsibilities.

5. Optimize the ED care manager role.

Orlando Health already had care managers located in the ED, but it wanted to improve collaboration between physicians and care managers in the admissions process. To accomplish this objective, the health system identified workspaces within the ED where care management would be visible and could interact with physicians as status decisions were being made. Care management coverage in the ED was altered to focus on times with historically high volumes, resulting in increased coverage hours of up to 24 hours a day at the largest facility. This change helped bring about the desired collaboration and improved documentation of medical necessity for admissions.

6. Revamp the physician advisor program.

Physician advisors are instrumental in promoting a health system’s financial health. The stringent financial constraints under which health systems must operate in today’s complex regulatory and compliance landscape can leave physicians confused, with patients often caught in the middle. Physician advisors bridge the gap between physician partners and the care management team while supporting the revenue cycle.

To fulfill this role, Orlando Health hired dedicated physician advisors to support these demands. The health system’s initial goal was to have one physician advisor per site, to be available to provide care management for all secondary reviews during business hours. An additional physician advisor was made available on call for the entire system after 5 p.m. to support portal-of-entry care managers. For weekends, the health system instituted a rotating call schedule where one physician advisor would provide coverage remotely systemwide. Because the physician advisors possess not only leadership skills, but also people skills, they have been well received by medical staff, nursing staff, executives and revenue colleagues.

Essential characteristics included:

  • Ability to educate colleagues in a non-confrontational fashion.
  • Strong communication skills to explain complex medical issues to physicians, medical directors of health plans, nursing and executives.
  • Strong written skills to appeal denials with payers.
  • Strong clinical skills, preferably boarded in their specialty, with the ability to formulate strong rebuttals to support medical necessity for hospital care.

7. Institute metrics and reporting to monitor LOS and observation rates.

Orlando Health recognized the need for metrics and reporting to advance and sustain the initiative. The key purposes for reporting are to:

  • Aid in completion of daily duties.
  • Provide visibility into performance metrics.

Targeted reporting for observation huddles and utilization reviews at the point of entry has been particularly beneficial for these areas. An observation scorecard dedicated to care management also was developed to enable the team to monitor performance of the new processes.

Observation huddles.
Although the observation units helped create cohorts of patients in a single space, observation patients could still be found on other units within the hospital at times of high census. Therefore, participants in the observation huddles needed a synchronized worklist to be successful. The health system therefore needed to create an observation census report, listing observation patients within the hospital and additional detail such as current LOS, initial diagnosis and payer source to aid discussion during huddles. The report is automatically created every morning to support care managers’ efforts to prioritize assigned observation patients at the start of the workday.

Portal-of-entry reviews.
The portal-of-entry team reviews cases in the ED for timely and appropriate status determination at the beginning of the patient stay. An indicator of the team’s performance is the rate of admissions for observation. To reduce this metric, a system-generated report is sent to portal-of-entry in the morning and afternoon. The information identifies which patients require an admission review, providing the team with a process to perform a concurrent review process that can have a real-time impact on the status determination process, instead of having to work a backlog of retroactive reviews.

The report alone does not ensure patients receive timely reviews. Incorporating it into the daily workflow, however, has resulted in an increase in patients whose utilization reviews are completed in a timely manner. The observation rate at admission decreased by nearly 10% over the course of four months.

Each facility also has a scorecard for its own metrics for the current month’s performance and trends over time. The most prominent indicators of performance in the scorecards are observation rates and observation LOS, viewed from both a hospital-wide and payer class perspective. Additional metrics included inpatient LOS and patient satisfaction scores.


By improving its process for determining patient status and reducing LOS, Orlando Health has achieved a total benefit exceeding $40 million. The initial 12-month period yielded additional revenue of $13 million from status determination improvements and $4 million from LOS improvements. At this level of performance, Orlando Health expects to continue achieving $27 million in annual benefit relative to the baseline period.

Looking at observation rates, the observation-to-inpatient ratio had decreased by 7% for all payer classes. Medicare observation rates decreased by over 10% at most facilities. Observation LOS decreased by nearly 10 hours across the system. Reduced LOS created additional bed capacity, enabling Orlando Health to backfill the newly available beds with additional patients and realize an increase in incremental revenue.

How Orlando Health Stemmed Healthcare Costs by Eliminating Unnecessary Clinical Process Variation

hfm logo

How Orlando Health Stemmed Healthcare Costs by Eliminating Unnecessary Clinical Process Variation

Feature: Thomas Kelley, MD | Donna Jansen, RN | Bart Richards, CHFP | Nick Radice, CHFP

A six-step initiative by Orland Health in central Florida to eliminate avoidable variation in healthcare delivery reduced the health system’s average length of stay (LOS) by roughly 0.75 days, while yielding a corresponding financial benefit of about $1.2 million.

Variation in healthcare delivery is necessary to some extent because of the need to tailor interventions to each patient’s unique circumstances. But it also can reflect inefficiencies in care processes that contribute unnecessarily to the nation’s high costs of care.

Recognizing this reality, in 2017, Orlando Health, a $3.8 billion not-for-profit healthcare system serving central Florida and beyond, embarked on an initiative to eradicate unnecessary variation in care to its patients with the goal of improving quality and outcomes while addressing rising hospital lengths of stay (LOS) and resource utilization. Unnecessary variation was defined as “differences in care provided by different caregivers for patients with the same diagnosis that increase costs without contributing to better outcomes.” The health system branded the initiative internally as “Right Care.”


The initiative’s goal was to design and implement standard processes, or care pathways, to deliver the most appropriate care to every patient, every time, across Orlando Health facilities. The care pathways aimed to define processes founded in evidence-based medicine wherever possible, and to supplement gaps in evidence-based care with physician consensus on how to deliver high-quality, consistent, patient care. The care pathways were designed to be interdisciplinary tools easily accessible for all Orlando Health providers. Although reducing practice variation was the primary goal, pathways were designed to allow for interventions to be tailored to unique patient needs.

The initiative was led by Orlando Health’s vice president of quality and clinical transformations, with a project management team (Right Care team) that included representatives from clinical informatics, clinical transformation and the enterprise data warehouse. Deployment of the care pathways was preceded by two years of groundwork in project planning, communicating with physicians, and organizing and validating necessary databases. The overall initiative encompassed the following six steps.


The initiative’s first phase involved determining which diagnoses would be best to target first for developing care pathways. The Right Care team planned to use these initial diagnoses as a pilot to refine processes for developing and implementing pathways in the future. Based on the time commitment for each diagnosis and the level of impact desired based on the time and the resources invested, the team decided to limit the initial focus to six diagnosis groupings.

The team determined that the most suitable diagnoses to focus on at this stage would be those that presented the greatest improvement opportunities. To identify where the greatest opportunities lay, the team analyzed key quality indicators based on patients’ discharge diagnoses, looking at discharges from the system’s five acute care hospitals for the prior 12 months of calendar year 2016.
Diagnoses were selected based on the following factors:

  • Cases with high actual LOS compared with expected LOS based on the diagnosis’s MS-DRG
  • High-volume cases systemwide
  • Disease states most capable of being standardized
  • Based on this review, the team selected the following diagnoses:
  • Large and small bowel procedures
  • Congestive heart failure
  • Sepsis
  • Chronic obstructive pulmonary disease
  • Pneumonia
  • Urinary tract infection


To lead in creating the care pathways, the Right Care team identified physician champions who possessed deep clinical expertise and a high degree of influence within the system. The physicians then provided input regarding who should be selected to be members of the focused multidisciplinary teams, called clinical consensus teams (CCTs), that would be charged with creating the pathways.

Although each CCT’s composition was tailored to the particular champion, CCTs typically included the physician champion, key specialist physicians and surgeons, hospitalists, quality officers, nursing staff, case managers, pharmacists and an executive leader. Depending on the nature of the diagnosis, the teams could also include representatives from therapy teams, nutrition, palliative care and other departments.
To incorporate input from across the system, and increase physician buy-in, participants were purposefully selected from each hospital. Wherever possible, the teams also tried to leverage existing system initiatives focused on a diagnosis to reduce duplicative work.


Once the CCTs were assembled, the Right Care team scheduled three working sessions with each team to collaboratively establish the process for creating care pathways. The in-person meetings were held in a conference room of the most centrally located and largest hospital in the system.

The rationale and goals for Right Care were introduced during the first of the three working sessions. The Right Care team reviewed with the CCT the benefits of reducing unnecessary variations in care and the reason for selecting the particular diagnosis as an initial area of focus for the project. To highlight the improvement opportunity, analytics were shared summarizing hospital and overall system performance in chief quality indicators for the targeted diagnoses.

Prior to each CCT’s initial meeting, the physician champion identified key articles and resources with the most up-to-date, evidence-based practices for the diagnosis. During the meeting, all attendees received flash drives with these resources and were asked to review them prior to the next working session.

The initial meeting concluded with an overview of the structure and benefits of care pathways.

Three to four weeks preceded each of the next two working sessions. These sessions were scheduled for four hours to provide dedicated time for the CCTs to develop, review and finalize their care pathways.

Care pathways were goal-oriented and time-specific based on a patient’s progression in care. Areas of focus varied depending on the diagnosis, but pathways typically accounted for the following:

  • Patient education
  • Consultations
  • Assessment and testing
  • Medication
  • Dietary recommendations
  • Recommendation for patient activity levels
  • Discharge criteria
  • Post-acute follow up

Based on key questions and follow-up items discussed during the second session, subgroups of four to six members were deployed to explore ideas and best practices and then return to the third working session to report recommendations to the greater team. Subgroups focused on topics such as pharmacy, lab, patient education, nutrition and anesthesiology.

The third working session served as the platform to finalize and review the care pathway. During this meeting, the subgroups presented their recommendations on key action items, and any incomplete areas from the previous session were addressed. At the end of the meeting, the CCT was given an opportunity to review the final draft of the care pathways and relay feedback to the Right Care team and physician champion.


To help all employees understand the mission and vision of the Right Care initiative, the Right Care team partnered with Orlando Health’s marketing and communications team on developing a comprehensive internal communication strategy and plan.

The goals of the plan were to:

  • Inform and educate
  • Connect the dots to strategic imperatives and Truven 100 goals
  • Obtain buy-in that Right Care is everyone’s responsibility
  • Ensure compliance

The communication plan was executed using electronic communication via all existing portals to all audiences, posters on nursing units, presentations to operations and team member councils and online assigned education through an internal platform. The plan helped to gain buy-in prior to the rollout of the pathways and continued to motivate the team throughout the implementation phase.


Once a care pathway draft was finalized, the physician champion brought the draft to the Orlando Health medical executive meeting for review and approval. Approved pathways then were rolled out at each of the system’s hospitals simultaneously (with the exception of Orlando Health’s children’s hospital), without any intervening pilot program. Leading up to the go-live date, targeted communication plans were deployed to inform physicians of the release, changes to workflows and expectations moving forward.

The Right Care team recognized early that the success of the pathways hinged on willingness of the system’s hospitalists to adopt them, and this was the reason each CCT included a hospitalist. During implementation, the teams conducted regular follow-up meetings with key hospitalists to socialize the pathways and reassure the physicians that their daily workflows would not be significantly impacted.

The Right Care team offered continuous support throughout the rollout to answer questions, collect feedback and quickly address barriers or concerns. Although the benefits of the pathways were clearly communicated, physicians were not formally required to use the pathways for their patients. To encourage adoption, the team developed and distributed tracking tools to demonstrate the benefits in care associated with the pathways.


The Right Care team worked closely with members of the system’s enterprise data warehouse to analyze and compare patient outcomes when care pathways were used and when they were not used. The outcomes were aggregated in monthly scorecards at the hospital and system level to monitor successes and identify improvement opportunities.

The scorecards tracked key quality metrics for patients who were eligible for a care pathway based on diagnoses and compared results with a baseline time frame prior to Right Care deployment. Results were reported for patients on a pathway compared with patients not on a pathway to illustrate the benefits associated with using the pathway. The key quality indicators included in scorecards were LOS, mortality, complications in care and readmissions.

The Right Care team also worked with the finance department to calculate the financial impact of the improvements in quality. These results were intermittently communicated to the physicians to further validate their efforts but not regularly tracked on the monthly scorecards.


Within a year after deploying the care pathways, Orlando Health realized the significant improvements in outcomes for patients with a pathway diagnosis. The health system attributed this success to strong project planning and execution, continuous communication, internal ownership and effective efforts to build a physician culture of continuous improvement.

Physician leadership, engagement and advocacy were paramount. From the very start, the continual and consistent physician messaging on the importance of clinical standardization and the expected benefits was instrumental in motivating physicians to get on board with the process of developing and utilizing the refined care pathways.

To ensure the pathways would live up to the promise of not substantially changing physicians’ daily workflows, which was deemed critical to success, the Right Care team worked closely with the clinical informatics department to integrate the pathways into preselected order sets in the electronic health record. To encourage hospitalists to use the order set, the team used the scorecards and other means to show them that the tools would promote higher-quality care, based on the most recent evidence-based medicine, without requiring additional consults or otherwise adding time to their day.

Beyond the quality and financial benefits, the team knew it had achieved success when physicians began to come forward without any prompting, asking to be part of CCT for the next care pathway.