Spurring hospital innovation
The 14 “intrapreneurs” gathered in the basement of Providence Park stadium, home of the Portland (Ore.) Timbers Major League Soccer team, one rainy morning this spring. Fueled by coffee and a regional favorite brand of protein bar — “Ooh, Picky Bars!” someone exclaimed — the group was preparing to choose improvement projects to work on over the next year.
Directors, division heads and executives from Providence Health & Services’ Oregon network stood at the back of the conference room, patiently waiting for their turn to pitch their projects.
The packed room hummed with energy as Gwen Conner, creator of the event, stood near a projector screen. Conner is director of the business accelerator, Oregon region, at Providence Health & Services, a nonprofit system based in Renton, Wash., that spans five states. Like many of the other participants that morning, she was dressed in casual Portland chic: skinny pants, fleece jacket and sneakers.
Conner launched Providence’s Innovation Fellowship in 2015. So far, 53 employees in the Oregon region have gone through the program, which has garnered $3 million in cost savings.
The Innovation Fellows, also known as intrapraneurs — for internal entrepreneurs — dedicate eight hours a week for a year toward an improvement project. The fellows are typically “emerging leaders” — those at the start or middle of their careers — selected with their managers’ endorsement. They come from across the organization, from areas including finance, information technology and product management.
In previous years, fellows would develop their own project ideas and pitch them to one another. But this year, Conner came up with a twist, something she calls the “reverse pitch.” Leaders across Providence Oregon would present their improvement ideas, and the fellows would choose which ones to work on.
Hence the nervousness in the room. Of the six pitches presented that morning, only four would be selected and, over the next year, the 14 fellows will work in small teams to execute them.
“We want to make sure our innovation pilots are aligned with our system’s targets,“ Conner explains. “Everything we do is tied to making an impact on strategic measures.”
It is a goal shared by many hospitals and health systems across the country. But while innovation and improvement are popular buzzwords these days, they can be interpreted in many, sometimes conflicting, ways. And marrying innovation with an organization’s strategic goals can be tricky.
Health Affairs devoted its March issue to delivery system innovation, with more than a dozen papers on the topic. “Innovation in health care has lagged behind that in many other industry sectors," wrote David Bates, M.D., chief of the division of internal medicine, senior vice president and chief innovation officer at Brigham and Women’s Hospital in Boston, and his colleagues in one of the papers. The authors note that providers are understandably reluctant to adopt new medical treatments that might not work or that might even “have adverse effects that become apparent only after large numbers of patients have been exposed.”
They add, however, that “part of the slow pace of innovation stems from the health care payment system. Especially under fee-for-service reimbursement, there are few incentives to improve efficiency. New payment models are changing this.”
Innovation in health care can succeed only if organizations make sufficient financial resources and physical space available, provide access to technology experts and keep members of the innovation group insulated from day-to-day demands on their time.
“If there is a single essential key to success, it is making innovation a strategic priority," the authors stress.
Learning from mistakes
Innovation doesn’t happen in a straight line. For the fellowship program at Providence Oregon, the reverse pitch was conceived after some previous innovations failed to take root.
Angi Frary, director of strategic accounts for Accountable Care Oregon at Providence, was in the first group of fellows in 2015. At the time, she worked as an insurance sales consultant for the Providence health plan. That year, Frary’s group selected the idea she pitched: redesigning the member explanation of benefits for the health plan.
“This is one of the biggest hassles in health care for people,” Frary explained. “We wanted to make it simpler."
The idea fit well with the training offered as part of the fellowship. Throughout the year, fellows learn human-centered design, with support from outside consultants. Human-centered design is a creative approach to problem-solving that starts with the people the team is designing for and ends with solutions that fit their needs. The process involves intensive research and exercises to sweep away preconceived notions or biases about the problem or the solution.
Also during the fellowship year, Conner brings in guest speakers from companies outside of health care, such as Whole Foods and Twitter, to share their innovation experiences.
Frary and the other fellows on her team applied human-centered design principles to revamping the explanation of benefits. They conducted focus groups with plan members. They used colors, charts and graphs rather than just words to explain deductibles and co-pays. They deployed various communications tools — paper, smartphone apps, websites — to deliver information to members about benefits. The team was proud of the prototype.
But, as it turned out, the project had a fatal flaw: Team members failed to make an effective business case to fund its rollout.
“It looked great, but we didn't have the resources to implement it,” Frary says. “It was unfortunate.”
Shortly after the project ended, the Centers for Medicare & Medicaid Services held a contest to redesign a health plan’s explanation of benefits. “The winner’s product was very similar to ours," Frary says.
Jamie Donnelly, an innovation fellow in 2016, also pursued a project that was never implemented. Her team tried to launch a digital platform to support patients with behavioral health conditions but ran into multiple problems, all of which are spelled out in the Bates Health Affairs paper. There were legal challenges to implementation. In addition, there was a misalignment between the platform they chose, which was mostly geared toward patients covered under employer-based plans, not Medicaid or Medicare. Providence needed a platform that was payer-neutral.
“We learned a lot about applications for population health management,” says Donnelly, who is now a project manager in women's and children’s services for Providence. “We were trying to stay very, very open to where we were leading this. But we needed more time to tackle something so new.” The behavioral health division continues to pursue a solution.
The fellowship has enjoyed some successes. A concussion management project aimed at young athletes and named “Hits Happen“ created user-friendly tools and a virtual connection to concussion experts, which improved care access and education. The project was handed off to Providence's sports medicine department for continuation. Another group of fellows created a peer support network for Portland seniors living at home who are at risk of isolation. The Providence Elder at Home program within the senior health department is continuing this initiative.
This year’s reverse pitch approach aims to eliminate financial or administrative roadblocks to implementing innovations. “That’s why we flipped it, so the business brings the ideas to the fellows,” Frary says.
Most important, a failure to implement a specific project or idea should not deter from future innovation, says Chris Butler, partner at Evolve Collaborative, the Portland-based human-centered design firm that is guiding the Providence fellows through the year. “We expect a lot of failures. And that’s OK, because we learn a lot from them.”
Making the pitch
The stakes were high for the individuals making reverse pitches at Providence this year. If selected, their departments would gain a team of three to four extra people to do the project work, at a combined 32 hours per week for an entire year. They would gain other resources as well. Providence innovation fellows have access to data analytics and other informatics staff time. They participate in two full workshop days each month with Evolve Collaborative to learn human-centered design and, this year, they are traveling to a conference in Seattle to learn about trends in health care from a consulting firm.
Fellows also come with money. The chosen projects are funded out of the innovation budget, not those of the departments selected.
One by one, the presenting teams stood at the front of the room and ran through their pitches, with PowerPoint aids. All had worked for weeks to formulate and hone their presentations. All gave compelling reasons why their ideas should be picked. One presenter handed out chocolate bars at the end of her pitch.
The first pitch was from the Providence Cancer Center staff. Cancer patients want better access to integrative medicine products, such as supplements and Chinese medicine herbs, that have been approved by clinicians. Although some of these products were offered at the cancer care center, supplies were limited and the inventory was not managed effectively. Additionally, the electronic health record didn’t document over-the-counter supplements. “The questions we have are: What products can we offer? What’s feasible in our space?” said Nicki Scoles, pitch presenter and senior manager at the cancer center.
Frary made the second pitch: how to navigate ambulatory care patients to appropriate same-day points of care while reducing wait times. Like many other health systems, Providence has expanded its outpatient footprint with branded urgent care centers, express care clinics and virtual visits. However, patients often choose to wait at one care location, sometimes for hours, rather than going to another one nearby that has no wait. “What are the barriers that prevent patients from going to other places? How do we get them there?” said Frary’s co-presenter, Wendy Carlton.
The third pitch was from Donnelly and a Providence pediatrician. Owen, the pediatrician’s son, had spent his first five months in the neonatal intensive care unit because of a serious congenital defect. Once Owen was home, his parents found themselves overwhelmed with managing not only a baby with complex care needs, but also his care plan and medical appointments. The opportunity for the fellows: Create a dynamic care plan to carry NICU children through their discharge from the hospital and the weeks, months and years ahead.
This plan would support the parents as they manage care from many sources, including occupational and physical therapists, schools and dentists. Lessons learned could be applied to other complex care populations, the presenters suggested. “We need this to be family-facing,” Donnelly told the fellows.
Pitch No. 4 offered the opportunity to tackle how Providence employees get to work. The presenter, Jen Massa Smith, who holds the uncommon title of active transportation manager, noted that the city of Portland requires employers to reduce the number of workers who drive to their jobs alone. Smith pointed out two other factors worth considering: 65 percent of Providence caregivers are overweight or obese; and parking, for now, is free. Initial research has shown that a slice of Providence employees have contemplated or are preparing to make the switch to public transit, biking, walking or another means of getting to work that doesn’t involve a car. “We don’t know who these people are,” Smith said. “We need to find them and work with them to make the transition.”
Jeremy Huwe, regional director of children’s services, gave Pitch No. 5, challenging the fellows to figure out how to keep new parents whose babies are delivered at Providence hospitals from choosing other health systems down the line. “Millennials are now the majority of childbearing age,“ Huwe noted. “And after them, Gen Z; they are going to blow the whole thing up. What do we need to know about these populations to form a lasting relationship?"
The final pitch — the one that came with chocolate — focused on reducing variation in acute care among the eight Providence hospitals in Oregon. It would involve ways to improve nurse communication, the consistent use of best practices at each location and a new structure for cutting variation in care delivery, explained Sue Giboney, Providence experience officer.
The winners
At the end of the pitches, Conner thanked the presenters, who left the room. The next phase of the reverse pitch began — discovering the pros and cons of each project through rapid-fire exercises. The fellows would not select the winning projects for another month. Rather, they would work in small groups to figure out which projects have the best chances for success, and then teams would coalesce around favorite projects.
The fellows were divided into four teams. Butler from the Evolve Collaborative and his two colleagues instructed the team to make “draft picks” of their first and second favorite pitches. Butler used numbered bingo balls to select the order in which teams would pick their favorites.
The fellows quickly chose their first- and second-round draft picks, with teams that got the lowest bingo number getting first pick. Favorite projects emerged quickly, with one project getting no takers. It was assigned to the team with the highest bingo number. Then, the teams conducted a 10-minute exercise using colorful sticky notes to map out each of the two selected projects' population needs, challenges and potential impact.
At one table, the fellows discussed the NICU care coordination project, noting that the potential impact of the project could be to “ease the way“ for parents, reduce stress and improve quality of life. The fellows were fired up about the project.
“We're going to be making decisions based on excitement and potential impact,“ Butler instructed the fellows about the immediate exercise. “We will work on delivery impact and feasibility another day."
During the lunch break, Butler said he purposely didn't give the fellows very much time to make choices at first. The goal after the pitches is for the fellows to begin thinking creatively about each problem identified that needs a solution. In later sessions over the next month, the fellows would go through more exercises to guide them in narrowing down the six projects.
Butler expressed some surprise at which pitched projects were the most popular with the fellows initially. The employee transportation project, for one, was not popular. Yet, Butler pointed out, it had attractive elements such as an already defined and captive population (Providence employees) and a clear, measurable goal that had strong backing from management, not to mention a mandate from the city. The project could have a big impact on the daily lives of employees.
By contrast, reducing variation across the eight Oregon hospitals was a popular pick among the teams initially, even though it would seem to require extensive coordination across facilities, some in remote regions, and changing behaviors among clinical staff. “That's a tough one to get your arms around,“ Butler remarked.
In going through a multistep, multiday process of choosing their projects, the teams would be able to explore the feasibility of delivering results at the end of the year, Butler explained. There would be no impulse buying and, hopefully, no buyer's remorse.
Frary's and Donnelly's projects (outpatient clinic navigation and NICU care plan, respectively) were both popular with the fellows. In later conversations, both women said separately that they believed their previous experience as fellows helped them to develop their ideas and fine-tune their pitches.
“One of the really hard parts of innovation in health care is understanding all the people and all the barriers," Frary said. “Having been through that myself, I think we can really help the fellows break down barriers and understand the places they need to go."
In late April, Conner announced the winners. The fellows chose both Frary's project to help patients navigate on-demand care options and Donnelly's project on NICU post-acute care coordination. Retention of millennial moms post-delivery was also selected. And the final of the four picks was the project that initially garnered little enthusiasm but one Butler from Evolve Collaborative predicted would have a good chance of success: employee active transportation.
Rebecca Vesely is a freelance writer based in San Francisco.
Making a difference
Providence Health & Services, based in Renton, Wash., launched its first regional innovation program in Oregon three years ago with the Innovation Fellowship and an innovation incubator. The program launched under the leadership of the regional CEO and uses funding from the Providence Health Plan and regional delivery system. Here are some of the Innovation Fellowship's accomplishments:
- Reached more than 2,000 people in Oregon with new care approaches.
- Collaborated with 23 partners, including community organizations, regional businesses and emerging technology companies.
- 100 percent of fellows rated program 4 (“high”) or 5 (“very high”) on overall satisfaction.
- Achieved major gains in adopting vital innovation behaviors (as measured by manager observations).
- 57 percent of fellows in the first cohort have been promoted.
- Through print and online media and conferences, the program has been shared with 12,000 people.
- Implemented successful ideas, including a concussion-management program and peer-support network for isolated seniors.
Trustee takeaways
Internal career training programs have been around for a long time in health care, but innovation fellowships can add an extra dimension that benefits both the organization and its employees.
More than half of the innovation fellows in Providence Health & Services' innovation program in its Oregon region were promoted within the first year of completing the fellowship, and the program enjoys a 100 percent satisfaction rate. Fellows say they believe the program gave them added skills and confidence to take on new assignments and even switch divisions or departments.
“The fellowship gave me exposure to senior leaders and other parts of the company,“ says Angi Frary, a former innovation fellow. “It probably helped me to branch out of the health plan side and make connections on the care delivery side and move up in the organization."
Innovation programs need the full support of executive leadership to be successful, according to recent studies on their impact.
Gwen Conner, director of innovation at Providence, reports to the chief strategy officer, who reports to the system's CEO.
“Having strong advocates at the top has made a huge difference in the success of the program," Conner said.