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Introduction

Our third article surveys the lifecycle of an ACO intervention, guiding the reader through each phase, from ideation through sustainability. Along the way, we offer systematic yet creative techniques in planning, piloting, promoting interventions to operations and then spreading. Our approach delivers efficient and measurable clinical and operational interventions that reduce costs, coordinate patient care, and improve outcomes.

Prior to the ACO team engaging in intervention development, it is critical they have addressed the common ACO partnerships pitfalls (refer to our first article) as well as invested time and energy in developing a high-performance multi-organizational team (refer to our second article). Once the team is aligned and pitfall mitigation is in place, the intervention lifecycle may begin.

Phase 1: Ideation

The first phase emphasizes the creative process of developing intervention ideas which support the agreed-upon ACO quantitative and qualitative goals. Recognizing our unique moment in the healthcare industry to deliver, manage and reimburse care differently, it is absolutely critical that the multi-disciplinary ACO team dedicate time to think ‘out of the box’. Much has been written about the delivery of disruptive interventions through ACOs; the ideation phase is when these ideas are born. In addition, there are some obvious and proven interventions (for example, reduce hospital readmission, re-direct ER usage, increase generic pharmaceutical prescribing) enabled by ACO partnerships.

The systematic approach we recommend throughout the ideation phase emphasizes pre-developed criteria to separate the ‘good’ ideas from the ‘not so good’ ones. Leveraging the industry’s newly forming knowledge on successful ACO interventions is equally important; do not start with a blank whiteboard. Developing a comprehensive yet realistic set of measures and metrics to gauge the performance and outcomes of the interventions is a critical and challenging process given the varying sets of data and agendas across the partner organizations. It is this phase in which the all-important ACO Logic Model is initiated. Also referred to as a “playbook”, intervention details are captured in a framework that enables ongoing measurement, refinement and, ultimately, growth and sustainability. Tools and techniques critical to Phase One include:

• Apply an Ideation Checklist when determining the fate of each idea-does the idea meet the criteria for an ACO intervention (reduce cost, improve quality, improve outcomes, sustainable, repeatable, data-driven, measurable)?
• Collect and analyze industry information on current intervention successes
• Identify intervention measures and metrics
• Initiate the ACO Logic Model, beginning with basic intervention information; description, tactics, performance metrics, process metrics, baseline data needs (to compare with outcome), category of intervention (clinical, operational, administrative), and current industry standards and benchmarks

Phase 2: Planning and Preparing

In the second phase, ideas evolve into a prioritized and bundled set of implementation plans. This phase focuses on developing the activities and resources to implement the interventions as well as collecting and analyzing baseline data. Interventions must be prioritized by anticipated results, level of effort and impact to the partner organizations. Bundle, or package, complementary and supporting interventions strategically, to achieve more impactful and holistic results. We have experienced the complicated and time-consuming task of establishing the cross-organization reporting process and data interoperability to support intervention monitoring and measurement; budget sufficient time and resource expenditure.

The Planning and Preparing Phase’s systematic approach begins by prioritizing the interventions from the ideation phase, identifying opportunities to thoughtfully bundle interventions which support each other and thus drive to a better result. A detailed planning effort is essential, with resource commitment, due date and dependencies for each activity. This is the phase where collecting baseline data, as identified in Phase One, is essential for measuring the interim and final results. Proactively build the reports and supporting process needed during the pilot phase. Tools and techniques essential for Phase Two include:

• Identify opportunities to bundle intervention pilots, for more impact
• Develop work plan for each bundled intervention, include resource commitments, due dates and dependencies between activities
• Validate integrity of baseline data, received from one or more partner organizations
• Develop supporting reports (to run interventions, and to measure outcome)
• Continue building the ACO Logic Model with additional information such as baseline data results, data source, bundling opportunities (synergies with other interventions), report descriptions, relative value, high level implementation steps, and go live date, and dependencies between interventions

Phase 3: Pilot and Refine

We recommend that the ACO leadership team acknowledges the “new world order” in which the ACO partnership creates a shared mission for the work, ruleImplementing and monitoring interventions for a specific length of time (often two to three years to realize impact) is the focus of the Pilot and Refine Phase. In our experience, the most significant challenge in this phase is the cross-organizational processes where data, patient or other hand-offs are essential. Gaining insight to the processes success and break-downs requires participation at multiple levels of each partner participating in the intervention and may be challenging to coordinate. In response, it is important to track established measures frequently, collect anecdotal feedback from those participating in the pilot and focus on interim performance metrics, allowing the team to continuously refine each intervention. Share successes and learnings with ACO leadership and build upon the ‘quick wins’ which interventions may produce. The ACO team is responsible for running and monitoring the interventions; a management dashboard is a vital tool in the Pilot and Refine Phase.

The approach we recommend for a successful Pilot Phase boils down to establishing and supporting many pathways for communicating intervention performance to the ACO team. Systemizing the variety of communication requires a single and consistent end point (ACO team), a single method for translating communication into performance and actions (Management Dashboard) and a method for determining whether to continue piloting the intervention (return on investment). With this communication, the team identifies lessons learned and refines the interventions as needed. Tools and techniques supporting the Pilot and Refine Phase include:

• Track interim and final results against the pre-determined ACO measures and metrics using an Management Dashboard
• Determine return on investment (ROI), applying both qualitative and quantitative measures which include contractual expectations and also unexpected and difficult-to-measure benefits
• Continue building the ACO Logic Model by documenting interim outcomes, lessons learned, intervention refinement, quantitative and qualitative measures

Phase 4: Promote Pilot to Operations

When each intervention pilot is nearing completion, the ACO Logic Model is used to analyze the outcome and determine whether the intervention was successful. In this phase, the ACO team transitions the responsibility for managing and monitoring interventions deemed successful to the appropriate departments within each organization. Each ACO partner transitions the intervention from project mode to integrated processes, services, management and reporting within their organization. We have observed that as organizations move closer to the ACO-centric service model, partner organizations may need to make core structural changes to successful manage the new methods for delivering, reimbursing and managing care.

The systematic approach for determining whether or not to promote a pilot intervention to operations is based on a comprehensive and consolidated view of results (data and observed) against expectation (metrics and measures). Fortunately, the ACO Logic Model, which has evolved through each phase, delivers this information. Executing the transition to operations requires much communication and coordination between the ACO team, ACO leadership and organizational management. Tools and techniques supporting this phase include:

• Apply an operational checklist – does the intervention meet ACO and partner organization criteria?
• Confirm detailed transition plan, identifying the resources, delivery dates and dependencies
• Complete the ACO Logic Model, adding decision to move to operations, high level transition activities and final intervention results

Phase 5: Spread and Sustain

Once the successful interventions are promoted to operations, each partner focuses on applying the intervention to a broader audience (for example, insurance products, and employer groups). As it is scaled, intervention delivery is increasingly efficient and effective as well as more impactful to the ACO partners and their constituents (e.g., members, patients, families, employer groups). The challenge in this situation, which we highlight in our first ACO article, is the potential overlap of regional or community ACO partners and acknowledging both the inherent competitiveness and possibilities for collaboration that benefit all constituencies.

The approach for spreading and sustaining the ACO-centric service model is specific to each organization and fundamentally guided by each partner’s strategic vision for their evolving organization. Our recommendation includes surveying the market to understand the opportunities, performing an ROI and then confirming alignment with the strategic vision. Spread opportunities could include:

• Regional ACO
• New products
• Enhance existing products
• Broaden membership segment
• New ACO partners

Summary

How do disparate organizations partnered through an ACO relationship develop, pilot, implement and sustain disruptive interventions to enhance the delivery of care, reduce costs to healthcare delivery and administration and fundamentally improve outcomes? By following the ACO intervention lifecycle phases and using the supporting tools, as described in this article.

About the Authors

Shani Trudgian is a Partner at Kenny & Company and has over 20 years consulting experience with Accenture, Deloitte and Freed Associates. As a thought leader and industry advisor, Shani has guided her clients through health reform readiness strategy, ICD-10 readiness approach, ambulatory heath care delivery refinement, business model analysis, organizational development, change leadership and in other strategic areas. Shani’s industry experience includes medical groups/IPA, hospitals, health plan (public/private), safety net clinics, department of public health, dental insurance, oral health delivery, non-profit grant-making philanthropy, and behavioral health organizations. 

Over the last 30 years Julie Kliger has been measurably improving outcomes in hospitals and health systems. She has done this by applying Performance Improvement (PI), Change Management and Leadership Development principles into large, complex health care organizations. Ms. Kliger is a published author and her articles can be found in the Agency for Healthcare Research Quality (AHRQ), Archives of Internal Medicine (April, 2010), Joint Commissions’ Journal on Quality and Patient Safety (Dec, 2009 and Feb, 2012), Journal of Nursing Administration (March, 2010) among several other notable publications. She has been an invited speaker at numerous national conferences including, Joint Commission, National Quality Forum, University Health Consortium (UHC), RAND Corp., Stanford University, American College of Emergency Physicians (ACEP), BMJ’s International Conference, Robert Wood Johnson Foundation (RWJF), Moore Foundation, Institute for Healthcare Improvement (IHI), American Organization of Nurse Executives (AONE). Ms. Kliger completed her Master’s in Public Administration at Harvard University’s Kennedy School of Government where she focused on patient safety and error reduction policies. She holds a Bachelor’s of Science in Nursing from Columbia University in New York City and a Bachelor’s of Arts from UC Berkeley.

About Kenny & Company

Kenny & Company is a management consulting firm offering Strategy, Operations and Technology services to our clients.

We exist because we love to do the work. After management consulting for 20+ years at some of the largest consulting companies globally, our partners realized that when it comes to consulting, bigger doesn’t always mean better. Instead, we’ve created a place where our ideas and opinions are grounded in experience, analysis and facts, leading to real problem solving and real solutions – a truly collaborative experience with our clients making their business our business.

We focus on getting the work done and prefer to let our work speak for itself. When we do speak, we don’t talk about ourselves, but rather about what we do for our clients. We’re proud of the strong character our entire team brings, the high intensity in which we thrive, and above all, doing great work.

This article was first published on www.michaelskenny.com on October 10, 2015.  The views and opinions expressed in this article are provided by Kenny & Company to provide general business information on a particular topic and do not constitute professional advice with respect to your business.

Field Guide to Effective ACO Management by Shani Trudgian and Julie Kliger, Kenny & Company is licensed under a Creative Commons Attribution-NoDerivs 3.0 United States License.