Patient-Centered, Clinically Integrated, Care Delivery

The Care Process Design System (CPDS)

As should be evident by now, the engine that really drives the train in a PCCI network is what I call the care process design system or CPDS. The CPDS is a systematic approach to designing, monitoring, and refining common care processes through a data-driven performance improvement approach at the local level by frontline caregivers. Here are the essential steps in the CPDS…

1. Selecting the care process — care processes or care process units (CPUs) can be something as simple as a diabetic patient’s follow-up visit with a primary care physician to a complex back surgery procedure performed by a neurosurgeon. The point is to choose processes that are done frequently and those that may benefit from a redesign to improve value, i.e., quality per unit of cost.
2. Mapping out the care delivery process or CPU — surprisingly, many providers do not really understand the individual steps in even the most simple CPUs. Mapping out each step, using a modified Lean process design mapping technique, and including each step done at least 10% of the time in each process will allow the providers to understand better what they do and how they do it daily. It will also allow the design team to identify areas that need to be improved by applying best practices (either determined from the evidence base of medical literature or by the experience and knowledge of the design team’s members). Therefore, as soon as the care process map is complete, the design team should ask what we need to do differently. NOTE: the design team needs to include clinical and non-clinical front-line staff who work on the CPU daily. These front-line staff should be listened to carefully as they frequently have the best ideas on improving processes.
3. Selecting monitoring metrics — since the overall goal of the PCCI network and the CPDS design teams is to improve value, metrics for both quality and cost should be chosen for each CPU and then collected to drive continuous process improvement activities. The design team should choose the quality metrics, not because they necessarily match up with nationally recognized metrics, such as those from the national clinical quality association (NCQA), but because they represent those outcomes that the design team believes truly reflect high-quality care delivery. Quality metrics that measure patient satisfaction and other elements of patient-centered practice should also be included. As opposed to process measures, outcome metrics should be favored (such as the number of heart failure patients requiring hospital admission vs. the number of heart failure patients prescribed an ACE inhibitor). Perhaps captured via digital technology, patient self-reported outcomes are also valid metrics to use for this purpose. Cost measures should be captured using a cost accounting methodology known as time-driven, activity-based cost accounting (TDABC). (1) This cost accounting methodology gives a true measure of the costs required to deliver services and is much preferred to other less reliable methods of measuring costs, such as charge to cost ratios or relative value units.
4. Ongoing monitoring of CPUs and data-driven performance improvement — each design team should regularly review the quality and cost measures they have chosen and use this data to drive improvements in the CPU via an iterative process. This will ensure continuous process improvement occurs over time and that CPUs remain current as best practices and other situations change. Design teams should also be held accountable for sharing their results, and where appropriate, those CPUs which seem to be getting the best results should be spread throughout the organization.

In the end, the CPDS provides for a decentralized, locally relevant, continuous process improvement system that drives the PCCI network forward toward its goal of delivering high quality, low cost, i.e., high value.

(1) “Better Accounting Transforms Health Care Delivery.” Accounting Horizons, Allen Press, 2021, accessed June 14, 2021, https://meridian.allenpress.com/accounting-horizons/article-pdf/28/2/365/1591595/acch-50658.pdf (365–83).