Case study 2: Intermountain Healthcare

Intermountain Healthcare, is a non-profit health care system in the United States, that employs 32,000 staff in 23 hospitals and 160 clinics and primary care centres.

What is Intermountain’s approach to improvement?

In 1986, Intermountain began its improvement journey by striving to promote clinical excellence through the systematic pursuit of evidence-based medicine. Importantly, improvement at Intermountain occurs partly by allowing exceptions to guidelines, and using these to learn how the delivery of care can be improved.

Intermountain’s work is underpinned by a long-term commitment to quality improvement, reflected in its substantial investment in training and learning through its Advanced Training Programme. This involves a four-week commitment from participants, who include clinicians and managers. The curriculum incorporates the development of leadership skills as well as quality improvement methods and statistical techniques. Participants are required to apply their learning in a practical project before they graduate from the programme.

The impressive improvements in quality that have occurred at Intermountain have resulted from a relentless focus on tackling variations and reducing waste in clinical practice across many areas, from intensive care to primary care. More than almost any other high-performing organisation, Intermountain has succeeded in standardising care around accepted good practice. Its experience also indicates that high-quality care often costs less. One example is its work on substantially reducing mortality from life-threatening blood infections, thereby setting a new national standard.

What lessons are there for the NHS?

Intermountain’s experience of tackling unwarranted variations in clinical practices holds important lessons for the NHS in England. An early example is its work to reduce variation among surgeons treating prostate cancer. This involved analysing, for each surgeon, the time taken to operate, the amount of tissue extracted, the costs of each procedure, and the outcomes. The results showed wide differences which, when fed back to the surgeons, led to agreement on a new guideline for treatment. Over time, this not only reduced variations in surgical practice but also cut costs and, most importantly, improved patient outcomes.

A similar method was applied to other areas of care. In each, the doctors concerned took responsibility for bringing about improvements through a combination of measuring variation, developing guidelines, and peer monitoring and review. Intermountain focused on 104 medical conditions that accounted for around 95 per cent of its costs. The improvements achieved would not have been possible without well-developed medical leadership, and staff having gained skills in quality improvement methods through participation in the Advanced Training Programme.

Intermountain’s improvement work has been supported by investment in real-time information systems and a culture in which staff achieve improvements through a commitment to providing the best possible care, rather than by having to comply with externally imposed standards. Rather than trying to control physicians’ practices by top-down command and control, they relied instead on robust process and outcome data, professional values that focused on patients’ needs, and a shared organisational culture dedicated to providing high-quality care. The aim was to ‘make the right thing the easy thing to do’.

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