There was a very interesting paper in Health Affairs a few days ago, "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts," in which two delivery system experts at Intermountain Healthcare explain how Intermountain has been improving care and working to contain costs for the past 25 years. In numerous threads I've emphasized the need for health reform of any kind to be conceptualized as a quest for better value (health outcomes achieved per dollar spent) in our system; reform that doesn't seek to improve value will invariably be woefully inadequate. Intermountain offers an example--though only one example--of what pursuing value looks like. Intermountain is an integrated delivery system in Utah and Idaho consisting of 23 hospitals and 160 clinics. They consistently rank among the best integrated health care systems in the country (they've been number one in the Modern Healthcare ranking five times in the past decade or so), based on factors like efficiency and quality of care. The paper, as the title suggests, outlines how they've climbed to the top, trimming costs by improving care quality (i.e. increasing value). Some of the key points: Processes of care. Honing in on certain common treatments at Intermountain by breaking each treatment down into the elements it was composed of revealed that no doctors were consistently very good or very bad across all the elements of the treatment: "the findings forced Intermountain to focus on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes." Evidence-base care.The development of evidence-based clinical practice guidelines for providing various treatments (built into clinical workflows so doctors didn't have to remember to implement them, e.g. these elements were present during care delivery in things like checklists), paid big dividends: "In the subcategory of patients who were most seriously ill with acute respiratory distress syndrome, applying this method reduced the rate of guideline variances from 59 percent to 6 percent within four months. Patient survival increased from 9.5 percent to 44 percent; physicians time commitments fell by about half; and the total cost of care decreased by 25 percent." Data, data, data. (i.e. quality measurement and informed clinical decision-making) Generate/acquire data. Intermountain pursued a "measurement for improvement" strategy by implementing new clinical management information systems. This strategy "focuses on the processes of care delivery rather than the providers who execute them, and it generates data for front-line process management and improvement." Use data to improve care. Using data to identify and measure quality isn't enough. Intermountain reorganized the delivery of care to improve clinical care, in part by using physician-leader/nurse administrator pairs ("clinical leadership dyads") to help clinicians improve their practices using the available data. "They use the clinical management information system to review data on clinical, cost, and service outcomes for each care delivery group. More important, the clinical leadership dyads from across the entire Intermountain system meet monthly as a group to identify and address improvement opportunities. They test possible solutions and disseminate successful results. " It's worth noting that the authors emphasized the need for payment reform, lamenting the current volume-based incentives that have hurt Intermountain as it saved money and improved care by reducing unnecessary service volume: And, of course, the paper ends with reflections on the current period of health reform: This, what Intermountain has done and what the ACA is attempting to incentivize and stimulate, is what health care reform looks like: building a high-value health system by improving the way we pay for and deliver care.