- Alexander Smith, Kaitlin Saxton, David Barrett
- Jul 26, 2018
Value-based health care
The increasing emphasis on value-based health care (VBHC) indicates that the success of any private or public health care organization should be assessed on how well it meets the long-term goals and needs of patients. Value should be defined as a return on investment that considers patient and clinical outcomes in conjunction with cost, for the entirety of the patient journey.
The shift towards VBHC and measuring long-term health outcomes has placed an increasing emphasis on hospital purchasing, which works to provide products that ensure the best patient outcomes. Traditional hospital tendering processes are most often conducted at a distance from the patient, and decisions are largely made based on clinician preference and price. As such, products are often procured with budgets, rather than performance, in mind and their wider impact on system cost or long-term patient outcomes is not reflected in the selection process. Through this process, efficacy issues can arise and cause delays, cancellations, adverse events, and suboptimal care for patients, affecting their experience and outcomes, as well as the financial budgets of hospitals.
In recent years, health systems globally have been transitioning away from this traditional form of price-only-based procurement, and towards value-based procurement (VBP), where value is a function of price and quality.
Patient-reported outcome measures
Patient-reported outcome measures (PROMs) are measurement instruments completed by patients to obtain information on aspects of their health status that are relevant to their quality of life, including symptoms, functionality, and physical, mental, and social health. To collect PROMs, patients are surveyed about their experiences with clinical products and their reviews directly affect the decision to purchase or not purchase the product.
The main benefits of PROMs are that their analysis:
- Provides insight on the effectiveness of care from the patient’s perspective;
- Promotes the use of patient experience to inform the delivery of patient-centered care and quality improvement initiatives;
- Enhances the value of patient care an organization is able to deliver;
- Realizes economic efficiency;
- Increases patient involvement in their care;
- Enables an understanding of whether health care services and procedures make a difference to patients’ health status and quality of life;
- Enriches existing information and better informs decisions;
- Promotes transparency; and,
- Provides a platform for national comparisons and benchmarking of patient experience
Despite the many benefits of PROMs, adoption and implementation has been gradual due to various barriers related to their development, validation, and implementation.
While the benefits of PROMs are clear, very little research exists on them. In addition, the frameworks and metrics used by hospitals incorporating PROMs into their procurement processes are rarely published.
To address this gap in the literature, the purpose of this study was to serve as a resource for health care and procurement organizations interested in exploring, understanding and incorporating PROMs within hospital procurement processes.
An in-depth literature review was conducted on all available academic literature focusing on the incorporation of PROMs across Canada, the United States and the European Union, as well as a scan of various reports from other healthcare and support organizations. Shared service organization (SSO), group purchasing organization (GPO) and hospital personnel across Canada were invited to participate in an anonymous online survey about the current state, barriers and facilitators of incorporation of PROMs in procurement processes. The survey was completed by 62 participants from Ontario, British Columbia, Manitoba, Saskatchewan, Nova Scotia and New Brunswick.
In-depth interviews were conducted with 12 participants from a variety of hospital administrative roles to gain a deeper understanding of the perspectives of individuals interested in and/or currently implementing PROMs within their organization.
Current state of PROMs integration throughout Canada
Based on results of the key informant survey and interviews, the following three classifications of organizations, based on their status of integration and interest, were determined:
- Early adopters: Organizations that are currently incorporating PROMs into procurement
- Followers: Organizations that are not currently incorporating PROMs into procurement, but plan to do so in the future
- Laggards: Organizations that are not currently incorporating PROMs into procurement
Barriers to incorporation of PROMs
Based on the results of the key informant survey, the following barriers to the adoption of PROMs, in order of importance, were noted.
- Budget-related challenges: The key issue presented was related to the additional resources that would be required to properly incorporate, collect, measure and assess PROMs; most notably personnel and data infrastructure costs.
- Data-related challenges: Data integration, product traceability and data sharing capabilities are the primary barriers to the collection of patient outcome data. The administrative burden required for clinicians to report ad hoc patient feedback on a specific product to a purchasing team was also a concern. Further, it was noted that there is currently a void in sharing performance metrics.
- Stakeholder-related challenges: Several participants spoke of the challenges associated with connecting the various stakeholders required to make purchasing decisions, such as clinicians, administrators, purchasing personnel and patients.
- Patient-related challenges: In addition, participants expressed transparency concerns with revealing detailed financial data to patients. Others expressed concerns with the ability to engage patients in the process and allow patients to make informed and meaningful contributions to the procurement process.
Technical strategies to incorporate PROMs
The first step to facilitate the widespread incorporation of PROMs into the procurement processes of an organization is to establish proof-of-concept at a pilot site, as strategic scaling of these initiatives is necessary to garner a critical mass of support within each organization. Thereafter, it is possible for these practices and policies to permeate other sites within an organization. Participants noted several factors related to pilot site location and ward type which should be considered in initial adoption and of PROMs, as listed below:
- Selecting a site for first implementation of PROMs requires consideration of:
- Size: The size of an organization is closely tied to its ability to acquire patient input. Smaller organizations in rural settings are more likely to engage patients on an ad hoc basis, but larger organizations have a better opportunity to leverage data systems to integrate PROMs into procurement.
- Culture: The ability to connect with patients depends on the culture of the hospital. Organizations with a long-term culture of patient-centeredness are better positioned to lead PROMs.
- Community-based: PROMs initiatives are more likely to be successful in community-based settings such as patient homes and doctor’s offices instead of hospitals for two primary reasons: first, hospitals are trying to reduce the amount of time patients are in hospitals; and second, patients are vulnerable when in hospital.
- Selecting a ward or unit for first implementation of PROMs requires consideration of:
- Acuity: Acute care wards are not ideally suited for PROMs implementation, as these wards have shorter-term patient interaction.
- Significance: Large, defined services are potential areas where PROMs could be piloted within hospitals. Participants noted that these specialties are considered high-impact by patients and are therefore more likely to receive patient interest and engagement in procurement discussions.
- Patient volume: Wards with lower patient volumes are recommended as sites for implementation of PROMs initiatives that will require clinician assistance and/or input, as these sites have a lower patient-to-staff ratio. In contrast, for PROMs initiatives that are less reliant on clinicians and require maximal patient input, high volumes wards are ideal.
In addition to choosing an initial site and ward for implementation, the following aspects must also be considered:
- Choosing appropriate products: Patients should not be expected to have a full understanding of all products, and thus, should be involved with product evaluations on an ad hoc basis for those topics that are specific to their (or their families’) needs and personal experiences.
- Choosing criteria: When selecting PROMs criteria for consideration during a procurement initiative, it is important to consider the number of criteria, specific metrics and weighting. Participants recommended selecting four to five key clinical criteria for procurement to focus on with patients.
- When to incorporate: Two key stages for patient involvement in procurement processes are during the request for proposal (RFP) development and the evaluation/validation of the RFP.
- Educate stakeholders: Education initiatives directed towards both patients (and community members, more broadly), as well as health care and procurement personnel should be implemented to ensure proper understanding of established best practices and required processes to incorporate PROMs.
- Leverage data: Collection and understanding of patient data is critical and as such, is necessary to enable organizations to appropriately access and utilize this data. Facilitating and promoting the use of advanced data analytics is an important strategy to successfully incorporate PROMs into procurement decision-making. To do so, 1) longer-term data should be collected, 2) opportunities of data system integration should be pursued and 3) private sector partnerships should be leveraged.
Procurement approaches: Purchasers need to be willing to have open discussions with suppliers throughout the procurement process. To facilitate these types of conversations, purchasers should reframe their approach to facilitate a focused, outcomes-based dialogue.
Change management strategies to incorporate PROMs
Effective change management strategies will be a critical component of successful implementation efforts. Of particular importance is the establishment of a culture focused on VBP. Recent policy efforts focused on VBP have been effective at shifting organizational culture and procurement strategy towards total cost of care over a product’s lifecycle. These and related efforts should continue to be in hospitals by integrating long-term value metrics into performance incentives at all levels.
For organizations that have not yet ventured into the world of PROMs, it is recommended that a staged approach to implementation of patient engagement be adopted commencing with the incorporation of patient feedback for large, high-impact products in clinical units that already have a culture of engagement and/or VBP.
Engaging patients for procurement activities does not need to be the sole responsibility of one organization, but rather a larger integrated set of stakeholders should contribute to and encourage patient engagement to advance its incorporation within procurement processes. These stakeholders include industry, government, community care, SSO and academic representatives – each with their own unique perspective and role in health care and/or purchasing systems. As such, successful implementation of PROMs requires more broad and deep alliances between all levels of care within the province, including community care, long-term care, and acute care organizations, as well as patients from each of these levels.
When the health care system fails to implement value-based, patient-centred processes, such as implementation of PROMs in procurement, it does a disservice to its patients. As such, the most important benefit of application of this research is the potential to improve patient-centred care throughout Canada. Moreover, the incorporation of PROMs in tendering has the opportunity for hospitals to reduce costs by making procurement decisions based on the total cost of care rather than price alone. At a system level, these processes will reduce costs by encouraging collaboration and sharing of resources and knowledge across the system.
If health care systems are able to reorient their thinking towards patients through a model in which outcomes and value are at the centre of decision-making, we will be in a better place to ensure systems continue to deliver against the current and future needs of citizens. This research further proves that linking supply chain to patient outcomes is no longer a distant goal and suggests best practices for incorporation of PROMs in procurement processes that can be implemented throughout Canada.
David Barrett is the Executive Director of the Ivey International Centre for Health Innovation. Alexander Smith and Kaitlin Saxton are both Research Associates at the Centre.