Yale New Haven Health CCO Recommitted to Patient Safety and Care Quality

Yale New Haven Health is stepping up efforts to be a high-reliability organization.

For 2024, a top priority for the chief clinical officer of Yale New Haven Health is improving patient safety and care quality.

Thomas Balcezak, MD, MPH, has served as chief clinical officer of the health system since 2020. He previously held several positions at Yale New Haven Hospital, including chief medical officer, chief quality officer, director of performance management, and medical chief resident.

This year, Balcezak is focused on re-evaluating and retooling patient safety and care quality programs. Yale New Haven Health is doubling down on efforts to be a high-reliability organization that began a decade ago, he says.

"During the coronavirus pandemic and with the influx of new staff, we have seen an opportunity to recommit to the principles of high reliability," Balcezak says.

The effort involves the aspiration if not the actual achievement of zero harm for patients, he says. "It involves education. It involves making sure that we do a thorough evaluation of every serious safety event and near-miss event. It involves engaging staff members who can re-engineer processes and practices given the recognition that very few safety events are the fault of an individual. It is more often the fault of the system."

In the area of care quality, the health system has launched an initiative called Care Signature. The foundation of Care Signature is that patients should have the expectation that no matter where they go in the health system, they are given the same care based on their clinical condition, Balcezak says.

"You get the same therapeutic evaluation, the same access to cutting-edge therapeutics, and achieve the same outcomes no matter where you go," he says.

Care Signature involves operational standardization, according to Balcezak. For example, each hospital in the health system has the same radiologic protocols, the same laboratory protocols, and the same pharmaceutical formulary.

The initiative also seeks to influence physician behavior, he says.

"We want to reduce to the lowest possible denominator physician variation and how they approach diagnostic workups and therapeutic plan development," Balcezak says. "We are creating clinical care pathways, which include links to order sets within our electronic medical record for what tests should be ordered, what tests should be avoided, and what is the correct approach therapeutically for a patient with a given clinical condition."

Thomas Balcezak, MD, MPH, is chief clinical officer of Yale New Haven Health. Photo courtesy of Yale New Haven Health.

Financial turnaround

Balcezak is also focused on helping Yale New Haven Health improve its financial standing.

"Like many institutions, we had negative operating margins during and immediately after the pandemic for a variety of reasons such as inflation, labor tightness, and a lack of elective procedures," he says. "This will be the first year in which we break even on operations or even turn a small profit since the pandemic."

Clinical care efforts tied to financial performance at the health system include managing hospital length of stay and patient throughput as well as clinical stewardship, Balcezak says. Yale New Haven Health saw an increase in length of stay during the pandemic, and returning to a pre-pandemic length of stay has been a multifaceted body of work, he says.

These efforts include key drivers on hospital units such as setting an anticipated date of discharge, working with the patients and the care management team to get the patient ready for discharge, bringing the family into the discussion with the expectation about date of discharge, then holding all members of the care team accountable to hitting goals, Balcezak says. "For example, the physicians, the nurses, the care management team, and the social workers have to be held accountable."

Managing hospital length of stay and patient throughput is a top concern for clinical officers because it not only impacts cost of care but also is tied to the quality of patient experience and bed capacity.

Embracing clinical stewardship makes care delivery more efficient and cost effective, he says.

"In clinical stewardship, there was a time several years ago when we had an open pharmacy formulary, and you could get virtually any drug at the hospital. You could also order virtually any test," Balcezak says. "That was a time when physician autonomy as well as a lack of clear clinical guidance ruled. Clinical care guidance has become much clearer. How we do utilization review on the inpatient and the outpatient services has changed. Determining appropriate workups, appropriate testing strategies, and appropriate therapeutic regimens has become much clearer."

Clinical stewardship achieves more efficient medical care, which gets patients treatment faster, so it is more efficient financially and timewise for the patient, he says.

"We use the literature to help us guide us on care pathways, which gets us to better outcomes in a more efficient way," Balcezak says.

Coping with growth

Another priority for Balcezak this year is dealing with population growth in Connecticut.

"In the past, both outpatient and inpatient growth stalled. In our Connecticut communities in the late twenty-teens, growth in our population stalled," he says. "There was a net out-migration in Connecticut for at least a couple of years. The pandemic changed that trend. Since the pandemic, we have seen a net increase of particularly younger people seeking to live in Connecticut. We also have seen a growing elderly population."

Growth in the patient population over 65 is a concern for clinical officers nationwide.

Yale New Haven Health is experiencing growth in outpatient and inpatient services, Balcezak says.

"We have had growth across virtually all service lines," he says. "The growth has been between 2% and 4%."

Part of the health system's response to growth has been to launch a healthcare access initiative, Balcezak says. "The access initiative is in conjunction with the Yale School of Medicine to try to improve outpatient access for workups, diagnostics, and therapeutic treatments," he says.

On the inpatient side, Yale New Haven Health has been operating at record capacity, which makes length of stay work and throughput important beyond their impact on cost of care, Balcezak says.

"We cannot create new beds in an instant and we do not have any shuttered units that we can open and operate," he says. "So, the most important things we can do to accommodate inpatient growth is to lower length of stay and improve patient throughput."