One of the positive results of the pandemic has been increased collaboration among hospitals in metropolitan areas of the country. But the value of collaboration isn’t limited to crises. It can be a mechanism for improving quality and reducing costs in normal times. Collaborations among dozens of hospitals and physician organizations in Michigan that date back to 1997 are a case in point. They have scored impressive results in a variety of areas, including cardiovascular care, bariatric surgery, blood clot prevention, general surgery, joint replacements, and urology.
Amid a health care landscape of rising prices and inconsistent quality, many have called for more competition in the United States to solve these growing concerns. While proponents argue that this would force hospitals to deliver better care at a lower cost, competition is no panacea. The quality of care continues to vary dramatically between and within health systems, and studies suggest that competition might actually reduce quality and exacerbate inequities for patient populations deemed “unprofitable.”
An alternative solution that might be more effective is getting hospitals to collaborate. The idea of hospitals opening their books, sharing internal data, and working with “the shop across the street” may seem far-fetched, but it’s already happening. And it’s working.
Why Collaboration?
Within a company, collaboration leads to better problem solving, peer learning, shared purpose, and innovative ideas. But even between companies, collaboration plays a critical role. Years ago Rosabeth Moss Kanter argued that companies’ individual success relies intimately on their ability to maintain collaborative relationships with other organizations. The key features of successful collaborations between individual companies, she pointed out, were that they opened doors to unforeseen opportunities, created new value rather than simply being a zero-sum exchange, and were not controlled by a single entity but flourished from equal contributions from all stakeholders. She dubbed this the “collaborative advantage.”
Is there a collaborative advantage to be gained in health care? Decades’ worth of experience in Michigan suggests the answer is yes.
Case Studies in Collaboration
In 1997, Blue Cross Blue Shield of Michigan helped launch a fledgling program called the BMC2 Cardiovascular Consortium. Its mission was as simple as it was daunting: bring hospitals together to improve the care of patients with cardiovascular disease, the leading cause of death in the United States. Originally consisting of five hospitals, it grew to include over 50 hospitals across Michigan that shared deep clinical details — i.e., how each hospital was treating the same disease, how many patients at each hospital had a complication, and whether each hospital was using the best available technology.
This transparency enabled these hospitals to identify previously invisible performance gaps, develop new solutions, and change practices. Rather than trying to outcompete each other, they started learning from each other. If a hospital had impressively low infection rates after surgery, the collaborative turned to them to guide infection prevention protocols for the group. If another had a particularly successful smoking-cessation program, that approach was adopted throughout. Ultimately, this collaboration improved the quality of care and reduced cardiovascular complications, hospital readmissions, costs of care, and death across the state.
BMC2 was the first of what would become nearly two dozen different collaborative quality initiatives (CQIs) in Michigan. (This webpage lists some but not the newest ones.) Each CQI is a consortium of hospitals and physician organizations that work together to improve care for a specific specialty — where one focuses on abdominal surgery, another focuses on childbirth, another on joint replacement, another on cancer, and so on. Supported by Blue Cross Blue Shield of Michigan and led by physicians who design and implement value-based programs to transform care, these collaboratives have achieved remarkable results, including:
- Bariatric surgery — 56% reduction in mortality
- Blood clot prevention — 175,000 unnecessary lab tests prevented
- Cardiovascular care — 51% reduction in bleeding complications
- General surgery — 23% reduction in surgical-site infections
- Hospital medicine — Reduction in unnecessary antibiotics, leading to a change in national guidelines
- Knee and hip replacement — 53% fewer discharges to extended care facilities after surgery
- Urology — 50% reduction in procedure-related hospitalizations
On top of facilitating continuous improvement in specific areas, collaboration also enables health systems to better respond in times of crisis. The Michigan Hospital Medicine Safety Consortium was able to pivot existing collaborative work at over 40 hospitals to address the Covid-19 pandemic. Just one month after the first documented case of Covid-19 in Michigan, the collaborative launched a statewide database to track Covid-19 hospitalizations and identify important risk factors for severe illness. The result was a publicly available risk calculator that helped clinicians estimate patient risk on a case-by-case basis. Across the country, other health systems also collaborated to share information and resources in a similar way to combat the pandemic.
Preventing complications, keeping patients out of the hospital, and reducing unnecessary care saves money too. Ultimately, the CQIs have saved an estimated $1.4 billion in health care costs. According to a study conducted by the RAND Corporation, the costs of care in Michigan are among the lowest in the country. Other states such as Illinois and Wisconsin have now adopted this approach to improve care and reduce costs in a similar way.
Better care at lower costs — the elusive “win-win” scenario for health care — is one of competition’s central tenets. However, these examples illustrate that collaboration may be just as, if not more effective in achieving this goal.
How Does Collaboration in Health Care Work?
Collaborative quality improvement has existed in health care since the 1980s. At its most basic, it is simply a process by which multiple stakeholders — whether individuals (including clinicians and non-clinicians), departments, or entire hospitals — come together to share information, identify gaps in performance, and develop solutions to improve care. Far from the traditional notion of keeping operations proprietary to carve out a competitive advantage, this process fundamentally relies on transparency. Outcomes, processes, and even expenses are shared throughout the group.
Two remarkable things happen when hospitals and physicians do this. First, by sharing their performance with each other, individual hospitals can now see where they stand relative to their peers. Obviously, the sensitive nature of this data requires the utmost care and confidentiality, but once performance is mapped out across the group, it becomes easy to identify high performers, low performers, and everyone in between. It also allows hospitals to track performance over time to see what’s working and what’s not. In short, collaboration puts performance into context. Without context, it’s impossible to know whether you’re a leader or a laggard. And invariably, leaders in one area of care may be laggards in another.
The second benefit of collaboration between hospitals is that the improvement agenda is set by those delivering care. The value of buy-in from physicians and hospitals cannot be overstated. Once hospitals understand where they stand in the group, they can take ownership of solutions at a local level.
If a group of hospitals finds that the biggest challenge is patients being unable to urinate after spine surgery — which is precisely what the 26 hospitals in the Michigan Spine Surgery Improvement Collaborative found — then it is the local experts (i.e., spine surgeons, anesthesiologists, and nurses) who develop the specific solutions. In this case, those solutions ultimately saved an estimated $20 million.
This stands in stark contrast to traditional regulatory reform, where top-down regulations demand that every hospital address the same problem in the same way, often without the data to do so. Unfortunately, this approach can lead to inefficient utilization of resources and unintended patient harm. Collaboration, on the other hand, enables improvement precisely because each hospital can play to its own unique processes, challenges, and strengths.
Scarcity and Abundance
One way to think about competition and collaboration is in the context of the “scarcity” and “abundance” mindsets, terms coined by Stephen Covey. The push for competition in health care is rooted in a scarcity mindset, which sees resources as fixed and views the business of health care as a zero-sum game that depends on securing a competitive advantage. Board rooms often operate from this perspective. Other hospitals may be seen as competitors to be outperformed or acquired. In this framework, only the subset of hospitals that outcompete their peers will improve.
In an abundance mindset — which views opportunities as additive rather than exclusive — it is possible for every hospital to improve simultaneously. Whereas a scarcity mindset requires a loser for every winner, an abundance mindset sees “win-win” opportunities. Collaboration is an effective way to realize those opportunities. In Michigan, payers, providers, and patients have benefited from this collaborative approach for over two decades through reduced costs, improved quality, and higher patient satisfaction. Collaboration recognizes that health care flourishes when our greatest talents work with each other, not against each other. Ultimately, more collaboration may be just what health care needs.