Hartford HealthCare’s Clinical Care
Redesign Program –
A System Approach
Rocco Orlando, MD; Chief Medical Officer, Hartford HealthCare
With the changing healthcare landscape, organizations
are being tasked to rethink the way they deliver care
with the goal of improving clinical outcomes and
reducing costs. Hartford HealthCare has identified
care redesign as a strategic priority and has launched
the Clinical Care Redesign (CCR) program. The
CCR focuses on opportunities to reduce care
variation, improve quality and reduce cost. CCR is
founded on the principle that variations in care – from
both a quality and cost perspective likely represent
opportunities to improve results.
The identification of care variation begins a process
to re-examine and challenge the assumptions about
how we provide care. First, we need alignment with the
physicians providing care – specifically a willingness
to look at new models to treat a particular condition.
Second, we need data to define the outcomes in terms
of both quality and cost. Third, we need to assess best
practice based upon the experiences of other health
systems and published literature. This approach allows
us to develop new care paths for a particular condition-
paying close attention to the data that will measure our
success.
Hartford HealthCare has identified four target areas;
Cardiovascular Services, Colorectal Surgery, Hospital
Medicine, and Imaging Services. A robust governance
structure supports the redesign program with Executive
Leadership and a commitment to place the patient at
the epicenter. Physician and nurse dyad leaders execute
the redesign projects at Hartford HealthCare hospitals.
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This work requires a multidisciplinary approach
with partnership from Supply Chain Management,
Information Technology, Informatics, Project
Management, Nursing Education, and Revenue Cycle.
Collaboration as a system has led to early success.
In the Cardiovascular space, Hartford Hospital has
reached the National Cardiovascular Data Registry
(NCDR) top decile performance in door to balloon
time for acute myocardial infarction – an average of
47 minutes. By focusing as a system on early access to
interventional care, Hartford Hospital has achieved
100% door-to-balloon time within 90 minutes in the
past quarter. The COPD CCR team has improved
care for the COPD patient population by decreasing
unnecessary steroid utilization. Additionally, COPD
patients have seen a reduction in length of stay of
1.25 days and readmission rate reduction of 12%.
Colorectal Surgery providers have fully implemented
the best practice, Enhanced Recovery after Surgery
(ERAS) initiative which has led to a reduced length of
stay for colorectal surgical patients.
It is the effort behind the numbers that is a true
testament to Hartford HealthCare’s commitment
to excellence. Clinical Care Redesign is an example
of a system initiative that has rallied support from
team members across the organization. On behalf
of Hartford HealthCare, I would like to thank those
involved in this important program. Collectively our
work will help drive our organization’s mission of
“Most trusted for personalized coordinated care”. g
O P E N JO URNAL • W I NTE R 2018
Commentary
Dr. Orlando’s article provides a very high level summary of Hartford HealthCare’s approach to care redesign. It accurately describes efforts
to integrate best practices with consistent approaches to improve both clinical and financial outcomes. Although I am not as familiar with
what has happened in the Cardiovascular, Hospital Medicine and Imaging realms, I have been an active participant in the Colorectal
Surgery project and am very pleased with the progress and results we have seen.

The major emphasis of care redesign in Colorectal Surgery is the adoption of Enhanced Recovery After Surgery (ERAS) for these patients.
ERAS is a collection of approaches to surgical patients that taken together seem to provide safer outcomes, shorter hospital stays and greater
patient satisfaction. ERAS was pioneered in Europe where a number of preoperative strategies contrary to traditional thinking resulted
in improved performance. There is an emphasis on pre-surgical education for patients, including instructions to maximize exercise and
medical compliance prior to surgery. Other approaches include allowing clear liquid diets until two hours prior to surgery and giving an oral
carbohydrate drink within two hours of surgery. Preemptive analgesia with NSAIDs, acetaminophen, and gabapentin is used. Attention to
intraoperative temperature, glucose control, and limiting IV fluids are important. Post operatively encouraging immediate oral intake and
limiting narcotic analgesia allow for improved return of bowel function. There are specific goals for activity and ambulation.

In order to utilize this approach throughout Hartford HealthCare there was a coordinated effort with participation from each of the
hospitals. Colorectal surgeons and anesthesia providers from each hospital were polled about their individual treatment strategies prior
to implementing these goals. Consensus approaches that could be used at all the hospitals were adopted and integrated into Epic. Anesthesia
services are critical to making the perioperative approaches successful and their input at each hospital allowed for a smooth transition. Each
hospital has a Nurse/Physician dyad that leads the efforts. At Backus I am the physician leader and Nicole Porter is the nursing leader .
Dr. Sergio Casillas, our most active colon surgeon, was an engaged participant. All of our surgeons have been educated and have committed
to using this approach. Dr. Adam Goldstein provided invaluable anesthesia input. Claudette Faucher-Charles APRN, the administrative
leader, oversaw education for surgeons, anesthesia, the OR, and the post-surgical floors before starting the program . Having local
participation with a system-wide approach has allowed for the successful implementation at ERAS for Colorectal Surgery here at Backus
and throughout the system. The same approaches should be effective in other surgical areas and ERAS will be introduced soon to
Gynecologic Surgery and Orthopedics.

So, how have we done? We do not have data yet at Backus, but the data from the Hospital of Central Connecticut (HOCC) is compelling.
They compared their first thirty ERAS cases with thirty cases before the program was implemented. The median length of stay decreased
from four to two days. There were no significant differences in the incidence of complications or returns to the OR. There were significant
improvements in the amount of narcotic used on the day of surgery, the time it took to advance to a regular diet, and the number of patients
passing flatus on PO day #2.

Ms. Faucher-Charles is currently compiling data on our first one hundred ERAS colorectal cases. I hope to be able the share this information
in a future article. Preliminary evaluation leads us to believe we will see results similar to those at HOCC.
–David Kalla, MD

Editor’s Note:
EPIC is the perfect tool to deracinate variability. Funny how I distrust this rush toward the golden mean.
-Dennis Slater, MD

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