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Ensuring this occurs through accountable care organizations means relooking at the strategies,
processes, structures, and systems currently employed. It will require co-ordinated care and the
pieces to co-ordinate are elucidated on in more detail in this article.
The starting point is to keep the end in mind.
 Define quality care
Aim all workflows to achieve this
Determine the measures
Build in sustainability
In order to achieve the outcomes, the goals need to be set and all actions focused on achieving
them.
Focus on the right goals
Create a strategy to achieve them
Ask the question - how can we be resource practice conscious, as
well as cost effective at Medicare rates?
Review progress using the data
Define the required leadership behaviors
Healthcare providers and vendors need to be aligned to the macro- and marketplace environment
shifts that are occurring. Localized positioning is essential too and the ability to influence
desired changes and leverage relationships and resources.
Align with health reform
Create a culture of shared responsibility
Integrate between physicians, physician groups, wellness
providers, and hospitals
Integrate data and performance systems
The means to produce desired patient care outcomes derives from creating a culture that allows for
sound outcomes-based clinical, operational, and financial management.
Target quality care
Enhance patient relationship management
Concentrate on the diagnostics
Track monitoring metrics
Manage the clinical data
Manage payer relationships
Employ relevant metrics
Work with P4P (Pay for Performance)
Establish accountable cost centers
Assess and manage risk
Manage the financial data
Build an enabling and flexible structure
Ensure systems are integrated and utilized
Review processes
Optimize efficiencies
Manage interfaces between work areas and healthcare providers,
with the suppliers, and with patients
Manage the integration of all data necessary to lead an
accountable care organization
The steps taken to assist in healthcare and the data on patient health and patient care outcomes
can assist in patient population management.
Build in relevant metrics
Construct necessary processes
Manage the environmental interface
Source and utilize demographic and clinical information
Manage the data
Consider data sharing – work on a health information
exchange
Include pre- and post-hospital care
“Things fall apart, the centre cannot hold” (Chinua Achebe)
It all pivots on the ability to manage data effectively. The center that will allow for access to
required information, for pathways to mine needed data, for integration of the data and meaningful
repackaging of the information, and for fast, flexible, and informed decision-making is an
integrated data management system.
Work with manual and automated EMR and HIR
Establish data fields
Source, collect, and access data
Track data
Integrate data
Analyze data
Improve data efficiencies
Report the data in user-friendly formats
Utilize data for decision-making
Proactively impact actions and outcomes
There is data sitting in every organization. Where, in what format, to what level of detail, in
what categories, what it relates to, and what decisions or outcomes it should inform needs to be
established. This would allow data fields to be cleaned and the sourcing established. Then an
overlaid system to collect, integrate, and analyze the data is required. The logic that is followed
must make sense to the way in which the organization functions and how the managers make decisions.
This data relates to every facet of the Accountable Care Organization – the patient care outcomes,
the clinical, financial and organizational operations and management, co-ordinated care, and
patient population management.
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