slow and steady brings success

TriHealth’s Slow & Steady Progress to Success

Good Sam Bethesda

Georges Feghali, MD

Sr. VP, CMO, COO

Driven by Mission, Vision and Values

MissionTo improve the health status of the people we serve

VisionTo be where people want to work, physicians want to practice, and most importantly, where the community wants to go for the best quality, service, safety, and value in healthcare

Driven by Mission, Vision and Values

Values

• Respect for all people• Service excellence for all customers• Respect for our spiritual heritage• Stewardship• Responsive to community needs• Valuing differences

The “Tri” in TriHealth

TriHealth represents the triad of hospitals, physicians and the community working together to improve health and wellness.

We focus on patient care, teaching and research

How We Are Organized

A Few Facts and Figures• Two acute-care hospitals with nearly 900 beds (898)

• Good Samaritan (GSH) has the highest market share

in TriHealth’s four-county area, and Bethesda North

(BNH) is #2

• Over 11,000 births per year: GSH is #1 in Ohio; BNH is # 6

• Largest robotic surgery program in the U.S.

• Over 50 outpatient service locations

• Over 2,500 independent physicians (active & courtesy) &

greater than 200 employed physicians

• Over 10,000 employees

TriHealth Inc.

Prides itself on being able to handle multiple initiatives and set overall organizational initiatives

Avoids focusing on “flavor of the month” – what is the hot topic everyone is concerned about

Our goal is quality across the organization defined as “Doing the right thing, at the right time for the right patient EVERYTIME”

Evidenced Based Care

•Employ over 30 hospitalists between the two hospitals – part of role to collaborate on core measures. Measure Adherence to Order Sets

•Created a VP of Medical Affairs at both hospitals• Champions specific clinical initiative• Serves as resource for complex, high LOS cases

•Extended role of care coordinator to include review of core measures

Evidenced Based Care•CDMP works with physicians to assure appropriate documentation

•Incorporated into performance evaluations

EBC: Pneumonia•Pneumonia core team of physicians: Pharmacy, ED, Hospitialist, Clinical Quality, Pulmonologists

•Developed a Selection Sheet for appropriate antibiotic selection

•Vaccine protocol created which does not require a physician order

•Smoking cessation hard-stops and education built into electronic clinical documentation

EBC: Pneumonia•Receive weekly exception reports of missed opportunities

• Sends a core measure alert email to managers to review• Managers help educate staff

•Hardwired so everyone get info on smoking

•Developed “Pneumo News” to send out updates to managers•Use pyxis system to remind nursing about blood cultures prior to antibiotic administration

•Modified order sets

Pneumonia-Results 3Q 2008- BNH

Pneumonia    

PN All-or-None Composite Score 88%

PN-2: Pneumococcal vaccination 92%

PN-3b: BC performed in the ED prior to Initial Abx Rc'd in hospital

96%

PN-4: Adult smoking cessation advice/counseling 100%

PN-6: Initial abx selection for CAP immunocompetent pts 89%

PN-7: Influenza Vaccination  

Pneumonia – Results 3Q 2008 -GSH

PN All-or-None Composite Score 90%

PN-2: Pneumococcal vaccination 91%

PN-3b: BC performed in the ED prior to Initial Abx Rc'd in hospital

95%

PN-4: Adult smoking cessation advice/counseling 100%

PN-6: Initial abx selection for CAP immunocompetent pts

97%

PN-7: Influenza Vaccination  

EBC: AMI•AMI multidisciplinary task force at both facilities

• Cardiologists• Care managers• Educators• Clinical Quality• Documentation abstractors• ED Physicians• Cath Lab & ED management and staff

•Committed to never stop meeting and ongoing review of progress

EBC: AMI•Significant learnings regarding nuisances of documentation

• A number of cases with excellent times were excluded because of documentation related to EKG – learned better ways to document

• Sharing of information and data on continuous basis both from educational perspective and missed opportunities

• Added the new VP of Medical Affairs to the group

AMI – Results Q3 2008-BNHAcute Myocardial Infarction  

AMI All-or-None Composite Score 91%

AMI-1: Aspirin at arrival 99%

AMI-2: Aspirin prescribed at discharge 100%

AMI-3: ACEI or ARB for L VSD 96%

AMI-4: Adult smoking cessation advice/counseling 100%

AMI-5: Beta-blocker prescribed at discharge 97%

AMI-6: Beta-blocker at arrival 95%

AMI-7a: Fibrinolytic agent within 30 min of hospital arrival  

AMI-8a: Primary PCI within 90 min of hospital arrival 83%

AMI – Results Q3 2008-GSHAMI All-or-None Composite Score 93%

AMI-1: Aspirin at arrival 97%

AMI-2: Aspirin prescribed at discharge 100%

AMI-3: ACEI or ARB for L VSD 100%

AMI-4: Adult smoking cessation advice/counseling 100%

AMI-5: Beta-blocker prescribed at discharge 100%

AMI-6: Beta-blocker at arrival 85%

AMI-7a: Fibrinolytic agent within 30 min of hospital arrival  

AMI-8a: Primary PCI within 90 min of hospital arrival 88%

EBC: Heart Failure•Similar group as AMI but includes Pharmacy

•Took our Heart Failure story on the road and went to Internal Medicine & Family Practice

•Share missed opportunities on regular basis

•Developed preprinted progress notes with best practice for physician

EBC: Heart Failure•Discovered device patients were being discharged before CDMP was able to conduct a concurrent review- so Cath Lab now reviews charts & flags pertinent ones

HF – Results Q3 2008 - BNH

Heart Failure    

HF All-or-None Composite Score 98%

HF-1: Discharge Instructions 100%

HF-3: ACEI or ARB for LVSD 95%

HF-4: Adult smoking cessation advice/counseling 100%

HF – Results Q3 2008 - GSH

HF All-or-None Composite Score 88%

HF-1: Discharge Instructions 90%

HF-3: ACEI or ARB for LVSD 90%

HF-4: Adult smoking cessation advice/counseling 100%

EBC: SCIP

•Part of management goals & incorporated into our electronic balanced scorecard

•Multidisciplinary meets weekly (monthly GSH)

•Use missed opportunities reports – not available like other specialties due to quantity of indicators, volume & methodology to collect data

EBC: SCIP•Concurrent review done which team then identifies areas that make a difference in care (both inpatient & outpatient data)

•Data available on intranet to monitor progress

•Challenges:• Data in obtaining data from vendor• Indicators have potential to change quarterly

SCIP- Results Q3 2008 - BNHSurgical Care Infection Prevention  

SCIP-INF All-or-None Composite Score 85%

SCIP-INF-1a: Prophylactic abx rec'd w/i 1 hr prior to surgical incision

96%

SCIP-INF-2a: Prophylactic abx selection for surgical pts 99%

SCIP-INF-3a: Prophylactic abx discontinued within 24 hours after surgery end time/48 hours for CABG or Other Cardiac Surgery

95%

SCIP-VTE-2: Surgery pts who rec'd appropriate VTE prophylaxis w/i 24 hours prior to surgery up to 24 hours after surgery end time

84%

SCIP- Results Q3 2008 - GSH

SCIP-INF All-or-None Composite Score 88%

SCIP-INF-1a: Prophylactic abx rec'd w/i 1 hr prior to surgical incision

94%

SCIP-INF-2a: Prophylactic abx selection for surgical pts 99%

SCIP-INF-3a: Prophylactic abx discontinued within 24 hours after surgery end time/48 hours for CABG or Other Cardiac Surgery

94%

SCIP-VTE-2: Surgery pts who rec'd appropriate VTE prophylaxis w/i 24 hours prior to surgery up to 24 hours after surgery end time

95%

Mortality•Started years ago when community initiated sharing of comparison data

•Realized to fair well we need document conditions & co-morbidities that drive severity adjustments & co-morbidities

•Also driven by insurance such as Anthem soliciting participation in improving care in key areas such as open heart

Mortality•Clinical documentation management program put in place with extensive education

• Helps us to identify factors

•Premier Safety initiatives

•Development of clinical pathways/ order sets • Based on research through ZYNX• Updated on regular basis • Helps us keeps our eye on the ball of best

practices• Critical involvement of physicians

Mortality Results - BNH

0.00

0.20

0.40

0.60

0.80

1.00

Baseline May 2008 Jun 2008 Jul 2008 Aug 2008 Sep 2008 Oct 2008 Nov 2008 Dec 2008 Jan 2009

O/E Ra

tio

Mortality O/E Ratio - Period Mortality O/E Top Performance Threshold

Mortality Results-GSH

0.00

0.20

0.40

0.60

0.80

1.00

Baseline May 2008 Jun 2008 Jul 2008 Aug 2008 Sep 2008 Oct 2008 Nov 2008 Dec 2008 Jan 2009

O/E R

atio

Mortality O/E Ratio - Period Mortality O/E Top Performance Threshold

Cost of Care•High cost areas targeted for improvement teams

• Cardiology stents, devices, implants• Perioperative supplies• Gloves, trays,etc• Orthopedic joint implants• Spine

•Implemented Point of Use for charge capturing

•Premier Safety initiatives

Cost of Care

•Established Efficiency of Care group

• Membership: CMO, CNO, DSS, Care Management, Clinical Documentation, Nursing & other adhoc areas

• Targeted approach: Used Premier Clinical Advisor and internal databases to identify areas for improvement

Cost of Care

• Conducted chart review of patients with LOS of 5 days and Level 1 severity

• Push learnings back to appropriate pt care areas through opportunities

• Continue to slice data more refinely even though we look good

• Look at both cost and quality

Cost of Care - BNHCost of Care            

Time Period:

2008Q4

Number of Entities Reported for Baseline Period*: 163

Measure Results:Perform

ance

Hospital Total

Inpatient Cost per Case Mix Adjusted

Discharge

Variation from Top Performa

nce Threshol

d

Top Performa

nce Threshol

d

 Total

Discharges

Teaching and >=375 Beds       $6,540      

Teaching and <375 Beds $4,940 -$1,250 $6,190     6,263

Non-Teaching and >=175 Beds       $5,400      

Non-Teaching and <175 Beds       $5,170      

Note: Cost of Care data is considered preliminary until calculated Case Mix Index is available.

Cost of Care - GSHCost of Care            

Time Period:

2008Q4

Number of Entities Reported for Baseline Period*: 163

Measure Results:Perform

ance

Hospital Total

Inpatient Cost per Case Mix Adjusted Discharg

e

Variation from Top Performa

nce Threshol

d

Top Performa

nce Threshol

d

 Total

Discharges

Teaching and >=375 Beds $5,770 -$770 $6,540     7,117

Teaching and <375 Beds       $6,190      

Non-Teaching and >=175 Beds       $5,400      

Non-Teaching and <175 Beds       $5,170      

Note: Cost of Care data is considered preliminary until calculated Case Mix Index is available.

Summary•Incorporate processes into existing work processes

•Emphasis collaboration between disciplines

•Timely ongoing review

•Never satisfied with “good” - continue to drill down to find other opportunities to become better

•Better to be a “tortoise” making slow and steady progress

“Do the right thing, at the right time for the right patient EVERYTIME”

Summary

Good Sam

Bethesda

Fin

ish

Lin

e