clinical optimization: one approach to integration...21 fy 15 –ytd sep fy 16 ip los and discharges...
TRANSCRIPT
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Clinical Optimization: One Approach to Integration
Session #192, February 14, 2019
Dr. Hiloni Bhavsar, Associate Director, Quality & Safety, Rochester General Hospital
James Williams, VP of Integration, Rochester Regional Health
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Dr. Hiloni BhavsarHas no real or apparent conflicts of interest to report
James Williams, MHSAHas no real or apparent conflicts of interest to report
Conflict of Interest
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• Learning Objectives
• Organization Overview
• Clinical Optimization Program Discussion
– Overview and Background
– Performance Improvement Process: Heart Failure Example
– Work Done to Date
– Challenges
– Future Areas of Focus
• Open Discussion (Encourage Questions / Comments Throughout)
Agenda
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• Describe an enterprise-wide approach to use clinical analytics to
drive performance improvement
• Describe a sustainable process to support clinical performance
improvement projects
• Discuss a methodology focused on understanding variations of
care to drive clinical integration and improve clinical outcomes
• List examples on how disparate clinical teams came together to
establish standards of care
Learning Objectives
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Organization Overview
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To enhance lives and preserve health by enabling access to a comprehensive, fully integrated network of the highest quality and most affordable care, delivered with kindness, integrity and respect.
Rochester Regional Health: Our Mission
Source: Rochester Regional Health Website
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Rochester Regional Health
2,500+medical staff
16K+system employees
87+primary care & ambulatory locations
5hospital locations
936long term care beds
8senior living facilities
370Kbehavioral health visits
54Patient lab testing sites
1M+clinical trials tests
245K+emergency room visits
1,600+system volunteers
Source: Rochester Regional Health
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Right Care. Right Time. Right Place.
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United Memorial
Medical Center
Unity HospitalRochester
General Hospital
Newark Wayne
Community Hospital
Clifton
Springs Hospital &
Clinic
Source: Rochester Regional Health
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Has your organization undergone a recent merger?
1. Past 1 year
2. Past 2-3 years
3. Planning in next 12-24 months
4. None
Audience Polling #1
https://live.eventbase.com/polls?event=himss19&polls=5147
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Clinical Optimization Program Discussion
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Which of the following applies regarding EMR in your organization?
1. Single EMR system across facilities
2. Multiple EMR systems across facilities
3. EMR + Paper
4. Paper
Audience Polling #2
https://live.eventbase.com/polls?event=himss19&polls=5148
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Where is your organization in the evolution of addressing variations in care?
1. Initial phases of discussion
2. Projects initiated but not fully integrated
3. Design and implementation
4. Sustained projects with results
Audience Polling #3
https://live.eventbase.com/polls?event=himss19&polls=5149
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• Reduce variation
• Create a culture of High Reliability
• Develop consistent clinical and patient experience across the continuum
• Utilize and implement evidence-based standards of care
• Yield sustainable results
Clinical Optimization Program Overview & Background
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Principles of High Reliability Clinical Optimization
Deference to Expertise
Sensitivity of Operations
Reluctance to Simplify
Preoccupation with Failure
Commitment to Resilience
Clinical leads determine evidence based
approach for standardization
Understand current context to identify areas of
opportunity
Recognize value of reducing variation while
appreciating inherent complexity
Build in control plans to flex with future
changes/modifications, new sources of variation
Build in practice of rapid assessment and
improvement cycles that are data driven
Clinical Optimization Program Overview & Background
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• Using internal data, reviewed cost-per-case distribution for each DRG
• Establish internal peer-groups: system average cost-per-case and low-cost provider
• Run statistics for performance ranges to identify focus area
Clinical Optimization Program Overview & Background
Example
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# PLM - Product Case Count1 SDV + Mean
(System Avg)
1 SDV + Mean
(System Best)
Excess
Days
AVG SDV %
of Mean
1IP Other Medical 5,934 $3,666,263 $5,884,001 10,636 92%
2IP General/GI/Endocrine Surgery 2,776 $3,027,795 $8,101,527 8,606 66%
3IP Cardiac - Medical 4,916 $2,029,466 $3,477,155 6,153 79%
4IP Respiratory 3,711 $1,799,741 $3,097,401 5,150 80%
5IP Orthopedic Surgery 4,665 $1,648,500 $4,084,207 4,309 38%
6IP Gastroenterology 3,190 $1,144,384 $2,002,984 3,787 78%
7IP Nervous System 2,475 $1,140,282 $2,338,849 4,307 78%
8IP Neurosurgery 1,235 $998,915 $2,225,799 1,585 53%
9IP Cardiac Valve 400 $941,129 $941,129 1,084 50%
10IP Oncology/Hematology 1,135 $900,603 $1,614,253 1,890 98%
11IP Nephrology 1,711 $880,301 $1,328,587 3,008 98%
12IP Acute Rehab 482 $767,959 $1,817,588 4,438 78%
13IP Acute Psych 1,395 $753,280 $3,229,544 6,187 114%
14IP Surgical Other 515 $549,881 $4,817,101 4,831 111%
15IP Cardiothoracic Surgery 305 $513,883 $687,814 719 64%
SUBTOTAL 34,845 $20,762,383 $45,647,938 66,689 N/A
GRAND TOTAL 53,040 $26,619,455 $58,523,681 81,257 72%
OB (Special Care, Vaginal
Delivery, C-Section, Newborns)9,058 1,327,322 4,345,980 1,965 59%
% of Total 2015 Statistics 100% 8% 19% 31% N/A
Clinical Optimization Program Overview & Background
Volume
assessment
DRG Grouping
Engaged leaders
Data Source: EPSI, FY 15, Jan-Sep FY 16 inpatients, no exclusions
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Performance Improvement ProcessExample: Heart Failure
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Performance Improvement: Approach
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1. Macro-Analysis: Heart Failure Example
LOS largely driven by
discharge disposition
LOS largely driven by admit
day of the week
30-day readmission rates
higher than CMS targets
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FY 15 – YTD Sep FY 16 IP LOS by Discharge StatusMS DRG 291 Heart Failure Shock w/ MCC
Data Source: EPSI, FY 15, Jan-Sep FY 16 inpatients, no exclusions
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FY 15 – YTD Sep FY 16 IP LOS and Discharges by Day of Week
Enc –
MS DRG
CMS
ALOS
Admit Day of the Week - ALOS
Mon Tue Wed Thu Fri Sat Sun
293 3.1 2.75 2.60 2.65 2.80 3.46 2.51 2.40
292 4.5 4.27 4.64 4.69 4.74 4.50 4.47 3.67
291 5.9 5.12 5.83 5.75 6.17 6.21 6.32 5.85
Enc -
MS DRG
% of Cases Discharged by Discharge Date
Mon Tue Wed Thu Fri Sat Sun
293 15% 18% 16% 17% 19% 7% 8%
292 15% 16% 19% 17% 18% 7% 9%
291 15% 18% 18% 19% 18% 8% 5%
Enc -
MS DRG
% of Cases Admitted by Admit Date
Mon Tue Wed Thu Fri Sat Sun
293 18% 15% 14% 18% 15% 11% 10%
292 17% 15% 13% 14% 17% 13% 11%
291 19% 17% 13% 13% 15% 11% 13%
Data Source: EPSI, FY 15, Jan-Sep FY 16 inpatients, no exclusions
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HospitalPredicted
Readmission [a]
Expected
Readmission [b]
Excess Readmission
Ratio [c]
National Observed
Readmission [d]
NWCH 26.5% 21.8% 1.2152 21.9%
RGH 25.6% 21.8% 1.1732 21.9%
UNITY 21.8% 21.4% 1.0220 21.9%
UMMC 24.4% 20.8% 1.1709 21.9%
CLIFTON 22.9% 22.7% 1.0094 21.9%
[a] The 30-day readmission rate predicted on the basis of your hospital’s performance with its observed case mix and your hospital’s estimated
effect on readmissions (provided in your hospital discharge-level data). The Predicted Readmission Rate is also referred to as "Adjusted Actual
Readmissions" in Section 3025 of the Affordable Care Act.
[b] The 30-day readmission rate expected on the basis of average hospital performance with your hospital’s case mix and the average hospital
effect (provided in your hospital discharge-level data).
[c] Ratio of the predicted readmission rate [d] to the expected readmission rate [e]. (Note: Due to rounding the Excess Readmission Ratio may not
be the exact ratio of the numbers in columns D and E; see the replication instructions for how to exactly replicate the results in column F). The
Excess Readmission Ratio (also referred to as the Standardized Readmission Ratio [SRR]) is the measure that will be used to determine the
payment adjustment for the Program. If a hospital performs better than an average hospital that admitted similar patients (that is, patients with
similar risk factors for readmission such as age and comorbidities), the ratio will be less than 1.0000. If a hospital performs worse than average, the
ratio will be greater than 1.0000. Excess Readmission Ratios greater than 1.0000 will be included in the payment adjustment formula.
[d] The number of eligible unplanned 30-day readmissions nationally divided by the number of eligible discharges nationally.
Hospital Discharge Period: July 1, 2012 through June 30, 2015
CMS Public Reporting :Hospital Readmissions Reduction Program (HRRP) for Heart Failure
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2. Prioritization and Roadmap: Heart Failure ExampleBased on the data, the team identified areas where heart failure care can be improved.
We prioritized and mobilized four workgroups.
Work Groups
Wave 1: March - June
a. Standard Care Process
b. Medication Reconciliation
c. High-Risk Care Management
Wave 2: September
d. Home Health & SNF Care
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3. 90 Day Improvement Cycle: Heart Failure ExampleOnce the three workgroups were identified and mobilized, they each went through a
90-day improvement cycle.
Completed SWOT analysis
to develop current state
Identified gaps between
current/future statesDeveloped Heart Failure
initiative roadmap
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• Physician Champion on-board
• Existing HF care pathway at UH
• Institutional Support
• Collaboration with eHealth at Home
• Telemedicine support
• Poor identification and tracking of high-risk
patients
• Lack of adequate O/P care management
resources
• Inefficient med rec process at admission
• Non-standardized handoffs at transitions of
care
• Gap in patient medication knowledge
• No evidence standard HF care pathway in I/P
(built into care connect) and O/P setting
• Introduction of new positions (i.e, Nurse
Navigator, Practice Manager, Data
Analyst positions)
• Further education of community and
patients
• Improve patient and family experience
through care process (i.e. pharmacy-led
d/c medication counseling)
• Participation in clinical trials
• ED Avoidance/Admission –
Decrease in value
• PCP potentially view clinic and
eHealth at home O/P care
strategies as a threat
• Reimbursements
Strengths Weaknesses
Opportunities Threats
Current State – SWOT Analysis
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Gap Analysis
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Phases of Implementation
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4. Implement: Heart Failure Example
Workgroup Initiative
Medication
Reconciliation
Create minimum standards and standardized grading system for medication
reconciliation at admission
Pilot pharmacy-led medication counseling at discharge
Standard Care
Process
Build inpatient HF order set
Develop heart failure care pathway for Home Health patients
High-Risk Clinic
Pilot Heart Failure RN at RGH
Design and Build Heart Failure bricks and mortar clinic (lead by RGH Cardiology Dept)
At the end of the 90-day improvement cycle, six individual initiatives were ready for
implementation.
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4. Sustain and Monitor: Heart Failure ExampleThe team identified LOS and Readmissions as an opportunity; therefore, we will regularly monitor our
performance against these metrics.
Data Source: Premier/HF Dashboard/SQL Reporting
- RGH LOS and Readmission (Jan’ 16- Dec ‘16)
- MS-DRG Codes 291-293
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Discussion/Questions So far?
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Work Done to Date
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Work Done to Date
1 Sustain results and spread work
2Enhance physician engagement and
ownership
3Increase collaboration with Hospital
Capacity Management
4 Launch new teams
5 Further advance analytical tools
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RGH UHEastern
RegionUMMC GRIPA LTC Home Health
Heart Failure
Medication Reconciliation
Order Set Pending Pending
Home Care
PathwayPending Pending
Home Care
Pathway
High-Risk Clinic
Care
Transitions
ED Pathway
Daily Rounds
Stroke
Coding / Documentation
Order Sets
Imaging
Orthopaedics Joint Class Improvements
Sepsis 90-Day Improvement Cycles (System-Wide Initiative)
COPD 90-Day Improvement Cycles (System-Wide Initiative)
Bundled
Payments
Behavioral Health Schizophrenia Care Pathway
Oncology GI Cancer
1. Sustain Results and Spread Work
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Original Clinical Optimization
Steering Committee
Chair: James Williams
Administration 9
Service Line Physician Leaders 0
Service Line Administrators 1
Business Intelligence 1
Finance / Supply Chain 1
IT & S 0
Quality Safety Institute and Clinical Optimization 1
2018 Clinical Optimization &
Hospital Capacity Management
Steering Committee
Chairs: Hiloni Bhavsar, MD & Anil Job, MD
Administration 2
Service Line Physician Leaders 3
Service Line Administrators 3
Business Intelligence 1
Finance / Supply Chain 2
IT & S 1
Quality Safety Institute and Clinical Optimization 3
The governance structure has evolved over the past two years to be chaired by two physician leaders and become more multi-disciplinary. This has resulted in enhanced physician ownership and engagement in the process.
2. Enhance Physician Engagement & Ownership
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Hospital Capacity Management (HCM) was initially a separate work group. Clinical optimization work and
hospital capacity management are tightly linked in terms of impact on process implementation and outcomes.
3. Increase Collaboration with Hospital Capacity Management
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How do you identify drivers of capacity or throughput in your organization?
1. External data analytics (Premier, Vizient etc.)
2. Internal metrics
3. Both
Audience Polling #4
https://live.eventbase.com/polls?event=himss19&polls=5150
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COPD
• Launched four groups focusing on:
• Order Sets
• Pulmonary Rehab
• POET Clinic Expansion
• Education
Behavioral Health
• Trained the Trainer
• BH Team independently managed CO process
• Developed 10-day clinical pathway for treatment of Schizophrenia across RRH
Bundled Payment (February 2019
Update)
• Launched program on Oct 1, 2018 at NWCH
• Two bundles selected: AMI and GI Obstruction
• More information to come in Feb. 2019
Cancer Committee
• American College of Surgeons Commission on Cancer Accreditation requires annual quality studies and improvement projects
• Clinical Optimization approach was used to study GI cancer LOS
4. Launch New TeamsExpand Clinical Optimization framework to new clinical and service line areas.
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SYSTEM
Rochester Regional Health(Clinical Outcome View)
Clinical BundleBaseline
(2017)
Current
MonthPrevious Month Year to
DateMAR 2018 FEB 2018
LO
S
(Geo.
Mean) COPD 0.79 0.90 0.82 0.87
Heart Failure 0.94 0.90 1.07 0.98
Ortho 0.95 0.88 0.88 0.88
Sepsis 1.02 1.08 1.09 1.08
Stroke 1.00 1.05 1.27 1.07
Readm
issio
ns COPD 1.42 1.59 1.68 1.49
Heart Failure 1.39 1.33 1.79 1.53
Ortho 1.18 1.66 0.77 1.33
Sepsis 1.24 1.10 1.55 1.27
Stroke 1.36 1.63 1.04 1.55
Mort
alit
y
COPD 0.62 0.78 0.85 0.89
Heart Failure 0.74 0.99 0.79 0.95
Ortho 0.68 0.00 0.00 0.49
Sepsis 0.85 0.80 0.79 0.87
Stroke 0.86 1.04 0.76 0.88
SYSTEM
Rochester Regional Health(Clinical Bundle View)
Clinical BundleBaseline
(2017)
Current
MonthPrevious Month Year to
DateMAR 2018 FEB 2018
CO
PD LOS (Geo) 0.79 0.90 0.82 0.87
Readmissions 1.42 1.59 1.68 1.49
Mortality 0.62 0.78 0.85 0.89
Heart
Failu
re LOS (Geo) 0.94 0.90 1.07 0.98
Readmissions 1.39 1.33 1.79 1.53
Mortality 0.74 0.99 0.79 0.95
Ort
ho LOS (Geo) 0.95 0.88 0.88 0.88
Readmissions 1.18 1.66 0.77 1.33
Mortality 0.68 0.00 0.00 0.49
Sepsis LOS (Geo) 1.02 1.08 1.09 1.08
Readmissions 1.24 1.10 1.55 1.27
Mortality 0.85 0.80 0.79 0.87
Str
oke LOS (Geo) 1.00 1.05 1.27 1.07
Readmissions 1.36 1.63 1.04 1.55
Mortality 0.86 1.04 0.76 0.88
5. Further Advance Analytical Tools
![Page 39: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/39.jpg)
An interactive and
near real-time
dashboard was
developed for use
by leaders across
RRH.
5. Further Advance Analytical ToolsSample Clinical Optimization Dashboard
![Page 40: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/40.jpg)
40
Major Themes Across Work Streams
Standard Terminology/
Defintions
• Standardizing clinical criteria
• Building consensus on treatment protocols
• Standardizing application of clinical definitions
• Documentation and coding consensus
Evidence Based Workflow via EMR
• Creating order sets
• Clinical pathways
• Implementing clinical decision support tools
• Utilizing reports for compliance
Education/Training
• Broad system based education
• Training for new workflows via online learning
• Knowledge builders for EMR based workflows
• System wide communication of new workflow
Role/Resource Standardization
![Page 41: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/41.jpg)
41
Challenges
![Page 42: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/42.jpg)
42
• More work added to the RRH IT queue
• Clinician time
• Resource competition
• Competing priorities
• Recently merged health system
• Timelines for implementation
• Control phase monitoring
Challenges
![Page 43: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/43.jpg)
43
Future Areas of Focus
![Page 44: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/44.jpg)
44
• Sepsis
– Consensus for definitions, EMR workflow via alerts/order sets, clinical pathway
• Supply Chain
– Physician Preference Items
– Resource utilization
• Pharmacy
– Roll-out of Premier Service-Line Analytics
– Value-analysis; cost versus quality
• Sustainability of Clinical Optimization
– Develop model for sustainability and growth
Future Areas of Focus
![Page 45: Clinical Optimization: One Approach to Integration...21 FY 15 –YTD Sep FY 16 IP LOS and Discharges by Day of Week Enc – MS DRG CMS ALOS Admit Day of the Week - ALOS Mon Tue Wed](https://reader035.vdocuments.us/reader035/viewer/2022070904/5f6e4b9a07c1692c20586226/html5/thumbnails/45.jpg)
45
Dr. Hiloni Bhavsar
Associate Director, Quality & Patient Safety
Rochester General Hospital
Rochester Regional [email protected]
James Williams, MHSA
Vice President of Integration
Rochester Regional [email protected]
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