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Session #28:Clinical Standards Work To Improve
Evidence-Based Care Delivery: A How-To Workshop
Charles G. Macias MD, MPHChief Clinical Systems Integration Officer, Texas Children’s
Pre-Session Poll Question
On a scale of 1 to 5, how effective is your organization’s ability to deliver coordinated care for clinical conditions?
1) Not at all effective
2) Somewhat effective
3) Moderately effective
4) Very effective
5) Extremely effective
6) Unsure or not applicable
Terri Brown MSN, RNAssistant DirectorClinical Outcomes & Data SupportEvidence Based Outcomes CenterTexas Children’s
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Texas Children’s Hospital
2
Hospital Statistics
Number of Beds 595
Annual Inpatient Admissions
32,446
Annual Outpatient Visits
1.44 million
Emergency Room Visits
117,275
Inpatient Surgeries
9,053
Outpatient Surgeries
16,216
West Campus/Woodlands, Health Plan, pediatric practices, Pavilion for Women, physician services organization
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Johnny Jones8 year old boy with a history of lung transplant
Emergency department: his triage evaluation demonstrated heart rate and other findings consistent with early signs of shock
• Delivery of critical resuscitation fluids was slow and undertreated
• Antibiotics arrived hours after they were ordered
Lung inpatient unit: a “Rapid Response Team” was called 3 ½ hours after the evaluation of concerning signs and symptoms
Pediatric Intensive Care Unit
• Blood pressure was not obtainable
• Put on a ventilator
• Aggressive drug therapies
• Procedural interventions to artificially oxygenate his blood
Johnny died 18 hours after he first arrived
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Root cause analysis
Diagnostic and therapeutic errors identified in the ED and the inpatient ward by multiple provider types
A gap in meaningful communication between providers created confusion in management plans
Neither management guidelines nor the EMR were providing clinical standards or clinical decision support for practitioners
Systems were not well integrated
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…and in New York
12 year old boy with a laceration from a fall 2 days prior arrived at an Emergency DepartmentHe received intravenous fluids and drugs to prevent vomiting after laboratory analyses were obtained, but not reviewedDischarged and returned the next day with fulminant signs and symptoms of septic shockRory Staunton died 2 days later
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New York State Department of Health
The Rory Staunton ActHospitals shall have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis/septic shock…Analytics: all severe sepsis/septic shock patients to be entered in the NYS database for annual risk adjusted mortality rates
Public Health Law, State of New York, Sections 405.2 and 405.4 of Title 10
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Defining quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
KN Lohr, N Engl J Med, 1990
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Poll Question #2
How many medical articles are published each year?a) 1,000,000b) 800,000c) 600,000d) 400,000
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Explaining variation: it is impossible for the mind to evaluate and translate all of the existing evidence to formulate medical decisions
IOM 2013
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Kharbanda AB, Hall M, Shah SS, Freedman SB, Mistry RD, Macias CG, Bonsu B, Dayan PS, Alessandrini EA, Neuman MI. Variation in resource utilization across a national sample of pediatric emergency departments. J Pediatr. 2013
Describing variation in care in three pediatric diseases: gastroenteritis, asthma, simple febrile seizure
• Pediatric Health Information System database (for data from 21 member hospitals)
• Two quality-of-care metrics measured for each disease process
• Wide variations in practice
• Increased costs were NOT associated with lower admission rates or 3-day ED revisit rates
Correlation between quality and cost
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Poll Question #3
What percentage of healthcare expenditures are attributed to waste?a) 8%b) 14%c) 22%d) 36%
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Overuse for tests and therapies beyond established evidence
Procedural/surgical intervention vs appropriate watchful wait
Discretionary use of services or devices
Unnecessary choice of higher-cost services
The US healthcare system is inefficient
36%
$765B of healthcare expenditures is waste (2009)
• Unnecessary services• Inefficiently delivered services• Excess administrative costs• Prices that are too high• Missed prevention opportunities• FraudIOM, The Healthcare Imperative 2010; Berwick JAMA 2012
$210 Billio
n
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Reforming healthcare
Institute of Medicine Best Care at Lower Cost 2013
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Clinical practice guidelines
Systematically developed statements or recommendations to assist the practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.
Institute of Medicine (1992). Guidelines for clinical practice: from development to use
Ubiquitous nature
• Existence‒ Textbooks: “Treatment”‒ Drug of choice in hospital formulary‒ Hospital policy
• Informal process for development: variable performance
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Poll Question #4
What % of a patient population is a reasonable target for guidelines?a) 20%b) 50%c) 80%d) 95%
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Empowering the “art” of medicine
Evidence-based guidelines help control complexity• Summarize available evidence and translate to guidance for care
• Address treatment uncertainties and reduce variation in care delivery where evidence lacks
• Help maximize use of healthcare resources: system efficiency
• Improve patient outcomes: diagnostic accuracy and therapeutic effectiveness
• Enhance shared decision making between patients and physicians
• Provide a framework for analytics
Pareto principle
• 80/20 rule
• 20% of the problems cause 80% of the trouble
Freeing the clinician to focus on the “art” of medicine
Adapted from Penney and Foy. Best Practice and Research, 2007
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Outcomes
Adapted from D Eddy MD, PhD
Scientific judgment
Preference Judgment
Understanding epistemology in order to create a clinical standards system
EVIDENCEANALYZE EVIDENCE
BENEFITS, HARMS,
AND COSTDECISIONS
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Performance measures
Adapted from D Eddy MD, PhD
Evidence & Recommendation
Evaluation
Transparency: values and preferences
Decision making and quality
EVIDENCESHARED
BASELINE
HIGH QUALITY
CARE
DATA TRANSFORMATION
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An institutional home: Evidence-Based Outcomes Center at TCH
Andrea Jackson, MBA, RNResearch Specialist
Tom BurkeResearch Assistantnt
Sherin RajuResearch Assistant
Jennifer Nichols, MPHResearch Specialist
Christine Procido, MPHResearch Specialist
KaGibbs, MSN/MPH, RNResearch Specialist
Charles Macias, MD, MPHMedical Director of
EBOC, CCEMD Lead, Clinical
Programs
Ellis Arjmand, MD, MMM, PhDDirector of Practice
Standards, Dept of SurgeryAssociate Director of EBOC
Terri Brown MSN, RNAssistant Director of
EBOC
Ashley Breland MSN, RNClinical Decision Support
Specialist
Magliaro, MS, RN, CS, CPHAClinical Specialist, PFW
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1. Evidence-Based Outcomes Center (TCH): systematic development of clinical standards
Identifying quality gaps
• High prevalence
• Resource intensive care
• High morbidity or mortality
• Marked variations in care
EDW, analytics, and the key process analysis
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Searching for existing guidelines
National Guideline Clearinghouse
• www.guidelines.gov
Professional societies
• American Academy of Pediatrics (AAP): http://aappolicy.aappublications.org
Academic institutions:
• Pediatrics: Texas Children’s Hospital, Seattle Children’s, CHOP, Cincinnati Children’s
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AGREE II (Appraisal of Guidelines Research and Evaluation)
23 item list with six domains
• scope and purpose
• stakeholder involvement
• rigor of development
• clarity and presentation
• applicability
• editorial independence
Each item rated from “strongly agree” to “strongly disagree” by reviewers
An additional overall assessment
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2. W. Edwards Deming and teams
Team• Community or Subject Area Practitioner
Leader • Champion of Guideline topic• Sub-specialists in the area of focus• Nurses• Pharmacist• Other Allied Healthcare providers (RTs,
OT/PT, etc.)• Family / patient
Clinical Effectiveness and other support• Facilitator • Methodologist• Librarian• Data analyst and outcomes coordinator• Educator
“Bottom-up” team building and
interdisciplinary functioning as
tenets of quality improvement
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3. Identifying the questions in PICO format
P I C O
Population Intervention Comparison Outcome of Interest
”In ED patients with suspected
sepsis…”
“…does application of a trigger tool…”
”when compared to routine
assessment…”
“lead to shorter time to recognition”
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4. Conducting the search with library-trained personnel
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5. Evaluating the evidence: GRADE Grading of Recommendations, Assessment, Development, and Evaluation
Developed by a widely representative group of international developers
Clear separation between quality of evidence and strength of recommendations
• Quality (evidence)
‒ How sure one is that the estimate of treatment effect is sufficient to support the recommendation
• Strength (recommendation)
‒ How sure one is that adherence to recommendation will result in improved outcome
Explicit acknowledgment of values and preferences Guyatt et al, BMJ 336;924
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Transparency
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Standardization
Standardize regardless of gaps in evidence include pathways• Revisit evidence frequently
and rigorously
• Clinical/outcomes research to increase evidence base
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Clinical Decision Support
29
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6. Engage stakeholders: EBOC transparency for approval
GovernanceContent and analytics team
Evidence-based steeringMedical, surgical, women’s health champions, and research assistantsEnterprise-wide vetting
Legal database archiving: “standard of care”
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Develops clinical standards (guidelines) and oversees clinical
data/ predictive analytics
EMR and all clinical technologies
Clinical Implementation
Team
Clinical Technology
Council
Quality Improvement and permanent care
process teams
Content and Analytics Team
Prioritizes and Assess technology initiatives that integrate with
the EMR or proposed as independent
solutions
Oversees development and implementation of clinical programs/
analytics and knowledge assets
EBP and the Enterprise Data
Warehouse are part of this structure
Clinical System Integration Executive Leadership Council
Clinical Systems Integration Governance Structure
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Clinical SystemsIntegration domains
“The means to facilitate the
coordination of patient care
across conditions,
providers, settings, and
time in order to achieve
care that is safe, timely,
effective, efficient,
equitable, and patient
focused.” -The American Medical
Association
Analytic System
Science and Clinical
StandardsImplementation
Automation Centric
Increased reliability but poor validity
Organizational Centric
(Clinicians stop coming to meetings if evidence and measurement are both
missing)
Information System Centric
IT determines interpretation of
science
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Evidence-Based Outcome CenterAcute Chest Syndrome *updatedAcute Gastroenteritis Acute Heart FailureAcute Hematogenous OsteomyelitisAcute Ischemic StrokeAcute Otitis MediaApparent Life-Threatening Event (ALTE)Appendicitis *updatedArterial ThrombosisAsthma *updatedAttention Deficit Hyperactivity DisorderAutism Assessment and DiagnosisBronchiolitis *updatedCancer Center Procedural ManagementCardiac ThrombosisCentral Line-Associated Bloodstream InfectionsClosed Head InjuryCommunity-Acquired Pneumonia *updatedCystic Fibrosis – Nutrition/GI >12 y/o *updatedC-Spine AssessmentDeep Vein ThrombosisDiabetes Perioperative ManagementDiabetic Ketoacidosis Fever and Neutropenia in Children with Cancer
Fever Without Localizing Signs (FWLS) 0-60 Days *updatedFever Without Localizing Signs (FWLS) 2-36
Months *updatedHyperbilirubinemiaIntraosseous Line PlacementIV Lock TherapyKawasaki DiseaseMigraine Treatment-Emergency CenterNeonatal ThrombosisNutrition/Feeding in the Post-Cardiac NeonateObstetric Hemorrhage due to Uterine AtonyPerioperative Management of Anterior Mediastinal MassesPICC SecurementProcedural Sedation *updatedRapid Sequence IntubationRespiratory Management of Preterm Infants Septic ArthritisSeptic ShockSkin and Soft Tissue Infection Status EpilepticusSuspected Child Physical AbuseTracheostomy ManagementUrinary Tract Infection
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Measurement and analytics (EDW): Patient outcomesFinancial metrics
Utilization metrics
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Financial Impact-inpatient
35
Bronchiolitis LOS Sickle Cell Disease LOS
Pneumonia LOS0
1
2
3
4
5
6
Length of Stay
Year 1 Year 2 Year 3 Year 4 Year 5
Bronchiolitis Charges
Sickle Cell Disease Charges
Pneumonia Charges
0
5000
10000
15000
20000
25000
30000
35000
Charges
Year 1 Year 2 Year 3 Year 4 Year 5
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-$5,000
-$4,500
-$4,000
-$3,500
-$3,000
-$2,500
-$2,000
-$1,500
-$1,000
-$500
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2
Asthma: Margin
EBG in EMR
Care Process Team
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Outcomes
Adapted from D Eddy MD, PhD
Scientific judgment
Preference Judgment
Understanding epistemology in order to create a clinical standards system
EVIDENCEANALYZE EVIDENCE
BENEFITS, HARMS,
AND COSTDECISIONS
Evidence based
Outcomes based
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Lessons learned
• Wide variations in practice can be minimized with systematically developed clinical standards
• Quantitative assessments (KPA) can help identify gaps in quality
• Systematic use of tools (e.g. GRADE) will help standardize approaches to the integrity of clinical standards
• Governance and a systems integration strategy are critical to effective uptake
• Evaluation of outcomes through analytics allows guided implementation and transparency of outcomes
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Poll Question #5
40
On a scale of 1-5, how well is your organization using data to drive provider behavioral change and performance improvement in clinical care?
1) Poorly
2) Not well
3) Reasonably well
4) Well
5) Extremely well
6) Unsure or not applicable
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Choose one thing…
41
What one thing (or more) can you do differently after hearing this presentation?
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Analytic Insights
AQuestions &
Answers
42
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Thank You
43
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Session Feedback Survey
1. On a scale of 1-5, how satisfied were you overall with this session?
1) Not at all satisfied
2) Somewhat satisfied
3) Moderately satisfied
4) Very satisfied
5) Extremely satisfied
2. What feedback or suggestions do you have?
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Upcoming Sessions
Breakout Sessions – Wave 5 (2:20 PM – 3:05 PM)
31) Panel – Data Governance in Healthcare
32) How One ACO Is Using Analytics to Position Itself for Population Health Management and Shared SavingsJames J. Dearing, DO, FACOFP, FAAFP, Vice President, Chief Medical Officer, Honor Health
33) Panel – Best Practices in Achieving Physician Engagement
34) Panel – Precision Medicine and Embracing Variability
35) Improving Analytics and Processes to Ease Hospital CrowdingWes Elfman, Visualization Developer, Clinical and Business Analytics, Stanford Health CareTerrill Wolf, Manager, Data Architecture, Clinical and Business Analytics, Stanford Health Care
Imperial Ballroom B
Imperial Ballroom A
Grand Salon
Murano
Venezia
Location