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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

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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