QBPFocus on COPD

Presentation to OHA : HealthAchieveBonnie Burnes, William Osler Health System

November 5th, 2014

Agenda Overview

1. Organizational Strategic and Clinical Context

2. QBP Governance & Phased Approach

3. COPD Case Study

4. Key Successes and Lessons Learned

2

3

A Typical Day at Osler

4

More than…

600

20

195

156

Emergency Visits

Babies born

Dialysis clinic visits

Surgeries

Osler’s Corporate Strategic Plan

5

Deliver exemplary care in the eyes of our patient and peers

Create health services with an unwavering commitment to patient inspired care

Foster bold innovative partnerships to create a unified health system

Create impact beyond our immediate community through education and innovation

SD 2 - Priorities:

1. Continually refine services to meet the needs of target populations

2. Ensure clinical best practices across the organization

3. Ensure sustainability by meeting the challenges of new funding models

5

Osler’s Clinical Priorities Plan

66

A system designed to support timely accessto appropriate care, across the continuum of care.

Effort to prevent onset and/or exacerbation of chronic diseases, such as diabetes, COPD and CHF.

Osler’s Clinical Priorities Plan

7

se Increased Scheduled Outpatient Activity

Reduce Unscheduled/ Avoidable Emergency Visits & Inpatient Admissions

7

QBP Governance Structure

Corporate Quality

Governance Council

QBP Steering Committee

COPD Expert Panel

CHF Expert Panel

Stroke Expert Panel

Hip FractureExpert Panel

Endoscopy Expert Panel

Senior Leadership Team (SLT)

Dr. Tamara Wallington, Co-ChairBonnie Burnes, Co-ChairCorporate Chief of EDDirector of Quality, Practice & Patient Safety (HHCC)Director of Client Services & Clinical Analytics (CW CCAC)Hospitalist LeadGeneral Internist LeadDirector of Nursing and Professional PracticeFinance/Case CostingDecision SupportCoding & Transcription

99

Quality Improvement

Plan

Osler Expert Panel

Core Team• CCE Rep• Pharmacy• Educator • Resource Nurse• Front line MD, Nurse• Nurse practitioner• Allied Health – OT/PT/SLP• CCAC• Decision Support• Discharge Planner• Clinical Informatics• Administrative support• Coding

10

Ad Hoc• Finance• Headwaters Health Care Centre• Palliative Care• Telehomecare• ED Chief and educators• Library staff• Lab• Palliative Care• Research

10

QBP Phases of Development

1111

Phase 1 Current State Assessment

Phase 2QBP

Assessment

Phase 3Gap Analysis

Phase 4Closing the

Gap

Phase 5 Monitor

Implementation Accountability/ Sustainability

Osler’s Progress with QBPs

12

Phase 1Current State Assessment

Phase 2QBP

Assessment

Phase 3Gap Analysis

Phase 4Closing the

Gap

Phase 5Implementation/Accountability/Sustainability

Jan 2014 Feb 2014 Mar 2014 May 2014 Aug 2014

COPD

Feb 2014 Mar 2014 Apr 2014 Jun2014 Aug 2014

CHF

May 2014 Jun 2014 Jul 2014 Aug 2014 Oct 2014

Hip Fracture

May 2014 Jul 2014 Aug 2014 Sep 2014

Stroke

Aug 2014 Oct 2014

GI Endoscopy

Current State and QBP Assessment

14

How do we create sustained improvement?

Current State and COPD Process Map

15

Patient arrives Emergency(Walk-in/EMS/Transferred from

Outpatient Clinic)

Patient taken to ED (Placement based on CTAS score*)

Primary Care Nurse initiates Medical Directive

Patient assessed by Triage Nurse Patient assessed by ED Physician

Order written

Discharge Planning Referral to CCAC Referral to West Park

Decision? Admit to MAU

Referred to Internal Medicine

Discharge home

CTAS score

RESUS Acute Sub-Acute

* Patient Placement

OR OR ATC

Order executed

Decision made based on result

Patient with COPD automatically referred to Respirology Consultant

Patient goes home

Waiting time

Bed available?

Patient stays in ED

No Yes

Bed available?

Patient stays in ED

No

Patient transferred to Medical Unit

Yes

Patient admitted to Medical Unit OR

% of admitted to MAU

OR

Develop COPD Order Set

Patient transferred to MAU with Order Set filled by ER Physician

Patient transferred to MAU with handwritten order

Patient daily assessed by MD/NP

MAU is 48 hours Unit run by MD and supported by NP

Patient stays maximum 48 hrs starting from Triage point

Delay in ED depletes 48 hr time limit

Patient seen by ALC team (PT/OT/RT/Dietician/SW/Pharmacist/COPD Educator)

Discharge Planning: Transportation arrangement CCAC PFT referral Referral to other outpatient clinic Give Patient the copy of Lab/DI test result for revisit NP consultant notes sent to FP For Patient without FP: provide resource package and ask Patient come back to Urgent Care Clinic/ED

Decision?Admit to Medical Unit

Discharge home

Patient goes home With family By EMS By alternative transportation

Transportation Issues

Develop Order Set for Discharge

Patient transferred to Medical Unit

Confusion around the Primary Care Physician:

FP or Walk-in Clinic?

Connection to Telehomecare

Referral to COPD Education Clinic

Referral to Pulmonary Rehab

Care Connect

NRT

Respirology Patient goes to

other medical unit

Regular Inpatient Process followed(ALC Team: OT/PT/RT/Dietician)

As blend unit (GIM/Resp), Respirology receives a lot of non-Resp patient

Admission decision cohorts Patient to appropriate unit

Order Set Utilization

Having Respirologist on

the floor

Isolation beds shortage

Longer stay in ED may cause Patient not receiving appropriate

care; Patient could end to Critical Care Unit instead

Inconsistent process – Patient may/may not Come with Resp. Order Set Assigned to Resp. Hospitalist Have RT consultation Referred to Respirologist Get PFT Refer to COPD Education Clinic/

Pulmonary Rehab Clinic

% of Pt with short breath/chest complain/

COPD history

COPD Patient sits in waiting area with

other PatientsWaiting time

50% Patient with Order Set

Med

ical

Uni

tM

AU

Emer

genc

y

Measurements

Issues & Hot spots

Potential Leverage Points

% of Diagnosed % of Admitted

Typically COPD Patients are CTAS 2/3

Investigation and treatment initiated

Pulmonary baseline

GIM/Respirologist involves in

decision-making

% of Discharge

home

Patient admitted to Medical Unit

% of admitted to Medical Unit

CTAS 1

UCCOR

CTAS 2 CTAS 3 CTAS 4/5

Respirology Educuation

CCAC Responsible Nurse RT Consultant

Pharmacy Tech sees patient in MAU for BPMH

Closing the Gap – Leverage Points

16

• Streaming to Respirology Cluster• Spirometry: baseline• Consults: RT, Dietitian• Greater involvement with Specialists/ Referral to Respirologists• Nicotine Replacement Therapy Module & Smoking Cessation• COPD Order Set• Pulmonary Rehab Clinic• COPD education• Pharmacist consult for med rec• Vaccines: influenza and pneumococcal• Automatic referral to CCAC for Rapid Response Nurse program• Automatic referral to Telehomecare• Standardization of antibiotic ordering practices

Order Set Implications to Referrals

18Time

Prop

ortio

n of

QBP

CO

PD v

isits

rec

eivi

ng in

terv

entio

ns

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14

COPD Education

Telehomecare Referral

Respirology Referral Order set implementation

Order Set Implications to RIW and Readmissions

19Time

Res

ourc

e In

tens

ity W

eigh

t

0

0.05

0.1

0.15

0.2

0.25

0.3

0.80

0.90

1.00

1.10

1.20

1.30

1.40

1.50

1.60

1.70

1.80

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14

RIW

Readmissions

Order Set Implementation

Rea

dmis

sion

Rat

e

COPD Average LOS and Readmission

20

Order Set Used

6.02 days

Average LOS

Order Set Not Used

7.24 days

0.12

5.90

ALC

Acute

7.04

0.20 ALC

Acute

Order Set Used

16%

30 day Readmission

Order Set Not Used

18%

Discharges between December 18, 2013 and June 30, 2014

COPD Telehomecare6 months Before & After Enrollment (Sept 2014)

21

Sustainability

22

Outcome Measures:1. Readmissions to Osler within 28 days post discharge for COPD2. Average total LOS for acute inpatients 3. Volumes of COPD QBP acute inpatients4. Resource Intensity Weights

Process Measures:1. Number of patients enrolled in Telehomecare 2. Number of referrals to the Rapid Response nurse (24 hrs. discharge)3. % patients admitted to Respirology unit4. Order set utilization5. Referral to COPD education and Pulmonary Rehab

Osler Lessons Learned

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• Team and front line ownership is critical

• Broad team representation is necessary to achieve buy in

• Changing behaviours is challenging

• It takes time to implement and sustain change

• Benefits to having a structured governance approach across all QBP’s

• Standardized process has provided tremendous learning and consistency for the organization

Questions and Comments

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