presented by: dr. stephen taylor, president west hospital ortho co-management laurie m. johnson, rn...
TRANSCRIPT
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ORTHOPAEDIC SERVICES AT METHODIST WEST HOSPITAL
Presented by:Dr. Stephen Taylor, President
West Hospital Ortho Co-Management
Laurie M. Johnson, RNExecutive Director - Orthopaedics
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Total Joint Replacement (TJR) has been the most effective treatment for advanced
arthritis since the 1970’s
Goal of TJR → Quality Results Relieve Pain Restore Function Long Lasting (>25 years) Avoid Complications
More than 700,000 TJR’s are currently performed each year
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INCREASING DEMAND FOR TOTAL JOINT REPLACEMENT
Increasing senior population
Greater desire for active lifestyle
Greater acceptance of TJR by population
700% increase in TJR in the next 20 years
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INCREASED DEMAND FOR TJR
Success Requires:1) Adequate physician supply2) More efficient care process3) Care process must emphasize VALUE
VALUE = QUALITYCOST
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Reality:Healthcare dollars spent must be controlled and appropriately allocated
Allocation must be determined by value of product or service
In TJR we must maintain and improve quality, but we must also control costs
VALUE IN TOTAL JOINT REPLACEMENT
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IOWA HEALTH-DES MOINES COMMITMENT
IH-DM committed to meet the increased patient need for TJRCurrent facilities at IMMC couldn’t meet growing demand for OR’s and patient beds
MWH was designed to emphasize orthopaedic total joint care dedicating 4 of the 6 OR’s and 50% of the patient beds
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MWH ORTHOPAEDIC SERVICES
Focused, specialized careMutual project between IH-DM and Des Moines Orthopaedic Surgeons, PCAligned incentives of both organizations to improve QUALITY and VALUE for our patients“Co-Management” organization was formed to manage the entire process
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WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY, LLC
The WHOCC oversees the entire orthopaedic service line at MWH
emphasizing quality, patient safety & convenience, efficiency and
cost containment
Equal representation from IH-DM & DMOS
Medical Director from DMOS
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WHOCC MANAGEMENT
ACTIVITIES
Develop comprehensive plan of care for all orthopaedic
patients
Implement and direct strategic, financial and
operational plans
Assist in facilities management
Evaluate and recommend equipment
purchases
Assist in developing operational and capital
budgets
Supervise and/or train management
staff
Develop and oversee all cost containment
activities
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WHOCC BUSINESS MODELExecutive Committee
•Meets bi-weekly•Working committee
•Includes the Ortho Executive Director
•Reports to the Governing Board
Finance Committee•Meets quarterly
•Reviews financials and makes recommendations
•Reports to the Governing Board
WHOCC GOVERNING BOARD•Oversees all committee activities
•Reviews & approves meeting minutes•Makes final decisions
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WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY
Initial project was to interview and select the following key personnel:
Orthopaedic service-line Executive DirectorInpatient department Nurse ManagerSurgical Services department Nurse ManagerPhysical Therapy department Manager
All personnel are employees of IH-DM
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All physicians expected to comply at MWHNo significant exceptions are allowedAll physicians are invited and encouraged to participate in the process
WHOCC TEAM REVIEWS AND SETS ALL PROCESSES
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STANDARDIZED, UNIFORM PROCESSES AND PROCEDURES
Rationale: Repetitive, focused process and procedures maximizes efficiency and minimizes the risk of error or oversight.
Examples:OR nurses comfortable working with any surgeon due to standardized draping, supplies and instructions
Nursing unit care doesn’t vary by physician (common pain management regimen, blood transfusion protocol, dressing, etc…)
One standard Physical and Occupational therapy regimen for all surgeons that can be tailored to the individual needs of each patient
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EXAMPLES OF UNIFORM PROCESSES CREATED AND IMPLEMENTED BY WHOCC
1. Pre-op medical clearance request form2. Standardized scheduling process and form3. Pre-op orders4. Regional anesthesia5. Demand matching of implants6. Comprehensive uniform post-op orders,
including pre-emptive multi-modal pain management
7. Uniform activity and physical therapy goals
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WHOCC ACTIVITIES
VALUE IN TJRNew techniques, equipment and implants must be critically evaluated by hospital and physicians
Those new techniques or implants that add cost without significant improvement in quality should be avoided
VALUE = QUALITYCOST
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Is there enough scientific
evidence to warrant a trial?
Trial with defined evaluation and
results
Review by committee to
assess quality and
value of technique
Confirm or deny use of technique
or product
EVALUATION OF NEW TECHNIQUES AND SURGICAL PRODUCTS
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EVALUATION PROCESS EXAMPLES
Floseal → deny (evidence didn’t support)
V-lock suture → confirm (all use)
Participated in ‘Draping Boot Camp’ to streamline, trial and standardize surgical drapes → confirm (all use)
Surgical prep (Chloraprep) → confirm (all use)
Eliminated many trays by developing common instrument sets for all physicians by procedure → confirm (all use)
Covaderm Surgical Dressing → future trial Cold therapy/DVT wrap → future trial
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1. Base Management Fee Hourly at Fair Market Value
2. Incentives Quality of service Operational efficiency Financial/budgetary New program development
WHOCC PHYSICIAN COMPENSATION
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Measurable Controllable
Realistic Bound by time limits
INCENTIVE COMPENSATION DEVELOPMENT
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2010 INCENTIVES
Quality of Service (50%)SCIP Core MeasuresPatient SatisfactionDemand Matching
Operational Efficiency (20%)On-time startsOR turnaround time
Financial/Budgetary (20%)Length of StayCost per Case
New Program Development (10%)Expanded Patient Education
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2011 INCENTIVES
Quality of Service (50%)SCIP Core MeasuresPatient SatisfactionDemand Matching
Financial/Budgetary (30%)Cost per case (Goal – 4%↓)Vendor negotiations for spinal implants
New Program Development (20%)Hip and Knee scoringInfection rates (within 60 days)Readmission rate (within 30 days)Revision rate (within 1 year)
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INCENTIVE STRUCTURE2011 INCENTIVE FOR SCIP CORE MEASURES (15% OF TOTAL)
RANGE FROM: TO: ANNUAL PAYOUT:
<95% $0
≥95% <96% 60% of SCIP incentive
≥96% <97% 80% of SCIP incentive
≥97% Full Incentive
2011 INCENTIVE FOR PATIENT SATISFACTION (20% OF TOTAL)
RANGE FROM: TO: ANNUAL PAYOUT:
<91.1 $0
≥91.1 <91.9 50% of Pt. Sat. Incentive
≥91.9 <92.3 75% of Pt. Sat. Incentive
≥92.3 Full Incentive
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1. All implants placed in category based on technology• Cemented femoral stem• Tapered non-cemented stem• Revision stem
2. Each category included “substantially similar” implants
3. Target price established by WHOCC
4. All vendors allowed to participate
VENDOR NEGOTIATIONS
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5. Implants that meet target price for each category become “preferred” and permitted to use at MWH
6. Use of outliers is strongly discouraged
7. In a few select categories competitive bidding utilized – only one implant from single vendor allowedeg. Modular revision femoral stem (one vendor, one price for all components)eg. Revision segmental hinged knee
VENDOR NEGOTIATIONS, continued…
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DEMAND MATCHING
All implants categorized by Quality Level and Cost
A Level – Lowest cost B Level – Intermediate cost
C Level – High cost
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DEMAND MATCHING cont…
Three Patient Variables Considered
1. Patient Age2. Patient Health3. Patient EXPECTED activity level
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(scanned copy of form here)
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DEMAND MATCHING cont…
>90% Compliance expected
Results are reported by
Individual PhysicianAll Physicians
Transparency is a great motivator!
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WHOCC - SUMMARY
1. Aligned incentives of hospital and surgeons that are required for success
2. Emphasis on Quality and Cost = Value
3. Recognize importance and contribution of ALL team members:
•Surgical Techs & Nurses •Therapists•Patient Care Facilitators •Patient Care Techs •Management Staff •Physicians
Ultimate winners:•Patients •All team members
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WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY
OUR COMPANY Is COMMITTED to FRESH THINKING
andINNOVATIVE CARE THAT ADDS VALUE
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WHOCC METRIC RESULTS
VALUE = QUALITYCOST
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DATA COLLECTION
Information received monthly from various systems• Finance • Purchasing• ORSOS • Clinical Quality
Review, calculate and report Incentive Metric data monthly to Executive Committee
Determine if there is other data outside of the metrics that needs to be reported On-time starts, turnover times, and Average Length of Stay (ALOS) are not
part of the 2011 metrics, but continue to be monitored monthly for significant changes
Volume and cost data from broken, lost and (not) found instruments in Central Sterile is reported to the Executive Committee & the staff each month
The cost of implants that are opened but unused are reported in conjunction with the demand-matching metrics
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DATA COLLECTION continued… Whenever possible, total volumes are reviewed rather than
randomized selections 100% of all total joint procedures are reviewed for correct implants Over 90% of all eligible patients are included in the SCIP Core Measure
data review In addition to the overall patient
satisfaction score, each physician’sscores are calculated and reported
Direct variable cost-per-case isreported/reviewed by surgeon
All data is presented as an overall score and also by each physician and procedure
Transparency has been a key motivator for physician change
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QUALITY OF SERVICE 2010 GOAL 2010 ACTUAL 2011 GOAL 2011
CURRENT
DVT Prophylaxis within 24 hours before/after surgery 99.8% 100%
Appropriate antibiotics within 1 hour prior to surgery 98.7% 99.4%
Antibiotics stopped within 24 hours after surgery ends 98.8% 100%
% of patients who are normothermic after 15 minutes in PACU n/a n/a 85%
SCIP Overall Average ≥97% 99.3% ≥97% 96.1%
Patient Satisfaction ≥87 91.2 92.3 90.4
Implant Demand Matching ≥90% 88.7% ≥90% 89.2%
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NEW PROGRAM DEVELOPMENT 2010 GOAL 2010
ACTUAL 2011 GOAL 2011 CURRENT
Expand Patient EducationAll total joints patients at MWH
New program written by Patient Care Facilitators n/a n/a
Hip and Knee ScoringPrimary hips & knees only
n/a n/a Forms have been developed, data collection begins 5/1/2011
Infection rates (w/in 60 days)Primary hips & knees only
n/a Still calculating <1.5% Still calculating
Readmission rates (w/in 30 d)Primary hips & knees only
n/a n/a <5.0% 0.5%
Revision rates (w/in 1 year)Primary hips & knees only
n/a n/a <2.0% Still calculating
OPERATIONAL EFFICIENCY 2010 GOAL 2010
ACTUAL 2011 GOAL 2011 CURRENT
On-time starts ≥93% 91.8% n/a n/aOR turnaround time ≤20 min 16 min n/a n/a
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AVERAGE LENGTH OF STAY 2008 2009 2010 2011
CURRENT
Primary total hip and knee pts, commercial payers only 4.17 days 3.94 days 2.81 days 2.84 days
2008 2009 2010 2011 current
2.5
3
3.5
4
4.54.17
3.94
2.81 2.84
2010 goal3.45 days
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2008 2009 40210 40269 40330 40391 40452 40513 405757,400
7,800
8,200
8,600
9,000
9,400
8,7038,847
8,959 8,9728,772
8,573
8,186
7,8347,720
DIRECT VARIABLE COST-PER-CASE 2008 2009 2010 2011
CURRENT2011GOAL
Primary total hip and knee pts, commercial
payers only$8,703 $8.847 $8,186 $7,720 $7,939
2010 goal$8,196
2011 goal$7,939
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SUMMARY DO recognize that consistent, substantiated data is a key factor in engaging
the physicians and staff to achieve success DON’T underestimate the value of immersing yourself in the details DO plan to be in this ‘for the long haul’
Success doesn’t happen overnight• DON’T hesitate to build relationships with people who can help you
The advantage of a large organization is that many people are there to assist, but you may have to search for them
DO communicate results regularly with front-line staff They will be very engaged in the process They can have a big impact on achieving positive outcomes
DON’T overlook the small successes These are most important when things are progressing slowly
DO celebrate every milestone along the way, and DON’T forget to have fun!
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QUESTIONS?