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COMBINING DATA-DRIVEN ANALYTICS WITH RAPID CYCLE IMPROVEMENT

ANGELA WARD, RPH, MSBQUALITY & ANCILLARY SERVICES EXECUTIVE

SHARON ESTABROOK, RN-BCSENIOR NURSE NAVIGATOR

NICHE COORDINATOR

System-Wide Performance Improvement:

Alegent’s New Approach

Road Map

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Integrating Rapid Cycle Improvement across the System

Revealing Early Successes of with the Fall Initiative

Sharing Key Lessons

Taking a DRG-Based Approach

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Introducing Alegent Health

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NE IA

Case in Brief: Alegent Health, Sponsored by Catholic Health Initiatives (CHI) and Immanuel

• 10 Acute Care Hospitals

– 1,665 Licensed Beds

– 1,300 Physicians

– 3,000 nurses

– 8,600 Employees

• 1 Behavioral Health Hospital

– Clinics, Nursing Homes, Hospice House, Residential Facilities

– Home care, Hospice, Home Medical Equipment and Home Infusion

• 100 Sites of Service

– Clinics, Nursing Homes, Hospice House, Residential Facilities

– Home care, Hospice, Home Medical Equipment and Home Infusion

Faith-based, integrated healthcare organization, largest provider in Nebraska and southwest Iowa

2010

• Partnered with Crimson to assist physicians and executives in system-wide and local improvement

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The Case for Crimson

2011- Present

• Identified top 20 DRGs opportunities with Crimson

• Placed clinical performance improvement in the hands of those who deliver care

2009-2010

• Tackled some system of care expenses and established cost containment projects

• Existing data tool proved ineffective to track large scale improvements

A Care Delivery Focus

“If you really want to save money you have to look at how care is delivered. Safety saves money. Quality saves money. You can continue down the list.”

Rick Miller, DO,

Senior Vice President and Chief Quality Officer

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Origins of the Care Redesign Project

Re-launched As Care Redesign

Launched FirstDRG Project

Joined Crimson Continuum of Care

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• Rapid cycle improvement process

– Outcomes data utilization

– Design and standardization of selected DRGs, conditions, and processes

• Administrative structure

– Enhance engagement and support individual teams of physicians, nurses and clinicians.

The Story in Brief

Early Project Outcomes

98.9% Percentage of sustained improvement in quality metrics

90th Percentile, record system improvement

$2.7M Cost savings

Executive Summary

Starting with the Results

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Matching DRG Opportunities with Campuses

Step 1

Identify System-wide DRG Opportunities

• High-volume, high-cost

• Greatest performance variability

• Tied to a core measure

Aligning Priorities

Step 2

Align Opportunities with Campus Priorities

• Pre-existing initiative

• Passion or interest

• Unique circumstance (e.g. new OB pavilion)

Campus-Selected DRG Opportunities

Behavior Health Services:

Psychosis 885

Bergan: Uncomplicated

deliveries775

E-ICU: Vent weaning

IMC: Knee revisions, total knee

466, 467, 468, 469, 470

Lakeside: Stroke061, 062, 063, 064,

065, 066

Midlands: Heart failure 291, 292,

293

Mercy: Pneumonia193, 194, 195

Regional:Delirium

System: Falls and mobility

Develop Best Practices across First 100-Days

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Road Map

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Integrating Rapid Cycle Improvement across the System

Revealing Early Successes with the Fall Initiative

Sharing Key Lessons

Taking a DRG-Based Approach

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Breaking Down the Rapid Improvement Cycle Process

First 100 Days

1. Strategy

• Assign or select DRG, condition or process

DESIGN

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2. Model Development• Review Crimson data• Develop campus DRG teams• Establish “100 Day”

improvement cycle• Check best practices on all

campuses/entities• Engage the service line• Develop consistent change

model• Design review with DA

4. Development• Review products from owner • Review data/products• Review assessment & gap analysis

EVALUATE

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3. Refinement Plan• Select optimal metrics/

outcomes• Implementation plan• Communication plan• Coaching plan

6. Functional Check• Identify lessons• Validate & refine care standard• Define install plan & timeline

REVIEW & ADJUST

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30 Day Improvement Cycle

7. Freeze• Standard defined• Metrics collected/reviewed• Knowledge sharing• Primary owners approve

further iterations

5. Enhancement• Identify

improvements

REFINE

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STANDARD

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Engaging Staff to Drive Program Adoption and Rollout

Campus Project Sponsors Drive Initiative Locally

• Chief Nursing Officer

• Chief Quality Officer

• Chief Operating

or Finance Officer

Leaders Spearhead Each Initiative

Steering Committee of system and campus leaders:

• Evaluates opportunities• Selects initiative• Plans for system-wide

rollout• Assesses rollout during

regular conference calls

Campus leaders:

• Reallocate staff resources

• Communicate initiative with staff

• Involve specialty-specific staff and committees organized around DRG

Campus project drivers:

• Launch project locally across first 100 days

• Evaluate progress based on best-practice project management tools

• Report progress to Steering Comm. every 30 days

Senior-most executive on campus

At System Level At Campus Level At the Front Line

Local project drivers

Front-line staff execute initiative

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Reaching Hundreds of Our Staff

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Administrative Processes Provide the Framework for Execution

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Weekly Conference Calls Accountability and Progress

• Campus/entity and system leaders/members

• Weekly report out of progress

• Steering team conference call to follow report out

• Conference call technology works, all are on their own phones/computers

Overall Project Management Support and Documentation

• 100-day trade show

• 30-day report outs

• Updates and minutes, agenda provided in advance of call

A Different Topic or Frame Each Week

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STEEEP Think Lean

Category Examples

SafetyCentral line bundle, hand washing, time outs

TimelySTEMI- Door to balloon, Stroke – door to needle

EfficientMinimum necessary testing, less “daily” orders

EffectiveBest practices, evidence based care, care pathways

Equitable Age, sex, ethnicity, etc.

Patient CenteredHCAHPS measures, coordination of care, patient education and communication

Source of Waste Examples

OverproductionExcessive ordering of tests or treatments

WaitingDelays due to multiple visits on the last day

TransportMinimize the transport of IV pumps

Extra Processing

Rework – returns to surgery

InventoryMinimum supplies to efficiently operate

MotionReducing the distance to get IV supplies

Defects Hospital acquired infections

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Supporting Staff

• Physician and nursing leadership partnership

• Campus resources and clinical teams

• Project management

• Crimson support and user training

• Financial support

• Quality team

• Lean training and support

• Enterprise Intelligence team

• Education and patient team support

• Marketing and communications

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Reorganizing Support of Current Resources

“Whenever anyone brings up a good idea, someone always brings up the

budget.”

Charles Schulz, 1983

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Budget Neutral Project

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What? Who? When? Where?

• Those responsible for achieving the future state or those directly impacted by the future state

Business Case

• Importance of the problem• Note relevant background information necessary to fully understand the issue

• Consider the size and scope of the problem• Include data

Current State

• Diagram/Description of the current process• Label the diagram so that anyone could understand

• Note major problems • Include quantified measures of the extent of the problem

Critical Processes

• Processes, Tasks, Behaviors, Functions or Procedures necessary to transition from Current State to Future State

• Perform a Root Cause Analysis•List the problems•Decide what is most important to address first•Ask “Why” questions to reach the root cause

Key Stakeholders

Desired (Future) State

• Diagram/Description of the desired process• List the countermeasure(s) that will address the root cause(s) identified

• Include measureable targets (quantity, time)

Implementation Plan

Success Measures

• Actual Results

• How will you check the effects?

• When will you check them?

• Date check done• Results• Compare to predicted

• Plan

Analyzing Performance Using 30-Day Reports

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Creating the Care Redesign Performance Standard

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Standardized Products

Marked with a Seal of Approval

• order sets

• care pathways

• patient road maps

• staff and patient teaching tools

• work flow charts

• discharge follow up

• communication plan for physicians and staff

Enhanced Care

Patient-Focused PI

• Care Delivery

– Review, assess and design work/care flow

• Milestones

– Not LOS or days

– Focus on most effective treatments and evidence of progress

• Delays of Care

– Identify opportunities to eliminate

Rolling-Out Best Practices across the System

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Trade Show Facilitates Best-Practice Sharing

Teaching Lessons Broadly

Leaders Rally around Causes at Trade Shows

1st InitiativeDay 100

2nd InitiativeDay 130

3rd Initiative Day 160

4th Initiative Day 190

5th InitiativeDay 220

Campus-led DRG

Stroke

“Each campus had the opportunity to be both the teacher and the student in different phases of the project.”

Angela Ward,

Value Leader

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• Each campus tackles assigned opportunity and distills best-practice processes

• Stoke project leaders help other campuses adopt new stroke protocols locally

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Supplementing Best Practices with Resources

Care Redesign Products Assist Care Delivery

Evaluating the Care Redesign Project

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Tracking Project Performance

• Analytic process

– Clinical utilization patterns (Crimson)

– Financial

– Safety and Quality

– Patient Experience

– Readmissions

• Three stages of analysis

– Historical, one year retrospective

– Post design and gap analyses

– Diffusion into all entities/campuses

Assessing Early Gains

• Executive scorecard

– Financial (Margin per DRG/group)

– Quality (Alegent 40)

– Patient Experience (system)

– Readmission rate (system)

• Local campus/entity steering team scorecards

– Financial

– Quality

– Patient Experience

– Readmission rate

– Process Metrics

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Presenting Key Metrics with Executive Scorecards

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DRG GroupingsChange in Margin Avg Per Case

Change in Margin Overall YTD

Ischemic Stroke (DRG 61, 62, 63) ($1.269.99) ($21,590)

Hemorrhagic Stroke (DRG 64, 65, 66) $65.41 $17,987

Simple Pneumonia & Pleurisy w/ MCC (DRG 193)

($832.46) ($101,560)

Simple Pneumonia & Pleurisy w/o MCC (DRG 194 & 195)

$97.58 $37,179

Heart Failure & Shock (DRG 291, 292, 293) $781.14 $356,983

Revision of Knee Replacement (DRG 466, 467, 468 w/ Knee Px Cd)

$977.22 $94,791

Total Knee Replacement (DRG 469 & 470 w/ Knee Px Cd) previous effort, implant costs

$1,994.05 $1.456.293

Vaginal Delivery w/o CC (DRG 775) $66.86 $132.785

Behavioral, Psychosis (DRG 885) $325.16 $779.726

Total Estimated Savings $2,732,546

Care Redesign Total Estimated Savings - Year to Date May 2012

Quality98.8%

Experience 78.6% 90th

ReadmissionAMI 9.7% HF 3.8% PN 1.1% I Stroke 5.8%

Road Map

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Integrating Rapid Cycle Improvement across the System

Revealing Early Successes with the Fall Initiative

Sharing Key Lessons

Taking a DRG-Based Approach

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• Tom Frederickson, MD

• Jill Powers, OL Rehab

• Jane Carmody CNO

• Martha Snyder, Admin. IFH

• Brenda Bergman-Evans,PHD

DRG Spotlight: The Fall Mobility Initiative

Develop Best Practice Facilitates System-Adoption

Physician Chair: Campus Chief

QualityDr. Myles Gart

Fall / Mobility Steering Team

Sharon Estabrook RN-BC Lead

Clinical Experts Executive Project Sponsors

Co-Chair: Chief Nurse Executive

Kathryn Koehler MSN,MBA, RN

• Mike Tiesi, Pharmacy OD

• Susan Lorkovic, CN

Information Officer

• Sheree Keely, VP Behavioral

• Amy Knott, CFO

• Laura Hertzig, RN MHA

Patient Safety Officer

Evidence Based Practice

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Fall Mobility Initiative Products

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Deliverables Developed

• Gap Analysis: Minnesota Road Map

• Modified Risk Assessment Tool

• Post Fall Root Cause Analysis Team

• Road Map for Patient & Family

• Fall Prevention Communication Tools

• Education and Competency

• Accountability : Hourly Rounding

• Score Card

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Unlocking Key Success FactorsCommunication CommitmentEducation

• Providing education to physicians, nursing and ancillary staff, patient and family around fall prevention.

• Ex: Every Patient is My Patient ; Stay Safe and Active While in the Hospital.

• Share information: post fall analysis; High risk shift hand off Interdisciplinary Rounding , white board .

• Ex: Post fall email alerts, e-report documentation of in-house falls

• Ensuring staff are devoted to continuous performance improvement

• Ex: Reward and Remind, Senior Leadership Support

• Trending monitoring• Score Card- “ We’re all in it

together.”

• Ex: Monthly sharing of AH-HA events across the system.

Continuum-Focus

• Evaluate, Strengthen, Educate staff and patients.

• Every Patient Is My Patient

• Assessment of risk; Education, Hourly Rounding, Plan of Care

Nursing

AncillaryPT/OT

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Road Map

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Integrating Rapid Cycle Improvement across the System

Revealing Early Successes of with the Fall Initiative

Sharing Key Lessons

Taking a DRG-Based Approach

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Reflecting on Key Lessons

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Begin with Best Practices Involve the ED Engage Experts

Instill Accountability Communicate Effectively Manage Efficiently

• Primary campus/entity “owns” the DRG/assigned work and are accountable for:

• Effective roll out

• Implementation and maximization of their work;

• Approval of iterations and ongoing changes

• The project is bigger than “DRGs” but the name has stuck...it is really a Care Re-design Project

• Project management is needed to start

• Lean support is needed later

• As the primary campus/entity, launches a project they should collect best practices from other campuses

• Many care process begin in the ED, include the ED team on in the process

• If primary DRG is part of/or the work of a service line and leader, engage them from the beginning and ensure their support and leadership in the effort

• Clinical progress/milestones rather than “days“ of care

• Early mobilization

• Avoiding over-ordering outpatient tests as inpatients

• Medication de-escalation e.g. “antibiotic stewardship”

• Medication debridement

• Readmission risk

• Discharge process, follow up phone calls

• Scheduling and follow up appointments

• Medication affordability36

Common Themes and Opportunities

Uncovering Universal Improvement Opportunities

Identifying Focus Areas that Cut across Care Conditions

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So What?

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Care Redesign Results

• All members of the care team speak the same language, use common products/tools

• Organizational-wide commitment and culture of care improvement

• Improved clinical care by organizing its delivery, e.g. Stroke certification, noted as best practice

• Robust quality improvements reduce waste and costs

– Reduction of delays, tests, medication and type, LOS

“The real opportunities are not in those back-office areas anymore, the primary cost drivers are actual clinical processes because that generates 85% of the cost of care”

Michael Rowan, CHI, 2012Health Leaders

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Attention to specific diagnosis/conditions, uncovered care and communication processes that cut across most or all initiatives

Using Crimson data to improve practice

Dissemination and communication strategies for physicians

Engaging physicians in leadership roles in process improvement

Learn how evidence-based physician orders sets and care pathways work together and complement each other

Payer/funding requests for initiatives

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Now What?

More to come

• Hip and femur procedures• AMI• COPD

• Inductions• C-sections • Gallbladder surgery

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Questions?