3 strategies for maximizing service line efficiency, …...2014/11/03 · 3 strategies for...

3 Strategies for Maximizing Service Line Efficiency,

Quality, and Profitability

Miki Patterson PhD RNFA ONPVince Capasso, MSF, FACHE, MBB

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Speakers

• Certified Orthopedic Nurse Practitioner

• Over 30 years of clinical experience in healthcare, consulting, RNFA, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing

• Past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care

• Dr Patterson has done extensive work with hospital leadership desiring to improve their clinical quality and process issues while teaching change management and giving voice to clinicians and hospital personnel.

• PhD in Nursing Research from University of Massachusetts Medical School, a Master’s Degree from Boston College, and her B.S. in Nursing at Fitchburg State University

Miki Patterson PhD RNFA ONP

Miki Patterson, PHD ONPSenior Director,

Intralign Intelligent CareDesign

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Speakers

• Certified Six Sigma Master Black Belt and Fellow in the American College of Healthcare Executives

• Over 30 years of Business, Process Design, Strategy Deployment, and Balanced Scorecard experience in a broad variety of organizations that include consulting, government, manufacturing, service, and healthcare. His business experience includes executive leadership positions in Accounting, Finance, IT, and Supply Chain functions.

• Vince has managed hundreds of complex Process Improvement and Strategy Deployment projects. He has taught extensively on Lean Six Sigma, Human Centered Design, and Strategy Deployment; has developed Lean-Six-Sigma and Change Management courses for many global organizations, and has been published in national journals on the subject.

• Master of Finance degree from Bentley University and a B.S. of Accounting degree from Southern New Hampshire University 3

Vince Capasso

Vincent Capasso, MSF, FACHE,Six Sigma Master Black BeltSenior Director, Operational

Process CareDesign

Objectives

As a participant, you will be able to:

• Identify key operational and clinical indicators of orthopedic service line efficiency

• Describe how Surgical First Assists can add value in the OR

• List the steps in developing and/or evaluating or building an orthopedic service line

• Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line

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Healthcare in TransitionProviders must increase efficiency and control

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When outcomes are linked to reimbursement, providers must drive towards value based care.

Rehab$5,000 (10%)

AcutePost-Op

$5,000 (10%)

Intra-Operative$22,500 (45%)

Implant 41%Hospital 45%

Clinic/“Pre-hab”

$15,000 (30%)

Admission/Pre-Op

$2,500 (5%)

Sample of Total Joint Service Line Cost

• Roughly 45% of Episode costs are incurred in the intra-operative space

• Controlling the intra-operative space is key to improving efficiency, reducing cost and increasing quality

• Control begins in the Operating Room with efficient surgeon extension

• To gain Total Joint Service Line Excellence status, data transparency, process refinement, marketing and supply chain excellence are also needed

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Episode of care costs

Bending the Cost Curve

• Alignment of surgeons and hospitals; clinical and operational goals

• Integration of tools and strategies to enhance transparency and accountability

• Change management – Strength and capability to affect lasting, sustained change

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Innovative Vision

1. Alignment Alignment of Surgeons, Clinicians,

and Hospital with Patient Needs

Alignment

Why isn’t everyone on the same page?

The right tools can bring clarity to goals and objectives and create a common purpose.

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It takes some work!

3Ps of Alignment

Process

People

Purpose

Purpose

• Is Direction Clear? • Is the message Heard & Understood?• Are we using the right metrics?• Do we have a Strategy Deployment Process?

Process

• Are staff and managers trained in problem solving?• Is there a structured Process Improvement

Methodology?• What is the level of Efficiency? • Does the Organization utilize standard work?

People

• What is the level of Staff Satisfaction?• Are we Patient-Centric? • Are there Appropriate Resources?

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First, understand the various voices you will hear. Each has a different perspective.

Voice of the Customer (VOC)

• Used to describe customers’ needs and their perceptions of your services, product, or process.

Voice of the Business (VOB)

• Used to describe your business’ needs in creating the service or product.

Voice of the Process (VOP)

• Used to describe the current state of the process; how is the process performing. Is it capable of meeting customer needs?

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Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Management & Staff

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Education and Staff DevelopmentEquipment

CultureTrust/Cohesiveness/Accountability

TeamworkIntra Dept.

Financials

RO

SE /

Po

siti

ve

BUD / Opportunities

THORN / Problems

C-Suite Leadership“Revolving door”

Patients

SurgeonsIT Systems

MD Engagement

Staffing Levels

Facilities

Engagement

Efficiency

New Ventures

TeamworkInter Dept.

CultureAutonomy & Environment

New “learning” Leadership

Staff Flexibility

Surgeons not Engaged

Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Patients

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Not answering call-bells promptly

Great Nurses

RO

SE /

Po

siti

ve

Room has a View

Surgery went Well

Food is Very Bad

Was in Pain Waited a LONG Time

Nurse did Not Listen

Crowded and Loud Hallways

Would Like to have meal time flexibility Facilities need

upgrading

The Doctor is not always listening

Lots of noise

Receptionist was Rude

Great PT Staff

My Surgeon is Abrupt

BUD / Opportunities

THORN / Problems

Summarize the “Voices” and Synchronize with Strategy

Voice of The Business

Voice of The Process

Voice of The Customer

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2. Closing Operational Gaps Understanding Gaps Between

Current State vs. Desired Future State

Service Line Excellence The Drivers of Service Line Excellence

Infrastructure and Practices in Place to Drive Continuous Improvement

Service Line Integration & Efficiency: Patient Care Journey

Supply Chain Best Practices

Clinical & Operational Excellence:Pre-Op, Intra-Op, Post-Op

Effective Governance within a Just & Safe Culture

Effective Information Systems Structure & Analytics

Optimized Financial Management

Alignment of Partners Across the Continuum of Care

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Clinical and Operational Excellence

Efficient, Safe, High Quality Processes

Appropriate/Optimized Staffing

Effective/Efficient Sterile Processing

Employ Best Clinical Practices

Patient-Centered Care

% of patients with medical clearance 14 days prior to surgery

% charts with History & Physical complete 10 days prior to surgery

85% + On Time First Case Starts

Time patient waits in holding area

Frequency of same OR team operating together

Staffing levels are appropriate based on predictive modeling

Avg Turn Around Time < 21 min

Standard process in place and followed for OR set-up

Defect-free transfer of patient to PACU

Patient assessment complete and documented within 30 minutes of arrival in PACU and every hour thereafter

Driver Critical to Success

Indicator Critical to Success

Metrics

How Does The Critical-to-Success Tool Work?

Big Goal

Goal Driver #1

Goal Driver #2

Goal Driver #3

Critical to Success Indicator 1



Goal Drivers Critical to Success Indicators

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Building the Critical-to-Success Tree

Drivers are like themes. They frame and compartmentalize the goal.

Increase Ortho

Margin

Strong Surgeon Alignment

Surgical Process Efficiency

Best Practice Implant Management

Standardized Processes


Goal Drivers

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Critical to Success Indicator (CTSI)

These are another layer of compartmentalization. They break down the drivers into measurable areas.

Increase Ortho

Margin



Best Practice Implant Management

Standardized Processes



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Increase Ortho

Margin




Co-Management Agreement in Place

Surgeons Are Engaged

Best Practice Processes

Hospital provides consistent surgical teams

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Co-Management Agreement in Place

Surgeons Are Engaged

Best Practice Processes

Hospital provides consistent surgical teams

Critical to Success Indicators Critical to Success Metrics

On Time Starts at 85% +

75%+ of Surgeons participate in shared governance activity

20-30% of compensation is tied to gain sharing

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Timeline: Knee Replacement Observation

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Illustrating Pain Points9:45 10:45 11:15 11:45 12:15 12:45 1:15 1:45 2:15 2:458:45 10:159:158:157:45

Pt. in Room10:22

Tourniquet Off

12:05

Time Out10:26

Incision10:56

Surgeon Exit12:35

Dressing On12:49

Pt. Arrives in Pre-Op 8:30

Patient Waits67m

Anes. Arrives for Nerve Block8:57

Patient Waits27m

2nd Time Out10:53

Nerve Block Induction

9:15

Patient Wheeled Out

12:56

Spaghetti Diagram: Hip Surgery

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Metric Mapping

Key | # of In & Outs

Surgeon: 1

RN Circulator: 16

Device Rep: 9

Scrub Tech 1: 1

Scrub Tech 2: 6

Scrub Tech 3: 5

PA: 1

Anesthesia 1: 0

Anesthesia 2: 1

Other: 2

Total: 42

Value Stream Map : Flows and Waste

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3. Implementing Change Using the Correct Tools and Approach

to Move the Organization to a New Reality

Identify “Quick Wins” First

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Quick Wins

1 Update white Boards - room and Central (time slots for discharge and rehab)

2 Discharge Education Class - Pilot

3 Night before discharge call to family for transport

4 ON-Q ordering process / Improve

5 Nursing pain management assessment/training (i.e. heel slide to check pain)

6 Room discharge clearing for cleaning: belongings, CPM, tubes, meds, etc..

7 “Room Dirty” notification process

8 Sleeper sofa/plan around overnight

9 Potential for CPM install in AM/tech - day of discharge

10 Unit TV with Ortho-specific media content

11 Consider switching rehab gym with waiting room gym

12 PACU and TJ Floor use dual monitors | PACU needs Teletracker monitor, TJ Floor needs PICIS monitor

Plot projects based on Resources and ROI

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High

Med

Low

Low Med High

Return on Investment: Hard $ only

Res

ou

rces

Req

uir

ed

(tim

e, e

ffo

rt, s

taff

, co

st)

Improve Time Out

Disposable Supply Improvement

– Outside OR Core

Cell Saver Analysis/Redesign

Antibiotic Cement Analysis/

Redesign

Improve Discharge Process

Streamline Surgical Flow

Reduce Case Time Late Starts

Maintenance and Equipment

Improvement

Surgical Set Analysis/Flow

Roadmap of High-Impact Tactical Projects | Example

Improve Surgical Scheduling

Staff Resource Planning

Disposable Supply Improvement –

OR Core

Medicare TJA Bundled Care

Data Mapping

Revenue Cycle Assessment

TDABC Model

TJA Supply Chain Implant Cost

Medicare Pricing Accuracy

Improve TJA Education

What will give you most benefit for least effort?

Week 1-3

Week 4

Week 5

Week4-15

Week 16

Assessment

Project Kick-Off

Roadmap Remaining

Projects

Onsite

Remote Coaching

Onsite

Remote Coaching

Onsite

Remote Coaching

Co-creation, Recommendations, & Pilots Dashboard Implementation

100 Day Sprint Methodology

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Process Transformation: Project ExamplesSample Results: Peri-Op Infection Rate Reduction

Total Joint infection rates were at 3% vs a national average of .72%.

After 6 months the total joint infection rate was 0% resulting in a projected savings of $1.4 million per year through avoidance of extended length of stay/treatment and readmission.

Problem Result

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Sample Results: Surgical Cancelation Rate Reduction

The cancellation rate dropped to 6% and identified the potential to improve margin by 1.4M with estimated margin impact for FY 2013 of $500K.

Problem Result

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The surgery cancellation rate was consistently high for three years, at 13% at the time of engagement.

Process Transformation: Project Examples

Intelligent Process TransformationSample Results: Supply Chain Efficiency

The hospital was experiencing high supply cost, increasing OR supply chain labor cost, stock-outs and excess inventory.

Reduced total supply inventory by $670K. Reduced supplies on specialty carts by $70K and reduced labor cost of $80K.

Problem Result

Before After Before After

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“Sales reps have created this necessity for themselves with the surgeon, and we’re saying it’s not as necessary as everyone thinks it is.”

Justin Freed, Executive Director of Supply Chain at Loma Linda University Medical Center

Source: Lee, Jaimy. "Devicemaker Sales Reps Being Replaced in the OR." Modern Healthcare 16 Aug. 2014

The Role of the Sales Rep

• Lack of price transparency and rep presence leads to unnecessary up-sell

• Rep or multiple reps in OR slows room turnover

• Clinical support provided by the rep is not free – charged through hefty SG&A implant cost

Influencing the Cost of Orthopedic Implants

The result: Loss of control, reduced efficiency and higher supply costs.

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Effective Support of Operational & Clinical EfficiencySpecialized SFAs – the Smarter Alternative

Low High

Doctors assisting Partners

Practice Employed SFAs

Freelance SFAs

Hospital Employed SFAs

Specialized SFAs

Advanced Surgical Support Adds Value in the OR

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Skill Level / Efficiency

Consider Advanced Surgical Support

Experience Matters: University of MD St. Joseph Medical Center Case Study / 2013 data

Specialized Surgical First Assists are a Highly Skilled Group of Surgeon Extenders

ProcedureActual

procedure time

Typical procedure

time*

# of 2013 procedures

Minutes freed

General Surgery 100 138 1123 42,674

Urology 205 270 117 7,605

GYN 128 138 80 800

*Estimated average surgery time without SFA is based on 2012 Medicare data and top HCPCS codes associated with each procedure area. 36

Sustaining the Gains Maintaining Accountability, Automating

Dashboards and Linking Metrics to Projects

Maintaining the Gains / Strategy Execution

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Use Dashboards to track key metrics

Strategy

Goals

Projects

Metrics

Responsible

Maintaining the Gains / Strategy Execution Using your Critical to Success Metrics focus your data collection on the metrics that drive success

Strategy

Goals

Projects

Metrics

Responsible

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Thank You

3 strategies for maximizing service line efficiency, …...2014/11/03 · 3 strategies for...

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