making healthcare waste reduction and patient safety actionable - has session 6
DESCRIPTION
Multiple studies have estimated that at least 30% of US healthcare expenditures are wasteful. But how do you identify and reduce that waste? In this session, we will share with you a three-part framework for understanding, measuring and addressing waste reduction. In particular, we will highlight the importance patient safety and injury prevention, framing the importance of shifting from a system of incident reporting (which creates a culture of blame and guilt) to a system in which patient injury is regarded as a process failure rather than a person failure. To make that transition, health systems will need to 1) define process flows and metrics for each major type of patient injury; and 2) create a learning environment in which team members are engaged in process redesign to prevent process failure and injury. A leading health system in patient safety and quality will also share their best practices in how they have created a culture of patient safety and quality.TRANSCRIPT
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Session #6 – Making Healthcare Waste Reduction and Patient Safety Actionable
Current Session
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Poll Question
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Greg StockCEO, Thibodaux Regional Medical Center
Session #6 Making Healthcare Waste Reduction and Patient Safety Actionable
Mr. Stock has served for over 20 years as CEO of Thibodaux Regional Medical Center in Louisiana. He holds bachelors and masters degrees from Brigham Young University. He has served as CEO in three different HCA hospitals and in Northwest Hospital System in Arkansas. His career has been characterized by success stories of financial turnarounds, programmatic growth and growth in relationships with key stakeholders.
Dr. David A. Burton is the former Executive Chairman and CEO of Health Catalyst, and currently serves as a Senior Vice President, future product strategy. Before his first retirement, Dr. Burton served in a variety of executive positions in his 23-year career at Intermountain Healthcare, including founding Intermountain’s managed care plans and serving as a Senior Vice President and member of the Executive Committee. He holds an MD from Columbia University, did residency training in internal medicine at Massachusetts General Hospital and was board certified in Emergency Medicine.
David A. Burton, MD Former Chairman and CEO, Health Catalyst, Former Senior Executive, Intermountain Healthcare
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Poll Question #11) Which forms of waste do you feel have the greatest
opportunity for cost savings in your organization?
a) Ordering waste
b) Workflow waste
c) Defect waste
d) Unsure or not applicable
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Poll Question #22) How confident are you that your organization has a
good ability to identify waste opportunities?
a) Not at all confident
b) Somewhat confident
c) Moderately confident
d) Confident
e) Very confident
f) Unsure or not applicable
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Poll Question #33) How confident are you that your organization has the
ability to achieve cost savings through waste reduction?
a) Not at all confident
b) Somewhat confident
c) Moderately confident
d) Confident
e) Very confident
f) Unsure or not applicable
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Home(Patient Portal)
* To Invasive Care Processes
Clinic CareNon-recurrent
Clinic CareChronic Acute Medical
IP Med-SurgAcute Medical
IP ICU
Invasive Medical
Invasive Surgical
Diagnostic Work-up
Bedside care
Triage to Treatment Venue
Substance Preparation
Invasive* Subspecialist
Chronic Disease
Subspecialist
Screening & Preventive Symptoms
Procedure
Indications for Intervention
Diagnostic algorithms
Indications for Referral
Triage Criteria
Preventive, Diagnostic, Triage and Clinic Care, Algorithms; Referral & Intervention Indications (scientific flow)
Population Utilization
Knowledge Assets
Treatment and Monitoring Algorithms
Treatment and Monitoring Algorithms
Health Maintenance and Preventive Guidelines
Substance Selection
Substance Selection
Clinical Supply Chain Management
Admission Order SetsAdmission Order Sets
Supplementary Order Sets
Pre-Procedure Order Sets
Post-procedure Order Sets
Order sets and indications for selection of substances and clinical supplies (scientific-flow focus)
MD Per Case Knowledge
Assets
Post-procedure Care
Discharge
Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols
Standardized Follow-up
Post-acute care order setsIP (SNF, IRF)Home health
Hospice
Clinical ops procedure guidelines and patient injury prevention
Implementation of protocols based on MD orders and clinical operations-initiated activities (Lean/TPS workflow focus)
Clinical Ops Per Case Knowledge
Assets
Care Process Models
Value Stream Maps
The Anatomy of Healthcare Delivery
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Implementation of protocols based on MD orders and clinical operations-initiated activities (Lean/TPS workflow focus)
Clinical Ops Per Case Knowledge
Assets
Clinical OpsPer Case Utilization
Waste
Workflow Per Case
Waste
Clinical ops per case management
(individual patient focus)
Sample Metrics
Cost per caseNursing hours by unitOR minutesL&D minutesCycle timesCost per ancillary testEnvironmental services
Compliance with protocols for implementing care ordered
Population Health ManagementWaste reduction construct
PopulationUtilization
Waste
Per capita management
(population focus)
Sample Metrics
Admits/1000 membersIP days/1000 membersOP visits/1000 membersProcedures/1000 membersED visits/1000 membersReadmissions/1000 members
Compliance with value-based guidelines for diagnostic ordering, triage, referral and intervention
Per Capita Waste
Preventive, Diagnostic, Triage and Clinic Care, Algorithms; Referral & Intervention Indications
Population Utilization
Knowledge Assets
MD per case management
(individual patient focus)
MD Per Case Utilization
Waste
Sample Metrics
Cost/caseCost/procedureOR minutesL&D hoursOther LOS
Compliance with standard order sets, pharmaceutical, blood product and supply chain utilization
OrderingPer Case
Waste
Order sets, selection criteria (scientific-flow focus)
MD Per Case Knowledge
Assets
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care, substances and
supplies that do not add value
Variation in efficiency of delivering tests, care
and procedures ordered
Patient injuries incurred in delivering tests, care and procedures ordered
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Three forms of waste
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THIBODAUX REGIONAL MEDICAL CENTER
PURSUIT OF EXCELLENCEGreg Stock, CEO
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From Vision to RealityPatient Centered Excellence
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“Triple Aim”
Patient ExperienceClinical Quality Improvement
Cost-Effective Care
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Sustaining a High Level: Patient Experience
StatementsThibodau
x Regional
Terrebonne General Ochsner Our Lady
of LakeCleveland Clinic
East Jefferson
National Average
Nurses "Always" communicated well 87% 83% 75% 83% 83% 81% 78%
Doctors "Always" communicated well 89% 84% 79% 87% 82% 84% 81%
Patients "Always" received help as soon as they wanted 72% 65% 56% 63% 68% 59% 67%
Pain was "Always" well controlled 74% 73% 64% 75% 72% 72% 71%
Staff "Always" explained meds before giving it to them 68% 66% 59% 66% 66% 62% 64%
Room and bathroom were "Always" clean 79% 72% 60% 67% 78% 66% 73%
Area around room was "Always" quiet at night 78% 63% 60% 69% 57% 64% 60%
Patients reported YES, they were given information about their
recovery at home87% 85% 83% 87% 90% 84% 85%
Hospital rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) 78% 69% 65% 75% 84% 73% 70%
Patients reported YES, they would definitely recommend the hospital 83% 69% 70% 76% 87% 76% 71%
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Performance Results
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Clinical Quality Improvement
51% Decrease in HAI’s since 2009 Zero VAP’s in 2013 & 2014
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Clinical Quality Improvement
58% below the national benchmark Patient acuity and severity of illness have increased steadily
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Thi-bo-
daux
Ter-re-
bonne
Ochsner
West Jef-fer-son
Our Lady of
the Lake
Baton Rouge
Teche Reg Grp Best Practice
2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500 6,000 6,500 7,000
4,370
5,600
6,119 6,535
6,341
4,837 4,886
6,033
5,028
Medicare Cost per Discharge (CMI ADJ) – 2013
Cost of Care
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No debt—Strong Cash Position
FY 2011 FY 2012 FY 2013 FY 2014 LA AVG NAT. AVG0
100
200
300
400
500436
501 492
430
48
172
DAYS CASH ON HAND
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Good News
“You are the low-cost provider”
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Bad News
“You are the low-cost provider”
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Employee Engagement Results
2001 2003 2005 2007 2009 20120%
20%
40%
60%
80%
100%
120%
93% 92% 97% 91% 91% 93%
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Productivity
TGMC vs. TRMC FY 2013
Income Statements TGMC TRMC( in 000's or Thousands ) Net Revenue ( including Bad Debt ) $ 177,753 $ 152,021
Expenses
Salaries & Benefits $ 82,910 49.1% $ 66,319 43.6%Supplies & Materials $ 40,426 24.0% $ 33,006 21.7%
If TGMC had TRMC %'s : Salaries & Benefits $ 9,776 5.5% Supplies & Materials $ 4,088 2.3%
Savings per year $ 13,865
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Passion As A ValuePerformance From The Heart
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People can’t change
Awareness
Data
Knowledge
Beliefs
Values
Passion
Change
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Poll Question #4
4) How engaged is your medical staff in your healthcare transformation?
a) Not at all engaged
b) Somewhat engaged
c) Moderately engaged
d) Engaged
e) Very engaged
f) Unsure or not applicable
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Transforming an organization is the ultimate test of leadership. John P. Kotter, PhD
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Willie Nelson
What is the key to your success?“We play good music”
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The Future is Wellness
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Making waste reduction actionableDavid A. Burton, MD
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Population ordering waste reduction
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Sources of population ordering waste
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Population ordering waste reduction
Primary Care ordering variation within a population
Accessibility (emergency visits/1000 members) Diagnostics (laboratory tests, imaging studies)Compliance with value-based treatment and monitoring algorithms (office visits/1000 members, monitoring tests)
Therapeutics Substances (formulary compliance)Therapies (e.g., physical therapy)
Referrals to sub-specialists (compliance with indications for referral)
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Population ordering waste reductionCommunity Care dashboard
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Population ordering waste reduction
Admission ordering variation within a population. Triage to treatment venue based on objective clinical criteria (e.g., CURB-65 for Community Acquired Pneumonia)
Intervention variation within a populationAdditional diagnostic testing ordered by sub-specialist (lab test duplication; Dx studies) cath)
Compliance with indications for intervention for the applicable patient cohort
Facilitation of unbiased patient education regarding alternative treatment options for elective procedures
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Population ordering waste reductionNTSV C-Section rate with no induction attempt
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Per case ordering waste reduction (MD)
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Sources of per case ordering waste (MD)
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IP & OP per case ordering waste
Sources of ordering variation within a caseDiagnostics
Laboratory testsDiagnostic imaging studies
Therapeutics Therapies (e.g., respiratory, physical, et al) Substances (e.g., antibiotics, blood products)
Clinical supply chain (e.g., prosthetics, stents, synthetic bypass grafts, heart rhythm devices)Length of stay on a care unit
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Per case ordering waste
Approach and tools to wring out ordering wasteOrder sets. Evidence-based order sets for the Care Processes in the Pareto list to reduce variation in the ordering of simple diagnostic tests (lab, imaging)
Indications. Evidence-based indications and cost information to standardize utilization
Imaging tests (e.g., MRI, CT, US, nuclear scans) Substances (e.g., utilization criteria for blood, antibiotics, total parenteral nutrition)Major clinical supplies (e.g., joint prosthetics, cardiac and vascular stents, synthetic bypass grafts, heart rhythm devices, neurostimulators)
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Per case ordering wasteAppendectomy
Antibiotic order default changed on pre-op standing order set
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Per case ordering wasteAppendectomy
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Per case workflow waste reduction(clinical operations)
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Sources of per case workflow waste
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Workflow waste - surgical services
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Workflow waste – surgical services
reduce room turnover time
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IP per case waste reduction opportunityFacility perspective Per case ordering waste
Per case workflow waste
Per case defect waste
$144 MM~ 23%(100%)
Total IP per case waste
$57 MM*~ 9 %
(~40% of 23%)
$87 MM*~ 14 %
(~60% of 23%)
In Progress< 1** %* Preliminary Findings (work in progress)
** Extrapolated from OSHPD and CMS data
DRAFT
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Defect waste reduction
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• Ventilator-associated pneumonia (VAP)
• Adverse drug events (ADEs)
HAC cohorts/registries
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0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
% of Total Cost of Patient Injuries
% Total Cumulative %
Perc
ent T
otal
Cos
tPareto analysisCalifornia OSHPD data
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Pareto analysisRank-order list – CA OSHPD data
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Prevention processCLABSI flow diagram
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Defect waste reduction
CMS’s establishment of penalties weighted by measurement domain creates an incentive to choose CLABSI (#1) and CAUTI (#5) improvement initiatives (65% of total)
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Focus on workflow/defect waste
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Analytic Insights
AQuestions &
Answers
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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 satisfied2) Somewhat satisfied3) Moderately satisfied4) Very satisfied5) Extremely satisfied
3. On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)?
1) No interest2) Some interest3) Moderate interest4) Very interested5) Extremely interested
2. What feedback or suggestions do you have?
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