Reducing Risk Adjusted Mortality

(RAMI)March 18, 2019

Risk Adjusted Mortality Index - RAMI

• Number of Mortalities, divided by

• Number of Expected Mortalities (of the entire population of patients)

– This is based on age and other demographics, principle diagnosis, as well as other

comorbid conditions that are present at the time of admission

– This data all comes from the claim (billing)

– The claim is created based on the documentation present in the patient’s record

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Quality Ratings and Incentives that use RAMI

Most are Understandable1. USNWR – Survival Score is 37.5% of the overall score

2. Truven Top 100 – 11%

3. HealthGrades – Star Ratings heavily based on mortality

4. CareChex – Over 20% (Black Box)

5. Leapfrog (through PSI 04) - <10%

6. CMS Value Based Purchasing

7. Blue Cross (and other payer’s) Quality Incentives

Focus for the Session

• Reducing Preventable Mortality - We have opportunities, compared to our

own past performance and benchmarks, to reduce mortalities at Ochsner.

– How do we most effectively improve?

– How do we know if we’re successful?

Involves Advanced Analytics and fortunately we have a very good team that’s been a part of this

work since its beginning.

• Ensuring Accurate, Complete and Specific Provider Documentation

– How do we best approach this?

• How do we best focus on improvement, in either of these?

– Translate RAMI into actionable focus areas for Performance Improvement

What about Mortality Reviews

• Needed and you do learn from them

• You don’t learn enough (to optimally improve)

• You’ll find very few “Clearly here was where we went wrong”

• You’ll find a lot of “This patient was so sick, them dying was not a surprise”

– Reducing mortality in this group is where much of the opportunity lies

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What about Looking at RAMI by Service?

• Despite why you enter a hospital, there are only a few common ways you

actually die:

– Cardiac Arrest

– Pulmonary Arrest

– Multi-system Organ Failure – often from Sepsis

• If we can’t prevent you from dying, we can choose what we do to you before

you die

– Would the patient with advanced stage 4 cancer had chosen to be in home Hospice if

you had had the conversation?

– Is it good medicine to go with a Balloon Pump and Ventilator if a 90 y/o patient comes in

with an “out of hospital” cardiac arrest without CPR for 10 minutes?

Its almost never “this group of doctors, or this service” but usually

broader trends reflective of care processes and work flows

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Act Plan

Study Do

Experimental

Approach:

Model for

Improvement

Aim

Measures

Interventions *

IHI Model for Improvement

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Major Drivers & Opportunities

1. Recognizing Deterioration and Resuscitation

2. Sepsis Mortality

3. Evidence Based Selection for Procedures

4. Palliative Care

5. Transfer Center’s Clinical Triage

Preventing Death

How Do

Deaths Count

Both

Typical Month of Mortalities

• Post-liver Transplant presenting with Shock

• 63 y/o s/p liver transplant to unstable to move to OMC - Coded in OR

• Septic Shock - 2 cases

• 66 y/o NH patient in septic shock with Lactic Acid >12. Dies within 24 hours of admit

• 65 y/o RRC transfer - Dies the following day

• Out of hospital cardiac arrests - 2 cases (neither with advanced directive or goals of care

discussion PTA)

• 79 y/o ESRD patient on dialysis

• 76 y/o Parkinson's patient

• Metastatic Lung Cancer undergoing palliative XRT – age 70. Aspiration PNA due to

suspected TE fistula. No advance directives or goals of care/discussion PTA

Major Drivers/Opportunities for RAMI

1. Recognizing Deterioration/Resuscitation

2. Sepsis Mortality

3. Transfer Center’s Triage/QB Model

4. Evidence Based Treatments

5. Advanced Directives/Palliative Care

6. Documentation - Denominator

Can be Improved though Improved

Systems involving limited #s of people

Depends on every Provider

Why Driver’s Matter

• Its one thing to ask a group of physicians, or resident/medical student to work

on reducing RAMI

• Its another to say:

– We’re working on Sepsis Mortality

– The literature shows that time to antibiotics impacts mortality

– What are your ideas for PDSA cycles in order to shorten the time from when a patient is

first felt to have sepsis to the time that antibiotics are given?

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IHI: Driver Diagrams

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Core Interventions:1. Rescue Changes & iO Tool – Began 9/17 (1)2. QB Model - Started 10/17 (2)3. Code Sepsis at OMC – March, 2018 (3)2018 Interventions:1. Documentation Initiative began 11/17 2. Palliative Care Core Team began 3/18

Challenge/Opportunity:1. Documentation Excellence by front-line providers2. Palliative Care (first focus is ambulatory PC)Current and Future Interventions:1. Document. Excellence hardwiring and continue champion training (4)2. Respecting Choices – Est. start Dec, 2018 (5)3. Inpatient Hospice Beds OMC – Est. start Oct. 2018

How Have We Done?

Appendix

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Evolution of RAMI Spread and Scale

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RAMI Spread and Scale kickoff call

RAMI programs established at each site

Monthly system calls to share best practices and updates

Developing system infrastructure to support all sites

Westbank BIG WINS – Code Blue Calls

• Continued ZERO

codes on the floor

for third month in a

row.

• Observing slight

decrease in Rapid

Responses as a

result of identifying

a deteriorating

patient prior to

needing to call a

rapid.

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0

5

10

15

20

25

30

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Aug

17

Sep

t 1

7

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul 1

8

Aug

18

Sep

t 1

8

Oct

18

No

v 1

8

De

c 1

8

Non Critical Care Codes vs. Rapid Response Calls Q2 2018

Non Critical Care Rapid Response Calls

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0.76

0.88

1.29

0.81

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2015 YTD 2016 YTD 2017 YTD 2018 YTD

RAMI Scores by Year

RAMI RAMI Target

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

RAMI Scores, September 2017 - June 2018

System Quality Process Dashboard Draft – October, 2018

• Out of ICU codes

• High APACHE risk score transferred out of ICU

• Sepsis core measure sample (submitted to CMS)

• Sepsis in the ED – “Door to Antibiotics” Time

• # of PC consults/# of ADs in ICU patients (72 hrs.)

• Xenex Utilization

• Avasys Utilization

• Coding Density (POA)

• Non-POA “Coding Density”

• # of C. diff tests ordered

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Impacting RAMI: Documentation and Palliative Care Education Sessions

Documentation and palliative care (PC) are critical drivers of RAMI. As a

result, we are developing a training program encompassing both

documentation and PC that will be delivered to our critical, high impact

service lines. THE GOAL IS IMMEDIATE IMPACT

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Documentation Palliative CareRAMI

Opportunity

First Steps• Focuses on healthy

adults or those early in chronic illness. Will enable Ochsner to reach patients and their families earlier and will normalize palliative care from the outset

Advanced Steps

•Focuses on individuals with serious, life-limiting illness. Decreased use of resources in the last months to years of life by avoiding care the patient does not want (e.g., use of aggressive technology, ICU, ED visits)

SDMSI*•Whereas the other modules address the entire care team, SDMSI focuses on the central role of the physician/provider in helping patients make any treatment decision that aligns with their goals and values.

* Shared Decision Making for Those with Serious Illness

Combining First Steps, Last Steps and SDMSI covers the full continuum of care and incorporates all team members

Respecting Choices

Drivers of RAMI

Driver Maturity Stage

Sepsis

Resuscitation

Triage of Transfer Patients

Palliative Care

Selection

Documentation

Numerator

Denominator

1/3 of the way there

More than ½ way

Most of the way there

Distance to finish line

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Tail Analysis Assumes…

…That if serious failures are inspected and

eliminated, what remains is somehow

excellent

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