Session 36

Improve Reported Outcome Measures with Standardized Care Processes

Dr. Jess Bouma, MDNocturnistMultiCare

Amber Theel, RN, BSN, MBA, CPHQ, CPHRMDirector of Quality Outcomes and MetricsMultiCare

Learning Objectives

• Recognize the strengths and limitations of transparent data in identifying opportunities for improvement.

• Identify how in-depth planning informed by analytics saves time in the long run and leads to better decisions that more effectively support evidence-based care for patients.

• Identify the positive impact standardized, evidence-based order sets and protocols that support workflow have on patient outcomes.

• Recognize the strength of the interdisciplinary team in designing and successfully implementing redesigned care processes.

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We want to make sure that we treat our patients appropriately and do the best thing for them the first time.

-Tasheba West, Pharmacist, MultiCare

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5.7 million inpatient days

each year

8th

leading cause of death

Twoof the CMS

publically reported measures

The Turning Point & Opportunity

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Readmission and mortality rates for patients with pneumonia are a national performance measure. Through an internal review, leaders at MultiCare identified that care for patients with pneumonia was highly variable and could be improved.

Because of the nature of pneumonia, care for these patients involves multiple providers and care venues including hospital and community providers practicing in inpatient, outpatient, emergency department (ED), and skilled nursing facilities.

Launching an improvement effort for these patients would need to have strong leadership and a broad base of engaged participation with representation from many care locations and disciplines.

Medicine Collaborative Leadership Challenge

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MultiCare leadership tasked the existing Medicine Collaborative to form a multidisciplinary pneumonia workgroup to do the following:

Reduce pneumonia

mortality rate

Reduce pneumonia

readmission rate

Reduce pneumonia

avg. cost per case

Reduce pneumonia

length of stay

2016 Clinical Collaboratives

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Poll Question #1Reducing pneumonia readmissions and mortality rates requires collaboration across the entire facility (ED, inpatient units, outpatient units, transitional care and nursing home providers, physicians, nursing, respiratory, pharmacy, operations, information technology, organizational effectiveness, and physical therapy).

On a scale from 1-5, how effective is your facility/system at collaborating across the continuum of care and engaging the interdisciplinary team?

1) Not effective

2) Somewhat effective

3) Moderately Effective

4) Very effective

5) Extremely effective

6) Unsure or not applicable

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Results

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in pneumonia mortality rate

in pneumonia readmissions

in average variable cost per patient

36% reduction

21% reduction

8% reduction

in average total LOS

4.5% reduction

INVESTIGATE• ID root cause for

complex LOS, readmits, and mortality.

• Pull data, vet & document baseline.

• Identify best practice (internal & external).

DEVELOP• Develop & test

interventions.• Create supporting

documents – EPIC order sets, MHS policies, etc…

• Plan implementation.

IMPLEMENT• Implement • Obtain med staff

approval.• Instructor Led

Computer-Based Learnings (CBL’s).

• Conduct staff education & training.

• 3 Plan Do Check Act (PDCA) cycles = requirement to moving to stabilization phase.

STABILIZE• Ongoing

monitoring –monthly review of data application.

• Reaction plan for “red” or not sustaining targets.

PRIORITIZE• Criteria for

workgroup selection.

• Prioritization of future work.

Work Plan Timeline

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0 Month 1–3 Month 3–9 Month 9–12 Month 12 Month+

Prioritize

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Establish workgroup.• Enlist members to represent all care locations (e.g., ED, inpatient units, outpatient units, and

transitional care and nursing homes) and care providers (physicians, nurse practitioners, nursing, respiratory, pharmacy, operations, information technology, organizational effectiveness, and physical therapy).

• Allow for ad hoc representation to ensure input from anyone whose workflow is affected.Prioritize work. • Determine approach to accomplish the goals set by leadership to reduce pneumonia mortality,

readmissions, length of stay, and cost.

0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

Investigate

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The pneumonia workgroup completed a root cause analysis using detailed information from their analytics system. Upon completion, the workgroup recognized that MultiCare had four different patient populations with pneumonia, each with some unique needs:

• Community acquired pneumonia.• Hospital-acquired pneumonia.• Drug-resistant pneumonia.• Patients with pneumonia and drug allergies.

0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

Develop

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With the problem and population clearly defined, the pneumonia workgroup:• Identified focus areas and related interventions to test for impact on:

o Supporting appropriate use.o Improving clinical processes and efficiency.o Improving analytics processes and capability.

• Developed an order set, care pathway, and other supporting documents.

0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

ImplementSupporting Appropriate Use

• Engaged clinicians across the care continuum to ensure: • Right level of care in the right clinical setting.• Minimal unintended consequences from process changes.

• Built an enterprise-wide order set for pneumonia.• Included appropriate variation for each of the four patient populations.• Used decision support to ensure the patient received the best antibiotic and appropriate

dosing for a defined period of time, for the specific type of pneumonia.• Implemented a bronchodilator protocol.

• Provided decision support for nurses and respiratory therapists to modify treatment as needed.

• Engaged radiologists to identify appropriate use of radiologic procedures.

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0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

ImplementImproved Clinical Processes and Efficiency

Improved process for discharge appointments and follow-up phone calls.

• Social workers serve as “personal health partners” assisting with care management.• Identified medium-risk patients as the highest risk for readmission and focused services there.

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0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

ImplementImproved Analytics Processes and Capability

Provided faster access to data for pneumonia, as well as feedback at the patient and provider level.

• Expanded analytic capability and developed new metrics.

• Developed interactive pneumonia dashboard, providing ability to monitor individual provider performance and patient outcomes in relation to interventions provided.

• Provided access to comprehensive medication history in Emergency Department (ED) to help with triage and prescribing the correct antibiotic.

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0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

Example

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Stabilize

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• Analytics application mines the data about pneumonia patients and provides near real-time interactive data that shows the impact of interventions on the high-level outcome metrics: mortality, readmissions, length of stay, and cost.

• Quickly identify patterns and problem areas and make correction action.

• Data from multiple charts pulled to one dashboard, providing quick, easy access to pertinent patient information.

0 Month 1 – 3 Month 3–9 Month 9-12 Month 12 Month+

Example

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Poll Question #2How readily available is all the data your clinical teams need to make sound decisions regarding evidence-based treatment of patients with pneumonia?

a) We do not have all data available electronically.

b) We have data available electronically, but it is in multiple systems and may not be up to date. We lack decision support.

c) We have data available electronically, but it is in multiple systems and difficult to access. We lack decision support.

d) We have data available electronically, and we have decision support, but it is cumbersome and in multiple systems.

e) We have data and analytics tools that integrate data from multiple sources and present all relevant data to us. Sophisticated decision support.

f) Unsure or not applicable.

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How It All WorkedDecreasing Mortality

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36% reduction in pneumonia mortality is attributed to more patients receiving appropriate and timely care, especially with the correct antibiotic at the right dose for the appropriate duration.

• Analytics delivered new capability to correlate processes with outcomes, and a way to have a single view across medication and readmission histories.

• Thanks to the work of the pharmacists in partnership with physicians, over 95 percent of patients diagnosed with pneumonia in the inpatient setting are receiving the correct antibiotic.

How It All WorkedDecreasing Readmissions

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21% reduction in pneumonia readmissions is credited to many factors, including improved care and correct antibiotics as well as care management support and appropriate follow-up care.

• Due to the care management efforts of the personal health partners, 81 percent of pneumonia patients now have a follow-up appointment scheduled and completed.

How It All WorkedDecreasing Cost

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8% reduction in average variable cost per patient (charge ratio).

• By having the appropriate imaging tests within the order sets and educating providers, patients received appropriate, cost-effective care.

Lessons Learned

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1. Support from senior leadership is essential to the success of the Collaboratives. It conveys authority and respect across the organization, minimizing barriers and increasing willingness to change.

2. Leverage the subject matter experts of the inter-professional team and allow them to work on items that are within their scope: nursing, radiology, respiratory, pharmacy, and analytics.

3. Do not make assumptions about the patient population. Time invested to perform thorough investigation and analysis provided new insight, resulting in ability to better meet different patients’ needs.

Future Plans

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1. Continue to improve care for patients with pneumonia. 2. Evaluating the impact of CURB-65 Severity Score within

the order set for admits from outpatient setting. 3. Process validation and performance monitoring.4. Applied lessons learned from pneumonia to Chronic

Obstructive Pulmonary Disease (COPD). Developed in half the time it took to create pneumonia order set.

5. Evaluating expansion of the Patient Card screen to develop Physician Card screen. Would include performance and adoption metrics.

6. Evaluating expansion of Patient Card screen in use in the ED and leveraging for Primary Care. Estimate this could save 30-60 minutes in patient preparation.

7. Pharmacy expanding time with patients to provide medication counseling.

Analytic Insights

AQuestions &

Answers

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What You Learned…

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Write down the key things you’ve learned related to each of the learning objectives

after attending this session

Thank You

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