6/13/2012
IHI Expedition:
Partnering Quality & Finance Teams to
Improve Value
Kathy Luther, RN, MPM
Jill Duncan, RN, MS, MPH
These presenters have nothing to disclose
Introductions
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6/13/2012
Expedition Coordinator
Kayla DeVincentis, Project Coordinator, has
worked at IHI since 2009, starting as an intern in
the Event Planning department. Since then,
Kayla has contributed to the STAAR Initiative,
the IHI Summer Immersion Program, and the IHI
Expeditions. Kayla obtained her Bachelor’s in
Health Science from Northeastern University and
brings her interest in health and wellness to IHI’s
Health and Fitness team.
Expedition Director, Jill Duncan
Jill Duncan, RN, MS, MPH, Director, Institute for Healthcare
Improvement (IHI), is responsible for leading the strategic
planning and daily operations for IHI’s Impacting Cost + Quality
initiative as well as serving as faculty for IHI’s Leading Quality
Improvement: Essentials for Managers. Jill is also the Director
for a variety of new IHI Expedition programs in 2012-13. With
nearly 20 years of clinical nursing experience, Jill draws from
her learning as a Clinical Nurse Specialist, pediatric nurse
educator and front line nurse. Her clinical interests have
developed through experiences in a variety of settings including
Neonatal ICU, pediatric ER, clinical research and Early Head
Start health programming. Ms. Duncan has contributed to a
variety of collaborative publications in The Journal of Pediatrics
and she is co-author of Pediatric High-Alert Medications:
Evidence-Based Safe Practices for Nursing Professionals and
Stressed Out About Your Nursing Career.
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6/13/2012
Faculty Leader, Kathy Luther
Katharine Luther, RN, MPM, Vice President, Hospital
Portfolio Planning and Administration, Institute for Healthcare
Improvement (IHI), is responsible for furthering IHI's work to
help hospital leaders and staff achieve bold aims. Key to this
work is developing strategic partnerships that leverage
innovation, pilot testing, implementation, and continuous
learning across organizations, systems, professional societies,
and entire countries. Previously, she served as Executive
Director at IHI, designing new programs to impact cost and
health care quality. Ms. Luther has over 25 years of experience
in clinical and process improvement, focusing on large-scale
change projects and program development, system
improvement, rapid cycle change, developing and managing a
portfolio of projects, and working with all levels of health care
staff and leaders. Her clinical experience includes critical care,
emergency room, trauma, and psychiatry. Prior to joining IHI,
she held leadership positions at the University of Pittsburgh
Medical Center, MD Anderson Cancer Center, and Memorial
Hermann–Texas Medical Center. She has experience in Lean
and is a Six Sigma Master Black Belt.
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6/13/2012
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What is YOUR goal
for participating in this Expedition?
4
6/13/2012
Join Passport to:
• Get unlimited access to Expeditions, two- to fourmonth, interactive, web-based programs designed to
help front-line teams make rapid improvements.
• Train your middle managers to effectively lead quality
improvement initiatives.
. . . and much, much more for $5,000 per year!
• Visit www.IHI.org/passport for details. To enroll, call
617-301-4800 or email [email protected].
Where are you joining from?
5
6/13/2012
Agenda
• Welcome
• Expedition overview
• Today’s health care environment & its impact on
the value of care
• The science of improvement – What is its role in
improving value in health care?
• Getting started
• Building a team around improving value
• Two case study examples
• Homework for next call
What is an Expedition?
ex•pe•di•tion (noun)
1. an excursion, journey, or voyage made for
some specific purpose
2. the group of persons engaged in such an
activity
3. promptness or speed in accomplishing
something
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6/13/2012
Ground Rules
We learn from one another – “All teach, all learn”
Why reinvent the wheel? - Steal shamelessly
This is a transparent learning environment
All ideas/feedback are welcome and encouraged!
Expedition Aim
The focus of this program is improving the
quality of health care while finding the waste in
health care systems and removing it. Teams
will build a diverse portfolio and develop new
partnerships between clinical and financial
leaders in the endeavor.
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6/13/2012
Expedition Objectives
Participants will be able to . . .
• Identify potential cost reduction quality improvement
opportunities for your organization.
• Prioritize high-return ideas and map to energy grid for your
organization.
• Develop a set of quality metrics as well as a financial
measurement system to capture savings across your
portfolio.
• Obtain the tools and confidence to build and execute on a
portfolio of interventions to achieve results.
• Plan small tests of change you can test throughout the
Expedition.
Today’s Guest Faculty
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6/13/2012
Kevin Little, PhD
Kevin Little, PhD
IHI Improvement Advisor
Improving Ecological Design. LLC
Presbyterian Healthcare Services
Susan Quintana, RN, MSN
Manager, Quality Program Support
Quality Institute
Presbyterian Healthcare Services
Kay Armstrong
Financial Project Manager
Women’s, Children’s & Surgery Service Lines
Presbyterian Healthcare Services
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6/13/2012
Northeast Health
Norman Dascher, FACHE
Chief Executive Officer
Daniel Silverman MD
CMO Troy Division SPHP
Scarlet Clement
Executive Director,
Behavioral Health Services, Troy Division
Making Sense of It All
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6/13/2012
Parallel work: Leadership for changing health care
We
are
here!
Waste Through Different Eyes
• Unnecessary repetition (exams, histories, investigations)
Patient
• Longer stays
• Avoidable complications
• Higher health care costs; risk of being uninsured
Nurse
Physician/
Surgeon
• Time away from the bedside
• Searching for equipment
• Documenting
• Chasing down consults/results
• Time and unpredictability
• Unable to start operations/procedures on time
• Operating/procedure list over-runs
• Reduced margins
CFO
• Continuous financial pressure, and need to make “cuts”
• Frustration that QI promises savings, but rarely delivers
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6/13/2012
How is this different from traditional
cost-cutting?
• Requires process literacy and redesign
• Holds quality the same or improves it
• Needs different ways to categorize costs
and transparency
• Can unite people in a cause to control
health care costs
Our Vision
From . . .
• Arbitrary, reactive
cutting
disconnected to
the process of care
delivery
To …
• A systematic, targeted set of
interventions designed to
simultaneously
─ Improve patient outcomes
─ Control costs
─ Increase caregiver satisfaction
• Better dialogue and mutual
appreciation between clinicians and
managers
• Ability to engage caregivers in
dialogue about allocation of
savings, when realized
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6/13/2012
PRIMARY DRIVERS
WILL
Align Enterprise
Driver Diagram
IHI’s Cost + Quality
Collaborative Work
AIM
Reduce operating
expenses 1% per
year while continually
maintaining or
improving quality.
SECONDARY DRIVERS
• Establish True North Metrics (Big Dots)
• Align Waste Reduction Strategy Throughout Organization
• Align Systems for Efficiency
• Adopt Integrated Performance Measurement Systems
WILL
Engage Staff,
Physicians and
Patients
• Engage Staff in the What & Why of Value Delivery
IDEAS
Identify Waste
• Eliminate Clinical Quality Problems
• Establish Data & Feedback Loops
• Patient & Family Perspective of Waste
• Ensure a Safe Environment for Sharing Ideas
• Develop New Skills at All Levels
• Optimize Staffing
• Maximize Flow Efficiency
• Manage Supply Chain
• Reduce Mismatched Services—overuse, coordination
• Reduce Environmental Waste (Healthy Hospital Initiatives)
EXECUTION
Prioritize, Manage
Portfolio of Projects
to Remove Waste
PRIMARY DRIVERS
WILL
Align Enterprise
Driver Diagram
IHI’s Cost + Quality
Collaborative Work
AIM
Reduce operating
expenses 1% per
year while continually
maintaining or
improving quality.
• Evaluate Cost & Quality Impact
• Prioritize Projects and Manage Organizational Energy
• Create a Portfolio of Projects
• Solve Problems and Execute PDSA Cycles
• Measure and Monitor Results
SECONDARY DRIVERS
• Establish True North Metrics (Big Dots)
• Align Waste Reduction Strategy Throughout Organization
• Align Systems for Efficiency
• Adopt Integrated Performance Measurement Systems
WILL
Engage Staff,
Physicians and
Patients
• Engage Staff in the What & Why of Value Delivery
IDEAS
Identify Waste
• Eliminate Clinical Quality Problems
• Establish Data & Feedback Loops
• Patient & Family Perspective of Waste
• Ensure a Safe Environment for Sharing Ideas
• Develop New Skills at All Levels
• Optimize Staffing
• Maximize Flow Efficiency
• Manage Supply Chain
• Reduce Mismatched Services—overuse, coordination
• Reduce Environmental Waste (Healthy Hospital Initiatives)
EXECUTION
Prioritize, Manage
Portfolio of Projects
to Remove Waste
• Evaluate Cost & Quality Impact
• Prioritize Projects and Manage Organizational Energy
• Create a Portfolio of Projects
• Solve Problems and Execute PDSA Cycles
• Measure and Monitor Results
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6/13/2012
Partnering Quality and Finance Teams to
Improve Value: Starting with Quality
A Look at the
Model for Improvement
Kevin Little, PhD
Informing Ecological Design, LLC
This presentation is part of an on-line series, brought to you through a collaboration between
the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
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6/13/2012
How can you get to your destination?
Your QI Framework
You should use the QI language and
framework deployed in your health system.
Here’s a quick overview of the framework
we use at the IHI, based on the Model for
Improvement.
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6/13/2012
Example: Reducing Hospital
Acquired Infections
St. John’s Regional Health Center, Springfield, MO
Improvement Report on IHI website
http://www.ihi.org/knowledge/Pages/ImprovementStories/ReducingHealthcareAssociated
MRSAInfectionsonaSurgicalUnit.aspx
What are we trying to accomplish?
Aim: To sustain 30 percent reduction of surgical site infections
(SSIs), bloodstream infections (BSIs), and healthcare-associated
pneumonia (HAP) due to methicillin-resistant Staphalococcus
aureus (MRSA) by focusing on prevention of transmission on 7C
Surgical Unit. Sustain compliance at greater than or equal to 90
percent on process measures for reliable hand hygiene, contact
precaution for isolation patients, and appropriate room
cleaning/disinfections on 7C Surgical Unit. Achieve 98 percent
compliance obtaining admission active surveillance cultures (ASC)
in adult intensive care units (ICU), pediatric ICU, and the burn unit.
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6/13/2012
How will we know that a change
is an improvement?
Measures
Process Measures:
•% targeted patients with admission active surveillance
culture collected
•% environmental cleanings completed appropriately
•% patient encounters with compliance for contact
precautions
•% patient encounters with compliance for hand hygiene
Outcome Measures:
•Days between MRSA infections
•Rate of occurrence of MRSA SSI, BSI, and HAP per
1,000 patient days
What change(s) can we make that
will lead to improvement(s)?
Hand Hygiene:
• Provide alcohol-based hand rub for patients on bedside table
• Implement “hands up” campaign — the standard phrase or
action to use if you observe another co-worker NOT
performing hand hygiene when appropriate
Contact Precautions:
• Identify isolation patients by placing a sticker on patient menu
and placing in designated area for dietary staff
• Visual aid placed on isolation holders as a reminder to
encourage hand hygiene prior to donning PPE
Room Cleaning and Disinfection:
• Identify clean equipment with red “door knocker” tag
• High touch cleaning checklist provided to workers
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6/13/2012
A useful idea & data drive change
The project ‘tipping
point’ occurred when we
began to culture hands
and equipment of
workers [see image at
left depicting culture on
worker's hand and
culture on stethoscope
equipment]
Performance Measures
Process Measures
Outcome Measure
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6/13/2012
Questions we now know to ask
• What is the cost implication of reducing
HAI?
─What is an appropriate financial model?
─How can we track $ impact over time?
─What dollars are “dark green?”
• What changes are on the horizon from
payers that we need to prepare for?
The Model for Improvement
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6/13/2012
Three Fundamental Questions
for Improvement
• What are we trying to accomplish?
• How will we know that a change is an
improvement?
• What change can we make that will result
in improvement?
A Test Cycle
Act
Plan
Study
Do
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6/13/2012
PDSA sub-steps
Act
• What changes
Plan
•
•
are to be made? •
• Next cycle?
Study
• Complete the
analysis of the
data
• Compare data to
predictions
• Summarize
what was
learned
•
Objective
Questions and
predictions (why)
Plan to carry out the
cycle (who, what,
where, when)
Plan for data collection
• Document problems
and unexpected
observations
• Begin analysis
of the data
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
Do
• Carry out the plan
Tools you may use
Aim Statement (Charter) with
goals (targets)
Description of Key
Measures
Change Concepts and Ideas
organized in a rational way
PDSA Document forms
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6/13/2012
Project Charter
Date:
What are we trying to accomplish?
How will we know a change is an improvement?
Measurements that will be affected: Current Level
1.
2.
3.
Initial Activities/Cycles (What changes can we make that could result in improvement?)
1.
2.
3.
4.
5.
Originator:
People to Involve:
One page version
of PDSA template
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6/13/2012
Repeated Use of the Cycle
Changes That
Result in
Improvement:
A P
S D
After cycles have
demonstrated that
the change CAN
work, use more
cycles to help you
figure out how the
change WILL work,
every day
A P
S D
Hunches
Theories
Ideas
Investigation
Demonstration
Project Progress
Project
Name /
Month
4 – Significant progress
1 – Charter established
2 – Activity, but no changes 5 – Outstanding success
3 – Modest improvement
2011
1
2
Implementation
2012
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
1)
Example
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
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6/13/2012
Online Resources
On Demand
• On Demand Presentations feature streaming video synchronized with
presentation slides. These presentations are available at no charge and offer
in-depth training on key topics.
─ Science of Improvement White Board Videos (features Robert Lloyd, PhD)
─ An Introduction to the Model for Improvement (features Robert Lloyd, PhD)
─ Building Skills in Data Collection and Understanding Variation (features Robert Lloyd,
PhD)
─ Delivering Value for Individuals and Populations (features Thomas Nolan, PhD)
─ Using Run and Control Charts to Understand Variation (features Robert Lloyd, PhD)
Improvement Methods
• Tools: The Institute for Healthcare Improvement has developed and adapted a
basic set of tools to help organizations accelerate improvement.
• Tips for Effective Measures: Measurement is a critical part of testing and
implementing changes; measures tell a team whether the changes they are
making actually lead to improvement.
IHI Open School for Health Professionals
. We currently offer 17 online courses in the areas of quality improvement, patient safety,
leadership, patient- and family-centered care, and managing health care operations. We are
expanding our catalog and adding additional courses all the time. Each course takes 1-2 hours
to complete and consists of several lessons taking 15-30 minutes each. While the courses were
originally intended for students, we quickly saw substantial interest among health professionals
looking to develop their quality and safety skills. To access the courses, we offer 12-month
subscriptions that cost $250 for one person, and start at $3,000 for organization access.
User Range
Price (12 months)
Individual
$
250
Up to 50
$
3,000
51-100
$
4,500
101-250
$
7,500
251-500
$
11,500
501 +
Contact us with
number of participants
Purchasing an organization subscription gives a key contact from your organization access to our
reporting feature. This allows you to track participants’ course and lesson progress, as well as
their assessment scores and the date/time of completion.
Continuing education credits are available for nurses, pharmacists, and physicians. Each course
carries between 1 and 2 hours of credit, for a total of 22.5 credit hours. We have also recently
been approved by NAHQ to provide Certified Professional in Healthcare Quality (CPHQ) credits.
If you are interested in purchasing a subscription, you can go directly to www.ihi.org/lms or
contact [email protected]. If you would like to try a few sample lessons first, please visit
www.ihi.org/lms/home.aspx/SampleLessons.
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6/13/2012
References
• Don M. Berwick (1996), “A Primer on Leading the
Improvement of Systems,” BMJ, 312: pp 619-622.
• T. W. Nolan and L. P. Provost (1990), “Understanding
Variation”, Quality Progress, Vol. 13, No. 5.
• “Accelerating the Pace of Improvement - An Interview
with Thomas Nolan,” Journal of Quality Improvement,
Volume 23, No. 4, The Joint Commission, April, 1997.
• The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance, 2nd ed (2009)
Gerald J. Langley, Ronald Moen, Kevin M. Nolan,
Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost
Partnering Quality and Finance Teams
to Improve Value: Getting Started
25
6/13/2012
Select an Approach
Approach
Service Line
Condition based
Description
Organization Wide
Throughout organization
Examples
• Cardiac surgery
• Orthopedic procedures
• Projects in all
departments/areas
• Clinical and administrative
(admitting, environmental
services, food service)
Tools
Value stream
Flow maps
Waste Identification Tool
(WIT)
Waste Identification Tool (WIT)
Organization-wide engagement
• Identify waste- develop financial models• Identify projects – execute projects
• Track savings – manage quality
Set an Aim
• Aim in $$$
─Focuses the work
─Assists with prioritizing projects
• Aim in $$
─1-3% of total operating budget
─1-3% of service line budget
─1-3% -cost per case/ per member per month
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6/13/2012
Examples
Portfolio Management
• Aim of Portfolio:
Percentage of
Operating Budget
Savings in US Dollars
• Current Portfolio Projects:
Project Name
Totals
Projected
Savings
Savings to
Date
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Quality Metrics
27
6/13/2012
Projected Savings
Anne Arundel
$3,397,000
Estimated Savings
To date
$1,176,140
Baptist - Corporate
$7,989,145
$5,034,658
$ 2,882,000
$ 1,479,680
$110,000
$10,000
Baptist - DeSoto
1%
$5,000,000
$2,300,000
Baptist - Memphis
Blessing
Claxton Hepburn
Georgetown
Hackensack Univ Med Ctr
$1,195,147
$800,000
$700,417
$20,000
$2,400,000
$1,000,000
$1,100,000
$11,000,000
Highland Hospital
$109,861
$950,000
Hotel Dieu Hospital
Interim Homecare
Kenmore Mercy
$411,000
$1,200,000
Kingsbrook Jewish Med Ctr
$3,500,000
King’s Daughters
$6,000,000
$4051794
$6,000,000
$254,000
$236,826
$1,500,000
$1,030,161
$203,548
$1,900,000
Markham Stouffville
$1,814,450
Northeast Health
North Mississippi Med Ctr
Ocean Medical
OSF St. Francis
Presbyterian - SSL
$2,500,000
$2,000,000
$ 454,200
$ 183,186
$2,200,000
$ 16,938,000
$147,607
$ 3,682,350
$24,798
$1,000,000
$1,001,000
$331,000
$8,103,970
Presbyterian - WSL
Ryhov Co Hospital
Stonybrook Univ Med Ctr
$600,000
$9,090,000
Assessing Organizational
Capacity or “Energy”
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6/13/2012
Assessing Capacity (“Energy”)
• Who needs to be involved?
• How much energy do they need to
contribute?
• Do we have areas of the organization that
are over extended?
Departments / Support Services
Energy Grid Template
Priority #1
Priority #2
Priority #3
Priority #4
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6/13/2012
Organizational Energy Grid
1. List the organizational priorities along the top of
the energy grid.
2. List all organizational departments down the left
side of the grid.
3. Type “high” in the grid where a high level of
involvement is required from each support
service or department and “low” in the grid where
a low level of involvement is required. It is critical
that all areas that are associate with the work are
identified.
4. Review for bottlenecks or overload.
5. Determine feasibility of moving forward with all of
the priorities.
6. Make necessary adjustments.
Organizational Energy Grid
Exercise
• Where do we have bottlenecks due to excessive
requirements for energy?
• Where do we have under use of energy which
creates an opportunity to take on additional
work?
• Who needs to be involved on the team working
on the initiative?
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6/13/2012
Build Teams: Clinician & Finance
•
•
•
•
•
•
Finance
Spreadsheets
Aggregate numbers
MS- DRGs, icd-9s
Averages, means
Services, service lines
Payor class
•
•
•
•
•
•
Clinicians
Charts
Patients—one-at-a-time
Conditions
“Worst case”
Complicating factors
Social factors
Engaging Physicians-Clinicians
• Describing patients selected
• Understanding costs – physicians, clinicians
• Understanding patient characteristicsclinicians-finance
• Begin to build financial models
─More on this in upcoming sessions
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6/13/2012
Case Study Examples
• Northeast Health
─Alignment across the organization
─Multiple strategies to engage staff & patients
─Introduction to using a Waste Identification Tool
• Presbyterian Healthcare Services
─Alignment across service lines
─Attention to organizational capacity
─Partnership between clinical and financial leaders
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6/13/2012
USING MULTIPLE STRATEGIES TO ENGAGE
STAFF IN OUR PATIENT QUALITY EFFORTS
On the Call
Norman Dascher, FACHE, Chief Executive Officer
Daniel Silverman MD, CMO Troy Division SPHP
Scarlet Clement, Executive Director, Behavioral Health
Services, Troy Division
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6/13/2012
Northeast Health, an Integrated Delivery Network
in the Capital District of New York, began its IHI
journey in 2004
In October 2011, Northeast Health became a
founding member of St. Peter’s Health Partners
What IS
What is St. Peter’s Health Partners?
St. Peter’s Health Partners is the parent corporation formed from the
merging of three health systems, Seton Health, St. Peter’s Healthcare Services
and Northeast Health.
The merger creates the regions largest and most comprehensive
not-for-profit network of health care service providers which includes:
Albany Memorial Hospital- Albany
St. Peter’s Hospital- Albany
Samaritan Hospital- Troy
Seton Hospital- Troy
Sunnyview Rehabilitation Hospital- Schenectady
The Eddy system of continuing care- Region wide
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6/13/2012
Portfolio Management
• Aim of Portfolio: $ 2M saving in System Operating
Expenses
─ Current Projects:
Antibiotic Stewardship
1:1 Reduction on Behavioral Health
Decreasing Blood Utilization
Supply Cost Savings
Point of Service Collections
Waste Tool Use by Front Line Staff
ICU Sedation, Mobility, Delirium
Portfolio Management (sub-set of projects)
Project
Projected
Savings
Savings to Date
Blood Utilization
300K in 1st year
320 K in 10 months
1:1 utilization in
Behavioral Health
40K a year
37K in 8 months
Point of Service
co -pay collection
20% increase
Increased
Revenue
188K
Waste Tool
No projection
150 K
Antibiotic
Stewardship
58K
72K
plus 300K cost avoidance
Supply Costs
284 K
ICU increase
No projection
mobility & sedation
52 K
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6/13/2012
Primary Drivers
Secondary Drivers
Projects
Reduce settlements by changing process
when sentinel event occurs
Malpractice claims
Aim 1 Driver
Diagram
Prevent infections (SSI, CLI, VAP)
Clinical Quality
Problems
Coordination of Care
Prevent Decubitus Ulcers
Adverse Events and
Complications
Prevent readmissions
Turnover/Recruitment
Achieve optimum performance levels
Use a flexible staffing model
Premium Pay
Staffing
Reduce agency usage
Work Days Lost Due to
Injury/Illness
Use appropriate patient lifting techniques
Match Capacity :Demand
Dark Green Dollars
Reducing Operating
Budget by 1% a year
Implement an acuity identification system
Flow
Redesign care management
Redesign ER processes
Hospital Throughput
Redesign OR processes
Ancillary Throughput
Standardize purchasing
Base utilization on best practices
Mass Purchasing
Supply Chain
Purchase wholesale instead of retail
Pharmaceuticals
Switch from brand-name to generic
Prescribe based on industry norm
Wasted Materials
Stop denial rework
Mismatched
Services
Waste in Admin Services
Stop services not adding value (ex.
unnecessary landscaping)
End-of-Life Care
Improve chronic disease management
Unnecessary Procedures/
Hospitalizations
Primary Drivers
Stop performing outpatient services as
inpatient services
Secondary Drivers
Develop and use core strategic metrics
Aim 2 Driver
Diagram
Align strategy
Align the
Enterprise
Align systems
Measure performance
Continually improve quality
while reducing operating
expenses 1%/yr
Deploy a
system that
delivers value
and is
continually
improved
Create/maintain stable and standard processes
Identify and eliminate waste
Develop and use front-line data
Integrate value and improvement into daily work
Engage everyone in value delivery
Show respect
for people
Develop people
Ensure a safe environment
Build teamwork
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6/13/2012
Our Strategy
Use Big Dots, Big Dot Visual Management and
Waste Tools to actively engage staff in the quality
and patient satisfaction experience
Three Strategies to Connect Staff to
Our Quality Efforts
1. Big Dots
•
Using Big Dots to sort and categorize our
patient quality and satisfaction efforts for our
staff.
1. Patient Satisfaction
•
Aim: Meet or exceed U.S. HCAHPS avg. every
quarter
2. Safe Care
•
Aim: Decrease Harm Events to Patients by 25%.
in 2012
3. Financial
•
Aim: Identify and implement efforts to remove 1%
of the operating cost from the 2012 budget.
2. Visualize the Quality Goals
•
•
Creating a “Line of Site” between our staff
efforts and our Big Dot goals
Active staff involvement in identifying the
problem and participating in the solution
•
Using the Waste Identification Tool
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6/13/2012
Big Dots
Categorize and Focus the Quality Effort for Staff
Our Three “Big Dots”
1. Patient Satisfaction
•
Aim: Meet or exceed U.S. HCAHPS avg. every quarter
2. Safe Care
•
Aim: Decrease Harm Events to Patients by 25% in 2012.
3. Financial
•
Aim: Identify and implement efforts to remove 1% of the operating
cost from the 2012 budget.
38
6/13/2012
Big Dot Successes
• Mortalities decreased 6 out of the last 7 years (Safe Care
Big Dot)
• Decreased Central Line Infections, SSI and VAPS
Care Big Dot)
(Safe
Last VAP July of 2009
• Decreased Catheter related urinary tract infections by
73% (Safe Care)
• Saved over $1.2M in supply costs
(Finance Big Dot)
Visual Management of the Big Dots
Create a Line of Site Between Our Staff Efforts
and Our Big Dot Goals
39
6/13/2012
BIG DOT: Care Experience
Patient Engagement
Staff and Physician
Communication
Rewards And
Recognition
Aim:
Driver
Meet or
Exceed
National
HCAHPS Avg.
Every Quarter
Service Recovery
Service
Excellence
Program
Rounding
Scripting
Collect Patient Perception
Prior to Discharge
Care Environment
Preventing Violence in
the Workplace
Big Dot: Safe Care
Prevent Hospital Associated
infections – VAPS, CLABSI,
CAUTI, C. Diff, VRE, MRSA
Surgical Site Infections
Driver
Pressure Ulcers
Aim:
Prevent
Hospital
Acquired
Conditions
Decrease Harm
Events to
Patients by
25% in 2012
Falls with Injuries
DVT/PE
Level 4 and 5 Medication Errors
Prevent Never Events
Driver
Improve Care
Transitions
& Communication
Medication
Reconciliation
Decrease
Readmissions
Flow Improvement
Privacy & Security of Health
Information
40
6/13/2012
Big Dot - Finance
Improve Worksite
Safety
Decrease incidents
and lost time
Yankee Alliance Supply
View and other projects
Finance
Aim- Identify &
implement programs
to remove 1% ($2M)
of operating
expenses in 2012
Antibiotic Stewardship
Supply Chain Projects
Decrease Blood
Utilization
Documentation Program
Improve Clinical
Documentation
Physician Education
Waste Tools
Meet Core Measure &
Regulatory Requirements
Projects based on waste
tool identification
Waste Tools
Staff Participation on the Grand Scale
41
6/13/2012
Generic Waste Tool Template
HOSPITAL WASTE IDENTIFICATION TOOL_Template
Campus__________ Department_________________________ Job Title of Person Completing: ________________________________
Instructions: Log the location, date and time and place a check mark in the appropriate column for the type of waste identified
Unit/ Area of
Hospital
Room Number
(if applicable)
WASTE TOPICS
Date/
Shift
Other Waste
Identified
Comments
# Waste Topics
Identified
(Optional)
Total Observations
(Optional)
% Waste
Environmental Services (Customized) Waste Tool
HOSPITAL WASTE IDENTIFICATION TOOL- EXAMPLE
Campus__Samaritan Department_Environmental Services
Job Title of Person Completing: Environmental Services Associate_
Instructions: Log the location, date and time and place a check mark in the appropriate column for the type of waste identified
Unit/ Area of
Hospital
Date/ Shift
Room Number
(if applicable)
509-A
12/13- D
210-A
12/14-D
601-B
12/14-D
403-B
12/6-D
Discharge
Log Books
not
Accurate
X
Flow
Delay
X
WASTE TOPICS (EXAMPLES)
Isolation Procedure
Nursing
Poor Infection
not accurate
Item not
Control
Removed
Practice
Observed
Other Waste
Identified
Comments
X
X
X
X
X
X
X
X
X
X
# Waste Topics
Identified
(Optional)
Total
Observations
(Optional)
% Waste
*** Red column headings may be modified or customized to capture waste issues that are not listed.
42
6/13/2012
What Works and How it Works:
Developing and Using the Optimal Waste Identification Tool
1.
2.
3.
4.
5.
6.
IHI Waste Tool templates were a good starting point but in
many cases departments were eager to develop their own
Waste Tool templates.
While there is a temptation to create elaborate Waste Tool
documents, simple, straightforward documents achieved
greater staff participation.
Optimal Waste Tools were those created in staff meetings
in collaboration with leadership.
Staff carry the Waste Identification Tools with them while at
work and document problems they identify
Staff review their complted forms with their supervisors/
managers
Senior team reviewed each department’s Waste Tool
Findings
How Implemented
• Education to Leadership and then to front
line staff by Directors and VP
• Used by Clinical and Non Clinical Depts. –
Med/Surg., Primary Care Sites, Behavior
Health, Physicians, pharmacy, courier,
registration, dietary, physical therapy
• Over 400 observations completed in a 2
month period
43
6/13/2012
Prioritizing Waste Tool Findings
EFORT
Great
Effort,
Modest
Impact
GREAT
EFFORT,
GREAT
IMPACT,
LOW
EFFORT,
MODEST
IMPACT
LOW
EFFORT,
GREAT
IMPACT
IMPACT
Prioritizing Waste Tool Findings
44
6/13/2012
Sample of Waste Tool Follow-up Activity
Staff Identified Waste
Work Plan
Status
Insulin discarded
Nursing/ pharmacy discussion lead to insulin
vial reconfiguration
Complete
Non-formulary scripts
discarded when not used
Ordering and dispensing process changed for
non-formulary items
Complete
No place for Catering
Associates to place trays
Food Service and Nursing Staff meeting to look
at solutions
In process
Unnecessary Courier Trips
Materials Handling and Lab workgroup formed
and active
Complete
Excessive Bed Rentals (Sam)
Joint activity between Patient Care and Finance
New beds
ordered
Unnecessary Physical Therapy
Evaluations
Education by Physical Therapist on appropriate
criteria for consults provided to hospitalists and
nursing staff. Part of multidisciplinary rounds
Complete
Financial Gains from Waste
Finance
Waste Tools
Projects based on
waste tool
identification
Bulk Medication Transfer
$117,000K
Finance
Waste Tools
Projects based on
waste tool
identification
Insulin Replacement
$34,000K
Finance
Waste Tools
Projects based on
waste tool
identification
Outpatient Prescriptions
Decrease Expenses by
$5K
Finance
Waste Tool
Project based on
waste tool
identification
Physical therapy consults
on patients not meeting
criteria
Decreased inappropriate
evaluations by 50%
45
6/13/2012
Follow Up Contacts
Scarlet Clement,
[email protected]
Norm Dascher,
[email protected]
Dan Silverman MD, [email protected]
Sue Vitolins,
[email protected]
Rob Smith,
[email protected]
Presbyterian Healthcare Services
Albuquerque, New Mexico, USA
46
6/13/2012
Cost & Quality in an Integrated System
• Enterprise: Delivery System, Healthplan, Medical Group
─ Integrated Care Solutions – charged with finding innovative ways
to save money while maintaining quality for patients and
Healthplan members. Example: Transport Center and ED
Navigation System
─ Lean Six Sigma Black Belts – Innovation and Design to improve
quality, and save money. Example: Pathway for Total Joints
• Delivery System: Hospitals, Clinics, Specialty Care
─ Lean Specialists
─ VAT Teams (Supply cost reduction)
─ Clinical Quality Management (Cost and Quality Team)
Cost & Quality in Service Lines
Multiple initiatives
all utilize the
same service line
resources
Quality Managers
are assigned to
the service line –
help on multiple
projects but focus
and drive the work
in Cost & Quality
projects to fill the
gaps and
continually
improve
Integrated
Care
Solutions
Black Belt
Projects
Clinical Quality:
Cost & Quality
Continual
Improvement
Lean
Projects
VAT Team
47
6/13/2012
Primary Drivers
Projects
Lead Quality
Improvement Team
Cost & Quality in Service Lines
Reduction of C-Section ALOS
Clinical Quality
Program Design
and Improvement
Adverse Events and
Complications
Reduction of <39 weeks induction
Post-op PN reduction
Reduction in DVT Rate in Surgical
Patients
Reduction / Prevention of Harm
Evidenced Based Care Design
Total Joint Pathways
OR Utilization
Clinical Quality –
Cost & Quality Teams
Lean Six-Sigma Black Belts
Dark Green Dollars
Reducing Service Line
Operating Budget by
1% a year
Flow
Supply Chain
Mismatched
Services
Hospital Throughput
Ancillary Throughput
Clinic Flow and efficiency
Mass Purchasing
Pharmaceuticals
Wasted Materials
Waste in Admin Services
Readmission Reduction
End-of-Life Care
Unnecessary Procedures/
Hospitalizations
Lean Six-Sigma Black Belts
and Lean Specialists
Service Line VAT Teams
Integrated Care Solutions
95
Cost & Quality in Service Lines
• Low hanging fruit has been picked
• Other quality areas are charged to save large sums – big
projects – big dollars
• Still much to be done
• Still many opportunities
• Every effort counts
• Every effort makes a difference, and added together the
effect can be huge
• Working closely with SL in smaller continual projects is
changing our quality culture
48
6/13/2012
Cost & Quality in Service Lines
• Year 1: Women’s SL
─ Opportunity to reduce ALOS and save costs
─ Used Waste Tool to identify areas for improvement
• Year 2: Women’s SL & Surgery SL
─ Evidenced Based Care: Pulled back to work on EBC to support
decision points and reduce ALOS
─ Looking for small gains along the way
─ Energy Grid to find best areas to work
─ Small projects making a big difference
• Future: sharing across SL
─ Expanding and becoming what we do & who we are
─ Methods integrated into everyday quality work in all service lines
Date Created
September 2011
Status
Presbyterian Surgical Service Line Energy Grid
This is a re-creation . We use this as a living document and it has changed. Lessons learned: Save the old versions as part of the quality journey picture
In
Progress
2
Capacity for IHI Cost &
Quality
GREEN – Can
accommodate a
project
YELLOW – Limited
RED – NO Capacity
SCIP
Improvem
entImprove
preop
antibiotic
document
ation
Total Joint Class Instructor
Low
modest
improve
ment
planning
phase
4
5
TCAB
projects
on GSU
Reduce
occurren
ce of VTE
in TJR
patients
Activity, but
no changes
6
Effective
PASS
screening
Low
7
Activity,
but no
changes
Hold
PMG Cedar Nursing
PMG Kaseman Providers
PMG Kaseman Nursing
High
High
Low
High
PACU
GSU
SSC
STC
SC
Significant
progress
Activity,
but no
changes
9
10
11
12
Total Joint
Replacement
patients to
Orthopedic
Nursing Unit
Joint Camp
combined
therapy
Improve
Total Joint
Replacem
ent
Discharge
Coordinati
on
MRSA
Screening
in PASS
Alternativ
e Care for
high risk
surgical
patients
Improve
informat
ion flow
for
Preop
High
High
high
High
Low
High
Low
Low
Low
High
Low
High
Low
Low
Low
Low
High
Low
Low
High
High
High
Low
planning
phase
8
High
High
High
High
High
PMG Cedar Providers
PASS staff
Preop Nursing
Anesthesia
OR staff
Surgeons
Activity,
but no
changes
High
High
High
Low
High
High
High
High
Activity,
but no
changes
planning
phase
planning
phase
Activity,
but no
changes
13
14
15
16
CABG
project
Type and
Screen
Improve
ment
Kaseman
OR
Redesign
Standard
ize order
sets in
PASS/Pr
eop
High
High
Low
High
Low
High
High
High
Low
Med
Med
Low
High
Med
High
Low
Low
Low
Med
Med
High
High
High
High
Low
High
Med
High
High
Low
Med
Med
Rehab
Medical Director
High
Low
Director of Surgical Services
High
Nursing Dept Director
Pharmacy
Quality Clinical Manager
OR Manager
Preop/PACU/PASS Manager
OR Clinical/Quality Specialist
Nursing Unit Clinical
Specialist
Med
Low
Low
Low
98
High
Low
High
Low
Low
Low
Low
High
High
High
Med
High
High
Low
Low
Low
Low
Low
High
High
Low
High
High
High
Low
High
High
High
High
SSC/SC/STC Nurse Manager
GSU Nurse Manager
High
High
High
High
49
6/13/2012
Project Progress
•
•
•
•
•
1 – charter established
2 – activity, but no changes
3 – Modest Improvement
Project
Name /
Month
Pneumonia
Prevention
1 2 3 4 5
6
2 3
4 4 5
5
SCIPImprovement
projects
1
2 2 2
3
Total Joint
Replacement
VTE
Prevention
1
2 2 3
4
Surgical
Selection for
high risk
mortality
7
8
4 – Significant Progress
5 – Outstanding Success
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
1
Portfolio Management
• Aim of Portfolio:
Percentage of
Operating Budget
Savings in US Dollars
1% for entire SSL portfolio
1 million for entire SSL portfolio
$200,000 for SSL C&Q projects
• Current Portfolio Projects:
Project Name
Projected
Savings
Savings to
Date
Postoperative
Pneumonia
Prevention
$134,448
$ 20,688
Total Joint Replacement
Venous
Thromboembolism
(VTE) Prevention
$ 13,159
SCIP Improvement
$ TBD-VBP
$
Surgical selection for
high risk mortality
$ TBD
$
Totals
$147,607
$24,798
Quality Metrics
$3448 / case
Adult non ventilated surgical patients who
developed post-op pneumonia / Total non
ventilated adult surgical patients
$4,110
$822 / case
Adult total joint replacement patients who
developed a VTE in the encounter / Total
number of total joint patients in the same
time period
50
6/13/2012
2011 Cost Savings
Value Analysis Team
$10 Million
Process Excellence –
Black Belts & Lean
Projects
$8.6 Million
Quality & Cost
Improvement 2012
projected $200,000
Financial Model
• Internal costing system is our standard tool used
in our organization.
• Using our Internal Costing System we compared
average length of stay and variable cost for
patients who developed pneumonia or VTE to
patients who did not develop based on similar
DRGs.
• All data does not reside in one database,
therefore we run the risk of not identifying all
patients.
51
6/13/2012
Lessons Learned
• Every effort counts & over time will help change
organizational culture.
• Continual cost & quality improvement efforts will
change how you work, the quality of care for
your patients, and save money.
• Finance and clinical partnership creates synergy
for maximum benefit to organization and
patients
Contact Information
• Susan Quintana, RN, MSN
Manager, Quality Program Support
[email protected]
(505) 724-7796
• Surgery : Brenda Gonzales, RN
[email protected]
• Financial Support: Kay Armstrong
[email protected]
52
6/13/2012
Summary
Date Created
September 2011
Status
In
Progress
modest
improve
ment
planning
phase
Activity,
but no
changes
A ctivity, but
no changes
A ctivity,
but no
changes
Hold
Significant
progress
planning
phase
Activity,
but no
changes
Activity,
but no
changes
planning
phase
planning
phase
Activity,
but no
changes
Capacity for IHI Cost &
Quality
GREEN – Can
accommodate a
project
YELLOW – Limited
RED – NO Capacity
2
4
5
6
7
8
9
10
11
12
13
14
15
16
SCIP
Improvem
entImprove
preop
antibiotic
document
ation
TCAB
projects
on GSU
Reduce
occurren
ce of VTE
in TJR
patients
Effective
PASS
screening
Total Joint
Replacement
patients to
Orthopedic
Nursing Unit
Joint Camp
combined
therapy
Improve
Total Joint
Replacem
ent
Discharge
Coordinati
on
MRSA
Screening
in PASS
Alternativ
e Care for
high risk
surgical
patients
Improve
informat
ion flow
for
Preop
CABG
project
Type and
Screen
Improve
ment
Kaseman
OR
Redesign
Standard
ize order
sets in
PASS/Pr
eop
Total Joint Class Instructor
Low
Low
High
High
high
Low
High
Low
High
Low
Low
Low
High
Low
High
Low
Low
Low
Low
High
High
Low
High
High
High
High
High
High
PMG Cedar Providers
PMG Cedar Nursing
PMG Kaseman Providers
PMG Kaseman Nursing
PASS staff
Preop Nursing
Anesthesia
OR staff
Surgeons
PACU
High
Low
High
High
High
Low
High
High
High
Low
High
High
High
Low
Low
Low
High
High
High
High
High
Low
High
Med
High
High
High
Low
High
Low
High
High
High
Low
Med
Med
Low
High
GSU
Low
SSC
STC
High
SC
Med
Med
Rehab
High
Medical Director
Low
Director of Surgical Services
High
Nursing Dept Director
Pharmacy
Quality Clinical Manager
OR Manager
Preop/PACU/PASS Manager
OR Clinical/Quality Specialist
Nursing Unit Clinical
Specialist
Med
Low
Low
Low
High
High
High
Med
High
High
Low
Low
Low
Low
Low
High
High
Low
High
High
High
Low
High
High
High
Med
High
Low
Low
Low
Med
Med
Act
Plan
Study
Do
High
High
SSC/SC/STC Nurse Manager
GSU Nurse Manager
High
Low
High
Low
High
High
High
Questions?
Raise your hand
Use the Chat
53
6/13/2012
Resources
•
•
•
•
•
•
•
Berwick, D, Hackbarth, A. Eliminating waste in US health care.” JAMA. 2012
307(14).
Bisognano, M. Engaging the CFO in quality: Why it’s a must and how to make
it happen Healthcare Executive. 2009 Sept/Oct.
Gawande, A. (June 1, 2009). “The Cost Conundrum: What a Texas town can
teach us about health care.” The New Yorker.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Gwande, A. (January 24, 2011). “The Hot Spotters: Can we lower medical
costs by giving the neediest patients better care?.” The New Yorker.
James, BC and Savitz, LA. How Intermountain trimmed health care costs
through robust quality improvement efforts. Health Affairs, web exclusive, May,
2011.
Kaplan, R, Porter, M. How to solve the cost crisis in health care. Harvard
Business Review. 2009.
Luther K, Savitz LA. Leaders challenged to reduce cost, deliver more.
Healthcare Executive. 2012 Jan/Feb;27(1):78-81.
Homework for Next Call
1. Agree on an approach (either by service line, across your
organization or within a specific department)
2. Identity an aim (dollar aim; cost/case or cost/discharge)
3. Clarify your team and the roles of each member
Send ‘Tweet’
of 140 characters or less to Jill at
[email protected] by Friday, June 22nd
54
6/13/2012
Partnering Quality and Finance Teams to Improve Value
Expedition Worksheet
Align senior support
Decide where you want to start
Begin to build a partnership with leaders from the finance team
What is your aim? (% operating expenses? Cost/case? Cost/discharge?)
Engage frontline staff
Begin to identify projects that will get you to your aim
Begin building a portfolio
Consider projects you are already working on as potential for your portfolio
Don’t know where to start? Consider adapting and testing the Waste
Identification Tool
Build and leverage
partnerships
Collaborate with your financial colleagues to review your suggested portfolio
and identify what might get at dark green dollars.
Develop financial
models
Define how you will measure the potential and actual savings for each
project
Monitor quality to
assure improvement
Identify best practices, financial models, aims & charters for each area of
work
Develop a series of projects around the ones identified by your team (your
portfolio)
Develop a sequencing plan for the work
Test improvement interventions as well as financial measurement strategies
Implement systems to encourage rhythm and discipline around the work
Track progress
Learn & spread across a
community
Spread learning and best practices
Re-engage & re-commit on a regular schedule
Partnering Quality and Finance Teams to Improve Value
Expedition Worksheet
Align senior support
Decide where you want to start
Begin to build a partnership with leaders from the finance team
What is your aim? (% operating expenses? Cost/case? Cost/discharge?)
Engage frontline staff
Begin to identify projects that will get you to your aim
Begin building a portfolio
Consider projects you are already working on as potential for your portfolio
Don’t know where to start? Consider adapting and testing the Waste
Identification Tool
Build and leverage
partnerships
Collaborate with your financial colleagues to review your suggested portfolio
and identify what might get at dark green dollars.
Develop financial
models
Define how you will measure the potential and actual savings for each
project
Monitor quality to
assure improvement
Identify best practices, financial models, aims & charters for each area of
work
Develop a series of projects around the ones identified by your team (your
portfolio)
Develop a sequencing plan for the work
Test improvement interventions as well as financial measurement strategies
Implement systems to encourage rhythm and discipline around the work
Track progress
Learn & spread across a
community
Spread learning and best practices
Re-engage & re-commit on a regular schedule
55
6/13/2012
Expedition Listserv
We have set up a listserv for participants in this
Expedition to share improvement strategies, and
pose questions to one another and faculty.
To use the listserv, address an email to
[email protected]
If you would like additional people to receive session
notifications please send their email addresses to
[email protected].
Schedule of Calls
• Session 1 – Tuesday, June 12th 1:30 – 3:00 EDT
─ Align senior support & build and leverage partnerships
• Session 2 – Tuesday, June 26th 2:00 – 3:00 EDT
─ Engage frontline staff & prioritize portfolios
• Session 3 – Tuesday, July 10th 2:00 – 3:00 EDT
─ Develop financial models
• Session 4 – Tuesday, July 24th 2:00 – 3:00 EDT
─ Monitor quality to assure improvement
• Session 5 – Tuesday, August 7th 2:00 – 3:00 EDT
─ Learn & spread across a community
56
6/13/2012
Thank You
57