External retrospective Validation of BIG criteria. An example of PDSA for Neurotrauma patients.

Transcription

1 External retrospective Validation of BIG criteria. An example of PDSA for Neurotrauma patients. Ahmed M. Raslan, MD Assistant Professor in Neurological Surgery Neuroscience quality medical director Oregon Health and Science University Attending Neurosurgeon Portland Veterans Affairs Medical Center

2 Consultancy St. Jude Medical P.I. InVivo Pfizer Integra St. Jude Grants St. Jude Medical Medtronic Boston Scientific Cyberonics Disclosures

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7 The Health Care Problem is a Global Issue Health Care Spending vs GDP and Wage HC Spend HC Spend HC Spend GDP Income GDP Income GDP Income HC Spend HC Spend GDP Income HC Spend GDP Income GDP Income Notes: Indexes based on local currencies; Income = Personal Disposable Income; HC expenditures as % of GDP are OECD estimates Source: Economist Intelligence Unit May 2014, BCG analysis

8 Principles of Value-Based HealthCare Delivery Value = Health outcomes that matter to patients Costs of delivering the outcomes Value must be measured for the overall care of a patient s medical condition over the cycle of care - not for hospitals, specialties, episodes, or interventions. Outcomes are the full set of health results that matter for the patient s condition Costs are the total costs of care for the patient s condition over the care cycle The most powerful single lever for reducing cost is improving outcomes

9 QI and Medicine Triple Aim Value is the key to improved quality and reduced cost Examples Virginia Mason Cinncinati Children Neurological Surgery

10 Lean and process excellence Waste Definition Healthcare Examples Transportati on Unnecessary movement of materials or supplies Moving samples/specimens, equipment, supplies Inventory Motion Waiting Overprocess ing Overproduc tion Supplies, equipment, or information not needed by the customer now Unnecessary movement of people Delays in the value stream (absence of flow) Work that creates no value Producing more than customer needs right now Medications, linens, equipment, parts, supplies, instruments, documents Moving patients, moving staff, searching for X, getting equipment/supplies Admission delays, bed assignment delays, testing/treatment delays, discharge delays Duplication of work, rework, complexity Treatment or testing done to optimize staff or equipment productivity, not patient needs Defects / Poor Quality Neurological Surgery Product or service that does not conform to customer requirements Medication error, wrong procedure, incorrect X, missing Y, incomplete Z

11 Just-In-Time Patient Systems Flow of patients ED ICU Acute Care Discharge Supply of services or care can be thought of as a chain.

12 Just-In-Time Patient Systems Push If we push the end of the chain it quickly starts to pile up in the middle! Where push exists in our operations, this piling up happens in the form of waiting patients, orders, etc.

13 Operational Effectiveness is not a strategy

14 Content excellence and examples Neurological Surgery

15 Disadvantages of Lean Burn out Efficient in producing mediocre quality Waste might be necessary and even benefecial Neurological Surgery

16 Helpful Lean processes PDSA Value stream A3 Kaizen events Neurological Surgery

17 Neurological Surgery PDSA

18 Cost vs charge Cost vs Charge Cost vs Price Cost vs Out of pocket Cost vs Employer contribution Costing methods Neurological Surgery

19 Measuring Costs:. # 1: Confusion of Costs with Prices (Charges) o Currently, provider expenses are allocated to patient care based on charges or relative value units neither of which is a good surrogate for the actual costs incurred o Costs are not assigned to unbilled or unreimbursed processes and procedures # 2: Wrong Unit of Analysis for Measuring Costs o Currently, costs are measured for organizational units, clinicians, or individual procedures and events, not for the full cycle of care to treat a patient s medical condition. # 3: Economists, administrators, and policy makers believe many health care costs are fixed o We wish! If health care costs were fixed, we wouldn t have a health care cost crisis. Courtesy of Robert Kaplan, PhD and Harvard Business School

20 Patient-level costs should be measured over a complete cycle of care for a clinical condition, along with the associated outcome measures. Patient problem Assess appropriateness Assess risk Schedule OR Procedure Recovery MD encounter Possible need for procedure Shared decision making Preprocedure testing Tier 1,2 outcome measures Tier 3 outcome measures Source: Tim Ferris, MD, personal communication Courtesy of Robert Kaplan, PhD and Harvard Business School

21 Measuring Patient s Cost over a Complete Cycle of Care for a Clinical Condition Initial consultation Minutes Cost/ minute *Total MD X 1 Y RN X 2 Y CA X 3 Y ASR X 4 Y $ Surgical procedure MD X 1 Y Anes. X 2 Y RN X 3 Y Tech X 4 Y OR X 5 Y $ Follow-up or post-operative visit MD X 1 Y RN X 2 Y CA X 3 Y ASR X 4 Y $73.66 Courtesy of Robert Kaplan, PhD and Harvard Business School

22 Project

23 OHSU PDSA: mild TBI patients Plan study current state, internal validation of BIG criteria Do designing/roll out of new protocol for mild TBI patients Study prospective validation of new protocol, cost analysis Act amend protocol according to findings

24 OHSU PDSA: mild TBI patients Current state: all OHSU patients who sustain TBI are subjected to Repeat CT 6hr interval 24hr ICU-level observation Medical and/or surgical mgmt PRN Background: no consensus exists for appropriate management of mild TBI No consistent definition of mild Injury severity risk of progression

25 OHSU PDSA: mild TBI patients Pro: conservative approach ensures that any injury progression is captured Con: too many mild TBI patients receiving high level care Human/hospital resources Radiation exposure Excessive costs for nominal injury Overtreatment Complications Neurological Surgery

26 OHSU PDSA: mild TBI patients Initiative: reduction of clinically low-impact repeat CT heads and ICU admissions in patients with mild TBI Need: an accurate identification of lowrisk, low-severity injury patient population Neurological Surgery

27 OHSU PDSA (P) Brain Injury Guidelines (BIG) Joseph, et al (2014): Created and validated guidelines for identification and classification of risk of progression in neurotrauma patients (n=1232/retrospective, n=254/prospective) OHSU: Retrospective chart review of 2 years consecutive adult neurotrauma patients (n=590)

28 OHSU PDSA (P): BIG validation Neurological Surgery

29 OHSU PDSA (P): BIG validation OHSU Modified BIG Criteria Variable BIG 1 BIG 2 BIG 3 GCS <14 Skull fracture Non-displaced Non-displaced Displaced CAMP No No Yes SDH 4mm 5-7mm 8mm EDH 4mm 5-7mm 8mm IPH 4mm, 1 location 5-7mm, 2 locations 8mm, multiple locations tsah Trace Local Scattered IVH No No Yes Neurological Surgery

30 OHSU PDSA (P): BIG validation BIG1 = 121 (9.8%) BIG2 = 313 (25.4%) BIG3 = 798 (64.7%) CT progression Neurologic decline Procedural intervention BIG1 (n=88) BIG2 (n=116) nil 17 (14.7%) BIG3 (n=386) 145 (37.6%) mbig1 (n=109) 4 (3.7%) nil nil ---- nil nil nil 61 (15.8%) nil BIG1 = 88 (14.9%) BIG2 = 116 (19.7%) BIG3 = 386 (65.4%)

31 OHSU PDSA (P): BIG validation BIG 1&2 populations = ~35% of TBI patients Demonstrates consistent, predictable subset of patients at low-risk for clinically significant progression of injury Neurological Surgery

32 OHSU PDSA (D): Practice Change Ideal state of change: BIG 1 BIG 2 BIG 3 but CULTURE BEATS STRATEGY

33 OHSU PDSA (D): Practice change New neurotrauma protocol created: BIG 1 patients defer ICU admission 23hr obs BIG 1-2 patients do not receive routine rcth BIG 3 patients continue with interval rcth + ICU admission

34 OHSU PDSA (D): Interdisciplinary education Required education/cooperation of multiple disciplines: ED (MD/nursing) Trauma service (MD/nursing) Radiology (for consistent reads) Neurological Surgery

35 OHSU PDSA (S): Cost analysis Over 590 patients, cost savings of at least $165K of direct cost to hospital solely from room/board & rct does not include savings from critical care time/radiologist interpretations, etc This will lead to marked spending and charge cost (CT 72 $ cost, 800 $ charge) Neurological Surgery

36 OHSU PDSA (S): Prospective validation IRB-approved prospective validation for 1-2 years

37 OHSU PDSA (A): Modifying protocol Incremental changes to BIG 1 & 2 management to reflect initial study Potential state-wide application to reduce interhospital transfers Neurological Surgery

38 Lessons learned so far Interdisciplinary Inter rater variability Education Scholarly benefit

39 Side effects of better healthcare Reduction of revenue Reduce utilization of an expensive space Over utilization of other spaces Waiting in ED

40 Culture strategy Culture eats strategy for breakfast Everyone has a plan until they get punched in the mouth (Mike Tyson) You can not standardize to mediocrity, you have to standardize to excellence (Jeffrey Raskin, MD)

41 Management System Methods Mindset

42 Improving value through content excellence

43 OHSU Neurological Surgery Thank You