Andrew Shin MD Claudia Algaze MD

Transcription

1 Andrew Shin MD Claudia Algaze MD

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3 Cost Volume-Driven Healthcare Value-Driven Healthcare Quality

4 Massive variation in clinical practice High rates of inappropriate care Unacceptable rates of preventable care-associated patient injury and death Striking inability to do what we know works Significant amounts of waste, leading to rising prices that limit access to care

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6 A program grounded in learning the most effective and sustainable models to reduce unnecessary variation while maintaining & improving excellent outcomes for patients Focused on achieving value in our current health care system for the patient & family and the organization through a data driven and data transparent approach Supplements existing organizational process improvement and quality improvement for MDs

7 Performance Improvement (PQMS) Quality Improvement (QSS Board of Directors) Clinical Effectiveness (Governance) Determines priority schema for CE direction Determines amount and allocation of resources Analyzes Impact of CE on program s bottom line Clinical Effectiveness (CORE) Planning, development and implementation of CE Measure outcomes, process and balancing metrics with iterative modifications and critical feedback to frontline staff Utilization of FTE fractions (Physician leads and Analyst) Local Improvement Teams (LITs): Monitor, Audit CE work Critical feedback to Oversight Committee Microsystem Level Tailoring/Designing of CE LIT LIT LIT LIT LIT LIT

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9 Identify Program Type Identify Problem Identify Goals Clinical Effectiveness Program High hospital census High variability in care Suboptimal value (high cost without high quality) Reduce LOS of elective surgical cases Focus on Heart Center (pilot division: cultural readiness)

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11 CHD account for approximately $6 billion in hospital costs annually Compared with other birth defects, CHD are associated with * Highest hospital costs and charges * Longest hospital stays * Highest mortality rates Benavidez Pasquali Go AS et SK al. OJ et Circulation. et al. al. Congenit Cardiovasc 2013;127(1):e6 e245., Heart Qual Dis. 2007;2(5): Outcomes. 2011;4(3): Ungerleider Connor Anon. MMWR JA et RM al. Morb et Pediatrics. al. Mortal Ann. Thorac. Wkly 2005;116(3): Rep. Surg. 2007;56(2): ;64(1):44 48 Ungerleider RM et al. Ann. Surg. 1997;225(6): ; discussion

12 One pathway Identify clinical champions, Coordinate stakeholder teams Analysis of the problem Fishbone analysis Determine drivers Review of evidence, guidelines Determine benchmark Develop pathway Planning Tailor to local environment, Communication, coordination, Training Implementation Review and audit Feedback Implementation Significant time commitments Limited resources Cultural challenges Disagreement Poor fit Unknown benefit Aggregate Experience

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16 Patient Encounter Outcome Next Patient Encounter Data Generated Variable Penetrance

17 Patient Encounter Outcome Shared Mental Model Aggregate Patient Data Next Patient Encounter

18 Candidate Operation Historical Cohorts Developed from EHR

19 LOS (days) Statistical Process Control Chart Postoperative LOS For X Surgery UCL CL 3.6 LCL

20 Candidate Operation Historical Cohorts Developed from EHR Benchmark Targets Displayed at Point of Care

21 Candidate Operation Historical Cohorts From Aggregate Patient Data Ventilator Days Set Goal Extubation Time Target Based Care Intensive Care Days Hospital Duration Set Goal Transfer Date Set Goal Discharge Date Frontline Providers

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24 Length of Stay (days) 11/30/12 1/31/13 2/4/13 4/4/13 4/30/13 5/21/13 6/18/13 7/3/13 7/23/13 7/26/13 8/23/13 10/28/13 11/26/13 12/12/13 12/20/13 1/17/14 2/9/14 3/16/14 3/21/14 11/3/14 11/21/14 1/6/15 1/12/15 2/9/15 4/6/15 8/14/15 9/15/15 9/24/15 4/20/16 4/28/16 10/27/16 1/27/17 1/31/17 3/6/ Characteristics Tetralogy of Fallot -Valve Sparing repair Pre-Intervention N = 19 Post-Intervention N = 15 p-value Time to Extubation (days), mean (SD) 1.42 (1.02) 0.13 (0.35) <0.01 Postoperative ICU LOS (days), mean (SD) 3.58 (1.46) 2.00 (0.93) <0.01 Total postoperative LOS (days), mean (SD) 7.37 (2.00) 5.33 (1.11) <0.01 UCL 14.3 CL 7.4 LCL 0.4 Intervention Individual Patients by Surgical Date

25 Length of Stay (days) Characteristics Tetralogy of Fallot - transannular patch Pre-Intervention N = 6 Post-Intervention N = 9 p-value Time to Extubation (days), mean (SD) 1.50 (0.55) 0.11 (0.33) <0.01 Postoperative ICU LOS (days), mean (SD) 4.50 (1.87) 2.33 (0.50) <0.01 Total postoperative LOS (days), mean (SD) 7.00 (1.26) 5.89 (1.45) UCL 10.2 CL 7.0 LCL 3.8 Intervention Individual Patients by Surgical Date

26 Length of Stay (days) Characteristics Ventricular Septal Defect repair Pre-Intervention N = 54 Post-Intervention N = 21 p-value Time to Extubation (days), mean (SD) 0.85 (1.37) 0.14 (0.48) 0.02 Postoperative ICU LOS (days), mean (SD) 2.67 (1.63) 1.67 (1.51) <0.01 Total postoperative LOS (days), mean (SD) 6.2 (1.50) 4.62 (1.50) Intervention UCL CL 6.2 LCL Invidivual Patients by Surgical Date

27 Operation Eligible Enrolled Completed Target LOS (median) Observed LOS (median) Hospital Day opportunity Atrial Septal Defect repair Coarctation Repair, age < 30 days 9 Annualized Hospital day opportunities Coarctation Repair, age > 30 days 2 34% 2 Reduction 2 in 7 Hospital 5.5Length 1.5 of Stay 31.5 Ventricular Septal Defect repair Arterial Switch Operation 14 Tetralogy of Fallot - Valve Sparing Hospital Days Created: 291 days Tetralogy of Fallot - Transannular Patch Common atrioventricular canal repair 7 Norwood Estimated Cost Savings: Cavopulmonary Anastomosis ~$2.5 million annualized cost savings Fontan operation Truncus Arteriosus repair 15 Annualized Hospital Days Created: 77.5

28 Coarctation of Aorta VSD TOF AVC ASO GLENN FONTAN TRUNCUS NORWOOD Length of Stay STS (High Volume Centers) Pre-Intervention Post-Intervention

29 Clinical Effectiveness Family Satisfaction % of Families Who Gave Highest Rating 0% 20% 40% 60% 80% 100% Measure A Measure B Measure C Measure D Measure E Distribution of Responses Very Poor (1) Poor (2) Fair (3) Good (4) Very Good (5) Measure A: How well was your child's pain controlled? Measure B: To which degree did doctors keep you informed using language you could understand? Measure C: To which degree did you feel ready to have your child discharged? Measure D: What is your overall rating of care given at this hospital? Measure E: What is the likelihood of you recommending this hospital to others?

30 Reintubation Rates Readmission to CVICU 30 Day Readmission

31 Leveraging EHR Data at the Point of Care to Provide Target Hospital Goals was associated with Improved Outcomes Preserved (Improved) Family Satisfaction Improved Institutional Costs

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37 LOS (days) Reverse Engineering a Pathway Postoperative LOS For Patients Undergoing Repair for Tetralogy of Fallot UCL 7.6 CL 3.5 LCL

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40 Turning EHR Data into Information and Knowledge Aggregate Experience Informed Practice EHR Workflow Tools to Decrease Variation and Improve Outcomes Evidence Based Medicine Practice Based Evidence

41 Use of [EHR] data, beyond their original purpose of supporting the healthcare of individual patients, can speed the progression of knowledge

42 You acted unwisely! I cried as you see by the outcome. He calmly eyed me: When choosing the course of action, said he, I had not the outcome to guide me -Ambrose Peirce (The Lacking Factor) The physicians and nurses caring for my son was guided by the outcomes of the many patients before him. We are grateful. -Parent