Collaboration Is Key To Increasing Surgical Value. David Skarda, MD Jeannette Prochazka, MSN Katie Liljestrand, RN, MBA Wendy Gort, MBA

Transcription

1 Collaboration Is Key To Increasing Surgical Value David Skarda, MD Jeannette Prochazka, MSN Katie Liljestrand, RN, MBA Wendy Gort, MBA

2 Disclosure Intermountain has partnered with Empiric Health to commercialize ProComp

3 Objectives Identify key components of a successful multi-disciplinary team Discuss how data cohorts are created and maintained to make meaningful and comparable data to reduce variation in practice Give examples of how collaboration with teams has reduced cost and improved surgical outcomes

4 Healthcare in Fitting a square peg in a round hole

5 Financial Distress

6

7 A Highly-Integrated Health System Hospitals Since hospitals 2,784 licensed beds SelectHealth Since 1983 Health plans 700,000+ members Medical Group Since ,200 employed physicians 558 advanced practice clinicians Clinical Programs Since key service lines

8 Clinical Management Infrastructure CLINICAL PROGRAM INFRASTRUCTURE Collaboration BEGINS here Information Management Infrastructure Measurement System Implementation Support System-wide physician, and clinical administrative operations leaders needed to implement best practice Development teams identified and established Staff support personnel and systems necessary to measure clinical, financial and satisfaction outcomes for key clinical processes Staff and systems necessary to develop, disseminate, support and maintain the clinical knowledge base necessary to implement best practice INFORMATION TECHNOLOGY

9 Clinical Programs and Services Working Together Neurosciences Pediatrics Intensive Medicine Surgical Services Women & Newborns Cardiovascular Musculoskeletal Primary Care Oncology Behavioral Health Supply Chain Nursing Imaging Respiratory Pharmacy Rehab Nutrition Laboratory

10 Development Team Structure Elements of a strong physician leader Who to pick & who to avoid What motivates this leader? Good data makes all of the difference!

11 Development Team Structure Physician Lead(s) Physician Representatives Administration Supply Chain Pharmacy OR Directors Clinical Program Directors Data Analysts Project Manager ProComp Nurse SelectHealth Compliance/ Quality

12 Development Teams: Key to Physician Engagement Anesthesia Bariatric Surgery Blood Management Endoscopy General Surgery Geriatric Hip Fracture Gyn Surgery ENT Plastics Robotics Spine Total Joints Urology Vascular/CV Multiple Clinical Program Collaboration

13 Houston.We have a problem.. Intermountain We have a goal Variation in clinical practice and supply utilization Incomparable cost and outcome data Lack of transparency in cost and outcomes data Working in silos Disengaged physicians and clinicians

14 ProComp: a technology & services platform to encourage evidence-based clinical practice COMPARE procedures & workflows Identify procedural variation and waste ENGAGE clinicians with personalized insight Reach consensus on best practice REDUCE unnecessary clinical variation & cost Create a culture of evidence-based clinical practice

15 Surgeons ProComp is the center of the solution Central Processing ProComp Supply Chain Organization Operating Room Staff Surgical Services Clinical Program Development Teams

16 History of Intermountain ProComp development Intermountain launches ProComp to reduce variation in surgical services Empiric Health formed. Empiric launched at HIMSS Intermountain cohort and savings metrics specialties 6 cohorts 15 specialties 8 cohorts 40 exhorts 10 specialties 12 cohorts 127 exhorts 39 specialties 13 cohorts 236 exhorts 128 savings $15M savings $58M savings $80M savings $92M

17 COMPARE procedures & workflows Delivering comparable and meaningful data Identify procedural variation and waste

18

19 Creating Refined, Comparable, and Transparent Data

20 I would rather look at a lower volume of cases knowing those cases were all alike versus looking at all of the encounters knowing that some of those cases didn t really fit in. ~Dr. Jay Bishoff, Urology

21 Intermountain cohorts present truly comparable encounters Traditional Procedural Data Intermountain Cohorts Co-developed with physicians Procedures with the same primary procedure code often have additional secondary procedures Cohorts define comparable procedures exactly the way physicians want to look at them Currently 251 Cohorts, 131 Exhorts All definitions available for review with physicians Ability to create new or refine existing definitions

22 Lifecycle of a Cohort

23 Cohort Types Standard Cohorts Primary Procedure (ICD or CPT) List of secondary May Have or May Not Have procedures May also use age, supplies, trauma levels, MSDRGs, etc. 72 distinct rules Currently 169 Standard Cohorts Examples: Lap Cholecystectomy Inpatient (>=15yrs) Total Hip Arthroplasty Total Knee Arthroplasty Tonsillectomy and Adenoidectomy

24 Cohort Extractor - When a basic cohort just isn t enough Key terms are tagged in records and encounters can be included or excluded appropriately. Examples include: prostatectomy, hysterectomy, bariatric, robotic, and spine procedures.

25 Cohort Types Cohort Extractor (Tagged) Cohorts Each case reviewed and tagged by an Outcomes nurse Primary procedure (posterior lumbar fusion) Approach (laparoscopic, robotic) Qualifiers (anterior, posterior, revision) Additional Details (complications, surgical technique) 14 distinct rules Currently 82 Tagged Cohorts Examples: Prostatectomy, Robotic Simple (CE) Levels Total Laparoscopic Hysterectomy Total Laparoscopic Hysterectomy with Lymphadenectomy

26 Cohort Types Exhorts Most cohorts contains a partner exhort Same primary definition as cohort, but falls into exhort due to additional procedures (ex. appendectomy and cholecystectomy in same case) Eliminates known variation Able to account for all cases for a primary procedure for analysis on volumes, SSI, etc. Currently 131 Exhorts

27 Cohort Types Procedure Groups When there isn t a cohort defined for a primary procedure, the case falls into a procedure group Able to account for all surgical services cases for analysis on savings, OR utilization, etc. Also used to determine potential defined cohorts Examples: Blepharoplasty, lower eyelid Rhytidectomy 00500ZZ Destruction of Brain, Open Approach 00590ZZ Destruction of Thalamus, Open Approach

28 ENGAGE clinicians with personalized insight Collaborating across the system to engage caregivers Reach consensus on best practice

29

30 Engaging clinicians through Development Teams What matters to you and your patients. Identify best practice based on evidence Standardize best practice throughout Intermountain Look for variation in cost and outcomes Align with Intermountain goals

31 Spine Development Team Low attendance by surgeons Problems Data that was not meaningful Cost reduction goal (without outcome data) Engaging physician lead Solution Creation of clinically relevant data

32 Billing data (ICD and CPT) combines multiple fusion levels. This data is not comparable.

33 Spine Development Team Improvements Dashboard Component Examples Created dynamic dashboard (unblinded data) Solution Encouraged input on meaningful data metrics Increase in attendance by surgeons Outcome Discussion of cost reduction- Reduction of implant suppliers led to $4.2 million savings Participation in national registry for outcome data

34 Spine Development Team Cohort Extractor (Tagged) Cohorts Facilities Surgeons

35 Spine Development Team Cohort Extractor (Tagged) Facilities Surgeons

36 Consistent practice through standardized order sets General Surgery Development Team: Evidence-based practice Physician decisions Pharmacy and ID expertise Operationalizingstandardized order sets Dashboard development and tracking orders

37 General Surgery Development Team Standard Cohorts (Lap Appendectomy and Lap Cholecystectomy) Facilities Surgeons

38 General Surgery Development Team Standard Cohorts (Lap Appendectomy and Lap Cholecystectomy) Facilities Surgeons Some cohorts further defined during reporting by searching for key terms on operative report ex. ruptured (perforated, ruptured, gangrenous)

39 Anesthesia Development Team Quality Measure Variation Reduction PSI-11 Post operative Respiratory Failure Anesthesia Development Team- Identify root cause PSI-11 Failure Rate (per 1000 discharges) Collaboration with Clinical Documentation Specialists, Respiratory Services 3.30% 2.60% Education to: Intensivists, Surgeons, Resident Physicians 1.40% Quarter 1 Quarter 2 Quarter 3 Continued ADT review of PSI 11 Failures Identification of high risk patients (OSA, multimodal pain management)

40 Engaging with the Individual Physician One physician was using a product 234% > any other physician. Product = $170/case Opportunity Identified ProComp Nurse presented data on cost/case variation and related outcomes. Physician decreased utilization over a few months and now rarely uses the product. Savings in one year = $36,000 Decreased Utilization

41 REDUCE unnecessary clinical variation & cost Identification of variation and operationalization of best practice Create a culture of evidence-based clinical practice

42

43 T & A surgery within Intermountain High volume, high variability in cost and complications o 4,007 T & A surgeries (Cohort), 751 T & A surgeries (Exhort) o Hospital Mean Cost per Case- $1000-$2400

44 Meaningful Data Influences Physicians Behavior Personalized data sent to ENT surgeons quarterly Parent-reported study shows more expensive cautery does not improve outcomes.

45 T&A Cohort- over 4 year period Results: Change in behavior and reduction of cost per case T&A Cohort- Over 3 year period

46 One Appendectomy

47 Appendicitis is Common Most common surgical emergency in children Surgical technique is variable Outcomes are consistently good Cost to treat per child with non-ruptured appendicitis in US o $5,000 to $10,000 Cost to treat per child with ruptured appendicitis in US o $10,000 to $30,000 Ideal target to improve value

48 Less Expensive Alternatives Exist Port Items available but not used were over 81% less than what was being used Loops instead of staplers Loops are over 86% less than Staplers Endocatch bag Use the bag $ No use $0 Disposable fascia closure device Use the device $ No use $0 Heat source Harmonic scalpel $ Ligasure $ Hook cautery $0

49 All Patients with Appendicitis Appendectomy Device Cost Skin to Skin OR Time (min) Historical Controls N=346 Mean (95% CI) $ ( ) 34.8 ( ) Standardized Procedure N=362 P Value Mean (95% CI) $ ( ) 37.0 ( ) <0.001 $195,041.98/year Roll-in Roll-out OR time (min) 59.3 ( ) 61.7 ( ) No difference in Outcomes

50 3 Years Later Cost Per Case Per Surgeon Surgeons

51 Intermountain Healthcare Pediatric Sedation/Anesthesia/Procedural Care Policy A Principled Compromise Solution

52 The Problem: There are well-defined high-risk populations Premature babies Babies 0-12 months old Children ASA 3+ 7 high-risk specific clinical scenarios System variability in who can do what where We had an event Mandate... stop the bleeding... and make a policy

53 Process: Created and met with a Stakeholder group

54 Matt Pollard David Harker Michael Cragun Marcie Sherner Nate Kofford Bill Hamilton Sabrina Cole Kelly Davis Nancy Nelson Mark Ott NORTH REGION CENTRAL REGION Mike Broadbent Pat Watkins Larry Haws Ruth Zimmer Shannon Phillips Carolyn Reynolds Pramod Sharma Deanna Welch PRIMARY CHILDREN S REGION Jeremy Meier Jeff Schunk Douglas Barnhart Sheldon Furst Christopher Maloney SOUTH REGION Jonathan Meyers Craig Grose Darren Obray Becky Davis Steve Bigler Will Shakespeare Gary Beck Todd Plumb Tyler Nelson SOUTHWEST REGION Steve Van Norman

55 Process: Created and met with a Stakeholder group Analyzed external and internal data and guidelines Evaluated a number of potential options Came to a potential deadlock Generated a principled compromise solution Policy approved by IH clinical leadership

56 Spectrum of Pediatric Policy No Policy Everyone does what they want Facility or Regional Control Prior to Aug 1 Strong Regulation System standards Facility limitations Central Control Sweet Spot Region-based Administration Region-based Monitoring System-wide Adoption of UCR Policy Criteria-based access to high-risk groups Principled Compromise Proposal

57 You don t have to Pass It to know what is In It Treats all facilities and all providers equally All facilities and providers can treat healthy children (7 months old and older, ASA 1-2) Defines high-risk populations and who can treat them Creates an ongoing pediatric SAP outcome monitoring process

58 Facilities Surgeons

59 Facilities Surgeons

60 Report Metrics Volumes PACU Duration Return to OR Readmission Mortality

61 PRBC Utilization

62 We Had a Problem Intermountain used a lot of PRBCs 2009 cross matched PRBC Units transfused 39,567 Total of PRBC discarded products 3,128 Total Transfusion reactions 222 PRBCs are expensive... $1800-$2800/unit transfused PRBCs can cause problems

63 System PRBC transfusion Indications

64 PRBC Transfusion Reduction Project Educate clinicians Indications One unit at a time unless MTP Monitor leading and lagging measures Provide clinicians with feedback

65 Monthly Letter to clinicians that transfuse PRBC s Dear Esteemed Colleague: You are receiving this because you ordered a PRBC transfusion in an Intermountain facility during the month of January. Intermountain Healthcare has a continued focus on reducing the number of unnecessary PRBC transfusions in the population. Thank you for your participation to decrease PRBC transfusions and I invite you to click on this link, Physician Blood Utilization Report, from a computer inside the Intermountain Healthcare firewall and using your standard Intermountain user ID/password, so you can view your transfusion data. Intermountain Ongoing Blood Utilization Goals: 1. Minimize the frequency of two-unit transfusions 2. Minimize the frequency of transfusion for Hematocrit > 22.9% Most patients do not need an elective blood transfusion for hematocrits above 21%. When a blood transfusion is appropriate, one unit instead of two units is usually the appropriate volume. Please consider giving your patient one unit of blood and then reevaluating the patient before routinely giving them the second unit of blood. We know that this is different from what you may have learned in medical school and residency, but is well supported by the best evidence based guidelines below. Please compare your personal blood transfusion practice to these best evidence based guidelines for transfusion indications based on hematocrit level and medical history:

66 Blood Utilization

67 Blood Utilization

68 Blood Utilization Cost Savings > $4,000,000

69 Summary- How to fit a square peg in a round hole Strong physician leader Multi-disciplinary team- expert opinions/insight Involve physicians in data refinement process Comparable and meaningful data Standardization of processes in large system is possible!