Value by Design A Blueprint for Slashing Waste, Lowering Costs, & Improving Quality. January 28, 2015 Scripps Health

Transcription

1 Value by Design A Blueprint for Slashing Waste, Lowering Costs, & Improving Quality 1

2 Today s Interactive Session Our roundtable today is designed to be a discussion involving you. For our virtual audience, please ask any question of the presenters at any time by typing your question into the chat box on your screen. Please note that your questions will remain anonymous. We will address as many questions as we can during each of the panels of today s program. 1 PANEL 1 Restructure the Leadership Matrix to Build Accountability and Reduce Variation Mary Ellen Doyle, Corporate Vice President for Nursing Operations James LaBelle, MD, Corporate Senior Vice President, Chief Medical Officer Barbara Price, Corporate Senior Vice President for Business and Service Line Development, Project Management Chris Van Gorder, President and CEO 2 Mary Ellen Doyle, Corporate Vice President for Nursing Operations A member of the Scripps corporate medical management division, Mary Ellen Doyle has more than 15 years of nursing executive experience. During the past four years, she has led efforts to standardize and integrate outcomes-driven nursing care throughout Scripps Health. Currently, she serves as executive sponsor for acute care Value by Design transformation. 3 1

3 James LaBelle, MD, Corporate Senior Vice President, Chief Medical Officer Dr. James LaBelle is responsible for the overall executive leadership of the organization s Value by Design program and plays a critical role in maintaining and expanding the partnerships Scripps Health has built with physicians during the last decade. Under Dr. LaBelle s direction, Scripps Health continues to engage physicians in the coordination and management of clinical care, as well as in linking Scripps hospitals more closely with the organization s growing ambulatory care network. Dr. LaBelle, whose background is in emergency medicine, previously served as corporate vice president for quality, medical management, and physician comanagement at Scripps Health. 4 Barbara Price, Corporate Senior Vice President for Business and Service Line Development, Project Management Barbara Price oversees horizontal clinical operations, including clinical support, clinical ancillaries, and clinical service lines. She has been a key leader in horizontal management since 2010 when Scripps Health changed its organizational structure to eliminate waste, help reduce costs, improve care, and preserve jobs. Price is also responsible for the internal consulting capability within Scripps Health s Project Management Office and executive leadership for the organization s Value by Design program, including strategic deployment of Lean-based methodology and management systems to continue performance improvement and increase the value of care for patients. 5 Chris Van Gorder, President and CEO Chris Van Gorder is widely recognized for leading Scripps Health s financial turnaround and positioning it as a national leader for value-based, patient-centered care. In 2010, in anticipation of healthcare reform, he implemented an innovative management restructuring model across the system that is credited with cutting costs, improving patient care, and preserving jobs. Scripps Health has trimmed more than $340 million in annual costs since integrating horizontal management into the organizational structure without resorting to layoffs or compromising quality. Under Van Gorder s leadership, Scripps Health has taken the next major step toward continuous improvement by introducing Value by Design, a frontline, team approach to identify and eliminate waste and bring more value to patients. 6 2

4 Overview Scripps Health is a nonprofit integrated health system based in San Diego, Calif. Scripps treats a half-million patients annually through the dedication of 2,600 affiliated physicians and 13,500 employees among its five acutecare hospital campuses, hospice and home health care services, and an ambulatory care network of physician offices and 25 outpatient centers and clinics. Recognized as a leader in the prevention, diagnosis and treatment of disease, Scripps is also at the forefront of clinical research, genomic medicine and wireless health care, and has three highly respected graduate medical education programs. 7 About Scripps Health HISTORICAL LEGACY Miss Ellen Browning Scripps Scripps Memorial Hospital & Metabolic Clinic Founded in 1924 Mother Mary Michael Cummings & Sisters of Mercy Founded St. Joseph s Hospital, 1890 Named Mercy Hospital in About Scripps Health 9 3

5 About Scripps Health 10 It was a constant competition for capital resources. Each believed that their campus was more important than any other campus, even if that meant duplicating services that existed relatively close by in the healthcare system. Chris Van Gorder, Scripps Health President and CEO 11 New Structure The creation of four horizontal divisions that crossed the healthcare system, including corporate medical, clinical operations, support services, and administrative services Each division is headed by a corporate senior vice president, each with goals to reduce standardize clinical operations and reduce variation across the system Campus CEOs remain, but all capital requests go through the system vice presidents for team and system analysis and approval 12 4

6 One Scripps: Four Divisions 13 It s a shift from an individual-based accountability to a team-based accountability. We understood that healthcare is not administered by individuals. It s administered by teams of caregivers. Chris Van Gorder, Scripps Health President and CEO 14 An Evolution: Value by Design 15 5

7 PANEL 2 Empower the Healthcare Team to Experiment and Drive Value By Design Speakers: James Bruffey, MD, Orthopedic Surgeon Rose Colangelo, RN, BSN, Emergency Department Patient Care Manager Jeremy Delashmit, RN, Emergency Department Nurse Mary Ellen Doyle, Corporate Vice President for Nursing Operations James LaBelle, MD, Corporate Senior Vice President, Chief Medical Officer Michelle Tressler, PhD, Assistant Vice President, Project Management 16 James Bruffey, MD, Orthopedic Surgeon Dr. James Bruffey participated in a Value by Design supply chain cost-saving exercise that looked at spine surgical implants and biologics being used at the five Scripps hospital campuses. Spine surgeons and administrators came together to create a formulary system for devices and materials while taking into consideration the volume and variety of surgeries being performed. Vendors must now meet the price defined for a specific formulary category to participate, which allows spine surgeons to maintain preference and choice while generating savings for Scripps Health by eliminating cost variance and positioning the organization to save more in the future through further consolidation of categories. 17 Rose Colangelo, RN, BSN, Emergency Department Patient Care Manager A Scripps Health registered nurse since 2007, Rose Colangelo has been recognized for her leadership in helping to elevate patient and staff satisfaction scores, reduce expenses in the supply arena, and maintain a door-to-doc time that is the lowest among the emergency rooms in the system. Colangelo currently oversees the Scripps La Jolla Emergency Department Throughput Rapid Improvement Event, and is working with the Value by Design team on implementing strategies and practices for daily improvement in the emergency department. 18 6

8 Jeremy Delashmit, RN, Emergency Department Nurse A Scripps Health registered nurse since 2007, Jeremy Delashmit was a team leader in this successful Value by Design Rapid Improvement Event, which resulted in a significant reduction in the time emergency room nurses spend on medication reconciliation without sacrificing quality and patient safety. The exercise also had the effect of saving time for floor nurses. 19 Michelle Tressler, PhD, Assistant Vice President, Project Management With more than 20 years of experience in healthcare delivery, health plan strategic development, and operations and management consulting, Michelle Tressler oversees system decision support, strategic project management, and the internal Value by Design team. She has overseen the organization s continuous improvement model and training for the past five years. For the past 18 months, she has been leading the internal team s efforts to create a cultural transformation in a very high-performing, horizontal system organization. 20 Bringing Horizontal to the Front Line Needed to align, coordinate, and consolidate multiple efforts all impacting the front line at the same time Value by Design brings horizontal to the front line Rebuilding the management system to support sustainment is critical to long-term success 21 7

9 Recognize It s an Evolution A journey to realign our health system for success Push ourselves to best meet the needs of our patients and the community Leverage our legacy Engage ALL staff Practice Value by Design vs. Value by Accident 22 Prioritizing Where to Work Is Critical Horizontal and site leaders identified opportunities for improvement looking specifically at how those opportunities aligned with the organizational strategic objectives Focused redesign efforts in two areas with most significant opportunity Inpatient (core processes) Surgery (supply waste) 23 Value by Design Project: ED Flow Problem: ED throughput inefficient due to poor communication and coordination of care activities 24 8

10 Value by Design Project: ED Flow Radiology would dispatch transport and then transport would come to the ED, pick up the patient, and then take the patient to radiology. When the test was done, radiology would again page transport. So we found that there was about 40 minutes of just wasted time in that, which then adds up because then the next patient has to wait that additional 40 minutes. By the time you get to the fourth or fifth patient who s waiting for a test, it could already be like an hour and a half by that point. Process improvements Imaging studies reduced wait times Rose Colangelo, RN, BSN, Emergency Department Patient Care Manager Radiology communicates directly to designated ED tech partner who then transports patient to radiology/ct Wait times reduced from 40 minutes to 5 minutes 25 ED Flow: Process Improvements Patient chief complaint and history eliminated duplication RN/physician jointly interview patient at bedside, resulting in patient not having to repeat the information Lab results reduced turnaround times Nurses do routine lab draws, eliminating wait times due to unattainability of lab tech Reduced the time ordered to time reported from 35 minutes to 19 minutes Clean room availability eliminated workaround Modified computer system to provide RNs a visual queue that ED room is both empty and clean Staff saved 10 minutes of wasted time by being more aware of which rooms were actually ready for patient placement 26 Value by Design Project: Medication Reconciliation Medication reconciliation identified as an organizational priority through value stream analysis Problem: Ineffective tools and processes were affecting the ability of the care team to make timely, informed patient care decisions Inpatient nurse averages minutes completing a complicated med reconciliation of admission, often requiring additional follow up 27 9

11 Medication Reconciliation: Expected Outcomes One form Process redesign Visual management Data source Admission med list to follow patient throughout continuum of care Clearly defined process owners and roles and responsibilities Visual clues to all regarding status of med rec process Reliable preliminary med list (PML) from source of truth Redeployed resource Trained person to provide accurate and trusted admission med list (AML) to physician at time he or she writes admission med orders (AMO) 28 Medication Reconciliation: Process Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Step 7: Patient registration triggers preliminary med list (software solution mines local, regional, national pharmacies for prescriptions) ED RN captures critical med information ED pharmacy tech validates preliminary med list and generates an admission med list Admitting physician confirms patient med info and writes admin med order Floor RN finalizes data capture of med info Floor pharmacist reconciles admin orders and admin med list Floor RN ongoing med information data capture 29 Medication Reconciliation: Results Metric Baseline Results Admission med list complete at time admitting physician writes orders Average time to complete med rec/patient admission 0% 92% 52 min. 33 min

12 Value by Design Project: Physician Preference Items Decisions were made kind of in a vacuum. In my hospital, once the vendors were picked, it excluded 50% of our current operational activity. So half of what we did was no longer available to us. James Bruffey, MD 31 Value by Design Project: Physician Preference Items Spine implants vendor selection transitioned away from limited number to open on a pay to play model. Any vendor meeting our defined price points is welcome to contact with Scripps. New items or vendors tested and evaluated before being added to the formulary, only added if meeting cost. 32 Physician Preference Items: Results Savings of more than $1.04 million for the system Opening the formulary was a major physician satisfier Allowed surgeons to have an increased comfort level with implants available Capability to best match patient anatomy to implant 33 11

13 The devil s in the details. When you implement, you find the holes between what sounds good on paper versus what happens in reality. Michelle Tressler, PhD, Assistant Vice President, Project Management (head of the Value by Design internal staff) 34 Improvement Initiatives Become Sustained Workflow It is critical for both initial success and sustainment that continuous improvement is owned by the people doing the work A foundation was laid with previous systemwide training on performance improvement tools and techniques Moving from performance improvement initiatives to it becoming the DNA of the organization 35 Improvement Initiatives Become Systematized Workflow Repurposed internal staff to support growing efforts System support core team: Moved from doing to coaching : 9 senior coaches (internal sensei) 12 operational coaches (site-based leadership moved to interim fellowship type program for in-depth training) 1 full-time professional development specialist as well as existing staff and material support from system Center for Learning and Innovation 36 12

14 Break We will reconvene at: 1:45 p.m. (Eastern) 12:45 p.m. (Central) 11:45 a.m. (Mountain) 10:45 a.m. (Pacific) 37 PANEL 3 Drive for Population Health Through Primary Care Redesign Speakers: Siu Ming Geary, MD, Vice President, Ambulatory Care, Scripps Clinic Anil Keswani, MD, Corporate Vice President of Ambulatory Care and Population Health Management James LaBelle, MD, Corporate Senior Vice President, Chief Medical Officer Chris Van Gorder, President and CEO 38 Siu Ming Geary, MD, Vice President, Ambulatory Care, Scripps Clinic Dr. Siu Ming Geary, whose background is in internal medicine, has been a leader in the management of population health through primary care redesign and the development of a team around the primary care provider that aims to eliminate inefficiencies and increase the quality of patient care. Dr. Geary is the medical director for the Primary Care Redesign initiative at Scripps Health, and is participating in one of the two initial pilot care teams

15 Anil Keswani, MD, Corporate Vice President of Ambulatory Care and Population Health Management Dr. Anil Keswani has 18 years of experience in medical management and more than a decade of senior executive healthcare experience. His focus includes Lean management, primary care redesign, innovative access points (retail health and telehealth), care navigation, physician alignment strategies, and population health IT and analytics. Dr. Keswani works closely with primary care, skilled nursing professionals, and other specialties to further develop outpatient capabilities and seamless patient transitions. 40 If we really want a robust healthcare delivery system, we wouldn t start in the hospital. We d start on the ambulatory side, where most healthcare is delivered. Chris Van Gorder, Scripps Health President and CEO 41 Primary Care Redesign From a base of only a half-dozen ambulatory sites a decade ago, Scripps has 25 now Property purchased throughout the county for future growth Two years after the horizontal system leaders were created, corporate senior vice president of ambulatory care and population health management added 42 14

16 Primary Care Redesign Goal was to develop a team around the primary care provider. Redesigned care team consists of two full-time physicians, one physician extender who is either a nurse practitioner or physician assistant, plus a licensed vocational nurse. Physician extender spends 75% of the time seeing patients who are part of the two physicians panels. The other 25% of the time is spent on population management, answering phone calls or returning messages. 43 Primary Care Redesign The standard work sets designate certain kinds of patients for physicians to see and others for the nurse practitioner The care team holds a huddle every morning to review the day and make any necessary adjustments to get patients in 44 Thank You For follow-up questions, please Jim Molpus at jmolpus@healthleadersmedia.com 45 15

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