Utilization of Hospital-wide Metrics to Guide Learning Within

Transcription

1 This presenter has nothing to disclose Utilization of Hospital-wide etrics to Guide Learning Within and Across Projects for Achieving Results Lloyd Provost April 7, 216

2 Flow an Diego 5 Freeway epulveda Pass outh Bound Los Angeles * On Any Afternoon

3 Hospital Flow as a ystem

4 ystems Linkage: Levels of Detail Low acro Level of Detail High eso icro API, Inc. 22 All Rights Reserved

5 Concept of an Organization s Family of easures Understanding the performance of an organization (at acro, eso, or icro level) requires the use of multiple measures. o single measure is adequate to inform leadership of performance of a complex system. ince Kaplan and orton s article "The Balanced corecard - easures that Drive Performance published in the Harvard Business Review in 1992, the Balanced corecard methodology has become one of the most popular performance and strategic management frameworks used in both public and private organizations around the world.

6 Concept of an Organization s Family of easures The collection of measures used for this purpose has been called: Family of measures Balanced scorecard Report card Dashboard Clinical Value Compass Instrument panel Vector of measures Family of easures Financial Patient Operations Employee

7 A Vector of easures 7. The concept of a vector provides a good analogy when we consider the purpose of this family of measures. A vector is an engineering concept that describes both magnitude and direction. The individual components of the vector are not useful by themselves, but when the components are combined, useful information is obtained.

8 Concept of Vector of easures Like the various dials on a car: ome measures describe the past (odometer reading), ome describe the present (speedometer), ome are there to indicate problems (oil pressure light), and ome describe the future (gas gauge). The vector of measures brings together information from all parts and perspectives of the organization and thus provides a tool for leaders to focus learning, planning, and decision making on the whole system.

9 ome Categories Used to Develop VO Balanced corecard (Kaplan and orton) Organization Clinical Values Compass (elson) Group of Patients IO Dimensions of Quality HEDI (CQA Healthcare Effectiveness Data and Information et) Hospital (Example) Organization Health Plans Hospital Customers Functional afety Effectiveness of Care Employee Learning and Growth atisfaction Effectiveness Access to Care Clinical Excellence Financial Costs Patient Centeredness atisfaction afety Internal Business Processes Clinical Timeliness Use of ervices Operational Efficiency Equity Health Plan Descriptive Information Cost of Care Patient Perspective (ervice) Community Health Plan tability Informed Health Choices Finance ource: The Data Guide. Provost and urray 21

10 Example: IHI Whole ystem easures afe IO Dimension Effective & Equitable Patient-Centered Timely Efficient Proposed ystem easure ADEs/1 doses HR Functional Outcomes (F-6 for Chronic disease) Inpatient atisfaction patients dying in hospital Days to 3 rd next available appointment Health care costs per capita Hospital costs per discharge

11 But a problem.. Organizations are largely looking at their family of measures as: Tables of numbers Current values are related to meeting goal or target Color codes for each measure: Green - currently meeting goal Yellow - not at goal but within an established distance to the goal (e.g. 75 of goal) Red not at goal and not near it or heading in wrong direction o focus on prediction and minimizes learning

12 Legend for tatus of Goals (Based on Annual Goal) Goal et (GREE) Goal 75 et (YELLOW) Goal ot et (RED) Patient Perspective 1. Overall atisfaction Rating: Percent Who Would Recommend (Includes inpatient, outpatient, ED, and Home Health) 2. Wait for 3rd ext Available Appointment: Percent of Areas with appointment available in less than or equal to 7 business days (n=3) Patient afety Goals FY 2 FY 2 FY 2 Q1 FY 2 Q2 FY 2 Q3 Long FY Term Goal Goal afety Events per 1, Adjusted Patient Days Percent ortality Total Infections per 1 Patient Days Clinical 6. Percent Unplanned Readmissions Percent of Eligible Patients Receiving Perfect Care--Evidence Based Care (Inpatient and ED) Employee Perspective 8. Percent Voluntary Employee Turnover Employee atisfaction: Average Rating Using 1-5 cale (5 Best Possible) Operational Performance 1. Percent Occupancy Average Length of tay Physician atisfaction: Average Rating Using 1-5 cale (5 Best Possible) Community Perspective 13. Percent of Budget Allocated to on-recompensed Care Percent of Budget pent on Community Health Promotion Programs Financial Perspective 15. Operating argin-percent onthly Revenue (illion)-change so shows red--but sp cause good related to occupancy FY 2 Hospital ystem-level easures

13 What is the problem.. Where is the opportunity? oving from these views to one where: Each measure is displayed on an appropriate time series chart (Run chart or hewhart chart) All time series charts are on same page to see the whole system Helps us: ore accurately assess progress of changes in system Become aware of system interrelationships Appreciate both dynamic and detail complexity Predict performance of the system

14 To Improve On This We Use hewhart Charts to Display easures: What Is It? Data is usually displayed over time Rate per 1 Discharges UCL = 8.32 Target = 7.5 or Less CTL = 5. LCL = 1.69 Rate of Unplanned Returns to ED u chart -6 A A O D - F A A hewhart chart will include: Center line (usually mean) Data points for measure tatistically calculated upper and lower 3 sigma limits (Limits typically created with 2 or more subgroups)

15 electing the Appropriate hewhart Chart Type of Data Count or Classification (Attribute Data) Continuous (Variable Data) Count (onconformities) Classification (onconforming) ubgroup ize of 1 Unequal or Equal ubgroup ize Equal Area of Opportunity Unequal Area of Opportunity Unequal or Equal ubgroup ize C Chart U Chart P Chart I Chart (X chart) X-Bar and chart umber of onconformities onconformities Per Unit Other types of control charts for attribute data: 1. P (for classification data) 2. T-chart [time between rare events] 3. Cumulative sum (CUU). Exponentially weighted moving average (EWA) 5 G chart (number of opportunities between rare events) 6. tandardized control chart Percent onconforming Individual easures Average and tandard Deviation Other types of control charts for continuous data: 7. X-bar and Range 8. oving average 9. edian and range 1. Cumulative sum (CUU) 11. Exponentially weighted moving average (EWA) 12. tandardized control chart

16 hewhart Chart Allows us to Distinguish Two Types of Variation Common Cause: causes that are inherent in the process, over time affect everyone working in the process, and affect all outcomes of the process Process stable, predictable Action: if in need of improvement must redesign process(es) If we are testing changes and see only common cause it means our changes have not yet resulted in improvement pecial cause: causes that are not part of the process all the time, or do not affect everyone, but arise because of special circumstances Process unstable, not predictable Action: go learn from special cause and take appropriate action ay be evidence of improvement (change(s) we tested working) or evidence of degradation of process/outcome

17 Rules for Detecting pecial Cause

18 Performance Better Than Target but is all OK? 1 Rate of Unplanned Returns to ED u chart 12 Rate per 1 Discharges UCL = 8.32 Target = 7.5 or Less CTL = 5. 2 LCL = A A O D -1 F A A O D

19 AIER arch, 21 Analysis Leading: Among the leading indicators, six were judged to have a positive trend in February, with two of those six hitting new cycle highs: 1 money supply and the yield curve index. Conversely, two were judged to have a negative trend: new orders for consumer goods and average workweek in manufacturing. As mentioned above, four indicators were assessed as neutral, a result consistent with a higher degree of uncertainty in the economic data. American Institute of Economic Research

20 Legend for tatus of Goals (Based on Annual Goal) Goal et (GREE) Goal 75 et (YELLOW) Goal ot et (RED) Patient Perspective 1. Overall atisfaction Rating: Percent Who Would Recommend (Includes inpatient, outpatient, ED, and Home Health) 2. Wait for 3rd ext Available Appointment: Percent of Areas with appointment available in less than or equal to 7 business days (n=3) Patient afety Goals FY 2 FY 2 FY 2 Q1 FY 2 Q2 FY 2 Q3 Long FY Term Goal Goal afety Events per 1, Adjusted Patient Days Percent ortality Total Infections per 1 Patient Days Clinical 6. Percent Unplanned Readmissions Percent of Eligible Patients Receiving Perfect Care--Evidence Based Care (Inpatient and ED) Employee Perspective 8. Percent Voluntary Employee Turnover Employee atisfaction: Average Rating Using 1-5 cale (5 Best Possible) Operational Performance 1. Percent Occupancy Average Length of tay Physician atisfaction: Average Rating Using 1-5 cale (5 Best Possible) Community Perspective 13. Percent of Budget Allocated to on-recompensed Care Percent of Budget pent on Community Health Promotion Programs Financial Perspective 15. Operating argin-percent onthly Revenue (illion)-change so shows red--but sp cause good related to occupancy FY 2 Hospital ystem-level easures

21 Percent Willingness to Recommend ean = LL ean = What Does a VO Look Like? 2. Areas eeting 3rd ext Apt Goal = LL = 29.8 ean = Error Rate afety Error Rate per 1, Adj. Bed Days =.7 ean =.33 LL = ean =.6 LL. ortality. Rate per 1O Pt. Days Infection Rate per 1 Patient Days ean = ean = 5.8 LL 6. Percent Unplanned Readmissions Percent Eligible Patients Given Perfect Care ean = 7.2 LL ean = 6.6 LL Percent of Employee Voluntary Turnover ean = 5.79 LL Average core 9. Average Employee atistaction (1-5 cale, 5 Best).8 =.1.. ean = LL = = ean = LL = Percent Occupancy ALO Days = 6.1 ean = 5. LL = Average Length of tay Average core Average Physician atisfaction (1-5 cale, 5 Best) 5 =.87 ean = LL = Percent of Budget pent on Uncompensated Care 12 1 = ean = LL = Operating Budget: Community Health Promotion =.76 ean = = 2.61 ean =.11 LL = Percent Operating argin $ illions = ean = onthly Revenue in illions 21 ource: The Health Care Data Guide. Provost and urray 211

22 How is afety Error Rate Doing? Goals FY Goal Long Term Goal FY 2 FY 2 FY 2 Q1 FY 2 Q2 FY 2 Q3 3. afety Events per 1, Adjusted Patient Days afety Error Rate per 1, Adj. Bed Days.5 UCL =.8 Error Rate..3.2 CTL =.33 LCL = D ource: The Health Care Data Guide. Provost and urray 211

23 How is 3 rd ext Available Appointment Doing? Goals FY Goal Long Term Goal FY 2 FY 2 FY 2 Q1 FY 2 Q2 FY 2 Q3 1 8 UCL = Areas eeting 3rd ext Apt Goal 6 CTL = LCL = 29.8 D ource: The Health Care Data Guide. Provost and urray 211

24 onth Infection Rate per 1 Patient Days 1.3 F A A O D F A A O D F A A Rate per 1O Pt. Days ame Approach With onthly Data Infection Rate per 1 Patient Days-Total UCL = 9.15 CTL = 3.91 D ource: The Health Care Data Guide. Provost and urray 211

25 onth Infection Rate per 1 Patient Days 1.3 F A A O D F A A O D F A A Rate per 1O Pt. Days ame Approach With onthly Data Infection Rate per 1 Patient Days-Total UCL = 9.15 CTL = 3.91 D ource: The Health Care Data Guide. Provost and urray 211

26 Percent Willingness to Recommend ean = LL ean = What Does a VO Look Like? 2. Areas eeting 3rd ext Apt Goal = LL = 29.8 ean = Error Rate afety Error Rate per 1, Adj. Bed Days =.7 ean =.33 LL = ean =.6 LL. ortality. Rate per 1O Pt. Days Infection Rate per 1 Patient Days ean = ean = 5.8 LL 6. Percent Unplanned Readmissions Percent Eligible Patients Given Perfect Care ean = 7.2 LL ean = 6.6 LL Percent of Employee Voluntary Turnover ean = 5.79 LL Average core 9. Average Employee atistaction (1-5 cale, 5 Best).8 =.1.. ean = LL = = ean = LL = Percent Occupancy ALO Days = 6.1 ean = 5. LL = Average Length of tay Average core Average Physician atisfaction (1-5 cale, 5 Best) 5 =.87 ean = LL = Percent of Budget pent on Uncompensated Care 12 1 = ean = LL = Operating Budget: Community Health Promotion =.76 ean = = 2.61 ean =.11 LL = Percent Operating argin $ illions = ean = onthly Revenue in illions 26 ource: The Health Care Data Guide. Provost and urray 211

27 Aim of your Flow Initiative 27 Provide the right care, in the right place, at the right time.

28 Draft Hospital Flow etrics Emergency Department Hospital acro Average Occupancy Rate Readmissions within 1 week of discharge Readmissions within 3 days after discharge Patient experience (HCAHP measures related to waits & delays) Clinician and staff satisfaction related to workload (ex. DQI) umber of off-service patients umber of HACs (ex. falls with injury, VAPs, etc.) ED diversions o # of diversions o hours per month Patients who left without being seen Visits per day Average length of stay o for patients who are discharged o for patients who are admitted Door to provider time Time from decision to admit to transfer to inpatient unit umber of ED boarders waiting to be admitted to a hospital bed Time from decision to have emergency surgery to OR Percentage of EI level & 5 patients (low acuity) Percentage of patients who were admitted

29 Draft Hospital Flow etrics ed/urg Units Critical Care Units Average Census Average Length of tay umber of LO outliers per month umber of decedents spending 7 or more days in the ICU in the last 6 months of life umber of ICU diversions due to lack of capacity (# of off-service patients ) ursing Overtime umber of HACs Delays in Transferring Patients to ed/urg Units Average Census Average Length of tay umber of LO outliers per month ursing Overtime umber of HACs edian discharge time (or discharge profile) Operating Rooms umber of emergency cases by day umber of scheduled cases by day Percentage of OR utilization umber of changes from schedule for Elective urgical Cases Actual and cheduled tart Times for Elective urgical Cases ursing Overtime o OR o PACU umber of overnight PACU patients

30 easures Used by >75 of Participants 3 Patient experience (HCAHP measures related to waits & delays) -Hosp 82.9 umber of HACs (ex. falls within injury, VAPs, etc.) -Hosp 92.7 Average Occupancy Rate -Hosp 95.1 Readmissions within 3 days after discharge -Hosp 95.1 Percentage of EI level & 5 patients (low acuity) -ED 78. Average length of stay: patients discharged; patients admitted -ED 87.8 Door to provider time -ED 87.8 Time from decision to admit to transfer to inpatient unit -ED 9.2 umber of "ED boarders" waiting to be admitted to a hospital bed -ED 9.2 Percentage of patients who were admitted -ED 9.2 Patients who "left without being seen" -ED 92.7 Visits per day -ED 92.7 umber of HACs -Critical 75.6 Average Census -Critical 8.5 ursing Overtime -Critical 85. ursing Overtime -edurg 82.9 Average Length of tay -edurg 85. Average Census -edurg 87.8 Percentage of OR utilization -OR 75.6 Actual and scheduled start times for elective surgical cases -OR 75.6 umber of scheduled cases by day -OR 85.

31 ummary of Prework from 1 Participating Hospitals or ystems 31

32 Average Occupancy Rates (at hospital or unit levels) and the Day-to-Day Realities of anaging Patient Flow 32 # of Patients Time

33 H Forth Valley Daily Elective & on-elective Hospital Admissions (1 an 21 3 une 21)

34 ystem Level easures Health Care Delivery ystem Transformation trategic Improvement Priorities and ystem Level easures ACCE FLOW PATIET AFETY CLIICAL EXCELLECE REDUCE HALE TEA WELLBEIG FAILY CETERED CARE 3 rd ext available appointment of eligible patients with delays Discharge Prediction and Execution Growth Prediction Adverse drug events (ADE) per 1, doses osocomial infection rates: Bloodstream infection rate urgical site infection rate infection rates: VAP afe Practices erious afety Events Codes outside the ICU rate/1 days tandardized PICU ortality Ratio Expected/ Actual use of Evidence- Based Care for eligible patients Functional Health tatus Functional Health tatus Touch Time for Providers Risk Adjusted Cost per Discharge Employee atisfaction taffing Effectiveness taff Physician atisfaction Voluntary staff turnover rate Accident rate for staff with Work days lost Overall Rating: Patient Experience Frederick C. Ryckman, D Professor of urgery / Transplantation r. Vice President edical Operations Cincinnati Children s Hospital

35 Critical Flow Failure Recognition

36 Critical Flow Failures

37 7/16/2 1/1/2 1/12/2 /12/2 7/11/2 1/9/2 1/7/21 /7/21 7/6/21 1//21 1/2/211 /2/211 7/1/211 9/29/211 12/28/211 3/27/212 6/25/212 9/23/212 12/22/212 3/22/213 6/2/213 9/18/213 12/17/213 3/17/21 6/15/21 9/13/21 12/12/21 3/12/215 6/1/215 9/8/215 # of Patients with a ew Failure Critical Flow Failures Delayed or Canceled urgery Due to Bed Capacity

38 Timeliness of consults Process Expansion econd and third unit performance management Transparency of Data Pharmacy process optimization Preoccupation With Failure Key stakeholder buy-in and shared ownership

39 Psychiatry Patients outside ental Health

40 Predicting ICU Discharge

41 fm CHA Press Ganey Patient atisfaction Overall ean core ew ED Fully Open Patient Partner Rapid Assessment mean score ew ED Partially Open percentile 6. 5-Q1 5-Q2 5-Q3 5-Q 6-Q1 6-Q2 6-Q3 6-Q -Q1 -Q2 -Q3 -Q -Q1 -Q2 -Q3 -Q -Q1 -Q2 -Q3 -Q 1-Q1 1-Q2 1-Q3 1-Q 11-Q1 11-Q2 11-Q3 11-Q 12-Q1 12-Q2 12-Q3 12-Q WH ean core -5K visits ile

42 Example of Improvement (c) urrell 215

43 odel Outputs Accuracy measured daily for each unit

44 Example Results -- UPC P Resar,, Roger Resar,.D.; Kevin olan,.a.; Deborah Kaczynski,..; Kirk ensen,.d.,.b.a., F.A.C.E.P., anagement to Improve Hospitalwide Patient Flow, oint Commission ournal on Quality and afety, ay 211 Volume 37 umber 5, pp

45 ome Important Administrative Issues with Vector of easures (VO) Ideally graph data monthly rather than quarterly If less that 12 data points use run chart rather than hewhart chart When graph has 2-3 data points update the limits When special cause has occurred indicating a new level of system performance update the limits how some future time periods on the chart to encourage prediction. When graph too crowded, aggregate earlier points (e.g. monthly to quarterly).

46 Percent Willingness to Recommend ean = LL ean = What Does a VO Look Like? 2. Areas eeting 3rd ext Apt Goal = LL = 29.8 ean = Error Rate afety Error Rate per 1, Adj. Bed Days =.7 ean =.33 LL = ean =.6 LL. ortality. Rate per 1O Pt. Days Infection Rate per 1 Patient Days ean = ean = 5.8 LL 6. Percent Unplanned Readmissions Percent Eligible Patients Given Perfect Care ean = 7.2 LL ean = 6.6 LL Percent of Employee Voluntary Turnover ean = 5.79 LL Average core 9. Average Employee atistaction (1-5 cale, 5 Best).8 =.1.. ean = LL = = ean = LL = Percent Occupancy ALO Days = 6.1 ean = 5. LL = Average Length of tay Average core Average Physician atisfaction (1-5 cale, 5 Best) 5 =.87 ean = LL = Percent of Budget pent on Uncompensated Care 12 1 = ean = LL = Operating Budget: Community Health Promotion =.76 ean = = 2.61 ean =.11 LL = Percent Operating argin $ illions = ean = onthly Revenue in illions 6 ource: The Health Care Data Guide. Provost and urray 211