Learning Objectives. 3 Keys to Deliver Value. Why a Care Experience?

Transcription

1 Deliver Value with Volume: Operating Room Efficiencies Anthony M. DiGioia III, M.D. OR A19 & B19 This presenter has nothing to disclose December 9, :30am- 10:45am 11:15am- 12:30pm Learning Objectives! Deliver both value and volume in the OR safely by building a Focused Care Center.! Improve clinical outcomes and operational efficiencies by focusing on the whole OR experience from the perspective of patients and families.! Use our mission (ie: care of our patients) to drive change. The New delivery systems coupled with new payment systems Costs must be driven down while improving outcomes and experiences The biggest hurdle is the lack of the How to PAYMENT MODEL CHANGES AHEAD Deliver Value by Developing a Patient Focused Care Center! Deliver care for a specific disease process but viewed from the patient s and family s perspective! Treatment for a full cycle of care and implemented by design! Reorganize and manage all resources and personnel to meet the needs of patients and families! Accountability for all outcomes and costs 3 Keys to Deliver Value 1. View All Care as an Experience Through the Eyes of Patients and Families 2. Co-Design 3. Implementation Why a Care Experience? Ø Defined through the eyes of patients and families and includes everything that impacts their journey to wellness. Ø Include outcomes, communication, transitions in care, safety, costs and for a full cycle of care. 1

2 Hurdles to Achieve Value! Care pathways, process improvement, safety initiatives, disease management and other overlays to the current structure are beneficial, but not sufficient! Fundamental restructuring is required for significant improvement The Patient at the Center is the How To Design for Value Our Mission is the Focus for Change Developing a Hospital within a Hospital From the Ground Up Free Standing Subspecialty Hospital OR Within an Existing Hospital The Patient and Family Centered Methodology and Practice (PFCC) Ideal Experience Current State 5. Shared Vision of the Ideal 3. Shadow, Current State, Urgency 2. Guiding Council 1. Define Care Experience 6. PFCC Project Teams Close the Gap 4. Working Group thru Touchpoints With the Patient at the Center Simple and singular focus Develops the sense of urgency that is needed to drive and maintain transformational changes Engages and partners with patients, families and ALL constituencies Builds high performing care and implementation teams The Magee Bone and Joint Center The Keys to Deliver Value is to Focus on the Patient 2

3 Our Results 1,816 surgeries FY14, only 2 OR s/day 90+% of all patients are discharged to home and with lowest length of stay Outcomes by readmission rates, transfusion rates, infection rates and SCIP compliance and functional outcomes Lowest cost per case (now real costs) Surgeon Time Performing Surgery vs. Annual TKA Procedure Volume IHI Total Joint Learning Community 2014 Value with Volume in the OR Outcomes Flow Chart While we believe that the concept of operating-room efficiency is an important one, and efficiency can be improved by making process changes, we also want to emphasize that no increase in efficiency can substitute for good, safe patient care. Saleh, Shaled J., MD, Wendy M. Novicoff, PhD, David Rion, MD, Linda H. MacCracken, MBA, and Richard Siegrist, MS, MBA. "Operating-Room Throughout: Strategies for Improvement. JBJSC. The Orthopaedic Forum (2009). Pg NP Visit Patient demograp hics In-patient PT DOS activity ROM Ambulation distance Pain level Assistive support at D/C Surg Sched Visit FORCE TJR signup Out-patient PT TJR functional scale (SSP) Pre-Op Testing MRSA/MSSA screening SF12 (SSP) TJR functional scale (SSP) FORCE/PRO baseline SF36 & HOOS/KOOS RAPT (SNF risk) 1mo F/U PRO s Readmission rate Infection rate HCAHPS Net Promoter Score (NPS) DOS MRSA/ MSSA compliance SCIP compliance 3mo F/U SF12 (SSP) OR FORCE implant data 6mo F/U FORCE/ PRO postop SF36 & HOOS/ KOOS Inpatient Transfusions LOS SCIP compliance Pain level Mortality D/C destination Adverse events 1 year F/U FORCE/ PRO postop surveys SF36 & HOOS/ KOOS Improving Safety, Quality & Waste Reduction Total Joint Replacement Care Experience TKA FY14 BJC - AMD National Avg Average LOS 2.7 days 3.3 days Infection Rates 0.2% 1.2% Mortality Rates 0.0% 0.2% Discharge Destination 9 Home THA FY14 Average LOS 2.4 days 4.2 days Infection Rates 0.0% 1.5% Mortality Rates 0.0% 0.7% Discharge Destination 96% Home Readmission Rate Within 30 days TKA = 0.9% THA = 0.6% When You Deliver Real Value Patients and Families Become Evangelists 100% 80% 60% 40% 20% 0% Bone and Joint Center National HCAHPS Percentile Rankings Recommend Hospital 2007 (n= 217) 2008 (n= 225) 2009 (n= 230) 2010 (n= 265) 2011 (n=357) 2012 (n=418) BJC Net Promoter Score Company NPS Total Joint Replacement BJC 95 Average Total Hip Replacement 71 Apple 69 First Direct (Banking) 61 Average Total Knee Replacement 49 Sony 44 Samsung 36 Nationwide 33 3

4 How can we all get there? Tools for You to Understand Current State Care Pathways Gap Analysis Opportunities for Improvement How We Got Started! One month post-op f/u surveys for every patient and family! Start a patient and family advisory council! GoShadow to determine your current state, care pathway and the true touchpoints and care givers Current State Shadowing 2. Guiding Council 1. Define Care Experience Ideal Experience 6. PFCC Project Teams Close the Gap 5. Shared Vision of the Ideal 4. Working Group thru Touchpoints 3. Shadow, Current State, Urgency Shadowing Shadowing is repeated observations of patients and families as they move through each step of their healthcare journey Shadowing Determines Your Current State Accurately and Efficiently 4

5 2014 IHI Na*onal Forum: Deliver Value with Volume and Opera*ng Room Efficiencies Example: The Day of Surgery Care Experience Touchpoints! Parking! Family Lounge! Pre-Op Room! Operating Room! PACU! Floor Care Givers! None! DOS Nurse! DOS Nurse, Anesthesiologist, CRNA, Surgeon! Surgeon, Sales Rep, CRNA, PA, Surgical Tech, RN, Float RN, Anesthesiologist, Housekeeper! Transporter, X-Ray Tech, RN, Anesthesiologist! PCT, Surgeon, Dietary Aide, Rehab Aide, Internist, PT, Housekeeper, PA, Case Manager, Social Work, RN, Transporter OR Shadowing Project Shadowing: Day of Surgery Observations Main Entrance Locked at 5am Resolution Directions to Enter ER Skeletal Parking No Valet 5am-9am until Valet Expected Routine Disrupted Difficult/Long Walk to Surgical Services Clear Wayfinding Wheelchairs and Scooters Available at Garage OR Flow Study Data Sheet! Patient in room! Surgeon in room! Tourniquet deflation (for TKR s)! Anesthesiologist in room! Surgeon breaks scrub! Induction (gen/l) and! Incision closed start of spinal! Anesthesia turnover to OR! Patient out of room/psa called! PSA in room staff! Foley in! PSA out of room! Prep complete! Case Cart in! Tourniquet inflation! Begin to open (for TKR s)! Next patient in! Incision In the OR: Dedicated Team Approach! OR s Assigned to BJC to Manage! OR Specialty Teams! Subspecialty Anesthesia Team! Central Processing Partnership! Housekeeping Team! Assigned Nurses to Pre-Op Room! Committed PACU Slots Create Efficiencies 3 Teams for 2 OR s 3rd Team: Swing Team! Consists of RN and Surgical Tech! Liaison for Central Processing,, Patient Prep, etc.! Relieve 1st and 2nd teams for breaks! Double check prep for next case 5

6 High Performance OR Teams - TKR Wheels out to Wheels in Comparison Joint Replacement Learning Community Magee Bone and Joint Center High Performance OR Teams TKR Patient In to Patient Out Joint Replacement Learning Community Magee Bone and Joint Center Mean 16 ±2 31 ±14 Mean 111 ±44 Best ± m i n u t e s m i n u t e s Achieve the Value Trifecta: Blood Conservation Program Improved Outcomes Better Experience Decrease Cost TKA, THA 0%, Overall 0.8% Decreased LOS Reduced Complications Only One Blood Draw POD#1 Reduced Transfusions Reduced Anxiety No AutoVac Savings $75,951/yr No T/C $242,112/year ($208/pt) No T/S $240,657/year ($206/pt) But This Doesn t All Happen in a Vacuum It s a Systems Approach The Office Sets the Stage Education materials Surgery preparation Follow-up appts Prescheduled Flow of accurate information OR Reservations/ One Stop Shop Pre-op Testing and Education Patient and Family Activation, Shared Decision Making, PRO s Pre-op screening and infection prevention program (Project JOINTS) Sets the stage for transitions in care No delays or OR cancelations Decreased LOS 6

7 Patients Tell Their Stories for Other Patients Benefit Is your pain more or less then expected? 1:38 2:21mins Low Overhead Anesthesia and Pain Management Manage Patient Expectations Integrate Pre-, Intra-, Post-op Care Pain and nausea treatment plans Complimentary Therapies Ice and CPM Rapid rehab, increase ROM, reduced LOS, maximize outcomes, and comfort Strategy for Post-Op! PACU gridlock affects OR efficiencies! Anesthesia recovery time Saleh, Shaled J., MD, Wendy M. Novicoff, PhD, David Rion, MD, Linda H. MacCracken, MBA, and Richard Siegrist, MS, MBA. "Operating-Room Throughout: Strategies for Improvement. JBJSC. The Orthopaedic Forum (2009). Pg Deliver Value by Design Value = Health Outcomes (Important to Patients) Cost What is the cost? Business Expense? Hospitals - Charges? Insurers Reimbursements? MD s Overhead? Patients OOP Expenses? True Costs = TDABC Time Driven Activity Based Costing Identifies true cost to deliver care: Robert S. Kaplan and Michael E. Porter How to Solve the Cost Crisis in Health Care, HBR

8 Patient Centered Value Tool = PFCC + TDABC Patient Shadowing Cost Accurately and efficiently determines data needed to implement TDABC Develops the implementation team Real World Example: TJR Bundling and Reference Pricing Care Segments (30 days before to 90 days after) Home Physician Office Acute Hospital Health Pharmacy Insurance Home Health Outpt Therapy Rehab or Skilled Nursing Facility 1 PRE-OP/OFFICE 1a: New Patient Scheduling 1b: Pre Surgical Office Visit 1c: Billing 2 PRE-OP TESTING & CONSULTS 2a: Pre-Op Testing 2b: MD Consults 2c: Special Testing 2d: Pre-Op Admin Support 3 DAY OF SURGERY/OR 3a: Day of Surgery Unit 3b: OR 3c: Central Sterile 4 PACU 4: PACU 5 INPATIENT STAY 5a: Day 0 6 THERAPY 6a: Home Therapy 7 FOLLOW UP VISITS 7a: 4 Week Follow Up Shadow the Patient 5b: Day 1 5c: Day 2 5d: Day 3 6b: Outpatient PT 6c: Inpatient Rehab/SNF 7b: 3 Month Follow Up 7c: Post-Op Admin Support OR Costs OR Costs 83% 16% THR 78% TKR 20% 83% 16% THR 78% TKR 20% (Implant 86% of ) (Implant 79% of ) 8

9 83% OR Costs 16% THR Implant Cost in a Bundle (Implant 86% of ) 78% TKR 20% (Implant 79% of ) THR: 40% TKR: 30% 53% of Cost related to Consumable Costs Total Hip Replacement 77% Implant 1 Medications 5% Custom Hip Pack 2% General Nursing For the Full Bundle 2% Saw Blades Skin Antiseptic Surgical Dressing Suture Materials Pilot TDABC UPMC Two TJR Hospital Comparisons Fast Track TJR ± Exparel Rehab at SNF Inpt Nurse Workflow, Central Sterile, Pre-op CXR Hysterectomy ± Robotic Joint Replacement Learning Community Implant Costs 4x Variation Types of Anesthesia: General, Spinal ± Intrathecal Morphine, Nerve Blocks, Intra-articular Injections High Impact Variation OR Time (TKR): 31 to 155 mins A Common Platform Patient Care Cost Tightly Couple Clinical + Financial Performance Cost Reduction Tool Opportunities for Improvement Patient Centered Value Tool Care Experiences Clinical Outcomes, Quality and Safety Patient and Family at the Center True $ Cost Patient Reported Outcomes 9

10 The Patient Centered Value Tool Provides the focus to drive change that is also our mission Builds care teams Generates urgency Breaks down silos Implementation tool for transformational change by coupling clinical and financial performance The Community of Practice United States: 27 International: 7 Total 34 IHI National Forum: High-Value Practices for Total Joint Replacement Wednesday, December 10th 9:30am-10:45am & 11:15am-12:30pm Webinar: Go Shadow Wednesday, December 17 th 2:00-3:00pm Webinar: PFCC Preview Thursday, December 18 th 11:00am-12noon Deliver Value and Reduce Your Healthcare Costs Transparency, Bundling, Reference-Pricing and Direct Contract Friday, February 13 th, 2015 Pittsburgh, PA for more information 10