Duke University Health System Experience of Redesigning Care for Improved Quality and Efficiency CAITLIN DALEY, DR. GEORGE CHEELY, DR.

Transcription

1 Duke University Health System Experience of Redesigning Care for Improved Quality and Efficiency CAITLIN DALEY, DR. GEORGE CHEELY, DR. TOM HOPKINS 1

2 Learning Objectives Describe the Duke University Health System Care Redesign performance improvement approach Describe the key interventions and outcomes from the Care Redesign work Describe the prioritization methodology to select focus areas 2

3 Agenda Background of Care Redesign work at Duke Program management: Improvement process Intervention examples Performance reporting Communication tools Prioritization methodology to select new projects Case study Future directions Q&A 3

4 BACKGROUND 4

5 Care Redesign Background - Beginning FY12: Oversight Committee formed to govern changes Aims: Improving outcomes and experience of care Improving the health of populations Reducing the cost of care Key Lessons Avoided days in the hospital Reduced unplanned returns Opportunity identification could be more systematic FY13: Convened 7 clinical teams Primarily Cardiac and Orthopedic (2 bundled payment pilots) FY14: Convened 9 additional teams Surgical, Medical, GYN, Peds Projects took months Partnership to analyze clinical cost data and track financial benefits could be expanded 5

6 Care Redesign Background Phase FY14-FY15: Transforming our Future Care Redesign Project Consultant engagement Projects identified based on largest variation in variable direct cost/case Guided teams through 16 Week Design process and 16 Week Implementation process FY16 to Current: Duke Care Redesign Program Team of industrial engineers, healthcare business professionals and quality improvement nurses hired and based in Performance Services Partnership with Epic (EHR), Patient education, Research Services, and Finance Developed annual assessment process to target projects based on health system priorities Project schedules based on scope and deliverables, using Six Sigma improvement methodology 6

7 Project Teams To Date Developed a redesign approach Then a program Now tackling even bigger areas July 2012 June 2014 Clinical Teams FY13: Prepare for Bundled Payments PCI CHF Total Hip Total Knee Hip Fracture CVA TIA FY14: Spread Outcomes/Waste Improvement Afib Ablation CABG Cardiac Valve Replacement Bariatric Surgery Total Laparoscopic Hysterectomy Cystectomy Colorectal Surgery Peds Asthma COPD Exacerbation Wave 1 January 2014 June 2017 Clinical Teams Hip and Knee: Next Wave of Improvements Septicemia - Adult Hematological Malignancies Spine Wave 2 Complex ICU Adult Complex ICU and Septicemia - Peds Neonatology Obstetric Deliveries Wave 3 Heart Transplant and VAD Kidney and Liver Transplant Pediatric Cardiac Surgery Wave 4 PCI + Diagnostic Cath: Next Wave of Improvements Cerebrovascular Disease: Next Wave of Improvements Renal Failure Wave 5 Colorectal Surgery: Next Wave of Improvements Lung Transplant Psychological and Behavioral Disorders Wave 6 Nephrectomy and Prostatectomy July Clinical Teams Spring FY17 Lower Extremity Wound and Amputation OR Utilization Improvement Infusion Denials Improvement Cardiac Bundled Payment Preparation (AMI and CABG) Fall FY18 Inpatient Imaging Appropriateness Avoiding Outliers in Length of Stay Delirium Management and Prevention Inpatient Mobility Improvement

8 IMPROVEMENT PROCESS 8

9 Care Redesign Summary Why? What do we do? How do we do it? What results have we achieved? To improve quality and experience outcomes for our patients To improve value for our patients To simplify and streamline processes Guide redesign efforts for identified patient populations across the health system Bring expertise related to project management, quality improvement, and change management Pair members of our team with clinical leaders and process experts of the identified populations to facilitate improvement work Complete data analysis, stakeholder interviews, and process maps Determine project goals, identify key drivers, brainstorm and select solutions Develop solutions Implement and monitor results Improvements for patients and care teams across 30+ teams Demonstrated LOS and cost savings Collaboration with electronic health record and Research Services to develop cutting edge solutions Developed an annual assessment process to select future projects 9

10 The How of Care Redesign The Magical Combination Clinicians Staff Care Redesign Project Manager Clinical Expertise + Process Expertise + Project Management, Quality Improvement, and Change Management Expertise = 10

11 Team Co-Leads and Project Managers are Assigned at Project Launch Care Redesign Team Co-Leads Physician and Nurse Serves as the clinical expert for the care redesign population Identifies multidisciplinary membership and key stakeholders Establishes professional, collaborative, inclusive atmosphere for the team Ensures that evidence and leading practice are incorporated throughout the design phase Serves as the bridge to build system-wide relationships and consensus among physicians and nurses in partnership with hospital-level physician and nurse leads Uses/supports data to focus initiatives and drive care redesign Supports the identification and prioritization of initiatives Presents team status to Oversight Committee Care Redesign Project Manager Manages project and guides team through improvement process: Schedules and facilitates meeting Communicates and follows up on action-items between meetings Analyzes data to identify key drivers Collaborates with Core Team and Sub-Team members to design and document future state Supports Care Redesign Team Co-Leads in identification of risks and barriers Develops performance reports and targets with team Manages implementation of care redesign elements Page 11

12 Program Leadership Partners Care Redesign Medical Director Acts as physician leader to break down organizational barriers, address issues raised by peer clinician leaders and shepherd project through appropriate clinical committees Mentors Clinical Team co-leads Works with co-leads to ensure clinical guidelines incorporate latest evidence Collaborates with Project Manager and Care Redesign Program Leads to refine project scope and to ensure interventions are likely to achieve targeted impacts Nursing Lead Mentors team co-leads and ensures nurse involvement across DUHS Communicates progress to DUHS nursing leadership and facilitates CPC approval process Facilitates collaboration with patient and staff education Coordinates with nursing informatics to ensure appropriate integration of Care Redesign workflows with Epic 12

13 Other Key Partners Involved with Projects Each team is partnered with a representative from: Epic provider builder Research services Clinical education and professional development Finance Multidisciplinary core team is assembled with members from Providers, Physicians, Ancillary Services (pharmacy, case management, PT, OT, pharmacy, respiratory therapy, etc), Patient Education, Patient Advisory Council member 13

14 Improvement Process Analyze current state process and data; Conduct staff and patient interviews; Gather best practice evidence; Identify key drivers; Launch Core Team Validate key drivers and establish subteams; Brainstorm improvement strategies with subteams; Create prioritized list of initiatives; Develop initiatives Complete initiative design; Develop key performance indicators; Finalize any pilot plans Develop implementation plan, that includes communication and staff education plan; Finalize SBARs and submit to Epic Implement; Monitor go-live with teams and adjust as needed; Review performance reports; Launch continuous improvement 14 Tollgate sessions setup with project manager and Care Redesign leadership team to assess project direction and discuss any support needed

15 Care Redesign Oversight Committee Responsibilities Membership Provide oversight for the Care Redesign program Review and approve Team Charters Review and approve design initiatives Hold teams accountable to achieve team milestones and performance targets Review progress to ensure redesign initiatives are on track Resolve issues and remove barriers to making progress Support prioritization and phasing of new projects Chief Medical Officer, DUHS (Chair) Executive Vice President, DUHS Chief Nursing Officer, DUHS Hospital Presidents Chief Health Information Officer, DUHS Associate Chief Financial Officer, DUHS Associate VP Performance Services, DUHS Clinical Department Chairs (Ad Hoc) 15

16 Examples of Improvement Tools Used 16

17 INTERVENTION EXAMPLES 17

18 Intervention Examples Patient Impact Theme Intervention Team Improvement of pain control Improvement of time to therapy Strategies to reduce complications Improvement of outpatient access Improvement of patient education and expectations Multimodal pain management Hip and Knee Replacement Development of pain regimes; pain education added to Lung Transplant pre-op class NEWS score and BPA alerting RN Sepsis Efficiency of induction process OB Transfer center workflow design Stroke Sedation protocol PICU, PCICU, Adult ICU Protocol for evaluation of GI hemorrhage Proactive identification of need for dialysis Infection prevention tactics Febrile neutropenia prophylaxis Shifting chemotherapy regimens to outpatient setting Expedited vascular access process Transitional medical home program Patient journey board Careplan in Epic and DUHS education materials Heart Transplant and VAD Renal Failure Adult ICU Hematologic Malignancies Hematologic Malignancies Renal Failure ICN Peds Cardiac Surgery Colorectal Surgery, Urology 18

19 Intervention Examples Care Team Impact Theme Intervention Team Increased data and information available to guide decision making Improvements in workflow and communication Epic clinical data summary view; patient risk assessment and mitigation process Epic clinical data summary view Daily rounding process standards; patient family communication bundle ICU and transplant joint rounds Kidney and Liver Transplant PICU, PCICU, Adult ICU Adult ICU Lung Transplant 19

20 PERFORMANCE REPORTING 20

21 Outcome Performance Reporting 21

22 Team Specific Key Process Metric Reporting Examples 22

23 COMMUNICATION TOOLS 23

24 Communication Tools Project and Program Project Biweekly project updates to coleads and key stakeholders Routine co-lead meetings to discuss project strategy Program Routine meetings with hospital CMOs/CNOs Quarterly updates at hospital leadership councils Monthly Care Redesign Oversight Committee meetings à team report-outs and program updates Featured teams and patient impact stories on Duke Intranet Sharepoint website (*next slide) 24

25 Care Redesign Sharepoint Site Share monthly project updates and key learnings List of all current projects Post implementation toolkits for new staff training Submit new project ideas List and pictures of Care Redesign project managers 25

26 PRIORITIZATION METHODOLOGY TO SELECT NEW PROJECTS 26

27 Annual Project Planning Timeline Winter Fall Fall projects launched Collect project ideas from stakeholders and DUHS leaders Complete variation and external benchmark analysis Spring Care Redesign Oversight Committee sets priorities for upcoming fiscal year Score top ~15 projects with prioritization matrix Spring projects launched Summer Care Redesign Oversight Committee selects projects using prioritization matrix 27

28 Fall Prioritization FY18 Project Matrix Prioritization Summer 2017 # Project Ideas Quality/ Safety Priority Primary Patient Experience Margin Improvement Secondary Ease of Implementation Total - Magnitude of Impact 1 Liver failure Low Low Medium Medium Inpatient imaging utilization Medium High Medium Not Complex Inpatient mobility improvement Medium High High Complex Endoscopy cancellation rate Low High Medium Medium Readmissions - Hospital care transitions model High Medium Medium Complex Rapid IP to OP transition for DPC patients Low Medium Medium Complex Peds Neurology and Neurosurgery LOS Low Medium Low Medium LOS Outlier management Medium Medium High Medium Sepsis High Medium Low Medium Sickle Cell readmissions Low Medium Medium Medium ICN LOS improvements Low Low High Complex Surgical patient flow Medium Medium Medium Complex Tracheostomy Low Medium High Complex Delirium management and prevention High Medium High Complex Avoidable ED Utilization Medium High Low Medium

29 CASE STUDY 29

30 Nephrectomy and Prostatectomy Project selected in Fall 2016 Formal memo noting roles and responsibilities sent to physician and nurse co-lead Multidisciplinary core team kicked off in December

31 Define/Measure - Improvement Phase Project charter drafted Data analyzed: Vizient comparative data analyzing LOS, readmissions, and mortality Internal direct cost/case data analyzing variation by provider and service group HCAHPS patient experience Other process metric data analyzed as relevant (i.e. OR case times, infections, NSQIP, etc) Stakeholder interviews conducted and key themes summarized Best practice evidence analyzed by Research Services team 31

32 Cost Domain Level Analysis Nephrectomy Prostatectomy Kelli Notes: [1] Cost is the total direct cost defined by DUHS [2] Analysis is for Adult cases (defined as patients ages 18 and up at time of service) [3] Data Source is FY15-16 (July 2014 June 2016)

33

34 Analyze - Improvement Phase Quantitative and qualitative data summarized into key driver diagram Subteams formed to tackle key drivers Brainstorming sessions held to validate key drivers and brainstorm solutions 34

35 Subteam Structure Pre-op Periop Post-op Standardization of Surgeon Practice Patterns 35

36 Improve and Control Improvement Phase Subteams complete intervention design Develop key process metrics Finalize any pilot plans Develop implementation plan, including communication and staff education plan Finalize IT requests and submit to Epic Implement; monitor and adjust as needed Review performance reports and launch continuous improvement 36

37 Standardized Practice Patterns ERAS Prostatectomy and Nephrectomy Pre-Op Care 37

38 Standardized Practice Patterns 38

39 Standardized Practice Patterns 39

40 Implementation Slide Example - Implement Early Recovery After Surgery (ERAS) Principles Why Change? Each of the surgeons performing prostatectomies and nephrectomies has different pre-op and post-op practice patterns. There is no standardized anesthesia pathway for this patient population. Data for other patient populations shows that implementing ERAS principles reduces length of stay and reduces complications. What are the Changes? Standardize pre-op and post-op practice patterns and hardcode via pre-op and post-op order sets Create narcotic sparing anesthesia pathways for prostatectomies and nephrectomies Create pocket cards to remind providers of which text to use in the patients AVS and which drugs to prescribe at discharge What is the Plan for Changing? Orders sets will go live in Epic on 7/19/17 Physicians will be educated during Grand Rounds on 7/19/17; the Epic Concierge will set up favorites by 8/1/17 Nursing staff and anesthesia staff will be educated through July 2017 Go live will be on 8/1/17 Who Should I Contact with Questions about This Change? Urologist Project Co-lead ERAS Coordinator Clinical Leader on 6300 Project Co-Lead Anesthesiologist Urology APP 40

41 Enhanced Patient Education 41

42 Process Metric Examples 42

43 Initial Outcome Data Results % Improvement Metric (Pre to Post - 5 months) HCAHPS Pain Management 3% 30 Day Readmission Rate 23% ALOS 7% 43

44 Key Lessons Learned Importance of physician and nursing co-lead to drive change Good quantitative and qualitative data drive decision-making Project management resource can help move work forward faster Process metric and outcome data feedback is critical to teams Important collaborators include Epic, Finance, and Research Services Identify operational home for control and continuous improvement phase 44

45 FUTURE DIRECTIONS 45

46 Continue to evolve improvement approach Integrate approach with Lean quality management system Better engage frontline staff and connect key initiatives across projects Hardwire changes through standard work and new management tools Pilot clinical consensus group Develop approach and framework Leverage current infrastructure and identify key metrics of success Develop 3 year strategic goals Complete best-practice benchmarking sessions with other programs Outline key priorities with Oversight Committee Advance on Value Transition goals and gain more experience in population health projects 46

47 Q&A 47

48 Question and Answer What tactics to reduce clinical variation have worked at your organization? What have been the challenges? What sustainment tactics have you used? How does your organization prioritize areas to focus on? 48

49 Contact Information Caitlin Daley Dr. George Cheely Dr. Tom Hopkins 49

50 Performance Services Website: Duke Performance Services 50