Clinical Pathways: A Platform for Continuous Quality Improvement. Jane Lavelle, MD Aileen P. Schast, PhD Office of Clinical Quality Improvement

Transcription

1 Clinical Pathways: A Platform for Continuous Quality Improvement Jane Lavelle, MD Aileen P. Schast, PhD Office of Clinical Quality Improvement

2 Checking In How many in the audience provide clinical care to patients? How many in the audience are hospital administrators? How many in the audience work at a hospital where clinical pathways are used?

3 The CHOP Philosophy The Clinical Pathways Program brings multidisciplinary healthcare teams together to create standardized, evidencebased, shared mental models of medical care. Our clinical pathways combine principles of quality improvement science, organized workflows, and clinical decision support tools to make it easier for healthcare teams to make the best decisions for patients at the point of care. Information measured from each pathway is iteratively incorporated into care delivery to close the gap between evidence and practice.

4 What are we trying to accomplish Patient & Provider Resources Link to QI Project Data Population Evidence External Resources CHOP Program Med Alerts (if applicable) Authors Revision Dates

5 Decision Support Make it easy to do the right thing AKA the DO-NOT-Order Set Link to Internet Pathway Recommended Evaluation is pre-checked

6 Pathway Development - ~6-9 months 1) Submit Pathway Request 5) Team Reviews Test Link, More Editing 2) Meet with assigned Improvement Advisor 4) Final Draft Sent to Web Team Decide on Decision Support 2) Team & IA Perform Iterative Drafting 3) Final Draft reviewed by Pathways Director & Program Manager This step is the most critical and time consuming. 1. Must be multidisciplinary 2. Teams meet biweekly 3. Team reviews evidence and develops algorithm 4. Later drafts should be shared with broader stakeholder groups to ensure accuracy and acceptability 6) Final Pathway Published Online! Decision support active in EMR 7) Pathway Education Roll-Out 8) Monitor & Maintain Pathway

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8 Improving the Evaluation of Shunt Obstruction Reduce radiation exposure of patients with VP shunt by: Reducing unnecessary scans Use of low dose radiation protocol Reducing unnecessary shunt survey Reduce number of revisits in 72 hours Improve interdisciplinary team work and communication

9 Decision Support Collaborative effort among ED, Radiology, and Neurosurgery providers produced clear pathway with recommendations including the use of a new lower dose CT scan protocol in addition to providing specific indications for obtaining a shunt series which included less images.

10 Improvement

11 Improvement

12 Improvement Marchese, R., Schwartz, E., Heuer, G., Lavelle, J., Huh, J., Bell, L., Luan, X., and Zorc, J. (in press). Reduced Radiation in Children Presenting to the ED with Suspected Ventricular Shunt Complication. Pediatrics.

13 Post-Operative Care for Spinal Fusion Goal: to standardize the post-operative care of the AIS patient undergoing a posterior spinal fusion. Focused on pain control and mobility Required collaboration among orthopedic surgeons, anesthesiologists, and nurses.

14 Decision Support

15 Improvement Post-operative LOS had been 5.5 days consistently. Muhly, W.T., Sankar, W.N., Ryan, K., Norton, A., Maxwell, A.G., DiMaggio, T., Farrell, S., Hughes, R., Gornitzky, A., Keren, R., McCloskey, J. & Flynn, J.M. (2016). Rapid Recovery Pathway Following Spinal Fusion for Idiopathic Scoliosis: A Quality Report. Pediatrics, 137(4): e Since pathway implementation, median LOS has consistently been 3.3 days Pathway Live Order Sets Live

16 Evaluation of the Febrile Child for a UTI Decrease unnecessary laboratory tests, expenses Decrease use of expensive antibiotics and resistance in community Spare patients unnecessary testing, f/u, pain

17 Implementing the Pathway POC urinalysis increased 20% to 64% Pathway Go Live Lab urinalysis decreased 75% to 25% Nursing Re-Education First improvement focus was on how the urine sample was tested wanted to decrease the slower and more expensive lab testing Urine culture following a negative screen decreased 22% to 6% Next turned to decreasing culturing samples that screened negative

18 Be Curious In young children, a negative screen is almost always associated with a negative culture but we are catheterizing hundreds of children every year! Is there a better way to safely screen patients that does not use a catheterized sample?

19 Cathing s a Drag Use a Bag! 100% Cathed Converted Bagged 90% 4 80% 70% 60% % 0 40% 30% Target<30% % 10% 0%

20 Improvement Implementation PDSA Cycles Project Timeline Project Start PDSA Cycles Project Moves to Sustain

21 Sustaining Improvement More than 2000 children have been spared an unnecessary catheterization Lavelle, J.M., Blackstone, M.M., Funari, M.K., Roper, C., Lopez, P., Schast, A., Taylor, A.M., Botos, C., Henien, M., & Shaw, K.N. (2016). Two-Step Process for ED UTI Screening in Febrile Young Children: Reducing Urethral Catheterization Rates. Pediatrics, 138(1): e /peds

22 Other Improvements and Impact As of 2015, approximately 68% of children treated in ED or Main Hospital were cared for by Clinical Pathways Bronchiolitis Pathway Sickle Cell with Fever Pathway Oncology Patient with Fever Anaphylaxis Pathway Febrile Infant Pathway Albuterol use decreased from 70% to 18% Since 2014, admission rate decreased by 33% Admissions decreased by 16% in ED, 33% in Oncology clinic Days spent in hospital decreased by average of ~3 days Since 2014, admission rate decreased by 60% The proportion of febrile babies who do NOT get an LP in the ED has doubled.

23 Additional Benefits Peer-reviewed publications (since 2015) 9 Posters/Presentations (since 2014) 26 Book Chapters, Reviews 13 CHOP Staff involved in pathway development: 481 Physicians 274 RNs, APPs 98 FLOCS 98 Pharmacists 11 Physicians granted MOC credit for participation in pathway development in

24 Additional Impact >14,000 Chop.edu/Pathways visitors per month Avg 9,500/month external visitors Avg 4,925/month internal visitors Average 8 inquiries/month from outside hospitals Jan Dec 2016 Stats

25 What Does it Take? Know which conditions are ripe for a pathway Good guidance or need for consensus The right team Strong lead, all stakeholders represented A good facilitator Improvement Advisor who understands the milieu - does not need to be a content expert Informatics support Strong analytics team when it s time to do QI

26 Find us at or us at Office of Clinical Quality Improvement Katie Halkyard, MPH - Program Manager Jane Lavelle, MD Medical Director Aileen Schast, PhD Director, CQI Ron Keren, MD Vice President, Quality

27 Driving High-Reliability and High-Value Care via Clinical Pathways Andrew R. Buchert, MD, FAAP Gabriella A. Butler, MSN, RN Clinical Resource Management Children s Hospital of Pittsburgh of UPMC

28 Who we are 315-bed free-standing quaternary care pediatric hospital 41 bed ED and Trauma Center, 36 Bed PICU, 12 Bed CICU, 55 Bed NICU 8 bed rehab unit located at a satellite facility 10-story, 300,000-square foot research facility Department of Pediatrics with 19 Divisions, and also home to pediatric divisions of the Departments of Surgery, Radiology, CriMcal Care Medicine, Thoracic and Cardiovascular Surgery, Urology, Orthopaedic Surgery, and Pathology Pediatric Residency and Fellowship Programs 85 General Pediatrics Residents, 16 Internal Medicine-Pediatrics Residents, 9 Triple Board Pediatrics- Psychiatry-Child and Adolescent Psych Residents Pediatric Subspecialty and Surgical Subspecialty Fellowships Clinical site for other non-pediatric residency training programs UPMC Surgical, Surgical Subspecialty, Anesthesiology, Radiology, Emergency Medicine, Family Medicine, Psychiatry, and Pathology residents

29 Strategic IniMaMve Commitment to zero harm to both paments and staff High-value care Develop evidenced-based, technology enabled clinical pathways that span the episode of care (preadmission, during the admission, and postadmission) for high-cost and high-volume pediatric condi<ons

30 Desired Outcomes Reduce Unnecessary variamon in care Unplanned Readmissions Acute care Length of Stay (LOS) Improve Outcomes (Quality, Safety & Financial metrics) ConMnuity of care (pre and post admission) PaMent, Family & Provider samsfacmon Eliminate Non-value added tesmng

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32 Guideline vs Pathway Clinical EffecHveness Guideline Evidence-Based Limited EducaMon Variable interdisciplinary collaboramon Focused se]ngs of Care Clinical Pathway Evidence and consensus-based Formal educamon and rollout Inter- and MulM-disciplinary Across the ConMnuum Real-Mme measurement & feedback loop Strategic Alignment

33 QLIK SCREEN SHOTS

34 Measurement & Feedback

35 EvaluaMng Clinical Pathways - Impact Impact Health of PaHents OrganizaHonal Systems of Care Hospital and Health System Individual PaHents i.e. Reducing readmissions, LOS, infec<on rates, central line u<liza<on PopulaHon i.e. Reduce exposure to unnecessary care, focus on health promo<on & wellness Processes, workflow, pahent flow i.e. Improving throughput, decrease bed u<liza<on, enhance medica<on delivery Economics i.e. Improve revenue and decrease at-risk revenue, reduce variability of controllable costs Strategy i.e. Create buy-in for addi<onal pathways, promote and support service-lines, grow market

36 1 Idea GeneraMon 2 IdenMfy Team 3 Gather Evidence 4 Design & Development 5 IT Build 6 EducaMon & Rollout 7 Measurement & Feedback 8 Disseminate Knowledge Process

37 GOALS OF APPENDICITIS PATHWAY Measureable Elements of AppendiciHs Pathway Pre-operaHvely: NPO AdministraMon of CefoxiMn (Flagyl/ Cipro for PCN Allergy) within 60 minutes of the incision Post-operaHvely: Uncomplicated Order to DC IVF if taking PO Regular diet order before transferred to inpament unit Order for OOB Order for PO Oxycodone/Tylenol Order for D5 ½ NS w/ 20KCL No anmbiomcs (unless fever, suspected sepsis) No addimonal labs Post-operaHvely: Complicated Order for Strict Is/Os Order for Clear Liquids Order for OOB Order for D5 ½ NS w/ 20KCL AdministraMon of Ertapenem for (min) 24 hours Order for PO Oxycodone/Tylenol

38 AppendiciMs Pathway Impact Health of PaHents OrganizaHonal Systems of Care Hospital and Health System Individual PaHents Reducing readmissions, LOS, infecmon rates, central line umlizamon PopulaHon Decrease CT umlizamon (referring organizamons) Processes, workflow, pahent flow Improving throughput, decrease bed umlizamon, medicamon delivery Economics Improves revenue and decrease at-risk revenue Strategy Creates buy-in for addimonal pathways

39 LOS (hours) hrs Actual LOS LOS - Complicated AppendiciHs Consensus for Management Obtained Actual LOS for PaMents "On Post-Op Pathway" Actual LOS for PaMents "Off Post-Op Pathway" Powerplan released Median LOS (prior to Pathway) Median LOS for PaMents"On Post-Op Pathway" Median LOS for PaMents "Off Post-Op Pathway" Controllable Cost/Case - Complicated AppendiciHs 109hrs Goals Limit IV AnMbioMcs post-surgery Eliminate use of central lines LimiMng post-op labs LimiMng IV NarcoMcs (encouraging PO) Encouraging ambulamon Advancing diet ajer surgery What we changed Provided retrospecmve clinical & financial data Developed standardized pre- & post-op management approach Supported design of new PowerPlan Implemented sustainable feedback loop What we didn t change Staff Surgeons PaMent PopulaMon Surgical intervenmons Jul 14' Aug 14' Sept 14' Oct 14' Nov 14' Dec 14' Jan 15' Feb 15' Mar 15' Apr 15' May 15' Jun 15' Jul 15' Aug 15' Sept 15' Oct 15' Nov 15' Dec 15' Jan 16' Feb 16' Mar 16' Apr 16' May 16' Jun 16' Jul 16' Aug 16' Sep 16' Oct 16' Nov 16' Dec 16' 100 hrs Controllable Cost/Case Impact 31% decrease ALOS 7% decrease in controllable cost

40 LOS (hours) Feb hrs Apr-2013 Jun-2013 Aug-2013 Actual LOS Oct-2013 Dec-2013 Feb-2014 Apr-2014 Jun-2014 Aug-2014 Oct-2014 Actual LOS for PaMents "On Post-Op Pathway" Actual LOS for PaMents "Off Post-Op Pathway" LOS - Uncomplicated AppendiciHs Consensus for Management Obtained Dec-2014 Feb-2015 Apr-2015 Jun-2015 Aug-2015 Powerplan released Oct-2015 Dec-2015 Controllable Cost/Case - Uncomplicated AppendiciHs Feb-2016 Apr-2016 Median LOS (prior to Pathway) Jun-2016 Aug-2016 Oct-2016 Median LOS for PaMents"On Post-Op Pathway" Median LOS for PaMents "Off Post-Op Pathway" 29 hrs 26 hrs Dec-2016 Goals Limit IV AnMbioMcs post-surgery Eliminate use of central lines LimiMng post-op labs LimiMng IV NarcoMcs (encouraging PO) Encouraging ambulamon Advancing diet ajer surgery What we changed Provided retrospecmve clinical & financial data Developed standardized pre- & post-op management approach Supported design of new PowerPlan Implemented sustainable feedback loop What we didn t change Staff Surgeons PaMent PopulaMon Surgical intervenmons Controllable Cost/Case Impact 17% decrease ALOS 3% decrease in controllable cost

41 Strategic Impact Increasing NICU Demand Average Daily Census 52.5 InpaMents: 1074 FY15 (rolling 12 months April15-Mar16: 1253) ObservaMon PaMents: 45/year ALOS: 18.2 days (excludes Obs pts)

42 Comparison: NICU Days All Peer Hospitals Select Peer Hospitals CHP 1020 patients out of 3865 (26%) spent at least 1 day in a NICU 171 patients out of 625 (27%) spent at least 1 day in a NICU 41 patients out of 87 (47%) spent at least 1 day in the NICU Patients with Principal Dx Hyperbilirubinemia 7/1/14-6/30/15

43 Isolated Hyperbilirubinemia Total LOS for InpaHents LOS (hours) UCL:46 LCL:12 Consensus Obtained UCL:33 LCL:18 NICU Avg: 31 Avg:25 Acute Care:21 Goals Decrease inappropriate admissions to the NICU Decrease LOS More efficient resource umlizamon Align management approach with peers 5 Apr-2015 Jul-2015 Oct-2015 Jan-2016 Apr-2016 Jul-2016 Oct-2016 Isolated Hyperbilirubinemia (All Units) Controllable Cost per Case What we changed StandardizaMon of pament placement Developed standardized management approach Implemented sustainable feedback loop Provided educamon for targeted staff Consensus Obtained Controllable Cost/Case Impact 14% decrease in LOS 5% decrease in controllable cost Dec 14' Mar 15' Jun 15' Sept 15' Dec 15' Mar 16' Jun 16' Sep 16'

44 Planned Cholecystectomy UCL:33 Planned Cholecystectomy PaHents Median LOS/month (hours) Consensus Obtained Goals Decrease post-operamve admissions and overnight stays More efficient resource umlizamon ProacMve and consistent pain and nausea management LOS (hours) Avg:27 LCL:22 UCL:23 Avg:[VALUE] What we changed Clear, consistent expectamons discussed pre-operamvely PaMent/family educamon Shijing case Mmes to first case Developed standardized management approach with anesthesia Provided educamon and nurse-acmvated future orders in SDS Implemented sustainable feedback loop 6.5 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Impact 53% decrease in LOS

45 Current Pathways Pathways Impact & Outcomes Complicated AppendiciMs Uncomplicated AppendiciMs EaMng Disorders IniMaMon of Propranolol for Hemangioma PaMents Isolated Hyperbilirubinemia Planned Cholecystectomy 7% decrease controllable costs since July % decrease LOS since Jan % decrease controllable costs since July % decrease controllable costs since March % decrease controllable costs since Aug % decrease controllable costs since December % decrease in LOS

46 EvaluaMon and SelecMon Process PredicHng potenhal impact through the analysis of actual clinical & financial data, per CHP DataWarehouse, Cost Management System, & PHIS Compiled a list of 21,696 pahents that occupied a bed in FY16 (via DW) Determined their Final Diagnosis & LOS Determined cost/pament in Cost Management System Grouped paments into relateddiagnosis categories Generated opportunity score for each category based on: Volume Controllable Cost LOS VariaMon LOS Highest Greatest variamon Cost Highest Cost Greatest VariaMon Decision: Clinical Pathway or Guideline Volume Highest Volume Peer Benchmarking

47 AddiMonal ConsideraMons Is this potenhal pathway prachcal at this Hme? Do we have the capacity? Would all of the stakeholders have buy-in? Do we have the resources to support this potenhal pathway? To perform an analysis of the current state/weigh pros and cons To develop and support the pathway - includes data analysis, PowerPlan development & QlikView dashboard What evidence is available? Is this an exismng (In-house) clinical effecmveness guideline? Is there peer-reviewed, published evidence? Do any of our peer insmtumons have a clinical pathway or guideline?

48 Improving Asthma Care Across the ConMnuum

49 Improving Asthma Care Across the ConMnuum Create consistency in definihons, workflows, management When to Step-Up / Step-Down therapy When to refer Improve the pahent/family experience Common educamonal materials and AcMon Plan Appropriate expectamon se]ng Enhance communicahon MiHgate barriers to ophmal health

50 Improving Asthma Care Across the ConMnuum

51 QuesMons?