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1 Today s Session: Monitoring Quality to Assure Improvement WebEx Quick Reference Welcome to today s session! Please use Chat to All Raise your hand Participants for questions For technology issues only, please Chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text 1

2 When Chatting Please send your message to All Participants If you re joining with colleagues, please type the organization you represent & the number of people joining from your organization. Example: Midwest Health Alliance 3 Please type your name and the organization you represent in the chat box! Example: Chris Jones, Midwest Health Alliance 2

3 IHI Expedition Team Kathy Luther, RN, MPM Vice President, IHI Jill Duncan, RN, MS, MPH Director, IHI Kayla DeVincentis Project Coordinator Today s Guest Faculty Kevin Little, PhD IHI Improvement Advisor Principal, Improving Ecological Design. LLC Hoa Cooper, RN, BSN, MHSA, NEA-BC OSF Saint Francis Medical Center 3

4 Agenda Welcome & homework review Measuring, Monitoring, and More Wrap up and next steps Expedition Objectives Participants will be able to... Identify potential cost reduction quality improvement opportunities for your organization. Prioritize high-return ideas and map to energy grid for your organization. Develop a set of quality metrics as well as a financial measurement system to capture savings across your portfolio. Obtain the tools and confidence to build and execute on a portfolio of interventions to achieve results. Plan small tests of change you can test throughout the Expedition. 4

5 Driver Diagram IHI s Cost + Quality Collaborative Work AIM Reduce operating expenses 1% per year while continually maintaining or improving quality. PRIMARY DRIVERS WILL Align Enterprise WILL Engage Staff, Physicians and Patients IDEAS Identify Waste EXECUTION Prioritize, Manage Portfolio of Projects to Remove Waste SECONDARY DRIVERS Establish True North Metrics (Big Dots) Align Waste Reduction Strategy Throughout Organization Align Systems for Efficiency Adopt Integrated Performance Measurement Systems Engage Staff in the What & Why of Value Delivery Establish Data & Feedback Loops Patient & Family Perspective of Waste Ensure a Safe Environment for Sharing Ideas Develop New Skills at All Levels Eliminate Clinical Quality Problems Optimize Staffing Maximize Flow Efficiency Manage Supply Chain Reduce Mismatched Services overuse, coordination Reduce Environmental Waste (Healthy Hospital Initiatives) Evaluate Cost & Quality Impact Prioritize Projects and Manage Organizational Energy Create a Portfolio of Projects Solve Problems and Execute PDSA Cycles Measure and Monitor Results Homework Review - Ground Rules We learn from one another All teach, all learn Why reinvent the wheel? - Steal shamelessly This is a transparent learning environment All ideas/feedback are welcome and encouraged! 5

6 Homework Review For your selected approach, identify and discuss several key waste streams. For one (1) of the streams discuss how you d build a financial model Royal Commission Medical Center Yanbu Industrial City - KSA IHI Expedition: Partnering Quality & Finance Teams to Improve Value 6

7 Assignment # 3 For the (Delay in Patient s Discharge): After collecting the data for about 3 weeks using the designated checklist, the following key waste streams were identified as the main causes behind the delay in patients discharging form the hospital: 1. Lab test results delay: the delay of the results of the patient s lab tests may postpone the discharge of the patient. The most responsible physician is usually linking his/her discharge decision to the lab test result when the patient's clinical signs makes the him/her fit for discharge. 2. Pending transfer to another facility: the hospital s ambulance crew would not transfer any patient from the hospital premises to another hospital unless there is a written approval from the executive director of medical affairs (EDMA). This is sometimes not achievable especially during the weekends, when the EDMA is not around. 3. Patient needs an assisting equipment before being discharged home: sometimes, the patient stays in the hospital beyond the planned discharge day due to the non-availability of needed assisting equipment he/she might need at home after leaving the hospital. Assignment # 3_continued An estimate of any extra unnecessary patient s stay at the hospital was calculated, in collaboration with the finance department staff who participate in the IHI expedition team: The average cost of the patient occupancy of the bed/day is SAR 400; this value can be divided upon 2 parts: SAR 350 which cover the fixed costs (costs of utilities, maintenance and salaries), the meals served, the bed and the toilet room supplies and SAR 50 which cover the medications and the medical supplies provided to the patient during his/her extra days stay. 7

8 Assignment # 3_continued According to the data collected by two of the team members, the patients stay on average 4 extra (unnecessary) days per week. This means a total of (4x52) = 208 days per year. This means that on average, an avoidable cost of $ 83,200 is incurred to the hospital every year because of the extra (unnecessary) days of patients stay. Measuring, Monitoring, and More Kevin Little, Ph.D. Informing Ecological Design, LLC Improvement Advisor, IHI 8

9 MEASURING Measuring: Cost and Quality Processes and projects need measures to assess performance and drive learning Value for patients and payers is a function of cost and quality: Value = quality/cost 9

10 Measurement Tasks by Project Phase Project Phase Set-up/Plan Doing the Project Study/Act (Wrap Up) Measures work Define useful Q + C measures to track performance to estimate project impact Track measures to assess progress and support learning Create and share monthly summary Estimate project Q+C impact (annualized) Four types of opportunities Reduce Harm to patients (type H) Improve Delivery of Care (type D) Improve Supply Chain performance (type S) Improve Administrative performance (type A) Close enough to PDSA to remember! 10

11 Quick Poll 1. Yes / No: Does your portfolio include projects that reduce the direct harm to patients? 2. Yes / No: Does your portfolio include projects that improve delivery system performance? 3. Yes / No: Does your portfolio include projects that improve supply chain value? 4. Yes / No: Does your portfolio include projects that reduce waste in administrative/support area processes 5. Yes / No: Excluding clinical quality projects (type H), how many have started thinking of balancing quality measure? Type H Project: CLABSI Improvement OSF SFMC changed protocols, policies and central venous catheter kit components CLABSI Rate (infections per 1000 central line days) FY 2010 FY 2011 Change Housewide % Adult population % Quality measurement immediately available from OSF tracking system No extra work to measure quality. 11

12 CLABSI example (con t) Financial estimates: based on incidence Estimated Direct Costs ($ millions) FY 2010 FY 2011 Change Housewide $ 8.6 $ % Adult population $ 6.7 $ % Financial estimates had to be generated (not immediately available). required local financial staff to be part of team to calculate and validate calculations. Type A Project : Change in Staff Compensation Interim Health, a home health agency, changed from reimbursement/visit to salaried (moved away from fee for service!). They are estimating they will save $1.5 million in wages for 2012; they are working with 40-fewer staff and business has grown by 3%. --June 2012 monthly check in report, Impacting Cost & Quality, summarized by J. Duncan Financial impact estimate immediately available from existing reports and measurements 12

13 Compensation Example (con t) Interim saw some attrition in staff initially but over time they have noted increased staff satisfaction (95% retention for 2012 to date); great (per the CFO) patient satisfaction scores and no negative impact to their clinical outcomes data. They are seeing increased protocol use, improved visit management by staff, more telephone support and increased use of tele-health for some of their follow up. --June 2012 monthly check in report, Impacting Cost & Quality, summarized by J. Duncan Quality Advisor 13

14 OSF CLABSI Interim Staff Compensation Tracking your measures over time: Tell the story MONITORING, REMINDER 14

15 Readmission Within 30 days (all) Median Apr 10 Jun 11 1 st 4 months of Fiscal Year Pilot started AMU & 5G July Readmission Rate: after Any Disease Target OSF readmissions project SCIP 3 Antibiotic Discontinuation 2Q 2010 SCIP 3 Prophylactic Antibiotic Discontinued Within 24 hrs After Surgery End Time 2Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q percent 3.45% 16.67% 22.86% 12.12% 13.79% 42.31% 53.33% 95.83% 94.44% 96.30% 90.48% 90.91% 81.82% % p chart T emporary: UCL = 87.87, CT L = , LCL = Inspected M ean = 23.11, Counts M ean = % 100 Top 10% - 99% Top 10% % % % S tate Ave Nati onal State Ave - 92% Ave % National Ave - 91% UCL % % 92.31% 94.12% 93.75% % % % % Percentage CTL LCL % 2Q Automatic % prophylactic Abx discontinuation and MD Profiling % % 4Q 2007-Concurrent monitoring and revision of CPOE Abx discontinuation Action : Physician Champion Involvement Concerned MDs were counseled Above or Within State and National Average Sustained X10Q % % % 1 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 2010 Quarter and Year Kingsbrook Jewish Medical Center 15

16 Monitoring Tools Links Run charts and Control Charts IHI web tools on Run charts IHI on-demand video Run Charts and Control Charts R.J. Perla et al. (2011), The run chart: A simple analytic tool for learning from variation in healthcare processes, BMJ Quality and Safety, 20 (1), abstract L.P. Provost and S.K. Murray (2011), The Health Care Data Guide: Learning from Data for Improvement, San Francisco: Jossey-Bass. Demonstrations of good performance are foundation for MORE 16

17 Pilot Testing Reminders Adapt good ideas to your world Build staff capacity to modify standard work Increase belief that changes actually work Develop a useful story to share Guidance on Scale of a Test source: Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2 nd edition, Jossey-Bass, San Francisco Associates in Process Improvement, used with permission. 17

18 Managing a Complex Portfolio for Long-term Success CASE STUDY EXAMPLE OSF Saint Francis Medical Center Peoria, Illinois United State 18

19 Introduction OSF Saint Francis Team Quality Plus Cost Steering Team Quality Plus Cost Workgroup Flagship hospital of the OSF Healthcare System 616 bed teaching hospital affiliated with University of Illinois College of Medicine Average daily census = 475 More than 5,900 employees 850 physicians on staff and 215 adjunct staff Quality Improvement Methodology 6 Sigma Methodology Rapid Improvement Model PDCA Aim of Portfolio: Portfolio Management Current Portfolio Projects: Project Name Percentage of Operating Budget Projected Savings Savings to Date 1. Clinical documentation $ 4,000,000 $ 400,000 D 2. Antibiotic Stewardship $ 1,000,000 $ 545,000 S 3. Project BOOST - readmission $ 1,500,000 $ 800,000 D 4. HAC VAP, BSI $ 4,200,000 $ 1,229,000 D 5. Transplant Services $ 500,000 $ 73,000 D 6. Palliative Care Services $ 788,000 $ 220,740 D 7. ED Case Management $ 2,000,000 $ D 8. Core Measure $ 750,000 $ D 9. Care Coordination/LOS $ 1,000,000 $ 580,000 D 10. ED professional fee $ 1,400,000 $ A Totals $ 16,938,000 $ 4,068,480 Savings in US Dollars $ $8,103,970 $4,068,480 Quality Metrics 19

20 Project Progress 1 Charter established 4 Significant progress 2 Activity, but no changes 5 Outstanding success 3 Modest improvement Project Name / Month Document ation Antibiotic Readmis VAP/BSI Transpl Palliative ED CM CM LOS ED fee Portfolio Management Dedicated project sponsor and process owner to continue: Real time monitor process, progress and barrier Review data to identify opportunity Process changes to ensure optimal outcome Accountability Sponsor report out to the leadership team with action plan to close the gap 20

21 Clinical Excellent Quality Plus Cost Hoa Cooper, Dr. Gorman, Jennifer Ulrich, Cassy Horack, Kelly George, Dana Hobson, Bryan Kaiser (meeting bi- weekly) Project Started and need to accelerate and focus on achieving the quality outcome 1. Reducing Readmission: BOOST 2. HAC: fall, CAUTI, Pressure Ulcerculture of safety focus on all three indicators 3. Pay for performance core measure workgroup, readmission 4. Palliative Care inpatient consultation, adult inpatient unit, outpatient palliate care 5. Rehab transfer process proactive screening process, rehab care coordination and discharge process New Projects focus on improving quality and reduce cost and/or increase reimbursement 1. Coding: present on admission, CC/MCC, Complication, coding (grouper) 2. ED Frequent Readmission: ED Case Management/appropriate admission, Palliative Care in the ED 3. ED Professional fee charge capture 3. LOS Management - Care Model/Care Coordination, focus on high opportunity service line, high LOS, transition of care to SNF, Home Health, LTAC etc., Rehab 4. Medical Management/Medicare effectiveness 1. Pneumonia 2. Transplant services The Quality Plus Cost Core Group are to identify opportunity, priority and to motivate & collaborate with the interdisciplinary care team including MD to charter, plan and execute the plan 21

22 Clinical Excellent Guidance Council B. Anderson, L. Wiegand, Dr. Cruz, K. Harbaugh, J. Ritchie, M. Hohulin, Dr. Velazquez, Dr. Martin, Dr. Gorman, Dr. Miller, C. Horack & Hoa Cooper 1 st Wednesday at 0800 pay for performance 4 th Wednesday at 0900 care management Quality Plus Cost BC & BS Pay for performance Quality, Utilization, Patient sat. Cat Pay for performance Core measure, readmission, CLBSI, Mortality Reduce Infection Medication Safety Human Resources Capacity Management Throughput Care transition Culture of Safety Quality plus cost Documentation/coding improvement ED Case Management/Palliative Care LOS Management Medicare Effectiveness DRG specific Pneumonia and Transplant ED Charge Capture The council is to set strategic vision, monitor our metrics, performance indicators, approval of projects, hold leaders accountable to execute the plan against our strategies. Financial Model Cost saving is calculated with actual data as much as possible. Comparing pre and post implementation actual direct cost The team compose to support the alignment of quality plus cost projects Clinical physician Process Improvement Master Black Belt Operation Director of Operation Financial Director of Finance 22

23 Learning from tests of change What has changed in the way you work? Process Improvement is part of what we do, continue to identify gap, opportunity Replicate the process improvement Communicate the success to leader and staff to create excitement and engagement OSF Contact Hoa Cooper

24 Questions? Raise your hand Use the Chat Additional Resources Brooks, DT. Cutting Costs and Improving Quality: The Everett Experience Above all in Frontiers of Health Service Management, Volume 27(2), Winter, Clark, DD et al. Cost Cutting in Health Systems without Compromising Quality Care Eber, M. R., R. Laxminarayan, et al. "Clinical and Economic Outcomes Attributable to Health Care-Associated Sepsis and Pneumonia." Arch Intern Med 170(4): Nolan T., and Bisognano M. (2006). Finding the balance between quality and cost. Healthcare Financial Management Magazine. 2006; 60 (4): O'Brien-Pallas, L., P. Griffin, et al. (2006). "The Impact of Nurse Turnover on Patient, Nurse, and System Outcomes: A Pilot Study and Focus for a Multicenter International Study." Policy Politics Nursing Practice 7(3): Shamliyan, T. A., R. L. Kane, et al. (2009). "Cost savings associated with increased RN staffing in acute care hospitals: simulation exercise." Nursing Economic$ 27(5): 302. Sparling, K. W., F. C. Ryckman, et al. (2007). "Financial Impact of Failing to Prevent Surgical Site Infections." Quality Management in Healthcare 16(3):

25 Quality Advisor Partnering Quality and Finance Teams to Improve Value Expedition Worksheet Align senior support Decide where you want to start Begin to build a partnership with leaders from the finance team What is your aim? (% operating expenses? Cost/case? Cost/discharge?) Engage frontline staff Begin to identify projects that will get you to your aim Begin building a portfolio Consider projects you are already working on as potential for your portfolio Don t know where to start? Consider adapting and testing the Waste Identification Tool Build and leverage partnerships Collaborate with your financial colleagues to review your suggested portfolio and identify what might get at dark green dollars. Develop financial models Monitor quality to assure improvement Define how you will measure the potential and actual savings for each project Identify best practices, financial models, aims & charters for each area of work Learn & spread across a community Develop a series of projects around the ones identified by your team (your portfolio) Develop a sequencing plan for the work Test improvement interventions as well as financial measurement strategies Implement systems to encourage rhythm and discipline around the work Track progress Spread learning and best practices Re-engage & re-commit on a regular schedule 25

26 Homework for Next Call For each project you have identified, run through the Quality Advisor flow chart. For D, S and A type projects, identify appropriate balancing quality measures. Can you use measures already being collected? Send Tweet-like message of 140 characters or less to Jill at jduncan@ihi.org by Monday, August 6 th Expedition Listserv We have set up a listserv for participants in this Expedition to share improvement strategies, and pose questions to one another and faculty. To use the listserv, address an to QualityFinanceExpedition@ls.ihi.org If you would like additional people to receive session notifications please send their addresses to improvementmap@ihi.org. 26

27 Schedule of Calls Session 1 Tuesday, June 12 th 1:30 3:00 EDT Align senior support & build and leverage partnerships Session 2 Tuesday, June 26 th 2:00 3:00 EDT Engage frontline staff & prioritize portfolios Session 3 Tuesday, July 10 th 2:00 3:00 EDT Develop financial models Session 4 Tuesday, July 24 th 2:00 3:00 EDT Monitor quality to assure improvement Session 5 Tuesday, August 7 th 2:00 3:00 EDT Learn & spread across a community Driver Diagram IHI s Cost + Quality Collaborative Work AIM Reduce operating expenses 1% per year while continually maintaining or improving quality. PRIMARY DRIVERS WILL Align Enterprise WILL Engage Staff, Physicians and Patients IDEAS Identify Waste EXECUTION Prioritize, Manage Portfolio of Projects to Remove Waste SECONDARY DRIVERS Establish True North Metrics (Big Dots) Align Waste Reduction Strategy Throughout Organization Align Systems for Efficiency Adopt Integrated Performance Measurement Systems Engage Staff in the What & Why of Value Delivery Establish Data & Feedback Loops Patient & Family Perspective of Waste Ensure a Safe Environment for Sharing Ideas Develop New Skills at All Levels Eliminate Clinical Quality Problems Optimize Staffing Maximize Flow Efficiency Manage Supply Chain Reduce Mismatched Services overuse, coordination Reduce Environmental Waste (Healthy Hospital Initiatives) Evaluate Cost & Quality Impact Prioritize Projects and Manage Organizational Energy Create a Portfolio of Projects Solve Problems and Execute PDSA Cycles Measure and Monitor Results 27

28 Thank You 28