Creating the New Care Design L2 George Kerwin, CEO Patient of Bellin Health Bellin Health Team Objectives Identify the five views of the Production System necessary to Create a Connected Personal Experience Review the results that can be achieved through redesign in each of the five views of the Production System Begin an Organizational Self-Assessment to support new care designs 2 1
Session Outline 1:00 Introductions George Kerwin 1:10 Overview of Bellin George Kerwin 1:30 Production System Design Concepts Pete Knox & Mark Hillert 1:45 Anatomy of the Production System Anne Hale 2:15 Break 2:30 Redesign Case Studies Product View Across the Continuum Stroke Functional Area Nursing Department & Therapies Commonality Aftercare Lori Rexses Laura Hieb Mary Hiltunen Dr. Ed Millermaier 3:45 Connected Personal Experience Driver Diagram Chris Woleske 4:10 Organizational Self Assessment Chris Woleske 4:20 Report Out, Summary and Close Chris Woleske & Pete Knox 3 Pete Knox 4 2
Mark Hillert 5 Anne Hale 6 3
Lori Rexses 7 Laura Hieb 8 4
Mary Hiltunen 9 Dr. Ed Millermaier 10 5
Chris Woleske 11 Overview of Bellin Health George Kerwin President & CEO 12 6
13 Bellin Health Overview Serving a market of 600,000 people Bellin Hospital, a 220-bed community hospital with proven excellence in heart and vascular care; orthopedics and sports medicine; family programs and services; and minimally invasive procedures including robotic surgery. Oconto Hospital & Medical Center, a critical-access hospital in Oconto. Bellin Medical Group, a 93-member primary care group with 34 clinic sites and proven excellence in disease management and wellness care. Physician Partners, Ltd, more than 170 independent specialty physicians. NorthReach, a 26-member primary care group managed in partnership with Bay Area Medical Center in Marinette. Bellin Orthopedic Surgery Center, an ambulatory orthopedic surgery center merged in partnership with a local orthopedic physician practice. Bellin Psychiatric Center, a dominant provider of in- and outpatient behavioral health services. Bellin College with baccalaureate and masters degree programs to educate and train nurses and radiologic technologists. Unity Hospice, providing hospice and palliative care services. 14 7
MISSION Bellin Health is a community-owned not-for-profit organization responsible for the physical and emotional health of people living in Northeast Wisconsin and the Upper Peninsula of Michigan. Directly, and in partnership with communities, employers, schools, and government officials, we guide individuals and families in their lifelong journey toward optimal health. We are committed to providing safe, reliable, cost-effective total health solutions with respect and compassion. Our innovative work will impact healthcare delivery in our region, as well as throughout the world. VISION The people in our region will be the healthiest in the nation. 15 SERVICE AREA 16 54% Employers, Children, & Families 324,000 people 18% Medicaid 108,000 people 16% Medicare 96,000 people 12% Uninsured 72,000 people 8
Production System Design Concepts Pete Knox Executive Vice President Chief Learning & Innovation Officer 17 Connected Personal Experience Journey Connected Personal Experience AIM for the Organization Completed an Organizational Assessment through a Driver Diagram Exercise Driver Diagrams outline what it takes to create the Connected Personal Experience 18 9
Connected Personal Experience Across the Continuum The sum total of all the things that happens to a patient across a system in pursuit of a Common Aim. 19 Production System Activated Patient Our Focus for this Presentation Connected Personal Experience across the Continuum Culture Information Technology The Production System Measurement 20 10
Optimal Performance The Marriage of Production System and Measurement System 21 The Role of the Production System Design and Delivery to Specifications 22 11
Patient s Voice Mark Hillert 23 Three Tools of Production System Design 1. The Product Plan 2. The Differentiation Plan 3. The Commonality Plan 24 12
The Ability to Tailor Products Reduce development cost and time Reduce manufacturing cost Reduce production investment Reduce system complexity Lower risk Improve services 25 The Conversation Customers care about features Costs are driven by commonality 26 13
Anatomy of the Production System Anne Hale Team Leader Production System Design 27 Designing a Connected Personal Experience Across the Continuum The Production System Knowledge of the Connected Personal Experience health & life goals $ 28 H Q 14
Anatomy of the Production System Five different views 1 Product across the continuum 2. Functional or Operational area 3. Department 4. 5. Large Scale Commonality 29 Designing a Connected Personal Experience Across the Continuum 1 Product Across the Continuum Knowledge of the Connected Personal Experience health & life goals $ 30 H Q 15
Product Across the Continuum Definition: The specific individual products that the organization is producing. The Product crosses many areas of the organization and functions. Examples: Stroke Care, Healthy Knee, Healthy Heart 31 Designing a Connected Personal Experience Across the Continuum Functional Level 2 Knowledge of the Connected Personal Experience health & life goals $ Nursing 32 32 H Q 16
Functional / Operational Definition: An operational area that is positioned in many areas of the organization and as a result supports the production of many different products. A functional area supports and/or provides resources to many areas of the organization or the entire system. Examples: Nursing, Information Technology, Quality Services, Decision Support 33 Designing a Connected Personal Experience Across the Continuum 3 Department Knowledge of the Connected Personal Experience health & life goals $ 34 H Q 17
Department Level Definition: A distinct individual department or unit that contributes to the product continuum. They are a part of the patient experience. Examples: Therapy Services, Radiology Services, Valet Services 35 Designing a Connected Personal Experience Across the Continuum Knowledge of the 4 Connected Personal Experience * health & life goals $ 36 H Q 18
Level Definition: The individual productivity and contribution to the production of products and services. Examples: Physical Therapists, Security Officers, Nurses, Technologists, Housekeepers, Valet Attendants 37 5 Designing a Connected Personal Experience Across the Continuum Commonality Plan Knowledge of the Connected Personal Experience health & life goals Community Health Wellness & Prevention $ Acute Care After Care 38 H Q 19
Commonality Plan Definition: The extent to which products share common assets: Components Processes Knowledge People and Relationships Examples: Community Health, Wellness & Prevention, Acute Care, Aftercare 39 1 Continuum 2 Five Views of the Production System 3 4 * Knowledge of the Connected Personal Experience health & life goals 5 Community Health Wellness/ Prevention $ Acute Care After Care 40 H Q 20
Along Came Betty 41 Lori Rexses Vice President Invasive Clinical Services 42 21
Redesign Case Study: Stroke Product 1 Stroke Care Across the Continuum Knowledge of the Connected Personal Experience $ health & life goals H Q 43 PCP/ Prevention EMS ED Hospital Stay PT, OT, ST Post Hospital IRD, SNF Home F/U Specialty Care Education Support Group Multi-Specialty Stroke Clinic All Phases of Stroke Care Are Linked 44 22
AIM Create an infrastructure for a consistent Stroke Care experience that manages cost and quality and delivers a patient-centered experience. Decrease the incidence of Stroke in our Region. Maintain and enhance Bellin Hospital s standing as a certified Primary Stroke Center. 45 The Production System Steps 8 Define the new patient experience 1 Identify products Knowledge of the Patient 2 Identify customer needs, expectations and requirements 4 Create understanding of the current system Collective Patient Experience Knowledge of the System 5 9 Identify current roles and relationships Define the Aim of producing each product Define the new roles, relationships and structures Common Aim 6 Understand the measurement system 3 7 Knowledge for the system Define the collective knowledge of the patient experience 10 Spread learning 46 46 23
Key Innovations Developed new TIA protocol for observation status (diagnostic echo, Carotid U, Labs, MRI, complete work up prior to discharge) Target Stroke: Decrease Door to needle time (TPA) Neuroscience Advisory Board Hospital wide Neuro/Stroke Education Team Multidisciplinary Stroke Team-developed new follow up phone tool, and new discharge sheet Code Stroke Team-Provides for rapid assessment and care of the acute stroke patient Stroke Support Group 47 Key Results The American Heart Association has awarded Bellin the Target Stroke Award for a Door to tpa time of less than 60 minutes for 50% of patients in a three month period. There is only one other hospital in the state of Wisconsin Hospital that has received this award. We will be recognized at the International Stroke Conference this week. We are on track for the Silver Performance Achieve Award for a higher standard of care for our Stroke Patients. Implemented a TIA /Observation Unit in the Emergency Department. Over 200 EMS providers within our Region have had Stroke Symptom education All 1500 Bellin employee s receive stroke symptom education annually 48 24
Lessons Learned Listen to your Patients: The Betty Story Measurement - you need to get the right measures Commonality Plans are needed for Prevention and After Care phases 49 Laura Hieb Chief Nursing Officer 50 25
Redesign Case Study: Nursing 2 Functional / Operational Knowledge of the Connective Personal Experience health & life goals 51 Nursing H $ Q AIM Create an infrastructure for consistent Nursing Care that manages cost and quality and delivers a safe, patientcentered experience Create a Common Leadership Structure Develop Shared Governance Principles Implement Common Platforms of Work Includes the Patient Voice 52 26
Key Innovations As Nursing focuses on high quality and improved safety, patient experience and financials are positively impacted 12 Standard Production Platforms Bar coding Bedside Report Staffing guidelines/acuity measures/ Nurse Compass/Optilink Similar technology (Standard pumps, beds, vocera..etc) Multidisciplinary rounding, Nurse & Physician Rounding Standardized room- white boards SBAR communication Hourly rounding CDR s (Coding and Documentation Nurses) Informatics-streamlining documentation Follow up Phone Calls Video Monitoring 53 Key Result: Core Measures 54 27
Key Result: Days Between Serious Safety Events 55 Key Result: HCAHPS 56 28
Key Result: Nursing Satisfaction Over 5 Years 57 Key Result: Growing Volumes- Controlling Expenses Gross Revenue and Total Expenses Adjusted Patient Days $100,000,000 $90,000,000 $80,000,000 $70,000,000 $60,000,000 $50,000,000 $40,000,000 $30,000,000 $20,000,000 $10,000,000 $- 2006 2007 2008 2009 2010 2011 Annualized Gross Revenue 54,514,030 59,352,127 64,085,201 66,412,805 79,262,355 89,915,741 Total Expenses 32,229,081 33,932,181 37,411,224 37,212,246 39,169,535 42,033,371 46,000 45,000 44,000 43,000 42,000 41,000 40,000 39,000 38,000 2011 2006 2007 2008 2009 2010 Annualized Adjusted Patient Days 40,778 42,295 43,521 43,069 44,300 45,054 Gross Revenue and Total Expenses Per Adjusted Patient Day $2,500 $2,000 $1,500 $1,000 $500 $- 2006 2007 2008 2009 2010 YTD June 2011 Gross revenue per adjusted patient day Total expense per adjusted patient day 1,337 1,403 1,473 1,542 1,789 1,996 790 802 860 864 884 933 58 29
Lessons Learned: Steps 1. Set a Common Vision 2. Front Line Staff Engagement in Redesign and Platform Work 3. Identify Key Evidence-Based Platforms that are Applicable to Your Organization 4. Build Innovation and Quality Work into Your Staffing Pattern 5. Standardize and Hardwire the Platforms 6. Constant Communication for Adoption and Sustainability 59 Mary Hiltunen Vice President Orthopedic & Sports Medicine 60 30
Designing a Connected Personal Experience Across the Continuum 3 Department Knowledge of the Connected Personal Experience health & life goals $ H Q 61 Redesign Case Study: Knowledge of the Connected Personal Experience 4 * health & life goals $ H Q 62 31
Boundaries System Goals Brand Goals Department Goals Outpatient Therapy 15 Locations From Referral to Discharge 63 Staff Goal s AIM Improve quality, decrease costs and provide a patient-centered experience Grow Revenue Accountability for the goals and outcomes 64 32
Quality in Daily Work Steps 1. Define your purpose 2. Identify your key internal/external customers 3. Identify the needs and expectations of your key customers 4. Define your key products 5. Identify your key processes 6. Identify your suppliers and what you need from them 7. Identify how well your key processes are performing 8. Determine what you need to be improving 9. Define your approach to a disciplined improvement cycle with your area 10. Define how you tell your story to customers 11. Determine how you will continually enhance the culture within your team 65 Key Innovations Redesigned our Access Platform Implemented FOTO (Patient outcomes tracking tool) Developed Collaborative Care Teams Improved Productivity Measures 66 33
Key Results FOTO: Functional Change Measures: Target 50% @ 70% Cost to Produce: Goal: $31 @ $27.15 Decreased cancellation and no show rate by 21% Goal: 12% @ 11% Press-Ganey Scores Improved from 90.2% to 95.4% 3 rd Available improved from 3.5 days to 1.8 days Revenue increased by 10% one year and over 12.5% the next year 10% increase in Patient Volume We expanded our geographical reach to Primary Care Clinics from 7 locations to 5 more in 2 years: 20.6% increase in patient volume to the clinics Productivity: Goal @ 24 units per therapist @ 24.3 Employee Engagement: Goal at 24 @ 24.53 67 Lessons Learned Link Vision, Mission and Strategies so staff understand what we were doing and why it was important Engage front-line staff in the improvement work Patient Engagement was Key: We held patient focus groups to gather their requirements and needs Physician Engagement included both the physicians and key staff making the referrals We used our measures in every staff meeting to show progress and areas for further improvement. Had stars share their best practice and successes We celebrate our successes every 120 Days 68 34
Therapy Department Score Card 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J K L M N O P Q R S OUTPATIENT DEPARTMENT SCORECARD -- FY10-11 FY 10 Annual FY 10 Monthly FY11 Monthly 11 Actual Units 10/10 11/10 12/10 1/11 2/11 3/11 4/11 5/11 6/11 7/11 8/11 9/11 10 Actual Total Measure, Performance Key Factor Actual Actual Goal Average GROWTH Volume New/Evals # 6,370 531 586 580 560 623 631 507 619 520 600 638 512 654 555 6999 583 Repeat # 44,511 3,709 4094 3850 4056 4452 4105 3707 4479 4273 4209 4416 3312 4320 3780 48959 4080 Total # 50,881 4,240 4681 4430 4616 5075 4736 4214 5098 4793 4809 5054 3824 4974 4335 55958 4663 Procedures (goal set by indiv mnth) # 111,930 9,328 10,436 10393 10685 11758 10998 9786 11161 11020 11087 11189 10157 11909 10157 130300 10858 Procedures Stretch Goal # 10,436 Revenue Billed Revenue (Gross Patient Revenue) $ 10,709,095 892,425 1,001,137 969,648 1,000,079 1,099,863 1,029,614 918,562 1,103,845 1,032,757 1,037,553 1,108,310 951,649 1,111,006 $11,362,886 1,032,990 Gross Revenue Stretch Goal $ 1,021,159 Allowances/(Deductions From Revenue) $ 4,322,402 360,200 326,953 318,182 323,442 360,183 343,135 327,922 378,437 353,948 348,737 369,988 325,839 371,702 $3,821,515 347,410 Reimbursement/(Net Patient Revenue) $ 6,386,693 532,224 674,184 651,466 676,637 739,680 686,479 590,640 725,408 678,809 688,816 738,322 625,810 739,304 0 $7,541,371 685,579 EFFICIENCY Cost 69 Key Results: Score Card 70 35
Dr. Ed Millermaier Chief Medical Officer 71 Redesign Case Studies Commonality Plan 72 36
Redesign Case Study: Commonality 5 Commonality Plan Knowledge of the Connected Personal Experience health & life goals Community Health Wellness & Prevention $ Acute Care After Care 73 H Q AIM Create an infrastructure for a consistent After Care Experience that manages cost and quality and delivers a patient-centered experience. Create a Structure to Connect the Patient Back to Their Medical Home Create a Structure to Connect the Patient to Community Resources Provide a Support Network or Group, When Appropriate 74 37
Boundaries Aftercare in our Scope is Defined as the Post Acute Care Continuum It is the Platform for the AfterCare Plan following the Acute Care Episode Starts at the Time the Person Leaves the Hospital Until the Person Returns to their Medical Home 75 Defining Key Measures Defining Measures and Metrics on Quality, Cost and Experience Measurement Examples: Patient Experience Readmission Percentage of Patients with Advanced Directives Ambulatory Specific Conditions Admitted to the Hospital Primary Care Specific Conditions seen in the Emergency Department Percentage of Referrals to Other Levels of Care Cost Savings and Expenses with New Design 76 38
Exploring Key Innovations Transitional Care Coaches Extended Care Program Community Relationships and Connections to the Most Appropriate Place for Care Leverage Technology Care Buddy Telemedicine Support Groups & Networks 77 Next Steps Pulling Together a Group with Representation Across the Continuum and the Community Patients will be Involved in this Work Discovering our Gaps Creating Strategy, Goals and Measures to Close Those Gaps 78 39
Chris Woleske Executive Vice President Hospital Clinical Services 79 Purpose Production System Production Planning System Flow Standard Work Physical Layout knowledge, skills and abilities to change behavior Activated Patient Customized support, intervention and resources Prepared and capable Care Team Personalized action plan Focus on multiple domains Connected Personal Experience Across the Continuum Culture Structure Goals and Measurements Communication Learning System Leadership Information Technology Informed Care Team Informed & Family Production Process Flow Intelligence Customer Relationship Knowledge Information Governance & Mgt for Product Knowledge Measurement Process Knowledge Outcome Knowledge Measurement Infrastructure Analytics and Reporting Measurement Governance & Management 40
Organizational Self-Assessment The Five Driver Diagrams for a Connected Personal Experience: System of Production Activated Patient Culture Information Technology Measurement 81 Article: Connecting Culture to Organizational Change by Timothy Galpin, HR Magazine, March 1996 Production System Assessment Review the Driver Diagram Assessment for the Production System for your organization Share your organization s strengths and opportunities for improvement At the report out, share your table themes 82 41
Assessment: Production System Not Developed Fully Developed Purpose: alignment with mission & vision; clear boundaries, customer requirements known Production Planning: 5 levels System Flow: effective handoffs Standard Work: defined system owner, consistent processes & work Physical Layout: workspace, equipment, supplies Strength Area: Leverage Total Points Area for Development: 83 Report Out Each group will report on the their key learnings from today s session 84 42
Summary & Wrap-Up 85 Production System Purpose Production Planning System Flow Standard Work Physical Layout knowledge, skills and abilities to change behavior Connected Personal Experience Across the Continuum Activated Patient Culture Customized support, intervention and resources Prepared and capable Care Team Personalized action plan Focus on multiple domains Structure Goals and Measurements Communication Learning System Leadership Information Technology Informed Care Team Informed & Family Production Process Flow Intelligence Customer Relationship Knowledge Information Governance & Mgt for Product Knowledge Measurement Process Knowledge Outcome Knowledge Measurement Infrastructure Analytics and Reporting Measurement Governance & Management 43
Assessment: Production System Not Developed Fully Developed Purpose: alignment with mission & vision; clear boundaries, customer requirements known Production Planning: 5 levels System Flow: effective handoffs Standard Work: defined system owner, consistent processes & work Physical Layout: workspace, equipment, supplies Total Points 87 Assessment: Activated Patient knowledge, skills & abilities to change behavior Customized support, intervention and resources Prepared and capable Care Team Personalized Action Plan Focus on multiple domains Not Fully Developed Developed Total Points 88 44
Assessment: Culture 89 Structure: to coordinate care across the continuum Goals & Measurements: system in place to measure triple aim Communication: system to support connected experience Learning System: includes training, feedback and coaching Leadership: defined & resourced a strategy for connected experience Total Points Not Fully Developed Developed Assessment: Information Technology Informed Care Team Informed & Family Production Process Flow Intelligence Customer Relationship Knowledge Information Governance & Mgt for Product Knowledge Not Fully Developed Developed Total Points 90 45
Assessment: Measurement Process Knowledge Not Fully Developed Developed Outcome Knowledge Measurement Infrastructure Analytics & Reporting Measurement Governance & Management Total Points 91 Assessment: Connected Experience Production System Total Score Observations Activated Patient Culture Information Technology Measurement Strength Area - Leverage: Area for Further Development: 92 46