A Collaborative Approach to Sustainable Cost Savings St. Michael s Hospital Anne Trafford, Vice President Quality, Performance, Information Management & CIO Danielle Jane Paton Project Director Improvement Program & Director Decision Support
Agenda In response to a challenging financial environment and increasing patient expectations, St. Michael s created the Improvement Program to identify, implement and sustain efficiencies strategies. As we are in the third year of the program, we want to: Share our journey, including approach and methodology Provide practical case studies of cost saving initiatives Discuss our lessons learned 2
About St. Michael s 3
Why Are We Doing This The Big Picture Project began during a time of fiscal restraint Four-year freeze on hospital budgets did not end until 2016-17 Ontario provincial budget Uncertainty remains re future funding 4
Why Are We Doing This The St. Michael s Picture A change was needed because: Can t count on one-time, year-end government funding Government funding moving from annual lump-sum funding to activity-based funding tied to volume, performance Inflation and an aging population driving up costs Our old method of 1-2 per cent annual cuts not an efficient, sustainable budget model 5
Why Are We Doing This The St. Michael s Picture Our goal was to find innovative, long-term sustainable solutions in order to: Continue to provide quality patient care and improve the patient experience Preserve core priorities and existing programs Protect volumes Have the flexibility to transform ourselves in the future Issued a RFP to engage outside consultants with international expertise If it were easy we would have figured it out already Asked them to give us tools and training (KT) to enable us to take over the work ourselves 6
How We Got Started Improvement Project Management Office (ipmo) -- with expertise from across the hospital (DSS, Finance, Communications, HR) Undertook operational reviews with three programs that volunteered to go first: Heart and Vascular, PeriOperative Services, Supply Chain All clinical programs and support services have undergone similar reviews or will soon Board and executive team 100 per cent supportive 7
Continuous performance improvement has become central to the success of St. Michael s Hospital over the last three years and the ipmo is the engine that powers it. Dr. Bob Howard President & Chief Executive Officer 8
Improvement Program Governance Board of Directors Accountability Steering Committee Senior Leadership ipmo: Meets every two weeks for check-ins, updates Sponsor, Project Director, Workstream Leads, Finance, Communications, DSS, Quality, HR Report on Delivery Involvement with Finance, Communications, HR etc. Workstream 1 Directors, Physicians, Managers, ipmo, Project Manager etc. Workstream 2 Directors, Physicians, Managers, ipmo, Project Manager etc. Workstream 3 Directors, Physicians, Managers, ipmo, Project Manager etc. Involvement with Finance, Communications, HR etc. 9
What Kinds of Opportunities Are There? Standardization Process Redesign Cost Reduction Revenue Reduce variation through implementation of standard practice; and common equipment/ supplies Review and redesign of service delivery models/processes to find efficiencies in utilization Review and identification of cost reduction strategies and elimination of duplication supply chain opportunities Review and identification of opportunities to create or increase revenue 10 10
This is About Value Value = Highest quality care at best possible cost The Improvement Program is part of the Efficiency dimension of SOAPEE - our Quality Improvement framework Excellent patient care is efficient care changes to our processes will lead to better patient experience 11 11
You Need Everyone s Help Change is always difficult It will take more of some people s time than you realize A significant number of physicians need to be significantly involved for this to be successful Transparent communications and visible leadership essential 12
A Collaborative Approach is Key 13 Don t forget to conduct lessons learned!
Our Methodology Tricks & Tips Running list of quantified opportunities Prioritization ensures we are focused on right initiatives Documentation, risks & action logs are key 14
Onto The Case Studies Throughout the reviews several key themes emerged. Successes and lessons learned were translated to other areas. Operating Room Utilization Catheterization/Electrophysiology Lab Supply Chain Back Office Initiatives Family Health Team Phone Centre Sneak Peek! 15
I was anxious about having my program go through the ipmo cycle as I had assumptions that it was simply about cutting costs and reducing staff. However, we were pleased to see the emphasis on improving processes and enhancing the patient experience. While there were tough decisions made regarding efficiencies and staffing, it was done in a thoughtful and respectful manner that was beneficial to my program, the organization and ultimately patient care. Jonathan Fetros Program Director, Diabetes Comprehensive Care 16
But First The Role of the Leads Directors/Managers lead the charge and had to manage push back from a variety of sources. Support for them and their adeptness at managing change was essential. Catherine Hogan Program Director, Perioperative Services and Infection Prevention and Control Peter Longo Director, Supply Chain and Logistics 17
Question 1 Where do you think the biggest opportunity for in year savings was? Link to live results https://manage.eventmobi.com/en/ars/results/question/ 17500/340823/59900817d0891ca7f7b6b6c6e0a2579e/ 18
Question 1: Answer Where do you think the biggest opportunity for in year savings was? Supply Chain Supply Chain Staffing Procedure Room Usage Revenue Generation 19
In a year that presented us with a fiscal challenge, we had to find ways to save without impacting quality care. My division conducted a large-scale review that identified several improvement opportunities. I once again had to face taking staff through the uncertainty of change. In situations like this, leaders have to consistently share the vision, know when to forge forward and when to course correct. I learned that I had to be comfortable with being perceived as the disrupter, to trust my instincts, and to remain unwavering in the face of strong resistance until it becomes evident that improvement was necessary and was achievable. Erone Newman Program Director, Heart & Vascular 20
Question 2 Which project ran into the most unexpected resistance? https://manage.eventmobi.com/en/ars/results/question/17500/340825/4de 8a5ae1288520fdcd7b2014219b125/ 21
Question 2: Answer Which project ran into the most unexpected resistance? OR Utilization Standardization of Printer of Printer Toner Toner Cartridge Cartridge Catheterization Lab Supply Standardization Creating a Single Patient Call Centre Across 6 FHT Sites 22
Case Study 1: Improving Elective OR Utilization Opportunity: Introduced improved booking and scheduling processes and realigned operating blocks to improve our efficiency for elective procedures in the main OR. How We Did This: Adherence to start times, standard turnaround times, transparent booking and scheduling process, fewer overruns Positively impacted patient experience through reduced delays, cancellations Changes intended to support current funded volumes, not reduce volumes Savings: $700,000 for a full year (block reductions meant fewer FTEs, managed through attrition) 23
Case Study 1: Improving Elective OR Utilization Utilization is monitored, weekly reports to division chiefs and PeriOperative executive We saw general improvements in utilization Continuous work in progress 24
Case Study 1: Improving Elective OR Utilization Majority of blocks saw improvements in start times Improvement opportunities still exist in block overruns Note: 15 min grace period existed week 1 of implementation 25
Case Study 1: Physicians as Partners Input and support of medical directors, chief and staff physicians o Came up with innovative solutions o Role of surgeon champions Excellent engagement throughout o Early morning and evening meetings o Time and effort was substantial Leadership support CEO and CMO were key 26
Case Study 2: Cath Lab Supply Chain Opportunity: Based on the high number of products and costs, the Catheterization/Electrophysiology lab was chosen as an area for review. Before After 27
Case Study 2: Cath Lab Supply Chain Insert Victoria s Video https://vimeo.com/239167856 Password is Victoria 28
Question 3 How much money did we save per year through inventory management and standardization in the Cath Lab alone? https://manage.eventmobi.com/en/ars/results/question/17500/34 0824/f1ecc3c526b275a845f17f7f1ea8fb87/ 29
Question 3: Answer How much money did we save per year through inventory management and standardization in the Cath Lab alone? $100,000 $250,000 $400,000 $500,000
Case Study 2: Cath Lab Supply Chain How we did this: Consolidated supplies in fewer locations Set more realistic PAR levels Reduced wastage and expired products Worked with physicians to standardize products and remove products no longer being used: o Kept 11 models of guide-wires instead of 28 o Were using two types of balloons. Most preferred less expensive model, so we just stocked less of the expensive one on the shelves Savings: $400,000 a year 31
Case Study 2: Cath Lab Supply Chain Sustainability supported through newly implemented Value Analysis Team (VAT) Created Supplier Representative Policy Strong partnership between the program and Supply Chain teams 32
Case Study 3: Additional Focus on Back Office Opportunity: Balance focus across clinical and back office functions. Working group of Back Office VPs created to implement improvement initiatives. Printer Toner Standardization How we did it: Standardized print toner purchases across hospital Published a list of eligible print toner by printer model, which was hardcoded into the Staples ordering website Savings: $80,000 per year Lessons Learned: Unexpected pushback; risk of over-communication 33
Case Study 3: Additional Focus on Back Office Centralization of Minor IT Spend How we did it: Centralized procurement of desktop, laptop computers, ipads, desk phones and printers in IT Improved inventory management Saved money: cancelling software licenses for equipment not in use Savings: $265,000 per year 34
Case Study 4: FHT Centralized Patient Phone Service Opportunity: Poor phone service was No. 1 patient complaint in FHTs Varied approach to managing the phone lines across sites often lead to frequent clerical interruption and therefore poor productivity How we did this: 8 FTEs were centralized geographically into a phone centre covering for six sites Standard operating procedures and process maps were developed Opportunity to improve customer satisfaction and invest in training Required a phone queuing system and collaboration with IT Savings: $100,000 per year, driven by reduction in clerical FTE 35
Question 4 How many calls does the Family Health Team receive per month? https://manage.eventmobi.com/en/ars/results/question/17500/340826/6ef3480cfa20 238440657a4c97bdef2e/ 36
Question 4: Answer How many calls does the Family Health Team receive per month? 10,000 20,000 25,000 30,000 37
Case Study 4: FHT Centralized Patient Phone Service All six sites were phased into the phone centre Chart shows snapshot of a week before four sites began the pilot o The four sites in the pilot decreased the average wait time o Two sites not in pilot still struggled Indicator Before Pilot (All 6 sites) Phase 1 Sites (4 sites) Non Pilot Sites (2 sites) Week of: May 15 July 10 July 10 % of phone calls answered 81% 94% 71% % of calls dropped 18.1% 5.7% 27.7% Average time to answer phone % calls picked up within 45 sec 2:08 00:42 3:16 35.6% 68.9% 23.0% Call volume 4461 3538 1719 38
Case Study 4: FHT Centralized Patient Phone Service Lessons Learned: Change was challenging as there are more than 75 physician schedules and booking practices, six sites and complex patient inquiries Change required extensive staff and physician engagement Also did continuous reporting and PDSA cycles 39
It was great to move this from an external consultant-focused project to a strategic priority of the hospital. It helped to have several projects rolling out simultaneously with a community of practice developed to offer support. My only recommendation is to ensure that key stakeholders are fully engaged from the beginning, particularly patients and physicians. Linda Jackson Program Director, Family Health Teams 40
Sneak Peek: IV Direct Administration Opportunity: St. Michael s is developing protocols, processes to support RNs administering select medications directly via IV rather than by minibag. Why We Will Do This: Small savings add up Each dose administered directly via IV saves $2.83 in minibag and tubing costs. Savings could be up to $200,000 Launching in January 2018 41
By The Numbers Improvement Program 2015/16 2016/17 2017/18 Programs 1 $7.4M $8.5M $8.5M Programs 2 $0 $6.4M $7.1M Programs 3 $0 $0 $4.1M* Total $7.4M $14.9M $19.7M 200 26 $2M More than 200 initiatives implemented How many are one-time only; rest will mean continued savings in future years Additional positive HBAM funding impact through coding work 42 * 2017/18 represents Oct YTD
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Importance of Strategically Aligning Cost with Quality Even though a financial pressure was the burning platform, we used this as an opportunity improve the way we do business. Although some projects were more cost-oriented in nature, quality impact and risks assessments were completed to ensure that quality was either maintained or improved through the work. This helped align the interests of varying groups, from front line to leadership. 44
Beyond the Numbers Link to Quality Reduction in pre-op LOS for Heart & Vascular patients Created an Acute Care for the Elderly Unit Improved the patient experience in Medical Imaging Implemented Standard Operating Procedures for Acute Care Surgery Diverted 214 admissions in the first year of a Rapid Referral Clinic Improved access for Ultrasound by creating a new schedule 45
The work was intense but we achieved results. Quality initiatives that we had wanted to do for quite some time, but didn t have the horsepower to get done, did get done. It wasn t driven just from a financial perspective but with a quality lens which helped gain the buy in from the physicians and staff. Dawn-Marie King Director, Medical Imaging & Labs 46
Operate at a New Pace and Encourage New Ideas First and foremost, the process is a lot of work, operating at a quick pace Give priority to projects that can result in in-year savings Having the right people at the table allowed us to make decisions, remove barriers and drive projects forward Create a culture of idea generation Mantra of no idea is a bad idea Respectful challenge encouraged Fish or cut bait - but understand why an idea is rejected 47
Balance Programmatic & Organization-Wide Initiatives It became evident there were common issues across the hospital that were better tackled in a cross-cutting way Tough to go on your own Need to standardize Better results if done systematically vs. piecemeal Example Projects Include: Nursing Resource Team PAR levels / Inventory Management Bed Footprint 48
How to Work Effectively With External Consultants Value of having consultants Bring external expertise, objectivity Support a burning platform and set pace Pressure to use them while they are here But remember to Explicitly build KT into the plan; embed internal resources into the work Own the analysis, project plans and implementation; demonstrate that the work will not cease when consultants leave Take charge of communications and positioning you know your organization best 49
Transitioning to the Internal Team Over time, we transitioned the framework, structure and tools to a small internal team Invested in internal team Project Director role Hired project managers with Business acumen Experience in operations Negotiation skills Assertiveness Analytical and inquisitive Leverage new internal expertise First workstream leads served as mentors Buddy system with peers who were going through the process 50
Bottom line - it s been a really productive collaboration. Dr. Robert Sargeant Division chief, General Internal Medicine 51
52 For additional information Email: ipmo@smh.ca