Clinical Operations in a Service Line Model

Clinical Operations in a Service Line Model John D Angelo, MD, FACEP Executive Director & Senior Vice President Sarah Healey Herod, MPH Director, Service Line Development Jill Castaneda Project Manager, Clinical Operations Team Emergency Medicine Service Line Northwell Health December 12, 2017 1

Agenda Introductions What is the Service Line? IHI and Process Improvement Origin & Evolution of the Clinical Operations Team Continuous Site Improvement work Data & Analytics Accountability & Sustainability Questions and Discussions Friday, November 24, 2017 2

What is a Service Line? 3

Emergency Medicine Service Line > 900,000 annual ED visits 5 Tertiary EDs 11 Community EDs 1 Free-Standing ED Friday, November 24, 2017 4

Service Line Vision To be a fully integrated network of emergency departments and acute care centers capable of consistently delivering high quality care in the most efficient manner possible Northwell Top Line Initiatives Hospital Top Line Initiatives Physician Nurse & ACP Collaboration Patient Friday, November 24, 2017 5

Service Line Responsibilities The Emergency Medicine Service Line is responsible to drive strategy across the entire continuum of unscheduled acute care services: Market Growth Operations Patient Experience Teaching & Research Employee Investment Community Benefit Finance Quality Friday, November 24, 2017 6

Service Line Strategy Optimize service line team Effective Site Leadership Implementation of best practice standards and workflow models Comprehensive performance improvement program Leveraging all forms of technology for documentation, communication, delivery and marketing Key contributor to Northwell Health financial success Improve market share and prepare for future healthcare landscape Friday, November 24, 2017 7

EMSL Centralized Services 8 8

How do we work with our Emergency Departments? Partner with MD & RN Leaders Share best practices Guide operational improvements Standardize Practices Clinical & Administrative Quality Review & Data Collection Education & Development Nursing Education Physician Admin Fellow Clinical Leadership Development Program New Business Development Northwell Strategy Support Market Growth Patient Experience Six Sigma Projects Patient Referral Programs Financial Tracking & Reporting Centralized Budget Ongoing Financial Assessments Telehealth Expansion Telepsych & Telestroke eicu Collaboration Service Line Collaboration Pediatrics, Psychiatry, Hospitalists, Cardiology, HR, Nursing Program Development ACP (NP/PA) Fellowship SAFE Program Quality Committee 9

IHI & Process Improvement 10

Process Improvement Create a culture in all Northwell Emergency Departments of continuous introspective review and enhancement using improvement science techniques to optimize operations and provide the best care and treatment of patients and family members. Continuous Transparent Site Led Metric Driven Multidisciplinary Month Day, Year 11

The IHI Model for Improvement Aim Measures Ideas What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Month Day, Year 12

The IHI Model for Improvement: Plan Do Study Act (PDSA) Small tests of change, Continuous, Sequential and easy to begin What changes are to be made? Next cycle? Act Plan Objective Why? Who, what, where, when? Analysis of the data Compare to predictions Summarize what was learned Study Do Carry out the plan Document barriers Begin analysis of data Month Day, Year 13

The IHI Model for Improvement Plan Do Study Act (PDSA) Steps Step 1: Plan Plan the test or observation, including a plan for collecting data. State the objective of the test. Make predictions about what will happen and why. Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?) Step 2: Do Try out the test on a small scale. Carry out the test. Document problems and unexpected observations. Begin analysis of the data. Step 3: Study Set aside time to analyze the data and study the results. Complete the analysis of the data. Compare the data to your predictions. Summarize and reflect on what was learned. Step 4: Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for the next test. Month Day, Year 14

Origin and Evolution of the Clinical Operations (Clin Ops) Team 15

Northwell /IHI Collaborative Timeline focus on early identification & treatment in the ED Getting Started: Learning Session 1 Action Period Learning Session 2 Action Period Learning Session 3 Action Period includes calls & activities February 2012 includes monthly calls & team reports July 2012 includes monthly calls & team reports January 2013 includes monthly calls & team reports Learning Sessions: Improvement Science methodology Team Report Outs Sharing of experiences, challenges and solutions Goal Setting Structure: Teams from each site Leaders, front line staff Executive Sponsors Data Definitions / Reporting Team site / E-list / Collaborative Calls Month Day, Year 16

Clinical & Operational Performance Month Day, Year 17

Northwell Health Sepsis Mortality: Jan 2008- September 2017 Month Day, Year 18

How do we know what to do? Because the Sepsis Collaborative worked! Develop a Structure for leadership, partnering, communication, sharing and reporting. Promote Change Identify and overcome Barriers Focus on culture, work with site leadership on engaging front line Define the Outcomes that you want to achieve and develop processes to obtain them Data Definitions are crucial to acceptance of results Utilize Improvement Processes to facilitate change Process Maps Small Scale tests of change (ex. PDSAs) Run Chart analysis Share lessons learned and best practices Month Day, Year 19

Clinical & Operational Excellence EM Strategy for Sustainable Results Standard Accountability System Must Haves Standardization Aligned Goals Aligned Behaviors Aligned Process Strategic Goals Leader Accountability Process Cascade of Goals Communication & Transparency Success Sharing Co-Leadership Model Driving positive culture and productive organizational energy Selecting and Retaining Talent Leadership & Staff Training & Development Drive towards Excellence in all mission critical areas Improvement Methodology Leader Evaluation & Performance Scorecard Standardized PI Process Month Day, Year 20

Risk Taking and Organization Change The Change Equation C=(DxVxF) > R* Three factors must be present for meaningful organizational change to take place, and together they must be greater than the RESISTANCE of those who fear the change. C = Change D = Dissatisfaction with the status quo V = Vision of a better future state F = Practical First Steps R = Resistance to Change by people or the organization system Before the change: When planning a major change, planning teams need to make sure all three elements are built into their plans. During the change: Use it as trouble-shooting tool for figuring out why people are resisting the change. * Change Equation formula developed by Richard Beckhard 1977; modified by David Gleicher, and Kathy Dannemiller.

Where the rubber meets the road. EXECUTION 22

Clin Ops Team Structure Director, Clinical Optimization Project Manager Assistant Director, QM Collaboration Regional Physician VP Regional Analysts Regional Nurses Month Day, Year 23

How do we work with our Sites? Physician Chair Nursing Director Vice/ Asst. Chairs Clin Ops Team RN Managers ACP Leads ED Administrator Month Day, Year 24

Typical Emergency Department Flow Input Triage Room placement Throughput Provider interaction, Work up, Intervention Output Provider Signoff Discharge: home or hospital Press Ganey Scores Average Admit LOS 25

Where does Clin Ops find work? Continuous Site Improvement projects (SIPs) Data and Analytics to transform patient care Sustainability & Accountability Model This slide will break out through animation into examples for each category Month Day, Year 26

Continuous Site Improvement projects (SIPs) 27

Continuous Site Improvement Projects (SIPs) Swim Lane Process Mapping Fast Track Decision Making Priority Pay Off Matrix LEAN Events Town Halls Brainstorming Identification of non-value added waste Month Day, Year 28

LEAN Events with our Sites Problem Statement: The introduction of an electronic medical record highlighted an inefficient intake process resulting in an increasing Door to Provider time. Plainview Hospital Plainview, NY Volume: 33,000 ED Beds: 26 Pediatrics: 9% Admission Rate: 24% Stroke Center Action Steps by Clin Ops and ED Team: LEAN Event with an interdisciplinary group of frontline staff Workflow process mapping Redesign of triage documentation PDSA testing Friday, November 24, 2017 29

Plainview: Decrease Door to Provider < 30 mins Multidisciplinary LEAN event Measurable results Workflow mapping Friday, November 24, 2017 30

Plainview Door to Provider Month Day, Year 31

Lenox Hill Problem Statement: A small Fast Track footprint hindered efficiency of care for treat and release (T&R) patients; the Fast Track area treated 37% of all patient volume, and there was a high LWOBE rate from the area with complaints of lack of privacy. Friday, November 24, 2017 32

Lenox Hill: Increased capacity, throughput and patient and staff experience Action Steps: Redesign use/purpose of clinical space LEAN Event with an interdisciplinary group of frontline staff Workflow process mapping Role redesign PDSA testing Month Day, Year 33

Lenox Hill LEAN Event Buy-in from front line staff Brainstorming Solutions and Causes Workflow process mapping Month Day, Year 34

Minutes Current Data: Door to Provider Time 40 Average Door to Provider 35 30 25 GOAL 26min 20 15 10 5 0 1/1/16-2/21/16 2/22/16-2/29/16 MARCH APRIL MAY JUNE JULY DTP 31 38 33 29 25 24 24 Month Day, Year 35

Minutes Current Data: Treat and Release Average LOS 225 T&R ALOS 220 215 210 205 GOAL 205min 200 195 190 185 1/1/16-2/21/16 2/22/16-2/29/16 MARCH APRIL MAY JUNE JULY Series1 222 222 218 215 207 207 200 Month Day, Year 36

Current Data: Treat and Release Length of Stay Month Day, Year 37

Long Island Jewish Medical Center Problem Statement: 52% of patients seen at LIJ are an ESI level 3 and represent 68% of patients that LWOBE. In 2015 the avg. Door to Doc was 85 mins and this has contributed to increased LOS, increased LWOBE rates, decreased patient and employee satisfaction. LIJ Medical Center New Hyde Park, NY Volume: 97,736 ED Beds: 60 Admission Rate: 26% Stroke Center, Chest Pain Center, Cath Lab LEAN Event with Front-line Staff to brainstorm causes and solutions and swimlane out the process map for ESI 3 patients in the department. 38

LIJ: Baseline Data Emergency Department Volume 7% Increase 88,263 93,964 Left Without Being Evaluated 9% Increase 1.40% 2.60% 2014 2015 2014 2015 303 T&R LOS 334 ED Door to Provider 65 85 2014 2015 2014 2015 39

Total Volume LIJ: Addressing the Volume Phenomenon A decade of growth and change 100,000 LIJ ED Volume 90,000 80,000 70,000 Capacity 65K Capacity 85K 100,000 visits 2017 60,000 50,000 40,000 30,000 20,000 10,000 - Renovations Renovated ED Opens Capacity: 65K Closures Increased Capacity Increased Efficiency 5 Hospitals close In Queens Separate Peds ED Opens HEC Closes BH Intake Area Created Clinical Decision Unit (CDU) Opens LIJ Split Flow Phase I increases capacity by 20K visits Patient Experience Lean QUID Initiative Split Flow V2 2007 2008 2009 2010 2011 2012 2013 2014 2015 Proj 2016 40

LIJ: Goals met and Sustained Improvement Goal is to decrease ED Turnaround times by January 2017: Reduce Door to Provider times to < 60 minutes Reduce ED LWOBE < 2 % Reduce ED Treat and Release LOS to < 280 minutes Improve Patient Satisfaction Scores Friday, November 24, 2017 41

Data and Analytics 42

Emergency Medicine Data Metrics QUALITY Pneumonia Sepsis Lactates Sepsis - Abx Cardiac Care- Balloon &EKG Cath Door to EKG, Door to PCI Pediatrics Restraint Sedation Hand-washing Pain Control Documentation & Timeliness Vital Signs Transfers Capnography Care of Sexual Assault Survivors Abuse Screen Med Errors Adverse Drug Reactions Falls Stroke Code VOLUME Total Registered Total Admissions Treat & Release Pediatric Treat & Release Pediatric Admits Pediatric Transfers Unplanned Returns CDU admits & Treat & Release THROUGHPUT Door to Bed Door to RN Door to Provider Provider to Disposition Decision to Admit to Bed Assignment Bed Assignment to ED Departure Total ALOS ALOS Treat & Release ALOS Admitted Patients ALOS Transfers ALOS Pediatrics ALOS Psych ALOS ERHO ALOS CDU ALOS Class 1 OR ED Midnight Census Ambulance Volume Ambulance TAT LWBS Diversion ED Registration Mortality within 24hrs FINANCE PQRI IV Start and Stop P&L E&M Distribution Tech & Pro Charges Utilization by physician Revenue Billed vs. Budget Pro Charges Avg Charge Avg Payment Gross Collection Rate Trending/ Variance Analysis KPI Monitoring PATIENT SATISFACTION Overall Satisfaction Likelihood to Recommend How well was your pain controlled Physician and Nursing Section Scoring Top Box scores EMPLOYEE ENGAGEMENT Annual employee engagement surveys Tier leaders Over 200 metrics are captured by the EMSL sites. This slide highlights a portion of those metrics. Friday, November 24, 2017 43

Dynamic Dashboards Our Dashboards identify opportunities for operational improvements (T&R LOS) and help us to see which sites need support. The dashboards are dynamic allowing the sites control and transparency over their data. Friday, November 24, 2017 44

Static Monthly Dashboards Door to Doc 2017 Targets Aug Sep Oct Nov Dec 2017 YTD Threshold Goal 22 17 17 23 20 21 20.86 20.18 21.61 19.11 Avg. 20 20 24 21 Lenox Health GV 2017 2016 Baseline Jan Feb Mar Apr May Jun Jul Median 13 13 10 11 13 13 13 13 11 13 13 12 202 200 188 200 190 188 188.75 180.88 194.84 181.78 T&R LOS Avg. 201 191 195 190 Median 168 173 171 159 171 160 161 153 154 159 151 161 425 346 362 384 355 369 405 327.38 361.77 366.18 Admit LOS Avg. 407 370 Median 365 381 317 330 331 335 340 334 298 326 329 332 218 211 200 213 202 200 200.33 191.74 205.54 193.01 Total LOS Avg. 215 203 3070 2707 2914 3127 3185 3101 2984 2908 3146 3184 Volume Total 36,648 30,326 5.2% 5.1% 5.5% 4.5% 5.1% 4.3% 7.3% 5.6% 5.1% 5.2% Admit Rate % 4.70% 5.3% # of pts 1,716 159 137 159 142 162 133 219 162 161 167 1,601 1.40% 1.11% 1.48% 1.92% 1.79% 1.42% 1.71% 1.55% 1.53% 1.82% LWOBE Rate % 1.82% 1.58% 1.6% 1.5% # of pts 666 43 30 43 60 57 44 51 45 48 58 479 8 12 4 11 11 6 9 3 1 Sepsis - Fluid % Compliant 63% 80.0% 63% 67% 8 12 4 11 11 6 9 3 1 Sepsis - Abx % Compliant 86% 86.2% 87% 92% 84.6% 95.2% 92% 77% 94% 78% 90.0% 76.9% 100% 95.7% Cauti % Compliant 86% 88.4% 90% 91% Patient Exp. - Likelihood to Recommend Patient Exp. - Likelihood to Recommend 79.0 81.3 75.3 72.9 67.0 71.7 70.90 71.40 74.8 66.2 Top Box Score 73.3 74.0 74.7 75.4 94.0 99.0 77.0 67.0 40.0 60.0 57.0 58.00 75 35 Percentile Rank 74.0 71 80 83 Friday, November 24, 2017 45

Static Monthly Dashboards Friday, November 24, 2017 46

Operational Dashboards Clinical Details Dashboard Collaboration with Krasnoff Quality Management Institute (KQMI) Team Allows for deep dive into clinical presentation of ED patient population Friday, November 24, 2017 47

Transparency and Accountability 48

Using Data and Analytics to Transform Patient Care Nursing and Tech Staffing Month Day, Year 49

Sustainability & Accountability 50

SIP Meetings with Sites Aim: All sites will focus SIP work on reducing Treat and Release LOS Structure: Meetings organized by Volume Cohort (<35k, 35-60k and > 60k) Frequency: occur every 6 weeks and alternate with the EMSL leadership meeting. Format: Webex to increase participation and convenience Accountability: Site update on PDSA cycles (3 slides) Month Day, Year 51

Formal Report Outs of Improvement Work EMSL Leadership Meetings occur once every six weeks. Provide 2-3 ED Leadership teams and Front Line staff the opportunity to report out in front of peers. Formal presentation to entire EMSL once a year. Allows for feedback and questions from all Eds. Friday, November 24, 2017 52

STIPs: Individual Provider Score Card (Academic sites) Emergency Department Performance Quality Operations Patient Experience Metric Severe Sepsis/ Septic Shock- Abx w/in 180 min: Overall department performance (Percent Compliance) Severe Sepsis/ Septic Shock- Fluids w/in 30 min: Overall department performance (Percent Compliance) Door to Provider time - Overall department performance TRLOS- Overall department performance Press Ganey Likelihood to Recommend - Overall department performance Top Box Score Emergency Department Provider Performance Citizenship Academic Patient Experience Metric Objective criteria to be determined by Site Chairs (Examples - meeting attendance, committee participation, community benefit initiatives (ex. EMS directorship) Objective criteria to be determined by Med School Chair based on milestones within academic tracks (Examples - research, education, innovation, etc.) Press Ganey- MD Took Time (Courtesy)Question; Top Box Score for Individual Provider ** Friday, November 24, 2017 53

STIPs: Individual Provider Score Card (Non-academic sites) Emergency Department Performance Quality Operations Patient Experience Metric Severe Sepsis/ Septic Shock- Abx w/in 180 min: Overall department performance (Percent Compliance) Severe Sepsis/ Septic Shock- Fluids w/in 30 min: Overall department performance (Percent Compliance) Door to Provider time - Overall department performance TRLOS- Overall department performance Press Ganey Likelihood to Recommend - Overall department performance Top Box Score Emergency Department Provider Performance Citizenship Patient Experience** Metric Objective criteria to be determined by Site Chairs (Examples - meeting attendance, committee participation, community benefit initiatives (ex. EMS directorship) Press Ganey- MD Took Time (courtesy) Question;Top Box Score for Individual Provider ** Based on department and individual provider performance. Friday, November 24, 2017 54

STIPs: Physician Leadership Service Line Performance (%) Financial Patient Experience Quality Operations Emergency Department Performance (%) Financial Patient Experience Quality Operations Chairs and Vice Chairs are held to the same metrics at the Service Line and Department level for their sites. Friday, November 24, 2017 55

Thank You Questions? 56