Clinical Operations in a Service Line Model

These presenters have nothing to disclose. 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? Origin & Evolution of the Clinical Operations Team IHI and Process Improvement Continuous Site Improvement work Data & Analytics Accountability & Sustainability Questions and Discussions 2

What is a Service Line? 3

Emergency Medicine Service Line > 800,000 annual ED visits 5 Tertiary EDs 11 Community EDs 1 Free-Standing ED 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 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 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 7

EMSL Centralized Services 8 8

Origin and Evolution of the Clinical Operations (Clin Ops) Team 10

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 11

Northwell Health Sepsis Mortality: Jan 2008- September 2017 12

What did we learn from the IHI Collaborative? 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 13

IHI & Process Improvement 15

Framework of 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 16

The IHI Model for Improvement Aim: What are trying to accomplish? Measures: How will we know that a change is an improvement? Ideas: What change can we make that will result in improvement? Act Study Plan Do 17

The Steps To Change 18

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 19

Clinical & Operational Excellence EM Strategy for Sustainable Results Tools To: Increase Customer Satisfaction Decrease Process Variance Decrease Process Defects Decrease Cycle Times Engage Frontline Employees Sustain Change Through Process Redesign LEAN events Swim Lane Process Mapping Fast Track decision making Priority Pay Off Matrix PDSA Town Halls Brainstorming Identification of non-value added waste Reduce wastedata Driven Solutions We spend 75-95% of our time doing things that increase cost and create no value for the customer 22

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 24

Clin Ops Team Structure Director, Clinical Optimization Project Manager Assistant Director, QM Collaboration Regional Physician VPs Regional Analysts Regional Nurses 25

How do we work with our Sites? Physician Chair Nursing Director Vice/ Asst. Chairs Clin Ops Team RN Managers ACP Leads ED Administrator 26

Typical Emergency Department Flow Input Triage Room placement Throughput Provider interaction, Work up, Intervention Output Provider Signoff Discharge: home or hospital 28

And this is where our ED workflow redesign team went insane. 29

Clin Ops Approach to Workflow Redesign Continuous Site Improvement projects (SIPs) Data and Analytics to transform patient care Sustainability & Accountability Model 30

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 31

Plainview: Decrease Door to Provider < 30 mins Multidisciplinary LEAN event Measurable results Workflow mapping 32

Plainview Door to Provider 33

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. 34

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 35

Lenox Hill LEAN Event Buy-in from front line staff Brainstorming Solutions and Causes Workflow process mapping 36

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 37

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 38

Current Data: Treat and Release Length of Stay 39

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. 40

LIJ: Baseline Data Emergency Department Volume 7% Increase 88,263 93,964 Left Without Being Evaluated 9% Increase 1.40% 2.60% 2014 2015 303 T&R LOS 334 2014 2015 ED Door to Provider 85 65 2014 2015 2014 2015 41

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 42

LIJ: Current Data ED Treat &Release LOS 350 313 300 273 250 200 150 2016 2017 YTD Series1 313 273 ED Door to Provider 100 80 77 60 56 40 20 0 2016 2017 YTD Series1 77 56 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% ED Left Without Being Evaluated 2.40% 1.20% 2016 2017 YTD Series1 2.40% 1.20% Magnet 27% decrease in D2D??? 13% decrease in T&R LOS 50% decrease in LWOBE 2% increase in Volume YTD which equates to 3% when decrease in LWOBE is factored in 43

Data and Analytics 44

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 Turnover and mobility Over 200 metrics are captured by the EMSL sites. This slide highlights a portion of those metrics. Monday, December 11, 2017 45

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 46

Static Monthly Dashboards 47

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. 48

Transparency and Accountability 49

Using Data and Analytics to Transform Patient Care Nursing and Tech Staffing 50

Sustainability & Accountability 51

Regular Site Improvement Project (SIP) Meetings with Sites Aim: All sites will focus SIP work on reducing treat and release LOS with a measureable outcome in a designated timeframe Structure: Collaborative touch points with like-volume cohort (<35K, 35-60K, and >60K) Frequency: every six weeks Format: Webex Conference Accountability: each site presents a 3 slide upon based upon the PDSA cycle 52

Formal Report Outs of Improvement Work Emergency Medicine Service Line Leadership Meeting Logistics Service line leadership meeting every 6 weeks Each site presents once annually Goals ED leaders share their successes Leaders in the audience ask questions, get new ideas EMSL Leadership Meeting Date & Time: Tuesday, November 14 th, 2017 10:00 AM 12:30 PM Location: 2000 Marcus Avenue Conference Rooms 1 & 2 New Hyde Park, NY 11042 Video Conference Locations: 130 East 59 th St. NYC, Maimonides Medical Center, Staten Island University Hospital-North Time(s) Item(s) Presenter(s) 10:00 am 11:00 am 1. Site Improvement Project Updates Glen Cove Hospital Huntington Hospital Lenox Health Greenwich Village Glen Cove ED Leadership Team Huntington ED Leadership Team LHGV ED Leadership Team 11:00 am 11:15 am 2. Updates from the SVP Dr. John D Angelo 11:15 am 11:25 am 3. Updates from the VP Paula Fessler 11:25 am 11:30 am 4. Committee Report Outs A. Sepsis B. Opioids C. Quality Council 11:30 am 12:00 pm 5. PDSA Cycle Simulation Lucy Wu Dr. Boris Khodorkovsky Dr. Adam Berman Dr. Yves Duroseau/Kristen Lawton Emergency Medicine Service Line 1981 Marcus Avenue, Suite 214 New Hyde Park, New York 11042 Tel (516) 336-6475 53

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 ** 54

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. 55

STIPs: Physician Leadership Service Line Performance (40%) Financial Patient Experience Quality Operations Emergency Department Performance (60%) 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. 56

Thank You Questions? 57