Leading System Change to Meet the Needs and Get Results

Leading System Change to Meet the Needs and Get Results Helen Macfie, Chief Transformation Officer Critical Care Symposium April 2018 About MemorialCare Total Assets $3.3 billion Annual Revenues $2.3 billion Bond Rating AA- stable Hospitals Patient Discharges 67,000 Patient Days 317,000 ER Visits 214,000 Babies delivered 10,500 Surgeries IP/OP 31,700 Ambulatory Access At Risk Lives/ACOs 260,000 Seaside Health Plan 40,300 Medical Group Visits 600,000 Ambulatory Surgeries 57,000 Workforce Employees 11,000 Affiliated Physicians 2,600 Employed Physicians 230 1

Evolving to integrated care Physician Steering Committee formed Catalina Physicians as Partners 1996 Best Practice / Evidence-Based Medicine Launched Physician Commitment Society to EMR A Brand is Born Created 1997 2000 2003 First Inpatient EMR go live 2006 First AEMR practice live 2007 Physician Leadership Academy: 1 st Class 2008 Formed Medical Foundation / Acquired Bristol Park Medical Group 2011 Acquired Knox Keene Acquired Established Nautilus & Seaside Health Affiliated Plan with GNP 2012 Added Ambulatory Imaging Centers Added Outpatient Surgical Centers (JV) Partnered on primary care clinics MemorialCare Partners to Launch Vivity Anthem Blue Cross ACO PPO MemorialCare and Aetna create ACO CMMI Bundled Payment Program Improvement (BPCI) NextGen ACO (CMS) MemorialCare Health Alliance chosen by Boeing for their employees Added partnership for ambulatory dialysis Brand is refreshed Clinical Integration Pediatric partnership GNP Epic Pilot 2013 2014 2015 2016 2017 2018 Session Goals Focus: Creating Bold Goals to foster performance on the Triple Aim for Critical Care Keys: Aiming for transformation Key drivers 1. Setting Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions 2

Aiming for Transformation Concept: Aiming High, Aiming Wide Aim High Islands of Excellence Transformation Low Just Good Enough Incremental Improvement Unit Level System Level Breadth of Aim 3

The IHI Leadership Framework It still works! It really is a journey Start where you are There s no one best way Take the ideas you like, store the rest It takes years 4

Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions The importance of Strategic Linkage 5

What are the MOST important safety issues to focus on in Critical Care? What would you pick? 6

Keys to setting priorities Understanding what s important Preventable mortality and harm Improved outcomes Not taking on world health all at once Create focus on the vital few Establishing bold targets Evolution Hospital Strategic Quality Priorities (Vital Few) Reaffirm the work each year, 2006 - Present Big Dots Key Drivers Measures Reduce Mortality Reduce Needless Harm Improve Patient & Family Experience Early Response Clinical Reliability Sepsis Care Reduced Infections Reduced Complications Improved screening Population health Endorsement and Loyalty Codes Outside ICU Perfect Care Sepsis Mortality Central Line, VAP, CAUTI, SSI Hand Hygiene Hospital Acq. Pressure Ulcers Patient Falls, all VTE/DVT prevention Medication reconciliation Medical Foundation Big 5 OB care C-section Inpatient: HCAHPS Ambulatory: CGCAHPS 7

Concept: The Art of Selecting Targets You want to create stretch Getting to transformation vs. improvement Better than average or truly benchmark? Thoughts on Perfect Care at the patient level Going for Zero harm ( Zero Zone ) Having said that, start where your team can support, and evolve MemorialCare s safety Bold Goals Today, by June 2018 Reduce mortality Severe sepsis mortality by >70 % Achieve perfect care Core Measure sets all diagnoses/bundles to > 95% Medication Reconciliation metrics: all 3-90% Reduce harm to Zero Zone Hospital acquired infections (HAI) Achieve 100% hand hygiene compliance Hospital acquired pressure ulcers (HAPU) Patient falls with injury Harm Across the Board by > 80% Promote Population Health NTSV C-Section rate to < 15% Medical Foundation goals to top 10 th percentile Screening colorectal; diabetes care HbA1c > 9, childhood immunizations (combo 10), controlling BP in hypertension 8

Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions Pursuing Best Practice The power of the Physician Society The Physician Society Growth in Membership 95% of admissions Responsibilities Professional association. Board level. Committed to development and utilization of evidence-based/best practice medicine Lead development of best practice Implement best practice guidelines at the bedside / visit-side Leadership of physician informatics and outcomes 20 Years of Innovation Over 300 Best Practice guidelines Best Practice Teams, multidisciplinary Ambulatory Anesthesia Blood Use Breast Care Antimicrobial Stewardship Cardiac Colorectal Emergency Neonatology Orthopedics Pediatrics Pain Pulmonary & Critical Care Sepsis Stroke Wellness Women s Health Wound Care 9

Hardwiring in the Evidence Ex: Best Practice Collaborative Reducing Avoidable Sepsis Deaths Initial Bold Goal mortality by 25% -> 30% Surviving Sepsis campaign Mortality (severe, shock) baseline 38 per100 pts -> 32/100 Revitalized Campaign in 2012-13 Update definition (back over time), removed DNR within 24h Patient stories success & failure Updated Best Practice guidelines and EMR/Epic tools Workflow redesign ED, acute Best Practice team datamart Culture education data by 55%. BOLD Goal now to by 70% by June 18 With noted increased prevalence over time Decrease cost per case (R65.20+R65.21, ICD-10 codes) Current focus testing IV Vit C/B1, timing of Abx vs M 10

Action network map Key learning: Incorporation of Five Lean Kata Coaching Questions Coaching Kata behavior or pattern 1. What is the target condition? 2. What is the actual condition now? 3. What obstacles are preventing you from reaching the target condition? Which are you addressing now? Who out there is doing it better? What toolkits already exist? What could work here? 11

Key learning: Incorporation of Five Lean Kata Coaching Questions Coaching Kata behavior or pattern 4. What is your next step? What could work here? Who will champion this? Who should be on the team to work out the details? What tests of change can we do where, in order to test our theories next Tuesday? How to launch, educate, monitor and provide feedback? 5. When can we go and see what we have learned from taking that step? Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions 12

Culture of Safety Survey Results Considerations Visibility is key! Thoughts on transparency No one best way, but DO start Another journey - Price range pen and paper to e-tools - If its not up-to-date, it doesn t have that oomph Leveraging for conversation and action - Leadership rounding - Visibility Boards and Huddles front line and executives 13

Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions PI Radar Dashboard Shows where we started, have been, are now How it works: Stretch targets (Green = hard!) Scalable Balanced Performance over time Inservice: Bold - move out, to/beyond the green line ( Australia ) Leads us to the Rest of the Story 14

System-Wide Strategic Visibility Board Target: INPATIENT MORTALITY & HARM Focus: improve overall PI Radar plot, reduce key harms Current State/Graphs: Harm Across the Board ROLL-UP** Hospital Acquired Infection ROLL-UP** BTR: If you could break or change one rule in service of a better care experience for patients or families, what would it be and why? Visibility Board Key Analysis and Activities: Bold Goals focused on Perfect Care for Core Measures, rapid response teams, reduction of harm and sepsis mortality Launched new CMS core measure Sepsis perfect care set MEWS (adult), PEWS (peds) and OB (MEWTS) early warning systems rolled out Epic tools, trackboards, response algorithms Infections UV robots acquired, rolled out, Task Force renewed VBP/P4P $ - Reached 82% for 2017 reporting Participating/Sharing in Hospital Improvement and Innovation Network (CalHIIN) and IHI Leadership Alliance What We re Working On, Will See Next: Initiative/ Tactic Who Target Action/Status Harm Across the Board Infections Drill Medication Reconciliation Breaking the Rules (IHI, BTR) IHI Leadership Alliance FY 19 Goals, HAB Metric Wynn Leo Macdonald Mascotti Macfie Leo Macfie, Team Macfie, Leo Macfie, Leo 1FQ 18 C.Diff protocols revised, launched July 17 Antimicrobial Stewardship BPT project plan New Epic ICON/AMS module launched Reviewed Xenex use & outcomes system-wide 2FQ 18 Revised Discharge Med Rec indicator & leaned out Epic Navigator list launched Jan 18 Feb 26 Mar 2 Updated: March, 2018 (By: Macfie, Leo) Participated in global week huddles, on-line > 140 ideas received to review Q Close April 2018 Co-chairing Big Waste work group for IHI Collaborating on Equity work group for IHI 4FQ 18 Quality Close reviewed hospital goals Apr 18 adding opioid & antibiotic Bold Goals, plus further halving of HAB measure BOD Jun 18 MCMF Goals revised for CY 2018 For internal use related to strategy, quality and performance improvement purposes only. PI Dashboard Target: Hospital Acquired Infections FY 18 Goal to reduce rate (Note: Links to Standardized Infection Ratios (SIR) on PI Radar) Current State/Graphs: MemorialCare ROLL-UP** CMCLB LBMC OCMC SMC Key Analysis and Activities: HAI Task Force activated key recommendations in 2015, 2016, 2017 55 cases in 4Q 17 for total of 200 in CY 17 for a 42% reduction overall vs 2016 (and 54% reduction vs 2015) Clinical business case for Xenex UV light robots approved; rollout done Lean A3 held for new Epic ICON/AMS modules PRC approved. Work completed to sync to Cerner Lab system. Modules launched 2017 Note: Includes hospital acquired infections (those that we can t prove we didn t cause): device associated, surgical site related and/or due to multi-drug resistant organisms. % = raw # per 100 Discharges, not risk-adjusted (see SIRs on Radar) What We re Working On, Will See Next: Initiative/ Tactic Who Target Action/Status Xenex rollout system-wide IP VAT D. Wynn HAI Task Force D. Platt Ongoing 3Q 17 Colorectal BPT Antimicrobial Stewardship Lean A3 and BPT C. Chuen Dr. Patel J. Leo C. Chuen 1Q 16 Monitor use / technique HCAHPS impact noted Literature supportive Evaluation of effectiveness see Drilldown Each campus drilldown on local opportunities Revised C.Diff Standardized Testing 1Q 17 Activated new BPT Share SSI best practices Letters to physicians 1Q 17 4Q 17 Updated: March, 2018 (By: C.Atkins) Convened new BPT, recs underway Rolled out new ICON / AMS Epic modules Visibility Board For internal use related to strategy, quality and performance improvement purposes only. 15

CalHIIN HAI Reports CLABSI ICU Benchmarking 4Q 16-3Q 17 LBMC OCMC SMC 4 observed, SIR 0.65 1 observed, SIR 0.34 0 observed, SIR 0.00 CalHIIN HAI Reports CAUTI - ICU Benchmarking 4Q 16-3Q 17 LBMC OCMC SMC 1 observed, SIR 0.13 1 observed, SIR 0.3 3 observed, SIR 1.33 16

Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions Healthcare Value VALUE If Value = Quality Cost, what happens when we provide lots of services that don t help patients? Cost goes up Quality remains unchanged (at best) or worsens (harm), and Value declines 17

Encouraging Creativity Innovation is a GOOD thing! Overdiagnosis and overtreatment: definitions Overdiagnosis: The diagnosis of a condition or abnormality which will, if left alone, never cause symptoms, complications, or shortened life Overtreatment: By definition, treatment cannot possibly help patients who are overdiagnosed The only potential outcomes of treatment are either no effect or adverse effects, and increased cost to the patient and healthcare system H. Gilbert Gil Welch, M.D. Author of Overdiagnosed 18

How to Overdiagnose 1. First, change the rules Condition/ Threshold Diabetes Fasting BG 140 126 Old Definition New Definition New Cases Resulting % Number Needed to Treat to Benefit 11,697,000 13,378,000 1,681,000 14% (Death, MI, CVA, RF) 250 (Prevent limb loss) Number Needed to Treat to Harm 6 (hypoglycemia w/ hospitalization (1) Hypertension SBP 160 140 DBP 100 90 Hyperlipidemia Cholesterol 240 200 Osteoporosis in Women T Score 2.5 2.0 38,690,000 52,180,000 13,490,000 33% 12 (2) 49,480,000 92,197,000 42,647,000 86% 50 (MI); death 244 5-20 (myalgia, weakness, cognition, DM) (3) 8,010,000 14,791,000 6,781,000 85% ~500? (4) Prediabetes 0 52,000,000 52,000,000 4-8 Lifestyle change 14 (metformin) (5) 2.4 (6) 2. Improve technologies to see more 3. Look harder 4. Stumble onto incidental findings 1. www.thennt.com 2. Redberg R, JAMA Int Med 11.13.2016 3. www.thennt.comn 4. Gruber A et al., Int J Clin Pract 2006;60(5):590 5. Drug Facts and Comparisons Oct. 2004 How Medical Literature Overinflates Benefits 75% Reduction in Mortality!...? RRR: Relative Risk Reduction the relative reduction in adverse outcome with a given treatment Odds Ratio (OR) and Risk Ratio (RR): fractional relationship of an exposure to an outcome ARR: The absolute reduction in likelihood of the adverse outcome NNT: How many patients you have to treat to achieve the desired outcome, or to avoid the undesired outcome/harm (NNTB, NNTH) POEMs: Patient-Oriented Endpoints that Matter Assume: Mortality in Control Group 4% Mortality in Treatment Group 1% RRR = 75% (4%-1%) 4% OR: 0.2424 RR: 0.25 ARR = 3% (4% - 1%) NNT = 33.3 1 ARR = 1 0.03 Will diagnosis/treatment help me avoid suffering or death? 19

Example #1: PCV-13 (Prevnar) Synopsis: Basis for FDA approval, adults 65 Study done in The Netherlands 84,492 patients randomized to PCV-13 or no PCV-13, then followed for development of vaccine-type CAP (VT-CAP) or VT- IPD IMPORTANT: Prior pneumococcal vaccination was an exclusion criterion, so no patients had both PPSV-23 and PCV-13 Vaccine type community acquired pneumonia: Mean follow-up 3.97 years Case of VT-CAP: 49 vs. 90 Relative Risk Reduction (reported in article) 45.56% Absolute Risk Reduction 0.097% NNTB was 1,030 (not reported in article) in 4 yrs Invasive Pneumococcal Disease: Relative Risk Reduction 75% Absolute Risk Reduction 0.0497% NNTB was 2,011 (also not reported in article) And No mortality difference between groups Cost/dose: $150-156 Cost per avoided case of CAP: $159,438 Cost to bring current population up to guideline compliance: $6.3 billion, + $595 million/yr All for not a single additional life saved Example #2: PCSK9 Inhibitors Synopsis: Injectable antibody against PCSK9 Produces ~ 60% lowering of LDL cholesterol highly effective FOURIER Trial: first clinical outcomes trial 27,564 patients (DBRCT), all patients on maximally tolerated statin already 2.2 years median duration Outcomes: Composite endpoint of CV death, MI, CVA, hospitalization for unstable angina, coronary revascularization Hazard Ratio cited in abstract: 0.85 ARR: 1.5% (not cited in study) NNT: 67 Annual cost: $14,000 Cost/POEM: $2,063,600 20

How to inform yourself www.thennt.com Addressing Overdiagnosis head-on We are stewards of precious resources OVERDIAGNOSIS & OVERTREATMENT The diagnosis of a condition or abnormality which will, if left alone, never cause symptoms, complications, or shortened life Opportunity to override per indication (evidence-links). Active learning over time greater impact than % followed The Prescription: Make it strategic, hosting broad discussions Understanding NNTB/NNTH and POEMS Smart alerts wisely choosing wisely Shared decision-making TheNNT.com Advocacy P4P measures that promote overtreatment Addressing publication bias publicizing ALL research 21

Key Drivers 1. Setting strategic Bold Goals/aims 2. Creating a learning system 3. A word on culture 4. Outcomes 5. Overdiagnosis & overtreatment the new math 6. Where to next and questions Bold Goals and PI Focus for FY 19 (Jul 18-Jun 19) DRAFT from Quality Close Quality Committee/Board Continue our current focus areas, update targets (vs benchmarks) Leverage strategic focus on equity and use of REAL and social determinants of health for performance improvement Further reduce Harm Across the Board by another 50% Change PI Radar infections to #/100 (with CDC SIR drilldown) ADD new Bold Goals for opioids and antimicrobial stewardship TBD: 90% of new start patients (e.g. post-op) with Rx not > 7days TBD: 90% of clean/clean contaminated surgical procedure patients are NOT given antibiotics after closure of the surgical incision 22

The only thing we know about the future is that it will be different. Peter Drucker Thank you! Final thought: This work takes vision, clinical leadership and great partnerships. It s about Will, Ideas & Execution. Please leave your ego at the door Questions? Helen Macfie, Pharm.D. Hmacfie@memorialcare.org 23