Dedication to Quality Improvement Delivers on the Triple Aim: Saves Tens of Millions Annually

Transcription

1 Session #16 Dedication to Quality Improvement Delivers on the Triple Aim: Saves Tens of Millions Annually Nicole Kveton, RN, BSN, MHA Vice President, Allina Health Group Quality, Value, and Nursing Sue Fairchild, PMP Program Manager, Allina Health Strategic Project Management Office

2 Learning Objectives Recognize how to broadly reduce variation, improve quality, and lower costs across a multi-hospital health system. Determine how to organize to effectively execute on a systemwide improvement plan. Illustrate how to use the information to identify improvement opportunities and monitor progress.

3 Poll Question #1 How much effort does your hospital or health system put into reducing clinical variation compared to 2-3 years ago? 1) Less effort than before 2) The same amount as before 3) More effort than before 4) Unsure or not applicable

4 Allina Health believes Improving value requires improving one or more outcomes without raising costs, or lowering costs without compromising outcomes, or both. Michael Porter and Thomas Lee, MD

5 Allina Health: Region s Largest Health Care Organization Allina Health is dedicated to the prevention and treatment of illness and enhancing the greater health of individuals, families and communities throughout Minnesota and western Wisconsin. 85 clinic sites and ambulatory care centers. 5,000 physicians. 3.0 million+ clinic visits. 12 hospitals. 103,000+ inpatient hospital admissions. $4B in revenue. 31% Twin Cities inpatient market share.

6 Total national healthcare expenditures account for 17.1% of the GDP projected to rise to nearly 20% by % $265 billion (30%) of healthcare spending is waste.

7 Creating Value Across the Continuum Imperative Value/Volume industry shift Clinical standardization is a cost imperative. Also, a critical aspect of achieving improved outcomes. Increasingly competitive markets Clinical and cost outcomes are pivotal to maintaining and growing market share. Better care/ experience for individuals. Better health for the population. Reduce per capita costs of care for populations. Organizational vitality.

8 Roadblocks to Improving Clinical Value at Allina Health Scarce resources. Minimal visibility of implementations Large system. Lack of awareness regarding value of work. Need for greater prioritization of improvement work across the system.

9 Turning Point Market and system demands require a sharpened focus on identifying ways to fund Allina Health s mission. 1. Increasing clinical value. Gain a deeper understanding of how clinical quality improvements actually contribute to the margin. 2. Performance improvement initiatives spanning the organization. Strategic target = 3% margin. Requires identification of $50-$150M of performance improvement opportunities annually. Action: Launch systemwide effort to measure clinical value by quantifying the value of our clinical change work to improve outcomes while reducing costs and increasing revenue for reinvestment in care.

10 Examples of Results Achieved Across the System Women s Health initiative elevated the patient care experience while simultaneously lowering the per capita cost of care for each one. $210,000 in increased revenue because of improved access, projected to be $280,000 within 12 months. 20.8% relative improvement in no-show rate. 20% increase in available ultrasound appointments and 18.2% increase in utilization. A minimalist approach to TAVR improves outcomes and costs, yielded the following results: $1.1M savings in less than one year. 31% relative reduction in length of stay (LOS). 17.4% relative reduction in median procedure time. Heparin improvement team has successfully improved clinical value through processes of care and clinical outcomes associated with IV heparin administration. 7% relative improvement in the percentage of patients therapeutic within 24 hours of protocol initiation. Paring 20+ site-based documents (e.g., policies, protocols, and order sets) to one systemwide guideline and four systemwide protocols.

11 icv Program Results 3 Year Timeframe PROCESS STEP IDENTIFICATION CHARTER DEVELOPMENT VALIDATION APPROVAL PROGRESS Opportunities reviewed, discussed and possibly shared with potential vehicle of 100 Q identified for 2017 (portfolios). Q314 Q project charters developed project charters developed. Q117 Q project/program charters developed. Q314 Q projects reviewed. $26M validated projects reviewed. $12.1M validated. Q117 Q projects reviewed. $8.6M validated. Q314 Q projects reviewed and approved projects reviewed and approved. Q117 Q projects reviewed and approved. COMMENTS By the Improving Clinical Value Analytics Work Group - opportunities from Lab, Pharmacy, SCM, TeleHealth Clinical Data analysis (variation, LOS, PPC/R), as well as Clinician / Physician Driven By Implementation Leaders (Specialty Service Line Program Leaders / Project Managers) Started a quality assurance review step w/system wide representation from PI and PMO to ensure defined patient population, metrics and timeline. By Finance Partners (Hospital Finance VPs/Directors and System Office Finance) By Hospital Presidents & Specialty Service Line Leadership

12 icv Program Results 3 year timeframe PROCESS STEP Hospital RESOURCE ASSIGNMENT IMPLEMENTATION CLOSE PROGRESS 40 projects reviewed. 4 projects assigned hospital resources Q314 Q415: Sepsis - Start / Stop Infusion. Mental Health - Alcohol Withdrawal. Oncology - SSI/ERP. Hospitalist - Standardizing Heparin. 25 projects reviewed. 4 Projects assigned hospital resources 2016: ED Nursing Documentation Standardization. ED Chest Pain. ENT PTA. ERP / project status reports reviewed monthly. Many projects implemented and closed. COMMENTS By Hospital Nurse Executive Council / Operational Executive Council and supported resource assignment when requested. Monthly reports from Implementation Leaders to Quality, Finance, SCM, Specialty Service Lines, Hospital, and IS leaders. Implementation timeline completed, status reporting ceased, financial tracking for 12 months.

13 Setting the Course for Improving Clinical Value

14 icv Program Optimize outcomes, cost, and appropriateness of our clinical processes. Value = Appropriateness (binary) * (outcomes / cost). Link clinical quality and fiscal rigor. Save money in the short-run. Form the core of our ability to be successful in value-based reimbursement. Use analytics to help identify the variation and targets areas to improve care.

15 icv Program Objectives Enable and manage the paradigm shift of driving value in care delivery while taking out cost by bringing together organizational stakeholders (multidisciplinary) to identify, prioritize, and implement needed projects. Enable consistent, accurate, and reproducible identification and reduction of unwarranted clinical variation across Allina Health while maintaining or improving patient care. Develop and apply a prioritization approach by determining the value of projects, enabling appropriate resource assignment (PI, PM, IS, and vendor contracts as applicable), as well as implementation timing. Identify, determine, and build evidencebased opportunities where providers are caring for patients differently.

16 icv Program Group Stakeholder Representation Quality Operations Value Finance Physician / Clinician Supporting Depts.* * SCM, pharmacy

17 icv Program Structure SUPPORT COMMITTEES icv PROGRAM SPECIFIC PROCESS COMMITTEES Hospital Division Quality Committee Executives Financial benefit validation workgroup Hospital presidents Clinical Information Performance Leadership Team Clinical Leadership Team Program sponsors Operatio ns Analytics work group Physician / Clinician Quality Value Supportin g Depts.* Finan ce Implementation leaders Nurse Executive Council / Operations Executive Council Performance Leadership Team

18 Implementing the Evidence-based Opportunities Identification & Validation Identify Opportunity for Program Committee: APR data analysis. Care Model change / Physician round table discussions / decisions. Support departments: SCM. Pharmacy. TeleHealth. Lab. Physician / Organization Interest? Assess initial estimate / expectation. Assign System Office Resources (Clinical Data Analyst / Finance Analyst / PI / PM) Develop assessment team. Develop Charter / Business Case. Define Scope / AIM Statement. Identify Metrics / Measurements (Quality, Patient Experience / Other). Identify Stakeholders. Develop timeline Milestones. Determine Value: Utilize quality metrics and estimated risk to develop financial value to organization ( + / - ). Quality Assurance of Charter / Business Case / A3. Validate financial value. Implementation Prepare for Implementation: Finalize charter development. Understand and document change management (impact of change to organization by role). Assign Hospital Resources. Assign IS Resources. Develop implementation team. Add (reassess system office resources). Execution: Develop specific timeline with associated tasks. Develop and implement communication plan for stakeholders. Develop and implement training plan. Implement change. Workflows. Roles / responsibilities. Excellian development. Monitor / Control: Report monthly status to implementation timeline. Track and report issues / risks / barriers to success. Track financial impact to organization for 12 months. Track quality metrics / balancing metrics. Executive Review / Approve Close Transition to business as usual / program committee. Reassign resources. As appropriate for size and complexity of work.

19 Opportunity Identification Collaboration across functions (finance, payer relations, and clinical leaders) and the use of analytics are critical to identify and shape opportunities. Key factors: Focus on clinical conditions with high cost and high variation. Look for the drivers of cost and variation by the nine part break categories. Examine variation by facility and/or provider. Drill down to homogeneous patient populations by segmenting on severity, diagnoses, procedures. Analyze the impact of other factors, such as LOS, PPRs, PPCs. Clinical Condition (high $ opportunity Variation by facility & provider Other Factors: PPR, PPC, LOS 9 part break (drivers) Further Segmentation By: Severity level, dx, proc Opportunity

20 Opportunity Example Epilepsy Room Costs (Opportunity $378k) Room cost variation is driven by consistent, longer LOS for specialist groups compared to shorter more variable LOS for hospitalists. Minnesota Epilepsy Group cares for onequarter of the epilepsy patients with the remainder cared for by hospitalists. The majority of the opportunity is at United where the LOS exceeds GMLOS. Specialists with long LOS and low variation. Responsible Provider Group Volume % with Neuro Consult Performance to GMLOS Room Opportunity 598 $378,872 PPR A/E Ratio (Excess) Allina Medical Clinic - United Hospitalist Service 95 40% 103% $86, (9.0) Minnesota Epilepsy Group, PA % $68, (-4.5) Allina Medical Clinic - ANW Hospitalist Service % 92% $64, (-1.7) Cuyuna Regional Medical Center 27 52% 183% $48, (-1.4) Midwest Internal Medicine 48 90% 92% $28, (0.9) Allina Medical Clinic - Unity Hospitalist Service 43 81% 87% $10, (0.6) Mercy HealthPartners Hospitalists 15 87% 82% $10, (1.5) Rotilie, Toman and McGraith LLC 10 20% 83% $8, (-0.2) Source: GOAT Dashboard Selections: July 2015 June 2016; ICD Program Epilepsy; Outliers Excluded

21 Poll Question #2 How effective is your organization in using data to identify and reduce inappropriate variation? 1) Not effective 2) Somewhat effective 3) Moderately effective 4) Very effective 5) Unsure or not applicable

22 Determining Opportunity Value Reducing Care Variation Outlier Reduction Opportunity Cases Reduce outlier practices in a smaller number of facilities or providers. Provides more immediate results, but diminishing returns over time as outliers are reduced. Shifting The Mean Requires a change in practice amongst the majority. Continuous focus on improvement: takes longer to achieve but drives long-term results. Source: The Advisory Board Company, Crimson Continuum of Care. (2016). The care variation short list: Targeting high ROI opportunities for reducing care variation. Retrieved from

23 Implementing the Evidence-based Opportunities Identification & Validation Identify Opportunity for Program Committee: APR data analysis. Care Model change / Physician round table discussions / decisions. Support departments: SCM. Pharmacy. TeleHealth. Lab. Physician / Organization Interest? Assess initial estimate / expectation. Assign System Office Resources (Clinical Data Analyst / Finance Analyst / PI / PM) Develop assessment team. Develop Charter / Business Case. Define Scope / AIM Statement. Identify Metrics / Measurements (Quality, Patient Experience / Other). Identify Stakeholders. Develop timeline Milestones. Determine Value: Utilize quality metrics and estimated risk to develop financial value to organization ( + / - ). Quality Assurance of Charter / Business Case / A3. Validate financial value. Implementation Prepare for Implementation: Finalize charter development. Understand and document change management (impact of change to organization by role). Assign Hospital Resources. Assign IS Resources. Develop implementation team. Add (reassess system office resources). Execution: Develop specific timeline with associated tasks. Develop and implement communication plan for stakeholders. Develop and implement training plan. Implement change. Workflows. Roles / responsibilities. Excellian development. Monitor / Control: Report monthly status to implementation timeline. Track and report issues / risks / barriers to success. Track financial impact to organization for 12 months. Track quality metrics / balancing metrics. Executive Review / Approve Close Transition to business as usual / program committee. Reassign resources. As appropriate for size and complexity of work.

24 Opportunity Conversion Steps and Timeline Analysis Project Charters Completed Quality Assurance and Financial Validation Review / Approval January March March April April June May June July September July / August September October November October / November December Project Charters due June 5th or sooner for Q2 submittal. Quarterly project submission aligns with implementation leadership desired timing as well as hospital planning.

25 icv 2017 goals $12 million positive margin impact by expense reduction and additional hospital in/outpatient revenue through addressing clinical variation and improving and standardizing care processes. To efficiently and nimbly navigate volume to value, we will understand the value of our work prior to implementation. Identify $25 million in improvement opportunity for 2018 in preparation for Allina Health budgets.

26 In a data-driven, multidisciplinary team effort, Allina Health organized and implemented a systemwide program to measure the value of their clinical standardization and improvement efforts.

27 Lessons Learned Minimize outside distractions pave the way. Success is multidimensional true systemness. Enable collaborative dialogue.

28 Future Plans Continue to strengthen the utilization of the value process to enable business as usual behavior.

29 Thank You