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Hartford HealthCareClinical Care Playbook

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Hartford HealthCare’s (HHC) vision is to be “Most trusted for personalized coordinated care.” The Clinical Care Redesign (CCR) Program helps to achieve this vision by rethinking the way teams deliver care. The goal of a clinical care redesign project is to reduce variation, improve patient outcomes, and reduce cost. This Playbook acts as a guide in support of this goal to ensure that the project is executed in a thoughtful, consistent manner.

To be successful, a redesign project must be carefully planned with detailed actions for implementing new care protocols. Some key drivers for successful redesign are executive leadership support, involvement from internal partners (IT, Lean, Supply Chain, etc), and engagement from service line team. The purpose of the Playbook is to establish a standard for speed of execution, consistency, accountability and repeatability. The Playbook also functions as both a business plan and ‘how-to’ guide for creating value while providing step-by-step direction for tactical redesign plan. The Playbook includes flexible processes, timelines and templates to facilitate successful program launch.

MissionTo improve the

health and healing of the people and

communities we serve.

VisionMost trusted for

personalized coordinated care.

Values

EXCELLENCEINTEGRITY

SAFETYCARING


PLAYBOOK OVERVIEW

• Key Drivers for Successful Clinical Care Redesign 4

• Clinical Care Redesign Basics /

INTAKE AND SELECTION/INITIATION

• CCR Benefit Methodology Inclusion Criteria 6

• Quality/Cost Validation Assessment /

• HHC ELT Approvals /

• Council/Service Line Engagement /

• Identification of MAP Opportunities /

PLANNING

• Charter Development 15

• Team Meetings Work Flow /

• Engage Lean Methodology and Tools /

• Develop Care Pathway/Best Practice Grid (Sample) /

• Steps to Development of Quality Goals /

• HHC Council and MEC Approval for New Care Pathways /

• Communication Action Planning /

• Identification of Supply Chain Engagement /

• Development of Action Plan (SAMPLE) /

EXECUTION

• Design and Configuration of the Electronic Health Record 25

• Clinical Dress Rehearsal/Integrated Test /

• Go Live Planning /

– Go Live Huddles/Go Live Issue Mitigation /

– Training Plan Development/Execution /

• Communication Plan Deployment: Staff Education /

• MAP Benefit Sign Off /

TABLE OF CONTENTS


MONITOR AND CONTROL

• Operational and Executive Dashboard Reporting 31

• 30, 60, 90 day quality/financial benefit realization /

• MAP Tracker /

PROJECT CLOSURE

• Project Closure Survey Template 35

• Project Closure Checklist Template 35

• Project Closure Standard Work 35

URL DIRECTORY OF DIGITAL RESOURCES 36

TABLE OF CONTENTS


Key Drivers for Successful Clinical Care Redesign

PLAYBOOK OVERVIEW


Clinical Care Redesign Basics

Intake & Selection/Initation Prepare for redesign project by outlining core team, identifying stakeholders, and creating a governance strucutre

Planning Engage team and stakeholders to outling implementation plans

Excecution Includes dress rehearasal, go-live process, and launching communication plan.

Monitoring and Control Following go-live of redesign a project closure plan must be developed to create a sustainable monitoring process.

Closure Effective handoff of project to operational leads


Before a project can begin, program leaders must evaluate the readiness of a service line to undergo a redesign. To do so the following steps must be taken: Benefit Methodology Inclusion Criteria, Quality/Cost Validation Assessment, HHC ELT Approvals, and Council/Service Line Engagement.

• CCR Benefit Methodology Inclusion Criteria

• Quality/Cost Validation Assessment

• HHC ELT Approvals

• Council/Service Line Engagement

• Identification of MAP Opportunities

INTAKE & SELECTION/INITIATION


Scoring:< 7 does not have readiness | 7–15 limited readiness, re-evaluate | 15–20 strong potential for participation in CCR20 excellent candidate for CCR

Criteria Score: 0 1 2 3 Score

Leadership and team in place to support No

Minimal structural support

Strong leadership and moderate team

support

Strong leadership and staff support

Clinical Council in place NoYes but less than

3 monthsYes but less than

6 monthsYes greater than

6 months

Increase revenue or expense reduction Potential <100k 100-250k >250K >1 MM

Quality Outcomes Minimal Impact

2-3 Outcomes Could be Impacted

3-4 Outcomes Could be Impacted

>5 Outcomes Could be Impacted

Organization Impact Local/ Service line

Single EntityMore than one

entityAll HHC

Number of users or people impacted >200 30-80 80-200 <30

Impact to Regulatory No impact Minimal Impact Strong impact High Impact

Effort to Implement High Effort Strong Effort Moderate Effort Minimal Effort

Time to Implement >90 days 60-90 days 30-60 days <30 days

Impacted by other initiative Multiple Initiatives

One other initiativeOne other initiative

but relatedNo other initiative

CCR Benefit Methodology Inclusion Criteria


Quality/Cost Validation Assessment

Determine the Cost Opportunity Analysis Increase in Reimbursement

Departmental Cost Breakdown & Charge Details Level of Care

Utilization Reduction in Chargeable Items Procedure Length Reduction

Length of Stay Reduction Supply Pricing Improvement

CCR Project Approval Process

1.Determine Opportunity Through intake and selection processes determine the opportunity and readiness of service line using meaningful metrics.

2.CCR Executive Sponsor EndorsementOnce opportunity analysis is complete, endorsement from CCR executive sponsorship is necessary.

3.Clinical Service Line Leadership EndorsementEngagement from clinical service line leadership should be realized before proceeding forward.

4.Executive Leadership Team Final ApprovalELT should grant final approval over readesign project being pursued.

5.

Operations Committee/Stakeholder EngagementStakeholders represented in the operations committee should be engaged before launching execution of redesign project.

Quality/Cost Validation Assessment


Role Responsiblities

Executive Sponsor: The Executive Sponsor is responsible for oversight of the redesign project and helps to remove barriers with execution of key operational milestones

Executive Steering Committee: Typically a team of senior executives who provide oversight for the duration of the redesign process and make key strategic decisions and approve integration plans.

Operational Leads: Led by a senior director: Responsible for facilitating the work of the Operating Committee, providing guidance and direction to Functional Teams and reporting status to the Executive Steering Committee.

Operating Committee: Comprised of operational, financial and administrative executives who serve in coordination with project management during the redesign planning effort. Functions include identifying “blind spots”, assigning resources, making key project decisions and approving plans.

Dyad Leader: Typically a nursing and physician dual team. Responsible for facilitating the work of the work group, providing guidance and direction to functional Team members, coordinating activities and reporting status to the Operating Committee.

Work Group: Typically staffed with 1-10 employees who complete the majority of the work in developing redesign plans. Work Groups plan for the redesign in their service line (i.e. COPD, ERAS, etc)

Quality Management/Analytics: Representation from Quality is essential to develop meaningful dashboards for work group teams and executive leaders. Analytics must be monitored in order to track success of redesign on clinical outcomes


Stakeholder Engagement

Initial Engagement

• ELT roadshows

• HHC Council engagement

• Relevant Inter-professional teams

• Hospital Clinical Leadership Council

Ongoing Engagement

• Executive Sponsors

• Supply Chain Management

• Revenue Cycle

• ICP/ Case Coordination

• ITS

• Informatics

• Hospital Clinical Leadership Council

• Quality

• Relevant Clinical Councils

• Relevant Inter-professional Teams

• MAP team

• Finance

• Decision Support


Governance Structure

Clinical Care Redesign Program Governance


Alignment with Clinical Councils


Data Analysis and Opportunity Development (Quality Management)

Epic• Reporting workbench and Crystal Reports for process measures

• Leading indicators

EPSI• Cost data and resource utilization

• Leading indicators

Premier• Includes approximately 1,000 hospitals nationwide

• Facility sizes 25> 1,000 beds

• Can compare against hospitals for specialty division with a cohort of six of more facilities

• Lagging indicators (2.5 month gap)

Other service specific quality database(s)


Identification of Management Action Planning Opportunities


Before execution, a baseline must be established. The work group meeting structure should be outlined along with a kick off meeting. Engaging support structures is necessary to start to develop an action plan. Determining the current and future state will require investment from not only the work group leads but also executive leadership and stakeholders such as Lean Management and CareConnect.

Timely, effective clinical care redesign is largely dependent upon engaging the ‘right’ individuals and/or teams to lead the process. Before the project is approved, a core team is assigned to develop the strategy and oversee the implementation processes. The roles and responsibilities of the core team should be well defined to provide clarity, structure and direct accountability.

• Charter Development

• Team Meetings Work Flow

• Engage Lean Methodology and Tools

• Develop Care Pathway/Best Practice Grid (Sample)

• Steps to Development of Quality Goals

• HHC Council and MEC Approval for New Care Pathways

• Communication Action Planning

• Identification of Supply Chain Engagement

• Development of Action Plan (SAMPLE)

PLANNING


Charter Development

The project/dyad leads drafts a charter to document objectives, deliverables, performance indicators and a timeline for completion. Charter is approved by CCR executive sponsors. Also found in Project Management Office (PMO), Sharepoint: https://myhhc.hhchealth.org/SitePages/Home.aspx

Link to Charter Development


Sample Team Meeting Workflow (Customizable by service line)

Meeting Title Membership: Goals of Meeting Meeting Frequency

Dyad Meeting

• Dyad Leads• Quality • PMO• Facilitator

• CCR Announcements• Agenda creation for workgroup and sub groups • Timeline and milestone review • Barriers and next steps

Weekly

Pre-Workgroup Planning Meetings

• Dyad Leads• Quality• PMO• Facilitator

• Determine Workgroup Kick Off Date• Finalize Membership• Create the agenda• Discuss and Review opportunity data to be presented

Bi- weekly

Work Group Meetings

• Dyad Leads• Quality• PMO• Facilitator• Stakeholders• All regional membership

• Provide overview of CCR• Review areas of opportunity• Discuss subgroup and identify champions• Decide meeting cadence• Review next steps

Weekly

Sub group Kick Off Meeting

• Dyad Leads• Quality• PMO• Facilitator• Stakeholders• All regional membership

• Overview of CCR• Review areas of opportunity• Identify owners and next steps to investigate areas of opportunity• Determine meeting cadence

Bi- weekly


Engage Lean Methodology and Tools

Depending on the service line, work groups may have a future state that is determined by industry best practice (i.e. COPD Gold Guidelines). However, for redesign projects that do not have a future state identified, lean methodology is useful for assessment of current gaps in care. Lean tools such as A3 Problem Solving Template, Sample Workflow, and Fishbone tool can be found in appendix (8.6)

Link to Lean Tools


Develop Care Pathway *Thumbnails with Links to Documents - is there more than one?

(source document: COPD and PNA Pathway Handout 03 19 18)

Link to Develop Care Pathway


Steps to Development of Quality Goals

To effectively manage improvement two sets of improvement measures were determined. Primary improvement measures include, length of stay, complication rates, etc. This set of measures should be gathered in two ways; using internal data sources and nationally benchmarked data sources. Second-ary improvement measures include percent compliance of provider adherence to order sets, patient education compliance, adherence to medication, etc. These improvement measures are gathered from internal electronic health record reporting, which was recently implemented at all facilities.

Once performance improvement measures were determined, CCR project teams are able to formalize actions plans, project milestones, and opportunity interventions. Formalized scorecards can be developed for each team helped ensure performance and project deliverables.

To monitor improvement measures a multilayered governance structure should be developed. At daily progression rounds, regional teams evaluate secondary measures. Care teams tracks patient progress using electronic health record reporting and provide real time intervention. On a monthly basis CCR leads and a multidisciplinary (finance, revenue cycle, quality, etc.) operating committee monitor primary improvement measures.

Primary Improvement Measures Secondary Improvement Measures

Monitored Monthly by Dyad Leads and Multidisciplinary Operating Committee

Monitored Daily by Regional Facility teams at Daily Progression Rounds

Measure Source Measure Source


HHC Council and MEC Approval for New Care Pathways

Any change made to the policies, procedures, guidelines or practice should be approved by the relevant councils it directly impacts. The subject matter expert or representative must be available to provide feedback and mediate any revisions to gain council approval. Once agreement is met by the requestor(s) and council(s), the document will be presented to the local MEC for final approval. Once complete, the change can be implemented.

In order to track HHC Council approval see checklist here

Link to HHC Council and MEC Approval


Communication Action Planning Template

Go Live Communication

Readiness

Patient Education Communication

Staff Education Communication

Stakeholders

Roll-out lead

Target Launch Timeline

See communication resources on theHHC Patient Education Web Site


Communication Action Planning Template

Review Data and Identify Opportunities

Review supply data based on volume, cost, number of suppliers, and benchmarking like intuitions. Identify key supply category opportunities.

Identify Stakeholder

Identify stakeholders and decision makers for supply categories across the system

Survey Process Hold project kick off with stakeholders. Use real time survey tool to obtain feedback on preferred venders for supply categories.

Survey Results / RFP Process

Review survey results with team and provide suggested outcomes based on their feedback. Stakeholder team agrees on possible scenarios which drives RFP process

Review RFP Results Determine Award

Decision

Review RFP results with stakeholder team. Determine award decision scenarios. Supply chain notifies suppliers based on award decision


Development of Action Plan

Link to Development of Action Plan


EXECUTION

Effective execution requires prioritization; therefore integration implementation should focus on completing items described in the detailed timelines, particularly high priority value creators. If implemented correctly, HHC’s integration goal to build and manage collaborative processes that yield benefits in excess of costs should be maximized. Desired integration benefits include:

• Design and Configuration of the Electronic Health Record

• Clinical Dress Rehearsal/Integrated Test

• Go Live Planning

– Go Live Huddles/Go Live Issue Mitigation

– Training Plan Development/Execution

• Communication Plan Deployment: Staff Education

• MAP Benefit Sign Off


Design and Configuration of the Electronic Health Record


Preparation for the practice go-live requires careful planning. The below grid describes the key milestones that must be completed in order to launch a Clinical Dress Rehearsal. In the appendix below is a detailed Dress Rehearsal outline.

Clinical Dress Rehearsal/Integrated Test

Dress Rehearsal Key Milestones

Best Practice Grid – Paper pathway completed

Order set(s) Completed

EPIC Pathway completed (if appropriate)

Education material completed as appropriate for disciplines/roles affected.

Education scheduled to be completed prior to go live/ Education or print materials have been distributed (or are scheduled prior to go live.

Communication to stakeholders of go live date has been completed

Support team for go-live has been identified and scheduled

Concurrent report is available and has been validated — available to appropriate team members

Dashboard ( all levels of communication) has been completed and validated — available to appropriate team members

Go-live huddle/follow up process for feedback and troubleshooting has been outlined and scheduled check–ins have been reserved – based on specialty and go-live needs


Sample Go-Live Huddle Tools

Role Description Assigned Team Member

Epic Navigator Navigate the inpatient List

Time keeper Monitor time spent discussing each patient. Queue the team to take longer conversations offline

RecorderRecord patient name and MRN who are active on pathway. Indicate assignments and themed opportunities. Indicate If CDI review is needed

Morning HuddleMid-day Rounding

(Tiger Text Available)Afternoon Huddle

Day 1 Leads

Go Live Huddles/Go Live Issue Mitigation (Sample)

Go Live Informatics Support (Sample)

Sample Go-Live Huddle Tools

Go Live Patient Tracker (Sample)

Sample Go Live Patient Tracker


Communication Plan Deployment:

Before Go Live it is important that all members of the care team are education on new protocols. Below are key learning objectives for staff that should be reviewed before Go Live.

Staff Education Objectives

Examine the core protocols and elements of new pathway/guidelines

Describe the benefits of the new pathway/guidelines

Apply principals of new pathway/guidelines – using protocol tools with entire care team


Communication Plan Deployment:

Link to MAP Benefit Sign Off


MONITOR AND CONTROL

A detailed post-redesign audit is executed by the Executive Steering Committee to identify and document opportunities for improvement

MONITOR AND CONTROL

• Operational and Executive Dashboard Reporting

• 30, 60, 90 day quality/financial benefit realization

• MAP Tracker

MAP Tracker


Operational and Executive Dashboard Reporting

Operational Dashboard

Executive Dashboard


MAP Tracker

MAP Tracker


CARE PATHWAY

COPD Pathway DocumentERAS Pathway Document


Project Closure Survey Template

Project Closure Checklist Template

Project Closure Standard Work

Project Closure Checklist Template Project Closure Standard WorkProject Closure Survey Template

CLOSURE

Project Title:

Date Prepared:

Purpose: To document client satisfaction level of the product/service. The project manager distributes the Client Satisfaction Sur-vey form during the Closing Process. The project manager collects the forms and stores them in the project repository. The project manager should summarize the results of the Client Satisfaction responses in the Project Closeout Report.

As a valued client, your perception of the service is important. Please take a moment and grade the product/service on the following statements.

Please respond by placing an “x” in the columns labeled 1 to 5 or in the N/A column for each of the statements below. (1 = low, 5 = high)

1 2 3 4 5 N/A

The team displayed a total commitment to the project.Project team met or exceeded my expec-tations.Communicated appropriately and effectively, to the right people at the right times.Product/Service met due date commitment or provided the best possible alternative if the original due date could not be met.Communicated project goals to all clients and kept them involved and informed.Ensured timely monitoring and follow-up of project objectives and milestones.Used timely, effective escalation to ensure client satisfaction.Conducted timely project meetings and conference calls. Negotiated and published project plans.The specific product and/or service require-ments were met.Had good knowledge of products and services involved in the project.Conducted a post project evaluation and pro-vided feedback on successes or suggestions for improvement.The project was handled professionally.

Project Name:

Project Sponsor: Project Manager:

Prepared by: Date Prepared:

Purpose: This document presents to the sponsor and primary stakeholder(s) of this project, a list of project deliverables for approval and signature. Upon signature, this project will be considered to have met all requirements and will be considered closed and transitioned to ongoing operations – with any exceptions as noted below. The summary information captured in this report is supported by detailed source documents in the project archive.

Key Milestones & Deliverables

Milestone/Deliverable (major) Actual Date Completed

Comments Explain any variance between the original and revised target date.

All exceptions remaining unmet at this time along with their agreed upon remediation are as follows:

Exception Description Remediation Plan Date Due

Project Benefit Summary

Description Metric Responsible Party

Project Cost Summary

Item/work Product Cost Budget Variance

Standard Work for Closeout Report

Process Information

Process Description Project Outcomes & Closeout Report

Goal Close & transition to operations

Process Boundaries

Staff H3W PMO Total Cycle Time 1 week

1 Added to project executive sponsor checklist

Notes

2 Built off charter baseline and project deliverables

Steps Role Task Description Equipment Cycle Time

Start Process

1 owner Introduce to project sponsor at the beginning of the project before the kickoff as part of executive sponsor checklist

60


URL Directory of digital resources

Page Document URLPg.8 Quality Cost Validation Assessment www.http://hartfordhealthcare.org/

Pg.16 Charter Development https://myhhc.hhchealth.org/SitePages/Home.aspx

Pg.18 Lean Tools www.http://hartfordhealthcare.org/

Pg.19 Develop Care Pathway www.http://hartfordhealthcare.org/

Pg.21 HHC Council and MEC Approval www.http://hartfordhealthcare.org/

Pg.22 HHC Patient Education web site https://hartfordhealthcare.org/patients-visitors/patients/patient-education

Pg.24 Development of Action Plan www.http://hartfordhealthcare.org/

Pg.28 Go Live Huddle Tools www.http://hartfordhealthcare.org/

Pg.28 Go Live Patient Tracker www.http://hartfordhealthcare.org/

Pg.30 MAP Benefit Sign-Off www.http://hartfordhealthcare.org/

Pg.31 MAP Tracker www.http://hartfordhealthcare.org/

Pg.32 Operational Dashboard www.http://hartfordhealthcare.org/

Pg.32 Executive Dashboard www.http://hartfordhealthcare.org/

Pg.33 MAP Tracker www.http://hartfordhealthcare.org/

Pg.34 ERAS Pathway Document www.http://hartfordhealthcare.org/

Pg.34 COPD Pathway Document www.http://hartfordhealthcare.org/

Pg.35 Project Closure Survey Template www.http://hartfordhealthcare.org/

Pg.35 Project Closure Checklist Template www.http://hartfordhealthcare.org/

Pg.35 Project Closure Standard Work www.http://hartfordhealthcare.org/