Embed Size (px)
Citation preview
7/23/2012
1
Today’s Session: Monitoring Quality to Assure Improvement
WebEx Quick Reference
• Welcome to today’s session!
• Please use Chat to “All Participants” for questions
• For technology issues only, please Chat to “Host”
• WebEx Technical Support: 866-569-3239
• Dial-in Info: Communicate / Join Teleconference (in menu)
Raise your hand
Select Chat recipient
Enter Text
7/23/2012
2
When Chatting…
Please send your message to
All Participants
If you’re joining with colleagues, please type the organization you represent & the number of
people joining from your organization.
Example: Midwest Health Alliance – 3
Please type your name and the organization you represent in the chat box!
Example: Chris Jones, Midwest Health Alliance
7/23/2012
3
IHI Expedition Team
Kathy Luther, RN, MPM
Vice President, IHI
Jill Duncan, RN, MS, MPH
Director, IHI
Kayla DeVincentis
Project Coordinator
Today’s Guest Faculty
Kevin Little, PhDIHI Improvement AdvisorPrincipal,Improving Ecological Design. LLC
Hoa Cooper, RN, BSN, MHSA, NEA-BCOSF Saint Francis Medical Center
7/23/2012
4
Agenda
• Welcome & homework review
• Measuring, Monitoring, and More
• Wrap up and next steps
Expedition ObjectivesParticipants will be able to . . .
• Identify potential cost reduction quality improvement opportunities for your organization.
• Prioritize high-return ideas and map to energy grid for your organization.
• Develop a set of quality metrics as well as a financial measurement system to capture savings across your portfolio.
• Obtain the tools and confidence to build and execute on a portfolio of interventions to achieve results.
• Plan small tests of change you can test throughout the Expedition.
7/23/2012
5
• Evaluate Cost & Quality Impact
• Prioritize Projects and Manage Organizational Energy
• Create a Portfolio of Projects
• Solve Problems and Execute PDSA Cycles
• Measure and Monitor Results
PRIMARY DRIVERS SECONDARY DRIVERS
Reduce operating
expenses 1% per
year while continually
maintaining or
improving quality.
AIM
WILLAlign Enterprise
WILLEngage Staff, Physicians and Patients
IDEASIdentify Waste
EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste
• Establish True North Metrics (Big Dots)
• Align Waste Reduction Strategy Throughout Organization
• Align Systems for Efficiency
• Adopt Integrated Performance Measurement Systems
• Engage Staff in the What & Why of Value Delivery
• Establish Data & Feedback Loops
• Patient & Family Perspective of Waste
• Ensure a Safe Environment for Sharing Ideas
• Develop New Skills at All Levels
• Eliminate Clinical Quality Problems
• Optimize Staffing
• Maximize Flow Efficiency
• Manage Supply Chain
• Reduce Mismatched Services—overuse, coordination
• Reduce Environmental Waste (Healthy Hospital Initiatives)
Driver Diagram IHI’s Cost + Quality Collaborative Work
Homework Review - Ground Rules
We learn from one another – “All teach, all learn”
Why reinvent the wheel? - Steal shamelessly
This is a transparent learning environment
All ideas/feedback are welcome and encouraged!
7/23/2012
6
• For your selected approach, identify and discuss several key waste streams.
• For one (1) of the streams discuss how you’d build a financial model
Homework Review
Royal Commission Medical Center Yanbu Industrial City - KSA
IHI Expedition:
Partnering Quality & Finance Teams to
Improve Value
7/23/2012
7
Assignment # 3For the (Delay in Patient’s Discharge):After collecting the data for about 3 weeks using the designated checklist, the following key waste streams were identified as the main causes behind the delay in patients’ discharging form the hospital:
1. Lab test results delay: the delay of the results of the patient’s lab tests may postpone the discharge of the patient. The most responsible physician is usually linking his/her discharge decision to the lab test result when the patient's clinical signs makes the him/her fit for discharge.
2. Pending transfer to another facility: the hospital’s ambulance crew would not transfer any patient from the hospital premises to another hospital unless there is a written approval from the executive director of medical affairs (EDMA). This is sometimes not achievable especially during the weekends, when the EDMA is not around.
3. Patient needs an assisting equipment before being discharged home: sometimes, the patient stays in the hospital beyond the planned discharge day due to the non-availability of needed assisting equipment he/she might need at home after leaving the hospital.
Assignment # 3_continued
• An estimate of any extra “unnecessary” patient’sstay at the hospital was calculated, incollaboration with the finance department staffwho participate in the IHI expedition team:
─ The average cost of the patient occupancy of thebed/day is SAR 400; this value can be divided upon 2parts: SAR 350 which cover the fixed costs (costs ofutilities, maintenance and salaries), the meals served,the bed and the toilet room supplies and SAR 50 whichcover the medications and the medical suppliesprovided to the patient during his/her extra days stay.
7/23/2012
8
Assignment # 3_continued
• According to the data collected by two of the teammembers, the patients stay on average 4 extra(unnecessary) days per week. This means a totalof (4x52) = 208 days per year.
• This means that on average, an avoidable cost of$ 83,200 is incurred to the hospital every yearbecause of the extra (unnecessary) days ofpatients’ stay.
Measuring, Monitoring, and More
Kevin Little, Ph.D.
Informing Ecological Design, LLC
Improvement Advisor, IHI
7/23/2012
9
MEASURING
Measuring: Cost and Quality
• Processes and projects need measures to assess performance and drive learning
• Value for patients and payers is a function of cost and quality:
Value = quality/cost
7/23/2012
10
Project Phase Measures work
Set-up/Plan Define useful Q + Cmeasures •to track performance •to estimate project impact
Doing the Project •Track measures to assess progress and support learning•Create and share monthly summary
Study/Act (Wrap Up)
Estimate project Q+C impact(annualized)
Measurement Tasks by Project Phase
Four types of opportunities
• Reduce Harm to patients (type H)
• Improve Delivery of Care (type D)
• Improve Supply Chain performance (type S)
• Improve Administrative performance (type A)
Close enough to PDSA to remember!
7/23/2012
11
Quick Poll
1. Yes / No: Does your portfolio include projects that reduce the direct harm to patients?
2. Yes / No: Does your portfolio include projects that improve delivery system performance?
3. Yes / No: Does your portfolio include projects that improve supply chain value?
4. Yes / No: Does your portfolio include projects that reduce waste in administrative/support area processes
5. Yes / No: Excluding clinical quality projects (type H), how many have started thinking of balancing quality measure?
Type H Project: CLABSI Improvement
OSF SFMC changed protocols, policies and central venous catheter kit components
CLABSI Rate (infections per 1000 central
line days)
FY 2010
FY 2011
Change
Housewide 1.88 1.45 -22.8%
Adult population 1.95 1.32 -32.3%
Quality measurement immediately available from OSF tracking system No extra work to measure quality.
7/23/2012
12
CLABSI example (con’t)
Financial estimates: based on incidence
Estimated Direct Costs ($ millions)
FY 2010
FY 2011
Change
Housewide $ 8.6 $ 8.0 -7.0%
Adult population $ 6.7 $ 5.3 -20.9%
Financial estimates had to be generated (not immediately available). required local financial staff to be part of team to calculate and validate
calculations.
Type A Project : Change in Staff Compensation
Interim Health, a home health agency, changed from reimbursement/visit to salaried (moved away from fee for service!).
“They are estimating they will save $1.5 million in wages for 2012; they are working with 40-fewer staff and business has grown by 3%.”
--June 2012 monthly check in report, Impacting Cost & Quality, summarized by J. Duncan
Financial impact estimate immediately available from existing reports and measurements
7/23/2012
13
Compensation Example (con’t)
“Interim saw some attrition in staff initially but over time they have noted increased staff satisfaction (95% retention for 2012 to date); ‘great’ (per the CFO) patient satisfaction scores and no negative impact to their clinical outcomes data. They are seeing increased protocol use, improved visit management by staff, more telephone support and increased use of tele-health for some of their follow up.”
--June 2012 monthly check in report, Impacting Cost & Quality, summarized by J. Duncan
Quality Advisor
7/23/2012
14
OSF CLABSI
Interim Staff Compensation
MONITORING, REMINDER
Tracking your measures over time: Tell the story
7/23/2012
15
Readmission Within 30 days (all)
4.00
6.00
8.00
10.00
12.00
14.00
Readmission Rate: after Any Disease Target
Pilot started AMU &
5G July 2011
Median Apr ’10 – Jun ‘11 1st 4 months of Fiscal Year
OSF 2011-12 readmissions project
SCIP 3 Antibiotic Discontinuation2Q 2010
Pe
rce
nta
ge
Pe
rce
nta
ge
Pe
rce
nta
ge
Pe
rce
nta
ge
SCIP 3 Prophylactic Antibiotic Discontinued Within 24 hrs After Surgery End Time 2Q 2010SCIP 3 Prophylactic Antibiotic Discontinued Within 24 hrs After Surgery End Time 2Q 2010SCIP 3 Prophylactic Antibiotic Discontinued Within 24 hrs After Surgery End Time 2Q 2010SCIP 3 Prophylactic Antibiotic Discontinued Within 24 hrs After Surgery End Time 2Q 2010
Quarter and YearQuarter and YearQuarter and YearQuarter and Year
1 Q 2006
29
1
3.45%
2 Q 2006
36
6
16.67%
3 Q 2006
35
8
22.86%
4 Q 2006
33
4
12.12%
1 Q 2007
29
4
13.79%
2 Q 2007
26
11
42.31%
3 Q 2007
30
16
53.33%
4 Q 2007
24
23
95.83%
1 Q 2008
18
17
94.44%
2 Q 2008
27
26
96.30%
3 Q 2008
21
19
90.48%
4 Q 2008
11
10
90.91%
1 Q 2009
11
9
81.82%
2 Q 2009
21
21
100.00%
3 Q 2009
19
19
100.00%
4 Q 2009
13
12
92.31%
1 Q 2010
17
16
94.12%
2 Q 2010
16
15
93.75%percent
p chartp chartp chartp chart
T emporary: UCL = 87 . 87 , CT L = 56 .9 7 , LCL = 2 6 .07T emporary: UCL = 87 . 87 , CT L = 56 .9 7 , LCL = 2 6 .07T emporary: UCL = 87 . 87 , CT L = 56 .9 7 , LCL = 2 6 .07T emporary: UCL = 87 . 87 , CT L = 56 .9 7 , LCL = 2 6 .07
Inspe cted M ean = 23 .11 , Counts M ean = 13 . 17Inspe cted M ean = 23 .11 , Counts M ean = 13 . 17Inspe cted M ean = 23 .11 , Counts M ean = 13 . 17Inspe cted M ean = 23 .11 , Counts M ean = 13 . 17
UCLUCLUCLUCL
CTL
LCLLCLLCLLCL
T op 1 0%T op 1 0%T op 1 0%T op 1 0%
S ta te AveS ta te AveS ta te AveS ta te AveNati ona l AveNati ona l AveNati ona l AveNati ona l Ave
3. 45%3. 45%3. 45%3. 45%
16. 67%16. 67%16. 67%16. 67%
22. 86%22. 86%22. 86%22. 86%
12. 12%12. 12%12. 12%12. 12%13. 79%13. 79%13. 79%13. 79%
42. 31%42. 31%42. 31%42. 31%
53. 33%53. 33%53. 33%53. 33%
95. 83%95. 83%95. 83%95. 83%
94. 44%94. 44%94. 44%94. 44%
96. 30%96. 30%96. 30%96. 30%
90. 48%90. 48%90. 48%90. 48%
90. 91%90. 91%90. 91%90. 91%
81. 82%81. 82%81. 82%81. 82%
100. 00%100. 00%100. 00%100. 00%
92. 31%92. 31%92. 31%92. 31%
94. 12%94. 12%94. 12%94. 12%93. 75%93. 75%93. 75%93. 75%
Top 10% - 99%Top 10% - 99%Top 10% - 99%Top 10% - 99%
State Ave - 92%State Ave - 92%State Ave - 92%State Ave - 92% National Ave - 91%National Ave - 91%National Ave - 91%National Ave - 91%
1 Q 2
006
2 Q 2
006
3 Q 2
006
4 Q 2006
1 Q 2007
2 Q 2
007
3 Q 2
007
4 Q 2
007
1 Q 2
008
2 Q 2
008
3 Q 2
008
4 Q 2
008
1 Q 2
009
2 Q 2
009
3 Q 2
009
4 Q 2
009
1 Q 2
010
2 Q 2
010
0
20
40
60
80
100
•2Q 2007 -Automatic
prophylactic Abxdiscontinuation and MD Profiling
•4Q 2007-Concurrent monitoring and
revision of CPOE Abxdiscontinuation
Action :Physician Champion Involvement –Concerned MDs were counseled
•Above or Within State and National
Average –Sustained X10Q
Kingsbrook Jewish Medical Center
7/23/2012
16
Monitoring Tools Links
Run charts and Control Charts• IHI web tools on Run charts
• IHI on-demand video—Run Charts and Control Charts
• R.J. Perla et al. (2011), “The run chart: A simple analytic tool for learning from variation in healthcare processes”, BMJ Quality and Safety, 20 (1), 46-51. abstract
• L.P. Provost and S.K. Murray (2011), The Health Care
Data Guide: Learning from Data for Improvement, San Francisco: Jossey-Bass.
MORE
Demonstrations of good performance are foundation for…
7/23/2012
17
Pilot Testing Reminders
• Adapt good ideas to your world
• Build staff capacity to modify standard work
• Increase belief that changes actually work
• Develop a useful story to share
source: Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco © Associates in Process Improvement, used with permission.
Guidance on Scale of a Test
7/23/2012
18
CASE STUDY EXAMPLE
Managing a Complex Portfolio for Long-term Success
OSF Saint Francis Medical Center
Peoria, Illinois 61637
United State
7/23/2012
19
Introduction
• OSF Saint Francis Team
─ Quality Plus Cost Steering Team
─ Quality Plus Cost Workgroup
• Flagship hospital of the OSF Healthcare System ─ 616 bed teaching hospital affiliated with University of Illinois College
of Medicine
─ Average daily census = 475
─ More than 5,900 employees
─ 850 physicians on staff and 215 adjunct staff
• Quality Improvement Methodology ─ 6 Sigma Methodology
─ Rapid Improvement Model
─ PDCA
Portfolio Management• Aim of Portfolio:
• Current Portfolio Projects:Project Name Projected
Savings Savings to
DateQuality Metrics
1. Clinical documentation $ 4,000,000 $ 400,000 D
2. Antibiotic Stewardship $ 1,000,000 $ 545,000 S
3. Project BOOST - readmission $ 1,500,000 $ 800,000 D
4. HAC – VAP, BSI $ 4,200,000 $ 1,229,000 D
5. Transplant Services $ 500,000 $ 73,000 D
6. Palliative Care Services $ 788,000 $ 220,740 D
7. ED Case Management $ 2,000,000 $ D
8. Core Measure $ 750,000 $ D
9. Care Coordination/LOS $ 1,000,000 $ 580,000 D
10. ED professional fee $ 1,400,000 $ A
Totals $ 16,938,000 $ 4,068,480
Percentage of Operating Budget
Savings in US Dollars
$ $8,103,970 $4,068,480
7/23/2012
20
Project Progress1 – Charter established
2 – Activity, but no changes
3 – Modest improvement
ProjectName / Month
2012 2013
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Documentation
1 2 2 2 3 3
Antibiotic 1 2 2 3 3 3
Readmis. 1 2 2 3 3 3
VAP/BSI 1 2 3 3 3 3 3
Transpl. 3 3 3 3 3 3 3
Palliative 2 3 3 3 3 3 3
ED CM 2 2 2 2 2 2 2
CM 2 2 2 3 3 3 3
LOS 1 2 2 3 3 3 3
ED fee 1 2 2 2
4 – Significant progress
5 – Outstanding success
Portfolio Management
• Dedicated project sponsor and process owner to continue:
─Real time monitor process, progress and barrier
─Review data to identify opportunity
─Process changes to ensure optimal outcome
• Accountability
─Sponsor report out to the leadership team with action plan to close the gap
7/23/2012
21
Clinical Excellent – Quality Plus Cost Hoa Cooper, Dr. Gorman, Jennifer Ulrich, Cassy Horack, Kelly George, Dana Hobson,
Bryan Kaiser (meeting bi- weekly)
Project Started and need to accelerate and focus on achieving the quality outcome
1. Reducing Readmission: BOOST
2. HAC: fall, CAUTI, Pressure Ulcer-culture of safety focus on all three indicators
3. Pay for performance – core measure workgroup, readmission
4. Palliative Care –inpatient consultation, adult inpatient unit, outpatient palliate care
5. Rehab transfer process – proactive screening process, rehab care coordination and discharge process
New Projects focus on improving quality and reduce cost and/or increase reimbursement
1. Coding: present on admission, CC/MCC, Complication, coding (grouper)
2. ED Frequent Readmission: ED Case Management/appropriate admission, Palliative Care in the ED
3. ED Professional fee charge capture
3. LOS Management - Care Model/Care Coordination, focus on high opportunity service line, high LOS, transition of care to SNF, Home Health, LTAC etc., Rehab
4. Medical Management/Medicare effectiveness –1. Pneumonia
2. Transplant services
The Quality Plus Cost Core Group are to identify opportunity, priority and to motivate & collaborate with the interdisciplinary care team including MD to charter, plan and execute the plan
7/23/2012
22
Clinical Excellent Guidance CouncilB. Anderson, L. Wiegand, Dr. Cruz, K. Harbaugh, J. Ritchie, M. Hohulin, Dr.
Velazquez, Dr. Martin, Dr. Gorman, Dr. Miller, C. Horack & Hoa Cooper
1st Wednesday at 0800 pay for performance
4th Wednesday at 0900 care management
Quality Plus CostBC & BS Pay for performance
Quality, Utilization, Patient sat.Cat Pay for performance
Core measure, readmission,CLBSI, Mortality
Capacity ManagementThroughputCare transitionCulture of Safety
Reduce InfectionMedication SafetyHuman Resources
Quality plus costDocumentation/coding improvement ED Case Management/Palliative CareLOS ManagementMedicare Effectiveness DRG specific –Pneumonia and TransplantED Charge Capture
The council is to set strategic vision, monitor our metrics, performance indicators, approval of projects, hold leaders accountable to execute the plan against our strategies.
Financial Model
• Cost saving is calculated with actual data as much as possible.─ Comparing pre and post implementation actual direct
cost
• The team compose to support the alignment of quality plus cost projects─ Clinical – physician
─ Process Improvement – Master Black Belt
─Operation – Director of Operation
─ Financial – Director of Finance
7/23/2012
23
Learning from tests of change
• What has changed in the way you work?
─Process Improvement is part of what we do, continue to identify gap, opportunity
─Replicate the process improvement
─Communicate the success to leader and staff to create excitement and engagement
OSF Contact
• Hoa Cooper
─309-624-8817
7/23/2012
24
Questions?
Raise your hand
Use the Chat
Additional Resources• Brooks, DT. “Cutting Costs and Improving Quality: The Everett Experience” Above
all in Frontiers of Health Service Management, Volume 27(2), Winter, 2010.
• Clark, DD et al. “Cost Cutting in Health Systems without Compromising Quality Care”
• Eber, M. R., R. Laxminarayan, et al. "Clinical and Economic Outcomes Attributable to Health Care-Associated Sepsis and Pneumonia." Arch Intern Med 170(4): 347-353.
• Nolan T. , and Bisognano M. (2006). “Finding the balance between quality and cost.” Healthcare Financial Management Magazine. 2006; 60 (4): 67-72.
• O'Brien-Pallas, L., P. Griffin, et al. (2006). "The Impact of Nurse Turnover on Patient, Nurse, and System Outcomes: A Pilot Study and Focus for a Multicenter International Study." Policy Politics Nursing Practice 7(3): 169-179.
• Shamliyan, T. A., R. L. Kane, et al. (2009). "Cost savings associated with increased RN staffing in acute care hospitals: simulation exercise." Nursing Economic$ 27(5): 302.
• Sparling, K. W., F. C. Ryckman, et al. (2007). "Financial Impact of Failing to Prevent Surgical Site Infections." Quality Management in Healthcare 16(3): 219-225
7/23/2012
25
Quality Advisor
Partnering Quality and Finance Teams to Improve Value
Expedition Worksheet
Align senior support
Decide where you want to start
Begin to build a partnership with leaders from the finance team
What is your aim? (% operating expenses? Cost/case? Cost/discharge?)
Engage frontline staff
Begin to identify projects that will get you to your aim
Begin building a portfolio
Consider projects you are already working on as potential for your portfolio
Don’t know where to start? Consider adapting and testing the Waste
Identification Tool
Build and leverage
partnerships
Collaborate with your financial colleagues to review your suggested portfolio
and identify what might get at dark green dollars.
Develop financial
models
Define how you will measure the potential and actual savings for each
project
Monitor quality to
assure improvement
Identify best practices, financial models, aims & charters for each area of
work
Develop a series of projects around the ones identified by your team (your
portfolio)
Develop a sequencing plan for the work
Test improvement interventions as well as financial measurement strategies
Implement systems to encourage rhythm and discipline around the work
Track progress
Learn & spread across a
community
Spread learning and best practices
Re-engage & re-commit on a regular schedule
7/23/2012
26
Homework for Next Call
• For each project you have identified, run through the Quality Advisor flow chart. For D, S and A type projects, identify appropriate balancing quality measures.
• Can you use measures already being collected?
Send ‘Tweet-like’ message of 140 characters or less to Jill at [email protected] by Monday, August 6th
Expedition Listserv
If you would like additional people to receive session notifications please send their email addresses to
We have set up a listserv for participants in this Expedition to share improvement strategies, and
pose questions to one another and faculty.
To use the listserv, address an email to
7/23/2012
27
Schedule of Calls
• Session 1 – Tuesday, June 12th 1:30 – 3:00 EDT
─ Align senior support & build and leverage partnerships
• Session 2 – Tuesday, June 26th 2:00 – 3:00 EDT
─ Engage frontline staff & prioritize portfolios
• Session 3 – Tuesday, July 10th 2:00 – 3:00 EDT
─ Develop financial models
• Session 4 – Tuesday, July 24th 2:00 – 3:00 EDT
─ Monitor quality to assure improvement
• Session 5 – Tuesday, August 7th 2:00 – 3:00 EDT
─ Learn & spread across a community
• Evaluate Cost & Quality Impact
• Prioritize Projects and Manage Organizational Energy
• Create a Portfolio of Projects
• Solve Problems and Execute PDSA Cycles
• Measure and Monitor Results
PRIMARY DRIVERS SECONDARY DRIVERS
Reduce operating
expenses 1% per
year while continually
maintaining or
improving quality.
AIM
WILLAlign Enterprise
WILLEngage Staff, Physicians and Patients
IDEASIdentify Waste
EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste
• Establish True North Metrics (Big Dots)
• Align Waste Reduction Strategy Throughout Organization
• Align Systems for Efficiency
• Adopt Integrated Performance Measurement Systems
• Engage Staff in the What & Why of Value Delivery
• Establish Data & Feedback Loops
• Patient & Family Perspective of Waste
• Ensure a Safe Environment for Sharing Ideas
• Develop New Skills at All Levels
• Eliminate Clinical Quality Problems
• Optimize Staffing
• Maximize Flow Efficiency
• Manage Supply Chain
• Reduce Mismatched Services—overuse, coordination
• Reduce Environmental Waste (Healthy Hospital Initiatives)
Driver Diagram IHI’s Cost + Quality Collaborative Work
7/23/2012
28
Thank You
