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Advanced Efforts to Identify and Reduce Waste in Healthcare Delivery

Advanced Efforts to Identify and Reduce Waste in Healthcare Delivery. January 16, 2014 – David A. Burton, MD. 1. Constructs for understanding healthcare waste. Clinical Integration Construct. Clinical Programs – ordering of care. CV. W&C. GI. Neuro Sciences. Musculo-skeletal. General

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Advanced Efforts to Identify and Reduce Waste in Healthcare Delivery

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  1. Advanced Efforts to Identify and Reduce Waste in Healthcare Delivery January 16, 2014 – David A. Burton, MD

  2. 1. Constructs for understanding healthcare waste

  3. Clinical Integration Construct Clinical Programs – ordering of care CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression

  4. Clinical Integration Construct Clinical Support Services – workflow and defects CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression Diagnostic Clinical Support Service (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Clinical Support Services (Delivery of Care) Therapeutic Clinical Support Service (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Ambulatory Clinic Clinical Support Service (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Service (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Service (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

  5. Organization of teamsClinical and technical SENIOR EXECUTIVELEADERSHIP TEAM GUIDANCE TEAM Provides overall governance and prioritization of initiatives CONTENT ANDANALYTICSTEAM CLINICALIMPLEMENTATIONTEAM Provides steady state domain governance and oversight Supports developmentof clinical content and analytics feedback Refines Work Group output and leads implementation Chief Knowledge Officer WORKGROUP Provides l forum to develop and/or refine clinical content and analytics feedback

  6. Technical support personnel

  7. Organization of clinical teams = Subject Matter Expert = Data Capture = Data Provisioning & Visualization = Women & Newborn’s Clinical Program Guidance Team = Data Analysis Pregnancy MD Lead RN SME Gyn MD Lead RN SME NL Newborn MD Lead RN SME AbNL NB MD Lead RN SME Guidance Team MD lead (e.g., Pregnancy MD Lead) RN, Clinical Ops Director Pregnancy SAM AbNL NB 3-A SAM Normal Newborn SAM Gynecology SAM DataArchitect Application Administrator Knowledge Manager • Permanent teams • Integrated clinical and technical members • Technical personnel support multiple packets

  8. Repeatable system for deployment Implementation Design Kickoff AIM Statement Launch Approval Results Review • Mission • Cohort Discover • Data Analysis and Review • BMJ Best Practices • Building Multiple Potential AIMstatements • Supplement BMJ content • Refine Cohort • Refine Metrics • Develop Draft Visualizations • Develop Recommended AIM statement #1 • Cluster Reps Obtain Front Line Input • Finalize Cohort • Develop Additional metrics based on feedback • Develop Additional Visualizations to support • PDSA cycle • Cluster Reps Obtain Front Line Input • Improvement Plan • Implementation Plan • Develop cluster rep assignments, and deliverables • Collect cluster rep feedback • Prepare Initial Results from AIM statement #1 • Summarized report for historical review • Refine, recommend AIM statement #2 Monthly Tasks and Checkpoints 7 Steps (Work Streams) Gather knowledge assets Define cohort Select Aim Statement Select, build & refine metrics Develop implementation plan Implement plan Measure progress Select Initial Metric Build and Refine Build and Refine Build and Refine

  9. Population Health Management construct

  10. Population Health Management Medicare fee-for-service payments by venue - 2011 LTCH/IRF Home Health ClinicCare Outpatient Inpatient Hospice SNF $ 31.7 Billion 11.8% 77.6 Billion 28.8% 90.6 Billion 33.7% $ 29.7 Billion 11.0% $ 11.1 Billion 4.1% $ 18.4 Billion 6.8% $ 10.1 Billion 3.7%

  11. Population Health Management Anatomy of Healthcare Delivery Symptoms Screening & Preventive Prevention and Treatment Knowledge Assets Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules Health Maintenance and Preventive Guidelines Diagnostic Work-up Diagnostic algorithms Utilization Management Knowledge Assets Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications Home(Patient Portal) Triage to Treatment Venue Triage Criteria Admission Order Sets Admission Order Sets Clinic CareNon-recurrent Clinic Care Chronic Invasive Medical Invasive Surgical Acute Medical IP Med-Surg Acute Medical IP ICU Indications for Intervention Treatment and Monitoring Algorithms Indications for Referral Standardized Follow-up Substance Selection Pre-Procedure Order Sets Substance Preparation Substance Selection Supplementary Order Sets Invasive* Subspecialist Chronic Disease Subspecialist Clinical Supply Chain Management Bedside care Clinical ops procedure guidelines and patient injury prevention * To Invasive Care Processes Treatment and Monitoring Algorithms Procedure Post-procedure Order Sets Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols Post-procedure Care Post-acute care order sets IP (SNF, IRF) Home health Hospice Discharge

  12. Waste construct

  13. Utilization management waste and prevention and treatment waste Population Health Management Prevention and Treatment Waste Utilization Management Waste Per encounter and per case management (individual patient focus) Per capita management (population focus) Per Encounter or Per Case Waste Sample Metrics Admits/1000 members IP days/1000 members OP visits/1000 members Procedures/1000 members ED visits/1000 members Readmissions/1000 members Sample Metrics Cost/visit Cost/case OR minutes L&D hours LOS # of comorbidities Per Capita Waste 13

  14. Three forms of waste 14

  15. Ordering waste 15

  16. Clinical Integration Construct Clinical Programs – ordering of care CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression

  17. Ordering of careImprovement initiative process Care Process Models for KPA Care Process list Mapping of admin codes to HC clinical hierarchy Basic cohorts –admin rules Per Case Key Process Analyses Process and outcome metrics & visualizations AIM statement starter sets Prevention, treatment, & UM starter sets Advanced cohorts - admin and clinical rules

  18. Ordering waste example Wasteful Cardiac ventriculography to measure ejection fraction Contributory Cardiac echo to measure ejection fraction Brain natriuretic peptide (BNP) Diagnostic Two-view chest X-ray Arterial blood gases 18

  19. Workflow waste 19

  20. Clinical Integration constructClinical Support Services – delivery of care CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Clinical Support Services (Delivery of Care) Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

  21. Workflow (delivery of care) Improvement initiative process Mapping of client data to HC clinical hierarchy Triage of client data into care unit & ancillary depts Pareto and opportunity analyses Process and outcome metrics & visualizations Intra- & inter- departmental VSMs, A3s, & AIM statements Clinical department value stream maps

  22. Workflow waste – surgical services

  23. Workflow waste – surgical services reduce room turnover time

  24. Defect waste (patient injury) 24

  25. Clinical Integration constructClinical Support Services – delivery of care CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Clinical Support Services (Delivery of Care) Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

  26. Patient injury Improvement initiative process Patient Injury Prevention Process (PIPP) starter set maps AIM statement starter sets Hospital-Acquired Condition (HAC) cohorts Analysis of frequency, costs, potential savings Define care units to which PIPPs apply Define criteria for PIPP intervention PIPP intervention protocol starter sets PIPP surveillance process, outcome metrics & visualizations

  27. Defect waste – CLABSI prevention

  28. 2. Prioritization – Sample healthcare industry analyses

  29. Utilization versus prevention and treatment waste Population Health Management Prevention and Treatment Waste Utilization Management Waste Per encounter and per case management (individual patient focus) Per capita management (population focus) Per Encounter or Per Case Waste Sample Metrics Admits/1000 members IP days/1000 members OP visits/1000 members Procedures/1000 members ED visits/1000 members Readmissions/1000 members Sample Metrics Cost/visit Cost/case OR minutes L&D hours LOS # of comorbidities Per Capita Waste To be included in future waste analyses (at such time as claims data are available) Included in today’s analysis (a subset of the total waste in the healthcare system) 29

  30. Clinical ProgramsKey Process Analysis (KPA)

  31. Inpatient per case KPA CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression

  32. Inpatient per case KPA LTCH/IRF Home Health ClinicCare Outpatient Inpatient Hospice SNF $ 11.1 Billion 4.1% $ 29.7 Billion 11.0% $ 18.4 Billion 6.8% $ 31.7 Billion 11.8% 90.6 Billion 33.7% $ 10.1 Billion 3.7% 77.6 Billion 28.8%

  33. Inpatient per case KPA

  34. Top 32 Care Process Families account for 80% of the opportunity Inpatient per case KPA Top 10 Care Process Families account for over 40% of the opportunity Y-Axis = Percent of total resources consumed Cumulative Care Process Family % of total resources Individual Care Process Family % of total resources X-Axis = Care Process Families by resources consumed (High to Low)

  35. Inpatient per case KPA 3 1 PCI Y- Axis = Internal Variation in Resources Consumed 4 2 Bubble Size = Case Count X Axis = 2012-2013 Variable Direct Cost Bubble Color = Clinical Domain 35

  36. Inpatient per case KPA Grouped by APR DRG – Severity Score ~ $20,000 difference in Average Direct Costs between “highest cost” provider and “lowest cost” provider for patients with identical intermediate level severity scores Bubble Size = Case Count for provider X Axis = Average Variable Cost per Case for provider Bubble Color = APRDRG - Severity Score

  37. Inpatient per case opportunity analysis Mean Cost per Case = $20,000 Dr. J. 15 Cases $60,000 Avg. Cost Per Case $35,000 x 25 cases = $875,000 opportunity $40,000 x 15 cases = $600,000 opportunity Total Opportunity = $600,000 Total Opportunity = $1,475,000 Total Opportunity = $2,360,000 Total Opportunity = $3,960,000 Cost Per Case, Vascular Procedures

  38. Inpatient per case opportunity Grouped by APR DRG – Severity Score Waste reduction opportunity is calculated based on bringing the cases in each severity level of each APR-DRG down to the mean of the severity level Bubble Size = Case Count for provider X Axis = Average Variable Cost per Case for provider Bubble Color = APRDRG - Severity Score

  39. Inpatient per case opportunity*Physician variation perspective * This $97 MM is based on the impact of variation in MD practice across all types of relevant inpatient care units

  40. IP per case ordering wasteOpportunity analysis

  41. IP per case ordering waste CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression

  42. IP per case ordering waste Sources of ordering variation within a case • Diagnostics • Laboratory tests • Diagnostic imaging studies • Therapeutics • Therapies (e.g., respiratory, physical, et al) • Substances (e.g., antibiotics, blood products) • Clinical supply chain (e.g., prosthetics, stents, synthetic bypass grafts, heart rhythm devices)

  43. Sources of per case ordering waste Symptoms Screening & Preventive Prevention and Treatment Knowledge Assets Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules Health Maintenance and Preventive Guidelines Diagnostic Work-up Diagnostic algorithms Utilization Management Knowledge Assets Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications Home(Patient Portal) Triage to Treatment Venue Triage Criteria Admission Order Sets Admission Order Sets Clinic CareNon-recurrent Clinic Care Chronic Invasive Medical Invasive Surgical Acute Medical IP Med-Surg Acute Medical IP ICU Indications for Intervention Treatment and Monitoring Algorithms Indications for Referral Standardized Follow-up Substance Selection Pre-Procedure Order Sets Substance Preparation Substance Selection Invasive* Subspecialist Supplementary Order Sets Chronic Disease Subspecialist Clinical Supply Chain Management Bedside care Clinical ops procedure guidelines and patient injury prevention * To Invasive Care Processes Procedure Treatment and Monitoring Algorithms Post-procedure Care Post-procedure Order Sets Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols Post-acute care order sets IP (SNF, IRF) Home health Hospice Discharge

  44. IP per case ordering waste opportunity * The $57 MM is based on the impact of variation in ordering of tests and services from ancillary (non-patient-care) departments (e.g., lab, imaging, pharmacy, therapies, supply chain, central services) adjusted by APR-DRG severity level

  45. Reducing per case ordering waste • Order sets. Evidence-based order sets for the Care Processes in the Pareto list to reduce variation in the ordering of simple diagnostic tests (lab, imaging) • Indications. Evidence-based indications and cost information to standardize utilization • Imaging tests (e.g., MRI, CT, US, nuclear scans) • Substances (e.g., utilization criteria for blood, antibiotics, total parenteral nutrition) • Major clinical supplies (e.g., joint prosthetics, cardiac and vascular stents, synthetic bypass grafts, heart rhythm devices, neurostimulators)

  46. Reducing per case ordering waste • Health Catalyst advanced applications. • High-level Care Process map laying out the scientific flow • Aim Packet with 2-5 Aim statements • Cohort definition to support the Aim Packet • Common metrics plus additional outcome, process and balance metrics to support the Aim Packet • Starter visualizations such as dashboards, scorecards, and/or interactive drill down reports

  47. Workflow wasteOpportunity analysis

  48. Per case workflow waste opportunityClinical Support Services CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Infectious Disease Care Process Families e.g., Diabetes Care Process Families e.g., Urologic Disorders Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Clinical Support Services (Delivery of Care) Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

  49. Per case workflow KPA - OSHPD Source: CA Office of State-wide Health Planning and Development (OSHPD) Annual financial reports for 2011 351 hospitals Exclusions: Kaiser State hospitals Small psych H’s

  50. Per case workflow KPA - OSHPD CA OSHPD Data

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