SURGERY QUALITY WORKFLOW MANAGER SQWM Session 246

1. 1 SURGERY QUALITYWORKFLOW MANAGER (SQWM)Session #246 James Edwards William Gunnar

2. 2 Surgery in the VA 21 Veterans Integrated Service Networks 130 Hospitals performing surgery (2007) 754 operating rooms (ORs) in these hospitals (2007) ~358,000 cases in FY2009

3. 3 Surgery – The Old Way Patients arrive in surgery clinic, usually via consult package May be ready for surgery (path 1) or may need further work-up which could be surgical or medical (path 2) Path 1 – surgery typically scheduled in paper calendar, entered into VistA surgery package 24-72 hours prior to surgery

4. 4 Surgery – The Old Way Path 2 – tests and consults ordered, surgery may be scheduled on paper calendar No automatic reminders for test/consult completion, alerts of completion may go to different people, including residents who rotate off service No automatic check for completion prior to scheduled date

5. 5 Surgery – The Old Way VistA surgical package – written in 1980’s Command line interface Few management reports for utilization, efficiency Intra-op there are 7 pages of entry for OR nurses Rudimentary scheduling No block time allocation No vacation scheduling No surgeons preferences/case carts

6. 6 Surgery – The Old Way No link to bed management systems or bed reservations (except manual entry) Day of surgery processes basically manual Check-in Pre-op check lists Time outs Surgical times (in, out of room, etc.) Hand-offs Post-op recovery

7. 7 Surgery – The Old Way No automatic risk assessment prior to surgery VA Surgery Quality Improvement Program (VASQIP) - formerly National Surgery Quality Improvement Program (NSQIP) and Continuous Improvement in Cardiac Surgery Program (CICSP) provides delayed quality information on selected cases No automatic notification of critical events in OR

8. 8 Surgery – The Old Way No long term quality data collection - except 1 year follow-up for cardiac surgery No checking of surgeon’s privileges Utilization, efficiency, management reports require fileman downloads, data manipulation

9. 9 Surgery – What is New Multiple VA’s have developed software to overcome these limitations Most not linked to VistA, require double entry Those linked to VistA are class 3, cannot be shared

10. 10 Surgery – Why Change? Focus on quality and oversight of surgical programs Focus on wait times for surgery Surgery is a limited resource which is expensive New mandates (VA, Office of Inspector General (OIG), Joint Commission (JC), Food and Drug Administration (FDA), etc.)

11. 11 SQWM - Background 6 elements - broad reaching impact on multiple programs Assist VASQIP in evaluating post-op outcomes of all surgical procedures Provide risk assessment data for VASQIP Ensure that surgical care matches facility operative complexity designation Effectively report and manage surgery wait time and OR utilization Tracking of patients through pre-surgical process Provide data for Veterans Implant Tracking & Alert System (VITAS)

12. 12 SQWM – Business Drivers Requirements Comprehensive VASQIP – all cases Risk assessment and outcome tracking for all cases (VA Undersecretary for Health (USH) & OIG) Operative Complexity & Infrastructure Standards tracking (USH & OIG) Systems Redesign (Wait time data/OR utilization) (USH, Congress, & OIG) VITAS (Veterans Implant Tracking & Alert System) (FDA) Strategic Asset Management (SAM)/Financial Logistics Integrated Technology Enterprise (FLITE) JC/World Health Organization (WHO)/Medical Team Training (MTT) documentation Emphasize that this started with one OIG report on wait times, these other programs have arisen over last 2 years since this started as wait time tracking, able to add these things with little additional complexity and work (adding implant, collecting quality data) – big ticket item is the wait time programming, these are minor additionsEmphasize that this started with one OIG report on wait times, these other programs have arisen over last 2 years since this started as wait time tracking, able to add these things with little additional complexity and work (adding implant, collecting quality data) – big ticket item is the wait time programming, these are minor additions

13. 13 SQWM – Development Path SQWM Technical Working Group (TWG) initiated in June 2008 Subgroup of Flow Improvement Technical Advisory Group (TAG) Emphasizes surgery tracking, scheduling, safety, quality improvement, utilization optimization Progress to date New Service request submitted Business requirements document submitted Visualization using iRise software Sharing visualization with user groups

14. 14 SQWM - Function Common path for the implementation of the recommendations of multiple workgroups Surgery Quality report workgroup Operative Complexity & Infrastructure Standards Workgroup Implant tracking workgroup Flow Improvement Technical Advisory Group Class 3 to class 1 software development of the Portland Surgery Case manager/wait time tracker

15. 15 SQWM – Block Diagram 1 Green is safety, red is process, purple is quality, blue is patient activity Green is safety, red is process, purple is quality, blue is patient activity

16. 16 SQWM – Block Diagram 2 Examples – how hard paper process can be, error prone, duplicate processesExamples – how hard paper process can be, error prone, duplicate processes

17. 17 SQWM – Block Diagram 3

18. 18 SQWM – Block Diagram 4

19. 19 SQWM – Block Diagram 5 Supports current directives on wrong site surgery, retained foreign bodiesSupports current directives on wrong site surgery, retained foreign bodies

20. 20 SQWM – Block Diagram 6

21. 21 SQWM – Block Diagram 7 Templated discharge summariesTemplated discharge summaries

22. 22 SQWM – Block Diagram 8

23. 23 SQWM – Block Diagram 9

24. 24 Prototype Screen Capture

25. 25 Prototype Screen Capture

26. 26 Prototype Screen Capture

27. 27 Prototype Screen Capture

28. 28 Prototype Screen Capture

29. 29 Prototype Screen Capture

30. 30 Prototype Screen Capture

31. 31 Example Current process 85 yo with aortic occlusion, short distance claudication Lives outside of Spokane – 200+ miles away Wants operation between Bear and Elk hunting season Surgery clinic Indicated for surgery Needs cardiac work-up split between Spokane and Portland Needs to arrange ride to/from Portland, post-op help at home

32. 32 Example Paper request for surgery note by clerk on calendar for potential surgery date No automatic “tickler” to look for cardiac evaluation results or alert when local and remote data available Limited wait time tracking, either paper or duplicate entry into spreadsheet Pre-op Clinic No templated data entry VASQIP nurse needed to parse data Surgery scheduling transferred to ‘master’ paper calendar

33. 33 Example Surgery scheduling Hand entry into VistA command line interface (CLI) Meeting Facility complexity relies on good faith and surveillance after the fact No links to bed availability No physician privilege checking Difficult to look for duplicate critical equipment request Day of surgery Paper process, collection of vital signs, safety checklists OR nurse fills in 7 pages of data in VistA Command Line Interface

34. 34 Example Day of surgery Visualization of ‘real-time’ OR use on whiteboard Handoffs, quality data not collected Implant tracking in text fields and/or in log books OR management OR utilization reports from fileman, access now very limited, needs manipulation for usable data Implant recalls require manual searches of data

35. 35 SQWM – Conclusions A Powerful Tool to Meet Current VHA Needs Modern workflow, tracking of patients being evaluated for surgery and on day of surgery Robust scheduling package Real-time verification of Privileges Implant tracking Links to other VA flow management Software Robust reporting of utilization/workload/wait times Capture of quality assurance data on 100% of cases

36. 36 SQWM – Conclusions Critical to the progress and completion of multiple VHA mandates and initiatives Systems Redesign Operative Complexity and Infrastructure Initiative VA Surgical Quality Assurance Program Veterans Implant Tracking & Alert System Physician Privilege Verification This will improve quality, safety, increase utilization across system, This will improve quality, safety, increase utilization across system,

37. 37 Practical Applications This will improve patient satisfaction, quality, and safety Increase capacity without cost increase by improving utilization across system - lower cost per patient Regional & National monitoring, ? Re-allocation of resources to underutilized facilities

38. 38 Proposed SQWM Timeline No timeline available, data points are: Analyze needs, write service request – DONE Write Request for Proposals (RFP) Release RFP through contracting Analyze responses, select product Acquire product through contracting Complete national customization Complete Alpha test Complete Beta test Roll-out to all VAs

39. 39 What SQWM Will Replace Will not replace VistA surgery package, the data will be entered into SQWM and will automatically fill the surgery package Will not replace CPRS, but notes will be written in SQWM and then be transferred to CPRS Will replace paper Will replace local non-VistA linked programs

40. 40 Questions?