#HASummit14 Session #20 How to Drive Clinical Improvement That Get Results Tom Burton And the...

#HASummit14

Session #20How to Drive Clinical Improvement That Get Results

Tom BurtonAnd the Catalyst Academy Education Team

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What is a Clinical Program?

• Organized around care delivery processes

• Permanent integrated team of clinical and analytics staff

• Creates a iterative continuous learning environment

• Focus is on sustained clinical outcome improvement (not revenue growth)

• Not a Clinical Service Line (although you can Leverage Service Lines as a good start)

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Organizational AGILE Teams

= Subject Matter Expert= Data Capture= Data Provisioning & Visualization= Data Analysis

Women & Children’s Clinical Program Guidance Team

Pregnancy

MD LeadRN SME

Knowledge Manager

DataArchitect

Application Administrator

RN, Clin Ops Director

Guidance Team MD lead

Normal Newborn

MD LeadRN SME

Gynecology

MD LeadRN SME

• Permanent teams that meet weekly• Integrated clinical and technical members• Supports multiple care process families

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Incorporating the most effective learning methods

Teach Others - 90%

Practice by Doing- 75%

Discussion Group- 50%

Demonstration- 30%

Audiovisual- 20%

Reading- 10%

Lecture- 5% % represents average information retained through the particular learning method

‒ Duke University

0 20 40 60 80 100

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Session Objective4 Learning ExperiencesClinical Programs that Get Results Principles

Choose the right initiative

Understand variation

Improve data quality

Choose the right influencers

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Choose the right initiative

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Deal or No Deal Exercise

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DEAL or NO DEAL

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First Principle

• Picking an improvement opportunity randomly is like playing traditional DEAL or NO DEAL

• You might get lucky

• Choosing the loudest physician or the choosing based on non-data driven reason can dis-engages other MDs and use scarce analytical resources on projects that may not be the best investment

• It takes about as much effort to work on a large process as it does on a small process

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Pareto Example: Resources Consumed

Cumulative %

% of Total Resources Consumed for each clinical work process

Key Findings:

50%

• 50% of all in-patient resources are represented by 7 Care Process Families

7 CPFs Number of Care Process Families(e.g., ischemic heart disease, pregnancy, bowel disorders, spine, heart failure)

• 80% of all in-patient resources are represented by 21 Care Process Families

21 CPFs

80%

Analytic System

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Dr. J.15 Cases$60,000 Avg. Cost Per Case

Mean Cost per Case = $20,000

$40,000 x 15 cases = $600,000 opportunity

Total Opportunity = $600,000

Total Opportunity = $1,475,000

$35,000 x 25 cases = $875,000 opportunity



Cost Per Case, Vascular Procedures

Analytic System

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Excellent OutcomesPoor Outcomes

# of Cases


# of Cases

Excellent Outcomes

# of Cases

Poor OutcomesExcellent Outcomes

# of Cases

Poor Outcomes

1

2

3

4

Varia

bilit

y

High

Low

Resource ConsumptionLow High

Improvement Approach - Prioritization

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# of Cases


# of Cases

Excellent Outcomes

# of Cases

Poor OutcomesExcellent Outcomes

# of Cases

Poor Outcomes

1

2

3

4

Varia

bilit

y

High

Low

Resource ConsumptionLow High

Improvement Approach - Prioritization

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Internal Variation versus Resource Consumption

Y- A

xis

= I

nte

rnal

Var

iatio

n in

Res

ourc

es C

onsu

med

Bubble Size = Resources Consumed Bubble Color = Clinical DomainX Axis = Resources Consumed

1

2

3

4

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DEAL or BETTER DEAL

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Understand Variation

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The Popsicle Bomb Exercise

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Timer

When you’re finished note your time and enter it in the HAS app – Poll Question 1

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Variation in Results

• Corp Analytics – shows results

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Less Effective Approach to improvement:“Punish the Outliers”

# of Cases

Current Condition

• Significant Volume• Significant Variation

# of Cases

Option 1: “Punish the Outliers” or “Cut Off the Tail”

Strategy• Set a minimum standard of quality• Focus improvement effort on those

not meeting the minimum standard

Mean

Focus on MinimumStandard

Metric

Excellent OutcomesPoor Outcomes Excellent OutcomesPoor Outcomes

1 box = 100 cases in a year

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Effective Approach to improvement: Focus on “Better Care”


# of Cases

Current Condition

• Significant Volume• Significant Variation

Excellent Outcomes

# of Cases

Option 2: Identify Best Practice “Narrow the curve and shift it to the right”Strategy• Identify evidenced based “Shared Baseline”• Focus improvement effort on reducing

variation by following the “Shared Baseline”• Often those performing the best make the

greatest improvements

Mean

Focus on Best Practice Care Process

Model

Poor Outcomes

1 box = 100 cases in a year

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Round 2

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Timer

When you’re finished note your time and enter it in the HAS app – Poll Question 2

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Reduced Variation in Results

• Corp Analytics – shows results

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Improve Data Quality

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The Water Stopper Exercise

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Information Management

2525

DATA CAPTURE

• Acquire key data elements• Assure data quality• Integrate data capture into operational

workflow

DATA ANALYSIS

• Interpret data• Discover new information in the data

(data mining)• Evaluate data quality

DATA PROVISIONING

• Move data from transactional systems into the Data Warehouse

• Build visualizations for use by clinicians• Generate external reports (e.g., CMS)

Knowledge Managers (Data quality, data stewardship and

data interpretation)

Application Administrators (optimization of source systems)

Data Architects(Infrastructure, visualization, analysis, reporting)

= Subject Matter Expert

= Data Capture

= Data Provisioning

= Data Analysis

Fix it Here

Not HereNot Here

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Data Capture Quality Principles

• Accuracy

Does the data match reality?

Example: Operating Room Time Stamps

• Timeliness

What is the latency of the data capture?

Example: Billing data delay; end of shift catch-up

• Completeness

How often is critical data missing?

Example: HF Ejection Fraction

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Challenges with Data “Scrubbing”

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• Analyst time spent on re-working scrubbing routines

• Root cause never identified

• Early binding vs. late binding – what you consider dirty data may actually be useful for others analyzing process failures.

• Using data to punish vs. data to learn – punish strategy promotes hiding the problem so clinicians don’t look bad

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Choose the right influencers

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Paul Revere's ride Exercise

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Revere vs. Dawes

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Paul Revere

"Revere knew exactly which doors to pound on during his ride on Brown Beauty that April night. As a result, he awakened key individuals, who then rallied their neighbors to take up arms against the British.”

William Dawes

"In comparison, Dawes did not know the territory as well as Revere. As he rode through rural Massachusetts on the night of April 18, he simply knocked on random doors. The occupants in most cases simply turned over and went back to sleep."

Diffusion of Innovations (Free Press, 2003) by Everett M. Rogers

http://www.amazon.com/Diffusion-Innovations-5th-Everett-Rogers/dp/0743222091

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Innovators

earlyadopters

earlymajority

laggards(never adopters)

* Adapted from Rogers, E. Diffusion of Innovations. New York, NY: 1995.

latemajority

Innovators. Recruit innovators to re-design care delivery processes (like Revere)

Early adopters. Recruit early adopters to chair improvement and to lead implementation at each site.(key individuals who can rally support)

The

Cha

sm

N = number of individuals in group

N

N = number needed to influence group(but they must be the right individuals)

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Small Teams (Designs Innovation) • Meet weekly in iteration planning meeting

• Build DRAFT processes, metrics, interventions• Present DRAFT work to Broader Teams

OBInnovators

Guidance Team(Prioritizes Innovations)

• Meet quarterly to prioritize allocation of technical staff

• Approves improvement AIMs • Reviews progress and removes road blocks

OB Newborn GYN

W&N

W&N

Innovators

Innovators

Early Adopters

Broad Teams (Implements Innovation)

• Broad RN and MD representation across system• Meet monthly to review, adjust and approve DRAFTs• Lead rollout of new process and measurement

OB

W&N

W&N

W&N

Innovators

Early Adopters

Early Adopters

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Organizational AGILE Teams

= Subject Matter Expert= Data Capture= Data Provisioning & Visualization= Data Analysis

Women & Children’s Clinical Program Guidance Team

Pregnancy

MD LeadRN SME

Knowledge Manager

DataArchitect

Application Administrator

RN, Clin Ops Director

Guidance Team MD lead

Normal Newborn

MD LeadRN SME

Gynecology

MD LeadRN SME

• Permanent teams• Integrated clinical and technical members• Supports multiple care process families• Choose innovators and early adopters to lead

Innovators

Early Adopters

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How to identify innovators and early adopters• Ask

Innovators (inventors)

- Who are the top three MDs in our group who are likely to invent a better way to deliver care?

Early Adopters (thought leaders)

- When you have a tough case who are the top three MDs you trust and would go to for a consult?

• Fingerprinting selection process

Invite innovators to choose identify their top three MD choices from the early adopters to lead the Clinical Program

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Conclusion – TEACH OTHERS

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Teach Others Exercise Deal or No Deal

- Choose the right initiative

- Prioritize based on process size and variation

Popsicle Bomb

- Understand variation

- Measure variation and standardize processes

Water Stopper

- Improve data quality

- Fix the problem at the source

Paul Revere’s Ride

- Choose the right influencers

- Identify Innovators and Early adopters to

accelerate diffusion of innovationTake 1 minute and describe the purpose of each exercise to your neighbor, then swap and let them teach you

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Timer

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Exercise Effectiveness Q1

Overall, how effective were the exercises in explaining the principles?

1) Not effective

2) Somewhat effective

3) Moderately effective

4) Very effective

5) Extremely effective

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How effective was the Deal or No Deal Exercise at teaching the principle of prioritizing based on process size and variation?

1) Not effective



4) Very effective


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How effective was the Popsicle Bomb Exercise at teaching the principle of understanding variation and standardizing processes?

1) Not effective



4) Very effective


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How effective was the Water Stopper Exercise at teaching the principle of fixing data quality issues at the source?

1) Not effective



4) Very effective


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How effective was the “Paul Revere Ride” exercise at teaching the principle of choosing the right influencers based on their capabilities as innovators and early adopters?

1) Not effective



4) Very effective


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Are you interested in running these same exercises in your organizations?

a) Yes

b) No

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Analytic Insights

AQuestions &

Answers

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Session Feedback Survey

1. On a scale of 1-5, how satisfied were you overall with this session?1) Not at all satisfied2) Somewhat satisfied3) Moderately satisfied4) Very satisfied5) Extremely satisfied

3. On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)?

1) No interest2) Some interest3) Moderate interest4) Very interested5) Extremely interested

2. What feedback or suggestions do you have?

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