PRESENTATION FORLAFAYETTE MEDICAL EDUCATION FOUNDATION

Wednesday September 11, 2013

Presenters: Daniel Wickert, MD, OBGYN, FPN Lafayette OBGYN Brian Hudson, Lean Six Sigma, Franciscan St. Elizabeth Health

The Opportunity (care falls short of its theoretic potential)

1. Well-documented, massive, variation in practices (beyond the level where it is even remotely possible that all patients are receiving good care)

2. High rates of inappropriate care

3. Unacceptable rates of preventable care associated patient injury and death

4. A striking inability to “do what we know works”

5. Huge amounts of waste leading to spiraling prices that limit access (46.6 million uninsured Americans)

50+% of all resources expenditures in hospitals is quality-associated waste:

• Recovering from preventable foul-ups

• Building unusable products

• Providing unnecessary treatments

• Simple inefficiency

Anderson, C. 1991

James BC et al., 2006

Guiding Principles

Intermountain Healthcare Approach

Strive to Follow the Intermountain Philosophy• Board Level Commitment – 100%• Core business is to continuously improve clinical processes• Quality care is determined by:

– Evidenced-Based Processes– Processes are written– Processes are changed as needed, by facts and data

• Believable data is king• Drive out variation• Drive out fear• Educate physicians, staff, patients• Team Effort

– Downplay titles– Physician lead – Member of a team, not captain of a ship– Culture of excellence

Guiding Principles

Eight-Stage Process of Creating Major Change

Leadership Stages: (pointing the sail) – Establish Direction, Align People, Motivate and Inspire

1. Establishing a sense of urgency2. Creating guiding coalition3. Developing a vision and strategy4. Communicating the change vision5. Empowering broad-based vision

Management Stages: (getting the ship to shore) – Plan, Budget, Organize, Staff, Control, Problem-Solve

6. Generating short-term wins7. Consolidating gains and producing more change8. Anchoring new approaches in the culture

Best Practice Team

Projects - Completed Purpose Result

Mammography Screening

Standardize the process for mammography screening and increase the number of patients being appropraitely screened (to a target rate of at least 80% for all physicians' patients.) Patients then advised of appropriate action to take.

Physician compliance rate: 95%

HPV Vaccinations Discussion

Standardize the process for HPV vaccinations and increase the number of patients being appropriately screened (to a target rate of at least 80% for all physicians' patients.) Patient then advised of appropriate action to take.

Physician compliance rate: 87%

Colonoscopy screening

Standardize the process for colonoscopy screening and increase the number of patients being appropriately screened (to a target rate of at least 85% for all physicians' patients.) Patients then advised of appropriate action to take.

Physician compliance rate: 96%

Bone density screening

Standardize the process for bone density screening and increase the number of patients being appropriately screened (to a target rate of at least 85% for all physicians' patients.) Patients then advised of appropriate action to take.

Physician compliance rate: 94%

Group B Strep Screening at 36 weeks

Standarize the process for ordering and documenting results, ensure thid is being done on a consistent basis and easily accessible to LDRP staff.

Physician compliance rate: 96%

New OB NP Education & Standardization of patient education materials

Improve the quality of education for new OB patients to improve their clinical outcomes. Physician compliance rate:

94%

Best Practices Team

Best Practices Team

Projects - Completed Purpose Result

Screening and counseling patients regarding alcohol use during pregnancy

Standardize the process for Identify patients needing counseling regarding alcohol use during pregnancy and direct them to the appropriate resource, thereby improving their clinical outcome

Physician compliance for TACE scoring: 83%

Physician compliance rate for referring at risk patients: 45%

Gestational age at which Rhogam should be administered

Appropriate administration to prevent sensitization to Rh positive.

Best practice has been developed, approved by the WHA board and implemented

Gestational Diabetes Screening - gestational age to screen; lab values used for diagnosis

Consistent, reproducible timing of test to identify and treat individuals with gestational diabetes. So as to improve their clinical outcomes.

Best practice has been developed, approved by the WHA board and implemented

Standardization of nurse triage bookImprove the quality of medical advice given and reduce the number of inappropriate patient in-office visits

Anecdotal evidence from interviews with nurse practitioners points to a noticeable decrease in inappropriate patient visits. Higher patient satisfaction and patients improving their attention to their prenatal health.

Best Practices Team

Projects - Completed Purpose Result

Standardization of health history questionnaires - OB Questionnaire - Wellness Update - New Patient Questionnaire

Improve the efficacy of the questionnaires, reduce time involved with and expense of multiple questionnaires

35% reduction in staff time spent maintaining questionnaire paperwork.

HPV Vaccine Create a policy that promotes patient education about the importance of receiving the HPV vaccine. The education will be for patients, 26 years of age and younger, at their annual exam. The target rate for physician discussion and documentation of the discussion is at least 85%.

Policy created within the parameters given. Physician compliance rate 87%

Best Practices TeamProjects - In Process Purpose Result

Screening for hereditary cancer syndrome Improve patient clinical outcomes through early identification of risk factors present

In process

Standardize first NOB visit Promote consistency for the Front Desk

staff when scheduling NOB visitsIn process

Routine PAP smear recommendations Promote consistency throughout the

clinic and what is recommended to patients

In process

Determine routine screening and management of cardiac risk factors

Improve patients' clinical outcomes, vis a vis cardiac problems, through early detection of cardiac risk factors.

In process

Standardize routine preventative healthcare, (other than PAP and cardiac ….being covered in other projects)

Improve patient well being by creating a standard approach to preventative care.

In process

Standardize factors determinative for a repeat ultrasound on OB patients

Promote consistency for documentation and billing purposes

In process

Women’s Services Clinical Operation Group

WOMEN'S SERVICE COG TEAMPROJECTS - COMPLETED PURPOSE RESULT

INTERMOUNTAIN HEALTHCARE EDUCATION

INTERMOUNTAIN PROJECT #1 Neonatal Abstinence Syndrome Team: Dr. Sunkel, Vicki Nees, and Ivy Antonian

INTERMOUNTAIN PROJECT #2 Time to Induction Team: Dr. Wickert, Brian Hudson, Valerie Titus

Increase WS COG Team's knowledge to accelerate the WS-COG Team's progress

INTERMOUNTAIN PROJECT #1 Reduce the incidence and length of stay for infants with Neonatal Abstinence Syndrome

INTERMOUNTAIN PROJECT #2 Identify ways the process for labor induction can be altered to improve clinical outcomes and avoid adverse outcomes

▪ 6 attendees received certification of completion from Intermountain Healthcare after working on 2 projects (Neonatal Abstinence Syndrome and Time to Induction) for WS-COG Team during training

INTERMOUNTAIN PROJECT #1 ▪ Piloting universal drug screen at Lafayette OBGYN ▪ Developing protocol to perform at hospital

INTERMOUNTAIN PROJECT #2 ▪ Implemented a Pitocin protocol for nurses to start Pitocin before doctor rounds in AM ▪ Education for physicians / staff

CENTER FOR EXCELLENCE MINIMALLY INVASIVE GYN SURGERY

Become a recognized center of excellence program for minimally invasive GYN surgery.

▪ Received certification May 2013

OB ADMISSION TESTING Develop, in conjunction with anesthesia, a new criteria for testing patients during an OB admission

▪ As of Feb-2013, reduced Type & Screen : Transfused Patients from 100:1 to 13:1. ▪ As of Mar-2013, avg. cost per visit is $2.97; reduced from $45.49 prior to Sept 2012. ▪ Total Savings Since Sept 2012 = $46,390 ▪ 2013 Projected Savings = $78,654

RIGGS COMMUNITY HEALTH CLINIC PATIENT RECORDS ACCESS

FSEH to gain access to electronic medical records at Riggs Community Health Clinic to improve patient care and reduce duplication of services.

▪ Waiting on the IT Risk Assessment.

OB TRIAGE Identify ways for OB triage can be improved to achieve more efficient patient care by reducing the number of "unnecessary" triage visits and working towards an ACO model.

▪ Develop and initiate triage protocols ▪ Working with Riggs CHC to assign patients to an OB physician sooner

POSTPARTUM LENGTH OF STAY Decrease postpartum length of stay when patients are medically stable for discharge

▪ Provide newborn screening tests when patients are home ▪ Identified plan to request State of IN to review current law for testing newborns.

WOMEN'S SERVICE COG TEAMPROJECTS - CURRENT PURPOSE RESULT

The healing professions are changing

From: Craft-based practice• individual physicians, working alone (housestaff ::= apprentices)• handcraft a customized solution for each patient• based on a core ethical commitment to the patient and• vast personal knowledge gained from training and experience

To: Profession-based practice•groups of peers, treating similar patients in a shared setting•plan coordinated care delivery processes (e.g., standing order sets)

•which individual clinicians adapt to specific patient needs

•early experience shows– less expensive– less complex– better patient outcomes

Quality improvement process

The problem solving process

1. Identify/find high leverage opportunities

2. Gather the team

3. Develop the Aim statement

4. Develop measurement and Collect data

5. Analyze data and Gather evidence

6. Build evidence-based protocol

7. Implement the protocol

8. Monitor measures and give feedback to clinicians

9. Quantify project impact (lives, $, etc.)

1. Identify High Leverage Opportunities

• Lives affected/mortality• Number of patients affected• Opportunity for improvement• Procedure/test cost• LOS• Readmission• Quality of life

2. Develop the Aim Statement

Our goal is to . . .Clearly and concisely setting the aim by:

•Aligning with strategic goals•Improve patient care and outcomes•Use organizational data with measurable metrics•Have a timeframe

3. Develop measurement and collect data

4. Analyze data and gather evidence

6. Develop and Implement the protocol

• Order sets• Forms• Protocols or Procedures• Needed supplies and equipment• Training/rollout

7. Monitor performance and provide feedback

Performance Metric

40

45

50

55

60

65

1 11 21 31 41 51 61 71 81

8. Quantify impact of protocol

• Impact on Patient– Mortality/readmission– Length of stay– Recovery time and quality of life

• Financial impact– Direct cost/Compared to Medicare rates– LOS

• Quality measures– CMS, Anthem, other– HAI

The problem solving process

1. Identify/find high leverage opportunities

2. Develop the Aim statement

3. Develop measurement and Collect data

4. Analyze data and Gather evidence

5. Build evidence-based protocol

6. Implement the protocol

7. Monitor measures and give feedback to clinicians

8. Quantify project impact (lives, $, etc.)

Rapid Cycle Testing

PD

SA

PD

SA

PD

SA

PD

SA

Model for Improvement-1.What are we trying to accomplish?2.How will we know that a change is an improvement?3.What changes can we make that will result in an improvement?

Reducing the Time from Arrival to Start of Induction

Aim Statement

• Our mission is to improve the time from arrival to the unit to the start of the induction to 60 minutes for 60% of patients.

Conceptual process

Office visitProcedure scheduled

Pre-testing Admit to room C-SectionAssessment & Patient prep

Vaginal

Induction

Arrive &Registration

Admit to roomArrive &

RegistrationInduction

Epidural

Fetal distress

Failure to progress

Failed induction

Fetal Demise

Post Partum

NICU

Admit to roomRegistrationAssessment & Patient prep

Home

Home

Adoption

Boarder baby/CPS

Ante Partum

Unscheduled c-section

Transfer out

Labor

C-section

Sc

he

du

led

pro

ce

du

re

Observe(Up to 2 hours)

Registration

OBO

Observeand/or

treatmentRegistration

OBV

Un

sc

he

du

led

pro

ce

du

res

Induction Methods

Measurement – all methods

39.2% of the patients meet the time goal for the baseline period of October 2012-January 2013

High leverage points

• Policy of the MD seeing the patient prior to starting Pitocin-Seen within 7 days

• Lab start to draw blood– RN delays IV start• Pitocin induction initiation protocol—allow RN to start

Pitocin without waiting for MD assessment first.• Contacting MD morning of when ready• Patient pre-education at the office• Variation in nursing induction initiation/management• Staffing and timing of deliveries/volume.

Improvements Implemented

•RN education

•Scheduling changes implemented not allowing induction scheduling > 1 week out.

•Pitocin induction protocol adjusted for RN initialization.

•Enhance patient education at the office.

Making change happen

Changes Implemented:MD seeing pt in previous 7 daysAllow RN to start pitPit management education

Impacting quality care

• Improved patient satisfaction

• Improved efficiency of staff

• Reduction in unplanned c-section rate

• Decreased ‘admission to delivery’ time, reducing nursing labor and associated costs.

Lessons Learned

• Be a committed leader to change• Use the Service Line approach• Have a Continuous Improvement mindset• Engage and empower the workforce• Find like-minded people that want change• Take it at your speed, but keep moving forward

Organized CareHow could we create a system that

1.Consistently documents “the best medical outcome at the lowest necessary cost” for each patient, under each patient’s full, personal, control (true “patient-centered’ care, within professional parameters)

2.Learns from every case– Generates scientifically reliable knowledge from routine practice, quickly filling the

80-90% evidence gap regarding best practice; while empirically validating every new treatment.

3.Creates a life-long “residency training while in practice”– Organization-level capacity to (1) identify critical new knowledge, (2) blend it into

daily workflows, (3) package it for rapid learning, and (4) push it out to all who need it – reduce the time for widespread adaption of major new, scientific findings from ~ 17 years to less than 6 months.

4.Generates true transparency– Anytime any clinician says “in my experience” they mean “in my measured

experience.” Eliminate reliance on subjective recall; make physicians and nurses better counselors as they advise and support patients faced with treatment decisions.

5.Address innate clinical complexity– Provide support around critical clinical decisions (Shared Baselines)

Only One Pertinent Question:

Assume that front-line clinicians are:– as smart as you are– as dedicated to patients as you are– as hard-working as you are– as motivated as you are– are the only ones with fundamental knowledge

of how the front-line process actually works;

But they usually don’t control the systems that set

the context within which they work…

How will your proposed intervention make it easier

for them to do it right?

Professional Accountability

I will not tell you how to practice medicine…

I will argue the science, but if I cannot convince physicians “on the data”, I will not expect them to change how they manage patients.

I will try to create an environment of professional accountability…–Where groups of physicians and other professionals;–Who manage similar patients in similar settings;–Discuss best patient care practices; with resource to

the medical literature, expert opinion, and credible data

showing their own performance and outcomes.(a redefinition of traditional peer review)

Key Take-Aways

1. No protocol perfectly fits any patient– Solution: Shared Baseline “bundles”

(mass customization = “patient centered care”)

2. Serious limitations to protocol development– Solution: a Learning System (embedded variance and

outcomes tracking; continuous protocol review and tested improvement)

3. Reliance on human memory (craft of medicine) produces “55% execution”– Solution: tools to embed protocols in workflows

4. Only two differences from traditional practices: It requires (1) coordinated teams with (2) reliable data systems.

We dedicated time - We embraced change - We took actionCreated Core Values, Core Purpose and Vision Statement – total time: physicians and administrator time, approximately 160 hours (10 people) (all physician time was after hours)

Developed Strategic Project Teams - total time: physicians and administrator time, approximately 20 hours (10 people) (all physician time was after hours)

Visited Intermountain Healthcare, education to motivate change from silos & volume to quality care, drive out variation & fear - - total time: physicians, administrator, managers and staff time, approximately 288 hours (18 people)

Learned/Developed Leadership, Management and Team skills – total time: physicians, administrator, nurse practitioners, managers and staff time, approximately 750 hours (16 people) (all physician and manager time was after hours)

Developed Strategic Team projects, meeting and developing solutions - – total time: physicians, administrator, nurse practitioners, managers, Six Sigma participant and staff time, approximately 2,900 hours (20-30 people, over a period of 18 months) (all physician and most manager time was after hours)

Developed the Women’s Services Clinical Operations Group and related projects - total time: physicians, senior management, administrator, hospital management, Six Sigma participant, L&D nurses, manager and staff time, approximately 160 hours (13 people, over a period of 5 months) (most time for all involved after hours)

Reasons for Our Success

The 3-legged stool

PhysiciansAdministration

Clinical Support Staff

All having to work together