ORTHOPAEDIC SERVICES AT METHODIST WEST HOSPITAL

Presented by:Dr. Stephen Taylor, President

West Hospital Ortho Co-Management

Laurie M. Johnson, RNExecutive Director - Orthopaedics

Total Joint Replacement (TJR) has been the most effective treatment for advanced

arthritis since the 1970’s

Goal of TJR → Quality Results Relieve Pain Restore Function Long Lasting (>25 years) Avoid Complications

More than 700,000 TJR’s are currently performed each year

INCREASING DEMAND FOR TOTAL JOINT REPLACEMENT

Increasing senior population

Greater desire for active lifestyle

Greater acceptance of TJR by population

700% increase in TJR in the next 20 years

INCREASED DEMAND FOR TJR

Success Requires:1) Adequate physician supply2) More efficient care process3) Care process must emphasize VALUE

VALUE = QUALITYCOST

Reality:Healthcare dollars spent must be controlled and appropriately allocated

Allocation must be determined by value of product or service

In TJR we must maintain and improve quality, but we must also control costs

VALUE IN TOTAL JOINT REPLACEMENT

IOWA HEALTH-DES MOINES COMMITMENT

IH-DM committed to meet the increased patient need for TJRCurrent facilities at IMMC couldn’t meet growing demand for OR’s and patient beds

MWH was designed to emphasize orthopaedic total joint care dedicating 4 of the 6 OR’s and 50% of the patient beds

MWH ORTHOPAEDIC SERVICES

Focused, specialized careMutual project between IH-DM and Des Moines Orthopaedic Surgeons, PCAligned incentives of both organizations to improve QUALITY and VALUE for our patients“Co-Management” organization was formed to manage the entire process

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY, LLC

The WHOCC oversees the entire orthopaedic service line at MWH

emphasizing quality, patient safety & convenience, efficiency and

cost containment

Equal representation from IH-DM & DMOS

Medical Director from DMOS

WHOCC MANAGEMENT

ACTIVITIES

Develop comprehensive plan of care for all orthopaedic

patients

Implement and direct strategic, financial and

operational plans

Assist in facilities management

Evaluate and recommend equipment

purchases

Assist in developing operational and capital

budgets

Supervise and/or train management

staff

Develop and oversee all cost containment

activities

WHOCC BUSINESS MODELExecutive Committee

•Meets bi-weekly•Working committee

•Includes the Ortho Executive Director

•Reports to the Governing Board

Finance Committee•Meets quarterly

•Reviews financials and makes recommendations

•Reports to the Governing Board

WHOCC GOVERNING BOARD•Oversees all committee activities

•Reviews & approves meeting minutes•Makes final decisions

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY

Initial project was to interview and select the following key personnel:

Orthopaedic service-line Executive DirectorInpatient department Nurse ManagerSurgical Services department Nurse ManagerPhysical Therapy department Manager

All personnel are employees of IH-DM

All physicians expected to comply at MWHNo significant exceptions are allowedAll physicians are invited and encouraged to participate in the process

WHOCC TEAM REVIEWS AND SETS ALL PROCESSES

STANDARDIZED, UNIFORM PROCESSES AND PROCEDURES

Rationale: Repetitive, focused process and procedures maximizes efficiency and minimizes the risk of error or oversight.

Examples:OR nurses comfortable working with any surgeon due to standardized draping, supplies and instructions

Nursing unit care doesn’t vary by physician (common pain management regimen, blood transfusion protocol, dressing, etc…)

One standard Physical and Occupational therapy regimen for all surgeons that can be tailored to the individual needs of each patient

EXAMPLES OF UNIFORM PROCESSES CREATED AND IMPLEMENTED BY WHOCC

1. Pre-op medical clearance request form2. Standardized scheduling process and form3. Pre-op orders4. Regional anesthesia5. Demand matching of implants6. Comprehensive uniform post-op orders,

including pre-emptive multi-modal pain management

7. Uniform activity and physical therapy goals

WHOCC ACTIVITIES

VALUE IN TJRNew techniques, equipment and implants must be critically evaluated by hospital and physicians

Those new techniques or implants that add cost without significant improvement in quality should be avoided

VALUE = QUALITYCOST

Is there enough scientific

evidence to warrant a trial?

Trial with defined evaluation and

results

Review by committee to

assess quality and

value of technique

Confirm or deny use of technique

or product

EVALUATION OF NEW TECHNIQUES AND SURGICAL PRODUCTS

EVALUATION PROCESS EXAMPLES

Floseal → deny (evidence didn’t support)

V-lock suture → confirm (all use)

Participated in ‘Draping Boot Camp’ to streamline, trial and standardize surgical drapes → confirm (all use)

Surgical prep (Chloraprep) → confirm (all use)

Eliminated many trays by developing common instrument sets for all physicians by procedure → confirm (all use)

Covaderm Surgical Dressing → future trial Cold therapy/DVT wrap → future trial

1. Base Management Fee Hourly at Fair Market Value

2. Incentives Quality of service Operational efficiency Financial/budgetary New program development

WHOCC PHYSICIAN COMPENSATION

Measurable Controllable

Realistic Bound by time limits

INCENTIVE COMPENSATION DEVELOPMENT

2010 INCENTIVES

Quality of Service (50%)SCIP Core MeasuresPatient SatisfactionDemand Matching

Operational Efficiency (20%)On-time startsOR turnaround time

Financial/Budgetary (20%)Length of StayCost per Case

New Program Development (10%)Expanded Patient Education

2011 INCENTIVES

Quality of Service (50%)SCIP Core MeasuresPatient SatisfactionDemand Matching

Financial/Budgetary (30%)Cost per case (Goal – 4%↓)Vendor negotiations for spinal implants

New Program Development (20%)Hip and Knee scoringInfection rates (within 60 days)Readmission rate (within 30 days)Revision rate (within 1 year)

INCENTIVE STRUCTURE2011 INCENTIVE FOR SCIP CORE MEASURES (15% OF TOTAL)

RANGE FROM: TO: ANNUAL PAYOUT:

<95% $0

≥95% <96% 60% of SCIP incentive

≥96% <97% 80% of SCIP incentive

≥97% Full Incentive

2011 INCENTIVE FOR PATIENT SATISFACTION (20% OF TOTAL)

RANGE FROM: TO: ANNUAL PAYOUT:

<91.1 $0

≥91.1 <91.9 50% of Pt. Sat. Incentive

≥91.9 <92.3 75% of Pt. Sat. Incentive

≥92.3 Full Incentive

1. All implants placed in category based on technology• Cemented femoral stem• Tapered non-cemented stem• Revision stem

2. Each category included “substantially similar” implants

3. Target price established by WHOCC

4. All vendors allowed to participate

VENDOR NEGOTIATIONS

5. Implants that meet target price for each category become “preferred” and permitted to use at MWH

6. Use of outliers is strongly discouraged

7. In a few select categories competitive bidding utilized – only one implant from single vendor allowedeg. Modular revision femoral stem (one vendor, one price for all components)eg. Revision segmental hinged knee

VENDOR NEGOTIATIONS, continued…

DEMAND MATCHING

All implants categorized by Quality Level and Cost

A Level – Lowest cost B Level – Intermediate cost

C Level – High cost

DEMAND MATCHING cont…

Three Patient Variables Considered

1. Patient Age2. Patient Health3. Patient EXPECTED activity level

(scanned copy of form here)

DEMAND MATCHING cont…

>90% Compliance expected

Results are reported by

Individual PhysicianAll Physicians

Transparency is a great motivator!

WHOCC - SUMMARY

1. Aligned incentives of hospital and surgeons that are required for success

2. Emphasis on Quality and Cost = Value

3. Recognize importance and contribution of ALL team members:

•Surgical Techs & Nurses •Therapists•Patient Care Facilitators •Patient Care Techs •Management Staff •Physicians

Ultimate winners:•Patients •All team members

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY

OUR COMPANY Is COMMITTED to FRESH THINKING

andINNOVATIVE CARE THAT ADDS VALUE

WHOCC METRIC RESULTS

VALUE = QUALITYCOST

DATA COLLECTION

Information received monthly from various systems• Finance • Purchasing• ORSOS • Clinical Quality

Review, calculate and report Incentive Metric data monthly to Executive Committee

Determine if there is other data outside of the metrics that needs to be reported On-time starts, turnover times, and Average Length of Stay (ALOS) are not

part of the 2011 metrics, but continue to be monitored monthly for significant changes

Volume and cost data from broken, lost and (not) found instruments in Central Sterile is reported to the Executive Committee & the staff each month

The cost of implants that are opened but unused are reported in conjunction with the demand-matching metrics

DATA COLLECTION continued… Whenever possible, total volumes are reviewed rather than

randomized selections 100% of all total joint procedures are reviewed for correct implants Over 90% of all eligible patients are included in the SCIP Core Measure

data review In addition to the overall patient

satisfaction score, each physician’sscores are calculated and reported

Direct variable cost-per-case isreported/reviewed by surgeon

All data is presented as an overall score and also by each physician and procedure

Transparency has been a key motivator for physician change

QUALITY OF SERVICE 2010 GOAL 2010 ACTUAL 2011 GOAL 2011

CURRENT

DVT Prophylaxis within 24 hours before/after surgery 99.8% 100%

Appropriate antibiotics within 1 hour prior to surgery 98.7% 99.4%

Antibiotics stopped within 24 hours after surgery ends 98.8% 100%

% of patients who are normothermic after 15 minutes in PACU n/a n/a 85%

SCIP Overall Average ≥97% 99.3% ≥97% 96.1%

Patient Satisfaction ≥87 91.2 92.3 90.4

Implant Demand Matching ≥90% 88.7% ≥90% 89.2%

NEW PROGRAM DEVELOPMENT 2010 GOAL 2010

ACTUAL 2011 GOAL 2011 CURRENT

Expand Patient EducationAll total joints patients at MWH

New program written by Patient Care Facilitators n/a n/a

Hip and Knee ScoringPrimary hips & knees only

n/a n/a Forms have been developed, data collection begins 5/1/2011

Infection rates (w/in 60 days)Primary hips & knees only

n/a Still calculating <1.5% Still calculating

Readmission rates (w/in 30 d)Primary hips & knees only

n/a n/a <5.0% 0.5%

Revision rates (w/in 1 year)Primary hips & knees only

n/a n/a <2.0% Still calculating

OPERATIONAL EFFICIENCY 2010 GOAL 2010

ACTUAL 2011 GOAL 2011 CURRENT

On-time starts ≥93% 91.8% n/a n/aOR turnaround time ≤20 min 16 min n/a n/a

AVERAGE LENGTH OF STAY 2008 2009 2010 2011

CURRENT

Primary total hip and knee pts, commercial payers only 4.17 days 3.94 days 2.81 days 2.84 days

2008 2009 2010 2011 current

2.5

3

3.5

4

4.54.17

3.94

2.81 2.84

2010 goal3.45 days

2008 2009 40210 40269 40330 40391 40452 40513 405757,400

7,800

8,200

8,600

9,000

9,400

8,7038,847

8,959 8,9728,772

8,573

8,186

7,8347,720

DIRECT VARIABLE COST-PER-CASE 2008 2009 2010 2011

CURRENT2011GOAL

Primary total hip and knee pts, commercial

payers only$8,703 $8.847 $8,186 $7,720 $7,939

2010 goal$8,196

2011 goal$7,939

SUMMARY DO recognize that consistent, substantiated data is a key factor in engaging

the physicians and staff to achieve success DON’T underestimate the value of immersing yourself in the details DO plan to be in this ‘for the long haul’

Success doesn’t happen overnight• DON’T hesitate to build relationships with people who can help you

The advantage of a large organization is that many people are there to assist, but you may have to search for them

DO communicate results regularly with front-line staff They will be very engaged in the process They can have a big impact on achieving positive outcomes

DON’T overlook the small successes These are most important when things are progressing slowly

DO celebrate every milestone along the way, and DON’T forget to have fun!

QUESTIONS?