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Strategies for Cost Control & Collaboration
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Supplies
Discharge Status
Outcomes
Case Time
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• Co-management
• Collaboration
• Governance Model
• Benchmark Report
• Case Time
• Predictive Analytics
Agenda
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Strategies for Net Cost Reduction
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Aligned incentivesEffective
governance and leadership
Reduce unnecessary interventions that
don’t benefit patients
Efficient scheduling of staff and cases
Reduce case cancellations and
delaysReduce OR time
Reduce length of stay
“enhanced recovery”
Reduce complications,
readmissions, post-acute facility care
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Co-Management Agreements
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Several health systems have found co-management an effective way to engage surgeons and anesthesiologists in service-line specific or OR wide initiatives: Specific metrics can be crafted to target critical service line goals
Co-management allows for FMV incentives to be earned by physicians for their efforts: - -Fixed duty compensation available for hourly time spent in committees (From 0-50%) - -Performance metric compensation for demonstration of improvement from baseline for defined metrics (0-50%)
Co-management is a flexible alignment structure that can change over time and expand to include other programs:Metrics can be changed annually so physician effort is always maximizedPrograms such as bundles payments can be integrated into co-management programs
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Overview of Co-Management Structure: A Model of Clinical Co-Management
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Hospital Quality Efficiency Program
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Agree on Metrics –FMV by 3rd Party
(Horne LLP vs. Fair-Market Appraisers)
Goals are tiered and weighted – min.,
mod., stretch goals
Align with other service line HQEP’s
– one bucket per service line
Future is Value-Based Payment –
EBP (CJR, CABG), MACRA
*Most Important* -CAN NOT GET
PAID FOR WORK ALREADY DONE
Guideline: FMV is usually 1-3% of
revenue of service line
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Bundled Payment Requires Collaborative Governance
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StrengthentheperioperativegoverningbodytoalignincentivesforallaspectsofPerioperativeServices
Surgical Services Leadership Committee (SSEC)
Surgical Leadership
OR Nursing Leadership
AnesthesiaLeadership
Sr. HospitalLeadership
• Chaired by Medical Director(s) of Perioperative Services• Administration-sponsored Surgery Board of Directors• Controls access and operations of OR• Sponsors and directs Perioperative team activity
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Steering Committee Responsibilities
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Define supplies accepted per case
Identify key surgeon to approve
exceptions prior to surgery
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Supply Costs Can Be Controlled
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Cost Issues
Aquamantys Cautery Device
Implant Not on List
Supplies utilized with
no value
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Questions to Ask
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What are the benchmarks?
How do you address physicians who are outside benchmarks?
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Physicians Scorecard
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This image cannot currently be displayed.
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How to Address Outlying Behavior
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Gain Sharing Payment
Block Time
Flip Rooms
Dedicated Team
Physician Leadership is KEY
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OR Case Time is Very Expensive
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ASC
$20 Minute
Community Hospital
$40-$60
Minute Tertiary Hospital
$60-$80
Minute
The Elephant in the OR: Case Time
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Case Time Date: Driving Organizational Change
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Patient In
Anesthesia Ready
CutClose
Patient Out
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Reduce Case Time
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InformationTurnover Teams
Reduction of items or preference
cards
PA and tech set-up for complex
procedures
Anesthesia preference
cards
Surgeon in room when patient is in
room
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OR Case Time Variance By Procedure
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Impact
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CV Surgery:50 Per case reduction in 6 months
Urology:Robotic
Prostatectomy 45
minutes
Cost Per Minute:
$20
IMPACT:Reduced cost per case and increased revenue
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Case Study – East Coast Community Hospital
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Predictive Analytics in Perioperative Services
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Predictive Analytics improves
outcomes while optimizing
costs
Block Time &
Scheduling
Labor & Productivity
Anesthesia Costs
Nursing Costs
Clinical Outcomes
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Why is Efficient Block Scheduling Important?
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Establishes “draw down” and optimizes room utilization• 2.5 FTE/Room• Approximately $300,000
Anesthesia cost
Reduces costs from having under-utilized rooms
Reduces the cost per occupied bed
Figure 1. Heatmapping the operating room aids in visualizing peak operating hours and helps to minimize non-productive time.
Client logo placeholderEffective Block Design
The goal is to maximize access for the most productive surgeons
Block forecasting correlates physician practice patterns to precisely match demand for block
Predictive models also allocate appropriate time for urgent, emergent, and electively scheduled cases
- Drastically reduces overtime expense and improves throughput- Minimizes need for additional resources after hours
Hospitals use this schedule to forecast ICU admissions and efficiently manage beds
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Designing a Block Schedule by Forecasting Demand
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Helps to load balance the OR• Reduces variance and improves predictability of the daily
schedule
Improves surgeon access
Incorporates physician practice patterns into the model• Minimizes interference with clinic schedule
Reduces overtime cost• Provides “wiggle room”
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Scheduling Accuracy is a Critical Component of an Efficient Block Schedule
Helps control labor costs- Reduces day-to-day variability in the schedule- Provides sufficient notice of gaps or complex cases
Client logo placeholderScheduling Accuracy, cont.
Case Time 𝑇" is non-Gaussian- Log-normally distributed
Several effective approaches- How to best handle outliers?
• Use the expectation value: 𝐸 𝑇" (with some guidelines)
N(ln 𝑇"; 𝜇, 𝜎) =1
𝜎 2𝜋� 𝑒456 7849 :
;<:
Case Study - What is the Daily Huddle?
H HealthcareU UnitedD Daily (to make)D DecisionsL Leading toE Excellence
Recap of previous dayTotal case review for next days out –
PAT and scheduling completionReview of scheduleTotal number of anesthesia providers
to start the dayPAT problem reviewAntibiotics reviewReview pending action items
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Unused Time = 4 hours
Unused Time = 3 hours
4th Case = 1.5 hours
Turnover = 1 hour
Turnover = 1 hour
2nd Case = 1.5 hours
Turnover = 1 hour
1st Case = 1.5 hours
3rd Case = 1.5 hours
FlipRoom• Avg.Duration
1.5hours• Avg.Turnover
-15minutes
CalculatingUtilization
Withanegativeturnover:
=1.25x4=5/8‘unadjusted’ forflip=62%
Adding30minadjustedturnoverbetweeneachcase:
=1.5x4+.5x3=7.5/8.0IstheAdj.Util.=94%
Room 1 Room 2
1.25 1.25 1.25 1.25
1.50 .5 1.50 .5 1.50 .5 1.50
Utilized
Utilized
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Case Study - Solution for Room Flipping & Calculation for Adjusted Utilization
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Case Study - Impact
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Surgeons Engaged• Increased OR Volume• Increased Satisfaction
Anesthesia Engaged• Improved Efficiency
Strong Leadership• Nursing Director and Co-medical directors own daily
operations
Profitability• Hospital well-positioned and functioning efficiently• $20M Improvement
Client logo placeholderCase Study – Volume Snapshot 2015 & 2016
898 928 919 9101142 1012 1065 1038
27%
9%
16%14%
0%
5%
10%
15%
20%
25%
30%
0
200
400
600
800
1000
1200
June July August September
YT
D V
olum
e C
hang
e
Volu
me
2015 2016 Delta
Client logo placeholderCase Study – OR Utilization Snapshot 2015 & 2016
60% 61%65% 63%
75%70% 69%
73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
June July August September
Adj
. Util
izat
ion
(Pri
me
Tim
e)
2015 2016
Implementation Checklist
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Work Plan
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Steering Committee
• Physician Leadership
• Surgeons• Anesthesia• Quality• Business
Manager• Nursing• Administration
Payment for Physician Time
• Determine best model for your hospital
Gain Sharing
• Determine what works best for your hospital
Meeting Frequency
• What is necessary?
• What fits everyone’s schedule?
Work Group
• Clinical Redesign
• Information
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Information Collection
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Quality(SSI, DVT,
Retain Objects)
HCAP
Cost
Surgical Time
Readmission
Mortality
Discharge Status
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Physician Scorecards
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What to Include?
How to Display?
Assign Responsibility
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Clinical Redesign
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Value Stream
Mapping
Patient Scheduling
Presurgical Optimization
AnesthesiaPain Management
Equipment / Room Set-Up
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Protocol / Clinical Pathway
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Exclusion Criteria• BMI• Smoker• Comorbidity
ERAS Surgery• Time• Vitals
P.A.C.U.• Mobility• Ambulation• Discharge
Criteria• Pain
Management• PONV
Post Surgery Recovery• Dietary
Expectation• Hourly Clinical
Expectation• Pain
Management• Ambulation• Discharge
Expectation• Post Discharge
Daily Monitoring
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Patient Education
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Patient
Introduce Technology
Prepare for Surgery
(NPO,Sage Wipes)
Rehabilitation / Recovery
ExpectationsPost Surgery
Follow-Up
Who to Contact with Problems?
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Office Staff Education
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Bundled Goals
Clinical Checklist
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Risk Reduction Tools
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Home Support Comorbidity
Smoking Cessation
Home Evaluation
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Cost
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Incomplete Surgical Tray Preference Cards
Surgeon Deviates From Approved Set
Implants Not On Registry
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Implementation Checklist
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Steering Committee Information Physician
Score Cards
Clinical Redesign
Patient Education
Surgeon Office Staff
Patient Education
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Institution Support Is Key
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Project Champion
Anesthesia / Surgeon
Information
FinancialNavigation
Nursing Leadership
Time / Resources
Hospital Support
Surgical Directions541 N. Fairbanks Court
Suite 2740Chicago, IL 60611
T 312.870.5600 F 312.870.5601
www.SurgicalDirections.com
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