Care Redesign: A Team Approach to Improving Valueapp.ihi.org/FacultyDocuments/Events/Event-2491/Presentation-10465/Document-8747/... · Care Redesign: A Team Approach to Improving

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Care Redesign:A Team Approach to Improving Value

Mary O. Cramer

Senior Director

Process Improvement and

Ambulatory Management & Performance

Erin Conklin

Senior Consultant,

Center for Quality & Safety

December 9, 2014 Session: C3The presenters have nothing to disclose

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Care Redesign: A Team Approach to Improving Value

Objectives

• Describe how to establish and engage multidisciplinary care redesign teams

• Identify strategies to prioritize improvement opportunities, overcome barriers, and implement tests of change

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Agenda

• The Role of Care Redesign in our Healthcare Environment

• Leading a Team through the Journey

– Team Formation

– Roles and Expectations

– Redesign Process

– Change Management

– Deliverables

Original Campus Current Campus

Chartered in 1811; third oldest general hospital in the United States.

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1000 Beds, 47,000 Discharges, 1.4 Million Outpatient Visits, 88,000 ED Visits

Harvard Affiliated, Largest hospital research budget in the US – $764 Million

• Per capita health care costs have grown steadily for 40 years

• Unmet need is perpetual

• Expanding health insurance coverage magnifies cost pressures

• The US employer‐based health insurance system is a handicap in a global economy

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Pe

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apit

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(adjusted for inflation)

Per Capita Growth In Health Expenditures Has Increased at 2% Above Inflation For 40

Years

Source: 2009 presentation by Stuart Altman, PhD titled Growing Healthcare Spending: Can or Should It Be Controlled to Prevent a Health System “Meltdown” ?

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Our Collective Challenge

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The Path We’re Traveling

Pressure to reduce cost trend

New contracts with risk for trend

Internal PerformanceFramework

Investment in population management infrastructure

Changes to Partners structure –org chart and network

Partners in Care (PCMH & care coordination for high risk patients)

Sustained cost trends near GDP

Implement new local Incentives/compensation

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Bending the cost curve – recent headlines

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Bringing Value to Patient Care: The Value Agenda

Michael Porter, Harvard Business School, 2011 AIM:• Move toward a patient‐centered system organized around

what patients need.

• Shift focus to the patient outcomes achieved.

• Develop a system in which services for particular medical conditions are concentrated in health‐delivery organizations and in the right locations to deliver high‐value care.

STRATEGY:• Organize into Integrated Practice Units

• Measure outcomes and costs for every patient

• Move to bundled payments for Care Cycles

• Integrate care delivery across separate facilities

• Expand excellent services across geography

• Build an enabling IT platform

Michael Porter and Tom Lee, Harvard Business Review, October 2013

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Population Management

Episodes of Illness

Inpatient andOutpatient Encounters

Approach

• Improve quality

• Reduce unit cost

• Redesign care (fewer units)

Process

• Participate in Care Redesign Teams

• Design & test improvements

• Transition improvements to operations

• Pursue additional opportunities in clinical

redesign and patient affordability

MGH/MGPO Care Redesign

Care Redesign is a key pillar of our strategy to adapt to payment reform by improving the quality, coordination, and cost of the care

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GEC/Chiefs

Quality and Safety Steering Committee

PO Executive Committee

One Approach: MGH/MGPO Care Redesign

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MGH/MGPO Care Redesign Values

• Simplify/Structure: eliminate unnecessary processes and develop evidence‐based guidelines and metrics to guide improvements

• Strategize/Save: leverage shared knowledge to capitalize on opportunities for efficiency and cost savings

• Standardize/Streamline: reduce unnecessary variation to promote reliable, high‐quality care

• Serve/Satisfy: provide service that adds value to our patients

• Share/Sustain: foster teamwork, collaboration and communication to promote continuous improvement

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MGH/MGPO Care Redesign Approach

• Requires a planned and structured approach

• Needs strong, non‐hierarchical leadership to:

– Drive the work of the team

– Change the culture

– Ensure that improvements are successfully implemented and sustained

• Enlists the right group of people for the team

– Involves a multi‐disciplinary, collaborative effort

– Ensures that everyone is actively engaged with full buy‐in

– Sets expectations for roles and accountability

– Actively seeks to represent the voice of the patient

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Critical Success Factors

• Emphasis is on the process not on staff performance

• Empowers staff who know the processes best to design and test the changes

• Explicitly strives to assure acceptance of change

• Designs in accountability to implement and sustain the changes

Source: GE Performance Solutions

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Building Robust Teams

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Roles & Responsibilities

Team Leaders & Sponsors

• Actively and visibly lead the project

• Establish & communicate the vision and deliverables for the project

• Define the metrics

• Ensure that there is a plan to sustain and spread the improvements

• Leadership teams comprised of a Physician, Nurse, and Administrative

leader

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Team Members

• Composed of clinical and operational staff as well as patients and families –i.e. those closest to the process

• Brainstorm causes of the problem and solutions

• Participate in testing, implementation and spread

• Share the work of the team with colleagues

• Solicit feedback and share it with the team leader

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Process Improvement Consultants

• Collaborate with project leaders to develop a broad work plan

• Coach and guide on the approach to the project

• Assist with planning, developing & tracking the project plan

• Facilitate/support development of project deliverables

• Help ensure that milestones and deadlines are met

Applied Informatics & Measurement and Reporting Team

• Develop project dashboards and provide other analytic support


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Case Study:

Arthroplasty Care Redesign Team

Team Leaders:

– Orthopedic Surgeon Chief– Orthopedics Nursing Director– Orthopedics Anesthesia Chief– Ortho. Administrator– SVP (Executive Sponsor)

Project Support:

– Process Improvement Consultants– Data and Analytics

Team Members:

– Patient– Physical Therapy– OR Operations– OR Tech– Ortho. Administrative Mgr– Anesthesiologist– Analytics– Nurse Practitioner– Staff Nurse– Case Manager– Social Work– Pharmacy– Rehab Facility Clinicians

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Case Study:

Arthroplasty Care Redesign Team

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The Improvement Process

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Structured Approach

BASICS*

• PDCA (Plan‐Do‐Check‐Act) ‐ the foundational approach to process improvement is incorporated in the model

• Cyclical and iterative approach

• Incorporates reliable tools & Change Management concepts

*Source: Leveraging Lean in Healthcare. Charles Protzman, George Mayzell MD & Joyce Kepcher, Taylor Francis & Group, 2011

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Project Timeline

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Wave 1 ‐ EXCELerated Recovery Program

Post‐Acute Care

Summer Year 1

Fall Year 1

Winter Year 1

Spring Year 2

SummerYear 2

FallYear 2

Wave 2 ‐ EXCELerated Recovery Program

Data Analysis

Spring Year 1

1st Report Out 2nd Report Out 3rd Report Out

Case Study: Arthroplasty Care Redesign

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Blueprint: Set Up Project for Success

• Define the problem

• Develop scope & create an improvement target

• Enroll team members

Milestones

Select the project

Create charter (include problem, aim, scope, boundaries, measures)

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Case Study:

Arthroplasty Care Redesign Project

The Arthroplasty Care Redesign Team is charged with evaluating the current state of Arthroplasty care with the aim of achieving the following:

–Reducing cost–Improving efficiency –Optimizing the clinical and patient pathways

Total hip replacement (THR) and total knee replacement (TKR) procedures across all payers

Reduce cost by 10% by Fall Year 2

Charge & Aim

Scope

Goal

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Assess: Prioritize 1‐3 Areas for Improvement

• Understand the process

• Map the process

• Brainstorm & identify the things to improve

Milestones

Understand process: interview, focus group

Map the process

Find root cause (s)

Collect baseline data

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Value Stream & Process Mapping

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Current State Process Map

288

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Suggest: Prioritize Ideas and Develop Test Plans

• Brainstorm & Prioritize

solutions

• Create Test plans

• Form teams and identify team leads (process owners)

Milestones

Brainstorm solutions

Select solutions to pilot

Create test plan

Pilot: Key Elements

Tool Description What to look for…

1. Patient education pamphlet

• Describes next steps following decision for surgery, average LOS expectations and after‐hospital recovery options

2. EXCELerated Recovery patient candidate report

• Identifies patients meeting Case Management criteria to be discharged to home following surgery

• Report will be sent at the start of each week via email

3. “EXCELerated Recovery” field in OR Dynamic, Mosaic and PRISM

• Flag to identify patients as meeting EXCELerated Recovery Program criteria

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Pilot: Key Elements

Tool Description What to look for…

4. EXCELerated Recovery Order Set

• Sets EXCELerated Recovery plan of care in action allowing for early patient mobilization

• Major practice changes include:–Day 0 patient mobilization– Foley removal in PACU– Early physical therapy, occupational therapy and case management consults

–No patient controlled analgesia –No continuous passive motion

5. Bedside Patient Checklist

• Provides patients with their plan of care and outlines daily goals


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EXCELerated Recovery (2 day ALOS)

Surgeon’s Office

PATA

Pre‐Op OR Inpatient Floor

Case Mgmt

Pre‐Op ORInpatient Floor

PACU

PACU

Traditional Pathway (3 day ALOS)

EXCELerated Recovery Program:Pathway Overview

1 2 3

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RAPT tool integrated into registry/kiosk

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Patient pamphlet

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Risk Assessment Prediction Tool (RAPT) score review and OR schedule

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Weekly email

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Order set and medical management changes

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Bedside patient card

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Implement Pilots and Monitor Results

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Implement & Check: Conduct Pilot and Measure Results

• Communicate pilot plans

• Pilot test plans

• Measure, monitor & communicate outcomes

Milestones

PLAN: Pilot

DO: Implement tests of change

CHECK: Do rapid tests of change

ACT: Adapt as you go

Share successes

PLANCreate a written test plan

DOCarry out planMeasureMonitor closely

CHECKAnalyze data/resultsCompare results to predictionsSummarize what was learned

ACTAdoptAdaptAbandon

Source: The Improvement Guide: Gerald Langley, et. al., Jossey‐Bass, 1996.

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Total Joint Replacement ‐ Combined Hip and Knee Volume

Monthly ALOS and Total Volume

1/1/2011‐6/30/2012

101 99 99

110 112

105100

9399

79

107

82

90

109113

124 126120

3.5

3.7

2.8

3.9

3.8

3.33.2

3.83.8

3.7

3.5

3.7

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2011 2012

Average Length of Stay (Lines)

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Volume (B

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COMBINED VOLUME EXCELerated ALOS STANDARD ALOS COMBINED ALOS

Wave 1 ‐ EXCELerated Recovery Program:ALOS and Volume

Case Mgmtemail Status in

OR schedule Auto

email

Patient goalscard

1st caseDay 0 PT

Formalprogram roll‐out RAPT in

Kiosk

Interventions

5EXCELerated patient criteria: RAPT 7‐12 and plan to discharge to home6STANDARD patient criteria: RAPT 1‐6 and plan to discharge to facility

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1, 6%

2, 11%

15, 83%

Wave 1 ‐ EXCELerated Recovery Program:Patient Feedback

Strongly Disagree

My care team provided consistent information regarding my plan of care

2, 11%

4, 22%

12, 67%

My care was consistent with the EXCELerated Recovery plan outlined in my goals

1, 6%

5, 28%

12, 66%

I found this (patient goals) document helpful during my hospital stay

DisagreeAgreeStrongly Agree

• Positive narrative comments from patients4:– “..I was surprised at how much I could do immediately after knee replacement with physical therapy… I was

pleased I was able to move along as a fast track patient and become mobile quickly”– “Everything from surgery to nursing care to PT work was wonderful”– “Dr. X and his care team have been amazing at all levels – a fine doctor surrounded by a quality team of

health professionals”– “My care team gave me very good instructions”

n = 18 n = 18 n = 18

83%

11%

6%

67%

22%

11%

66%

28%

6%

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Massachusetts General Hospital

AIM: The ACR team will reduce cost, optimize the clinical pathway and improve patient care and satisfaction. The team is focused on total hip and knee replacement procedures from the initial office visit to discharge from the hospital.

TEAM LEADERS: Andrew Freiberg, MD Lauren Lebrun Robert Peloquin, MD

EXECUTIVE SPONSOR: Greg Pauly

Program Design: Designed and implemented the EXCELerated Recovery Joint Replacement Program Implemented new patient education materials setting recovery and LOS expectations prior to surgery. Developed post‐op orders for EXCELerated Recovery patients in POE. Utilized new anesthesia management protocols. Designed automated weekly program candidate report using Case Management, PATCOM and OR systems. Implemented early patient mobilization program. Utilized patient pathway materials.

CONCLUSIONS: Setting patient expectations leads shorter length of stay. Coordination and communication with patient and entire team have improved. 16% overall reduction in ALOS (850+ days saved/year); 26% reduction in ALOS in EXCELerated Recovery patient population 16% increase in volume (200+ cases added/year) 19 days/year PACU recovery time saved 6 IRB submissions complete/in‐progress National conferences and academic publications

NEXT STEPS: Continue to closely monitor LOS Continue to educate staff on new processes Explore Post Acute Care Management Explore options for expanding the patient population going directly to outpatient physical therapy

RESULTS:

Case Study:

Arthroplasty EXCELerated Recovery Program

3.56

2.65

3.88

3.24

3.93

3.75

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FY11 Q1‐Q2 FY11 Q3‐Q4 FY12 Q1‐Q2 FY12 Q3‐Q4 FY13 Q1‐Q2

Volume

Average

LOS

Total Joint Replacement ProceduresAverage LOS and Volume FY11Q1‐FY13Q2

Volume ‐ Total ALOS ‐ EXCELerated

ALOS ‐ Total ALOS ‐ Traditional

Start Interventions

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Results to Date

• 6% increase in overall hospital rating HCAHPs score

• 17% reduction in ALOS (600+ days saved/year)

• 18% increase in volume (200+ cases added/year)

• 19 days/year PACU bed time saved

• 6 IRB submissions complete/in-progress

• National conferences and academic publications

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Key Takeaways

• Engaged multidisciplinary team

• Trial and error and rapid cycle changes encouraged

• Small offline workgroups critical

• Constant communication to staff essential

• Care redesign is an opportunity to improve the patient experience

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Case Study: Arthroplasty Care Redesign Team

Sustainability

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Sustain: Maintain the Improvements

• Operationalize improved process(es)

• Identify accountable owner(s)

• Identify a venue to regularly report project results

• Actively monitor and act on outcomes

– Celebrate successes

– Make changes when needed

– Always communicate

Milestones

Regular project review with sponsors

Transition ongoing oversight to identified Operational Leaders

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Making Change Last: Why is This Important?

• Often disproportionate time is spent on the launch of an initiative rather than its spread and maintenance

• Every change initiative competes for time, resources and attention

• New behaviors are likely to revert back without a plan to ensure that the new process is sustained

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100% of all improvement projects evaluated as successful have a good technical solution or approach

Over 98% of all improvement projects evaluated as unsuccessfulalso have a good technical solution or approach

A Good Technical Solution Is Not Good Enough

A Word on Change Management ‐ Consider

Source: GE Performance Solutions

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A Word on Change Management

Q * A3 = E

Quality (Q) of the solution x

Alignment (A) with strategic priorities x

Acceptance (A) of the idea x

Accountability (A) and recognition for implementation

& ongoing monitoring

= Effectiveness of Project (E)

Source: GE Performance Solutions ‐ adapted

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Critical Success Factors: Alignment

It is essential to communicate:

• the purpose of the project & why it is important

• the problems to be solved ‐ not the solutions to be implemented

• what is happening, what is coming and

• what does this project mean to the individuals involved

COMMUNICATE –

COMMUNICATE –

COMMUNICATE!

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Critical Success Factors: Acceptance

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Critical Success Factors: Acceptance

• “We have a lot of information to share, we just don’t share it”

• “We’ve been hearing about these problems for years; we’ve needed a common way of problem solving”

• “When we’re all together, we can build on each other’s ideas”

• “Previously we’ve attacked this by working in our silos; now we’ve put our heads together to solve the problems”

• “We’re all part of the solution”

• “Regardless of role and level, everyone’s voice counts”

GEC/Chiefs PO Executive Committee

Critical Success Factor: Accountability

Teams’ Deliverables:

1. Project charter

2. Process map

3. Prioritized opportunities

4. Presentation of results and publication if possible

5. Articles for MGH/MGPO publications (Hotline, Fruit Street Physician, From the Desktop)

Ongoing Updates to Executive Sponsor (s), Service Chief, SVP

Quality and Safety Steering Committee

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Outcomes: Ensuring Success

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Accountability & Recognition –Quarterly Dashboard

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73%75%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline,

2011

Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

% = Ortho

Equipment Re

quested On tim

e/# Total C

ases

% Equipment Request Received 5 Days Prior to Surgery Goal=90%

Equipment Request Received 5 Business Days Prior to Surgery ‐Monthly Data(Excludes cases booked within 5 days prior to surgery, e.g. waitlist cases)

31%

25% 25% 23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY12Q2 FY12Q3 FY12Q4 FY13Q1 FY13Q2 FY13Q3 FY13Q4

% = Total Lunder 3 Flashes/Total Lunder 3 Cases

Autoclave Flashing Rate ‐ Quarterly Data(Lunder 3 only, excludes weekends and holidays)

% Flashes Goal = 10%

74%77%

79% 79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY12Q1 FY12Q2 FY12Q3 FY12Q4 FY13Q1 FY13Q2 FY13Q3 FY13Q4

% = Num

ber of Scheduled

Regional blocks/Total Regional Blocks

Scheduled Regional Blocks Prior to Surgery ‐ Quarterly Data(Lunder 3 only, % scheduled prior to surgery)

%scheduled Goal = 90%

90%

76%

87%

91% 91%

87% 88%

82%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

FY12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

%= HCA

HPS Rating

HCAHPS Overall Patient Satisfaction Rating ‐Monthly Data(Inclusive of all surveyed Main Campus Ortho Patients)

75th Percentile, National Benchmark MGH Score

90%

76%

87%

91%

93%

84%

65%

70%

75%

80%

85%

90%

95%

100%

FY12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

%=

HC

AH

PS

Rat

ing

HCAHPS Overall Patient Satisfaction Rating ‐Monthly Data(Inclusive of all surveyed main campus ortho patients)

MGH 75th Percentile

Lunder 3 Quality, Safety and Efficiency Dashboard ‐ A Work In Progress

Scheduling regional blocks is important for our nursing and anesthesia teamsto plan ahead for patient needs, ensure appropriate staff are available and prevent case delays.Source: Lunder 3 Periop Nursing AuditsContact: Laura Cameron, RN and Lisa Warren, MD

Our Equipment and Instrumentation teams rely on accurate and timely equipment forms in order to appropriately match surgeon preference cards to the case, and ensure instruments and implants are ready for the each case. Source: Lunder 3 Manual AuditsContact: Mark Vrahas, MD

75th Percentile

Goal= 10% or less

The rate at which we flash sterilize instrumentation, known as Immediate Use Sterilization – IUS, gives us insight into the availability of instrumentation throughout the day. Although there is no national benchmark for IUS, the Joint Commission, CMS and AORN recommend minimal use for infection control prevention. For our purposes, a goal of 10% or lower has been set for this metric.Source: Lunder 3 Flashing LogContact: Eddie Belmar, Mary Sinclair‐Dumais

Goal= 90%

Tracking sharps injuries is important in monitoring the safety of the operating room for staff. Although data from September 2012 forward suggests improvement, sharps injury rates in the OR have increased in the last couple of years.Source: Occupational HealthContact: Andy Gottlieb, NP

This HCAHPS data is one of several measures of patient satisfaction with the entire patient care journey including the OR experience.Source: Quality Data Management SystemContact: Evelyn Abayaah

This data set reflects how we perform on the timely administration of prophylactic antibiotics for Lunder 3 orthopaedic patients. Cases are considered appropriate if antibiotics are administered and documented within 1 hour prior to incision (2 hours for vancomycin or fluroquinolones) or if there is appropriate documentation indicating the need to delay or avoid antibiotics. The goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of incision.Source: MetavisionContact: Evelyn Abayaah

In the last year, turnover minutes have remained in the 40 minute. Our goal is a blended 30 minute inpatient/ambulatory average based on national benchmark data from other academic medical centers adjusted for MGH case mixSource: Advisory Board Surgical CompassContact: Evelyn Abayaah

The above data reflects the presence of 4 major components of the patient chart on the day of surgery. Overall, there has been a 16% increase in the number of charts with most major elements available in the chart on the day of surgery. Note: There is no baseline data for the presence of the Nursing Assessment.Source: Lunder 3 Nursing Manual Chart ReviewContact: Laura Cameron, RN and Evelyn Abayaah

0.30%

0.18%

0.09%

0.00%0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

% = Total Ortho/O

MF Sharps Injury/Total # of O

rtho/O

MF Ca

ses

Reported Sharp Injuries ‐Monthly Data(Anesthesia reports not included in data set)

61%

84%

58%

31%

70%

81% 81%

70%

47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Orders in Chart H&P within 30 days Consents Nursing Assessments All Documentation

Present

% = Presence of Com

pleted

Docum

ents in Chart Prior to

Day of Surge

ry

Audit of Patient Chart Completeness ‐Quarterly Data(Lunder 3 Ortho Cases Only)

Aug‐12 Mar‐13

Goal = 30 Minutes

Goal = 90%

Great care, On time, Every timeDesigning a Safer and less Stressful workplace

97.1% 96.6% 95.2%98.1% 98.5% 99.5% 99.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

Appropriate Timing of Perioperative Antibiotic ‐Monthly(Lunder 3 Ortho Cases only)

% On Time

Transforming the Culture

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What is Culture?

One Definition:

“Culture in a work organization is the sum of peoples’ deeply ingrained habits related to what they do and how they do it. It’s the way we do things here.”

Does culture matter?

Source: Mann, David,

Creating a Lean Culture, 2005

Culture Matters

You bet!

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Lean Philosophy: The Inverted Pyramid

Frontline Staff

Mid Management Leaders

Upper Management Leaders

Support

Support

Value is Added at this Level

Empowerment is key to success

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“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.”

‐ Charles Darwin1809 ‐ 1882

Finally

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Advice from MGH/MGPO Care Redesign Team Leaders

Link to video