Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’ CEO Forum Kananaskis, Alberta February 16, 2009 Les Vertesi.

Creating ‘Real Change’ Creating ‘Real Change’ in the Emergency Departmentin the Emergency Department with ‘Pay for Performance’ with ‘Pay for Performance’

CEO Forum CEO Forum Kananaskis, AlbertaKananaskis, Alberta

February 16, 2009February 16, 2009Les VertesiLes Vertesi

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Imagine .….Imagine .….

A Conversation with Government …A Conversation with Government …– If you could solve ONE problem in health what If you could solve ONE problem in health what

would it be? would it be? – Would you willing to PAY to do it?Would you willing to PAY to do it?

No? Why not?No? Why not?

– Under what circumstances would you be willing to Under what circumstances would you be willing to PAY to get there?PAY to get there?

33

Changing the QuestionChanging the Question

WHAT if you only had to pay for SUCCESS

… and didn’t have to pay for FAILURE?

44

The ResultThe Result

An Emergency Department Improvement Initiative An Emergency Department Improvement Initiative started in Four Vancouver Area Hospitalsstarted in Four Vancouver Area Hospitals

Purpose: Purpose: – to improve access to patients in the ED and work to eliminate to improve access to patients in the ED and work to eliminate

ED congestionED congestion– To gain experience with the best ways to use money to To gain experience with the best ways to use money to

improve qualityimprove quality

Part of a $100m innovation fund (F2007-08) Part of a $100m innovation fund (F2007-08) announced by BC Ministry of Financeannounced by BC Ministry of Finance

Implementation started in October 2007Implementation started in October 2007

55

Key PointsKey Points

Source of new $ was Ministry of Finance (not MoH)Source of new $ was Ministry of Finance (not MoH)

New money ($16.5m for 4 hospitals) dedicated to New money ($16.5m for 4 hospitals) dedicated to improving Emergency Congestionimproving Emergency Congestion

Not for monthly targets: Not for monthly targets: – Pay is for Pay is for eacheach patient that meets targets patient that meets targets

This is a competitive model, so This is a competitive model, so – Money must go to the Money must go to the HospitalHospital– Not to individualsNot to individuals– Not to the Health AuthorityNot to the Health Authority

Money must be Money must be earnedearned before it is paid before it is paid

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Necessary First StepsNecessary First Steps

1.1. Agree on a Definition and the best Measure of ED Agree on a Definition and the best Measure of ED CrowdingCrowding

2.2. Establish the “Rules” for P4P fundingEstablish the “Rules” for P4P funding Anticipate and Monitor for unintended consequences to patient Anticipate and Monitor for unintended consequences to patient

flowflow Make it fair --- not starting from same placeMake it fair --- not starting from same place Minimize possibilities for gamingMinimize possibilities for gaming Anticipate up-front vs. ongoing investment needsAnticipate up-front vs. ongoing investment needs

3.3. Establish tracking & information systemsEstablish tracking & information systems Attaching money makes it “serious”Attaching money makes it “serious”

77

Target: Total Time in EDTarget: Total Time in ED

Why Total Transit Time?Why Total Transit Time?

Why Three Separate Targets?Why Three Separate Targets?

1.1. $600 for Admitted Patients $600 for Admitted Patients to Ward Within 10 hrs ($600)to Ward Within 10 hrs ($600)

2.2. $100 for Non-Admitted Hi Acuity$100 for Non-Admitted Hi Acuity(CTAS 1-2-3) (within 4 hrs) (CTAS 1-2-3) (within 4 hrs)

3.3. $100 for Non-Admitted Low Acuity $100 for Non-Admitted Low Acuity (CTAS 4-5) within 2 hrs(CTAS 4-5) within 2 hrs

Payment is for EACH patient that meets targets

It Doesn’t Have to be Perfect … Definition of “Complete Success`` = 80% meeting targets

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What is a “Floor”?What is a “Floor”?

Each hospital has their own “funding floor” based on their Each hospital has their own “funding floor” based on their historical performancehistorical performance

Each new patient (above that floor) that meets the P4P Each new patient (above that floor) that meets the P4P guidelines for TT in department has the same $ valueguidelines for TT in department has the same $ value

Implies some recognition for previous investments in Implies some recognition for previous investments in accessaccess– But the go-forward rules and $ amounts are the same for all But the go-forward rules and $ amounts are the same for all

hospitalshospitals

Makes Makes bothboth Volume and Quality (access) count Volume and Quality (access) count

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The ResultsThe Results

Results 1: Changes We Can MeasureResults 1: Changes We Can Measure

Improved access times for Three StreamsImproved access times for Three Streams Admitted Patients - Admitted Patients -

1.1. All Admitted Patients (10 hr transit time)All Admitted Patients (10 hr transit time)

Discharged Patients Discharged Patients 2.2. High Acuity (4 hr transit time)High Acuity (4 hr transit time)

3.3. Low Acuity (2 hr transit time)Low Acuity (2 hr transit time)

1010Baseline (P6) = average performance for 1st six periods of FY2007/08

Time Period: Oct-07 thru Jan-09

All Sites: Numbers of Pts Meeting Targets

2,500

2,700

2,900

3,100

3,300

3,500

3,700

3,900

4,100

4,300

4,500

P6 P7 P8 P9 P10 P11 P12 P13 P-1 P-2 P-3 P-4 P-5 P-6 P-7 P-8 P-9 P-10

1,000

1,200

1,400

1,600

1,800

2,000

2,200

Non-Admit High Acuity

Non-Admit Low Acuity

Admitted P atients

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VGH: Numbers of ED Patients Meeting Targets

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

P6 P7 P8 P9 P10 P11 P12 P13 P-1 P-2 P-3 P-4 P-5 P-6 P-7 P-8 P-9 P-

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CTAS1-2-3

CTAS 4-5

Admits

Lions Gate: Numbers Meeting Targets

100

200

300

400

500

600

700

800

900

1,000


CTAS1-2-3

CTAS 4-5

Admits

Numbers of Patients {Meeting TargetsHospital = Richmond

-

200

400

600

800

1,000

1,200

Time Period

CTAS1-2-3

CTAS 4-5

Admits

St Paul's: Numbers Meeting Targets

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800


CTAS1-2-3

CTAS 4-5

Admits

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Fighting a HeadwindFighting a Headwind

Improvements in performance have come in spite of significant increases in workload and acuity

Changes in Visits Admissions and AcuityAll Hospitals

0.90

0.95

1.00

1.05

1.10

1.15

1.20


Period

Pct

Ch

ang

e fr

om

Bas

e

% Change in Visit Volume% Change in AdmissionsPct as Hi CTAS Relative to Base

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Percentages Meeting Transition Time Targets(All Hospitals)

30%

35%

40%

45%

50%

55%

60%

65%

70%


Percentages CTAS 1-2-3Percentages CTAS 4-5Percentages Admissions

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Percentage of Patients Meeting TargetsHospital = VGH

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%


Percentages CTAS 1-2-3

Percentages CTAS 4-5

Percentages Admissions

Percentage of Patients Meeting TargetsHospital = LGH

20%

30%

40%

50%

60%

70%

80%





Percentage of Patients Meeting TargetsHospital = Richmond

30%

40%

50%

60%

70%

80%

90%





Percentage of Patients Meeting TargetsHospital = St Paul's

40%

45%

50%

55%

60%

65%

70%

75%





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Changes more difficult to measureChanges more difficult to measure

1.1. About Working Faster?About Working Faster?

2.2. About Better investment?About Better investment?

3.3. About Using Data & About Using Data & Information?Information?

4.4. About Value?About Value?

5.5. About Front-line Commitment?About Front-line Commitment?

What Are We Learning?

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About Working FasterAbout Working Faster

We do We do notnot expect people to work faster in real time expect people to work faster in real time

But we CAN expect people:But we CAN expect people:– to pay more attention to time-related decisions in their workto pay more attention to time-related decisions in their work– to stop doing things that are not helpfulto stop doing things that are not helpful

DE-SEQUENCING: DE-SEQUENCING: – Finding things that are done in sequenceFinding things that are done in sequence– How many can be done in parallel?How many can be done in parallel?– How many don’t need to be done at all?How many don’t need to be done at all?

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About Better InvestmentAbout Better InvestmentSound Investments are Key to Sound Investments are Key to

Improvements:Improvements:

P4P creates a climate for Better P4P creates a climate for Better Investment Choices by:Investment Choices by:

Local Empowerment and Control of Local Empowerment and Control of DecisionsDecisionsShortening the Plan, Assess, Re-plan Shortening the Plan, Assess, Re-plan Cycle TimeCycle TimeFunding based onFunding based on What You EARN What You EARN instead of oninstead of on What you Spend What you Spend Conventional fixed funding methods Conventional fixed funding methods encourage “encourage “high askhigh ask” and “” and “spend it or lose spend it or lose itit” behaviors” behaviors

1818

About ValueAbout Value

There is a Moral Commitment to the need to ensure There is a Moral Commitment to the need to ensure reasonable access to both ED and in-hospital acute carereasonable access to both ED and in-hospital acute care

Until now, has been no FINANCIAL consequences for Until now, has been no FINANCIAL consequences for hospitals that allow admitted patients to be boarded in hospitals that allow admitted patients to be boarded in ED stretchersED stretchers

Placing a $ Value on ED access Placing a $ Value on ED access alignsaligns the financial the financial objectives of a hospital with the moral onesobjectives of a hospital with the moral ones

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Using Data & Information Using Data & Information

What Do You Believe?What Do You Believe?

Two Kinds of Information: Two Kinds of Information: – Those with NO consequencesThose with NO consequences– Those WITH consequencesThose WITH consequences

Adding the $$ Sign:Adding the $$ Sign:– CorrectCorrect– Relevant Relevant – TimelyTimely

2020

Personal CommitmentPersonal Commitment

Staff are our most important assetStaff are our most important asset

Staff become alienated when:Staff become alienated when:– No sense of controlNo sense of control– No sense of recognition for No sense of recognition for efforteffort

– No sense of common purposeNo sense of common purpose– No sense of achievementNo sense of achievement

It’s not about the Money It’s not about the Money

P4P uses $$ as a P4P uses $$ as a surrogatesurrogate for Feedback about for Feedback about Quality and what is being valued Quality and what is being valued

2121

Example of Daily PostingExample of Daily Posting(from Richmond Hospital)(from Richmond Hospital)

2222

Staff Morale and MotivationStaff Morale and Motivation

The majority of staff believe the initiatives at their site have been quite successful. The majority of staff believe the initiatives at their site have been quite successful. 45% rated success a score of 4 out of a possible 5. 45% rated success a score of 4 out of a possible 5. An overwhelming majority of respondents believe the project benefited patients. 91% An overwhelming majority of respondents believe the project benefited patients. 91% of surveyors rated success a 3 or higher (out of a possible 5). of surveyors rated success a 3 or higher (out of a possible 5). Some people felt that implementation of the initiatives was rushed and that more time Some people felt that implementation of the initiatives was rushed and that more time was necessary to make the changes. was necessary to make the changes. 87% of respondents say they received sufficient information about EDP initiatives to 87% of respondents say they received sufficient information about EDP initiatives to do their job. do their job. A key concern from staff noted that it is difficult to change the work culture and that A key concern from staff noted that it is difficult to change the work culture and that many staff aren’t aware of the benefits of the initiatives. many staff aren’t aware of the benefits of the initiatives. All staff that responded to the survey were aware of at least one to five project All staff that responded to the survey were aware of at least one to five project initiatives.initiatives.Staff believe the Rapid Assessment Zone (RAZ) and Medical Assessment Unit Staff believe the Rapid Assessment Zone (RAZ) and Medical Assessment Unit (MAU) were the most successful projects. (MAU) were the most successful projects. Some staff suggest that the rest of the hospital should have more involvement in the Some staff suggest that the rest of the hospital should have more involvement in the project. project.

Highlights of Staff Survey at VCH Emergency Departments(June 2008)

2323

Does P4P Really Work Does P4P Really Work as an Agent of Positive Change?as an Agent of Positive Change?

No, it doesn’t always workNo, it doesn’t always work

– But it CAN work if done rightBut it CAN work if done right

– This is a CULTURAL CHANGE This is a CULTURAL CHANGE – There is a LEARNING CURVE in getting it There is a LEARNING CURVE in getting it

rightright

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Some Tips on Getting it RightSome Tips on Getting it Right

1.1. No one keeps any of the money, so No one keeps any of the money, so rewardreward comes comes from local empowerment and sense of ownershipfrom local empowerment and sense of ownership

2.2. You need a very You need a very clear definitionclear definition of what you want to of what you want to achieve (and pay for) and how to measure itachieve (and pay for) and how to measure it

3.3. Need Need control andcontrol and flexibilityflexibility of the rules for funding of the rules for funding4.4. Targets that have no Targets that have no consequencesconsequences are not taken are not taken

seriously seriously 5.5. Constant (daily) Constant (daily) feedbackfeedback and reinforcement are and reinforcement are

powerful toolspowerful tools6.6. Competition and Cooperation can co-existCompetition and Cooperation can co-exist

Total $ Spent in 1st year: about $11m of $16m

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Spreading the GospelSpreading the Gospel

As of October 2008, funding source for As of October 2008, funding source for ED-P4P has been assumed by LMIIFED-P4P has been assumed by LMIIF

Confirmed for expansion to 4 Fraser Confirmed for expansion to 4 Fraser Health Hospitals as of January 2009Health Hospitals as of January 2009

Next Steps: Next Steps: (depend on new sources of $)(depend on new sources of $)

– Expansion to other FHA hospitalsExpansion to other FHA hospitals– Include other major ED’s in provinceInclude other major ED’s in province

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Questions?Questions?

Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’ CEO Forum Kananaskis, Alberta February 16, 2009 Les Vertesi.

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