Th 325pm Transmorning Your OR for Value and Quality · • Successful system under Value-Based ... Bridging worlds provide insight in overcoming barriers and taking your organization

11/4/2015

1

Surgical Directions © 2015

Why Focus on Perioperative Services?

Perioperative services drive hospitals’ performance.

• Over 68% of better performing hospitals’

revenue

• 60% of margin is derived from better performing

perioperative services.

• Successful system under Value-Based

Purchasing/ACO provides both surgeons and

payors more value for surgical services.

Equation: Outcome/Cost

By helping our clients tackle the complexities and

minimize the political and cultural barriers, our

clients have experienced significant improvements

in surgeon, staff, and patient satisfaction, which has

resulted in improved access to the OR, sustainable

growth in surgical volume, and increased market

share.


Healthcare Leaders Role

3

As healthcare leaders our goal is to improve the value of

Perioperative Services

11/4/2015

2


Bridging Worlds

Bridging worlds provide insight in overcoming barriers and taking your

organization to a new level.

• Integrate Co-Create:-Collaborative governance

-Pre surgical optimization

• Nimble Exceed Rate of Change:-Bundled payment-Surgical home

• Generate Data / Give Insight:-Surgical dashboard-Monitoring key processes

• Tell Stories/ Create Experiences

ERASE BOUNDARIES / SILOS

-INTEGRATE, CO CREATE

-NEW GOVERNANCE AND DELIVERY MODEL


Case Study:

Beaumont Royal Oak

Flagship Tertiary Level I Trauma Center

Underperforming:

– Financially

– Clinically

– Operationally

11/4/2015

3


Case Study: Beaumont Royal Oak

Flagship hospital in trouble and struggling:

• Not meeting financial goals:

• Merger talks with Henry Ford terminated• Merger discussion with Oakwood

• Bond refinancing

• CRNAs employed by hospital meeting to discuss unionization

• Anesthesiologist had only a marginal role in operational leadership andless than optimal relationship with surgeons, nurses, and CRNAs.

• Leadership goal is to be the top surgical hospital in the nation

o Exceed UHC hospital benchmarks


Royal Oak Has Opportunities for

Improvement

Metric Benchmark Royal Oak Rating

SharedGovernance

SSEC: Multi-disciplinary approach to operational leadership

Surgeon as Chair

Matrix organization with traditional ‘nurse in

charge’ model

Medical Director

Anesthesiologist / CRNA Co-manages OR with nursing

RespectedClinically Active

Surgeon and anesthesia

chair at each tower

Lack of collaboration and

cross coverage

Daily HuddleMulti-disciplinary approach to proactively manage the schedule

1, 3 and 5 days out

M, W, F Scheduling Meeting lacking depth

and scope in proactive schedule management

Accountability

Strong and decisive leadership

Metrics, Dashboards and KPIs to

monitor performance and objectives

Culture of Accommodation



Improvement

Metric Benchmark Royal Oak Rating

Block Schedule8 hr blocks plus open time;

75%-85% utilization

Current utilization under 50%

Cases per ORMain OR

IP 950 cases x 50% = 475 casesOP 1,400 cases x 50% = 700 cases

Total: 1,175 cases per ORCV 400

732 cases per OR

Day of Surgery Cancellations

<1%~1% Staff indicate much higher

Turnover TimeIP: 20-30 minutes

OP: 10-20 minutesNot Tracked

First Case On-Time Starts

90% or greater within 5-7 minutes of start time

Not Tracked

NA

NA

Notation: Excludes 4 CV OR’s and CV Case Volume

11/4/2015

4



Improvement

10

Metric Benchmark Client Rating

LeadershipDrive perioperative performanceDaily Huddle

Not involved in OR management

SafetyCreate a culture of safetyConsensus on protocols

Has a culture of safety but no consensus on protocols

PATProtocol drivenPatient optimized prior to surgery

Not protocol driven patients

Service Orientation

Service focusedWorking in silos and not in collaboration with nursing

Anesthesia


Case Study

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Block Utilization

Benchmark

Actual


Overview of Beaumont Royal Oak

Hospital Perioperative Improvement

Governance Structure and

Leadership

Process Improvement

Efficiency Initiatives

Anesthesia /

Pre-Anesthesia Testing

Surgeon Scorecards &

AccessStrategic Growth

12

11/4/2015

5

Surgical Services Executive Committee

• How do you build trust and a sense of joint ownership between

surgeons, anesthesia, and administrations/hospital staff?

• The Surgical Services Operations

Committee

• The committee membership

includes:

– Surgeons

– Anesthesia

– Nursing

– Senior Administration

13


A “New” Hospital Surgical Organizational

Structure that Aligns Incentives

SSEC(Administration Sponsored)

Nursing

Leadership

Business Director/

Manager

PreOp

Main OR (Hosp)

Data Analysis

Budgeting/

Financial Analysis

Business

Development

Medical

Directors

Performance

Improvement

Teams

PACU


Balancing Surgeons’ needs for Access, Efficiency, Safety

and Quality Care and Hospital’s need for OR Value /

Productivity

Effective OR Leadership:

11/4/2015

6


Daily Huddle

Participants

‒ OR Director‒ Anesthesia

‒ PAE‒ Central Sterile Supply

‒ Materials‒ Scheduling

‒ Case Management‒ Ancillary Services, when needed (radiology, lab,

etc.)

Task

Review Schedule for next 72 hours‒ Patient Risk Factors

‒ Equipment‒ Supplies

‒ Sequence of Patients‒ Staff Assignment

Outcome

• Minimize Cancellations <1%• Improve On-Time Starts >80%

• Decrease Case Delays <5%• Improve Profitability

• Improve Clinical Outcomes


Anesthesia Helps Drive

Perioperative Performance

Driving Perioperative Performance

Effective Medical Director

Strong leader

Stipend based on service

standards

Incentives aligned

Available effective regional blocks

PAT

Protocoldriven and evidenced-

based

Surgical Home & Bundled

Payments

Participate in Daily Huddle

On-time starts

Quick procedural turnover

time

Respected clinically

Well-positioned

for the future

Growth in Case Volume & Improved Bottom Line


Case Study: Pre-Anesthesia Testing

Effective PAT

Medical Director

Telephone Questionnaire

Single Pathway Scheduling

Risk Management

Strategies

Testing Protocols

Systems to treat patients

with co-morbid conditions

11/4/2015

7


Beaumont Royal Oak

Key Performance Indicators

19

Metric Current State Best Practice

Block Time / Prime Time Utilization 76% 70% - 85%

Cases per Operating Suite 838 1,219

Turnover Time 25 25 - 35

Same Day Case Cancellation 2.62% <1%

First Case On Time Start 65% >90%

Review Elective Cases 1, 2, & 3 Days Prior 100% >70%

Metric Jan-14 As of Jan-15 Variance

Improvement

Variance %

Block Time / Prime Time Utilization <50% 76% 26% 52%

Cases per Operating Suite 733 838 105 14%

Turnover Time 40 25 -15 38%

Same Day Case Cancellation 3.71% 2.62% -1.09% 29%

First Case On Time Start 29% 65% 36% 124%

Review Elective Cases 1, 2, & 3 Days Prior 25% 100% 75% 300%


Results: Beaumont Royal Oak

20

IMPACT ON VOLUME: 24%

IMPACT ON NET INCOME: $20M

Surgeons Engaged

Improvement in Clinical Outcomes

Hospital well-positioned and

functioning efficiently


Bundled Payments are Here!

• Hospital Joint Discourse

• Bundled Payment Early Adoption 2012

21

11/4/2015

8


Be Nimble Exceed Rate of Change

• CMS Goal 2018

– 50% Quality/Cost Initiatives

• 2016 Bundled Payment- Joint Replacement

• 75 Markets

• 800 Hospitals

• 90 day episode

• Cost

• Quality Measures

– Complications

– Readmission

– Patient Experience

22


Any services

72 hours

prior to

Admission

such as…

PAT

Physician Visits

(surgeon and other)

ED Visits

Any services

during the

Acute Stay

such as…

Hospital

Surgeon

Anesthesiologist

Consulting

Physicians

Any services during the 90-Day

Post-Acute Period

such as…

What is Included in the Target Price?

Inpatient Rehab

Skilled Nursing

Facilities & LTACH

Home Health

Agencies

Outpatient

Therapy Services

Readmissions

(to NYU or others)

Outpatient Services

Lab Services

DME

Physician Visits

(surgeon and other)

Part B Drugs

Days 91-120

CMS will be monitoring

the period immediately

following to ensure that

services are not being

shifted outside the

bundle.

NYULMC will be

financially responsible

if such behavior is

observed and may be

removed from the

program.


CLINICAL PATHWAYS & WORKFLOW

STRATEGIES

11/4/2015

9


Clinical Management Pathway

The Importance of Care Coordination

• Enforces best practices / standardization of pathways, workflows, and order sets

• Improves communication between providers and to the patient

• Ensures follow-up after care transitions

• Optimizes Patient Expectations and Outcomes


Goal

Develop a pathway that can be used for

90% of the patients with exclusions

determined by pathway criteria, not

physician preference


Preventing Hospital Readmissions

• Often suboptimal outcomes are tied to comorbidities or

complications associated with their TJA.

• Preoperative optimization of risk factors for suboptimal

outcomes is the best method of prevention.

• The use of an integrated preadmission testing and

clearance center utilizing the patient’s internist or a

hospital affiliated internist associated with a TJA specific

education and comorbidity identification process is

critical for medically complicated patients.

11/4/2015

10


Results

• Average of length of stay was decreased to 3.58

days from 4.27 days (Median LOS 3 days).

• Discharge to inpatient facilities has decreased

on average from 63% to 44% on average.


Conclusions

• Decreased length of stay

• Decreased discharges to inpatient facilities

• Decreased the cost of the episode of care

• Decreased readmission rate

• Positive margin


Fundamentals of Co-Management

Surgical Home

11/4/2015

11


Gain Sharing Metrics

• Patient Satisfaction

• LOS

• Unplanned 30 day readmission

• Compensation

– Fee Based on hours work

– Gain sharing tied to a percentage physician base

compensation if quality and lost metrics are achieved


Generate Accurate Data

Define Current State:

Generate Insight!


Elephant in the OR

IMPROVING OR PRODUCTIVITY

11/4/2015

12


Issue

Hospital for joint disease has limited capacity

Has initiatives to grow volumeBUT

Reducing case time is KEY to delivering

strategic objectives


Issue

Surgeons complain about turn over

time and same day cancellations

Most hospitals are afraid to address

case timeBUT

Cost per minute: $30 - $80


PUBLISHED OR METRICS DRIVE

CHANGE!

11/4/2015

13


Case Time Data

Driving Organizational Change

Patient In

Anesthesia Ready

CutClose

Patient Out


Physician Scorecard


Physician Scorecard (cont’d)

Th 325pm Transmorning Your OR for Value and Quality · • Successful system under Value-Based ... Bridging worlds provide insight in overcoming barriers and taking your organization

Documents