The Alzira Model The experience of Ribera Salud Hospital de la Ribera, Alzira (Valencia) October 6th, 2015 Dr. Elisa Tarazona Health Care Organisation manager Salvador Sanchis HR Director Carlos Catalán Medical Director Manuel Bosch Deputy Director of Strategy and Development
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The Alzira ModelThe experience of Ribera Salud
Hospital de la Ribera, Alzira (Valencia)October 6th, 2015
Dr. Elisa TarazonaHealth Care Organisation manager
Salvador SanchisHR Director
Carlos CatalánMedical Director
Manuel BoschDeputy Director of Strategy and Development
Summary
An Integration Model Clinical management
HR Strategy
Technological development
Results
Surveys
About Ribera Salud. Leading a process of change
Conclusions.
THE RIBERA SALUD MODEL
PPP Model
Capitated
Payment
Healthcare
Integration
Networking
Key Ideas
AN INTEGRATION MODEL
The Evolution of ourHealth Model Approach
The Evolution Of OurHealth Model Approach
The Evolution of OurHealth Model Approach
The Patient Today
P
A
T
I
E
N
T
PRIMARY CARE
HOSPITAL
HLME
OLD PEOPLE’SHOME
PRIMARY CARE
HOSPITAL
HLME
OLD PEOPLE’S HOME
P
A
T
I
E
N
T
ACUTE
PATIENT
CHRONIC
PATIENT
Most importantly: cultural change of the politician and healthcare organization
managers.
The most important thing is not the hospital.
What really matters is to stand by the whole healthcare network, its professionals
and other agents involved (City Councils, Schools, Nursing homes, old people’s
homes, etc)
To create a corporate culture: Population Health Management
The Integration Model
Capitative payment ….Objective:
“To achieve the best health conditions for the citizens”
S t r a t e g I c t o o l : h e a l t h c a r e I n t e g r a t i o n
P R O A C T I V I T Y
Integrated Primary Care Center - SUECA
Integrated Primary Care Center - SUECA
HRIT
Information Technologies:
Full EMR (all departments and levels integrated)Relationship doctors-patients (Health Portal) Relationship betwen profesional (hospital-Primary Care)t.Business Intelligence System (from professional to corporatemanager).Benchmarking. Cost analytics and what-if capabilities.
.
2 - People
Management:
Training financed by theOrganization, Teaching
(University and MIR) and Research
Incentives system. Career and professional
development
To achive strongerprofessionals´comitment in decision-making processes.
Do the correct in the best palcewith the best quality &EfficiencyChronic Health Plan. Proactivity in CareHome care, social andhealthcare network.Patient Safety Demand Management.
1 Clinical Management:
Triangle for Success
CitizenPatient
Care Giver
Population Healthcare Management: Proactivity• To promote preventive and health
promotion activities • To be proactive in patient’s care • Healthcare management of demand
and needs• Challenge: Chronic Diseases
Management• Segmentation of population
Professional Alignment: Primary Care Doctor – Hospital Doctor
Nurses: new roles, competences and responsibility: emergency triage case history management, etc.
Health objectives alignment across the whole organization
Variability decrease in clinical practice• Healthcare processes, Medical paths• High resolution
Healthcare continuity• Care longitudinally• IT integration
Management of Demand vs Needs Self management tools
• Health website• Florence Direct. To know “all” about your
“Els Ribera” comic, etc.) World Days (AIDS, tobacco, etc.)
Schools: Health education programme
City Hall: Health Days
Social Services: Social and Health Care Programme (senior citizens’ homes)
Pharmacies: Programmes about the proper use of medicines
Coordination with:
Other Promotional Activities
Activities carried out by health centre professionals.
Updating algorithms, clinical guidelines, “stop doing to
start doing” procedures.
Leaders responsible for pathologies in each basic area.
Ongoing training, follow-up tools.
Evaluation – feed-back with professionals.
Level 1 and 2
Chronic Patients Plan: Levels 1 and 2
Appointments: Hospital /Home-Care Unit / Primary Health Care / Social
Work.
Case management – responsibility of the Primary Health Care nurse
“Shared” patient Primary Health Care Doctor /Internist /Nurse.
24/7 Call-Center.
Digital clinical history to help continuity of treatment.
Managing new technologies.
Level 3. Case Management
Chronic Patients Plan: Level 3
Chronic Patients Plan: Level 3
Chronic Patients Plan: Level 3
PRIMARY CARE - HOSPITAL HOSPITAL - HOSPITALElectronic medical record: Virtual consultation (no patients)
Virtual: Video conferences, call conferences and intranet (e-learning) for clinical sessions, training, etc
On-site:• Specialist-consultant• Rotary training periods in hospital for
family doctors• Family doctors do shifts in emergency
service.
Electronic medical record: On-site and virtual consultations
Video conferences (healthcare network)
Interdisciplinary Committee: • Tumours• Infections• Pharmacy and rational use of medicines• Safety
Relationship Between Professionals
Health Portal
PRIMARY CARE: FAMILY DOCTOR AND
NURSE
HOSPITAL: SPECIALIST AND
CASE MANAGEMENT NURSE
Heath Portal
+ SALUD
External web page (open access)
Personal area “My health e-space”
The health portal “+SALUD”is a new interactive portaldesigned for patients. It is anonline platform wherecitizens can easily access allthe information regardingtheir health and well-being..
HEALTH PROMOTION
HEALTH
MANAGEMENT
Health Portal
Health Portal
The patient access to his/her electronic medical record from anywhere:- Virtual communication of test and citology results- Consultation from abroad- Texting with te primary care nurse and family doctor
Follow up and monitoring:- Cardiovascular risk factors- Diabetes mellitus type 1 and 2- COPD
Telemonitoring: - Cardiac insufficiency- COPD- Diabetes mellitus type 1 and 2
Health Portal
Patients with special needs:
Oncology patients in treatment with chemotherapy: family doctor and
primary care nurse, oncologyst and case management nurse.
Patients with inflamatory rheumatologic deseases in treatment with
biological therapies: family doctor, rheumatologist and case management
nurse.
Patients carrying ostomy: family doctor, primary care nurse and case
management nurse.
Health Portal
H.R. StrategyDiversity Management
Financed by the
organization
Hospitals with MIR (Resident Medical
Intern) and University accreditation
; Professionals as University teachers.
research projects and
performance of clinical trials
Retribution based on post and professional´s development:
[Ebitda (Earnings before Interest, Taxes, Depreciation and Amortization) Public Healthcare Authority Objective Plan (annual ranking between 24 health depts. that features 35 indicators related to health provision, published by the Regional Health Ministry).]
Concept and weighting system
80%
according tooccupationalcategories
20%for all employees: Ebitda, Objective
Plan, JointCommission, Chronic Plan
100%
Target. Different per
category
Incentive System
Incentive SystemSpecialized care, Associate Doctor
Successive/first consultations ratioTests/first consultations ratioFirst visit delay/waiting timesTests delay/waiting timesDRG case adjusted average stayDRG case adjusted tests/admissionSurgery waiting list0
Incentive SystemPrimary Care, Associate Doctor
GFAR - efficient and effective prescriptionVaccination coverageHealth e-Space
Centre’s balance sheetExpenditureAscribed populationHR costReferrals to hospital units
Remunerative SystemResults and Conclusions
Results
Personnel costs represents 45-50% of the company’s total expenditure
Bonus remuneration amounts to 20% of personnel total expenditure. For the doctors
category it can reach up to 35-40%
Last year, meeting of objectives averaged 94%
Conclusions
Adjustment: the variable system allows personnel costs to be adapted to the organization’s
outcomes and the quality of service we deliver.
Equitative: it recompenses the best and hardest workers in the organization.
Commitment: it fosters the development and long-term commitment of people within the
organization.
Balance: it aids tailoring the staff to real activity. The bigger the team, the lower individual
variable remunerations are.
Our incentives system is a key factor in talent attraction.
• External consultation proposals• Test requests• Consultation without patient referrals• Algorithms• Florence direct: automated information system• Hospital discharge. Online history• Pharmacy and medical material attribution
• Access to SIA Abucasis from Florence• Registration of all vaccinations in RVN• MPRE module for consultations and prescriptions:
• IT module, hospital prescriptions• Abucasis agendas used for appointments (emergency
room, pediatrics, hospitalization...). As an agenda manager (not for citizen)
Social and health centres, (homes of residence)Inspection: Electronic visa, IT follow-upPublic Health
Comunicaciones
Sistemas de Base (Windows XP/7)
Intranet Corporativa
Po
rtal
de
l Ciu
dad
ano
Gestión Económica y
Logística(Navision)
Gestión RR.HH
(Meta4)
Clínico Gestión
CMI Costes Reporting Iasist
PA
CS
(Car
estr
eam
Ph
ilip
s)
Lab
ora
tori
os
(Un
ilab
as)
Áre
as C
ríti
cas
(Dra
ger)
Ne
fro
logí
a (N
efr
olin
k)
Car
dio
logí
a (P
hili
ps)
…
SIP
RCLE
CMBD
ACTIQUI
SISAL
COMPAS
HEAVS
SIDO
ComunicaciónImpresiónCorreoOfficeOfimática
Gestión Asistencial ( Florence)
Estadística y Gestión
(Cognos)
Consellerí
a
GAIA
SIA-Abucasis
Lab-Online
General Idea– APLICATIONS (CAV))
Propuestas CCEE
Florence Directo
Interconsultas
Florence Gestión
Emergency Activity
Hospital
Emergency Distribution
Hospital/ Primary Care
Primary and Hospital Care integration
Primary Care Hospital
Source: Ribera Salud
Demand ManagementResults
Source: Ribera Salud. Data from Vinalopó Hospital
Number of PC referrals to specialties related to the orthopedic and trauma service
Referrals (left axis)
Inter consultations (right axis)
Evolution of orthopedic and trauma surgery activity (1st consultations)
Vinalopó Hospital
Demand ManagementResults
TRAUMA
REHABILITATION
RHEUMATOLOGY
Demand ManagementResults
Referrals from PC to specialities.Utilization rate per 1,000 inhabitants
Vinalopó Hospital
Waiting listsResults
Source: Conselleria de Sanitat (Alumbra 2014). National Benchmark: Indicadores Clave del SNS: INCLASS 2015”
52 39 32 32
CV66
SNS90
0
10
20
30
40
50
60
70
80
90
100
Alzira Torrevieja Denia Vinalopó
Lista de espera quirúrgica (días de espera)
18 31 28 29
CV41
SNS53
0
10
20
30
40
50
60
Alzira Torrevieja Denia Vinalopó
Lista de espera consultas especialista (días de espera)Surgical waiting list in 2014 (in days) Specialized waiting list in 2014 (in days)
ComplexityResults
Number of bypasses. Source: BMSD of 29 hospitals. Elaborated by IASIST.
Average complexity (DRG) per age group
Number of bypasses
0,00
0,50
1,00
1,50
2,00
2,50
3,00
0-4 AÑOS 5-14 AÑOS 15-44 AÑOS 45-64 AÑOS 65-74 AÑOS <75 AÑOS
Complejidad media (peso GRD) global y por grupo de edad
Alzira; 1,66
Torrevieja; 1,86
Denia; 1,78
Vinalopo; 2,03
España; 1,74
1,50
1,60
1,70
1,80
1,90
2,00
2,10
1
Peso medio por hospital
Average weight (in red RS concessions, in black Spanish benchmark) per age group. Source: RS MBDS, Spanish
benchmark from DRG Ministry of Health 2013 database.
50 100 150
0 20 40 60 80 100 120 140 160 180 200 220
Número de Bypass
Mortality in Bypass and Valve Surgery 2014.Source: BMSD of 29 hospitals. Elaborated by IASIST
Gross and adjusted mortality rate
Gross mortality rate (left axis)
Adjusted mortality rate (right axis)
Valve surgery
Satisfaction Survey
8,6
8,6
8,7
9,0
CV 8,5
0 2 4 6 8 10
Alzira
Torrevieja
Denia
Vinalopó
7,8
7,8
7,7
8,0
CV 7,8
0 2 4 6 8 10
Alzira
Torrevieja
Denia
Vinalopó
Satisfacción global en la atención hospitalaria 2014 Satisfacción global en la atención primaria 2014
8,6
8,6
8,7
9,0
CV 8,5
0 2 4 6 8 10
Alzira
Torrevieja
Denia
Vinalopó
7,8
7,8
7,7
8,0
CV 7,8
0 2 4 6 8 10
Alzira
Torrevieja
Denia
Vinalopó
Satisfacción global en la atención hospitalaria 2014 Satisfacción global en la atención primaria 2014 Global satisfaction in Hospital care in 2014Global satisfaction in Primary care in 2014
Source: Conselleria de Sanitat 2014
Chronic Patient PlanResults
Fuente: Brookings “Spain: Global Accountable Care in Action”
91% of the patients show their satisfaction withthe health care provided.
94% do not know the Alzira Model.
Satisfaction Survey
Work Environment Survey
93% of our employees recommend Ribera Salud centers as a place to work in.84% consider that the organization provides the required information to do their job inoptimal conditions.The pride in belonging to this Group is the most highly rated indicator. 8 out of 10employees are satisfied or highly satisfied.What our employees consider the most important aspects in our Organization is:
• Career development• Respect and courtesy to the patient• Good working atmosphere• Ackknowlegement of the work carried out
All surveys “Best Place to Work” (credibility, respect, impartiality, pride and fellowship) show that our indicators are over the average in healthcare sector. 90% of our employees consider they are contributing in a positive way to the societywelfare, 6 points over the average in the healthcare sector.