Post on 10-Jul-2020
Standardization of Patient Care in Post-Acute Settings
Ari J Cohen, M.D., FRSCS, FACS
Medical Director, Multi-Organ Transplant Institute
Head of Abdominal Transplant Surgery
Liver Transplant Surgeon
Surgical Director, Kidney Transplant Program
Director of Transplant Research
Professor of Surgery, University of Queensland
Ochsner Clinic
Disclosures
•Left-handed Canadian transplant surgeon
•I have no financial disclosures
•This is not a scientific talk
Volume Trends
2019 Data Annualized as of 7/31/19
0
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1000
1500
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2500
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3500
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4500
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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Multi Organ Transplant Program 1998-2019
Referrals Listings Transplant VADS LOPA
Definitely makes things faster in the morning too…. More
time for other important things.
Our Pursuit of Value in Transplant?
•Quality• Patient-focused• Eliminate non-value added
Process Variation
•Variation means a process does not produce the same result every time
•Some variation exists in all processes
•Variation directly affects the patient experience
Ground Rules
Patients always come first
We know:
•Patients are not cars
•Patients are not widgets
•Patients are not anything else similar
•We can still learn from other industries
Quality Improvement Techniques
•Identify/remove waste
•Lead to improved performance
•IncludeoSix SigmaoLeanoTotal Quality Management (TQM)
0
50
100
150
200
250
300
350
Referral, FinancialApproval
Work upEvaluation
TransplantWaitlist
Transplant
7 Days
Nat Avg 250 days
3-5 Years
No Benefit with Prolonged Workup
• Poor quality or deterioration of health
• Pts on dialysis 20-50% mortality rate/year
• Vascular access issues
0
50
100
150
200
250
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350
Referral,FinancialApproval
Work upEvaluation
TransplantWaitlist
Transplant
Old
Patient Experience Transformed
<90 Days
7 Days
Nat Avg 250 days
3-5 Years
Dead Ends
•Lean•Innovation Fridays•No national standard for kidney evaluation
October 10, 2019
Creating Buy-In
•Patient First•Shared Vision
•Transplant Providers – Easy•External Providers – Not so easy
No Focus
•Subsequently scheduled
•8-12 trips to clinic
•20% no-show rate
>295 days
Before
We’re GonnaDo What?
Patient Focus
•Lab•Regulatory Consents•Pharmacists•Regulatory Education•Nephrologists•Surgeon•Infectious Disease•Social Workers•Transplant Coordinators•Dietician•Chest X-ray•Ultrasound•Cardiology
< 90 days
After
•Reduced no-shows
•Increased patient satisfaction
•Increased physician productivity and satisfaction
Possible Other Appts•Mammogram•Pap Test•Stress Test•Colonoscopy•Other Tests
Day 1 Evaluation
7 AM Registration, Vital, Labs, Med-Rec, Consents
8 AM Group Education
9 AM
Round Robin: Surgeon,Nephrologist, Social Worker, Financial Coordinator, Dietician, ID
12 PM Break for Lunch
1 PM Ultrasound 2 PM Chest X-Ray4 PM Cardiology
Efficiency x Empathy x Environment = Experience
Round Robin Surgeon Note
Kidney Round Robin Multi-Provider Charges
Surgeon Schedule
Old Schedule
8a Patient 1Patient 2
9a Patient 3Patient 4
10a Patient 5Patient 6
11a Patient 7Patient 8
New Schedule
8a Patients 1, 2, 3, 4, 5, 6, 7, 8
9a
10a
11a
Clinic Navigator
Patient 1 Patient 2 Patient 3
9aNephrologist Social Worker
•Surgeon•Dietician/ID•FinancialCoordinator
10a •Surgeon•Dietician/ID•FinancialCoordinator
Nephrologist Social Worker
11aSocial Worker
•Surgeon•Dietician/ID•FinancialCoordinator
Nephrologist
Operational Efficiency
•Clinic Staff
•Pre-Office Coordinators
•Group Education
•Coordination withoRadiologyoCardiologyoInfectious DiseaseoLab
2012 2013 2014 2015 2016 2017 2018 2019
Referrals 1651 1818 1912 2059 2036 2085 2258 2467
Total Patients Listed in Year
308 391 429 442 317 330 301 280
Waitlist 781 925 1058 1197 1157 1047 988 858
* 2019 Annualized as of 9/30/2019
Continued Growth
Be Careful What You Wish For
Workflow Redesign
•Surgeons
•Nephrologists/ Hepatologists
•Coordinators
•Procurement Staff
Transplant Continuum of Care
• OR Optimization = $130 variance
• Efficiency Drift corrected • Improved CGCAHPS
• Revised 186protocols this year
• 24/7 Unit Based APPs, 100% adherent to pathways•Achieved documentation
excellence
One-Day Clinic
Protocolized Care
Standardized OR
Pathways
Before: No standard way
•Transplant surgeon of week
•Daily labs
•No standard way o Review timeo How to act on resulto Frequencyo Weekends/holidays
(about 10 labs/day to review)
After: Standardized lab review
✓Reduced weekend labs to less than weekend day
✓Standardized review time and method
✓ Established for first sixty days after transplant
✓ Labs either M; M, Th or M, W, F
Post-Transplant Lab Review
Ari’s Lab Instructions
Post-Transplant Patient Education
•Hospital to rest of their life (long)
•200-page patient post-care guide
•Quiz
•Multidisciplinary
•Multilingual
➢Digital and available in MyChart
Ochsner-On-Call
•450 national protocols•45 transplant center-specific protocols •120 calls per month
Reasons by Time Category Column Labels
Row Labels Kidney Liver
Weekday 6am-8am 38 42
Weekday 8am-5pm 117 117
Weekday 5pm-8pm 238 224
Weekday 8pm-6am 136 149
weekend/holiday 500 576
Grand Total 1029 1108
Count of Organ Column Labels
Row Labels Kidney Liver
Weekday 5pm-8pm
Call EMS 911 Now 1 3
Call PCP Now 47 37
Call PCP Now Go to ED Now 1
Call PCP When Office is Open 19 20
Call PCP When Office is Open Go to ED Now 1
Call PCP Within 24 Hours 17 18
Call PCP Within 24 Hours Home Care 1
Call Pharmacist Within 24 Hours 1 2
Call Transferred to Provider on Call 4
Discuss With PCP and Callback by Nurse Within 1 Hour 2 4
Duplicate Contact Calls 6 5
Duplicate Contact Calls No Contact Calls 1
Error Encounter 1
Go to ED Now 15 23
Go to ED Now (or PCP Triage) 12 14
Go to ED Now (or PCP Triage) Callback by PCP or Subspecialist Within 1 Hour 1
Go to ED Now (or PCP Triage) See More Appropriate Guideline 1
Go to ED Now (or PCP Triage) See Physician Within 4 Hours (or PCP Triage) 2 1
Go to ED Now Go to ED Now (or PCP Triage) See Physician Within 4 Hours (or PCP Triage) 1
Home Care 48 42
Home Care Call PCP When Office is Open 1
Information or Advice Only Call 3 3
Information or Advice Only Call Home Care 1
Lab Test Only Within 24 Hours 1
No Contact Calls 14 12
Count of Organ Column Labels
Row Labels Kidney Liver
Weekday 5pm-8pm 238 224
Weekday 6am-8am 38 42
Weekday 8am-5pm 117 117
Weekday 8pm-6am 136 149
weekend/holiday 500 576
Grand Total 1029 1108
Reasons by Time Category Column Labels
Row Labels Kidney Liver
Weekday 6am-8am 38 42
Weekday 8am-5pm 117 117
Weekday 5pm-8pm
ABDOMINAL PAIN 5 3
ABDOMINAL PAIN BLURRED VISION 1
ADVICE ONLY 94 101
ALLERGIC REACTION 1
ALTERED MENTAL STATUS 1
BACK PAIN 1
BLOATED 1
CHEST INJURY 1
CHEST PAIN 5
CONSTIPATION 1 1
COUGH 4 1
DENTAL PAIN 1
DEPRESSION 1
DIARRHEA 6 3
DRUG OVERDOSE 1
DYSURIA 1
FACIAL PAIN 1
FATIGUE 2 2
FEVER 8 10
FEVER POST CHEMO 1
FEVER CHEST PAIN 1
FEVER DIARRHEA 1
FEVER SORE THROAT 1
FEVER URI 1
FLANK PAIN 1
FOLLOW-UP 1
FOOT SWELLING 1
HAND INJURY 1
HAND PAIN 1
HEADACHE 1 1
HEMATURIA 1
HERPES ZOSTER 1
HYPERGLYCEMIA 1 2
Care Companion: Kidney Transplant
• 12-week interactive care plan for post-kidney transplant patients
• Guides patient through post-transplant recovery
• Empowers patient to be engaged in post-transplant care
• Allows patient’s care team to remotely monitor patient
• Seeks to reduce readmissions by notifying patient’s care team of abnormalities sooner
• Aim to develop 2.0 version!
Transplant Continuum of Care
One-Day
ClinicProtocolized
CareStandardized
ORPathways One-Path
Optimal Hospital
MyChart Bedside
Digital Education
Epic Care Companion
Ochsner On-Call
Video Visits
Liver Transplant 3-Year Quality Trend
Quality Graph 1 (RAMI) Quality Graph 2 (ECRI)
“Saving the world, one organ at a time” – A. J. Cohen