Evidence Based Value Analysis:

An Objective Assessment of Costs

Charlotte Guglielmi MA,BSN,RN,CNOR

Perioperative Nurse Specialist

Beth Israel Deaconess Medical Center

Boston, MA

Adam Robinson BS

Manager, Field Operations

Covidien

Disclosures

Charlotte Guglielmi

None

Adam Robinson

Covidien

BIDMC at a Glance

318,335

Radiology Visits

6,100 Full-Time Employees(Excluding Research)

621 Licensed beds

25,997Surgeries

41,125 Inpatient Discharges

Level 1 Trauma Center Roof-top heliport

4776 Births

524,521 Outpatient

Clinical Visits

56,589

Emergency Department

Visits

22, 035 Out patient

GI procedures

3,4998

Cardiac

Catheterizations

22,345

Radiation Oncology

Procedures

Perioperative Services

o Overall

• 400 FTE

• Budget $75 million (Staff - $35 million & Supply $40 million)

• Academic Teaching Center with Level 1 Trauma Center

• 3 Operating Suites – 40 Rooms

o 25,997 Surgeries

• All adult services except heart & lung transplants

o Peri-Anesthesia

• 3 PACUs & Pre-op Areas as well as a PAT Clinic

o CPD

• 3 sites servicing ORs, L&D and 74 clinics

• Items processed in 2012 = 243,000

The Value Analysis Enablers

• 1996 – Merger between Beth Israel and Deaconess

Hospitals

• 2002 – Financial Crisis

• 2004 – Financial Turnaround

• 2010 – GPO Conversion

• 2012 – Regional Purchasing Coalition

Challenges

• Emotional product categories

• GPO provided numerous opportunities

with attractive savings targets

• Resource constraints to implement

• New Product Requests

Too many requests, not enough resources

The Evolution of Value Analysis

2002

Resource Management

1. Cost containment

2. Cost reduction

2010

Clinical Quality Value Analysis (TM)

1. Non-salary cost reduction

2. GPO conversion/RPC

2012

Evidenced-based Value Analysis

1. Clinical Evidence

2. Clinical Benefit

3. Cost Impact

Evidenced Based Value Analysis• Cross Functional, High Performance Team• Product Request Process

– Evidenced based• Statistically significant observation• Published Data

– Preference versus Consensus

• Savings Initiatives– Create a Project Plan– Cultivate executive support by linking initiative to

Institutional Objectives

• Consistent Application of Value Analysis Tools

Creating the Cross-Functional TeamFunctional Roles

Physic ian Nursing Administ rat ion

Surgeon Associate Chief Nurse Business Director

ENT Perioperative Services

Co-Chair Co-Chair Co-Chair

Surgeon Nurse Manager Director, CQVA

Ortho East & West OR

Surgeon Nurse Manager Clinical Contract Manager

OB-GYN Cardiovascular

Nurse Specialist Materials Manager

Perioperative Services

East Campus Clinical Advisors

ENT/Cysto/GYN/GU/Ortho/PlasticFinancial Analyst

West Campus Clinical Advisors

CV/Ortho/Neuro/Thoracic/Bariatric

Leadership

Redefining the Processassess current state

Redefining the Process“fast track” requests that do not raise costs

The Role Clinical Evidence• Devise a methodology to stratify value of clinical

evidence

• US Preventative Services Task Force (1)

– Level I: Evidence obtained from at least one properly designed randomized

controlled trial.

– Level II-1: Evidence obtained from well-designed controlled trials

without randomization.

– Level II-2: Evidence obtained from well-designed cohort or case-control analytic

studies, preferably from more than one center or research group.

– Level II-3: Evidence obtained from multiple time series with or without the

intervention. Dramatic results in uncontrolled trials might also be regarded as this

type of evidence.

– Level III: Opinions of respected authorities, based on clinical experience,

descriptive studies, or reports of expert committees

Clinical Acceptability vs Preference

• Significant Savings Opportunity

• One or more surgeons adverse to change

• Acceptability

– What do you prefer?

– What can you use?

Clinical Acceptability vs Preference

• Develop an Evaluation Tool– Engage clinicians and/or vendor to develop an

evaluation

– Three Level Lickert Scale • Disagree (“0”)

• Neither Agree or Disagree (“1”)

• Agree (“2”)

– Engage all clinical touchpoints• MD’s

• RN’s

• ST’s

• Ensure you survey clinical acceptability!

Case Studies

• Standardization of Hemostasis

• Qualifying Instrument Purchases

• Trocars

• Managing Waste

Case Study #1

Hemostat Standardization

• Project Charter

• Savings Goal – 20% cost reduction

• Clinical Evidence/Application

• Action Plan

• Results

PROJECT CHARTER

Project Name: Standardization of

Hemostasis Products

Project Leader:Chip McIntosh

Project Sponsor: Charlotte Guglielmi

Goal: Reduce spending on hemostasis agents by 20% from the current spend

Links to Institutional Goals:- Meeting/exceeding operating budgets- Improve reliability through standardization- Maximize efficient utilization of staff, equipment & supplies

Problem/Opportunity:There are multiple hemostasis agents currently used in our ORs purchased at a spend rate of $900,000/year. The greatest opportunity for improvement and standardization is in neurosurgery, ortho spine and then cardiac surgery. This team will review costs and evidence for agents currently used.

Scope: East and West ORsProject Completion: 12/31/2013

Suggested Approach:1. Look at lists of all agents for Surgicel and Surgiflo to review all hemostatic agents currently used at BIDMC2. Review Instructions for Use (IFUs) to determine appropriateness of applications by surgeon and services3. Consider reducing the number of products and sizes4. Identify specific surgeon use for products 5. Identify which agents are used by a single service

Hemostat Cohort

Description Name Size (cc)Cost per unit of

purchase

Cost per CC

1

Open repair of large vessels as an adjunct to staples or sutures.

Bioglue5 $$$ $$$$

10 $$$$ $

Fibrin Sealant adjunct to hemostatis Evicel Fibrin2 $ $$$5 $$ $$

2If hemostasis cannot be achieved by ligation or pressure

Surgifoam

12 $ $$$50 $$ $$

100 $$$ $

3

Used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control areimpractical or ineffective

Surgicel Absorbable 207 $ $

Nu Knit Surgicel 348 $$ $$

Hemostat Surgicel Fibrillar

103 $$$ $$$

Value Analysis

Proposed solutionHemostatic

AgentAction Rationale

Savings Estimate

EvicelStandardize

to 2 cc

1. Reduce waste - 4 cc is generally used when a 5 cc is pulled2. Less Inventory3. Less confusion for staff

$15,200

BioglueConvert

to Evicel 2 cc

1. Less Inventory2. Less confusion for staff3. Evicel ~ 1 yr to break down vs Bioglue ~ stays intact for life

$18,000

SurgicelConvert

to NuKnit

1. On aortic procedures, 74 units of Surgicel are routinely used2. Surgeons have evaluated NuKnit and agreed to use 5 units of NuKnit3. All agents are bacteria static and absorb within ~ 2 weeks

$188,000 -$564,000

SurgifoamEliminateextra small Surgifoam

1. Only used 27 times in past year2. Has expired on the shelf3. Highest cost/cc4. Replaced by larger sizes

Case Study # 2

Instrument Standardization

• Project Charter

• Savings Goal – 20% cost reduction

• Clinical Evidence/Application

• Action Plan

• Results

PROJECT CHARTER

Project Name: Eye Service Instrument

Standardization and IUSS Reduction

Project Leader:Deb Martinez

Charlotte Guglielmi

Project Sponsor: Elena Canacari

Goals:1. Reduce IUSS rate of 27-44% to 2-5%2. Reduce # of kits and instrumentation

Links to Institutional Goals:- Improve reliability through standardization- Maximize efficient utilization of staff, equipment & supplies

Problem/Opportunity:Instrument kits are no standardized. Unused instruments in kits are leading to wasted process, set-up, and count times. Number of kits may not be adequete to support case volume. Eliminating unused instruments and establishing an adequete instrument/kit inventory could reduce IUSS.

Scope: East ORsProject Completion: 5/17/2013

Suggested Approach:1.Develop methodology and tools2. Recommend instrument acquisition to reduce IUSS3. Template process to spread the learning

Value AnalysisIdentify Instruments Used

Proposed Solutionreduce inventory

Analyze Instrument Utilization

• Remove Instruments that are not used

• Consider peel-packing low use instruments

Calculate

• Number of Kits needed to properly clean and sterilize instruments in CPD rather than using IUSS

Value AnalysisCalculate Average Turnover Time

Proposed SolutionUse evidence to justify purchase

CPD Time

Determine time needed by CPD to properly clean and sterilize instruments and deliver to OR

Case Time

Use representative or average case times to calculate the

number of kits required

Decision to Purchase

If time study justifies, purchase additional kits as needed

Example Time Study

ResultsPurchased additional kits, dramatically reduced IUSS

• Purchase of two (2) additional BIOM Kits for a total of three (3) kits

• Over six month period, IUSS was only needed on four days – well within goal (2-5%)

1 1

2

4

3

5

3

1

2 2

3 3

2

3 3

4

2

3

1 1

2

111

3 3

4

1 1 1

0

1

2

3

4

5

6

IUS

S C

yc

les

Date

Staff Reinforcement

Maintain a Performance ScorecardMonitor Process Towards the Goal

40%

27%

44%

38%

61%

30%

17%

12%15% 14%

10%8%

4%

14%

9%

0%

10%

20%

30%

40%

50%

60%

70%

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

IUSS Rate

July IUSS rate less BIOM would have been 7.6%

Oct 7: Received Dr. Meilkie's instrumentation

June: If Dr. Mielki uses the new kits & the kits were here, the June IUSS rate would have been 2.9%

Only 3 unidentified loads in May - unlikely any or all were eye loads

61% Feb:Log sheets were implemented on 2/1 w/ability to track loads to service lines. [Data was previously under-reported.]

GOAL: 2-5%

March 25: Place in service 5 Phaco Extras

Nov: only 54% of the 13 loads had accurate documentation

Feb 22, 2013: Start Team

Dec: 4 unidentified loads that might be eye

Staff Feedback

“Since I started working on this

project, when I see a log that is

incomplete, I seek out my colleague

who ran the IUSS load and have them

complete the log.”(comment from RN team member 9/2013)

Leverage the Experience

• Service by Service Review of IUSS

• Apply the metrics to requests for addition instrument purchases outside of annual budget

• Apply the metrics for projected service line growth

Case Study # 3

Trocar Standardization

• Project Charter

• Savings Goal – 20% cost reduction

• Clinical Evidence/Application

• Action Plan

• Results

Project CharterProject Name:

Trocar Standardization

Project Leader:Chip McIntoshAdam Robinson

Project Sponsor: Chris Awtry

Goals:1. Reduce trocar costs by leveraging GPO/RPC contracting2. Increase utilization of lower cost sleeves for alt port sites

Links to Institutional Goals:- Improve reliability through standardization- Meeting/exceeding operating budgets- Maximize efficient utilization of staff, equipment & supplies

Problem/Opportunity:90 surgeons use 11,000 trocars per year at a total cost of $467,000. Five different types of trocars are used, manufactured by two companies. The team will use evidence and enduser feedback to determine clinical acceptability of standardization.

Scope: East ORsWest ORsProject Completion: 6/30/2013

Suggested Approach:1. Analyze potential impact of GPO/RPC Contract2. Through surgeon analysis of the clinical evidence, develop patient selection criteria3. Implement recommendations 4. Track progress to goal

Value Analysis

Trocar Cohort

Description NameUtilization

ShareSleeve Savings

Total Trocar (Sleeve/Ob)

Savings

1 Radially Expandable Versastep 80% $$$ $$$

2 Bladeless Optical Versaport Optical 0% 77% 48%

3 Bladeless Versaport 8% 83% 54%

4 Bladed Optical Visiport 8% n/a 21%

Physician Review of Evidence• Cross Functional Group of Surgeons across

several institutions reviewed published clinical evidence

• “85+%” of cases can be safely done with bladeless trocars

• Exceptions include patients with the following risk factors:

• Morbidly obese patients (BMI > 40 kg/m2)

• Previous abdominal surgery with strong suspicion of adhesions

Internal Messaging to Clinicians

• Describe the focus of the initiative include clinical evidence, usage, spend, savings potential Name a surgeon champion

• Present the savings strategy• Single vendor• Conversion away from high cost trocars

• Detail exceptions• Morbidly obese patients (BMI > 40kg/m2)• Previous abdominal surgery with strong suspicion of adhesions

• Outline the process to secure an exception• Provide opportunities to learn about products• Be clear about where to take clinical concerns• Provide a strategy to gather feedback through the process

• Reinforce with projected savings and evidence• Implement

Exemption Requests

Analyze the Current Utilization

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Applied Medical Bluntport Versaport Versastep Visiport

Preferred Trocar as of February 2012n = 28

Post-Conversion Feedback

3

4 2

1 21

1

43

12 1

4

78

5

54 5

2

66

1

13 21 2 4 3

0

5

10

15

20

25

30

Versaport15mm

bladeless

Versaport12mm

bladeless

Versaport5mm

bladeless

Versaport5mm

bladelessoptical

Versaport15mmbladed

Versaport12mmbladed

Versaport5mm bladed

Do Not Use Unacceptable Barely acceptable Acceptable Very Good Superior

Address ConcernsClinically Acceptable vs. Clinically Preferred

Yes36%

No32%

Not a concern32%

Would you use a bladed trocar in lieu of a bladeless trocar to reduce insertion force?

Case Study # 4

Managing Wasted Items

• Project Charter

• Savings Goal – 20% cost reduction

• Action Plan

• Results

PROJECT CHARTERProject Name:

Intraoperative Waste Reduction

Project Leader:Charlotte Guglielmi

Project Sponsor: Nick Foundas, Elena Canacari

Goal: Reduce incidence of intraoperative waste. A 20% reduction would save $110,000

Links to Institutional Goals:- Meeting/exceeding operating budgets- Maximize efficient utilization of staff, equipment & supplies

Problem/Opportunity:Waste currently accounts for $550,000/year in lost expenses. The greatest opportunity for improvement is in orthopedics and general surgery. This team will review means for data capture and intervention to reduce rate of waste

Scope: East and West ORsProject Completion: 12/31/2011

Suggested Approach:1. Implement data capture in intraoperative record to improve insight into waste reasons2. Review data by service, work with clinical staff to understand root cause3. Educate Surgeons4. Open high cost items only if needed

System Architectureenable data visibility

Value AnalysisService FY08ORTHO $259,631CARDIAC $67,435NEURO $58,155GEN $42,597PLASTIC $25,978PODIATRY $21,662GYN $16,189VASCULAR $14,418TRANSPLANT $13,449UROLOGY $11,008EYE $8,659THORACIC $6,565ENT $4,109DENT\ORAL $392

Waste by Surgeon

Surgeon OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP YTD

C

ol

u

m

n1 Total Spend Waste %

Surgeon A $1,022 $1,665 $4,897 $4,292 $855 $4,125 $4,467 $3,625 $14,416 $4,030 $1,229 $5,040 $49,663 $3,066,103 1.6%

Surgeon B $1,546 $1,947 $2,058 $2,839 $1,567 $1,118 $623 $817 $2,648 $1,607 $1,055 $298 $18,122 $681,412 2.7%

Surgeon C $3,608 $563 $4,096 $1,371 $1,387 $744 $1,104 $3,281 $148 $868 $17,168 $1,102,998 1.6%

Surgeon D $10 $160 $321 $139 $14,197 $6 $876 $78 $185 $15,973 $1,215,753 1.3%

Surgeon E $1,088 $919 $284 $831 $319 $0 $26 $4,082 $3,474 $514 $2,946 $14,483 $1,241,204 1.2%

Surgeon F $261 $100 $100 $456 $91 $1,815 $960 $72 $161 $3,302 $4,400 $88 $11,804 $825,065 1.4%

Surgeon G $1,739 $154 $423 $1,748 $795 $553 $1,032 $532 $439 $387 $996 $1,033 $9,831 $723,161 1.4%

Surgeon H $4,860 $3,996 $10 $904 $2 $7 $9,779 $92,700 10.5%

Surgeon I $1,067 $8 $160 $1,005 $2,644 $2,082 $473 $1,380 $72 $8,892 $1,127,453 0.8%

Surgeon J $1,263 $1,463 $140 $37 $106 $295 $355 $1,153 $813 $703 $1,192 $388 $7,908 $500,389 1.6%

Proposed Solution

• 10 Surgeons account for half the waste

• Focus on Orthopedics and GYN services

• Show data to surgeons– Control message through surgeon champion

– Deidentify to remove “blame”

• Action Plan– High cost devices unopened until needed

– Improve intraoperative sizing

Results

$0

$200,000

$400,000

$600,000

FY08 FY09 FY10

$32,000Reduction

$135,000Reduction

Thank you!

Questions?