From “Solution Shop” to “Focused Factory ” in Cardiothoracic Surgery

David J. Cook, M.D. Professor, Department of Anesthesiology

Mayo Clinic College of MedicineCenter for the Science of Healthcare Delivery

Has no relevant financial relationships to disclose.

Will not be discussing off-label/investigative use(s) of commercial devices.

Case Study: The Medicare Gap in CVS

• Reduce cost per case by 20%

Operational analysis: Stakeholder analysis

CV Surgical Care Model:

“Who’s patient is this?”

CV Surgical Care Model:

“Who’s patient is this?”

Unwarranted variation (total variable costs):

Actual Hours Per Day of CV Surgery (Nov 2, 2009 to Jan 29, 2010)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

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90.0

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DateH

ours

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ery

Daily matching demand and capacity

ICU length of stay (routine)

Surgical Hours

Duration UCI

Christensen HBS: Typology of Business Models:

Business Model example Payment model

Solution ShopUnstructured problems, undifferentiated complexity, expertise and intuition

Consulting, architecture, law, medicine

Fee for service

Value-adding Process (VAP)(via Focused Factory)

Process application increases value,manage product (output)

Refining,Manufacturing,Healthcare (surgicenter, imaging, lab facilities)

Pay for outcome

FFS

Facilitated network

Manages exchanges: services, data or information

Cable services, insurance, banking

Membership, subscription, transaction fees

Solution Shop Model:

Unstructured problem:Decision making by ‘expert”Unique knowledge, trainingExperience and intuition

Value-Adding Process Model:

Solution Shop Model:

• Create a standardized, protocol-based pathway across care geographies (Focused Factory)

• Support delivery via communication, information-systems, geography

• Empower bedside providers and shift decision-making

Anesthetic managementHemodynamic DripsBlood Component TherapyAntibiotics Wean mechanical ventilation

Fluid managementWean hemodynamic supportRemove “lines”

UCOAmbulationChest tubes outPacer wires out

Product and Process Specifications

Informed/empowered bedside provider

Process: Urinary Catheter Out (UCO)

©2011 MFMER | 3123886-11

19218016815614413212010896847260483624120

MedianMean

70656055504540

19218016815614413212010896847260483624120

MedianMean

70656055504540

95% Confidence I ntervals

95% Confidence I ntervals

Cook, Thompson et al., Am Journal of Medical Quality Aug, 2013

15614413212010896847260483624120

Median

Mean

4038363432302826242220

15614413212010896847260483624120

Median

Mean

4038363432302826242220

95% Confidence Intervals

95% Confidence Intervals

Vertical histograms showing distribution for duration of ICU length of stay control (2008-upper panel) and intervention (2012- lower panel) groups (n = 769 for each group). Median and mean values as well as 95% confidence intervals are shown below respective panels.

Resource Utilization: ICU Length of Stay

Cook, Pulido et al. Annals of Surgery Dec. 2014

UHC: Total Variance from Predicted LOS (DRG’s 216 – 221)

2012

2008

Variable§ Pre (2008)(N=769)

Post (2012)(N=769)

P-value*

Initial ventilation duration (h) † Re-intubated Initial ICU length of stay (h) Readmission to the ICU

9.3 (6.2, 14.5) 

5 (1%) 

26.3 (23.6, 44.3) 

19 (3%)

6.3 (4.7, 9.2) 

1 (0%) 

22.5 (20.0, 25.8) 

18 (2%)

<.001 

0.22 

<.001 

1.0

* P-values are from rank-sum tests for continuous variables and Fisher’s exact tests for categorical variables. †There were 14 missing values for initial ventilation duration. § Values are n (%) for categorical variables and median (q1, q2) for continuous variables .

In-Hospital Safety:

Cook, Pulido et al. Ann Surg December 2014

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2008 2012

Hospital Cost

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2008 2012

OR Cost

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40,0

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ICU

Cos

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2008 2012

ICU Cost

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,000 40

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PCU

Cos

t

2008 2012

PCU Cost

All costs were reported in 2012 U.S. Dollars.

ICU=Intensive Care Unit; PCU=Progressive Care Unit; OR=Operating Room.

Cost Distribution in 2008 and 2012

Distribution of costs pre- and post-implementation of focus factory model is shown. The red line of in each box indicates the median cost; the lower and upper border of the boxes show the 25th and 75th percentiles of the cost distribution, while the stars (*) indicates the outliers. (n=769 per group).

14-15% reduction In cost

**

**

Cook, et al. Health Affairs: May2014

Process metrics → Outcome MetricsCook, et al. Health Affairs: May2014

COST

Cook, et al. Health Affairs: May2014

2012 data

Observations/Conclusions:

• Health care delivery provides a product as a result of a process (business model)

• Complexity and unwarranted variation drive poorer

outcomes and higher cost

• Specifications can be established for both process and product

→ Predictability

Cost/Complexity Distribution in Populations:

• Very different practice (business) models

• Implications for:

decision model (expert or algorithm) work model practice improvement

normative data on process, outcome and cost

Learning Objectives:

By the end of this session, participants should be able to: Understand the origins of unwarranted

variations in surgical care Understand means to reduce unwarranted

variations Understand the implications of the

distribution of cost and care complexity for populations of surgical patients