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IHI Expedition:Partnering Quality & Finance Teams to

Improve Value

Kathy Luther, RN, MPM

Jill Duncan, RN, MS, MPH

These presenters have nothing to disclose

Introductions

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Expedition Coordinator

Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor’s in Health Science from Northeastern University and brings her interest in health and wellness to IHI’s Health and Fitness team.

Expedition Director, Jill Duncan

Jill Duncan, RN, MS, MPH, Director, Institute for Healthcare Improvement (IHI), is responsible for leading the strategic planning and daily operations for IHI’s Impacting Cost + Quality initiative as well as serving as faculty for IHI’s Leading Quality Improvement: Essentials for Managers. Jill is also the Director for a variety of new IHI Expedition programs in 2012-13. With nearly 20 years of clinical nursing experience, Jill draws from her learning as a Clinical Nurse Specialist, pediatric nurse educator and front line nurse. Her clinical interests have developed through experiences in a variety of settings including Neonatal ICU, pediatric ER, clinical research and Early Head Start health programming. Ms. Duncan has contributed to a variety of collaborative publications in The Journal of Pediatricsand she is co-author of Pediatric High-Alert Medications: Evidence-Based Safe Practices for Nursing Professionals and Stressed Out About Your Nursing Career.

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Faculty Leader, Kathy Luther

Katharine Luther, RN, MPM, Vice President, Hospital Portfolio Planning and Administration, Institute for Healthcare Improvement (IHI), is responsible for furthering IHI's work to help hospital leaders and staff achieve bold aims. Key to this work is developing strategic partnerships that leverage innovation, pilot testing, implementation, and continuous learning across organizations, systems, professional societies, and entire countries. Previously, she served as Executive Director at IHI, designing new programs to impact cost and health care quality. Ms. Luther has over 25 years of experience in clinical and process improvement, focusing on large-scale change projects and program development, system improvement, rapid cycle change, developing and managing a portfolio of projects, and working with all levels of health care staff and leaders. Her clinical experience includes critical care, emergency room, trauma, and psychiatry. Prior to joining IHI, she held leadership positions at the University of Pittsburgh Medical Center, MD Anderson Cancer Center, and Memorial Hermann–Texas Medical Center. She has experience in Lean and is a Six Sigma Master Black Belt.

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What is YOUR goal

for participating in this Expedition?

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.

• Train your middle managers to effectively lead quality improvement initiatives.

. . . and much, much more for $5,000 per year!

• Visit www.IHI.org/passport for details. To enroll, call 617-301-4800 or email improvementmap@ihi.org.

Where are you joining from?

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Agenda

• Welcome

• Expedition overview

• Today’s health care environment & its impact on the value of care

• The science of improvement – What is its role in improving value in health care?

• Getting started

• Building a team around improving value

• Two case study examples

• Homework for next call

What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

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Ground Rules

We learn from one another – “All teach, all learn”

Why reinvent the wheel? - Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

Expedition Aim

The focus of this program is improving the quality of health care while finding the waste in health care systems and removing it. Teams will build a diverse portfolio and develop new partnerships between clinical and financial

leaders in the endeavor.

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Expedition ObjectivesParticipants will be able to . . .

• Identify potential cost reduction quality improvement opportunities for your organization.

• Prioritize high-return ideas and map to energy grid for your organization.

• Develop a set of quality metrics as well as a financial measurement system to capture savings across your portfolio.

• Obtain the tools and confidence to build and execute on a portfolio of interventions to achieve results.

• Plan small tests of change you can test throughout the Expedition.

Today’s Guest Faculty

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Kevin Little, PhD

Kevin Little, PhDIHI Improvement AdvisorImproving Ecological Design. LLC

Presbyterian Healthcare Services

Susan Quintana, RN, MSN

Manager, Quality Program Support

Quality Institute

Presbyterian Healthcare Services

Kay Armstrong

Financial Project Manager

Women’s, Children’s & Surgery Service Lines

Presbyterian Healthcare Services

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Northeast Health

Norman Dascher, FACHE Chief Executive Officer

Daniel Silverman MD CMO Troy Division SPHP

Scarlet Clement Executive Director, Behavioral Health Services, Troy Division

Making Sense of It All

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Parallel work: Leadership for changing health care

We are

here!

Waste Through Different Eyes

Patient

Nurse

Physician/Surgeon

CFO

• Unnecessary repetition (exams, histories, investigations)

• Longer stays

• Avoidable complications

• Higher health care costs; risk of being uninsured

• Time away from the bedside

• Searching for equipment• Documenting• Chasing down consults/results

• Time and unpredictability

• Unable to start operations/procedures on time• Operating/procedure list over-runs

• Reduced margins

• Continuous financial pressure, and need to make “cuts”

• Frustration that QI promises savings, but rarely delivers

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How is this different from traditional cost-cutting?

• Requires process literacy and redesign

• Holds quality the same or improves it

• Needs different ways to categorize costs and transparency

• Can unite people in a cause to control health care costs

Our Vision

From . . .

• Arbitrary, reactive cutting disconnected to the process of care delivery

To …

• A systematic, targeted set of interventions designed to simultaneously

─ Improve patient outcomes

─ Control costs

─ Increase caregiver satisfaction

• Better dialogue and mutual appreciation between clinicians and managers

• Ability to engage caregivers in dialogue about allocation of savings, when realized

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• Evaluate Cost & Quality Impact

• Prioritize Projects and Manage Organizational Energy

• Create a Portfolio of Projects

• Solve Problems and Execute PDSA Cycles

• Measure and Monitor Results

PRIMARY DRIVERS SECONDARY DRIVERS

Reduce operating

expenses 1% per

year while continually

maintaining or

improving quality.

AIM

WILLAlign Enterprise

WILLEngage Staff, Physicians and Patients

IDEASIdentify Waste

EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste

• Establish True North Metrics (Big Dots)

• Align Waste Reduction Strategy Throughout Organization

• Align Systems for Efficiency

• Adopt Integrated Performance Measurement Systems

• Engage Staff in the What & Why of Value Delivery

• Establish Data & Feedback Loops

• Patient & Family Perspective of Waste

• Ensure a Safe Environment for Sharing Ideas

• Develop New Skills at All Levels

• Eliminate Clinical Quality Problems

• Optimize Staffing

• Maximize Flow Efficiency

• Manage Supply Chain

• Reduce Mismatched Services—overuse, coordination

• Reduce Environmental Waste (Healthy Hospital Initiatives)

Driver Diagram IHI’s Cost + Quality Collaborative Work

• Evaluate Cost & Quality Impact

• Prioritize Projects and Manage Organizational Energy

• Create a Portfolio of Projects

• Solve Problems and Execute PDSA Cycles

• Measure and Monitor Results

PRIMARY DRIVERS SECONDARY DRIVERS

Reduce operating

expenses 1% per

year while continually

maintaining or

improving quality.

AIM

WILLAlign Enterprise

WILLEngage Staff, Physicians and Patients

IDEASIdentify Waste

EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste

• Establish True North Metrics (Big Dots)

• Align Waste Reduction Strategy Throughout Organization

• Align Systems for Efficiency

• Adopt Integrated Performance Measurement Systems

• Engage Staff in the What & Why of Value Delivery

• Establish Data & Feedback Loops

• Patient & Family Perspective of Waste

• Ensure a Safe Environment for Sharing Ideas

• Develop New Skills at All Levels

• Eliminate Clinical Quality Problems

• Optimize Staffing

• Maximize Flow Efficiency

• Manage Supply Chain

• Reduce Mismatched Services—overuse, coordination

• Reduce Environmental Waste (Healthy Hospital Initiatives)

Driver Diagram IHI’s Cost + Quality Collaborative Work

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Partnering Quality and Finance Teams to Improve Value: Starting with Quality

A Look at the Model for Improvement

Kevin Little, PhD

Informing Ecological Design, LLC

This presentation is part of an on-line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.

Property of the Wisconsin Office of Rural Health.

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How can you get to your destination?

Your QI Framework

You should use the QI language and framework deployed in your health system.

Here’s a quick overview of the framework we use at the IHI, based on the Model for

Improvement.

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Example: Reducing Hospital Acquired Infections

St. John’s Regional Health Center, Springfield, MOImprovement Report on IHI website

http://www.ihi.org/knowledge/Pages/ImprovementStories/ReducingHealthcareAssociatedMRSAInfectionsonaSurgicalUnit.aspx

What are we trying to accomplish?

Aim: To sustain 30 percent reduction of surgical site infections (SSIs), bloodstream infections (BSIs), and healthcare-associated pneumonia (HAP) due to methicillin-resistant Staphalococcusaureus (MRSA) by focusing on prevention of transmission on 7C Surgical Unit. Sustain compliance at greater than or equal to 90 percent on process measures for reliable hand hygiene, contact precaution for isolation patients, and appropriate room cleaning/disinfections on 7C Surgical Unit. Achieve 98 percent compliance obtaining admission active surveillance cultures (ASC) in adult intensive care units (ICU), pediatric ICU, and the burn unit.

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How will we know that a change is an improvement?

MeasuresProcess Measures:

•% targeted patients with admission active surveillance culture collected

•% environmental cleanings completed appropriately •% patient encounters with compliance for contact

precautions •% patient encounters with compliance for hand hygiene

Outcome Measures:

•Days between MRSA infections •Rate of occurrence of MRSA SSI, BSI, and HAP per

1,000 patient days

What change(s) can we make that will lead to improvement(s)?

Hand Hygiene:

• Provide alcohol-based hand rub for patients on bedside table • Implement “hands up” campaign — the standard phrase or

action to use if you observe another co-worker NOT performing hand hygiene when appropriate

Contact Precautions:

• Identify isolation patients by placing a sticker on patient menu and placing in designated area for dietary staff

• Visual aid placed on isolation holders as a reminder to encourage hand hygiene prior to donning PPE

Room Cleaning and Disinfection:

• Identify clean equipment with red “door knocker” tag• High touch cleaning checklist provided to workers

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A useful idea & data drive change

The project ‘tipping point’ occurred when we began to culture hands and equipment of workers [see image at left depicting culture on worker's hand and culture on stethoscope equipment]

Performance Measures

Outcome Measure

Process Measures

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Questions we now know to ask

• What is the cost implication of reducing HAI?

─What is an appropriate financial model?

─How can we track $ impact over time?

─What dollars are “dark green?”

• What changes are on the horizon from payers that we need to prepare for?

The Model for Improvement

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Three Fundamental Questions for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What change can we make that will result in improvement?

A Test Cycle

PlanAct

DoStudy

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PDSA sub-steps

Act

• What changesare to be made?

• Next cycle?

Plan• Objective• Questions and

predictions (why)• Plan to carry out the

cycle (who, what, where, when)

• Plan for data collection Study

• Complete the

analysis of the data

• Compare data topredictions• Summarize

what waslearned

Do• Carry out the plan• Document problems

and unexpectedobservations

• Begin analysisof the data

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Aim Statement (Charter) with

goals (targets)

Description of Key

Measures

Change Concepts and Ideas

organized in a rational way

Tools you may use

PDSA Document forms

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Project Charter Date:

What are we trying to accomplish? How will we know a change is an improvement? Measurements that will be affected: Current Level 1. 2. 3. Initial Activities/Cycles (What changes can we make that could result in improvement?) 1. 2. 3. 4. 5. Originator:

People to Involve:

One page version

of PDSA template

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Repeated Use of the Cycle

Hunches Theories

Ideas

Changes That

Result in

Improvement:

After cycles have

demonstrated that

the change CAN

work, use more

cycles to help you

figure out how the

change WILL work,

every day

A P

S D

A P

S D

Investigation Demonstration Implementation

Project Progress1 – Charter established

2 – Activity, but no changes

3 – Modest improvement

ProjectName / Month

2011 2012

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

1) Example

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

4 – Significant progress

5 – Outstanding success

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Online ResourcesOn Demand

• On Demand Presentations feature streaming video synchronized with presentation slides. These presentations are available at no charge and offer in-depth training on key topics.

─ Science of Improvement White Board Videos (features Robert Lloyd, PhD)

─ An Introduction to the Model for Improvement (features Robert Lloyd, PhD)

─ Building Skills in Data Collection and Understanding Variation (features Robert Lloyd, PhD)

─ Delivering Value for Individuals and Populations (features Thomas Nolan, PhD)

─ Using Run and Control Charts to Understand Variation (features Robert Lloyd, PhD)

Improvement Methods

• Tools: The Institute for Healthcare Improvement has developed and adapted a basic set of tools to help organizations accelerate improvement.

• Tips for Effective Measures: Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement.

IHI Open School for Health Professionals

. We currently offer 17 online courses in the areas of quality improvement, patient safety,

leadership, patient- and family-centered care, and managing health care operations. We are

expanding our catalog and adding additional courses all the time. Each course takes 1-2 hours

to complete and consists of several lessons taking 15-30 minutes each. While the courses were

originally intended for students, we quickly saw substantial interest among health professionals

looking to develop their quality and safety skills. To access the courses, we offer 12-month subscriptions that cost $250 for one person, and start at $3,000 for organization access.

User Range Price (12 months)

Individual $ 250

Up to 50 $ 3,000

51-100 $ 4,500

101-250 $ 7,500

251-500 $ 11,500

501 + Contact us with

number of participants

Purchasing an organization subscription gives a key contact from your organization access to our

reporting feature. This allows you to track participants’ course and lesson progress, as well as their assessment scores and the date/time of completion.

Continuing education credits are available for nurses, pharmacists, and physicians. Each course

carries between 1 and 2 hours of credit, for a total of 22.5 credit hours. We have also recently

been approved by NAHQ to provide Certified Professional in Healthcare Quality (CPHQ) credits.

If you are interested in purchasing a subscription, you can go directly to www.ihi.org/lms or

contact openschool@ihi.org. If you would like to try a few sample lessons first, please visit

www.ihi.org/lms/home.aspx/SampleLessons.

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References

• Don M. Berwick (1996), “A Primer on Leading the Improvement of Systems,” BMJ, 312: pp 619-622.

• T. W. Nolan and L. P. Provost (1990), “Understanding Variation”, Quality Progress, Vol. 13, No. 5.

• “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.

• The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed (2009) Gerald J. Langley, Ronald Moen, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost

Partnering Quality and Finance Teams to Improve Value: Getting Started

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Select an Approach

Approach Service Line Organization Wide

Description Condition based Throughout organization

Examples • Cardiac surgery• Orthopedic procedures

• Projects in all departments/areas

• Clinical and administrative (admitting, environmental services, food service)

Tools Value stream Flow mapsWaste Identification Tool (WIT)

Waste Identification Tool (WIT) Organization-wide engagement

• Identify waste- develop financial models-• Identify projects – execute projects• Track savings – manage quality

Set an Aim

• Aim in $$$

─Focuses the work

─Assists with prioritizing projects

• Aim in $$

─1-3% of total operating budget

─1-3% of service line budget

─1-3% -cost per case/ per member per month

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Examples

Portfolio Management• Aim of Portfolio:

• Current Portfolio Projects:Project Name Projected

Savings Savings to

DateQuality Metrics

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

Totals $ $

Percentage of Operating Budget

Savings in US Dollars

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Projected Savings Estimated Savings To date

1%

Anne Arundel $3,397,000 $1,176,140 $5,000,000

Baptist - Corporate $7,989,145 $5,034,658

Baptist - DeSoto $ 2,882,000 $ 1,479,680 $2,300,000

Baptist - Memphis

Blessing $110,000 $10,000

Claxton Hepburn $1,195,147 $800,000

Georgetown $700,417 $20,000 $2,400,000

Hackensack Univ Med Ctr $1,000,000 $1,100,000 $11,000,000

Highland Hospital $109,861 $950,000

Hotel Dieu Hospital

Interim Homecare

Kenmore Mercy $411,000 $1,200,000

Kingsbrook Jewish Med Ctr $3,500,000 $1,814,450 $2,500,000

King’s Daughters $6,000,000 $4051794 $6,000,000

Markham Stouffville $254,000 $236,826 $1,500,000

Northeast Health $2,000,000

North Mississippi Med Ctr $1,030,161 $203,548 $1,900,000

Ocean Medical $ 454,200 $ 183,186 $2,200,000

OSF St. Francis $ 16,938,000 $ 3,682,350 $8,103,970

Presbyterian - SSL $147,607 $24,798 $1,000,000

Presbyterian - WSL

Ryhov Co Hospital $1,001,000 $331,000 $600,000

Stonybrook Univ Med Ctr $9,090,000

Assessing Organizational Capacity or “Energy”

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Assessing Capacity (“Energy”)

• Who needs to be involved?• How much energy do they need to

contribute?• Do we have areas of the organization that

are over extended?

Energy Grid Template

Priority #1 Priority #2 Priority #3 Priority #4

De

pa

rtm

en

ts / S

up

po

rt S

erv

ice

s

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Organizational Energy Grid

1. List the organizational priorities along the top of the energy grid.

2. List all organizational departments down the left side of the grid.

3. Type “high” in the grid where a high level of involvement is required from each support service or department and “low” in the grid where a low level of involvement is required. It is critical that all areas that are associate with the work are identified.

4. Review for bottlenecks or overload.5. Determine feasibility of moving forward with all of

the priorities.6. Make necessary adjustments.

Organizational Energy Grid Exercise

• Where do we have bottlenecks due to excessive requirements for energy?

• Where do we have under use of energy which creates an opportunity to take on additional work?

• Who needs to be involved on the team working on the initiative?

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Build Teams: Clinician & Finance

Finance

• Spreadsheets

• Aggregate numbers

• MS- DRGs, icd-9s

• Averages, means

• Services, service lines

• Payor class

Clinicians

• Charts

• Patients—one-at-a-time

• Conditions

• “Worst case”

• Complicating factors

• Social factors

Engaging Physicians-Clinicians

• Describing patients selected

• Understanding costs – physicians, clinicians

• Understanding patient characteristics-clinicians-finance

• Begin to build financial models

─More on this in upcoming sessions

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Case Study Examples

• Northeast Health

─Alignment across the organization

─Multiple strategies to engage staff & patients

─ Introduction to using a Waste Identification Tool

• Presbyterian Healthcare Services

─Alignment across service lines

─Attention to organizational capacity

─Partnership between clinical and financial leaders

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USING MULTIPLE STRATEGIES TO ENGAGE STAFF IN OUR PATIENT QUALITY EFFORTS

On the Call

� Norman Dascher, FACHE, Chief Executive Officer

� Daniel Silverman MD, CMO Troy Division SPHP

� Scarlet Clement, Executive Director, Behavioral Health

Services, Troy Division

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Northeast Health, an Integrated Delivery Network in the Capital District of New York, began its IHI journey in 2004

In October 2011, Northeast Health became a founding member of St. Peter’s Health Partners

What IS

What is St. Peter’s Health Partners?

St. Peter’s Health Partners is the parent corporation formed from the merging of three health systems, Seton Health, St. Peter’s Healthcare Services and Northeast Health. The merger creates the regions largest and most comprehensivenot-for-profit network of health care service providers which includes:

� Albany Memorial Hospital- Albany

� St. Peter’s Hospital- Albany

� Samaritan Hospital- Troy

� Seton Hospital- Troy

� Sunnyview Rehabilitation Hospital- Schenectady� The Eddy system of continuing care- Region wide

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Portfolio Management

• Aim of Portfolio: $ 2M saving in System Operating Expenses

─ Current Projects:

�Antibiotic Stewardship

�1:1 Reduction on Behavioral Health

�Decreasing Blood Utilization

�Supply Cost Savings

�Point of Service Collections

�Waste Tool Use by Front Line Staff

� ICU Sedation, Mobility, Delirium

Portfolio Management (sub-set of projects)

Project Projected Savings

Savings to Date IncreasedRevenue

Blood Utilization 300K in 1st year 320 K in 10 months

1:1 utilization in Behavioral Health

40K a year 37K in 8 months

Point of Service co -pay collection

20% increase 188K

Waste Tool No projection 150 K

AntibioticStewardship

58K 72Kplus 300K cost avoidance

Supply Costs 284 K

ICU increase mobility & sedation

No projection 52 K

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Primary Drivers Secondary Drivers Projects

Dark Green Dollars

Reducing Operating

Budget by 1% a year

Clinical Quality

Problems

Staffing

Flow

Supply Chain

Mismatched

Services

Mass Purchasing

Pharmaceuticals

Wasted Materials

Standardize purchasing

Base utilization on best practices

Purchase wholesale instead of retail

Switch from brand-name to generic

Prescribe based on industry norm

Turnover/Recruitment

Premium Pay

Work Days Lost Due to

Injury/Illness

Achieve optimum performance levels

Use a flexible staffing model

Reduce agency usage

Implement an acuity identification system

Use appropriate patient lifting techniques

Malpractice claims

Coordination of Care

Adverse Events and

Complications

Reduce settlements by changing process

when sentinel event occurs

Prevent infections (SSI, CLI, VAP)

Prevent Decubitus Ulcers

Prevent readmissions

Waste in Admin Services

End-of-Life Care

Unnecessary Procedures/

Hospitalizations

Stop denial rework

Stop services not adding value (ex.

unnecessary landscaping)

Improve chronic disease management

Stop performing outpatient services as

inpatient services

Match Capacity :Demand

Hospital Throughput

Ancillary Throughput

Redesign care management

Redesign ER processes

Redesign OR processes

Aim 1 Driver

Diagram

Continually improve quality

while reducing operating

expenses 1%/yr

Show respect

for people

Deploy a

system that

delivers value

and is

continually

improved

Align the

Enterprise

Develop and use core strategic metrics

Align strategy

Align systems

Measure performance

Create/maintain stable and standard processes

Identify and eliminate waste

Develop and use front-line data

Integrate value and improvement into daily work

Engage everyone in value delivery

Develop people

Ensure a safe environment

Build teamwork

Aim 2 Driver

Diagram

Primary Drivers Secondary Drivers

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Our Strategy

Use Big Dots, Big Dot Visual Management and Waste Tools to actively engage staff in the quality

and patient satisfaction experience

Three Strategies to Connect Staff to

Our Quality Efforts

1. Big Dots• Using Big Dots to sort and categorize our

patient quality and satisfaction efforts for our staff.

2. Visualize the Quality Goals• Creating a “Line of Site” between our staff

efforts and our Big Dot goals

• Active staff involvement in identifying the problem and participating in the solution

• Using the Waste Identification Tool

1. Patient Satisfaction

• Aim: Meet or exceed U.S. HCAHPS avg. every quarter

2. Safe Care

• Aim: Decrease Harm Events to Patients by 25%.

in 2012

3. Financial

• Aim: Identify and implement efforts to remove 1% of the operating cost from the 2012 budget.

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Big DotsCategorize and Focus the Quality Effort for Staff

Our Three “Big Dots”

1. Patient Satisfaction• Aim: Meet or exceed U.S. HCAHPS avg. every quarter

2. Safe Care• Aim: Decrease Harm Events to Patients by 25% in 2012.

3. Financial• Aim: Identify and implement efforts to remove 1% of the operating

cost from the 2012 budget.

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Big Dot Successes

• Mortalities decreased 6 out of the last 7 years (Safe Care

Big Dot)

• Decreased Central Line Infections, SSI and VAPS (Safe

Care Big Dot) Last VAP July of 2009

• Decreased Catheter related urinary tract infections by 73% (Safe Care)

• Saved over $1.2M in supply costs (Finance Big Dot)

Visual Management of the Big Dots

Create a Line of Site Between Our Staff Efforts

and Our Big Dot Goals

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Aim: Meet or

Exceed

National

HCAHPS Avg.

Every Quarter

Service

Excellence

Program

Patient Engagement

Staff and Physician

Communication

Rewards And

Recognition

Service Recovery

Rounding

Scripting

Collect Patient Perception

Prior to Discharge

Care Environment

Preventing Violence in

the Workplace

BIG DOT: Care Experience

Driver

Aim:Decrease Harm

Events to

Patients by

25% in 2012

Prevent

Hospital

Acquired

Conditions

Improve Care

Transitions

& Communication

Prevent Hospital Associated

infections – VAPS, CLABSI,

CAUTI, C. Diff, VRE, MRSA

Surgical Site Infections

Pressure Ulcers

Falls with Injuries

DVT/PE

Level 4 and 5 Medication Errors

Prevent Never Events

Medication

Reconciliation

Decrease

Readmissions

Flow Improvement

Privacy & Security of Health

Information

Big Dot: Safe Care

Driver

Driver

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FinanceAim- Identify &

implement programs

to remove 1% ($2M)

of operating

expenses in 2012

Improve Worksite

Safety

Supply Chain Projects

Improve Clinical

Documentation

Waste Tools

Big Dot - Finance

Projects based on waste

tool identification

Documentation Program

Physician Education

Meet Core Measure &

Regulatory Requirements

Yankee Alliance Supply

View and other projects

Antibiotic Stewardship

Decrease Blood

Utilization

Decrease incidents

and lost time

Waste ToolsStaff Participation on the Grand Scale

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Generic Waste Tool TemplateHOSPITAL WASTE IDENTIFICATION TOOL_Template

Campus__________ Department_________________________ Job Title of Person Completing: ________________________________ Instructions: Log the location, date and time and place a check mark in the appropriate column for the type of waste identified

WASTE TOPICS

Unit/ Area of Hospital Room Number (if applicable)

Date/ Shift

Other Waste

Identified

Comments

# Waste Topics Identified

(Optional) Total Observations

(Optional) % Waste

Environmental Services (Customized) Waste Tool

HOSPITAL WASTE IDENTIFICATION TOOL- EXAMPLE

Campus__Samaritan Department_Environmental Services Job Title of Person Completing: Environmental Services Associate_ Instructions: Log the location, date and time and place a check mark in the appropriate column for the type of waste identified

WASTE TOPICS (EXAMPLES)

Unit/ Area of Hospital Room Number (if applicable)

Date/ Shift Discharge

Log Books

not

Accurate

Flow

Delay

Isolation Procedure

not accurate

Nursing

Item not

Removed

Poor Infection

Control

Practice

Observed

Other Waste

Identified

Comments

509-A 12/13- D X X X

210-A 12/14-D X X X

601-B 12/14-D X X X

403-B 12/6-D X X X

# Waste Topics Identified

(Optional) Total Observations

(Optional) % Waste

*** Red column headings may be modified or customized to capture waste issues that are not listed.

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43

What Works and How it Works:Developing and Using the Optimal Waste Identification Tool

1. IHI Waste Tool templates were a good starting point but in many cases departments were eager to develop their ownWaste Tool templates.

2. While there is a temptation to create elaborate Waste Tool documents, simple, straightforward documents achieved greater staff participation.

3. Optimal Waste Tools were those created in staff meetings in collaboration with leadership.

4. Staff carry the Waste Identification Tools with them while at work and document problems they identify

5. Staff review their complted forms with their supervisors/ managers

6. Senior team reviewed each department’s Waste Tool Findings

How Implemented

• Education to Leadership and then to front line staff by Directors and VP

• Used by Clinical and Non Clinical Depts. –Med/Surg., Primary Care Sites, Behavior Health, Physicians, pharmacy, courier, registration, dietary, physical therapy

• Over 400 observations completed in a 2 month period

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44

Prioritizing Waste Tool Findings

Great Effort,

Modest Impact

GREAT

EFFORT,

GREAT

IMPACT,

LOW

EFFORT,

MODEST

IMPACT

LOW

EFFORT,

GREAT

IMPACT

IMPACT

EFO

RT

Prioritizing Waste Tool Findings

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45

Sample of Waste Tool Follow-up Activity

Staff Identified Waste Work Plan Status

Insulin discarded Nursing/ pharmacy discussion lead to insulin

vial reconfiguration

Complete

Non-formulary scripts

discarded when not used

Ordering and dispensing process changed for

non-formulary items

Complete

No place for Catering

Associates to place trays

Food Service and Nursing Staff meeting to look

at solutions

In process

Unnecessary Courier Trips Materials Handling and Lab workgroup formed

and active

Complete

Excessive Bed Rentals (Sam) Joint activity between Patient Care and Finance New beds

ordered

Unnecessary Physical Therapy

Evaluations

Education by Physical Therapist on appropriate

criteria for consults provided to hospitalists and

nursing staff. Part of multidisciplinary rounds

Complete

Finance Waste Tools Projects based on waste tool

identification

Bulk Medication Transfer $117,000K

Finance Waste Tools Projects based on waste tool

identification

Insulin Replacement $34,000K

Finance Waste Tools Projects based on waste tool

identification

Outpatient Prescriptions Decrease Expenses by $5K

Finance Waste Tool Project based on waste tool

identification

Physical therapy consults on patients not meeting

criteria

Decreased inappropriate evaluations by 50%

Financial Gains from Waste

6/13/2012

46

Follow Up Contacts

Scarlet Clement, Clements@nehealth.com

Norm Dascher, Daschern@nehealth.com

Dan Silverman MD, Silvermand@nehealth.com

Sue Vitolins, Vitolins@nehealth.com

Rob Smith, Smithr@nehealth.com

Presbyterian Healthcare Services

Albuquerque, New Mexico, USA

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47

Cost & Quality in an Integrated System

• Enterprise: Delivery System, Healthplan, Medical Group

─ Integrated Care Solutions – charged with finding innovative ways to save money while maintaining quality for patients and Healthplan members. Example: Transport Center and ED Navigation System

─ Lean Six Sigma Black Belts – Innovation and Design to improve quality, and save money. Example: Pathway for Total Joints

• Delivery System: Hospitals, Clinics, Specialty Care

─ Lean Specialists

─ VAT Teams (Supply cost reduction)

─ Clinical Quality Management (Cost and Quality Team)

Cost & Quality in Service Lines

Clinical Quality:

Cost & Quality

Continual Improvement

Black Belt Projects

Integrated Care

Solutions

Lean Projects VAT Team

Multiple initiatives all utilize the same service line resources

Quality Managers are assigned to the service line –help on multiple projects but focus and drive the work in Cost & Quality projects to fill the gaps and continually improve

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48

Cost & Quality in Service Lines

95

Primary Drivers Projects Lead Quality

Improvement Team

Dark Green Dollars

Reducing Service Line

Operating Budget by

1% a year

Clinical Quality

Program Design

and Improvement

Flow

Supply Chain

Mismatched

Services

Mass Purchasing

Pharmaceuticals

Wasted Materials

Evidenced Based Care Design

Total Joint Pathways

OR Utilization

Adverse Events and

Complications

Reduction of <39 weeks induction

Post-op PN reduction

Reduction in DVT Rate in Surgical

Patients

Reduction / Prevention of Harm

Waste in Admin Services

Readmission Reduction

End-of-Life Care

Unnecessary Procedures/

Hospitalizations

Integrated Care Solutions

Hospital Throughput

Ancillary Throughput

Clinic Flow and efficiency

Reduction of C-Section ALOS

Clinical Quality –

Cost & Quality Teams

Service Line VAT Teams

Lean Six-Sigma Black Belts

Lean Six-Sigma Black Belts

and Lean Specialists

Cost & Quality in Service Lines

• Low hanging fruit has been picked

• Other quality areas are charged to save large sums – big projects – big dollars

• Still much to be done

• Still many opportunities

• Every effort counts

• Every effort makes a difference, and added together the effect can be huge

• Working closely with SL in smaller continual projects is changing our quality culture

6/13/2012

49

Cost & Quality in Service Lines

• Year 1: Women’s SL

─ Opportunity to reduce ALOS and save costs

─ Used Waste Tool to identify areas for improvement

• Year 2: Women’s SL & Surgery SL

─ Evidenced Based Care: Pulled back to work on EBC to support decision points and reduce ALOS

─ Looking for small gains along the way

─ Energy Grid to find best areas to work

─ Small projects making a big difference

• Future: sharing across SL

─ Expanding and becoming what we do & who we are

─ Methods integrated into everyday quality work in all service lines

98

Date Created

September 2011

Status In

Progress

modest

improve

ment

planning

phase

Activity,

but no

changes

Activity, but

no changes

Activity,

but no

changes Hold

Significant

progress

planning

phase

Activity,

but no

changes

Activity,

but no

changes

planning

phase

planning

phase

Activity,

but no

changes

Capacity for IHI Cost &

Quality

GREEN – Can

accommodate a

project

YELLOW – Limited

RED – NO Capacity

2 4 5 6 7 8 9 10 11 12 13 14 15 16 SCIP

Improvem

ent-

Improve

preop

antibiotic

document

ation

TCAB

projects

on GSU

Reduce

occurren

ce of VTE

in TJR

patients

Effective

PASS

screening

Total Joint

Replacement

patients to

Orthopedic

Nursing Unit

Joint Camp

combined

therapy

Improve

Total Joint

Replacem

ent

Discharge

Coordinati

on

MRSA

Screening

in PASS

Alternativ

e Care for

high risk

surgical

patients

Improve

informat

ion flow

for

Preop

CABG

project

Type and

Screen

Improve

ment

Kaseman

OR

Redesign

Standard

ize order

sets in

PASS/Pr

eop

Total Joint Class Instructor Low Low High High high

PMG Cedar Providers High High Low

PMG Cedar Nursing High Low Low

PMG Kaseman Providers High High Low

PMG Kaseman Nursing High Low Low

PASS staff High High Low High High High High

Preop Nursing High Low Low Low High Med High High

Anesthesia High High High High Low Low

OR staff Low High Low High High Med

Surgeons High High High High High High High Low Low Med

PACU Low High High Low

GSU High

SSC Low High Low High

STC

SC

Rehab Med High High

Medical Director High Med High

Director of Surgical Services Low High High High Med

Nursing Dept Director High Low Low Low High

Pharmacy High Low Low

Quality Clinical Manager Med

Low

Low Low

OR Manager Low Med Low High Low High Low

Preop/PACU/PASS Manager Low High Low Low High High High Med

OR Clinical/Quality Specialist Low High Low High High High Med Nursing Unit Clinical

Specialist Low High

SSC/SC/STC Nurse Manager High High High

GSU Nurse Manager High

Presbyterian Surgical Service Line Energy Grid This is a re-creation . We use this as a living document and it has changed. Lessons learned: Save the old versions as part of the quality journey picture

6/13/2012

50

Project Progress• 1 – charter established

• 2 – activity, but no changes

• 3 – Modest Improvement

ProjectName / Month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

PneumoniaPrevention

2 3 4 4 5 5

SCIP-Improvementprojects

1 2 2 2 3

Total Joint Replacement VTE Prevention

1 2 2 3 4

SurgicalSelection for high risk mortality

1

• 4 – Significant Progress

• 5 – Outstanding Success

Portfolio Management• Aim of Portfolio:

• Current Portfolio Projects:Project Name Projected

Savings Savings to

DateQuality Metrics

Postoperative Pneumonia Prevention

$134,448 $ 20,688 $3448 / case

Adult non ventilated surgical patients who

developed post-op pneumonia / Total non

ventilated adult surgical patients

Total Joint Replacement VenousThromboembolism (VTE) Prevention

$ 13,159 $4,110 $822 / case

Adult total joint replacement patients who

developed a VTE in the encounter / Total

number of total joint patients in the same time period

SCIP Improvement $ TBD-VBP $

Surgical selection for high risk mortality

$ TBD $

Totals $147,607 $24,798

Percentage of Operating Budget

Savings in US Dollars

1% for entire SSL portfolio 1 million for entire SSL portfolio$200,000 for SSL C&Q projects

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51

2011 Cost Savings

Process Excellence –Black Belts & Lean

Projects$8.6 Million

Value Analysis Team$10 Million

Quality & Cost Improvement 2012 projected $200,000

Financial Model

• Internal costing system is our standard tool used in our organization.

• Using our Internal Costing System we compared average length of stay and variable cost for patients who developed pneumonia or VTE to patients who did not develop based on similar DRGs.

• All data does not reside in one database, therefore we run the risk of not identifying all patients.

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52

Lessons Learned

• Every effort counts & over time will help change organizational culture.

• Continual cost & quality improvement efforts will change how you work, the quality of care for your patients, and save money.

• Finance and clinical partnership creates synergy for maximum benefit to organization and patients

Contact Information

• Susan Quintana, RN, MSN

Manager, Quality Program Support

squintana2@phs.org (505) 724-7796

• Surgery : Brenda Gonzales, RN

brgonzal@phs.org

• Financial Support: Kay Armstrong

KArmstro@phs.org

6/13/2012

53

SummaryDate Created

September 2011

Status In

Progress

modest

improve

ment

planning

phase

Activity,

but no

changes

Activity, but

no changes

Activity,

but no

changes Hold

Significant

progress

planning

phase

Activity,

but no

changes

Activity,

but no

changes

planning

phase

planning

phase

Activity,

but no

changes

Capacity for IHI Cost &

Quality

GREEN – Can

accommodate a

project

YELLOW – Limited

RED – NO Capacity

2 4 5 6 7 8 9 10 11 12 13 14 15 16 SCIP

Improvem

ent-

Improve

preop

antibiotic

document

ation

TCAB

projects

on GSU

Reduce

occurren

ce of VTE

in TJR

patients

Effective

PASS

screening

Total Joint

Replacement

patients to

Orthopedic

Nursing Unit

Joint Camp

combined

therapy

Improve

Total Joint

Replacem

ent

Discharge

Coordinati

on

MRSA

Screening

in PASS

Alternativ

e Care for

high risk

surgical

patients

Improve

informat

ion flow

for

Preop

CABG

project

Type and

Screen

Improve

ment

Kaseman

OR

Redesign

Standard

ize order

sets in

PASS/Pr

eop

Total Joint Class Instructor Low Low High High high

PMG Cedar Providers High High Low

PMG Cedar Nursing High Low Low

PMG Kaseman Providers High High Low

PMG Kaseman Nursing High Low Low

PASS staff High High Low High High High High

Preop Nursing High Low Low Low High Med High High

Anesthesia High High High High Low Low

OR staff Low High Low High High Med

Surgeons High High High High High High High Low Low Med

PACU Low High High Low

GSU High

SSC Low High Low High

STC

SC

Rehab Med High High

Medical Director High Med High

Director of Surgical Services Low High High High Med

Nursing Dept Director High Low Low Low High

Pharmacy High Low Low

Quality Clinical Manager Med Low Low Low

OR Manager Low Med Low High Low High Low

Preop/PACU/PASS Manager Low High Low Low High High High Med

OR Clinical/Quality Specialist Low High Low High High High Med Nursing Unit Clinical

Specialist Low High

SSC/SC/STC Nurse Manager High High High

GSU Nurse Manager High

PlanAct

DoStudy

Questions?

Raise your hand

Use the Chat

6/13/2012

54

Resources

• Berwick, D, Hackbarth, A. Eliminating waste in US health care.” JAMA. 2012 307(14).

• Bisognano, M. Engaging the CFO in quality: Why it’s a must and how to make it happen Healthcare Executive. 2009 Sept/Oct.

• Gawande, A. (June 1, 2009). “The Cost Conundrum: What a Texas town can teach us about health care.” The New Yorker. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

• Gwande, A. (January 24, 2011). “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?.” The New Yorker.

• James, BC and Savitz, LA. How Intermountain trimmed health care coststhrough robust quality improvement efforts. Health Affairs, web exclusive, May, 2011.

• Kaplan, R, Porter, M. How to solve the cost crisis in health care. Harvard Business Review. 2009.

• Luther K, Savitz LA. Leaders challenged to reduce cost, deliver more. Healthcare Executive. 2012 Jan/Feb;27(1):78-81.

Homework for Next Call

1. Agree on an approach (either by service line, across your organization or within a specific department)

2. Identity an aim (dollar aim; cost/case or cost/discharge)

3. Clarify your team and the roles of each member

Send ‘Tweet’ of 140 characters or less to Jill at jduncan@ihi.org by Friday, June 22nd

6/13/2012

55

Partnering Quality and Finance Teams to Improve Value

Expedition Worksheet

Align senior support

Decide where you want to start

Begin to build a partnership with leaders from the finance team

What is your aim? (% operating expenses? Cost/case? Cost/discharge?)

Engage frontline staff

Begin to identify projects that will get you to your aim

Begin building a portfolio

Consider projects you are already working on as potential for your portfolio

Don’t know where to start? Consider adapting and testing the Waste

Identification Tool

Build and leverage

partnerships

Collaborate with your financial colleagues to review your suggested portfolio

and identify what might get at dark green dollars.

Develop financial

models

Define how you will measure the potential and actual savings for each

project

Monitor quality to

assure improvement

Identify best practices, financial models, aims & charters for each area of

work

Develop a series of projects around the ones identified by your team (your

portfolio)

Develop a sequencing plan for the work

Test improvement interventions as well as financial measurement strategies

Implement systems to encourage rhythm and discipline around the work

Track progress

Learn & spread across a

community

Spread learning and best practices

Re-engage & re-commit on a regular schedule

Partnering Quality and Finance Teams to Improve Value

Expedition Worksheet

Align senior support

Decide where you want to start

Begin to build a partnership with leaders from the finance team

What is your aim? (% operating expenses? Cost/case? Cost/discharge?)

Engage frontline staff

Begin to identify projects that will get you to your aim

Begin building a portfolio

Consider projects you are already working on as potential for your portfolio

Don’t know where to start? Consider adapting and testing the Waste

Identification Tool

Build and leverage

partnerships

Collaborate with your financial colleagues to review your suggested portfolio

and identify what might get at dark green dollars.

Develop financial

models

Define how you will measure the potential and actual savings for each

project

Monitor quality to

assure improvement

Identify best practices, financial models, aims & charters for each area of

work

Develop a series of projects around the ones identified by your team (your

portfolio)

Develop a sequencing plan for the work

Test improvement interventions as well as financial measurement strategies

Implement systems to encourage rhythm and discipline around the work

Track progress

Learn & spread across a

community

Spread learning and best practices

Re-engage & re-commit on a regular schedule

6/13/2012

56

Expedition Listserv

If you would like additional people to receive session notifications please send their email addresses to

improvementmap@ihi.org.

We have set up a listserv for participants in this Expedition to share improvement strategies, and

pose questions to one another and faculty.

To use the listserv, address an email to

QualityFinanceExpedition@ls.ihi.org

Schedule of Calls

• Session 1 – Tuesday, June 12th 1:30 – 3:00 EDT

─ Align senior support & build and leverage partnerships

• Session 2 – Tuesday, June 26th 2:00 – 3:00 EDT

─ Engage frontline staff & prioritize portfolios

• Session 3 – Tuesday, July 10th 2:00 – 3:00 EDT

─ Develop financial models

• Session 4 – Tuesday, July 24th 2:00 – 3:00 EDT

─ Monitor quality to assure improvement

• Session 5 – Tuesday, August 7th 2:00 – 3:00 EDT

─ Learn & spread across a community

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57

Thank You