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

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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)

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50

100

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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

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100

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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