operationalizing clinical excellence: lessons learned

Operationalizing Clinical Excellence: Lessons LearnedMay 14, 2014

Speakers:•James Stein, M.D., Associate Chief of Surgery and Chief Medical Quality Officer Children’s Hospital Los Angeles•Mary Dee Hacker, R.N., Vice President, Patient Care Services, Chief Nursing Officer Children’s Hospital Los Angeles •Larry Burnett, R.N., Managing Director Huron Healthcare•Paul Kane, Senior Director Huron Healthcare

Learning Objectives

• Identify keys to improving clinical operations with DRG-based reimbursement

• Understand foundational strategies to support interdisciplinary communication and accountability

• Understand how to measure outcomes and sustain high quality care

2

Presentation OutlineI. Children’s Hospital Los Angeles Opportunities & Challenges

II. Transforming the Organization: Key Initiatives

A. Clinical Operations

B. Governance & Accountability

C. Enabling Technologies

III. Tracking Progress & Measuring Benefit

IV. Lessons Learned

V. Questions

3

About CHLA• Founded in 1901, oldest freestanding children’s hospital in California• By the numbers:

– 347 active beds overall– 106 pediatric critical care beds (more than any other hospital in the western U.S.)

– More than 5,200 employees and nearly 600 medical staff– Average length of stay: 7.4 days

• Annual statistics:– Admits 13,800 inpatients– Nearly 319,000 outpatient visits– More than 70,000 Emergency Department visits– More than 104,000 individual patients– More than16,000 pediatric surgeries performed

4

About CHLA – Affiliations and Accolades• The Saban Research Institute of CHLA is among the largest and most

productive pediatric research centers in the Western US• One of the country’s premier teaching hospitals, CHLA is affiliated with

the Keck School of Medicine of the University of Southern California• Children’s Hospital Los Angeles ranks among the top five in the nation

on the U.S. News & World Report Honor Roll of children’s hospitals• Children’s Hospital Los Angeles is one of just 13 children’s hospitals to

be designated a “Top Hospital” for 2013 by The Leapfrog Group• The hospital is designated a Magnet Hospital by the American Nurses

Credentialing Center—an honor held by only 7 percent of hospitals nationwide

5

Opportunities & Challenges• Children’s Hospital Los Angeles (CHLA) was forecasting a

significant impact to financial stability and needed to take immediate steps to transition to a DRG-based payment structure

• The organization embarked on a significant, organization-wide transformative journey, which included major changes to care delivery processes

• CHLA fully engaged all members of the care team in innovative ways, enabling them to work in a results-focused, mutually accountable, symbiotic manner, maintaining focus on the patient

6

Opportunities & ChallengesPrior to July 1st, 2013 After July 1st, 2013

MedicaidMedicaid Medicaid Managed CareMedicaid Managed CareCommercialCommercial

Percentages are based on

percentage of patient days.

Percentages are based on

percentage of patient days.

7

Presentation OutlineI. Children’s Hospital Los Angeles Opportunities & Challenges






IV. Lessons Learned

V. Questions

8

9

Leveraging Change Across the Continuum of Inpatient Care

10

Process Improvement, Accountability, and Operational Transparency

Presentation OutlineI. Children's Hospital Los Angeles Opportunities & Challenges






IV. Lessons Learned

V. Questions

11

Which area does your organization struggle with the most?

A. Patient Placement

B. Case Management

C. Interdisciplinary Care Coordination

D. Inappropriate Variation in Care Delivery

E. Governance & Accountability

12

Audience Question

Clinical Operations

Clinical Operations Key Areas

13

Restructure patient flow

Clinical Operations

Patient Placement Model Changes

14

Inconsistency

Variability

BEFORE AFTER

Case by Case

Clinical Operations

Centralized

Coordinated

Measurable

Patient Placement Metrics

15

Time Stamp Area Responsible

Bed Request Sending Area and/or Patient Placement

Bed Clean Environmental Services

Bed Assigned Patient Placement

Patient Ready To Move Sending Area (i.e. Portals, Nursing Units, ICU, Admitting, etc.)

Bed Occupied Receiving Unit

Clinical Operations


16

Improve Care Coordination,

Redesign

Best Practice Case Management Model

17

Psychosocial assessments

Abuse, neglect, domestic violence interventions

Crisis interventions and counseling for issues such as bereavement and end of life

Patient/family support and conferences

Interventions to help resolve barriers to care progression and facilitate discharge

Post-hospital care referrals Paperwork assembly/transportation

arrangements Authorizations

Clinical assessment Level of Care / Discharge Planning

Utilization Review Case escalation /

referral to resolve barriers to care progression

Discharge Planning

Clinical Operations

Case Manager Assistant

Case Manager Assistant

Case ManagerCase

ManagerSocial WorkerSocial WorkerPatient/

Family Patient/Family

Physician Advisor Program

18

The Physician Advisor is a CHLA physician who facilitates the safe and efficient flow of patients by providing guidance to the care team

Typical issues addressed by the physician advisor:• Delays in ancillary services (i.e. MRI delay), consults, discharge planning, or discharge orders• Secondary review (after Case Manager) and follow-up for non-adherence to Clinical

Pathway/Care Sets• Communication challenges or disagreements amongst the care team • Guidance and planning on care issues that may be more appropriate for the outpatient setting• Payer requests for further information to authorize care or prevent denials• Participates in yellow/red census alerts and works to improve throughput during high capacity• Clarification and follow-up for the Clinical Documentation Improvement (CDI) program

Clinical Operations


19

Improve Care Coordination

Interdisciplinary Care Coordination Model

20

Clinical Operations

Anticipated Date of Discharge Process

21

• Define patient-centered, team approach to align anticipated date of discharge (ADOD) process with • Daily care team communication forums • Proactive communication with patient/family about their course of

care, discharge plans, goals for stay/day and medical milestones• Why is this important?• How does it work?

Clinical Operations


22

Streamline Clinical Care

Reduce variation, decrease LOS and unnecessary resource consumption and enhance timely care for patients

Care Variation Management

23

Clinical Operations

Appendectomy, Pneumonia, Neutropenia and Cystic Fibrosis Workshops, Clinical Pathway Redesign and Medical Milestone Tools

Care Variation Management DRGs Selected

24

Appendectomy, Pneumonia Workshop & Re-design

Appendectomy/ Pneumonia Clinical Intervention/ Go-live & Neutropenia Approvals

Cystic Fibrosis Workshop

Cystic Fibrosis Clinical Approvals

Oct-Dec March MayAprilJan

Neutropenia Initiative Education, Training and Go-live

Feb

Appendectomy/ Pneumonia Clinical Approvals & Neutropenia Workshop

Prioritization of future CVM Initiatives

June

Clinical Operations

• Best/consensus practice• Education - patient and staff• Designation of appropriate metrics• Medical, Clinical and Physician Dashboards

Care Variation Management

25

Clinical Operations







IV. Lessons Learned

V. Questions

26

• Defined and Actionable Leadership Structure• Patient Flow Meeting

Governance

27

Governance

Leadership Structure

28

Governance

Approval and Monitoring Process

Objective: Retrospectively review performance on key metrics and identify and address root causes for unnecessary variationKey Impact: Optimal, reliable performance on outcome and process metrics increasingly available in the public domain

29

Governance

Referral Process

30

Governance

Patient Flow Meeting• Weekly meeting to promote the use of data and metrics in identifying, monitoring,

managing and improving issues in patient flow throughout the hospital using:– Focused, structure conversation– Identification/resolution of barriers– Measurement and goal-setting

• Analyze performance (PatientONTRAC™, Care Variation Management , Quality, Patient Satisfaction, Readmissions, Operational and Other Metrics)

• Address patient flow barriers and discuss performance improvement activities

• Set and manage to key performance indicator goals

• Celebrate successes and share best practices

31

Governance







IV. Lessons Learned

V. Questions

32

What systems/processes have you used, or are you considering for improving clinical operations? 1)Bed Board2)Case Management System3)Operational Metrics4)Clinical Benchmarking Data Program

33

Audience Question

Enabling Technologies

• Bed Board Optimization• Case Management System Implementation• Operational Metrics• Clinical Benchmarking Data Program

Implemented New and Optimized Existing Technology to Improve Operations

34

Enabling Technologies







IV. Lessons Learned

V. Questions

35

Project Results• Decreased severity-adjusted and straight length of stay• Created the capacity to serve additional patients• Continued re-enforcement of the historical decreasing

mortality rate trends• Reduced overall cost per case significantly• Reduced capacity-related admission denials • Mitigated negative readmissions impact to the hospital • Improved patient satisfaction• Enhanced overall clinical operations efficiency

36

• Severity Adjusted Average LOS has decreased by 1.45 days for all in-scope patients

• Severity Adjusted Average LOS has decreased by 1.94 days for Medi-Cal patients

Clinical Ops Improvement Outcomes

Estimated Range of Results3 Month Results

Annualized ConfirmedLow Mid High

Average LOS Reduction (Days) 0.3 0.45 0.6 1.45 1.45

Patient Day Reduction 3,300 5,000 6,700 5,115 20,462

Updated as of March 31, 2014

37

Revenue Enhancement & Cost Savings Benefit


Preliminary Draft Benefit Model(Currently Being Validated/Finalized)

Estimated Range of ResultsEstimated

AnnualizedLow Mid High

Revenue Enhancement/ Backfill Benefit(Based on Incremental Discharges in Nov Projected to April)

$5.5M $8.4M $11.3M

$6.5M

Dark Green (Excluding Nursing/Tech Labor) Cost Savings Benefit $6.2M

Subtotal Benefit $12.7M

Light Green (Nursing/Tech Labor) Cost Savings Benefit $6.6M

Total Potential Benefit $19.3M


38

Medi-Cal/ Medicaid LOS Trends vs. Case Mix Index



39

CDI Go-Live

ClinOps Go-LivePhysician

Advisor/CM Tool Go-Live

Significant Mortality Rate Reduction since Fiscal Year 2004

Expected vs. Observed Mortality Rates

40

Expected vs. Observed Mortality Rate Continuing Favorably Trend


41

CDI Go-Live

ClinOps Go-LivePhysician

Advisor/CM Tool Go-Live


Medi-Cal/ Medicaid Direct Cost Per Case % Reduction



42

Clinical Ops Improvement OutcomesAverage Daily Census Fiscal Year 2013 vs. 2014

43


Clinical Ops Improvement OutcomesAdmissions Fiscal Year 2013 vs. 2014

6.3% Increase In Admissions FY14 6.3% Increase In Admissions FY14

44


In addition to the strong LOS reduction, CHLA:•Created the capacity to treat more patients which is reflected in the significant decrease in capacity related admission denials•On track for an 75% in comparison to FY 2013


45


46

Readmission Data

46

Readmission Rates Remain Stable


47

• LOS reduction achieved while maintaining or improving patient satisfaction comments/scores

• How would you rate the overall teamwork between doctors, nurses, and staff?

Improving the Patient Experience

47

Rating Total Responses

Excellent 3152 58%

Very Good 1244 23%

Good 656 12%

Fair 304 6%

Poor 69 1%

Totals 5425 100%

Rating Total Responses

Excellent 1754 73%

Very Good 384 16%

Good 166 7%

Fair 69 3%

Poor 22 1%

Totals 2395 100%

November 2011-June 2013 July 2013 – March 2014







IV. Lessons Learned

V. Questions

48

Critical Success Factors1. Focusing on Quality Before Financials2. Leadership At All Levels3. Transparent and Consistent Communications4. Staff and Stakeholder Engagement and Buy-in5. Strategic Investments (e.g., IT Systems, Physician Advisors, Case

Management Assistants, External Implementation Expertise)

49

Next Steps1. Evolution of Clinical Operations

• Service based inpatient case management• Increased physician participation in care coordination rounds• Implementation of best practices in out of scope areas (NICU/Rehab)

2. Full Care Continuum Management• Ambulatory/outpatient redesign• Case management• Access• Clinic operations

3. Data Analytics and Performance Improvement Investments4. Labor/ Staffing Management5. Re-negotiating Contractual Arrangements

50







IV. Lessons Learned

V. Questions

51

Today’s Speakers

52

Larry Burnett, R.N.Managing DirectorHuron Healthcare

Mary Dee Hacker, R.N.Vice President, Patient Care Services, Chief Nursing OfficerChildren's Hospital Los Angeles

James Stein, M.D.Associate Chief of Surgery and Chief Medical Quality OfficerChildren's Hospital Los Angeles

Paul KaneSenior DirectorHuron Healthcare

APPENDIX

53

Project TimelineProject Initiatives May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Refresh Data Analysis, Finalizing Initiatives & Reporting Metrics

Develop Workplans, Team Charters and Workgroups

Complete design sessions

Implement Clinical Operations (CO) Management Tools & Execute on Implementation Plans

Improve CO Work Process to Drive Results

Monitor Realization and Sustain Value

Conduct CO Training and Knowledge Transfer

Implementation Timeline 12 MonthsImplementation Timeline 12 MonthsMonth

CM

CM

CVM

PP and CC

CM=Case Management, CVM=Care Variation Management, PP=Patient Placement, CC = Care Coordination

54

Medi-Cal/ Medicaid Average LOS trends by severity



55

Medi-Cal/ Medicaid Average LOS trends by severity



56

Medi-Cal/ Medicaid Direct Cost Per Case trends by severity



57

Significant reduction in mortality rates since Fiscal Year 2004


58

operationalizing clinical excellence: lessons learned

Healthcare

patient care services

unit clinical operations

magnet hospital

clinical operations

care delivery

care team

patient placement metrics

high quality care