1/23/2015

1

Managing Healthcare Change:

Lessons From the FrontlinesDC Gohn MD FACC FHRS

US Health Care Spending as Percent of GDP

Fee for ServiceIncentivized to do more

Fragmented, redundant care

Value Based Care

Focus on Quality/Cost

Population HealthBetting we can improve

the health of entire populationshttp://www.aspenideas.org/session/bringing-business-lens-healthcare?page=1

Healthcare Landscape

An Analogy

Your Task : Get a group of people from Lancaster to Kansas….

BUT :

Most of the group doesn’t really want to go

There is no map or GPS

Nobody has defined the arrival time

If you get there too soon you will get penalized

If you get there too late you will get penalized

Once you get there, Dorothy may already be gone.

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Getting to Kansas

• Build competencies that support the strategic vision

• Link competencies together to tackle larger problems

• Allow success/failure of competency development to guide

strategic vision

Standardization of Care

http://www.newyorker.com/magazine/2012/08/13/big-med

http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine?language=en

Amiodarone Infiltrate Examples

65 patients treated with IV amiodarone during observation period

54 infiltrates occurred in 38/65 patients

Odds of Patient Receiving Amio in the Population and

Odds of Infiltrate of Those Receiving Amio by Group

(Assumes homogeneity of patients between groups.)

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Odds of Amio Odds of Infiltrate

Od

ds

Ra

tio

THG

CC

HSL

p=0.028

p=0.046p<0.001

p<0.001

Ref. Ref.

Note: p=0.004 for CC vs. HSL Note: p=0.869 for CC vs. HSL

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Stratified by Period: Odds of Infiltrate of Those

Receiving Amio by Group

(Assumes homogeneity of patients between groups.)

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Odds of Infiltrate Pre Odds of Infiltrate Post

Od

ds

Ra

tio

THG

CC

HSLp=0.793

p=0.149

p=0.012

p=0.014

Ref. Ref.

Note: p=0.654 for CC vs. HSL Note: p=0.151 for CC vs. HSL

The Real Truth

Lesson Learned : Use Change Management Strategy

Overall HF SCAMP Outline

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Get the Team Involved….

Early Lean Six Sigma Methodology:

Process that involves

many Japanese words

Depends heavily on frontline staff

involvement and direction

Average Stick Time – 1st Case of the Day (Goal 0820)

8:06

8:09

8:12

8:15

8:18

8:21

8:24

8:26

8:29

8:32

Jul-14 Aug Sept Oct Nov Dec Jan-15 Feb Mar Apr May Jun

Average Stick time for 1st Cath Lab Case of the Day

Average Stick time for 1st Case of the Day Goal 08:20

Lean Project

Drive With Data….

But Not Too Much

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LHVI PERFORMANCE INDICATORS

FY2013

YTD FY2014

FY2013 FY2014 Jul Aug Sept Oct Nov

Cath/Intervention (MS-DRG 247, 251)

MS-DRG 247

Cases 384 146 119 25 22 26 22 24

Direct Cost/Case 9,813 9,859 9,500 9,433 8,747 11,767 9,487 7,814

ALOS 3.0 3.0 2.6 2.8 2.5 3.0 2.6 2.2

MS-DRG 251

Cases 179 77 68 16 21 13 10 8

Direct Cost/Case 10,426 10,132 9,842 10,374 9,345 10,023 10,860 8,519

ALOS 3.8 3.4 3.5 5.0 3.2 3.5 2.4 2.6

30-Day Readmission 11.90 9.76 9.30 2.56 3.23 **

% total PCI cases performed as Outpatient 36% 28% 41% 46% 44% 32% 36% 47%

% Outpatient PCI cases dc'd same day 16% 11% 18% 14% 12% 22% 25% 19%

Lab Productivity Index: Hrs Wkd/Room Hours 5.88 5.59 5.83 5.10 5.68 6.12 6.10 6.30

EP (MS-DRG 242-244)

Cases 211 95 84 16 19 17 17 15

Direct Cost/Case 12,075 12,015 15,263 13,637 13,445 17,215 16,288 15,927

ALOS 4.9 5.0 4.6 4.2 3.4 6.6 4.6 4.2

30-Day Readmission 10.90 0.00 10.53 5.88 11.76 **

% PG/ICD performed as Outpatient 46% 42% 50% 60% 44% 59% 43% 38%

% PG performed as Outpatient 29% 24% 43% 48% 38% 49% 41% 36%

% ICD performed as Outpatient 69% 67% 67% 75% 64% 92% 45% 44%

% Outpatient PG/ICD cases dc'd same day 27% n/a 66% 53% 65% 71% 70% 82%

Lab Productivity Index: Hrs Wkd/Room Hours 6.30 6.32 n/a 5.92

AF Cases 864 342 307 64 57 57 60 69

AF ALOS 3.7 3.7 3.1 3.6 2.6 2.7 3.0 3.7

AF Charges/Case 28,753 28,088 25,741 29,355 24,635 22,075 25,078 26,907

AF Direct Cost/Case 5,014 4,966 4,555 5,243 4,028 3,947 4,457 4,941

General Cardiology

Observation Chest Pain ALOS (Hours) 20.1 20.4 19.5 19.6 19.9 18.3 20.3 19.1

Patients discharged to home 19.9 20.2 19.2 19.3 19.3 18.2 20.1 18.9

Patients admitted 26.4 24.7 31.5 30.8 32.3 33.5 35.0 28.0

Time from stress test termination to interpretation (Stress ECHO) 1:38 1:15 0:56 0:56 0:41 0:00

Time from stress test termination to interpretation (Nuclear) 0:47 0:50 0:57 0:46 0:47 0:51

CV Surgery (MS-DRG 233-236)

Cases 254 106 131 32 28 25 23 23

PreOp ALOS 3.1 3.3 3.1 2.9 4.3 2.4 2.0 3.8

% elective 36% 36% 41% 56% 32% 44% 43% 26%

Direct Cost/Case 20,788 20,840 22,956 22,347 27,227 21,310 21,239 22,110

30-Day Readmission 9.92 12.50 7.14 28.00 4.35 **

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It Works !!

DRG FamilyFY 12

LOS (days)FY 13

LOS (days)FY 14

LOS (days)%

Reduction

AF 4.1 3.7 3.1 - 24 %

Pacemakers 6.0 4.9 4.4 - 27 %

Stents 3.3 3.0 2.6 - 18 %

Never as fast as you want :

Same Day Discharge Initiative

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Initiative Start

Don’t Get Frustrated by The Adoption Curve

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Choose Baseline Carefully

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Initiative Start

Learn How to Build SustainabilityPatient Satisfaction: Top Box MDC 5

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13Q3 13Q4 14Q1 14Q 2 14Q3 14Q 4 15Q1

6 East Likelihood to Recommend% Topbox

Listen to the voice of the customer

The Challenge :

Fragmented Care

Primary Care

LGHP

Consumers

THG of LG Health*

• CHF• Prevention• EP• Women’s• Valve

CTS of LG Health

LGHSurgical

Specialists

LGH• Cath Labs• EP Labs• IVU Labs• Interventional Radiology (LRA)• Ambulatory testing (CV)*• VAD Clinic

* Various locations

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Think Like a

Health System

Primary Care

LGHP

Consumers

LGH Downtown Pavilion• THG of LG Health• LGH Surgical Specialists• CTS of LG Health• Disease Clinics

CHF Valve Prevention Afib Vascular VAD

• Cardiac Urgent Care• Chest Pain• Arrhythmia

• Ambulatory testing (CV)*

LGH Duke Street• Cath Labs• EP Labs• IVU Labs• Interventional Radiology (LRA)

* Various locations

Fasten Your Seatbelt…

The Goal : Questions ?

dcgohn@lghealth.org