perspectives from the system level, provider leadership, …€¦ · swot: weaknesses...

Perspectives from the System Level, Provider

leadership, Quality and Value Owners

Ilan Rubinfeld, MD, MBA, FACS, FCCP, FCCM Chief Medical Officer-‐ Associate Henry Ford Hospital, Detroit

ExecuDve War College, New Orleans, 2017

Plan for the Conversation

• Overview from the the perspecDve on laboratory medicine from the system, hospital, quality and medical leadership

• CreaDng your LAB 2.0 infrastructure and pipeline: people, process, governance, soSware, projects, project, project, data, data, data

• Tools in acDon: Projects from the tools and learning perspecDve

Pain: across the system and where lab rests in the ”pain milieu” Value is a nebulous concept Unpredictable compeDDve markets Unstable assumpDons impede forecasDng and planning

Revenue ceiling is easier to find then limits on expenses Everyone wants to be a loss leader We never have enough data that transiDons to insight and knowledge The payors, pharma, device industry all invests heavily in analyDcs, and we are behind in this analyDcs arms race to insight

Lab is just one of the many expenses In a “lab” pursuit of excellence, the clinical and operaDonal needs may be secondary. No offense please, but lab doesn’t exactly make for great eye candy on a markeDng or philanthropy campaign

The great semantic game leading to Pain in any Value Future •  In every other industry and economic discussion Value is an euphemism for “cheap”

• Only in healthcare is it rolled into an expectaDon of increasing quality. •  The frame of reference has been co-‐opted by the payors

•  Decrease cost sound like a universally good thing •  But we must learn via Google translate: they mean our Revenue!

Revenue

Gain: What do we hope lab and lab informatics can do for us? • Keep the spend down, as you always have • Be lean, model lean, and teach everyone else how to be lean • Partner with other “expenses” and clinical drivers of uDlizaDon to decrease uDlizaDon across the board

• Develop and drive a “value engine”: enabled, empower, inspired by lab and lab informaDcs to work these uDlizaDon projects across the expense spectrum: ambulatory to inpaDent, populaDon to acute

•  PopulaDon is now a nebulous term: all of primary care? Just members of an at risk contract? ACO? HMO?

SWOT Analysis: HFHS as a system and Lab/Lab Informatics

Strength

• HFHS •  Lab/Lab InformaDcs

Weakness


Opportunity


Threats


SWOT: Strength

Health System

•  Excellent Care and Outcomes • Quality and Reliability Focus • CollaboraDve Improvement Culture

•  Strong Core Values • Mission Driven •  Succeeding with Growth IniDaDves

•  Improved Financial posiDon

Lab and Lab Informa4cs •  Excellent quality •  Excellent performance metrics •  Financial strength and vitality •  Lean mastery •  Growth via reference lab acDviDes •  Growth via new projects (precision medicine)

•  Increasing collaboraDve presence

SWOT: Weaknesses

Health System

• Uncertainty and Unpredictability •  Single Payor dominance •  Increased compeDDon for less commercial paDents, and the suburbs are really preiy

Lab and Lab Informa4cs •  Inward focus •  Non-‐prominence in governance, provider and operaDonal leadership

•  Nerd-‐geek-‐in-‐the-‐lab •  Making successes within the department clear successes across the enterprise

•  Not on the agreed upon shared plajorm (I understand there are fabulous reasons not to be in EPIC, but its also a risk and weakness)

SWOT: Opportunities

Health System

• Growth •  Referral •  M and A

• ACA ain’t dead yet • ConDnue to run faster then the compeDDon

• New Technologies • Acute care, emergent complex care

•  CollaboraDon: Pharmacy? Primary care •  New TesDng, Growth, Referral (high margin tesDng?)

•  DATA! DATA! DATA! •  You know certain things first •  Retail

Lab and Lab Informa4cs

SWOT: Threats Health System •  Risks related to urban coverage in a potenDal post-‐ACA world, less covered lives, less things covered

•  Single dominant payor, gets/seizes even more market power

•  Urban condiDons make referral business difficult to maintain

•  Expenses conDnue to rise despite aggressive management (market manipulaDve scarcity like the pharmaceuDcal markets)

•  Can Providers alignment for to thrive in Dmes of change (We know we must be bigger then HFMG alone)

• Can lab face the market manipulaDve scarcity like pharmacy? How will that distort everything? AutomaDon? Lean?

• Clinicians wont change and will not partner

• Retail: pharmacy?

Lab and Lab Informa4cs

Pay for Performance Programs at HFHS Dollars at Risk > $50M

•  CMS Pay for Performance $13.6M •  Value Based Purchasing (Core Measures, PaDent SaDsfacDon,

Outcomes, Spend per beneficiary)

•  Readmissions

•  Hospital Acquired CondiDons (CLABSI, CAUTI, complicaDons)

•  BCBS -‐ Hospital Bonus $ 12.0M

•  BCBS Doctor Group Bonus $4.2M

•  MiPCT $4.3M for Primary Care

•  Health InformaDon Technology 2011 to 2013 = $58M

•  30 CerDficaDon Programs (P2P) and Select Networks

•  Lab and Lab InformaDcs involvement: • HAI (CAUTI, CLABSI, SSI, MRSA, CDIFF)

• PaDent Safety Indicators: •  PSI 9: Post Op Hemorrhage •  PSI 10: Post Op Acute Kidney Injury •  PSI 13: Post Op Sepsis

•  PopulaDon Metrics related to •  HgbA1C, Glucose Control, Cholesterol, etc.

Help Us Build Value

•  In a parade of expenses be the prize winning float • Cannibalize yourself: partner on the “value” project •  Leverage your Lean •  Leverage your analyDcs and informaDcs •  Learn how and then be “THE” partner!, remember: Radiology, Pharmacy, Cardiac TesDng are all breathing down your neck

•  Find ways to create growth, bring in paDents and business: new medical records, high margin tesDng

Lab 2.0 Infrastructure: People, Process, Technology

FickenscherK, BakermanM. Physician Exec. 2011 Jan-‐Feb;37(1):73. Trastek VF, et al. Mayo ClinProceed. 2014;89(3):374-‐381

People

Process Technology

Change Management

Process Improvement

Strategic Planning

P6: LUTF: The System Lab Utilization Task Force: The activated clinical leadership •  Stage of Development: Launched, Here to stay, a proven team that gets the job done, a trusted and sought aSer partner, needs more resources and clinical actors to mature further and take on more projects of bigger scope

•  Targeted Metrics: •  Projects completed •  ROI in mulDple formats •  PublicaDons, podium presentaDons, system and

operaDonal metrics

•  Amount of Impact: •  Priceless

•  Top Line Goals through 2019: •  Develop the pipeline to provider reporDng,

scorecards and OPPE •  Refine ROI calculaDons based on believable

finance metrics •  Focus on the market-‐basket improvements

•  Lets look at tools in detail

• What are the ingredients in our uDlizaDon recipe for success?

•  The “Perpetual Stew” of LUTF

Agree to a Collaboration Framework

Process

CommunicaDon

Roles and RelaDonships

Authority and Leadership

Goals and Mission

Knowledge $ Relevance

Identify the Common Goal MulDdisciplinary and collaboraDve

framework for laboratory tesDng

Medically-‐relevant

Cost-‐ effecDve Scalable

and Integrated

Evidence-‐based

Self-‐learning and Open

Acquire Legitimacy: Stake your claim in the governance model

MulDdisciplinary

Provider Council

Medical Laboratory Formulary Commiiee

Clinical EvaluaDon and Technical Assessment

Commiiee

Laboratory UDlizaDon

Taskforce

PATHOLOGY LED-‐ Focusses on send out tesDng and provision of services within Pathology

PROVIDER LED-‐ Focusses on exisDng tesDng menu and find opportuniDes to standardize and raDonalize lab tesDng

ExecuDve leadership 13 members from across hospitals and business units

Form a ‘Steering Committee’

• Pathology CETAC/MLF

• Project mgmt

• System Performance Improvement

• Project mgmt

• Pathology & Lab Medicine

• Pathology Management

• Providers • Governance • AnalyDcs •  IT/EMR

Associate

CMO Clinical

Pathologist

Medical Technologist

Project Manager

Gather the ‘Team’

Providers

PaDent

Laboratory

Laboratory’s idea of stakeholders

Medical Leadership

EMR IT AnalyDcs Teams

Finance Experts

External Vendors

Extended scope of stakeholders

Define the Process and Pipeline: Project Ideation and Intake

Project Intake

Providers: Residents, Mid-‐levels, Faculty

Nursing and Other Allied Care providers

Laboratory

Guidelines, Evidence Base, Choosing Wisely

PaDent and Employee Feedback

Define the Process and Pipeline: Project Review

Project

Review

Finance

OperaDons

Evidence

Pilot Data

Usability: build implicaDons

Define the Process and Pipeline: Transition to pilot or fail fast

Intake

Providers

Laboratory

Guidelines

Pilot? Formal Project

Reject/DOA

ANALYTICS •  Incidence •  DistribuDon •  Affected party •  $?

EMR •  Reasons? •  Workaround ? •  Timeline?

Define the Process and Pipeline: governance and high level cover

Successful Pilot

Governance

DemonstraDon of proof-‐of-‐concept and underlying

data

Approval as standard of pracDce

Define the Process and Pipeline: Spread and Hardwire

Approved by Governance

AdopDon

ImplementaDon: EMR

EducaDon Roll out

Tracking of clinical and financial outcomes

5. Define the Process

Hardwiring &

Conclusion AdopDon Governance Pilot

Steering

Group IdeaDon

LAB Providers EMR AnalyDc Finance

Define the Process and Pipleine: Project Ideation and Intake

P6LUTF. EMR Build, Tricks, Games, and Pitfalls

Formulary and Beyond: Utilization options for the EMR •  IF it can’t be ordered it won’t be done, the formulary is very powerful • CreaDve naming can help avoid inappropriate ordering •  Immediate Alerts (Best PracDce Advisory), Choosing wisely, can help cancel an order, or perhaps gather informaDon on appropriate uDlizaDon.

• Build type can influence use: all blood products are ordered only from an order set to help guide and

•  Look for any and all uDlizaDon opportuniDes within the EMR

Pitfalls and Watch-outs

• Many ordering modes and methods: •  Can modify a system order and sDll find it on a preference list •  Ordering from an ED workflow looks very different from •  Despite the promise of order sets and the control they give over the ordering process, uDlizaDon must be watched and monitored, the a-‐la-‐carte order is oSen quicker by providers…

•  only force this when you really need to at the system level.

•  Flanking maneuvers intenDonal and unintenDonal •  Upgrades, referesh •  Backdoor orders

P6LUTF. Reporting and Analytics Need many tools in the tool chest

Different report focus and perspecDve

Labs, types, quanDDes, associated condiDons

Encounter and Episode reporDng

Individual Lab reports

Reporting and Analytics

• Many tools must be available in the quiver

P6 : Keys to success, maintenance and expanding collaboration

Labo

ratory

Providers

CommunicaDon Pathways

Aligned goals and understanding

Data-‐driven problem solving

Governance and process

Success in Collaboration

•  Face-‐to-‐face interacDon •  PosiDve interdependence •  Individual accountability •  Shared responsibility and

purpose •  Norms, structure, processes •  Willingness to fail •  Process beats power •  Shared system Values: One-‐

Henry

•  Watch out for these or you will hit a wall!

•  Not having a clear authority and joint-‐ownership with Clinical Leaders

•  Not triaging projects with actual data

•  Not having a clear and defined process

Quick rounds on a sample of projects, as requested

But the real prize is the Project of Project: building an enterprise utilization infrastructure for enduring value creation For each project we will briefly review its main goal and approach, and then discuss the tools for spread and enduring change developed therein

P1: Multiple Troponin Syndrome: Decreasing the “third negative troponin” occurrence

Delays TAT in ER Labs and delays

pa4ent discharge in the ED?

Is this appropriate u4liza4on?

Increases troponin orders in the ER labs

Order of a 3rd troponin

aCer 2 nega4ves

0

1000

2000

3000

4000

5000

HFH MCT WBF WYN

Third orders

Abnormal

CriDcal

P1: Multiple Troponin Syndrome: Decreasing the “third negative troponin” occurrence •  Stage of Development: Launched, Changes established, Handed off to clinical operaDonal team (slight fumble)

•  Targeted Metrics: •  Business unit rate of third negaDve troponin

•  Cost and Time in ObservaDon

•  Amount of Impact: •  Working on more robust ROI process •  Total troponins down, but have not captured LOS in recovery.

•  Top Line Goals through 2019: •  Get the measure to sDck on the ED system council dashboard

•  Tools and Methods Acquired: •  MulD-‐business unit support •  EMR build and System AnalyDcs methods •  SME process for targeted projects •  Handoff to clinical operaDonal ownership

P2: Eliminating ‘Daily’ Labs:

P2: Eliminating ‘Daily’ Labs: •  Stage of Development: Launched, Changes established, maturing metrics for next round Daily Lab 2.0

•  Targeted Metrics: •  Technical fix: no use of “daily” frequency in order

entry in EMR •  Labs per discharge, labs per D/C aSer 24 hrs

•  Amount of Impact: •  Depending on BU 5-‐10% reducDon of total labs

per D/C

•  Top Line Goals through 2019: •  Formalize the uDlizaDon metric and put in clinical

dashboards •  Develop more robust view of encounter and

episode lab uDlizaDon for provider dashboards with some adjustment

•  Working on repeated labs like: CBC q6 in GI bleeds

•  Tools and Methods Acquired: •  MulD-‐business unit support •  Accessed all levels of governance across the

organizaDon •  EMR build and System AnalyDcs methods •  SME process for targeted projects •  Increasing sophisDcaDon of lab uDlizaDon

metrics in collaboraDon with System AnalyDcs •  EvoluDon:

•  Labs per discharge •  Labs per hospital day (adjust for LOS) •  Labs aSer 24 hrs (adjust for maintenance which is

actual target) •  Developing provider dashboards with severity

adjustment to look at the “lab bucket” •  Labs per anemia burden?

P3: Blood Utilization: “7 is the new 10”, and “waste not, want not”

P3: Blood Utilization: “7 is the new 10”, and “waste not, want not”

•  Stage of Development: Launched, and operaDonal, improvements on blood wastage and transfusion avoidance is immense. Developing second round of improvements while conDnuing to improve from the mulD pronged first round.

•  Targeted Metrics: •  Total transfusion •  Transfusion with no prior documented Hgb < 7 •  Transfusion adjusted by anemia burden

•  Amount of Impact: •  On track for 100s of units of PRBCs a year.

•  Top Line Goals through 2019: •  Targeted intervenDons with willing partners: CT Surgery,

Orthopedics, Anesthesia •  Targeted admission types like GI bleed and L and D •  Develop an anemia burden for adjustment •  Develop the growth story: we have increased transfers

from the Jehova’s Witness community •  Mobilize uDlizaDon metrics especially Hgb 7 metrics to

dashboards for teams and individual providers •  Look at overall expenses in the transfused populaDon.

•  Tools and Methods Acquired: •  MulD-‐business unit support •  Partnered with exisDng uDlizaDon efforts •  Partnered with choosing wisely campaign and choosing wisely alerts from Stanson

•  Accessed all levels of governance across the organizaDon

•  EMR build and System AnalyDcs methods •  SME process for targeted projects •  Increasing sophisDcaDon of lab uDlizaDon metrics in collaboraDon with System AnalyDcs

•  Daily Harm reports: who got blood yesterday! •  EvoluDon:

•  Blood as a whole •  Blood with no HGB < 7 •  Team and Disease focused intervetnions •  Dashboards and adjusted data •  Anemia burden

P4: Vit D labs •  Stage of Development: Launched organically, strong year 1 performance, maturing the metrics, based on mature metrics will refine intervenDon

•  Targeted Metrics: •  Began with order less (labs total) •  Developing benchmarked versions

•  Amount of Impact: •  Decrease total order type •  Decrease expensive order type (less 1,25 OH)

•  Top Line Goals through 2019: •  Formalize the uDlizaDon metric and put in

populaDon health clinical dashboards •  Develop more robust view of encounter and

episode lab uDlizaDon for provider dashboards with some adjustment


•  Tools and Methods Acquired: •  MulD-‐business unit support, increased awareness and interacDon with primary care and populaDon health

•  EMR build and System AnalyDcs methods •  Ordering and Lab improvement

•  Formulary •  Naming •  Alerts and advisories

•  SME process for targeted projects: populaDon health

•  Increasing sophisDcaDon of lab uDlizaDon metrics in collaboraDon with PopulaDon and System AnalyDcs

•  EvoluDon: •  Total labs based on MEDC project •  NaDonal benchmarks: per visit, 1 vs 1,25 OH, and

benchmarking by CBC or Metabolic profile

P4: Vit D labs

Vitamin D -‐> Vitamin D (screening to be used only in symptomaDc paDents, no longer broadly indicated)

Vitamin D 1,25 DiHydroxy -‐> Vitamin D 1,25 DiHydroxy (Rarely indicated, Limited use, endocrinology and sarcoid use only)

Synchronize with other groups! (HFMG Amb 2016 iniDaDve)

685 683

805

582 617

585

463 491

402

322

192 150

P5: Choosing Wisely: Care and feeding of the BPAs in Epic (alerts, popups and other workflow annoyances) •  Stage of Development: Implemented and in place, pipeline developed for ongoing launch of nex alerts. ConDnuing to develop monitoring and intervenDons for alerts. ConDnuing to monitor alert and develop analyDc approach. Our commiiee owns all lab related alerts for the system (no other group has stepped forward for a slice)

•  Targeted Metrics: •  Began with order less (labs total) •  Developing benchmarked versions

•  Amount of Impact: •  Decrease total order type •  Decrease expensive order type (less 1,25 OH)

•  Top Line Goals through 2019: •  Formalize the uDlizaDon metric and put in populaDon

health clinical dashboards •  Develop more robust view of encounter and episode lab

uDlizaDon for provider dashboards with some adjustment


•  Tools and Methods Acquired: •  MulD-‐business unit support, increased awareness and interacDon with primary care and populaDon health

•  EMR build and System AnalyDcs methods •  Ordering and Lab improvement

•  Formulary •  Naming •  Alerts and advisories

•  SME process for targeted projects: populaDon health

•  Increasing sophisDcaDon of lab uDlizaDon metrics in collaboraDon with PopulaDon and System AnalyDcs

•  EvoluDon: •  Total labs based on MEDC project •  NaDonal benchmarks: per visit, 1 vs 1,25 OH, and

benchmarking by CBC or Metabolic profile

Conclusions

•  'Value' and 'Value based' reimbursement models will influence the design and delivery of healthcare

•  Any lab (or non-‐lab) service that improves quality and reduces costs is valuable

•  Laboratories are strategically situated in value delivey. •  Centrality in the care episode •  ConnecDon to all specialDes •  Data handling capabiliDes

Conclusions

•  The challenges that the laboratories face are our: •  Self imposed isolaDon and sole focus on the analyDc step •  Limited understanding of how our customers uDlize our services

•  These challenges can be overcome by: •  CollaboraDng with providers through a structured process and framework

•  Making the clinical care processes more efficient by provision of correct and Dmely laboratory services, and measuring its financial and quality impact

perspectives from the system level, provider leadership, …€¦ · swot: weaknesses...

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