Transcript Measuring Clinical Value at the Besdide

Measuring Clinical Value at the
Bedside
Janice Thalman RCP,MHS-CL, FAARC
Duke University Medical Center
[email protected]
Objectives
• The evolution of value in healthcare
• Eliminating waste and maximizing value
• Respiratory care contributions to the
success of our health care system
• Critical considerations in staffing and
productivity management
The trouble with the future is that is usually arrives
before we’re ready for it.
Value Definition
• Shared goal that unites the interests and
activities of all stakeholders
• Defined as health outcomes achieved per
dollar spent
• Currently unmeasured and misunderstood
Value
• For patients it must become the overarching
goal of health care delivery
• Primary/Preventative care
– Measured for a defined patient group with similar
needs
• Medical Condition
– Multiple specialties and numerous interventions
– Combined efforts over full cycle of care
Value
• Value = results not input
• No longer volume of services delivered
• May spend more on some services to reduce
the need for others
• Mayo: Value = outcomes; quality; safety and
patient satisfaction divided by cost over time.
Value Culture
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Add value in quality outcomes, cost, customer
satisfaction
Embedding RT in clinical pathways
Protocol based services ( why we don’t need so
many ABG’s with vent patients)
Navigation of high ricks pulmonary patients
( COPD; asthma)
Pt education at Discharge
Smoking Cessation Consults
Pulmonary Rehab Screening
Collaborative
• 2012 High Value Healthcare Collaborative was launched
• 26 million $ grant funded by the Center of Medicare and Medicaid
Innovation
• Decrease utilization & cost by 64 million over 3 years
– patients are engaged and empowered to make health care decisions
based on own values and preferences.
• 6 leading health care organizations
• 150,000 patients
• Improve care and reduce cost
– Collect and exchange data on quality outcomes and cost for expensive
high-variation conditions and treatments
– Identify and Evaluate best practice health care models and innovative
value based payment
– Share knowledge and lessons learned with the public.
HVHC
9 Condition/Disease Areas
• Wide Variations in rates, costs and outcomes
nationally
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Total knee replacement
Diabetes
Asthma
Hip Surgery
Heart Failure
Perinatal Care
Depression
Spine Surgery
Weight Loss Surgery
MD Collaborative
• Complex delivery with interdependent teams
• Identify Practice variation
Outcome Dimensions
• Tier 1. The health status that is achieved or
retained
• Survival
• Degree of recover
• Tier 2. Recovery Process
• Time required and return to normal or best function
• Disutility of care or treatment process
• Tier 3. Sustainability of health
• Recurrences
• New problems as a consequence of treatment
HCAHPS Measures
• Nurse Communication
• Doctor Communication
• Pain Management
• Communication about Medications
• Cleanliness and Quietness of Hospital Environment (average of the 2
responses)
• Responsiveness of Hospital Staff
• Discharge Information
• Overall Rating of Hospital (excludes recommend hospital item)
AAA- Local level
• Availability, Affability, Ability
– Be here
– Answer pages and calls
– Be where the action (need) requires
– Be nice ( golden rule)
– Be a resource
– Be responsible to learning and advancing skills
( this is life support, not Wal-Mart )
Hard-Work- Local Level
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Scope of care
Relationship with the physicians
Reputation with airway management
Mechanical ventilator management
Consultation service
Technical edge
Research
Stamina
Love of the profession
Respiratory Therapy
Service Cost per Discharge
OPCSU
CHILDRENS
HEART
PULMONARY
GENERAL MED
NEUROSCIENCES
TRANSPLANT
GENERAL SURG
All OTHER CSU's
TOTAL RESPIRATORY CARE
COST PER CASE
FY2008 Q2
3,182,469
2,347,681
866,385
734,140
603,938
519,757
509,017
FY2009 Q2
3,923,981
2,692,609
1,009,742
761,548
713,854
798,325
474,327
Change
741,512
344,928
143,357
27,409
109,917
278,568
(34,690)
1,166,760
1,131,697
(35,063)
-3%
9,930,147
11,506,084
1,575,937
16%
964
1,204
239
25%
Impacting increase in Respiratory Therapy Costs
• Nitric Oxide
+127%
• Ventilator
+12%
% Change
23%
15%
17%
4%
18%
54%
-7%
Nitric Oxide D/C Protocols
• Meeting with key physicians
– Adult and ICN
– Identify clinical objectives
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Agreement on clinical conditions
Communication, education strategies
Rapid wean ( therapist driven)
Reduce total hours on Nitric Oxide
Replace NO with Iloprost
Quality and Patient Safety
Spontaneous Breathing Trial PI Project
Project Goal: Improve the % of patients that receive a spontaneous breathing trial
to assess readiness for extubation.
Importance: Part of IHI Ventilator Bundle to prevent VAP
Project Target: Achieve 90% compliance to fully achieve, 95% to exceed
expectations.
100%
95%
90%
85%
88.4%
88.4%
SBT
Target FA
Target EE
80%
75%
70%
65%
60%
1st Qtr FY 2nd Qtr FY 3rd Qtr FY 4th Qtr FY
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YTD
Leadership Focus in Shifting from
Volume to Value
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Quality and Safety
Enablers and Provision of Resources
Employee engagement
Service and strategy
Fiscal accountability
Vision and change
Value Culture
Behind Us
• Neb Jockey
• Concurrent Care
• Counting TX’s
• Activities
• Procedures
• Busy Hands
• Department success
Take Us Forward
• Quality
• One-on-one
• Protocols
• Outcomes
• Value Added
• Busy Heads
• Organization success
…Value is more than a set of skills
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Culture
Curiosity
Vision
Values
Passion
Scope
Reputation
Assets
Partnerships-Relationships
Mistakes
Take Us Forward Groups
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Intermediate Care
Core Teams- ICU
Emergency Response
Equipment
Cardio-Thoracic
I don’t want any yes men around me. I want the truth
even if it costs them their jobs.
Building the Structure to Support
Change
• Redesign care processes based on best practices
• IT that will improve access to clinical information
and clinical decision making
• Knowledge and skill management
• Development of effective teams
• Coordination of care across patient conditions,
services and settings over time
• Incorporation of performance and outcome
measurements for improvement and
accountability
I was going to buy a copy of The Power of
Positive Thinking , but thought What the
hell good would that do?
RCPs and Disease Management
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Physical exam and history
Home condition and family capability
Triggers to contact the MD, report to ER
Communication skills across encounters
Application of guidelines and protocols
Measure outcomes across the continuum
Relationship with MD office
COPD- and 30 Day Readmission
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Fourth leading cause of 30-day readmission
Significant cost, over 11 billion annually
Readmission cost of $20,757
30-day readmission rates as high as 28%
Assessment of care based on adherence to
guidelines suggest numerous opportunities
exist to improve COPD outcomes
Gary Brown, Patrick Dunne, COPD In-Patient Care: Time for a New
Paradigm. AARC Times November 2011
RCP Role in Avoiding
COPD Readmission
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Presence at the point of entry (ER/Clinic)
In-patient protocols/guidelines
Focus on evaluation and education
Discharge readiness and plan
Follow-up once home
Pulmonary rehab and clinic referrals
COPD Team/Specialist
Preparing the workforce for change
• Identify and agree on the steps and content
of communication
• Identify the platforms of communication that
will be used
• Identify the tree of communication; key
people per shift and area
Managing Change…
• Must continue to deliver quality work in the
midst of change
• Change has high emotional impact
• Phases of change
– Denial, mistakes, chaos, recovery
• Navigate change – Supportive communication
– Clarify, Share, engage
Communication Keys
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Clarify direction and expectations
Encourage participation and involvement
Support open communication
Lead by example
Reward and recognize
Support ongoing development
Supervisor and manager blood brothers
Defining Value
• Relative worth, merit, importance
• Value is often measured by the usefulness or
desirability of something
• Elimination of non-value/waste
Usefulness
Need/Desirability
Value 2015
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Reimbursement linked to quality
Emergence of Telemedicine
RC to evolve in complexity
Data driven clinical decisions
Protocol will be most common way to deliver RC
RC will need to be increasingly engaged with
research to demonstrate value of what they do
• Patients and families will play a greater role
• Information management system prevail
Kacmarek, RESPIRATORY CARE • MARCH 2009 VOL 54 NO 3
Reaction of Administrators
Beyond to 2012
– Customer satisfaction
– Outcomes focused
– Partnerships with providers
– New interest across the continuum
– Information technology
– Invest in what adds value
– Shift from volume to value
The First Step…
Why RCPs
• If someone else can do it better or for less cost, you will
not maximize overall efficiency for the hospital, despite
how good your productivity system is!
• You need to first define what RCPs do that is of unique
and unquestionable value:
▫ At the bedside 24/7
▫ Flex staffing models
▫ Cross utilization across procedures, units, sites, etc
▫ Intellect- experts in physiology/technology
▫ Broad legal scope with diverse skills
Therapist Workday per Hour per Area
Total: 6.12 Patient Care Hours
80
70
Minutes of Therapy
60
50
Total
6W
5W
11W
7W
BICU
5W
SICU
40
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Staff Reductions and Value
• Since value is defined as outcomes relative to
cost, cost reduction without regard to
outcomes achieved is dangerous and often
self-defeating.
• Can lead to short term “false savings” and
limiting the ability to provide effective care
• The best approach is often to spend more on
those services that reduce others
Porter, What is Value in Health care, NEJM Perspectives December 2010
Protocols
• All would agree that regardless how
productive your staff is, that time spent in
providing treatments that are not medically
necessary is not productive.
• You may be 100% productive in
performing 10,000 Med Aerosols per
month, but if only 4,000 are indicated, you
have wasted resources to provide 6,000
interventions, thus only 40% “effective
productivity”.
Effect of Reductions in Respiratory
Therapy on Patient Outcome
Zibrak JD, NEJM July 1996
• We studied the effect of the reductions in
respiratory therapy on patient outcome
• We conclude that consistent application of
prescribed guidelines for respiratory therapy
results in marked decreases in its use without
a reduction in the quality of care.
Value from Patients Perspective
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High-quality, appropriate care
Communicative providers
Human treatment
Access and availability
Environmental factors (Sleep, Food, Privacy)
Billing
Pichert JW, Vanderbilt University, Nashville TN
Bridging the Gap with Respiratory
Therapy
UNCC survey results
• 80% were either somewhat or not satisfied with
educational opportunities available to RTs
• 86% were interested in pursuing graduate education
in respiratory care or critical care medicine
• 49% were interested in midlevel practice
RT Gap
• Healthcare is experiencing a shortage of providers in
pulmonary and critical care medicine
• RTs with graduate education and specialized training in
pulmonary/critical care will increase access
• Utilizing RTs to augment the pulmonary/critical care
provider pool can positively effect primary care
• Respiratory care is overdue to academically meet
professions who were once peers
RT Gap
• Targeted outcomes studies
• Financial and economic studies
• Comprehensive comparison studies
• Workforce studies focusing on projected numbers of
midlevel providers needed in pulmonary and critical
care
39.5 Million Discharges Per Year
• 19%-post-discharge event
• 20% readmitted within 30 days ( Medicare)
I’ve tried relaxing- but I feel more comfortable tense.
Project Red
( Re-Engineered Discharge)
• Patient-centered standardized approach to
discharge planning and discharge education.
• Developed thru research funded by the
Agency for Healthcare research and Quality.
Resources
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High Value Healthcare Collaborative
Medpac - June 2007
J Gen Intern Med- Jan. 2011
Healthcare Cost and Utilization Project
American Journal of Resp. and Critical Care Med.-Jan. 2010
AARCTimes – Nov. 2011
Respiratory Care- March 2009/ vol.54 no 3
Pichert JW, Vanderbilt Univ.
Joint Commission Resources
– http://www.jcrinc.com/ahrq-project-red/
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Toffler and Associates
– Creating an agile healthcare organization
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New Eng J med 2010 363-2477-2481
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Michael porter PhD.
Journal of the Royal College of Physicians
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Charles RV Tomson