3 strategies for maximizing service line efficiency, …...2014/11/03 · 3 strategies for...
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3 Strategies for Maximizing Service Line Efficiency,
Quality, and Profitability
Miki Patterson PhD RNFA ONPVince Capasso, MSF, FACHE, MBB
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Speakers
• Certified Orthopedic Nurse Practitioner
• Over 30 years of clinical experience in healthcare, consulting, RNFA, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing
• Past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care
• Dr Patterson has done extensive work with hospital leadership desiring to improve their clinical quality and process issues while teaching change management and giving voice to clinicians and hospital personnel.
• PhD in Nursing Research from University of Massachusetts Medical School, a Master’s Degree from Boston College, and her B.S. in Nursing at Fitchburg State University
Miki Patterson PhD RNFA ONP
Miki Patterson, PHD ONPSenior Director,
Intralign Intelligent CareDesign
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Speakers
• Certified Six Sigma Master Black Belt and Fellow in the American College of Healthcare Executives
• Over 30 years of Business, Process Design, Strategy Deployment, and Balanced Scorecard experience in a broad variety of organizations that include consulting, government, manufacturing, service, and healthcare. His business experience includes executive leadership positions in Accounting, Finance, IT, and Supply Chain functions.
• Vince has managed hundreds of complex Process Improvement and Strategy Deployment projects. He has taught extensively on Lean Six Sigma, Human Centered Design, and Strategy Deployment; has developed Lean-Six-Sigma and Change Management courses for many global organizations, and has been published in national journals on the subject.
• Master of Finance degree from Bentley University and a B.S. of Accounting degree from Southern New Hampshire University 3
Vince Capasso
Vincent Capasso, MSF, FACHE,Six Sigma Master Black BeltSenior Director, Operational
Process CareDesign
Objectives
As a participant, you will be able to:
• Identify key operational and clinical indicators of orthopedic service line efficiency
• Describe how Surgical First Assists can add value in the OR
• List the steps in developing and/or evaluating or building an orthopedic service line
• Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line
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Healthcare in TransitionProviders must increase efficiency and control
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When outcomes are linked to reimbursement, providers must drive towards value based care.
Rehab$5,000 (10%)
AcutePost-Op
$5,000 (10%)
Intra-Operative$22,500 (45%)
Implant 41%Hospital 45%
Clinic/“Pre-hab”
$15,000 (30%)
Admission/Pre-Op
$2,500 (5%)
Sample of Total Joint Service Line Cost
• Roughly 45% of Episode costs are incurred in the intra-operative space
• Controlling the intra-operative space is key to improving efficiency, reducing cost and increasing quality
• Control begins in the Operating Room with efficient surgeon extension
• To gain Total Joint Service Line Excellence status, data transparency, process refinement, marketing and supply chain excellence are also needed
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Episode of care costs
Bending the Cost Curve
• Alignment of surgeons and hospitals; clinical and operational goals
• Integration of tools and strategies to enhance transparency and accountability
• Change management – Strength and capability to affect lasting, sustained change
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Innovative Vision
1. Alignment Alignment of Surgeons, Clinicians,
and Hospital with Patient Needs
Alignment
Why isn’t everyone on the same page?
The right tools can bring clarity to goals and objectives and create a common purpose.
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It takes some work!
3Ps of Alignment
Process
People
Purpose
Purpose
• Is Direction Clear? • Is the message Heard & Understood?• Are we using the right metrics?• Do we have a Strategy Deployment Process?
Process
• Are staff and managers trained in problem solving?• Is there a structured Process Improvement
Methodology?• What is the level of Efficiency? • Does the Organization utilize standard work?
People
• What is the level of Staff Satisfaction?• Are we Patient-Centric? • Are there Appropriate Resources?
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First, understand the various voices you will hear. Each has a different perspective.
Voice of the Customer (VOC)
• Used to describe customers’ needs and their perceptions of your services, product, or process.
Voice of the Business (VOB)
• Used to describe your business’ needs in creating the service or product.
Voice of the Process (VOP)
• Used to describe the current state of the process; how is the process performing. Is it capable of meeting customer needs?
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Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Management & Staff
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Education and Staff DevelopmentEquipment
CultureTrust/Cohesiveness/Accountability
TeamworkIntra Dept.
Financials
RO
SE /
Po
siti
ve
BUD / Opportunities
THORN / Problems
C-Suite Leadership“Revolving door”
Patients
SurgeonsIT Systems
MD Engagement
Staffing Levels
Facilities
Engagement
Efficiency
New Ventures
TeamworkInter Dept.
CultureAutonomy & Environment
New “learning” Leadership
Staff Flexibility
Surgeons not Engaged
Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Patients
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Not answering call-bells promptly
Great Nurses
RO
SE /
Po
siti
ve
Room has a View
Surgery went Well
Food is Very Bad
Was in Pain Waited a LONG Time
Nurse did Not Listen
Crowded and Loud Hallways
Would Like to have meal time flexibility Facilities need
upgrading
The Doctor is not always listening
Lots of noise
Receptionist was Rude
Great PT Staff
My Surgeon is Abrupt
BUD / Opportunities
THORN / Problems
Summarize the “Voices” and Synchronize with Strategy
Voice of The Business
Voice of The Process
Voice of The Customer
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2. Closing Operational Gaps Understanding Gaps Between
Current State vs. Desired Future State
Service Line Excellence The Drivers of Service Line Excellence
Infrastructure and Practices in Place to Drive Continuous Improvement
Service Line Integration & Efficiency: Patient Care Journey
Supply Chain Best Practices
Clinical & Operational Excellence:Pre-Op, Intra-Op, Post-Op
Effective Governance within a Just & Safe Culture
Effective Information Systems Structure & Analytics
Optimized Financial Management
Alignment of Partners Across the Continuum of Care
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Clinical and Operational Excellence
Efficient, Safe, High Quality Processes
Appropriate/Optimized Staffing
Effective/Efficient Sterile Processing
Employ Best Clinical Practices
Patient-Centered Care
% of patients with medical clearance 14 days prior to surgery
% charts with History & Physical complete 10 days prior to surgery
85% + On Time First Case Starts
Time patient waits in holding area
Frequency of same OR team operating together
Staffing levels are appropriate based on predictive modeling
Avg Turn Around Time < 21 min
Standard process in place and followed for OR set-up
Defect-free transfer of patient to PACU
Patient assessment complete and documented within 30 minutes of arrival in PACU and every hour thereafter
Driver Critical to Success
Indicator Critical to Success
Metrics
How Does The Critical-to-Success Tool Work?
Big Goal
Goal Driver #1
Goal Driver #2
Goal Driver #3
Critical to Success Indicator 1
Critical to Success Indicator 2
Critical to Success Indicator 3
Goal Drivers Critical to Success Indicators
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Building the Critical-to-Success Tree
Drivers are like themes. They frame and compartmentalize the goal.
Increase Ortho
Margin
Strong Surgeon Alignment
Surgical Process Efficiency
Best Practice Implant Management
Standardized Processes
Patient-Centered Care
Goal Drivers
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Building the Critical-to-Success Tree
Critical to Success Indicator (CTSI)
These are another layer of compartmentalization. They break down the drivers into measurable areas.
Increase Ortho
Margin
Strong Surgeon Alignment
Surgical Process Efficiency
Best Practice Implant Management
Standardized Processes
Patient-Centered Care
Goal Drivers Critical to Success Indicators
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Building the Critical-to-Success Tree
Increase Ortho
Margin
Strong Surgeon Alignment
Surgical Process Efficiency
Goal Drivers Critical to Success Indicators
Co-Management Agreement in Place
Surgeons Are Engaged
Best Practice Processes
Hospital provides consistent surgical teams
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Building the Critical-to-Success Tree
Co-Management Agreement in Place
Surgeons Are Engaged
Best Practice Processes
Hospital provides consistent surgical teams
Critical to Success Indicators Critical to Success Metrics
On Time Starts at 85% +
75%+ of Surgeons participate in shared governance activity
20-30% of compensation is tied to gain sharing
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Timeline: Knee Replacement Observation
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Illustrating Pain Points9:45 10:45 11:15 11:45 12:15 12:45 1:15 1:45 2:15 2:458:45 10:159:158:157:45
Pt. in Room10:22
Tourniquet Off
12:05
Time Out10:26
Incision10:56
Surgeon Exit12:35
Dressing On12:49
Pt. Arrives in Pre-Op 8:30
Patient Waits67m
Anes. Arrives for Nerve Block8:57
Patient Waits27m
2nd Time Out10:53
Nerve Block Induction
9:15
Patient Wheeled Out
12:56
Spaghetti Diagram: Hip Surgery
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Metric Mapping
Key | # of In & Outs
Surgeon: 1
RN Circulator: 16
Device Rep: 9
Scrub Tech 1: 1
Scrub Tech 2: 6
Scrub Tech 3: 5
PA: 1
Anesthesia 1: 0
Anesthesia 2: 1
Other: 2
Total: 42
Value Stream Map : Flows and Waste
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3. Implementing Change Using the Correct Tools and Approach
to Move the Organization to a New Reality
Identify “Quick Wins” First
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Quick Wins
1 Update white Boards - room and Central (time slots for discharge and rehab)
2 Discharge Education Class - Pilot
3 Night before discharge call to family for transport
4 ON-Q ordering process / Improve
5 Nursing pain management assessment/training (i.e. heel slide to check pain)
6 Room discharge clearing for cleaning: belongings, CPM, tubes, meds, etc..
7 “Room Dirty” notification process
8 Sleeper sofa/plan around overnight
9 Potential for CPM install in AM/tech - day of discharge
10 Unit TV with Ortho-specific media content
11 Consider switching rehab gym with waiting room gym
12 PACU and TJ Floor use dual monitors | PACU needs Teletracker monitor, TJ Floor needs PICIS monitor
Plot projects based on Resources and ROI
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High
Med
Low
Low Med High
Return on Investment: Hard $ only
Res
ou
rces
Req
uir
ed
(tim
e, e
ffo
rt, s
taff
, co
st)
Improve Time Out
Disposable Supply Improvement
– Outside OR Core
Cell Saver Analysis/Redesign
Antibiotic Cement Analysis/
Redesign
Improve Discharge Process
Streamline Surgical Flow
Reduce Case Time Late Starts
Maintenance and Equipment
Improvement
Surgical Set Analysis/Flow
Roadmap of High-Impact Tactical Projects | Example
Improve Surgical Scheduling
Staff Resource Planning
Disposable Supply Improvement –
OR Core
Medicare TJA Bundled Care
Data Mapping
Revenue Cycle Assessment
TDABC Model
TJA Supply Chain Implant Cost
Medicare Pricing Accuracy
Improve TJA Education
What will give you most benefit for least effort?
Week 1-3
Week 4
Week 5
Week4-15
Week 16
Assessment
Project Kick-Off
Roadmap Remaining
Projects
Onsite
Remote Coaching
Onsite
Remote Coaching
Onsite
Remote Coaching
Co-creation, Recommendations, & Pilots Dashboard Implementation
100 Day Sprint Methodology
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Process Transformation: Project ExamplesSample Results: Peri-Op Infection Rate Reduction
Total Joint infection rates were at 3% vs a national average of .72%.
After 6 months the total joint infection rate was 0% resulting in a projected savings of $1.4 million per year through avoidance of extended length of stay/treatment and readmission.
Problem Result
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Sample Results: Surgical Cancelation Rate Reduction
The cancellation rate dropped to 6% and identified the potential to improve margin by 1.4M with estimated margin impact for FY 2013 of $500K.
Problem Result
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The surgery cancellation rate was consistently high for three years, at 13% at the time of engagement.
Process Transformation: Project Examples
Intelligent Process TransformationSample Results: Supply Chain Efficiency
The hospital was experiencing high supply cost, increasing OR supply chain labor cost, stock-outs and excess inventory.
Reduced total supply inventory by $670K. Reduced supplies on specialty carts by $70K and reduced labor cost of $80K.
Problem Result
Before After Before After
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“Sales reps have created this necessity for themselves with the surgeon, and we’re saying it’s not as necessary as everyone thinks it is.”
Justin Freed, Executive Director of Supply Chain at Loma Linda University Medical Center
Source: Lee, Jaimy. "Devicemaker Sales Reps Being Replaced in the OR." Modern Healthcare 16 Aug. 2014
The Role of the Sales Rep
• Lack of price transparency and rep presence leads to unnecessary up-sell
• Rep or multiple reps in OR slows room turnover
• Clinical support provided by the rep is not free – charged through hefty SG&A implant cost
Influencing the Cost of Orthopedic Implants
The result: Loss of control, reduced efficiency and higher supply costs.
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Effective Support of Operational & Clinical EfficiencySpecialized SFAs – the Smarter Alternative
Low High
Doctors assisting Partners
Practice Employed SFAs
Freelance SFAs
Hospital Employed SFAs
Specialized SFAs
Advanced Surgical Support Adds Value in the OR
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Skill Level / Efficiency
Consider Advanced Surgical Support
Experience Matters: University of MD St. Joseph Medical Center Case Study / 2013 data
Specialized Surgical First Assists are a Highly Skilled Group of Surgeon Extenders
ProcedureActual
procedure time
Typical procedure
time*
# of 2013 procedures
Minutes freed
General Surgery 100 138 1123 42,674
Urology 205 270 117 7,605
GYN 128 138 80 800
*Estimated average surgery time without SFA is based on 2012 Medicare data and top HCPCS codes associated with each procedure area. 36
Sustaining the Gains Maintaining Accountability, Automating
Dashboards and Linking Metrics to Projects
Maintaining the Gains / Strategy Execution
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Use Dashboards to track key metrics
Strategy
Goals
Projects
Metrics
Responsible
Maintaining the Gains / Strategy Execution Using your Critical to Success Metrics focus your data collection on the metrics that drive success
Strategy
Goals
Projects
Metrics
Responsible
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Thank You