Data-driven Decision Making in the

Correctional Setting

Jane Leonardson, MDChief Medical Informatics Officer

John Pulvino, PA-CSenior Director, Quality and Outcomes

Amy Jo Harzke, DrPHSenior Biostatistician

Correctional Managed Care

The University of Texas Medical Branch

The University of Texas Medical Branch

Relationship Between TDCJ and UTMB

A Strategic Partnership between:

The Texas Department of Criminal Justice

The University of Texas Medical Branch at Galveston

Texas Tech University Health Sciences Center

Focused upon a shared Mission:

To develop a statewide health care network that provides

TDCJ patients with timely access to a constitutional level

of health care while also controlling costs

Managed by a statutorily established body:

The Correctional Managed Health Care Committee

CMC Unit Services FY17

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UTMB CMC provides medical, nursing, mental health and dental care at

83 TDCJ units to 119,000 patients

Outpatient Services Provided

Dental Mental Health

Telehealth Physiatry/Orthotics

Radiology Obstetrics/Gynecology

Physical Therapy Respiratory Care

Laboratory General Medical Visits

Dialysis Chronic Care Clinic

Optometry Assisted Living and

Hospice Dementia Care

Our goal is to provide state-of-the-art care to the

patients incarcerated in Texas Department of Criminal

Justice in the most efficient and cost-effective manner

possible

This is what UTMB-CMC has always done and now

the free-world is calling this:

VALUE-DRIVEN CARE

Which means: Getting the best care, supported by

data and at the best value

Goals of Data-Driven Decision Making

Employees: 3,000

Patients: 119,000

Facilities: 83

2 Regional medical facilities & 2 inpatient mental

health facilities

Hospital Galveston

Pharmacy in Huntsville

Specialized programs: HIV, Hepatitis C, Dialysis

& End Stage Liver Disease

Electronic Health Record (EHR) & Telehealth

UTMB CMC Overview

5

Electronic Health Record (EHR)

Implementation at UTMB-CMC 1999

1999—EHR implementation

The EHR is heavily customized by in-house

programmers and developers.

Automated pharmacy module tying patient information

to prescription data

Data collection within EHR is robust and has migrated

from scannable to “discrete” data

Foundation for dashboard creation allowing enhanced

population health metrics and monitoring

In 2017, there were 12,786,527 outpatient encounters

documented in the EHR

After 18 years of having an EHR, we have BIG DATA!

Implementation of EHR at UTMB CMC

Developed in 2014 by John Pulvino and several of his

colleagues

The dashboard is a central repository of many types of

information and is designed to produce POPULATION

HEALTH analytics, specifically for our population

Utilizes a data cube to query multiple data sets

Several iterations of data collection and enhancements to

reporting

Data is “real time”

Organizes data so that trends can be identified

Gathers data automatically to allow rapid, retrospective

analysis

CMC Dashboard Development

CMC Dashboard - How Does It Work?

Notify providers and management teams when they are

not hitting benchmarks

Give providers the tools to identify which patients need

extra attention

Alerts to unit management teams regarding standards not

being met

Use the data to identify processes that we can improve

and to measure improvement

Develop predictive analytics to estimate cost of care for

patient populations or to predict clinical outcomes

Intensive study by the Executive Quality Council to

identify problem areas and devise possible solutions

How is Data Used?

Dashboard

HEDIS Measures Used as Dashboard Metrics

Asthma Percentage of patients who were prescribed the appropriate treatment.

HypertensionPercentage of hypertension patients whose most recent blood pressure was < 140/90

Coronary Artery Disease Percentage of male CAD patients 21-75 years of age and female CAD patients 40-75 years of age who were dispensed a statin medication

Diabetes HbA1c Percentage of diabetes patients whose most recent HbA1c was <8%

Percentage of diabetes patients 40-75 years of age who do not have clinical cardiovascular disease who were dispensed a statin medication

Percentage of diabetes patients whose most recent blood pressure was less than or equal to 140/90

Nephropathy Screening

Mental Health Diabetes Screening Diabetes screening for People with Schizophrenia or Bipolar disorder who are using antipsychotic medication.

Glossary (just 2 of the measures)

Facility Dashboard

Org/Facility Drill Down (i.e. Prevention/Disease

Management)

Note: when

hovering over

data point, data

is present

Facility Scorecard

Facility Type……

Or Unit Name

Facility Compliance Map

Note:

Prediction

capability

Medication Administration

Note: when

hovering over

data point, data

is present

Corrections Health

Management Analytics

Alerts Summary By Unit

Measure Group: UTMB CMC TDCJ

Date of Alert: 5/9/2017

Summary of Unit Alerts sent for January/2017 CMC Dashboard Measures

Number of Alerts

Asthma Alerts: 28

Diabetes Alerts: 56

HTN Alerts: 57

Total Alerts: 141

Unit/Measure Actual Target

B MOORE (BM)

Asthma Care:

67%

90%

BARTLETT (BL)

Diabetes Care: BP <140/90:

50%

59%

BETO 1 (0B)

Asthma Care:

Under 60 Hypertension: BP <140/90:

Hypertension Total: BP Under Control:

89%

54%

54%

90%

56%

56%

Awesome Unit

Red Unit

Green Unit

Regional Management Team Alert Email

Asthma Care

CMC Target Goal: 90% National Average: 73%

Last 6 Months

August/2016: 100%

September/2016: 80%

October/2016: 80%

November/2016: 80%

December/2016: 75%

January/2017: 67%

Forecast

February/2017 74%

March/2017 72%

April/2017 71%

Corrective Actions May Include: Reevaluate the current active asthma diagnosis for

each patient not meeting goal. The number one reason

for failing this goal is an incorrect active diagnosis of

persistent asthma rather than intermittent asthma. If

the patient is diagnosed correctly with persistent

asthma, a steroid inhaler consistent with the current

asthma DMG will be required to meet goal. As

always providers should use their clinical judgment

when making diagnosis and treatment decisions.

See how your unit compares to other units for this

measure: Facility Scorecard

See how all CMC is performing on this measure:

CMC All Regions

HEDIS National Report Cards for this measure:

HEDIS

Corrections Health

Management Analytics

Unit Dashboard Alert!

Unit: BLUE

Date of Alert: 2/4/2017

The following January/2017 Dashboard measure for

the Blue facility is below goal and requires corrective

action. Patient lists for those not meeting goal are

available in the Dashboard “Patient List Spreadsheet”

section. Also please remember any measure falling

below goal must be addressed in the monthly facility

QIQM meeting including a detailed corrective action

plan.

Facility Management Team Alert Email

So what do we do with all of this cool data??

UTMB CMC Executive Quality Committee Flow

UTMB CMC Executive Quality

Council

UTMB CMC Regional Quality

Committee

UTMB CMC Facility Quality

Committee

CMC/TDCJ Mortality Review

Committee

TDCJ Quality Committees

UTMB CMC Peer Review

Committees

CMC Facility Dashboard

UTMB-Correctional Managed Care Executive

Quality Council Charter

Purpose:

The UTMB-CMC Executive Quality Council (EQC) provides

leadership, direction, and coordination of efforts to continually

improve health care outcomes, patient access to services and

information driven decision making. The Council is

accountable for clinical and process monitoring and outcomes

management, clinical resource and utilization management,

patient and employee safety, and risk management.

The Council carries out these responsibilities through

rigorous measurement processes, adherence to the CMC

clinical guidelines, policies and processes and promotion of

knowledge and use of performance improvement methods

and tools.

Lean Six Sigma

Monitoring metrics using the dashboard enables us

to better identify units where an intervention is

needed to improve actual performance in relation to

targets established

When unit management teams fall below the

thresholds established in the dashboard, the team is

required to submit a Corrective Action Plan (CAP)

designed to improve performance

Management teams are strongly encouraged to use

principles that all were trained on in the Lean Six

Sigma instruction that they all received

Corrective Action Plans

Performance Improvement Initiatives

Strong electronic data systems and frameworks

(e.g., EHR and CMC Dashboard) support

– Identification of problems

– Analysis of problems (i.e., “root cause” analysis)

– Improvement of processes

– Measuring improvement impact on effectiveness

and efficiency

– Continued monitoring and control of performance

What is Lean Six Sigma?

Continuous process improvement approach

Structured problem-solving framework

Fact-based, data-driven decision making methodology

Business excellence philosophy

A combination of Lean & Six Sigma, which are two different but complementary approaches to continuous performance improvement

– Lean emphasizes waste reduction & efficiency

– Six Sigma emphasizes consistency & effectiveness

Lean efficiency + Six Sigma effectiveness = Improved Performance

Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.

Why Lean Six Sigma?

Although Lean Six Sigma (LSS, hereafter) was originally developed for manufacturing/industry, it is being increasingly used and fully integrated into healthcare systems

Many major healthcare systems and hospitals have entire departments dedicated to performance improvement using LSS

– MD Anderson Cancer Center

– Memorial Hermann Healthcare System

– Virginia Mason Medical Center

– Mayo Clinic

– New York Presbyterian Hospital

– Johns Hopkins Hospital

LSS Education in CMC:

What Have We Done So Far?

Through a collaborative effort of the University of

Houston School of Technology and the

University of Texas School of Public Health, two

multi-disciplinary cohorts of CMC staff members

have

– Received LSS Green Belt Training

– Passed LSS Green Belt written exam

– Successfully completed improvement projects and

presented reviews of their completed projects to faculty

for full Green Belt certification

LSS Education in CMC:

What Have We Done So Far?

Developed a comprehensive, 6-module on-line LSS course for managers (July 2014 – October 2014)

– More than 500 individuals have successfully completed all modules as of September 1, 2017

Developed and delivered a 2-day (12.5 hours) classroom training for managers (January 2015 – August 2015;

July 2016)

– In 10 trainings across the state, 53 management teams & 265individuals trained

Developed a 7-module on-line training for all staff levels (October 2015)

– More than 2,000 individuals have successfully completed all modules as of September 1, 2017

Developed and delivered a 4-hour classroom training specifically tailored for executive and senior leadership(November 2015)

Teamwork in the Classroom!

The Numbers Game

Region 2 – Ferguson Club

House

The Marshmallow Exercise

Region 1 – Beeville Club

House

Teamwork in the Classroom!

Yellow Team

Analyzing Cause &

Effect

Green Team

Brainstorming

Improvements Blue Team

Selecting Solutions

LSS Engagement in CMC:

What Have We Done So Far?

All 53 manager teams that received the

classroom training initiated an improvement

project

As of September 1, 2017, 49 teams had

completed their improvement project,

having met and maintained their

performance targets

Management Team Projects

All 53 management teams that participated in an LSS classroom training initiated improvement projects, addressing a range of issues, such as

– Reducing no show rates

– Improving medication transfer unit to unit

– Improving/streamlining the sick call triage process

– Improving efficiency and effectiveness of flosser distribution process

– Reducing patient wait times

– Reducing the percent of patients arriving at HG but not being seen

– Improving patient throughput in the unit clinics

– Reducing shipping errors on expensive meds

– Improving and tracking workers compensation processes

– Improving hypertension control

Hypertension Control

51 50

43

60

75

75

68 67 6864

76 76

0

10

20

30

40

50

60

70

80

90

100

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

The team at one of our units was able to raise and maintain the rate of controlled hypertension among their patients <60 years of age

Pre-Implementation

Average=51%

Post-Improvement Average=71%

61%

78%

53%

88% 87%

75% 75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

% C

on

tro

lled

≤ 1

50

/90

Data Collection Month

BP Monthly % Controlled Post-Implementation

Monthly Average=74%

57%

32%

26%

47% 47%

53%

45%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% c

on

tro

lled

at

< 1

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Data Collection Month

BP Monthly % Controlled Pre-Implementation

Monthly Average=45%

Hypertension Control

Medication Compliance

Pre-Implementation

Medication Compliance

Post-Implementation

93

92

93

94

82

98

96

95

100

100

93

99

99

90

99

98

23

23

23

23

26

29

21

19

0 50 100

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

no medsordered

Non-KOP %

KOP %

98

97

98

98

98

99

100

95

99

100

100

100

100

100

0 20 40 60 80 100

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Non-KOP %

KOP %

Non-KOP Avg=97%, KOP Avg=93% Non-KOP Avg=99%, KOP Avg=98%

Monitoring & Control

Monitor the hypertension control data

monthly through use of the CMC

Dashboard

Declines in % under control addressed

through follow up with specific patients not

under control and with chronic care team

regarding process fidelity

LSS Engagement in CMC:

What Are We Doing Next?

Prioritize strategic objectives to guide selection of

targets & organization of staff for performance

improvement efforts

Integrate utilization of LSS methods into unit-based

performance improvement initiatives

Discuss, delineate, & document best practices for

specific processes (e.g., maintaining low no show rates)

Initiate discipline-specific discussions to address issues

and identify best practices (e.g., flosser distribution)

Collaborate with TDCJ on system-wide, highest priority

issues

Key References

DelliFraine JL, Langabeer JR, Nembhard IM. Assessing

the evidence of Six Sigma and Lean in the health

care industry. Q Manage Health Care. 2010; 19(3):

211-255.

Vest JR, Gamm LD. A critical review of the research

literature on Six Sigma, Lean and StuderGroup’s

Hardwiring Excellence in the United States: the need

to demonstrate and communicate the effectiveness

of transformation strategies in healthcare.

Implementation Science. 2009; 4 (35): 1-9.

Questions?

Working Together to Work Wonders 42