1

Andrew Buchert, MD

Gabriella Butler, MSN, RN

Driving High-Value Care via Clinical Pathways

2

Gabriella Butler, MSN, RNManager, Clinical Resource Management,

Clinical Analytics, and Data ScienceChildren’s Hospital of Pittsburgh of UPMC

Andrew Buchert, MDMedical Director, Clinical Resource Management

Children’s Hospital of Pittsburgh of UPMC

Assistant Professor of PediatricsUniversity of Pittsburgh School of Medicine

3

Disclosures

• We have no financial conflicts of interest to disclose.

• UPMC utilizes Cerner, Epic, and Qlik software.

4

Goals of this session: • Implement clinical pathways that will lead to critical process

improvement as well as advance the strategic mission of the organization

• Identify measurement tools that integrate outcomes, practice patterns, and cost data to achieve maximum impact of pathways of care

• Develop clinical pathways that span and link the entire continuum of care, including PCP offices and community resources

5

Children’s Hospital of Pittsburgh of UPMC• 315-bed free-standing quaternary care pediatric

hospital - 41 bed ED and Trauma Center- 36 Bed PICU- 12 Bed Cardiac ICU- 55 Bed NICU

• 21,800 Admissions- Inpatient- Observation- Same-Day Surgery Extended Recovery

• 80,000 ED visits

• 23,500 Surgical procedures

• >1 million outpatient visits

6

Primary Care and Referral Network• Children’s Community Pediatrics (CHP)

- 40 locations- More than 150 pediatricians- Primary care- Same-day sick appointments- Embedded behavioral health services

• Children’s Express Care (CHP)- 7 locations- Walk-in, after-hours care- Pediatricians from CCP- Evenings and weekends

• Other pediatric primary care groups- Pediatric Alliance, Kids Plus Pediatrics

7

• More than 30 academic, community, and specialty hospitals in Pennsylvania and New York State

• Hospitals and partnerships in more than 9 countries• Integrated health care delivery and finance system, with a health plan covering

more than 3.2 million members

8

9

High-variability between episodes of care and

across the continuum of care

Limited measurement of reliability to guidelines

Minimal outcomes data

Opportunities to improve patient and family

satisfaction due to perceived care discordance

Quality outcomes, patient safety, satisfaction, and

cost are driven by standardized delivery of care

across the continuum

Delivery of consistent, high-value, evidence-based

care

Meaningful and actionable data available in real-time to frontline caregivers

10

11

Evidenced-based and technology-enabled Clinical Pathways

Pre, during, and post-admission

High-cost and high-volume pediatric conditions

High-Value Care at CHP

12

Desired OutcomesReduce

• Unnecessary variation in care• Unplanned Readmissions• Acute care Length of Stay (LOS)

Improve • Outcomes (Quality, Safety & Financial

metrics)• Continuity of care (pre and post

admission)• Patient, Family & Provider satisfaction

Eliminate • Non-value added testing• Waste

13

DataWarehouse & Clinical Applications

Team

Nursing Informatics

FinanceClinical Champions

Analytics TeamPresident

CMIO/CIO

Manager, Clinical Resource

Management, Analytics, Data

Science

VPMAMedical Director, Clinical Resource

Management

14

15

Clinical Effectiveness Guideline Clinical Pathway

Evidence-Based Evidence and consensus-based

Limited Education Formal education and rollout

Variable interdisciplinary collaboration Inter- and Multi-disciplinary

Focused settings of Care Across the Continuum

Real-time measurement & feedback loop

Strategic Alignment

16

Impact

Health of Patients

Individual Patients

i.e. Reducing readmissions, LOS, infection rates, central

line utilization

Population

i.e. Reduce exposure to unnecessary care, focus on

health promotion & wellness

Organizational Systems of

Care

Processes, workflow, patient flow

i.e. Improving throughput, decrease bed utilization,

enhance medication delivery

Hospital and Health System

Economics

i.e. Improve revenue and decrease at-risk revenue,

reduce variability of controllable costs

Strategy

i.e. Create buy-in for additional pathways, promote and support

service-lines, grow market

17

Evaluation and Selection Process

Decision: Clinical

Pathway or Guideline

Internal Analysis

Peer Benchmarking

Hospital-Peer ALOS

Expected LOS/Observed

Hospital-peer CH CMI (LOS

Based)

Hospital-peer CH CMA LOS

Hospital-Peer LOS

LOS

COST

Volume

Predicting potential impact through the analysis of actual clinical & financial data,

per CHP DataWarehouse, Cost Management System, & PHIS

18

Is this potential pathway practical at this time?• Do we have the capacity?• Would all of the stakeholders have buy-in?

Do we have the resources to support this potential pathway?• To perform an analysis of the current state/weigh pros and cons• To develop and support the pathway - includes data analysis, PowerPlan development &

QlikView dashboard

What evidence is available? • Is this an existing (In-house) clinical effectiveness guideline?• Is there peer-reviewed, published evidence?• Do any of our peer institutions have a clinical pathway or guideline?

Additional Considerations…

19

1 • Idea Generation

2 • Identify Team

3 • Gather Evidence

4 • Design & Development

5 • IT Build

6 • Education & Rollout

7 • Measurement & Feedback

8 • Disseminate Knowledge

20

Process1.

• Idea Generation• What is the projected Impact

• Is it practical?

• Is it the right time?

2.

• Identify Team• Pathway Champions

• Nursing, Physician & Ancillary Stakeholders

3.

• Gather Evidence• Literature Research

• Benchmarking

• Market Survey

4.

• Design & Development• Define Patient Population – Inclusion & Exclusion Criteria

• Define “On” vs “Off Pathway”

• Select KPIs, outcome, and balancing measures

21

Process5.

• IT Build• PowerPlan (Order set)

• Dashboard

• Clinical decision support

6.

• Education and Rollout• Pathway Champions and key stakeholders

• Coordinators and Educators

7.

• Measurement and Feedback• Pathway champions and key stakeholders

• Leaders

• Frontline staff, including nurses, residents, fellows

8.

• Dissemination of Knowledge• Internal and external sharing of process and impact

• Publication

• Patient and family materials

22

23

Physician APhysician BPhysician CPhysician D

24

Physician APhysician BPhysician CPhysician D

25

Physician BPhysician CPhysician DPhysician EPhysician FPhysician GPhysician H

Physician APhysician B

Physician CPhysician DPhysician EPhysician FPhysician GPhysician H

Physician A

Physician B

Physician APhysician B

Physician A

Physician B

26

Complicated Appendicitis

Consensus for Management

Obtained

153155

97

42

0

50

100

150

200

250

300

LOS

(ho

urs

)

Median LOS/month (hours)

Median LOS UCL Average LCL

Consensus for Management Obtained

PowerPlan Available

27

Uncomplicated Appendicitis

3836

28

1817

22

27

32

37

42

47

LOS

(ho

urs

)

Median LOS/Month (hours)

Median LOS UCL Average LCL

Consensus for Management Obtained

PowerPlan Available

28

29

Planned Cholecystectomy

23

27

12

6

11

16

21

26

31

36

LOS

(ho

urs

)

Median LOS/month (hours)

Median LOS/month (hours) UCL Average LCL

Consensus for Management Obtained

PowerPlan Available

30

All Peer Hospitals Select Peer Hospitals CHP

1020 patients out of 3865 (26%) spent at least 1 day in a NICU

171 patients out of 625 (27%) spent at least 1 day in a NICU

41 patients out of 87

(47%) spent at least 1 day in the

NICU

Patients with Principal Dx Hyperbilirubinemia 7/1/14-6/30/15

Isolated Neonatal Hyperbilirubinemia

31

*Represents 78 IHB Patients admitted to the Neonatal Service between

Jan15-April16

**Represents 42 IHB Patients admitted to a General Pediatrics Service between

Jan15-April16

Internal Comparison

54

3733

13

5

15

25

35

45

55

65

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

LOS

(ho

urs

)

LOS for IHB patients admitted to Neonatal Service*

(includes ED LOS)

32

23

15

5

15

25

35

45

55

65

LOS

(ho

urs

)

LOS for IHB Patients Admitted to General Pediatrics**

(includes ED LOS)

32 *American Academy of Pediatrics, Clinical Practice Guideline, Management of Hyperbilirubinemia in the Newborn

Infant 35 or More Weeks of Gestation, PEDIATRICS Vol. 114 No. 1 July 2004

Maybe the patients we admit to the NICU are sicker?

33

Isolated Neonatal Hyperbilirubinemia

UCL

2723

20

LCL 14

10

15

20

25

30

35

40

45

50A

pr-

15

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

LOS

(ho

urs

)Median LOS/Month (hours)

Data1 UCL Average LCL

Consensus for Management Obtained

PowerPlan Available

34

Dissemination of Data

Frontline Staff (Nurses, APPs, Residents, Fellows, Attending Physicians)Clinical ChampionsPhysician Leadership (Division Chiefs, Clinical Directors)Nursing Leadership (Unit Directors, Senior Nurse Leaders)Residency Program LeadershipHospital Leadership

35

Summary Stats

Surgical Pathway Metric FY15 FY16 FY17 FYTD18(July17-Nov17)

Complicated Appendicitis

Pathway

Number of Encounters 125 106 111 62

Percentage of Patients that went to IR Post-Op 23 (18%) 16 (15%) 12 (10%) 6 (9%)

Percentage of Patients "On Pathway" Pre-Op 66% 75% 80% 82%

Percentage of Patients "On Pathway" Post-Op 47% 50% 60% 66%

LOS (hours) 130 hours 101 hours 99 hours 89 hours

Readmissions within 30 days not available not available 15.52% 12.9%

Uncomplicated Appendicitis

Pathway

Number of Encounters 312 338 325 144

Percentage of Patients that went to IR Post-Op 0 0 0 0

Percentage of Patients "On Pathway" Pre-Op 76% 79% 84% 81%

Percentage of Patients "On Pathway" Post-Op 10% 36% 46% 44%

LOS (hours) 33 hours 30 hours 27 hours 28 hours

Readmissions within 30 days not available not available 8.97% 0.7%

Planned Cholecystectomy

Pathway

Number of Encoutners 66 101 90 27

Percentage of Patients "On Pathway" Pre/Intra-Op NA NA 71% 55%

Percentage of Patients "On Pathway" Post-Op NA NA 92% 94%

LOS (hours) 27 hours 26 hours 9.5 hours 9 hours

Readmissions within 30 days not available 6 (6%) 0 0

36

Clinical Condition MetricPre-

PathwayPost-

Pathway Pre vs Post

Complicated Appendicitis

Median Length Of Stay (hours) 117 92 -25 hours 21% decrease

% Patients Requiring Interventional Radiology Procedures Post-Op

17% 11% -6% 35% decrease

Uncomplicated Appendicitis

Median Length of Stay (hours) 32 28 -4 hours 12% decrease

% Patients receiving post-op Antibiotics 13% 9% -4% 31% decrease

Planned Cholecystectomy

Median Length of Stay (hours) 26 9 -17 hours 65% decrease

30-day Readmissions 6% 0% -6%100%

decrease

Isolated Hyperbilirubinemia

Median Length of Stay (Admitted Patients; hours)

32 25 -7 hours 22% decrease

Median Length of Stay (Pts discharged from the ED; minutes)

206 180 -26 min 13% decrease

Cellulitis/Simple Abscess

Admission percentage (based on ED visits) 31% 25% -6% 19% decrease

Imaging Utilization (beyond X-Rays & US) 12% 7% -5% 42% decrease

37

Controllable Cost* Savings

Patient PopulationFY17 Savings per

EncounterNumber of Encounters

Complicated Appendicitis 7.30% 111

Uncomplicated Appendicitis no change 325

Planned Cholecystectomy 15% 90

Cellulitis/Simple Abscess 18% 525

*Actual cost of medications, supplies, lab/radiology studies, nursing care hours, blood products

38

Post-Op Pathway Adherence Nov 17:1 patient did not have a clear liquid diet ordered before they arrived to the inpatient unit

Pre-op Pathway Adherence Nov 17:100% patients had all pre-op elements met

Target: 80%

0%

20%

40%

60%

80%

100%

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

May

-16

Jul-

16

Sep

-16

No

v-1

6

Jan

-17

Mar

-17

May

-17

Jul-

17

Sep

-17

No

v-1

7

Ad

he

ren

ce (

%)

Percentage Adherence to Complicated Appendicitis Pathway (Pre-Op & Post-Op)

39

8

1

0 2 4 6 8 10

Did not receive appropriate*antibiotics within 60 min prior to

surgical incision

NPO not ordered pre-op

Reasons Patients "fell off" Pre-Op PathwayNov17

Target: 80%

0%20%40%60%80%

100%

Ad

her

ence

Pathway Adherence: Uncomplicated Appendicitis Pathway (Pre-Op & Post-Op)

1

4

7

1

1

0

0 5 10

No Order for "Out of Bed" before transferring toacute care

No order for Saline Lock

No Order for Regular or Advanced Diet beforetransferring to Acute Care

Pt did not have PO Narcotics ordered beforetransferring to acute care

Antibiotics were ordered post-operatively

Additional Labs were Collected Post-op

Reasons Patients "fell off" Post-Op PathwayNov 17

40

Cellulitis/Simple Abscess - Nov 2017

Patients "Off Pathway"

Disposition

Imaging Lab

Clindamycin

Route

Appropriate*

Yes = US/X-Ray

only or none

Yes = CBC,

BMP, or none

No = any other

imaging

No = ESR, CRP,

and/or blood

cultures

Patient 1 Discharged from ED Yes No No

Patient 2 Discharged from ED Yes No Yes

Patient 3 Discharged from ED Yes No No

41

Cellulitis/Simple Abscess

173 min

288 min

0

50

100

150

200

250

300

350

400

450

LOS

(min

)

ED Median LOS/month (minutes) n=582

On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway"

42

Cellulitis/Simple Abscess7 Patients with C & A admitted to Pediatrics Service (1 direct, 6 from the ED) in Nov

• 2 (29%) “On pathway”

• 5 (71%) “Off pathway”

1

5

0

0 2 4 6

Imaging: Pt had imaging beyondUS/Xray

Lab: Pt had lab work beyond CBC/BMP,including ESR, CRP and/or Blood…

Clindamycin Route*: IV was giveninstead of PO

Reasons Patients "fell off" Pathway

*Clindamycin • PO is preferred• IV only if:

• NPO • GI symptoms/unable to tolerate PO

43

Cellulitis/Simple AbscessPatients admitted to the General Pediatrics Service

23 hrs

33 hrs

0

10

20

30

40

50

60

70

80

LOS

(ho

urs

)Median LOS/month (hours)

n=246 patients admitted to Gen Peds with Simple C&A

On Pathway Centerline "On Pathway"

44

Bronchiolitis85 Patients with Bronchiolitis treated and released from the ED

• 53 (62%) “On pathway”

• 32 (38%) “Off pathway”

0

0

20

7

2

2

8

0 5 10 15 20 25

RVP was collected and sent

RSV was Collected and Sent

Patient had Imaging (CXR)

Patient Received Antibiotics

Patient Received Steroids

Deep Nasal Suctioning was Performed

Pt Received Respiratory Treatment

Reasons Patients "fell off" Pathway

45

Bronchiolitis

45

126

162

0

50

100

150

200

250

LOS

(min

)Median ED LOS/month (minutes)

n=1,124 patients with Bronchiolitis

On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway"

46

Bronchiolitis13 Patients with Bronchiolitis admitted to Pediatrics Service from the ED (no direct admissions)

• 3 (23%) “On pathway”

• 10 (77%) “Off pathway”

00

52

32

57

0 1 2 3 4 5 6 7 8

Respiratory Viral Panel Collected

RSV Collected

Patient Had Imaging (CXR)

Patient Received Antibiotics

Patient received Steroids (PO or IV)

Pateint was placed on Continuous Pulse Oximetry on the inpt Unit

Deep Nasal Suctioning was Performed

Patient received Respiratory treatments

Reasons Patients "fell off" Pathway

47

BronchiolitisPatients admitted to the General Pediatrics Service

47

23

20

0

10

20

30

40

50

60

70

LOS

(ho

urs

)Median LOS/month (hours)

n=208 admitted to Gen Peds with Bronchiolitis

On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway"

48

FY 18 Pathways• Cellulitis/Abscess – completed (Aug 1)

• Bronchiolitis – completed (Oct 1)

• Asthma – completed (Nov 1)

• Constipation – Go-live Jan-18

• Diabetes Mellitus – Go-live Feb-18

• Migraine

• Sepsis

• Pyloric Stenosis

• Inpatient brain MRI

• Vascular Access

49

Improving Asthma Care Across the Continuum

50

Improving Asthma Care Across the Continuum

• Create consistency in definitions, workflows, management– When to Step-Up / Step-Down therapy– When to refer

• Improve the patient/family experience– Common educational materials and Action Plan– Appropriate expectation setting

• Enhance communication• Mitigate barriers to optimal health

51

52 Thank you!