Dedication to Quality Improvement Delivers on the Triple Aim: Saves Tens of Millions Annually

Nicole Kveton, RN, BSN, MHAVice President, Allina Health Group Quality, Value, and Nursing

Sue Fairchild, PMP Program Manager, Allina Health Strategic Project Management Office

Session #16

Learning Objectives• Recognize how to broadly reduce variation, improve quality, and lower costs

across a multi-hospital health system. • Determine how to organize to effectively execute on a systemwide

improvement plan. • Illustrate how to use the information to identify improvement opportunities and

monitor progress.

Poll Question #1

How much effort does your hospital or health system put into reducing clinical variation compared to 2-3 years ago?

1) Less effort than before2) The same amount as before3) More effort than before4) Unsure or not applicable

Allina Health believes…

“Improving value requires improving one or more outcomes without raising costs, or lowering costs without

compromising outcomes, or both.”

Michael Porter and Thomas Lee, MD

Allina Health: Region’s Largest Health Care Organization

Allina Health is dedicated to the prevention and

treatment of illness and enhancing the greater health of

individuals, families and communities

throughout Minnesota and

western Wisconsin.

• 85 clinic sites and ambulatory care centers.

• 5,000 physicians.• 3.0 million+ clinic visits.• 12 hospitals.• 103,000+ inpatient hospital

admissions.• $4B in revenue.• 31% Twin Cities inpatient

market share.

Total national healthcare expenditures account for 17.1% of the GDP—projected to rise to nearly 20% by 2020.

$265 billion (30%) of healthcare spending is waste.17.1%

Creating Value Across the Continuum Imperative

Value/Volume industry shift• Clinical standardization is a cost imperative.

• Also, a critical aspect of achieving improved outcomes.

Increasingly competitive markets • Clinical and cost outcomes are pivotal to

maintaining and growing market share.

Better care/

experiencefor individuals.

Better healthfor the population.

Reduce per capita costs of care for

populations.

Organizational vitality.

Roadblocks to Improving Clinical Value at Allina Health

1 2 3 4 5

Large system.

Scarce resources.

Lack of awareness regarding value

of work.

Minimal visibility of implementations.

Need for greater prioritization of

improvement work across the system.

Turning Point

Market and system demands require a sharpened focus on identifying ways to fund Allina Health’s mission. 1. Increasing clinical value.

Gain a deeper understanding of how clinical quality improvements actually contribute to the margin.

2. Performance improvement initiatives spanning the organization.Strategic target = 3% margin. Requires identification of $50-$150M ofperformance improvement opportunities annually.

Action:Launch systemwide effort to measure clinical value by quantifying the value of our clinical change work to improve outcomes while reducing costs and increasing revenue for reinvestment in care.

Examples of Results Achieved Across the System

$210,000 in increased revenue because of improved access,

projected to be $280,000 within 12 months.

20.8% relative improvement in no-show rate.

20% increase in available ultrasound appointments and 18.2% increase in utilization.

Women’s Health initiative elevated the patient care

experience while simultaneously lowering the per capita cost of

care for each one.

$1.1M savings in less than one year.

31% relative reduction in length of stay (LOS).

17.4% relative reduction in median procedure time.

A minimalist approach to TAVRimproves outcomes and costs, yielded the following results:

7% relative improvement in the percentage of patients

therapeutic within 24 hours of protocol initiation.

Paring 20+ site-based documents (e.g., policies,

protocols, and order sets) to onesystemwide guideline and four

systemwide protocols.

Heparin improvement team has successfully improved

clinical value through processes of care and clinical outcomes

associated with IV heparin administration.

iCV Program Results3 Year Timeframe

PROCESS STEP

PRO

GR

ESS

CO

MM

ENTS

IDENTIFICATION

Opportunities reviewed, discussed and possibly shared with potential vehicle of change.• @ 100 Q314 – Q415.• @ 69 2016. • @ 90 identified for 2017

(portfolios).

By the Improving Clinical Value Analytics Work Group -opportunities from Lab, Pharmacy, SCM, TeleHealthClinical Data analysis (variation, LOS, PPC/R), as well as Clinician / Physician Driven

CHARTER DEVELOPMENT

Q314 – Q415• 49 project charters developed.2016• 40 project charters developed. Q117 – Q217• 17 project/program charters

developed.

By Implementation Leaders (Specialty Service Line Program Leaders / Project Managers)Started a quality assurance review step w/system wide representation from PI and PMO to ensure defined patient population, metrics and timeline.

VALIDATION

Q314 – Q415• 44 projects reviewed.• $26M validated.2016• 25 projects reviewed. • $12.1M validated.Q117 – Q217• 16 projects reviewed.• $8.6M validated.

By Finance Partners (Hospital Finance VPs/Directors and System Office Finance)

APPROVAL

Q314 – Q415• 40 projects reviewed and

approved.2016• 25 projects reviewed and

approved.Q117 – Q217• 24 projects reviewed and

approved.

By Hospital Presidents & Specialty Service Line Leadership

iCV Program Results3 year timeframe

PROCESS STEP

PRO

GR

ESS

CO

MM

ENTS

Hospital RESOURCE ASSIGNMENT

40 projects reviewed. 4 projects assigned hospital resources Q314 – Q415:• Sepsis - Start / Stop Infusion.• Mental Health - Alcohol Withdrawal.• Oncology - SSI/ERP.• Hospitalist - Standardizing Heparin.25 projects reviewed. 4 Projects assigned hospital resources 2016:• ED Nursing Documentation

Standardization.• ED Chest Pain.• ENT PTA.• ERP / SSI.

By Hospital Nurse Executive Council / Operational Executive Council and supported resource assignment when requested.

IMPLEMENTATION

@ 20 – 30 project status reports reviewed monthly.

Monthly reports from Implementation Leaders to Quality, Finance, SCM, Specialty Service Lines, Hospital, and IS leaders.

CLOSE

Many projects implemented and closed.

Implementation timeline completed, status reporting ceased, financial tracking for 12 months.

Setting the Course for Improving Clinical Value

iCV Program

Optimize outcomes, cost, and appropriateness of our clinical processes.

Value = Appropriateness (binary) * (outcomes / cost).

• Link clinical quality and fiscal rigor.• Save money in the short-run.• Form the core of our ability to be successful

in value-based reimbursement. • Use analytics to help identify the variation

and targets areas to improve care.

iCV Program Objectives

Enable and manage the paradigm shift of driving value in care delivery while taking out cost bybringing together

organizational stakeholders (multi-

disciplinary) to identify, prioritize,

and implement needed projects.

Enable consistent, accurate, and reproducible

identification and reduction of unwarranted

clinical variationacross Allina Health while maintaining or

improving patient care.

Develop and apply a prioritization approach by

determining the value of projects, enabling appropriate resource assignment (PI, PM,

IS, and vendor contracts as

applicable), as well as implementation

timing.

Identify, determine, and build evidence-based opportunities where providers are caring for patients

differently.

* SCM, pharmacy

Quality

Finance

Supporting Depts.*

Physician / Clinician

Operations

Value

iCV Program GroupStakeholder Representation

iCV Program Structure

Hospital Division Quality Committee

Hospital presidents

Clinical Information Performance Leadership

Team

Clinical Leadership Team

SUPPORT COMMITTEES

Executives

Program sponsors

Analytics work group

Implementation leaders

Financial benefit validation workgroup

Nurse Executive Council/ Operations Executive

Council

Performance Leadership Team

PROCESS COMMITTEES

iCV PROGRAM SPECIFIC

Quality

Finance

Supporting Depts.*

Physician / Clinician

Operations

Value

Implementing the Evidence-based OpportunitiesIdentification & Validation Implementation

Identify Opportunity for Program Committee:• APR data analysis.• Care Model change / Physician round table discussions / decisions.• Support departments:

• SCM.• Pharmacy.• TeleHealth.• Lab.

Prepare for Implementation:• Finalize charter development.• Understand and document change management (impact of change to

organization by role).• Assign Hospital Resources.• Assign IS Resources.• Develop implementation team.• Add (reassess system office resources).

Physician / Organization Interest?• Assess initial estimate / expectation.• Assign System Office Resources (Clinical Data Analyst / Finance Analyst / PI /

PM) – Develop assessment team.• Develop Charter / Business Case.

• Define Scope / AIM Statement.• Identify Metrics / Measurements (Quality, Patient Experience / Other).• Identify Stakeholders.• Develop timeline Milestones.

Execution:• Develop specific timeline with associated tasks.• Develop and implement communication plan for stakeholders.• Develop and implement training plan.• Implement change.

• Workflows.• Roles / responsibilities.• Excellian development.

Determine Value:• Utilize quality metrics and estimated risk to develop financial value to

organization ( + / - ).• Quality Assurance of Charter / Business Case / A3.• Validate financial value.

Monitor / Control:• Report monthly status to implementation timeline.• Track and report issues / risks / barriers to success.• Track financial impact to organization for 12 months.• Track quality metrics / balancing metrics.

Executive Review / Approve Close• Transition to business as usual / program committee.• Reassign resources.

As appropriate for size and complexity of work.

Opportunity IdentificationCollaboration across functions (finance, payer relations, and clinical leaders) and the use of analytics are critical to identify and shape opportunities.Key factors:

• Focus on clinical conditions with high cost and high variation.

• Look for the drivers of cost and variation by the nine part break categories.

• Examine variation by facility and/or provider.• Drill down to homogeneous patient populations

by segmenting on severity, diagnoses, procedures.

• Analyze the impact of other factors, such as LOS, PPRs, PPCs.

Further Segmentation By: Severity

level, dx, procOther Factors:

PPR, PPC, LOS

Opportunity

Variation by facility & provider

9 part break

(drivers)

Clinical Condition

(high $ opportunity

Opportunity Example EpilepsyRoom Costs (Opportunity $378k)

• Room cost variation is driven by consistent, longer LOS for specialist groups compared to shorter more variable LOS for hospitalists.

• Minnesota Epilepsy Group cares for one-quarter of the epilepsy patients with the remainder cared for by hospitalists.

• The majority of the opportunity is at United where the LOS exceeds GMLOS.

Source: GOAT DashboardSelections: July 2015 – June 2016; ICD Program Epilepsy; Outliers Excluded

Responsible Provider Group Volume

% with Neuro Consult

Performance to GMLOS

Room Opportunity

PPR A/E Ratio (Excess)

598 $378,872

Allina Medical Clinic -United Hospitalist Service 95 40% 103% $86,995 3.27 (9.0)Minnesota Epilepsy Group, PA 118 --- 145% $68,455 0.18 (-4.5)

Allina Medical Clinic -ANW Hospitalist Service 159 45% 92% $64,077 0.75 (-1.7)Cuyuna Regional Medical Center 27 52% 183% $48,955 0.00 (-1.4)Midwest Internal Medicine 48 90% 92% $28,259 1.44 (0.9)

Allina Medical Clinic -Unity Hospitalist Service 43 81% 87% $10,115 1.45 (0.6)Mercy HealthPartners Hospitalists 15 87% 82% $10,049 4.16 (1.5)Rotilie, Toman and McGraith LLC 10 20% 83% $8,322 0.00 (-0.2)Specialists with

long LOS and low variation.

Poll Question #2

How effective is your organization in using data to identify and reduce inappropriate variation?

1) Not effective2) Somewhat effective3) Moderately effective4) Very effective5) Unsure or not applicable

Determining Opportunity Value

Outlier Reduction• Reduce outlier practices in a smaller

number of facilities or providers.

• Provides more immediate results, but diminishing returns over time as outliers are reduced.

Shifting The Mean• Requires a change in practice

amongst the majority.

• Continuous focus on improvement: takes longer to achieve but drives long-term results.

Source: The Advisory Board Company, Crimson Continuum of Care. (2016). The care variation short list: Targeting high ROI opportunities for reducing care variation. Retrieved from https://www.advisory.com/-/media/Advisory-com/Technology/Crimson-Continuum-of-Care/Success-Pages/CCC_CareVariation_CG_011615.pdf

Opportunity Cases

Reducing Care Variation

Implementing the Evidence-based OpportunitiesIdentification & Validation Implementation

Identify Opportunity for Program Committee:• APR data analysis.• Care Model change / Physician round table discussions / decisions.• Support departments:

• SCM.• Pharmacy.• TeleHealth.• Lab.

Prepare for Implementation:• Finalize charter development.• Understand and document change management (impact of change to

organization by role).• Assign Hospital Resources.• Assign IS Resources.• Develop implementation team.• Add (reassess system office resources).

Physician / Organization Interest?• Assess initial estimate / expectation.• Assign System Office Resources (Clinical Data Analyst / Finance Analyst / PI /

PM) – Develop assessment team.• Develop Charter / Business Case.

• Define Scope / AIM Statement.• Identify Metrics / Measurements (Quality, Patient Experience / Other).• Identify Stakeholders.• Develop timeline Milestones.

Execution:• Develop specific timeline with associated tasks.• Develop and implement communication plan for stakeholders.• Develop and implement training plan.• Implement change.

• Workflows.• Roles / responsibilities.• Excellian development.

Determine Value:• Utilize quality metrics and estimated risk to develop financial value to

organization ( + / - ).• Quality Assurance of Charter / Business Case / A3.• Validate financial value.

Monitor / Control:• Report monthly status to implementation timeline.• Track and report issues / risks / barriers to success.• Track financial impact to organization for 12 months.• Track quality metrics / balancing metrics.

Executive Review / Approve Close• Transition to business as usual / program committee.• Reassign resources.

As appropriate for size and complexity of work.

Opportunity Conversion Steps and Timeline

Analysis Project Charters Completed

Quality Assurance andFinancial Validation

Review / Approval

January March March AprilApril June May JuneJuly September July / August September

October November October / November December

Quarterly project submission aligns with implementation leadership desired timing as well as hospital planning.

Project Charters due June 5th or sooner for Q2 submittal.

iCV 2017 goals

$12 million positive margin impact by expense

reduction and additional hospital in/outpatient

revenue through addressing clinical variation and

improving and standardizing care processes.

To efficiently and nimbly navigate volume

to value, we will understand the value of

our work prior to implementation.

Identify $25 million in improvement

opportunity for 2018 in preparation for Allina

Health budgets.

In a data-driven, multidisciplinary team effort, Allina Health organized and implemented a

systemwide program to measure the value of their clinical standardization and improvement efforts.

Lessons Learned

Minimize outside distractions—pave the way.

Success is multidimensional—true “systemness.”

Enable collaborative dialogue.

Future Plans

Continue to strengthen the utilization of the value process to enable business as usual behavior.

Thank You