improving quality and safety through care delivery redesign-steve narang

Clinical Process Redesign (CPR) The Resuscitation of an Academic Medical

Center

Steve Narang, MD, MHCM Chief Executive Officer

Banner – University Medical Center Phoenix

ENDLESS POSSIBILITIES.

• 29 Acute care hospitals and healthcare facilities

• 47,000 employees; largest private employer in Arizona

• Truven Analytics Top 5 large Health Systems (more than $1.5 billion total operating expense)

Banner Health

• 733 bed Academic Medical Center

• Teaching Hospital for University of Arizona College of Medicine Phoenix

• ACS Level 1 Trauma Center

• Magnet™ Recognized

• 3,814 Employees

• 1,529 Medical Staff members

• 336 Allied Healthcare Providers

Banner – University Medical Center Phoenix

Vision & Strategy

Vision for Banner University Medical Center Phoenix

• Highly coordinated destination for patients and families to experience value-

based care, including the treatment of highly complex diagnoses-

INSTITUTES

• Attract world-class physicians and members of multi-disciplinary teams to

participate in an environment of teaching, scholarship, and clinical

improvement

• Invite faculty to work alongside to contribute and deliver excellent outcomes

• Improve value through reduction of clinical variation and cost

• Use the science of healthcare delivery to engage physicians, medical

students, and staff in the improvement journey

Financial Performance

• 2013-2014

• Despite double digit increases in Inpatient Admissions, OR

cases, Endoscopies, Cath Lab Procedures– Net Revenue

had decreased YOY by over 10% leading to an operation

margin of only 2 %

– Multiple Reasons

» Degradation of Payer Mix

» Revenue Cycle

– Senior Leadership Team decided to use this opportunity to

launch a campus wide Engagement Effort to align Physician

Expertise and Leadership towards ‘Clinical Process Redesign’

(CPR) with a focus on reducing waste in key clinical processes

and misuse and overuse of supplies and pharmaceuticals.

7

Transparent outcomes data Analyze

variation

Identify

best

practices

Change

behavior

Feedback

and

learning

Publish

and share

outcomes

Results

Delivering superior outcomes that

attract patient volumes

Eliminate costs that do not

improve care

Create incentives for innovative

and better dialogue with research

Engage staff in improvement

efforts

1

2

3

4

Strategy – High-value Performance Improvement Teams

Source: Adapted from BCG Perspectives ‘The Value-Based Hospital’ – September 2014

Using high-value PI teams increase quality of care while reducing cost for a diagnosis

The Improvement Journey

Build the foundation

facility level infrastructure to support improvement projects

Identification of at least one PI project for each department that utilizes the tools of performance improvement

Education of at least 50% of BUMCP employees on performance improvement

Utilize the tools of PI

“Improve the way we improve” – focused effort on utilizing the tools of performance improvement related to three key themes:

1. Efficient & Timely Care

2. Patient Safety

3. Patient Experience

Disciplined Execution

Continue improvement journey

Each department to identify one PI project related to Efficient & Timely care and Patient Safety.

Design interventions, implement, and remain ‘in control’

2016 2015 2014

Clinical Process Redesign (CPR) to Reduce the Milliman Index (observed/expected LOS for key /DRGs)

The top ~25% of the DRGs (by total bed days) account for ~80% of the total bed days at BUMCP

Generate 80% of the Bed Days

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

% of Days

% of DRGs

Concentration of Bed Days

Cumulative Percentage of Bed Days vs. Percentage of DRGs

Total = 182k Days

Total = 714

DRGs

Focus on top

~25% of DRGs to

reduce LOS

There is significant variation in Average Length of Stay; ~56% of DRGs have a standard deviation of more than 2 days

~56% of the DRGs have an ALOS standard deviation of >2 days

Variation in Average Length of Stay (ALOS) Distribution of DRGs by Standard Deviation in Days

Total = 424 DRGs1

13%

43%

11 - 15 Days 6 - 10 Days

0%

2 - 5 Days 1 - 2 Days

31%

<1 Day

13%

1. DRGs with less than 10 cases have been excluded

Source: Banner – University Medical Center Phoenix Finance – Timeframe 3/2014 – 3/2015

We utilized a decision tree analysis to estimate potential savings through reduced patient days

Total Patient Days

Reduction in Patient Days if All

DRGs < = 25th Percentile

Reduction in Patient Days if All

DRGs < = 50th Percentile

Bottom 75% of DRGs Top 25% of DRGs

Process Flow Issues (Admitting, Discharge

Planning, etc.)

Coding Issues Variation in Care

Practices

Step 1: Identify

improvement range

1

Step 2: Prioritize within

selected range

2

Step 3: Identify

operational drivers for

change

3

ALOS Decision Tree Analysis

Focused DRG driven approach to reduce length of stay,

focusing on three key elements (Process flow issues, coding

and documentation, and variation in care practices).

27 Clinical Process Redesign teams currently assessing and redesigning practices in key clinical areas

Advanced Lung Institute & Critical Care

Medicine

Sepsis

Pneumonia

COPD

Cardiovascular Institute

Heart Failure

Stents/AMI

TAVR Program

Digestive Institute

Whipple Care Pathway

Pancreatitis

Endocrine and Diabetes

Hypoglycemic Management

Hepatobiliary

Encephalopathy

Musculoskeletal

Geriatric Fracture Care Pathway

Hip Fracture Care Pathway

Neuroscience/Neurosurgery

Spinal Fusion Care Pathway

Observation Length of Stay

Chest Pain

Women’s Health Institute

Normal Delivery

Wound Care Institute & Infectious Disease

Cellulitis Care Pathway

Transplant

Kidney Transplant Rejection Care Pathway

Urology

Stone Management

Clinical Documentation Improvement (CDI)

Pharmacy & Supply Variation Reduction

The team has developed a standardized care pathway for Heart Failure patients

Define

Identify best practices supported by evidenced based research and literature

Draft standardized clinical pathway to share with other stakeholders

Design

Create strong implementation toolkit to share knowledge with stakeholders (Providers, nursing, ancillary, case management, etc.)

Operationalize design work of the team

Implement

Implement the care pathway; monitor performance; establish accountability for results

BUMCP Heart Failure Clinical Pathway

We have identified two significant drivers of length of stay management for Heart Failure patients

Discussion

Obtaining an accurate daily weight is negatively correlated to

length of stay. That is, patients who are weighed daily are more

likely to have a lower length of stay (Milliman < 1.000).

Accurate, daily standing weight measurements are important

for length of stay management

Daily Weight & Milliman’s Index BUMCP Heart Failure Patients DRG: 291- 293 (Jan – Sep 2015)

Avg. Daily Lasix Dosage (mg) & Milliman’s Index BUMCP Heart Failure Patients DRG: 291- 293 (Jan – Sep 2015)

Discussion

Average daily Lasix dosage is negatively correlated to length of

stay. That is, patients with higher daily dosages of Lasix are more

likely to have a lower length of stay (Milliman < 1.000).

Aggressive Lasix dosing is critical to managing patient

length of stay.

A real-time report has been created to address accountability to the care pathway and provide a daily weight and Lasix trend

for Heart Failure patients

16

BUMCP Current Patients in House – Daily Weights

Trend by Day

BUMCP Current Patients in House – Total Lasix Administered

Trend by Day

Lasix dosage not appropriate

Daily weight not recorded

Heart Failure: Significant improvements seen in weight compliance and accuracy; 94% of patients received daily

weights

17

0

10

20

30

40

50

60

70

80

90

100

Ja

n-1

6

Oct-

15

Se

p-1

5

Au

g-1

5

Ju

l-15

Ju

n-1

5

Ma

y-1

5

Apr-

15

Ma

r-15

Fe

b-1

5

Ja

n-1

5

Apr-

16

Fe

b-1

6

De

c-1

5

No

v-1

5

Ma

r-16

Avg. Daily Lasix

Lasix on Day 0

Daily Wt %

Wt Accuracy %

BUMCP Heart Failure (DRG 291-293) Key Clinical Indicators

By Month, 2015-2016

Discussion

Significant improvements in daily weight capture and weight accuracy driven by nursing

Daily weight compliance improvement to all time high of 94% of weights captured and recorded daily

Continue to engage providers around appropriate diuretic dosing with awareness surrounding improved weight compliance and management

Intervention

1.019

1.194

1.393

0.840

0.9501.029

1.110

1.234

0.819

1.0951.0761.139

0.926

1.350

1.0480.997

Apr-

16

Mar-

16

Feb-

16

Jan-

16

Dec-

15

Nov-

15

Oct-

15

Sep-

15

Aug-

15

Jul-

15

Jun-

15

May-

15

Apr-

15

Mar-

15

Feb-

15

Jan-

15

Milliman’s Index has improved for Heart Failure patients during 2016 with our refocus with a 73% reduction in average patient length of stay days

18

BUMCP Heart Failure (DRG 291-293) Milliman’s Index

By Month, 2015-2016

BUMCP Heart Failure (DRG 291-293) Average LOS (Days)

By Month, 2016

Discussion

Length of stay for heart failure has improved during 2016YTD with a 73% reduction in overall average length of stay

Significant predictors for LOS include daily weight accuracy/timeliness and appropriate diuretic dosing; performance for both measures declined in 2016 causing

longer patient length of stays for these months. Patient acuity also a causal factor as CMI was all time highest in Jan of 2016 for this population.

5.65

Feb-16

6.80

Jan-16 Apr-16

4.90

-73%

Mar-16

5.00

BUMCP Performs More Whipple Procedures than Any Medical Center in the Southwest – 84 in 2015

15.2

9

0

5

10

15

20

BUMCP Mass General*

2015 Average Length of Stay

Project

Aim

Create a Whipple Care Pathway that incorporates evidence based research in perioperative care and

leads to a reduction in the overall length of stay, while maintaining excellent outcomes and

readmission rates.

Key

Findings

1. Post-surgical use of opioids for pain control leading to decreased ambulation and GI function

2. Opportunity to accelerate post-surgical clamping and intake schedule

3. Preoperative education and nutrition

Key

Pathway

Changes

1. Preadmission education on procedure, nutrition, spirometer,

2. Epidural analgesic to manage pain post-surgically

3. Avoidance of opioids for pain management – combination of epidural and NSAIDs

4. Accelerated post-surgical nutrition and tube clamping

*Average 9 day LOS since 2010. Fernandez-del Castillo, Carlos, et.al. Evolution of the Whipple procedure at the Massachusetts General Hospital,

Surgery, 5/2012

Da

ys

Whipple : Post-Implementation Month 4 – Epidural Comparison

15.21

12.25

14.44

0

2

4

6

8

10

12

14

16

2015 Prior to Go-live (n=52)

Post-implementation with Epidural (n=21)

Post-implementation without Epidural (n=11)*

Average Length of Stay

200

1413

0

200

400

600

800

1000

1200

1400

1600

Post-implementation with Epidural (n=21) Post-implementation without Epidural (n=11)

Average Total Opioid Usage During Inpatient Stay (Converted to PO Morphine in mg)

Notes: Data pulled from Cerner via Business Analytics; Data run 2/3/16; Cases originally scheduled for Whipple but not

done were omitted.

* Adjusted for patients with Length of Stay over 22 days due to complications

TAVR Update

Key Issues

Variation among cardiologist LOS

Team Activities

Structural Heart Service Line Goal: Manage patients undergoing specific structural heart procedures through a focused, collaborative team that will admit, manage and discharge the patients in a coordinated, safe and efficient manner.

Procedures that fall under the Structural Heart Service Line:

– TAVR

– Mitraclip

– Watchman

Structural Heart Rounding Team: Formal, scheduled rounds to allow for in-person exchange of information to ensure the goals and plan of care for each patient are clear to all members of the team. Ensure the patient/family unit receive consistent and accurate information.

Team Members:

– Structural Fellow

– Clinical Nurse Specialist

– Social Worker

– Case Management

– Physical Therapy

– Cardiac Rehab

– Pharmacy to reconcile meds

– CT NP

Implementation Week of May 16

5.2

6.3

4.6

3.6

5

18 16 19 10

63

0

10

20

30

40

50

60

70

0

1

2

3

4

5

6

7

TAVR 2016 YTD

ALOS Total Patients

Lumbar Spinal Fusion Update

Key Issues

• Delays in discharge by hospitalists, per Surgeons

• Improve rounding times for specific Surgeons

Team Activities

• Detailed review of outliers with Dr. Kumar next week to communicate – Discharge timelines

• Meeting with Dr. Menendez on data and cost for support

1.9

1.3

1

50 49

37

0

10

20

30

40

50

60

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

January February March

Lumbar Spinal Fusion 2016 YTD

Milliman Total Patients

Kidney Transplant Rejection - Update

Key Issues

Team Activities 1. Provided data and analysis to Dr. Hodges for Infusion

Center Infrastructure enhancements to discharge and/or manage rejection outpatient

2. Developed integrated process flow to discharge patients for outpatient treatment

3. Reviewed pricing comparison for drug therapy for inpatient vs. outpatient cases

4. Case Management identify unintended consequences for discharging patients

5. Define Transplant Institute next Steps for NP management of patients discharged to outpatient

6. Dr. Zuhl engaged in reviewing patient cases and providing feedback on improved efficiencies with Hospitalists

2.1

1.6

2

1.162

2.283

9 7

13

4

28

0

5

10

15

20

25

30

0

0.5

1

1.5

2

2.5

January February March April 2015

Kidney Transplant Rejection 2016 YTD

Milliman Total Patients

The team is developing a glycemic control pathway to reduce the number of hypoglycemic events (BS < 70) for inpatients

Initial Findings

Significant opportunity for all patients with diabetes

(expected LOS was 4.40 days in 2014 when patients

actually stayed 5.70 days).

Expected direct variable costs per patient was $11,983

when actual cost was $16,989.

Discussion

Evaluated data for n=3393 Type II DM patients admitted to

BUMCP between Jan’15 to July’15 with chart reviews to

identify possible causes for hypoglycemia.

Rate of hypoglycemia in Type II DM patients admitted to

BUMCP is 18%.

4.96

9.36

4.18

5.91

No Hypoglycemic Event

+19%

Hypoglycemic Event <70

+58%

Avg Arith LOS Expected - CS Sel

Avg Arith LOS Observed

5.705.505.37

5.164.97

4.384.59

4.83

2013 2011 2012 2014

Arithmetic Observed LOS (Days) Arithmetic Expected LOS (Days)

Observation Lap Appy and Chole clinical pathway and caresets have an anticipated implementation of June 2016

25

22.92

29.2028.10

20.42

40.25

Apr-16 Jan-16

-13%

Mar-16 Feb-16 May-16*

BUMCP Lap Appy/Chole Observation LOS (Hrs.)

By Month, 2016

Key Drivers

Measuring current performance/scorecard

Provider Coding Education

Pain Management

Enteral Management

Discharge Pathway & Patient Education

Care pathway currently being developed and refined –

connecting to system observation LOS team

WIS team continues to focus on reducing length of stay for three key DRGs

26

Q1 2016

1.82 1.86

Q4 2015

1.87

Q2 2015

2.01

Q1 2015

2.08

Q3 2015

BUMCP DRG:775 Vaginal Delivery w/o Complications LOS (Days)

By quarter, 2015-2016

Q4 2015

3.09

Q3 2015

3.13

Q2 2015

2.93 2.94

Q1 2016

3.16

Q1 2015

BUMCP DRG:766 Cesarean Section w/o Complications LOS (Days)

By quarter, 2015-2016

1.76

Q1 2015

1.70

1.76

Q2 2015

1.66

Q3 2015

1.64

Q1 2016 Q4 2015

BUMCP DRG:795 Normal Newborn w/o Complications LOS (Days)

By quarter, 2015-2016 Discussion

Incremental improvements (2% reduction) in average length of

stay days for normal newborn deliveries quarter over quarter

during Jan 2015 to Feb 2016.

Expected length of stay is 1.79 days.

2015 LOS index of 0.89; best in Banner System*

Discussion

Incremental improvements (3% reduction) in average length of

stay days for vaginal deliveries without complications quarter over

quarter during Jan 2015 to Feb 2016.



Discussion

Opportunity still exists for cesarean section without complications;

significant reduction seen during Q2 and Q3 2015, but trending

upward.



*): Using geometric mean; excludes facilities with patient counts of <500 patients per year – source Premier Cs-Select

We have developed a high level scorecard for each Clinical Process Redesign project to monitor key

process and outcome measures

27

PRELIMINARY

28

PRELIMINARY

Milliman’s Index (LOS)

2014: 1.030

2015: 0.966

Preliminary data estimates a Milliman’s index of 0.936 for April 2016*

31

-95

222

0.938

0.9300.930

1.025

-1,000

-900

-800

-700

-600

-500

-400

-300

-200

-100

0

100

200

300

0.91

0.92

0.93

0.94

0.95

0.96

0.97

0.98

0.99

1.00

1.01

1.02

1.03

Opportunity

Days

-386

0.962

Jan-16

-309

0.969

Dec-15

-785

0.920

Nov-15

-551

Oct-15

-706

Apr-16

0.936

Mar-16

-957

0.914

Feb-16

35 1.004

-633

Milliman’s

Index

May-15

-692

Apr-15

-288

0.970

Mar-15

88

1.009

Feb-15 Jan-15 Sep-15

-517

0.944

Aug-15

0.990

Jul-15

-217

0.977

Jun-15

-447

0.953

Patient Days

Milliman’s Index

*) Apr 2016 data is preliminary and includes encounters from Apr 1, 2016 – Apr 25th, 2016 that have been coded; Excludes DRG: 246, 277, and 518-520

Source: Encoder 3M; 2015 Milliman’s Index expected LOS benchmarks

CPR to Reduce the Misuse and Overuse of Pharmaceuticals in the Management

of Clinical Conditions

Pharmacy drug cost averages $718 per adjusted weighted admission for Jan-Apr 2016 with an unfavorable variance of

$1.4MM year to date

33

$251

$96 $110$138

$142 $133$108

$138

$79$111

$127$130 $132 $129

$508

$667

$412

$552$593

$608

$470 $501$527 $430

$677 $588

$445

$631

$711

$469

$32$39$34$37$47$41$41$43$41$0$0

$876

$622

$24 $26

Apr-15

$688

Mar-15

$703

Dec-15

$738

Nov-15

$776

$21

Oct-15 Feb-15

$710

Jan-15

$549

Mar-16 Apr-16 Feb-16

$789

$28

Jan-16

$587

$16

Jul-15

$641

$29

Jun-15

$793

May-15

$729

$602

Sep-15

$659

$23

Aug-15

$671

731850 IV Solutions 733105 Infusion Drugs 733100 Pharmaceuticals

BUMCP Pharmacy Cost per Adjusted Weighted Admission 2015-2016 by month; AU:1122100 Pharmacy-Hosp in ($)

We identified several cost drivers and have focused our opportunity analyses surrounding the four key themes

34

Standardizing Practice

Developing specific inclusion and

exclusion criteria for when a

medication should be ordered and

administered

Preserving more expensive drugs

as a last resort when less

expensive first line therapies are

available

Other

Only allowing single dose orders;

no PRN or scheduled

Removing drug from care set

Evaluation of evidence and

literature to support the continued

use of drug

Enact “one time only” utilization

Remove from Formulary

Removing high cost drugs and auto

substituting equally efficacious

alternatives supported by evidence

based literature

Utilization of patients’ home

medications when available

Alternative Therapies

Identification of lower cost and

equality efficacious drug therapies

supported by evidence based

literature

Cost Drivers Grouped by Theme

112 preliminary cost savings hypotheses have

been identified by the Pharmacy CPR team

Potential cost savings of $590K-944K

identified

Next steps include prioritizing list of hypotheses for implementation and connecting with physician stakeholders

and councils to drive change

35

Opportunity Testing Cost Baselining &

Hypothesis Identification

Recommendations & High-Level

Implementation Plan

2 1 3

Prioritize improvement opportunities for

analysis

Analyze and validate high potential

improvement opportunities

Develop rough estimate of opportunity size

and time, cost and risk to implement

Obtain and validate pharmacy

administrations and spend at the patient

level

Build baseline of drug costs and cost

drivers

Conduct stakeholder interviews to

understand current operations and

processes

Analyze relative cost/pricing of key

services

Develop initial long list of opportunity

hypotheses

Prioritize opportunities for

implementation

Develop final list of recommended

opportunities

Refine financial and time estimates

Develop integrated,

high-level implementation

plan and timeline

Today

Pharmacy Clinical Redesign Approach to Developing Recommendations

Each hypotheses to be ranked and prioritized for

implementation based on “ease of implementation” and

“likelihood of cost savings”

Prioritization of the 112 cost saving hypotheses is underway with alignment to physician specialty and

stakeholders.

Alternative Therapies

36

Medication Name Description – Medication type (What is

it?) and what is the alternative therapy?

Patient

Count (Q4 2015)

Total

Quantity (Q4 2015)

Cost

per

Unit (Q4 2015)

Total

Pharmacy

Spend (Q4 2015)

Potential

Savings (Q4 2015)

Range of

Expected Benefits (Annualized)

Physician

Lead/ Institute

Alignment Low High

DAPTOmycin 500 MG SDV INJ

Vancomycin first line for suspected MRSA-

Even if in AKI still OK to use vanco (consult

pharmacy to help dose)

71 594 $373.62 $221,930 $109,421 $218,842 $350,147 Dr. Yu

LINEZOLID 600 mg RTU-PB PO Linezolid OR vancomycin first line for

suspected MRSA 46 400 $42.50 $17,000 $16,626 $33,252 $53,203 ID

LINEZOLID 600 MG TAB Vancomycin first line for suspected MRSA 25 114 $16.27 $12,730 $4,329 $8,658 $13,853 ID

MICAFUNGIN 100 MG in 100 mL

NS

Fluconazole should be used FIRST ( see

pharmacy guidelines for use) 72 690 $68.77 $47,451 $36,314 $72,628 $116,205 ID

TOBRAMYCIN 300 MG/5 ML UD

INH SOLN IV tobramycin 17 238 $40.79 $9,708 $9,473 $18,946 $30,314 ID/Pulm

acetaZOLAMIDE 500 MG INJ Furosemide IV 20 115 $19.38 $2,228 $976 $1,952 $3,123 Cardiology

ARGATROBAN 250 MG in 250

mL NS Fondaparinox 5 25 $768.08 $19,202 $4,129 $8,258 $13,213

Cardiology

CISATRACURIUM 10 MG/1ML

20ML SDV INJ

Provider Preference - alternative therapy

(rocuronium) if normal renal fucntion. Will

need cistracurium if renal dysfunction

8 19 $155.19 $2,949 $1,532 $3,064 $4,902

MILRINONE 20 mg in D5W 100

mL RTU-IV Dobutamine 57 303 $29.47 $8,930 $3,460 $6,920 $11,072 Cardiology

BRINZOLAMIDE 1% OPH SUSP DORZOLAMIDE 2% OPH SOLN 10ML 6 7 $231.59 $1,621 $1,567 $3,134 $5,014

Total Savings Cost in $ $375,654 $601,046

Remove from Formulary

37



Patient

Count (Q4 2015)

Total

Quantit

y (Q4 2015)

Cost per

Unit (Q4 2015)

Total

Pharmacy

Spend (Q4 2015)

Potential

Savings (Q4 2015)

Range of


Physician

Lead/ Institute

Alignment Low High

ETHACRYNATE 50 MG INJ Other loop diuretic desensitization 2 3 $4,283.1

7 $12,850 $12,850 $25,700 $41,120 Cardiology

FOLIC ACID 5 MG/ML 10ML

MDV INJ PO folic acid 50 150 $32.30 $4,845 $4,839 $9,678 $15,485

MVI-12 10 ML SDV INJ PO MVI 55 172 $6.95 $1,195 $1,190 $2,380 $3,808

COMBIVENT RESPIMAT ORAL

INH Albuterol UD SVN Inh + Ipatropium UD SVN Inh 24 36 $228.50 $8,226 $8,209 $16,418 $26,269

Dr. Saggar/Lisa

DeRosa

COLESEVELAM 625 MG TAB Statins 3 54 $2.68 $145 TBD TBD TBD AMS / Cardiology

LANSOPRAZOLE 30 MG

DISSOLVE TAB PO pantoprazole or IV pantop if NPO 135 1313 $11.38 $14,942 $10,943 $21,886 $35,018 GI - Dr. Mills

ESTRADIOL VAG CR Hold med while in house OR have patient bring in from home 2 2 $193.82 $388 TBD TBD TBD

EZETIMIBE 10 MG TAB Hold med while in house OR have patient bring in from home 48 273 $8.07 $2,203 TBD TBD TBD

ERYthromycin 500 MG INJ Metoclopramide 5mg IV 18 71 $45.40 $3,223 $3,146 $6,292 $10,067 GI

ERYthromycin ES 200 MG/5 ML

BQ LIQ Metoclopramide 5mg PO 18 51 $321.34 $16,388 $16,384 $32,768 $52,429 GI

METHOCARBAMOL 1

GRAM/10ML SDV INJ Pharmacy to change to PO 9 55 $27.92 $1,536 $1,523 $3,046 $4,874 AMS

NITROPRUSSIDE 25 MG/ML

2ML SDV INJ Nicardapine / cevidipine 4 36 $820.10 $29,524 $13,450 $26,900 $43,040 Cardiology

Total Savings Cost in $ $145,068 $232,109

Standardizing Practice/Reducing Utilization

38



Patient

Count (Q4 2015)

Total

Quantit

y (Q4 2015)

Cost per

Unit (Q4 2015)

Total

Pharmacy

Spend (Q4 2015)

Potential

Savings (Q4 2015)

Range of


Physician

Lead/ Institute

Alignment Low High

ALBUMIN 25% 100 ML INJ

Potential savings is based on being able to

better standardize use.

341 1992 $37.56 $74,820 TBD TBD TBD Dr. Khurana

kidney/hepatology

ALBUMIN 25% 50 ML INJ 76 449 $37.56 $16,864 TBD TBD TBD Dr. Khurana

kidney/hepatology


kidney/hepatology


kidney/hepatology

AZTREONAM 2 GRAM INJ

Better standard practice needs to be

implemented to preserve more expensive

abx / broad spectrum. Should be used if no

other options available.

6 35 $48.61 $1,701 TBD TBD TBD ID

CEFTAROLINE 600 MG in NS 50

mL IVPB 9 95 $127.33 $12,096 TBD TBD TBD ID

ERTAPENEM 1 GRAM INJ 100 356 $68.35 $24,333 TBD TBD TBD ID

DESMOPRESSIN 4 MCG/1 ML 1

ML INJ

No other therapy available - should be

preserved for pt definite or suspected uremic

bleedine / DI

30 189 $38.13 $7,207 TBD TBD TBD Endo / SAFA

OCTREOTIDE 500 MCG in 100

mL NS Provider pref. Stop date for 2 days 110 469 $12.51 $5,867 TBD TBD TBD GI

EPOETIN 10,000 UNIT INJ

(DIALYSIS)

Should not be given if Hg > 11/12 -- often

times Hg is not checked prior to

administration

84 236 $112.16 $26,470 TBD TBD TBD

Total Savings Cost in $ TBD TBD

CPR to Reduce the Misuse and Overuse of Supplies in the Management of Clinical

Conditions

BUMCP Supply Costs

Reduce Variation & Waste Target High Volume/High Dollar

Opportunities Step 1: Define key supply cost

driver & goals

Step 2: Prioritize by Highest

Opportunity Areas

Step 3: Determine solution to

affect key driver

Identify Opportunities for

Vendor/Pricing Negotiations

Standardize

preference cards

for high volume/

variation

procedures

Immediate

opportunities

Identify high

volume, cost and

variation

procedures

Eliminate

multiple

manufacturers of

‘same use items’

Immediate

opportunities

Review and

consider

alternatives for

highest cost items

Identify lower cost

opportunities for

high-cost items

Improve utilization

of volume

discount

Negotiate vendor

discounts and

pricing volume in

high value areas

Align with

corporate supply

savings

initiatives

Identify missed

volume

discounts by

vendor

Elimination of

unused or low

usage high-cost

items

Highest opportunity areas included

immediate opportunities…low

hanging fruit

Goal - Utilize a three prong approach – Reduce Variation and Waste; Target High Dollar/High Value

Opportunities; and Identify Vendor/Price Negotiations to achieve a Average Supply Cost per Adjusted

Admission below $3,000

Total YTD - $3,720

Drugs - $800

Non-Drug Supplies - $2,913

Reduce variation and waste by standardizing preference cards for high-volume/high-value projects. Phase I - Selection criteria:

$1,672,647

$908,197

$616,539

$233,445 $232,958

50

66 67

23

36

0

10

20

30

40

50

60

70

80

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

TAVR Lumbar Fusion Cervical Fusion Aortic Valve CABG

Highest Cost Procedures Over 36% of Total OR Supply Cost in Q1 per

SurgiNet

Series1 Series2

Selection Criteria:

1. Highest Cost – over 36% of total OR Supply

cost

• TAVR

• Lumbar Fusion

• Cervical Fusion

• AVR

• CABG

2. Highest Volume

• I&D Lower Extremity

3. Alignment with Corporate Effort

• Hysterectomy

4. Highest Growth

• Ortho Trauma – 27% volume increase in

2016

5. Engaged Physician Leaders

Reduce variation and waste by standardizing preference cards for high-volume/high-value projects. Phase I - Estimated Savings by Surgery Type

Prmry Prcdr Desc

Q1 Count of

Procedures

Q1

AVERAGE

CASE COST

Q1 Used Cost

for Quarter

% of OR

Supply

Costs for

Quarter

per

Surginet

Data

Potential

Annualized

Savings -

Implementation

Standard Card

100% adoption*

Potential

Annualized

Savings -

Implementation

Standard Card -

50% adoption* Notes

High Dollar Spend

LUMBAR SPINAL FUSION 66 $13,760.56 $908,196.82 8% $239,067.28 $119,533.64 Neuro/MSKI - High Variation among surgeons - Standardization

CERVICAL SPINAL FUSION 67 $12,525.03 $616,539.29 6% $102,308.72 $51,154.36 Neuro/MSKI - High Variation among surgeons - Standardization

High Volume System Effort

HYSTERECTOMY 133 $1,468.92 $185,952.00 2% $208,493.64 $104,246.82

Women's Health - System effort pilot at BUMCP. Mourad already did

at Banner Desert

Highest Growth in Case Volume

ANKLE OPEN REDUCTION INTERNAL FIXATION 44 $1,252.11 $55,092.94 - $38,975.59 $19,487.80 MSKI - Highest Volume Ortho Trauma procedures

FEMUR INTRAMEDULLARY ROD INSERTION 28 $3,517.33 $98,485.26 - $3,957.02 $1,978.51 MSKI - Highest Volume Ortho Trauma procedures

TIBIA INTRAMEDULLARY ROD INSERTION 19 $3,714.64 $70,578.10 - $45,824.71 $22,912.35 MSKI - Highest Volume Ortho Trauma procedures

TIBIA OPEN REDUCTION INTERNAL FIXATION 14 $2,877.91 $40,290.75 - $11,307.01 $5,653.50 MSKI - Highest Volume Ortho Trauma procedures

SUBTOTAL $264,447.04 2% MSKI - Highest Volume Ortho Trauma procedures

High Dollar Spend

AORTIC VALVE REPLACEMENT TRANSCATHETER 50 $33,452.59 $1,672,647.00 16%

TAVR Team -Waste Reduction Review - Place high cost items in

hold bin. Dollar Amount to be determined

AORTIC VALVE REPLACEMENT 23 $10,149.77 $233,444.62 2%

CT Surgeons - Standardization and Waste Reduction Dollar Amount

to be determined

CORONARY ARTERY BYPASS GRAFT 36 $6,471.06 $232,958.11 2%

CT Surgeons - Standardization and Waste Reduction Dollar Amount

to be determined

IRRIGATION & DEBRIDEMENT LOWER EXTREMITY 152 $257.07 $39,074.01 0% Wound Institute - High use of Integra

Total Range of Annualized Savings $649,933.97 $324,966.99

*Lumbar Spinal Fusion - Calculated at average case cost of highest volume surgeons

*Cervical Spinal Fusion - Calculated at average case cost of highest volume surgeons

* Hysterectomy - Calculated at average case cost of highest volume surgeons

Teams and Institute Leads By Project Phase I

Project

Institute Physician Champion(s)

Lumbar and Cervical Spinal Fusion Neuro/MSKI Drs. Chutkan and Menendez

TAVR Cardiovascular Drs. Pershad, Fang, Amabile, Tasset (one tbd)

AVR and CABG Cardiovascular Drs. Fang, Amabile, Tasset (one tbd)

I & D Lower Extremity Wound Dr. Silverstein

Hysterectomy Women’s Health Dr. Mourad

Ortho Trauma MSKI Drs. Jones and Ringler

Return on Investment…?

• The CPR Team 600k Investment

• 2 FTEs (Senior Directors- Clinical Transformation)

• 3 Data Analysts

• 10 Physician leaders each paid at .1 FTE

• 2016 YTD vs 2015- 22 million more dollars in net income; Operating Margin increased from 2 % to 6%

• The Real Return on Investment… Physician Engagement

– Priceless

Questions?

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”

― Atul Gawande, Better: A Surgeon's Notes on Performance