Successful Clinical Process Redesign in a Connected Healthcare Community

Linus Diedling

Allison Foley, MD

Elliot Sternberg, MD

Michelle Woodley, RN

AGENDA

• Care Redesign from 3 Perspectives– Chief Medical Officer: Elliot Sternberg MD– Nurse/IT Executive: Michelle Woodley RN– Physician: Allison Foley MD

• Questions?

St. Joseph Health System Highlights

• $3.0 billion in revenues• 14 hospitals in 3 states• Licensed beds range from 47 to 851• Home health agencies, hospice care, outpatient

services, skilled nursing facilities, managed care operations, and multiple physician organizations

• In FY 2004, SJHS provided more than $310 million in community benefit and care for the poor services

Patient & Family

Centered Care

Safe & Effective

Equitable

Efficient & Timely

SJHS Values and IOM Goals

What is CRD?

“Care ReDesign…creating more holistic, patient-centered care that is technologically enabled, resulting in improved clinical excellence, customer satisfaction and operational performance.”

1. Computerized Physician Order Entry-CPOE2. PACS Digital Radiology3. Clinical Documentation-Hospital Setting4. Ambulatory Electronic Medical Record5. Physician / Clinician Web Portal

The “Wait State” of Health Care

Sick Patient

Well Patient

Sch

edul

e

Vis

it

Lab

Inte

rpre

tati

on

Re-

schedule

Re-V

isit

Pre

scri

be

Confirm

• Payer Verification• Scheduling• Voice to Voice Live Confirmation• Manual Chart Storage & Retrieval• Confirming Eligibility• Checking, Re-checking Patient History• Waiting for Confirmation

• Lower Patient Satisfaction• Higher Cost• Increased Errors• Harmful Delays

Wait State

Value Add

• Waste / Rework• Patient Dissatisfaction• Medical Errors• Frustrated Care-Givers• Unnecessary Costs

Care ReDesign Objectives

• Improve patient care (safety, quality, satisfaction)

• Provide improved process and information access for caregivers

• Reduce inefficienies in the care delivery process

Four “I”s of an Initiative

• Information • Involvement• Incentives• Investment

Involvement

Incentives

• System Fiscal Year Goals that affect

AT RISK PAY

Investment

• Care ReDesign– CPOE– AEMR– Clinical Documentation– PACS– Clinical Data Repository– Web Portal Connectivity– EMAR– Bed Tracker– Evidence-based Support

CARE REDESIGNCARE REDESIGN

Regulate, Mandate, or Innovate?

ClinicalClinical TransformationTransformation

SJHS Care Redesign InitiativeSJHS Care Redesign Initiative

10 Year IT Innovation Strategy10 Year IT Innovation Strategy98 99 00 01 02 03 04 05 06 07

Assess Organize Prepare Execute Excel Systemic Innovation

Organizational Excellence

Industry Leadership

Core System Implementation

IT Leadership Restructure

Century Preparation

Strategic IT Partnership

Strategic Plan Foundation

OrganizationPreparation

Complete VisionIntegration

System Optimization

Web Deployment Infrastructure Modernization

Web Transformation

IT Clinical Innovation (CPOE, Clin Doc, PACS, AEMR)

Business Process Design

Change Management Services

Manage with Information

Next GenerationTechnology

Ubiquitous Access

Transform Clinical Care

PATIENT SAFETYPATIENT SAFETYSJHS PRO-ACTIVE APPROACHSJHS PRO-ACTIVE APPROACH

Patient SafetyPatient Safety

CRD STRATEGY

• Be Pro-Active, Not Re-Active• Develop Key Partnerships• Utilize Collaborative Design Process• Deploy a Franchise-Model Approach• Innovate Not Mandate• Facilitate User Adoption Through

Communication Plan

GOALS OF CRD

• Decrease preventable medical errors

• Reduce wait-state

• Decrease operational inefficiencies

• Drive efficiencies by redesigning processes using automated technologies

• Provide real-time access to patient information

• Aggregate information to support quality of care improvement activities

Major CRD Phase

Phase I Lay the Foundation

Phase II Assess the Opportunity

Phase III Transform Clinical Care

Key Phase Deliverable

“Implement Clinical Technology Strategy”

“Manage With Information”

“Implement New Practices"

Change Drivers

Improve Operational Performance

Improve Patient Service Quality

Meet Industry Demands

Tie Relevant Information Together

Conduct Comparative Studies

Produce Actionable Findings

Implement technology enabled best clinical practices

Solidify Behavioral Change

Measure Change Achievement

Key Technology Components

Computerized Physician Order Entry Clinical Data Repository Enterprise Master Patient Index Clinical Documentation PACS Ambulatory EMR

Change Process

Facilitated Process ReDesign

High Impact Teams (SJ HS)

Clinically Focused Assessment

Clinician Sponsored

Management Process

SJ HS Driven Technology Partner Aggregation

Establish CRD Management Group

Timeline Efficiencies

Business Line Analysis

Population Health Management

Data Driven Marketing

TBD

Timing 8 year timeline with incremental delivery milestones

Begins with Phase I System Delivery Milestones (incremental benefit follows IT enablement)

Care ReDesign Roadmap

CRD Collaborative Approach

• Involve stakeholders from the start

• Redesign process workflow– Multidisciplinary work teams– Optimize available Technologies

• Build a CRD Franchise Model with multidisciplinary work teams

CRD CRD ImplementationImplementation Strategy Strategy

A Pilot ApproachA Pilot Approach

CRD Implementation Strategy

1

SystemUpgrade

For AdvancedClinical

Functions

SystemUpgrade

For AdvancedClinical

Functions

CRD Pilot Site Implementation StrategyCRD Pilot Site Implementation Strategy

ImplementPilot

PhysicianPre- printed

Order Sets

ImplementPilot

PhysicianPre- printed

Order Sets

Pilot Unit “Go Live”Physician

POM(CPOE)MAR

Clinical Doc

Pilot Unit “Go Live”Physician

POM(CPOE)MAR

Clinical Doc

POM(CPOE)

Hosp- wide“Go Live”Nursing

AndUnit Sec.

POM(CPOE)

Hosp- wide“Go Live”Nursing

AndUnit Sec.

Dec. 02, 2003

Ancillary Hosp- wide“Go Live”

Ancillary Hosp- wide“Go Live”

Phased UnitMAR

Hosp- wide“Go Live”

Phased UnitMAR

Hosp- wide“Go Live”

POM(CPOE)

“Go Live”PhysiciansHosp- wide

POM(CPOE)

“Go Live”PhysiciansHosp- wide

J an. 31, 2004 April 6

Nov, 2003

Phased UnitClinical

Doc.Hosp- wide“Go Live”

Phased UnitClinical

Doc.Hosp- wide“Go Live”

POM(CPOE)

“Go Live”Add’l

PhysicianChampionsHosp- wide

POM(CPOE)

“Go Live”Add’l

PhysicianChampionsHosp- wide

SJM

C I

mpl e

ment a

t ion S

t rate

gy

FranchiseDevelopment

Strategy

FranchiseDevelopment

Strategy

ImplementHouse- widePhysician

Pre- PrintedOrderSets

ImplementHouse- widePhysician

Pre- PrintedOrderSets

Aug. 31, 2003 J an - Mar 2004

POM(CPOE)

“Go Live”Add’l

PhysicianChampionsPilot Unit

POM(CPOE)

“Go Live”Add’l

PhysicianChampionsPilot Unit

November 15

CRDPhase 2

CRD Change Management, CRD Change Management, Adoption and CommunicationAdoption and Communication

Preaching the Gospel of Innovation – 2001

In Healthcare, if Innovation is not MANDATED or

REGULATED its usually

PROCRASTINATE

D!

Care ReDesign Objective

• Improve patient care (safety, quality, satisfaction)

• Provide improved process and information access for caregivers

• Reduce inefficiencies in the care delivery process

Information Technology and Clinicians

• Clinical system must be built by clinicians

• Collaboration between technical team and

clinicians key

– Process Workflow ReDesign

– Change Management

– Optimize Available Technology

• Right Process with the Right Technology

Nursing’s Key Leadership Role in IT Clinical Integration

• Professional Paradigm Shift

– Responsible for overall coordination of care

– Legacy to develop processes and systems that will improve quality of care

– Optimize efficient and effective workflow

“With passion and working smart, nurses will make it happen”

Keys to Physician Adoption

• Broad envisioning physician leaders driving sponsorship and participation

• Early physician involvement in concept, design and testing of new processes and systems

• Start small; achieve early (“quick wins”) and build on continuous successes

CRD at St. Jude Medical Center

18 Months at SJMC:– 95% of frequent

admitters in pilot unit using CPOE

– 900 staff and 450 physicians using online Clinical Documentation in all units

– Electronic Medication Administration Record in use in all units except ED

– Over 140,000 exams completed on PACS

Success Factors

• Patients are at the center of healthcare technology

• Care ReDesign is a journey and requires executive commitment

• Leadership must have a passion for automation and clinical transformation

• Be willing to commit resources needed

• Talk about the “end goals” constantly to keep them in sight

Live from Orange County:Live from Orange County:Saint Jude Medical CenterSaint Jude Medical Center

CRD Pilot SiteCRD Pilot Site

Monty Python: The Holy Grail

• The Medical Staff Perspective

Benefits to Physicians• Immediate access to patient record

• Decreased call backs to clarify orders

• Best Practice and Communication

• Access anywhere anytime

• Electronic signature of transcribed reports and verbal orders

• Assist with medication dosing calculations

• Associated data brought to point of ordering

• Ability to avoid some complications

Benefits to Patients• Allergy and adverse drug

reaction checking

• Medical history retained visit to visit

• Reduction in duplicate questioning and testing

• Coordinated care by multiple care providers having access to same record

Importance of Physician Involvement

• Leadership in evolving technology

• Drive technology to support workflow

• Order set development

• Medical Informatics Committee

Questions?