The Challenge of Clinical Integration

Jeffrey. H. Peters, MDSeptember 2015

QualitySafety

Healthcare Systems

Clinical Integration

High Reliability Medicine

Institutes

Large, Diverse Integrated Delivery System• Founded in 1866, 149 yrs of service

• $3.7 billion annual operating net revenue

• 25,000 Employees

• 1,752 registered beds

• 18 Hospitals in NE Ohio, 35 Major Outpatient Centers

• 923,081 Unique Patients Seen/yr

• 2,927 UH Providers, 1,576 Independent & Affiliated Providers• ~129,500 Discharges

• 83,929 Surgeries

UH Organizational Profile

Opportunities & Challenges

Systemwide Quality New ParadigmsInstitute deploymentHigh reliability MedicineThe example of OB CareVariability

Atul Gawande

Hospital Consolidation

US Farming Industry 1950-2000

Grocery Industry

By 2009, the top four food retailers Wal-Mart, Kroger, Costco and Supervalue controlled more than half of all grocery sales. largest 100 metropolitan areas, the four largest food retailers controlled 72% of sales by 1998.

Key Principles for Health System Integration

1. Comprehensive Services across the continuum of care2. Patient focus3. Geographic coverage & Access4. Standardized care delivery through multidisciplinary teams5. Performance management6. Information systems7. Organizational culture & leadership8. Physician integration9. Governance structure10. Financial integration

Big Med – Atul Gawande

“The theory this county is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in healthcare, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine cant be reduced to a recipe. Then again neither can good food; every dish requires attention to detail and individual adjustments that require human judgment.”

New Yorker Aug 13, 2012

The UH Difference

Center for Performance Improvement

Center for Patient Experience

Center for Quality Education

Center for Clinical Informatics

Center for Clinical Risk/Harm Prevention

Center for Quality Research

Center for Quality Care in Nursing

Integrates 7 Centers of Excellence to deliver unparalleled support for sustainable improvement and innovation in care delivery:

UH Quality Institute

Year over Year improvement in:• Mortality Index• Core Measures• Patient Safety Indicators• Hospital Acquired Infections• Readmissions• Measurable Improvement in Value

(Quality/Cost)• Patient Satisfaction

Confidential Quality Assurance/Peer Review Privileged Pursuant to Ohio Revised Code Sections 2305.24, 2305.25, .251, .252, .253

Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or

Older, 1999-2013

JAMA. 2015;314(4):355-365. doi:10.1001/jama.2015.8035

“The journey to provide safe, evidence based and effective care that drives out unnecessary

variation and creates value”

UH Center for High Reliability Medicine

High Reliability Heath Care; Getting There from Here

“As opposed to preoccupation with avoiding failure, hospitals and other health care organizations behave as if they accept failure as an inevitable feature of their daily work.”

MR Chassin & JM Loeb. 2013; Joint Commission

Confidential Quality Assurance/Peer Review Privileged Pursuant to Ohio Revised Code Sections 2305.24, 2305.25, .251, .252, .253

UH CLABSI 2014-2015

Pronovost P et al. N Engl J Med 2006;355:2725-2732

An Intervention to reduce Catheter Related blood Stream Infections in the ICU (n=103)

Pronovost et al. NEJM 2006; 355:

RBC July 2008 – July 2015

Big Med – Atul Gawande

“In medicine too we are trying to deliver a range of service to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention costs) for a given service routinely vary by a factor of 2-3, even within the same hospital.

New Yorker Aug 13, 2012

VARIABILITY

Confidential Quality Assurance/Peer Review Privileged Pursuant to Ohio Revised Code Sections 2305.24, 2305.25, .251, .252, .253

Colon Surgery – Length of Stay by Surgeon

DR A DR B DR C DR D DR E DR F0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Confidential Quality Assurance Peer Review Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252 and 2305.253

Top 6 Surgeons by volume for UHCMCSource: University Healthsystems Consortium, Year 2014, MS-DRG 330

30 © 2015 PREMIER, INC.

Serum lactate testing:Bundle utilization variation by point-of-entry care pathway

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

74%

60%

17%

59%

69%

80%

55%

44%

30%36%

73%66%

32%

64%56%

86%

68%

51%

71%

45%

ED Admit Admitted Other PathwaySystem Utilization Peer Utilization

Util

iza

tion

Ra

te

Total Case CountCase

MedicalBedford Conneaut Geauga Geneva Richmond St. Johns Ahuja Parma Elyria

ED Admit 640 157 65 336 59 337 628 538 673 619Other Pathway 834 45 23 149 13 61 47 246 80 66

Emergency Department admissions compared to other acute admission pathways:

SPECIAL ARTICLE

Variation in Hospital Mortality Associatedwith Inpatient Surgery

Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D.,and Justin B. Dimick, M.D., M.P.H.

ABSTRACT

The NEW ENGLAND JOURNAL of MEDICINE

BackgroundHospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important.MethodsWe studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications.

From the Michigan Surgical Collaborativefor Outcomes Research and Evaluation, the Department of Surgery, University of Michigan, Ann Arbor. Address reprint requests to Dr. Ghaferi at Michigan Surgical Collaborative for Outcomes Research and Evaluation, 211 N. Fourth Ave., Suite 201, Ann Arbor, MI 48104, or at aghaferi@umich.edu ...

N Engl J Med 2009; 361:1368-75.

Rates of All Complications, Major Complications, and Death After Major Complications, According to Hospital

Quintile of Mortality

Ghaferi, A., et al., N Engl J Med 2009;361:1368-1400

Variation in Hospital Mortality Associated with Inpatient Surgery

Ghaferi, A., et al., N Engl J Med 2009;361:1368-1400

pg. 1372

Although rates of death for patients who underwent inpatient surgery varied by a factor of nearly two (3.5% to 6.9%) across hospitals, these differences could not be explained by differences in postoperative complications. Specifically, high- and low-mortality hospitals had nearly identical rates of postoperative complications.

Variation in Hospital Mortality Associated with Inpatient Surgery

Ghaferi, A., et al., N Engl J Med 2009;361:1368-1400

pg. 1373

“Although the value of avoiding complications in the first place is obvious, our findings also suggest that improving the care that patients receive once complications have occurred is crucial for reducing.”

Patient Story71 y/o with history of HTN, transplant patient (immunosuppressed) with neurosurgical issues, hospitalized multiple times in the last 2 months at different hospitals. Admitted with increased weakness/lethargy after previously returning to normal neurological status admitted for possible neurosurgical intervention. On day 3 of admission…• 0900: T = 37.3, HR =103, RR = 20, BP = 96/63 (baseline 130’s systolic)• 1500: T = 36.9, HR = 73, RR = 16, BP = 91/56• 2045: T = 39.9, HR = 103, BP = 70/40

– Temps: 39.2 38.2 38.2– BP’s: 70/40 500cc bolus ordered --112/86 – RN notes dark urine with output <100c -- repeat 64/42 500cc bolus given– Repeat BP -- 70’s systolic no further action taken – deferred to day team

– No lactate drawn, blood cultures drawnSeptic Shock broad spectrum antibiotics = ~12 hours

Current state of Sepsis at UH-CMC• Current state of Sepsis at UH-CMC

– AVERAGE time recognition as SIRS positive to Sepsis diagnose/treat = 18 hours

– Variation in recognition time: 10hrs2 days

*by chart review, excludes ICU, Mac and Peds

Intelligence through UHCare

Quality

EfficiencyAnalytics

• Physician Notification

• CDI Prompt

• SIRS Alert Pilot

• Sepsis Order Set

• VTE assessment

• Smart Peds meds

• Antimicrobial rationalization

• Dashboards

• Care Guides

HRM WavesWave concept

–DRG Groupings –Prioritized (strategic, financial, leadership, system)–16 week focus followed by implementation –Steady state mgmt.–Disciplined tracking of outcome metrics

A Sea Change in Treating Heart AttacksImprovements 2003-2013

• Death rate down 38%

• 2007 - AHA goal of Rx within 90 mins

• Median time in US now 61 mins

• Medicare generated national database of times

• Re-engineered care - In field EKG

Kolata G. New York Times – June 19, 2015

• Harrington HVI Programs now at Elyria and Parma

• Harrington HVI Programs planned at Portage & Ashland

20 CurrentHarringtonHVI Sites

Ashtabula

Cuyahoga

Lake

Geauga

Portage

Results: D2B Quality Improvement

2007 2008 2009 2010 2011 2012 2013 20140

20

40

60

80

100

120

99

81

6570

63

49

70

57

80

86

59

5054

64

51

61

Door-to-Balloon Time (median, min)

CMC GMC AMC

ACC/AHA 90 min

Best Practice 60 min

2011: Ahuja opens, Geauga PCI without surgery onsite

Pre-hospitalECG transmission HHVI-GMC

PCI Lead

Big Med – Atul Gawande

“But the “casual dining sector” as it is known, plays a central role in the ecosystem of eating,…..The ideas start out in elite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Then the casual dining chains re-engineer them for affordable delivery to millions. Does health care need something like this?”

New Yorker Aug 13, 2012

System Hospital OB Care, Volume/2014(Maternal Level of Care, 1 - 4)

• UHCMC (MacDonald) 4,508 (4)• Geauga (GMC) 1,115 (2)• Elyria (EMH) 876 (2)• St John (SJMC) 828 (2)• Robinson (RMH) 680 (2)• Parma (PMC) 448 (2)

Guiding principles• Establish system-wide care paths for labor induction, fetal monitoring, and conduct of labor modified from MAC for community hospital setting. • Team-oriented strategies lead to decreased communication errors and a positive work environment• Changes in culture embraced from within each institution by their own champions•15 system wide “requirements” for delivering OB care in UH hospitals•Objective metric of outcomes – serious safety occurrence measured system wide.

To Heal. To Teach. To Discover.

QUESTIONS?