A Brief History of Tufts Medical Center

1Combining Art & Science, Innovations in Healthcare II, June 19, 2009

A Brief History of Tufts Medical Center

1894: Floating Hospital takes ill children & mothers out on Boston Harbor

1979: Graduate School of

Nutrition created, first in the US

1796: Boston Dispensary

founded

1981: World’s first pediatric trauma center established at the Floating Hospital

Notable benefactors: Sam

Adams & Paul Revere

First permanent medical facility in

New England

1886: Instructive District Nursing Association formed, the forerunner of the VNA

ca.1919: Similac invented

1938: 100-bed Pratt Clinic constructed, largest in the world

1997: Creation of Neely House, a first-of-its-kind

B&B-style home for cancer patients & their

families

2009:Adopted the BCBSMA Alternative

Quality Contract

1992: First, full-service private

teaching hospital created, with

addition of the maternity service

1852: Tufts University founded

The principal teaching hospital for Tufts University School of Medicine

Combining Art and Science to Create Value for Patients and Staff

Margaret M. Vosburgh, EVP, COOJune 19, 2009


What is value1?

A fair return or equivalent in good and services, or money for something exchanged

1 value. (2009). In Merriam-Webster Online Dictionary.Retrieved June 16, 2009, from http://www.merriam-webster.com/dictionary/value


Defining our Value Proposition

Patients and Families

Access to world-class healthcare Welcoming, calm environment

Physicians

Cases Reliable processes Educational experiences for medical students,

residents, and fellows

Staff

Predictable environment Support to provide top-notch service


The ART and SCIENCE

Trust Relationships Safety Compassion

Best Practices Voice of the

Customer Lean and Six Sigma Outcomes

Art Science


Throughput


Previous State of Hospital Throughput

?

?

?

?

?


Obstacles to Throughput

EDCase

ManagementCritical Care Management

Perioperative Services

Discharge Process

Diversion Denied

admittance 2100 beeper

coverage

LOS management - no targets

RN/VNA placement Case findings redundant

& complex BOP designation Roles are ill-defined and

unclear Non-inclusive VNA/sub-

acute process No unit-based ownership No unit-based metrics 66% of nurse managers

are within their first 18 months of management experience

Inadequate MD coverage

No standing protocols or discharge criteria

No RN-initiated clinical processes

PST: <50% patients

through PST OR:

Late Starts Room Utilization Turnover Time Block Time not

managed Inadequate add-

on capacity PACU:

No designated MD leadership

Random release criteria/service

Staffing: Skill mix is

inadequate

MD Rounds Blood draws Resident roles Unspecified

designated discharge time

Discharge is a reactive process

No Established Targets

No Measurement No Reporting


Optimization Task Force

Purpose To fast track organizational change by having process

owners analyze current systems and propose alternatives.

Participants MD, RN, and Staff leaders from across the hospital

Process Standing meetings and agenda report outs Formal template, complete for presentation


Operational Assessment & Plan

Where we are Inverse correlation between cost of care and quality outcomes Unfocused management team Patient volumes do not support our current operational and

financial structure

Where we want to be Over the next 12 months, the Hospital & Physician’s Organization

must focus on measurable outcomes: Increase quality Grow volume Reduce the cost of care Increase productivity

How we are going to get there Improve the operational and financial landscape Create high expectations:

Educate staff & drive accountability Measure outcomes regularly & relentlessly No excuses


2009 Operational Plan

INCREASE VOLUMEINCREASE VOLUME DECREASE COSTDECREASE COST

Create Admission Discharge Transfer (ADT) Center

Eliminate ED Diversion

Implement a new case management model

Accommodate new surgical OR volume

Implement a new nursing delivery model

Revise staffing plans to meet average daily census (ADC) and allow for fluctuations in census

Control contract labor cost

Employ Lean Six Sigma

Decentralize cost and quality responsibilities to designated Triads

Create infrastructure to increase volume, decrease cost & improve quality outcomes


Summary of 2009 Goals

Staff Development

Clinical Excellence / Quality

Profitability

Establish & implement leadership competencies FY09 Q1: Managers complete initial Manager Training modules FY09 Q1: Graduate 1 Lean Six Sigma Green Belt class

Infuse quality & patient safety principles into all clinical & business decisions: establish & monitor unit-specific goals

FY09 Q4: Meet Leapfrog ICU Staffing goals Dedicated ICU Intensivist Pharmacist rounding with team daily

FY09 Q4: Meet Leapfrog CPOE implementation goal FY09 Q1: Implement decentralized clinical & profitability responsibility to the quality

triad FY09 Q2: Improve CMS & IHI measures to meet or exceed required goals

Increase discharges to 17,832 – an additional 2 patients per day Reduce the ALOS to 5.5 days – decrease of 0.2 days per unit Reduce Cost per Discharge – Unit-specific UHC Benchmarking Reduce clinical denials to less than 10% - accurate charting Reduce administrative denials to less than 15% - accurate

charting


Structure and Goals of the Quality Triads

Quality

Profitability

Administration

Physician

Staff Development

Nurse

$

The mission of the Quality Triad is to ensure quality within the organization by understanding, measuring and managing key metrics and processes.


Foster a Culture of Quality

Lean / Six Sigma is a data-driven methodology (DMAIC) to solve issues, eliminate waste and improve processes.

Lean / Six Sigma is an integrated set of tools that produce breakthrough performance improvements.

Lean / Six Sigma will make it possible for the hospital to pursue leadership among our competitors through continuous quality improvement.

Define Measure Analyze Improve Control

Define the Customer, what is quality to them, and the core processes involved

Measure the performance of the core process involved

Analyze the data collected & process map determining root causes of defects & opportunities for improvement

Improve the target process by designing creative solutions to fix and prevent problems

Control the improvements keeping the process on the new course


Optimization Initiatives

ADT Center

Optimization Task Force

OR Leadership Forum

Critical Care Task Force


Solutions

ADT Center

Optimization Task Force Outpatient Scheduling Project Phlebotomy Improvement Project

OR Leadership Forum

Critical Care Task Force


I. ADT Center

The ADT Center facilitates the right level of patient care in the right setting at the right time with the right service

• Establish a seamless, one-stop admission process for all non-scheduled and appropriate admissions.

• Eliminate OR, PACU holds and ED diversions

• Coordinate diagnostic & treatment modalities

• Communicate with MD’s to foster movement to an alternative level of care in a timely fashion

• Prioritize access to beds based on patient care need and relationship with referring party

Mission Goals Design/HowTargets

• Decrease ALOS to Medicare GLOS

• Increase patient, staff & referring MD’s satisfaction

• Eliminate OR, PACU holds

• Eliminate ED diversion hours

• Decrease interval between referral &bed placement


ADT Center Design

Patient’s case enters the ADT Center

ADT Team consults with

appropriate resources

ADT Team facilitates a disease mgmt model•Hospital Departments

•Outside Sources

•Physicians

•Other

•Radiology

•Lab

•Pharmacy

•PT – PTT

•QSS

ADT Team

Medical Director2100NurseBed Coordinator

Proposed Coverage:

Weekdays, 7am – 7pm

Beeper other times

877 - OK - TUFTS


II. Discharge Optimization Scheduling Improvement

MD will request follow-up appts

when completing the discharge

orders

Form will print in the Pre-

Registration Department

Pre-Registration staff will schedule

follow-up appts

Pre-Registration staff will

communicate the appts to the

patient (before discharge)

Enhancements to Discharge Order Plan Tufts Medical Center Clinics Follow-up Appointments

Space for 3 appointments Can designate clinic, visit type, follow-up timeframe, type of

clinician, and any comments needed to ensure continuity of care

Tufts Medical Center Ancillary Testing Space for 3 appointments Can designate test, test type, follow-up timeframe and the

reason for the test/instructions


Discharge Orders


III. Phlebotomy Improvement Project

Previous # of Phlebotomists

Shift Start Times*

New # of Phlebotomists

0 5:30 a.m. 1

1 6 a.m. 5

1 6:15 a.m. 1

2 6:30 a.m. 1

4 7 a.m. 3

2 8 a.m. 2

Note: This reflects “report – to – work” in lab; arrival at patient units typically 10 to 15 minutes later, which constitutes the start of AM draw.


A.M. Lab Result Completion Times

7:36

8:04

8:33

9:02

9:31

10:00

10:28

TH

UR

S M

AY

2

FR

I M

AY

3

MO

N M

AY

5

TU

ES

MA

Y 6

WE

D M

AY

7

TH

UR

S M

AY

8

FR

I M

AY

9

MO

N M

AY

12

MO

N J

UN

E 2

TU

ES

JU

NE

3

WE

D J

UN

E 4

TH

UR

S J

UN

E 5

FR

I JU

NE

6

MO

N J

UN

E 9

TU

ES

JU

NE

10

WE

D J

UN

E 1

1

TH

UR

S J

UN

E 1

2

FR

I JU

NE

13

MO

N J

UN

E 1

6

TU

ES

JU

NE

17

WE

D J

UN

E 1

8

TH

UR

S J

UN

E 1

9

FR

I JU

NE

20

MO

N J

UN

E 2

3

TU

ES

JU

NE

24

PHASE 1

Sick Calls

Instrument ProblemsJune 4 & 5

Implementation Date

By improving Phlebotomist staffing patterns & prioritizing floors AM lab result times decreased.


IV. OR Throughput Improvements

ROOMMONDAY

(8.30a – 5.30p)TUESDAY

(7:30a - 5:30p)WEDNESDAY(7:30a - 5:30p)

THURSDAY(7:30a - 5:30p)

FRIDAY(7:30a - 5:30p)

1 GENERAL GENERAL GENERAL TRIAGE9:30-5:30

TRIAGE9:30-5:30

2 CLOSEDGENERAL

GENERAL: Week 1,3,5OPEN: Week 2 & 4

GENERAL

GENERAL

3 GENERAL GENERAL UROLOGY GENERAL UROLOGY

4 GENERAL GENERAL GENERAL ENT CLOSED

5 GYN OPEN7:30-3:30

GYN CLOSEDOPEN7:30-3:30

6OPEN8:30-3:30

OPEN7:30-3:30

OPEN7:30-3:30

OPEN7:30-3:30

OPEN7:30-5:30

7 NEURO GENERAL GENERAL CLOSED NEURO

8 NEURO NEURO NEURO NEURO

NEURO

9CARDIAC

CARDIAC CARDIAC CARDIAC

CARDIAC

10 CARDIAC CARDIAC CARDIAC CARDIAC CARDIAC

11OPEN8:30 – 3:30

ORTHO ORTHO ORTHO

ORTHO

12 ORTHO ORTHO ORTHO ORTHO

ORTHO

CYSTO CLOSED CLOSED CLOSED UROLOGY CLOSED

14 OPENGENERAL

UROLOGYOPEN7:30-3:30

CLOSED

15 GENERAL NEURO

NEURO OPEN7:30-3:30

NEURO

1 6 Overflow Overflow Overflow Overflow Overflow

17PEDI GI Gen Anes

PEDI GI Gen Anes

PEDI GIGen Anes.

PEDI GIGen Anes

PEDI GIGen Anes

18 GENERAL UROLOGY GYN DENTALGENERAL (4)GYN (4)

19 ENT ENTPLASTICS

DENTAL GYN

20

OPEN 8:30-12:30PLASTICS12:30-4:30

DENTAL7:30-12:30 GENERAL 12:30 – 5:30

ENTORTHO Trauma

GENERALLocal

21ENT

ORTHO NEURO ORTHO ORTHO

22 EYE EYE EYE EYE EYE

23 EYE EYE EYE EYE EYE


Model of Care


The Need to Re-evaluate the Current Care Model

Consumers are not satisfied with current care models

Current systems do not work

Dissatisfaction of clinical staff – moving away from the bedside

Need to deliver care in a more efficient and less costly manner

Need to reduce variation and improve outcomes

Public mandate / Pay for Performance

Current service delivery model has not been able to provide desired outcomes

Creating a new Model of Care is the most sustainable long-term strategy for Tufts Medical Center


New Model of Care

Patient Centered

Environmentally Aware

Forward Looking

Professionally Rewarding


Master Staffing Plan


Results: Increase Volume


Discharges Are Up

April YTD Discharges:

Above budget by 742 or 7.2% and above prior year 974 or 9.6%

FY09 Actual Budget Var to Bud FY08 Actual PY Variance

4,778 4,092 686 4,109 669

2,881 2,573 308 2,452 429

915 1,036 (121) 1,021 (106)

525 648 (123) 622 (97)

1,490 1,496 (6) 1,410 80

498 500 (2) 499 (1)

11,087 10,345 742 10,113 974

Year-To-Date

Adult Medicine:

Adult Surgery:

Maternity Obstetrics:

Maternity Newborn:

Pediatrics:

Total YTD Discharges:

Psychiatry:


Clinic Visits Are Up

April YTD Clinic Visits:

Above budget by 3.494 or 1.8% and above prior year by 11,733 or 6.3%

Year-To-Date April '09 April '08

Actual Budget Variance Actual Variance

Medicine Clinic: 66,700 66,406 294 61,950 4,750 Surgery Clinic: 65,809 63,939 1,870 62,204 3,605 Pediatric Clinic: 24,793 27,300 (2,507) 26,391 (1,598) Psychiatric Clinic: 10,358 10,210 148 10,622 (264) Other Clinic: 17,986 16,190 1,796 14,992 2,994 Maternity Clinic: 13,700 11,806 1,894 11,454 2,246

TOTAL: 199,346 195,852 3,494 187,613 11,733


Operating Room Cases (IP & OP) Are Up

April YTD

OR cases are up 462 or 6.9% over prior year

and above budget by 407 cases or 6.0%

OR Cases - YTD

7,202

6,7956,740

4,000

4,500

5,000

5,500

6,000

6,500

7,000

7,500

8,000

FY08 FY09 '09 BUD

FY08 FY09 '09 BUD


ED Visits are down & Admissions from ED Are Up

April YTD

ED visits YTD are 502 or 2.3% above budget but (748) or (3.3%) below prior YTD

Pedi ED visits were down (289) or (7.0%) from prior YTD

Adult ED visits were down (459) or (2.5%) from prior YTD

Inpatient admissions from the ED are above last year by 11.6%

18,546 18,689 18,230

4,012 4,117 3,828

0

5,000

10,000

15,000

20,000

25,000

FY07 FY08 FY09

ADULT PEDI

Emergency Department Visits-April YTD


INCREASE VOLUME: Reduce Emergency Room Diversion

Elimination of ED diversion

1 Hour ED Diversion = 1 Lost Inpatient Admission2008 Dec YTD = $1.3 million lost revenue

FY 2009 April YTD: Lost Revenue due to ED Diversion = $0

Lost Revenue Due to Emergency Room Diversion (Jan 2007 to Apr 2009)

1 Hour ED Diversion = 1 Lost Inpatient AdmissionLost Revenue 2007 Dec YTD = $2.5 million and 2008 Dec YTD = $1.3 million and

Lost Revenue 2009 Apr YTD = $0

$0$50

$100

$150$200$250$300$350

$400$450$500

Lost revenue due to ED Diversion trending at $0

Lost

Rev

enue

(th

ousa

nds)


Average Length of Stay TrendsJan 2008 to Apr 2009

4.50

4.75

5.00

5.25

5.50

5.75

6.00

6.25

6.50

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul 0

8

Aug

08

Sep

08

Oct

08

Nov

08

Dec

08

Jan

09

Feb

09

Mar

09

Apr

09

Ave

rage

Len

gth

of S

tay

Actual ALOS Budget ALOS

INCREASE VOLUME: Manage of Length of Stay

March 2008 ALOS peaked at 6.12

April 2009 YTD ALOS = 5.21 with LOS down by ~1 day

ADT Center Co-Director began working 1-on-1 with physicians

New Director Case Management implements process reducing ALOS


INCREASE VOLUME: Increase OR Volume

Redirected block time to realize a 15% increase in surgical cases to target

or ninety (90) additional cases/month

Trends Main OR Utilization Oct 2008 (Baseline) to Apr 2009

76%

91%

76%

86% 89% 91% 88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09

Util

izat

ion

(%)

All Staffed Time 7:30 AM-3:30 PM Target


Volume Has Grown

April YTD discharges are 742 over budget and 974 over prior YTD

April YTD surgery cases are 407 over budget and 462 over prior YTD

Operating Statistics (April MTD) Percent Achieved of Budget

111% 115%123%

107%117% 120%

0%

20%

40%

60%

80%

100%

120%

140%

InpatientDischarges

OR Cases Clinic Visits ED Visits ED Admits CATH LabPatients

% A

chie

ved

% of Budget Budget


Results: Decrease Cost


Financial Impact of Shift in RN:Tech Skill Mix in Operating Room

$5,130,946

$3,673,426

$348,083

$790,752

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

$5,000,000

$5,500,000

$6,000,000

85% RN: 15% Tech 66% RN: 34% Tech

To

tal

An

nu

ali

zed

Sa

lary

RN Salary Tech Salary

DECREASE COST: Operation Room Skill Mix

Shifting RN:Tech skill mix ratio from 85:15 to 66:341

Operating Room labor annualized savings of $1 million

Savings = $1,014,852

1 AORN Skill Mix Standard is 67% RN to 33% Tech


Financial Impact Shift in RN:Tech Skill Mix on Inpatient Units

$47.0 $44.9

$2.8$3.2$1.7

$0.0

15

20

25

30

35

40

45

50

55

Current Skill Mix 4:1

$ (M

illi

on

)

Annualized RN Salary Annualized Tech Salary Estimated Savings

DECREASE COST: Inpatient Nursing Skill Mix

RN:Tech skill mix ratio 3:1 to 4:1 SALARY SAVINGS = $1.7 million

Savings


DECREASE COST: Reduction of Contract Labor FTEs

77% reduction in Nursing Contract Labor FTEs

from high of 73 FTEs in May 2008 to 17 FTEs in April 2009

VP-Terry Hudson-JinksContract Labor 12 Month Trends: Inpatient Care Services

(Payroll Periods 5/31/08 to 5/02/09)

7368

5559

4137

25 25 23 25

19 1915 13 13

8 9 9 914

1620

17 1812

0

10

20

30

40

50

60

70

5/31

6/14

6/28

7/12

7/26

8/09

8/23

9/06

9/20

10/0

4

10/1

8

11/0

1

11/1

5

11/2

9

12/1

3

12/2

7

1/10

1/24

2/07

2/21

3/07

3/21

4/04

4/18

5/02

Payroll Period

FT

Es


DECREASE COST: Reduction of Contract Labor Expense

Total Contract Labor savings since May 2008 = $740K

Contract Labor Reduction: Nursing, Ancillary, and Clinic Areas Expense vs. Savings: April 2009 Update

$421,383

$321,344$256,445

$155,801

$910,069$780,013

$575,625

$446,483

$217,087$272,096 $250,680

$170,148

$588,725$488,686

$653,624$754,268

$334,444

$130,056

$463,586

$692,982 $637,973 $659,389$739,921

$0

$100,000$200,000

$300,000

$400,000$500,000

$600,000

$700,000

$800,000$900,000

$1,000,000

Base: May08

Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09

Contract Labor Expense Contract Labor Savings


Summary

Successful outcomes occur when Art and Science are combined.

Involving people, providing data & encouraging innovation will always lead to success.

Documents

A Brief History of Tufts Medical Center