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12/23/2013
1
Logical Steps Towards
Advancing Health Care and Patient Safety
Mark A. Warner, M.D.
The Scope of thePerioperative Surgical Home
Why A Surgical Home?
• Patient safety
– Biggest opportunity for a positive impact
• Cost-effectiveness
– Short-term care; major costs
• Efficiency
– Where it is needed most
• Standardization
– Multi-disciplinary; drives common care processes
How Did Anesthesiology Get Here?
• American Board requirements for more:– General medicine exposure in internship
– Preop medicine and expanded critical care
• ACGME requirements for:– Closer tie between internship and core
program
– More out-of-OR clinical experiences
• CMS support
Gaining Momentum
• April - May 2011: Anesthesiologists met with CMS (Berwick) and HHS (Sebelius) leaders
• Anesthesiologists provided input to CMS’s Center for Innovation request for proposals– Currently $64 M+ in related projects
So What Does This All Mean?
• Anesthesiology will change
• New models of care will evolve
• Anesthesiology trainees are increasing gaining experiences that will support this change
• Opportunities to decrease expensive complications and inefficiencies
Why Anesthesiologists?
• No one knows the perioperative practice better
• Can bring efficiencies and improvements that cross multiple provider groups
• Surgical complications represent 7-10% of hospital expenses; proven track record of anesthesiologists in preventing complications
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Perioperative Expense ReductionOpportunities
• Preoperative assessment and management– Improved patient efficiency
– Decreased testing
• Oversight of perioperative processes and patient management– Reduction in expensive complications
– Early recognition of problems (rapid response care)
A Few Important Opportunities
• Blood product oversight– Major opportunities to reduce the direct costs
and the many indirect complications of transfusion
• Allergy testing– Less than 10% of patients with assumed PCN
allergy are reactive
• Predictive medicine (still maturing)– Genetic testing, risk profiling, and
pharmacologic management
A Steady Progression
• Seems logical
• May not work – but studies suggest it will
• Should move forward
• Must study to determine what matters and how much it matters to improving health care finances and outcomes
The Goal: Cost-Effective, Efficient, and Safe Perioperative Care
Professor and ChairAssociate Dean & Acting Chief Medical Officer Department of Anesthesiology & Perioperative CareUC Irvine School of Medicine
Zeev Kain, MD, MBA
Creating a Real-World Surgical Home
A Change in Paradigm
Today Future
Fragmented Care Collaborative Care
Discounted Fee for Service Shared Risk/Reward
Payment for Volume Payment for Value
Isolated Patient Files Integrated Electronic Record
Adversarial Payer‐Provider Relations
Cooperative Payer‐Provider Relations
Focus on procedure Focus on triple aim
“Everyone For Themselves” Joint Contracting
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3
UC Irvine Health Perioperative Surgical Home
• PSH is a multi-departmental initiative aimed to transform surgical care by improving quality, lowering costs and
increasing patient and provider satisfaction.
Traditional Surgical Model Short Falls
• High perioperative care cost (est. 60% of Hospital Expenses)
• Fragmented continuum of care (btw. Hospital, Clinic, Lab, & Physician services)
• Idiosyncratic that focus on hospital reimbursement
• Order of consults and lab testing variability by medical & surgical services
• Post-operative care is generally disorganized, highly variable, & skilled labor dependent
• Poor accountability system
• Preventable Complications
UC Irvine PSH Mission
• Coordination of care
• Reduce cost of care and decrease LOS
• Reduce complication rate and re-admissions
• Standardization of practice using evidence based practices & guidelines
• Improve overall satisfaction of Surgeons, Anesthesia, Nursing & Patients
• Provide Quality & Performance Improvement Measures demonstrating success, outcomes based on research (NSQUIP, SCIP)
Joint Surgical Home Team
Ran Schwarzkopf
Laura Bruzzone
Alice IssaiRanjan Gupta Zeev Kain
SURGICAL HOME- GOAL
A HIGH RELIABILITY ORGANIZATION CONCEPT OF INTEGRATED PERIOPERATIVE CONTINUUM
Decision to Operate Early Return to Normal Activity
Evidence based standardization of practiceAchieving key health care metrics
AccountabilityEfficiency and effectiveness
17
PATIENT
Phase Preoperative Intra operative Post operative Post Discharge
•Variable support often leading to ER
•Minimal pre‐procedure planning
Decision to Operate
•Variable pre‐op assessment, testing and medical treatment
•Surgeon managed Post op•Few protocols
•Provider choice anesthesia•Lack of standardized protocols
SurgicalHome
Shared Decision Making, Patient Centered Care
Seamlessly Integrated, protocolized care at each phase of care
Traditional
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4
18
PATIENT
Phase Preoperative Intra operative Post operative Post Discharge
•Variable support often leading to ER visits
•Minimal pre‐procedure planning
Decision to Operate
•Variable pre‐op assessment, testing and medical treatment
•Surgeon managed Post op•Few protocols
•Provider choice anesthesia•Lack of standardized protocols
SurgicalHome
Shared Decision Making, Patient Centered Care
Traditional Surgical Care
• Shared decision making to outline the best course of treatment
• Patient education and expectation management
• Discharge planning (expected date of discharge)
• Referral to classes for optimal healing strategies
• Early Anesthesia intervention , pre-operative health and risk assessment
• Tailored optimization health/medical condition (hemoglobin, statin, beta blocker, VTE, nutrition management)
• Patient education and expectation management
• Discharge planning(Expected date ofdischarge)
• Pre-operative therapy prescriptions and
• Standardized protocols for tailored anesthesia care
• Standardized equipment and nursing protocols
• Infection prevention strategies
• Optimize fluid management technologies (goal directed fluid therapy)
• Multimodal
• Targeted recovery plan
• Early Ambulation, PT/OT
• Multimodal analgesia minimal systemic
• Early removal of drains and catheter
• Nutrition management
• Early intervention protocols for deviation from recovery goals or medical problems
• Discharge readiness
• Personal recovery pathway
• Early remote follow up (telephone or telemedicine)
• Home health, (if discharged home) wound management, ostomy management
• Physical activity/ PT
SEAMLESSLY INTRGRATED, TEAM BASED CARE
UC Irvine Formed 6 Teams…
Surgical Home
Leadership
PreOpAdmissions
IntraOp
Immediate PostOp
Post Discharge
QA & PI
Research
Protocols: Team A – Preoperative Admission
• Preoperative Evaluation Assessment
• Renal Risk Guidelines
• Pulmonary Risk Guidelines
• Delirium Risk Guidelines
• Cardiology Consult
• Dental Evaluation
• UA Protocols
• MRSA Guidelines
Measure: Pre-Admit Process Map
Pre-Op Admission Process Map
Protocols: Team B - Intraoperative
• Anesthesia & Nursing protocols for equipment & equipment repair in place
• QA protocols
– SCIP Antibiotics
– SCIP Normothermic
– SCIP VTE Prophylaxis
• Efficiency Metrics
– First case start
– Turnover times
Process Map Swim Lanes
T O C O R C i r c u l a t o r
S c r u b P e r s o n
E q u i p T e c h P P C U
Pt 1½ hr before
sched OR to bed
Pt Bathroom
Pt change clothes
Call interpreter
VitalsPg Anesth/Surg Res
ID Pt for BlockCall Block
Team
Surg visitIV
LabsMilestones
Check for Pt arrival in PPCU
w/o
To PPCUCheck Pt checklist
Repage resident for f/u needs
Comm.w/Anesth
Back to OR
Clean
Ask RN for Next case cart
Check case cart
Case cart
To room
Review preference card
Retrieve/Stage equip needed
Clean
Set up equip Remove excess
equiptest
Comm. w/Circulator & Scrub Tech about
needs
Reorganizes case cart
Next case cart staged
outside room
Review preference
cards
Comm. w/HA Tech for next case needs
Clean
Removes empty trays & organizes
case cart
Room ReadyNext Pt. Ready
w/o
w/o
w/o
w/o
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5
Define: Acute Post Operative
• Manage Patient from transfer from PACU to Discharge, including:
– Acute care
– Medical management
– Following SCIP measures
– Physical Therapy
– Discharge planning
– Patient Education
Project CharterProject Name: Joint Surgical Home-Acute Post Operation
Champion: Dr. Kain
Belt: Dr. Kain Master Black Belt: Dr. Kain, Henry Alvarez
Problem Statement:
Average length of stay (ALOS) for Total Knee Replacement (TKR) has been 3-4 days.
Average length of stay (ALOS) for Total Hip Replacement(THR) has been 4 days.
Project Goal:
To decrease ALOS for TKR patients to 2-3 days within 6 months of joint program implementation.
To decrease ALOS for THR patients to 3 days within 6 months of joint program implementation.
Project Y / Path-Y:
Y = Length of Stay
[Add Path-Y’s as necessary]
Scope:
Inpatient stay for elective joint replacement.
Single primary knee replacement, not bilateral.
Single primary hip replacement, not bilateral.
Team Members:Dr. Kyle Ahn, Anesthesia - Co Leader
Victoria Malonzo,RN - Ortho Inpatient Nurse Manager/Co Leader
Benjamin Reymer, Physical Therapy - Co Leader
Dr. Ran Schwarzkopf - Joint Replacement Surgeon
Tina Moeller - Case Management
Goli Shayboni, RN - Ortho Staff RN
Steven Bereta, RN, - Med/Surg Educator
Hiep Nguyen, RPh - Phamarcist
Tania Bridgeman, Administrator or Disease Management
Marianne Lovejoy – Patient Care Performance Improvement Advisor
Dr. Justin Hata
Dr Trung Vu
Steven Bereta – Med/Surg Educator
Benefits:
Provide a needed service to the community.
Patient satisfaction.
Staff satisfaction.
Reduce LOS.
Reduce hospital cost.
Increase bed capacity.
Timeline:Define/Measure [Completed 3/14/12]
Analyze [June 2012]
Improve/Control [July 2012]
Define: Post Discharge
• Manage patient 30 day post discharge from hospital
– Discharge order & instruction• Ortho scheduler/nurse navigator/case manager
• Home vs acute rehab vs skilled nursing facility
– Pain prescription
– Rehab and DME
– Wound care
– Prevent readmission– Telemedicine Initiative
– QA27
Team E: QA Measures & PI
• NSQIP‐Projected
Return to OR
Pulmonary Embolism
VTE Requiring Therapy
Renal Failure
Respiratory Failure
Unplanned Re‐admission
• AAHKS
• Quality, accountability and process measures
• PI Resource will be necessary to accomplish data collection
• SCIP-Current
SCIP 1- antibiotics given within 1 hour/Vancomycin over 120 m
SCIP 2- recommended antibiotics
SCIP 3-antibiotics d/c/24 hrs
SCIP 9 – urinary catheter removed POD1 or POD 2
SCIP 10- surgery pts with temp management
SCIP - cardiovascular-pts on beta blockers-give peri-op
SCIP VTE 1 & 2- VTE ordered and received
Orthopedics: Total Knee Replacement Clinical Pathway
12/23/2013
6
30
• Orthopedic Surgical Home Clinical Path
• Financial / Clinical Update
• One Year later
Clinical Path Dashboard: Joint Replacement (Primaries)
Metrics Metrics
35
12/23/2013
7
Urological Surgical Home
Nephrectomy/Nephroureterectomy Patient Care Pathway
Cystectomy Patient Care Pathway
UROLOGY SURGICAL HOME
38
TEAMS
Quality Assurance
Shermeen Vakharia, MDYasameen Faizy, MHA
Tania Bridgeman, PhD, RN
Urology Clinical Lead
Atreya Dash, MDPre Op TeamLes Garson, MD
Debra Morrison, MDAnna Harris, MD (Ad hoc)
Jaime Billingsley, RN Diane Rigger, RN
Young Kim, RN Jaime Pizziferri, RN (Ad hoc)
Jackie Stromberg (Ad hoc)Bernice Martinez
Ly DaoDavid Keymel, RN
Post Op TeamKyle Ahn, MD
Trung Vu, MDSusan Christensen, RNJaime Billingsley, RN
Heribert Bacareza, RNHiep Nguyen, Pharm D
Calvin Chang, PTDavid Keymel, RN
Post Discharge TeamAngela Parkin, MD
Jackie StrombergJaime Billingsley, RN
Susan Christensen, RNDavid Keymel, RN
Intra Op TeamDebra Morrison, MD
Susan Welbourne, BSN RNLaura Bruzzone, RN, MSN
Eenar Lee, MHANoreen Borromeo-Manalo, RN
Teri Houghtaling, RNDiane Rigger, RN (Ad hoc)
David Keymel, RN
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8
Communication to the Organization UROLOGY SURGICAL HOME
GO-LIVE
PSH Data Driven Process
• 1 Business Plan Metric
• 2 Process Metrics
• LSS Projects (1)Pre‐Operative
• 7 Business Plan Metrics
• 12 Process Metrics
• LSS Projects (4)Intra‐Operative
• 8 Business Plan Metrics
• 17 Process Metrics
• LSS Projects (1)Post‐Operative
• 4 Business Plan Metrics
• 1 Process MetricsPost‐Discharge
• 6 Business Plan Metrics
• 1 Process MetricAdministrative
•25 Business Plan Metrics
•58 Process Metrics
•101 Secondary Process Metrics
Total Collaborative Data Points
Target On-Line March 2014
Data Integration
Data Integration
Collaborative Data Driven Process
Collaborative Data Driven Process
Focus on x’s and not the Y’sPredictor Focus!
PSH Service Line Timelines
Orthopedic‐ Elective
‐ Total Joint Replacments
Orthopedic‐ Outpatient Services
Urology‐ Elective
‐ Cystectomy, Nephrectomy
LiveSeptember 2012 Live
November 2013 TargetApril 2014
Launch ScheduleLaunch Schedule
PHS Surgical Targeted Outcomes:• Cumulative decrease in Cost per Case• Cumulative decrease in 30 Readmission Rate• Cumulative decrease in Length of Stay• Decrease in Pain Management Sensitivity• Predictable & decrease in Complications• Cumulative Increase in Customer Satisfaction
PHS Winning Formula:• Patient Centered• Surgical Phase Accountability• Collaborative Data Driven Process Approach• Standardized Clinical Pathways
Early Patient Education / Management Process & Detailed Oriented Evidence Based Continually updated with base practice
• Lean Six Sigma (continuous improvement)
• FMEA introduction (continuous improvement)
Orthopedic‐ InpatientServices
TargetAugust 2014
Neurosurgery‐ Service line
TargetDecember 2014
46
It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change
- Charles Darwin
PSH Learning Collaborative
• ASA is pleased to announce the formation of a learning collaborative of health care organizations (HCOs) to improve the care of surgical patients through the implementation of the Perioperative Surgical Home (PSH).
• This PSH collaborative is targeted to begin the
second quarter of 2014.
• HCOs interested in participating in the PSH learning collaborative are invited to contact:
Celeste Kirschner, Perioperative Surgical Home Project Executive [email protected]
12/17/201347 Perioperative Surgical Home