Clinical Operations in a Service Line Modelapp.ihi.org/FacultyDocuments/Events/Event-2930/Presentation-16094/...Clinical Operations in a Service Line Model John D’Angelo ... This

Clinical Operations in a Service Line ModelJohn D’Angelo, MD, FACEPExecutive Director & Senior Vice President

Sarah Healey Herod, MPHDirector, Service Line Development

Jill CastanedaProject Manager, Clinical Operations Team

Emergency Medicine Service LineNorthwell Health

December 12, 2017

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Friday, November 24, 2017 2

Introductions

What is the Service Line?

IHI and Process Improvement

Origin & Evolution of the Clinical Operations Team

Continuous Site Improvement work

Data & Analytics

Accountability & Sustainability

Questions and Discussions

Agenda

3

What is a Service Line?

Emergency Medicine Service Line


> 900,000 annual ED visits

5 Tertiary EDs | 11 Community EDs | 1 Free-Standing ED

Service Line Vision


“To be a fully integrated network of emergency departments and acute care centers capable of consistently delivering high quality care in the most efficient manner possible”

Northwell Top Line Initiatives

Hospital Top Line Initiatives

Physician Nurse & ACP

Collaboration

Patient

The Emergency Medicine Service Line is responsible to drive strategy across the entire continuum of unscheduled acute care services:

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Market Growth

Patient Experience

Employee Investment

Finance

Quality

Community Benefit

Teaching & Research

Operations

Friday, November 24, 2017

Service Line Responsibilities

Service Line Strategy

Optimize service line team

Effective Site Leadership

Implementation of best practice standards and workflow models

Comprehensive performance improvement program

Leveraging all forms of technology for documentation, communication, delivery and marketing

Key contributor to Northwell Health financial success

Improve market share and prepare for future healthcare landscape

7Friday, November 24, 2017

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8

EMSL Centralized Services

How do we work with our Emergency Departments?

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Partner with MD & RN Leaders

Share best practices Guide operational

improvements

Standardize Practices

Clinical & Administrative Quality Review & Data

Collection

Education & Development

Physician Admin Fellow Clinical Leadership

Development Program

Telehealth Expansion

Telepsych & Telestroke eICU Collaboration

Service Line Collaboration

Pediatrics, Psychiatry, Hospitalists, Cardiology, HR, Nursing

Program Development

ACP (NP/PA) Fellowship SAFE Program Quality Committee

New Business Development

Northwell Strategy Support Market Growth

Patient Experience

Six Sigma Projects Patient Referral

Programs

Financial Tracking & Reporting

Centralized Budget Ongoing Financial

Assessments



Collection


Physician Admin Fellow Clinical Leadership

Development Program





Patient Experience


Programs



Assessments

Service Line Collaboration

Pediatrics, Psychiatry, Hospitalists, Cardiology, HR, Nursing



Collection


Nursing Education Physician Admin Fellow Clinical Leadership

Development Program





Patient Experience


Programs



Assessments

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IHI &

Process Improvement

Process Improvement

Month Day, Year 11

Create a culture in all Northwell Emergency Departments of continuous introspective review and enhancement using

improvement science techniques to optimize operations and provide the best care and treatment of patients and family

members.

Continuous Transparent Site LedMetric Driven

Multi-disciplinary

The IHI Model for Improvement

Aim•What are we trying to accomplish?

Measures

•How will we know that a change is an improvement?

Ideas

•What change can we make that will result in improvement?

Month Day, Year 12

Month Day, Year 13

The IHI Model for Improvement:

Plan Do Study Act (PDSA) Small tests of change, Continuous, Sequential and easy to begin

• Carry out the plan

• Document barriers

• Begin analysis of data

• Analysis of the data

• Compare to predictions

• Summarize what was learned

• Objective

• Why?

• Who, what, where, when?

• What changes are to be made?

• Next cycle?

Act Plan

DoStudy

The IHI Model for ImprovementPlan Do Study Act (PDSA) Steps

Month Day, Year 14

Step 1: PlanPlan the test or observation, including a plan for collecting data.State the objective of the test.Make predictions about what will happen and why.Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?)

Step 2: DoTry out the test on a small scale.Carry out the test.Document problems and unexpected observations.Begin analysis of the data.

Step 3: StudySet aside time to analyze the data and study the results. Complete the analysis of the data.Compare the data to your predictions.Summarize and reflect on what was learned.

Step 4: ActRefine the change, based on what was learned from the test.Determine what modifications should be made.Prepare a plan for the next test.

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Origin and Evolution of the Clinical Operations (Clin Ops) Team

Month Day, Year 16

Northwell /IHI Collaborative Timeline – focus on early identification & treatment in the ED

Action Period

includes monthly calls

& team reports

Getting Started:

includes calls & activities

Action Period


& team reports

Learning Session 2

July2012

Learning Session 3

January2013

Action Period


& team reports

Learning Session 1

February 2012

Learning Sessions:

Improvement Science methodology

Team Report Outs

Sharing of experiences, challenges and solutions

Goal Setting

Structure:

Teams from each site

Leaders, front line staff

Executive Sponsors

Data Definitions / Reporting

Team site / E-list / Collaborative Calls

Month Day, Year 17

Clinical & Operational Performance

Month Day, Year 18

Northwell Health Sepsis Mortality: Jan 2008- September 2017

How do we know what to do?Because the Sepsis Collaborative worked!

Develop a Structure for leadership, partnering, communication, sharing and reporting.

Promote Change

Identify and overcome Barriers

Focus on culture, work with site leadership on engaging front line

Define the Outcomes that you want to achieve and develop processes to obtain them

Data Definitions are crucial to acceptance of results

Utilize Improvement Processes to facilitate change

Process Maps

Small Scale tests of change (ex. PDSAs)

Run Chart analysis

Share lessons learned and best practices

Month Day, Year 19

Month Day, Year 20

Clinical & Operational Excellence EM Strategy for Sustainable Results

Standard Accountability System

Must Haves Standardization

Aligned Goals Aligned Behaviors Aligned Process Strategic Goals Leader

Accountability Process

Cascade of Goals Communication &

Transparency Success Sharing

Co-Leadership Model

Driving positive culture and productive organizational energy

Selecting and Retaining Talent

Leadership & Staff Training & Development

Drive towards Excellence in all mission critical areas

Improvement Methodology

Leader Evaluation & Performance Scorecard

Standardized PI Process

Risk Taking and Organization ChangeThe Change Equation

C=(DxVxF) > R*Three factors must be present for meaningful organizational change to take place, and together they must be greater than the RESISTANCE of those who fear the change. C = ChangeD = Dissatisfaction with the status quoV = Vision of a better future stateF = Practical First StepsR = Resistance to Change by people or the organization system

Before the change:When planning a major change, planning teams need to make sure all three elements are built into their plans.

During the change:Use it as trouble-shooting tool for figuring out why people are resisting the change.

* Change Equation formula developed by Richard Beckhard 1977; modified by David Gleicher, and Kathy Dannemiller.

Where the rubber meets the road….

EXECUTION

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Clin Ops Team Structure

Month Day, Year 23

Director,Clinical

Optimization

Project Manager

Assistant Director, QM

Regional Physician VP

Regional Analysts

Regional Nurses

Collaboration

Month Day, Year 24

How do we work with our Sites?

Clin Ops Team

Physician Chair

Nursing Director

Vice/ Asst. Chairs

RN Managers

ACP Leads ED Administrator

“Typical” Emergency Department Flow

InputTriage

Room placement

ThroughputProvider interaction,

Work up, Intervention

OutputProvider Signoff

Discharge: home or hospital

25Press Ganey Scores Average Admit LOS

Where does Clin Ops find work?

Month Day, Year 26

Continuous Site Improvement projects (SIPs)

Sustainability & Accountability Model

Data and Analytics to transform patient care

This slide will break out through animation into examples for each category

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Continuous Site Improvement projects (SIPs)

Month Day, Year 28

Continuous Site Improvement Projects (SIPs)

Swim Lane Process Mapping

Brainstorming

Town HallsLEAN Events

Priority Pay Off Matrix

Fast Track Decision Making

Identification of non-value added

waste

LEAN Events with our Sites


Problem Statement:The introduction of an electronic medical record highlighted an inefficient intake process resulting in an increasing Door to Provider time.

Action Steps by Clin Ops and ED Team: LEAN Event with an interdisciplinary group of frontline staff Workflow process mapping Redesign of triage documentation PDSA testing

Plainview Hospital

Plainview, NY

Volume: 33,000ED Beds: 26Pediatrics: 9%Admission Rate: 24% Stroke Center

Plainview: Decrease Door to Provider < 30 mins


Multi-disciplinary LEAN event

Workflow mapping

Measurable results

Month Day, Year 31

Plainview – Door to Provider

Lenox Hill


Problem Statement:A small Fast Track footprint hinderedefficiency of care for treat and release(T&R) patients; the Fast Track areatreated 37% of all patient volume, andthere was a high LWOBE rate from thearea with complaints of lack of privacy.

Month Day, Year 33

Lenox Hill: Increased capacity, throughput and patient and staff experience

Action Steps: Redesign use/purpose of clinical space LEAN Event with an interdisciplinary group of frontline staff Workflow process mapping Role redesign PDSA testing

Month Day, Year 34

Lenox Hill – LEAN Event

Brainstorming Solutions and

Causes

Buy-in from front line staff

Workflow process mapping

Current Data: Door to Provider Time

1/1/16-2/21/16

2/22/16-2/29/16

MARCH APRIL MAY JUNE JULY

DTP 31 38 33 29 25 24 24

0

5

10

15

20

25

30

35

40

Min

ute

s

Average Door to Provider

Month Day, Year 35

GOAL 26min

1/1/16-2/21/16

2/22/16-2/29/16

MARCH APRIL MAY JUNE JULY

Series1 222 222 218 215 207 207 200

185

190

195

200

205

210

215

220

225

Min

ute

s

T&R ALOS

Current Data: Treat and Release Average LOS

Month Day, Year 36

GOAL 205min

Current Data: Treat and Release Length of Stay

Month Day, Year 37

Long Island Jewish Medical Center

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Problem Statement:

52% of patients seen at LIJ are an ESI level 3 and represent 68% of patients that LWOBE.

In 2015 the avg. Door to Doc was 85 mins and this has contributed to increased LOS, increased LWOBE rates, decreased patient and employee satisfaction.

Volume: 97,736ED Beds: 60Admission Rate: 26% Stroke Center, Chest Pain Center, Cath Lab

LIJ Medical Center

New Hyde Park, NY

LEAN Event with Front-line Staff to brainstorm causes and solutions and swimlane out the process map for ESI 3 patients in the department.

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LIJ: Baseline Data

65

85

2014 2015

ED Door to Provider

1.40%

2.60%

2014 2015

Left Without Being Evaluated

303

334

2014 2015

T&R LOS

88,263

93,964

2014 2015

Emergency Department Volume

7% Increase9% Increase

LIJ: Addressing the Volume PhenomenonA decade of growth and change

40

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

2007 2008 2009 2010 2011 2012 2013 2014 2015 Proj 2016

Tota

l Vo

lum

e

LIJ ED Volume

Capacity 65K

Capacity 85K

Renovations

Renovated ED OpensCapacity: 65K

Closures Increased Capacity Increased Efficiency

5 Hospitals closeIn Queens

Separate Peds ED OpensHEC ClosesBH Intake Area CreatedClinical Decision Unit (CDU) OpensLIJ Split Flow Phase I increases capacity by 20K visits

Patient Experience LeanQUID InitiativeSplit Flow V2

100,000 visits2017


LIJ: Goals met and Sustained ImprovementGoal is to decrease ED Turnaround times by January 2017: Reduce Door to Provider times to < 60 minutes Reduce ED LWOBE < 2 % Reduce ED Treat and Release LOS to < 280 minutes Improve Patient Satisfaction Scores

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Data and Analytics


QUALITY

• Pneumonia

• Sepsis – Lactates Sepsis - Abx

• Cardiac Care-Balloon &EKG

• Cath – Door to EKG, Door to PCI

• Pediatrics

• Restraint

• Sedation

• Hand-washing

• Pain Control –Documentation & Timeliness

• Vital Signs

• Transfers

• Capnography

• Care of Sexual Assault Survivors

• Abuse Screen

• Med Errors

• Adverse Drug Reactions

• Falls

• Stroke Code

VOLUME

• Total Registered

• Total Admissions

• Treat & Release

• Pediatric Treat & Release

• Pediatric Admits

• Pediatric Transfers

• Unplanned Returns

• CDU admits & Treat & Release

THROUGHPUT

•Door to Bed

•Door to RN

•Door to Provider

•Provider to Disposition

•Decision to Admit to Bed Assignment

•Bed Assignment to ED Departure

•Total ALOS

•ALOS Treat & Release

•ALOS Admitted Patients

•ALOS Transfers

•ALOS Pediatrics

•ALOS Psych

•ALOS ERHO

•ALOS CDU

•ALOS Class 1 OR

•ED Midnight Census

•Ambulance –Volume

•Ambulance – TAT

•LWBS

•Diversion

•ED Registration

•Mortality within 24hrs

FINANCE

• PQRI

• IV Start and Stop

• P&L

• E&M Distribution Tech & Pro

• Charges

• Utilization by physician

• Revenue

• Billed vs. Budget

• Pro Charges

• Avg Charge

• Avg Payment

• Gross Collection Rate

• Trending/ Variance Analysis

• KPI Monitoring

PATIENT SATISFACTION

• Overall Satisfaction

• Likelihood to Recommend

• How well was your pain controlled

• Physician and Nursing Section Scoring

• Top Box scores

EMPLOYEE ENGAGEMENT

•Annual employee engagement surveys

•Tier leaders

Emergency Medicine Data Metrics

Over 200 metrics are captured by the EMSL sites. This slide highlights a portion of those metrics.

Dynamic Dashboards

Our Dashboards identify opportunities for operational improvements (T&R LOS) and help us to see which sites need support.

The dashboards are dynamic allowing the sites control and transparency over their data.



Static Monthly Dashboards

Threshold Goal

22 17 17 23 20 21 20.86 20.18 21.61 19.11

Median 13 13 10 11 13 13 13 13 11 13 13 12

202 200 188 200 190 188 188.75 180.88 194.84 181.78

Median 168 173 171 159 171 160 161 153 154 159 151 161

425 346 362 384 355 369 405 327.38 361.77 366.18

Median 365 381 317 330 331 335 340 334 298 326 329 332

218 211 200 213 202 200 200.33 191.74 205.54 193.01

3070 2707 2914 3127 3185 3101 2984 2908 3146 3184

5.2% 5.1% 5.5% 4.5% 5.1% 4.3% 7.3% 5.6% 5.1% 5.2%

# of pts 1,716 159 137 159 142 162 133 219 162 161 167 1,601

1.40% 1.11% 1.48% 1.92% 1.79% 1.42% 1.71% 1.55% 1.53% 1.82%

# of pts 666 43 30 43 60 57 44 51 45 48 58 479

8 12 4 11 11 6 9 3 1

8 12 4 11 11 6 9 3 1

84.6% 95.2% 92% 77% 94% 78% 90.0% 76.9% 100% 95.7%

79.0 81.3 75.3 72.9 67.0 71.7 70.90 71.40 74.8 66.2

94.0 99.0 77.0 67.0 40.0 60.0 57.0 58.00 75 35

Aug Sep Oct Nov Dec 2017 YTD2017 Targets

Door to DocAvg. 20 20 24 21

Lenox Health GV 2017 2016 Baseline Jan Feb Mar Apr May Jun Jul

T&R LOSAvg. 201 191 195 190

Admit LOSAvg. 407 370

Total LOS Avg. 215 203

Volume Total 36,648 30,326

Admit Rate% 4.70% 5.3%

LWOBE Rate% 1.82% 1.58% 1.6% 1.5%

Sepsis - Fluid % Compliant 63% 80.0% 63% 67%

Sepsis - Abx % Compliant 86% 86.2% 87% 92%

Cauti % Compliant 86% 88.4% 90% 91%

Patient Exp. -

Likelihood to

Recommend

Top Box Score 73.3 74.0 74.7 75.4

Patient Exp. -

Likelihood to

Recommend

Percentile Rank 74.0 71 80 83


Static Monthly Dashboards


Clinical Details Dashboard Collaboration with Krasnoff Quality Management Institute (KQMI) Team Allows for deep dive into clinical presentation of ED patient population

Operational Dashboards

Transparency and Accountability

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Using Data and Analytics to Transform Patient Care

Month Day, Year 49

Nursing and Tech Staffing

50

Sustainability & Accountability

SIP Meetings with Sites

Month Day, Year 51

Aim: All sites will focus SIP work on reducing Treat and Release LOS

Structure: Meetings organized by Volume Cohort (<35k, 35-60k and > 60k)

Frequency: occur every 6 weeks and alternate with the EMSL leadership meeting.

Format: Webex to increase participation and convenience

Accountability: Site update on PDSA cycles (3 slides)

Formal Report Outs of Improvement Work

EMSL Leadership Meetings occur once every six weeks.

Provide 2-3 ED Leadership teams and Front Line staff the

opportunity to report out in front of peers.

Formal presentation to entire EMSL once a year.

Allows for feedback and questions from all Eds.


STIPs: Individual Provider Score Card (Academic sites)


Emergency Department Performance

Metric

Quality

Severe Sepsis/ Septic Shock- Abx w/in 180 min: Overall department performance (Percent Compliance)

Severe Sepsis/ Septic Shock- Fluids w/in 30 min: Overall department performance (Percent Compliance)

OperationsDoor to Provider time - Overall department performance

TRLOS- Overall department performance

Patient Experience Press Ganey Likelihood to Recommend - Overall departmentperformance Top Box Score

Emergency Department Provider Performance

Metric

CitizenshipObjective criteria to be determined by Site Chairs (Examples -

meeting attendance, committee participation, community benefit initiatives (ex. EMS directorship)

AcademicObjective criteria to be determined by Med School Chair based on milestones within academic tracks (Examples -

research, education, innovation, etc.)

Patient ExperiencePress Ganey- MD Took Time (Courtesy)Question; Top Box Score for Individual Provider **

STIPs: Individual Provider Score Card (Non-academic sites)


Emergency Department Performance

Metric

Quality

Severe Sepsis/ Septic Shock- Abx w/in 180 min: Overall department performance (Percent Compliance)

Severe Sepsis/ Septic Shock- Fluids w/in 30 min: Overall department performance (Percent Compliance)

OperationsDoor to Provider time - Overall department performance

TRLOS- Overall department performance

Patient Experience Press Ganey Likelihood to Recommend - Overall departmentperformance Top Box Score

Emergency Department Provider Performance

Metric

CitizenshipObjective criteria to be determined by Site Chairs (Examples -meeting attendance, committee participation, community benefit initiatives (ex. EMS directorship)

Patient Experience**Press Ganey- MD Took Time (courtesy) Question;Top Box Score for Individual Provider **

Based on department and individual provider performance.

STIPs: Physician Leadership


Service Line Performance (%)

• Financial

• Patient Experience

• Quality

• Operations

Emergency Department

Performance (%)

• Financial

• Patient Experience

• Quality

• Operations

Chairs and Vice Chairs are held to the same metrics at the Service Line and Department level for their sites.

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Thank You

Questions?