Genesis Health System
PromiseCare
Research Summit – June 8, 2016
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PromiseCare - Concepts
The PromiseCare process is known by many
titles, and in summary is focused on:
• Re-designing clinical care to achieve these
goals
• Reducing variation in care
• Increasing reliability of outcomes
• Increasing efficiencies in the use of
resources
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Almost all studies that investigate the reliability of the application of clinical science in healthcare
conclude that there are significant opportunities for improvement.
Volume 348(26) 26 June 2003 pp 2635-2645
The Quality of Health Care Delivered To Adults In the United States
McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer:
DeCristofaro, Alison: Kerr, Eve A.
BACKGROUND
We have little systematic information about the extent to which standard processes involved in healthcare—a key element of quality—are delivered in the United States.METHODS
We telephoned a random sample of adults living in 12 metropolitan areas in the United States and…received written consent to copy their medical records…to evaluate performance on 439 indicators of quality of care
for 30 acute and chronic conditions as well as preventative care…RESULTSParticipants received 54.9 percent of recommended care.
CONCLUSIONSThe deficits we have identified in adherence to recommended processes for basic care pose serious threats
to the health of the American public. Strategies to reduce these deficits are warranted.
Reliability in HealthCare
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PromiseCare - Origins
The concept of decreasing variation in care is
not new.
It has been successfully implemented by
organizations such as Geisinger Health
System and Intermountain Health Care.
They have documented success in achieving
the desired results.
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Geisinger Model – Proven Care
Developed a process one procedure / DRG at
a time.
About 10 years in the making so far
Originally started with CABG
Led by a Cardiac Surgeon to start with
Currently about 17 projects in place
CABG Ave. LOS fell 0.5 days (6.2 vs. 5.7)
CABG 30-day readmission rate fell 44%
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GHS - Performance Excellence as Strategy
Physician Led - Professionally Managed
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The Promise in PromiseCare
Right Patient
Equitable Care Every time
Every patient
Right Time
Right Setting
Right Resources
Right Care
Safe Patient-Centered
Timely
Effective/Efficient
Crossing the Quality Chasm 2001 –
Institute of Medicine
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PromiseCare - Objectives
Differentiate Genesis based on quality outcomes
Reduce the overall cost to treat
• Research current best evidence
• Hardwire care delivery processes
• Reduce unwanted variation to deliver high clinical
reliability
• Reduce operational inefficiencies
• Provide effective and efficient clinical care
Develop the internal infrastructure (people, process and
technology) that will ensure sustained improvements,
maintain consistency and provide ongoing cost-effective care
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PromiseCare - Operational Structure
GHS Performance
Excellence
Leadership
Committee PromiseCare
Steering Committee Chair: CMO
Medical, Clinical &
Administrative Leadership
PromiseCare Project Support Team: IT, BIC, Finance, Quality, Nursing Education, Pharmacy,
and others
PromiseCare Coordinator and Specialist
GMC-Davenport MOC
GMC – Illini MOC
CAH MEC
Sepsis
Leadership
Team and
Workgroups
HF Leadership
(Phase I &
II)Teams and
Workgroups
Stroke
Rehab
Leadership
Team and
Workgroups
Condition Specific Leadership Committee Physician, Nurse & Administrative Champions
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Total Knee
Procedure
(Sleep Apnea )
Diabetes
(Phase I &
II)Teams and
Workgroups
PromiseCare - Steering Committee
Essential governance to make the process
consistent
Reports to the MOC and MEC on progress
and state of the program
Needs multidisciplinary input
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PromiseCare - Steering Committee
Differentiate Genesis based on quality outcomes
• Receive and review ongoing requests for PromiseCare
initiatives
• Approve selection criteria
• Select DRG / Diagnosis for Promise Care
• Charter DRG & Clinical Redesign Teams
• Monitor progress of PromiseCare projects
• Monitor attainment of metrics for Promise Care
initiatives (process and outcomes)
• Oversee communication plan
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Criteria Rank
(1 – 5 high)
Percentage
Weighting
Total
Availability of Evidence
Base Medicine
25%
Physician Leadership in
Area/Condition
20%
Quality Opportunity 20%
Sufficient Volume for
Change
15%
Availability of Data 10%
Financial Opportunity 10%
PromiseCare - Selection Criteria for Care
Redesign
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PromiseCare – What are We Doing?
Agreeing on what the right care is (Best Practice
Elements)
Designing the processes to ensure the right care
happens every time
Measuring compliance to the process measures
Measuring the outcomes
Expecting improved outcomes with less cost
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PromiseCare - Structure & Relationships
A methodology to bring the optimal coordination of
resources to a clinical situation in a consistent, quality
oriented, cost effective manner
Requires the utmost collaboration between all
components of patient care
Needs extensive resources
• Medical Oversight
• Nursing
• Pharmacy and other Disciplines
• Education
• IT
• BIC / Finance review
• Quality
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Stroke Rehab
Physician led - Dr. Chin
Professionally managed – Suzanne Schalber
Stroke Rehab process is fully implemented
and the model for the rest of the System to follow
Will promise future Stroke Rehab patients they will
deliver specific best practice elements
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Condition: GMC - Davenport Stroke Rehab - Variable Cost per Case
Discharges in
sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
n = 14 n = 17 n = 9 n = 18 n = 12 n = 15 n = 9 n = 12 n = n = n = n =
Compliance to Process Measures Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 YTD Avg.
PromiseCare Admit Stroke Rehab Power
Plan Percentage100.0% 100.0% 81.8% 100.0% 100.0% 93.8% 88.9% 92.3%
1% of Patients Assessed by Therapies within 24 Hours
of Receipt of Initial Rehab Order100% 100% 100% 100% 100% 100% 100% 100% 100%
2% of Patients Who Received a Dietary Consult within
24 hours of Receipt of Initial Rehab Order100% 100% 100% 100% 100% 93% 100% 100% 99%
3% of Patients Who received Bowel and Bladder
Training 100% 100% 100% 100% 100% 100% 100% 100% 100%
4% of Patients Who Completed Depression Screening
within 48 Hours of Receipt of Initial Rehab Order86% 100% 100% 100% 100% 100% 89% 100% 97%
5% of Patients Who Had Swallowing Assessment
Completed100% 100% 100% 100% 100% 100% 100% 100% 100%
6% of Patients With Communication Disorder Who
Received Training by SLP100% 100% 100% 100% 100% 100% 100% 100% 100%
7% of Patients With Cognitive Deficit Who Received
Training100% 100% 100% 100% 100% 100% 100% 100% 100%
8% of Patients Who Have Neurofeedback Assessment
Completed100% 100% 100% 100% 100% 100% 100% 100% 100%
9% of Patients Who Have Daily Monitoring for Skin
Integrity100% 100% 100% 100% 100% 100% 100% 100% 100%
10 % of Patients Who Receive 3 Hours of Therapy Daily 93% 100% 89% 100% 100% 100% 100% 100% 98%
11% of Patients Who Have Mobility Issues AND
Received PT Training100% 100% 100% 100% 100% 100% 100% 100% 100%
12% of Patients Who Have Self Care Issues AND
Received OT Training100% 100% 100% 100% 100% 100% 100% 100% 100%
13% of Patients Who Were Discharged by Estimated
Discharge Date100% 100% 78% 100% 100% 93% 100% 85% 94%
PromiseCare Stroke Rehab Bundle 98.1% 100.0% 97.2% 100.0% 100.0% 98.9% 99.1% 99.3% 99.2%
PromiseCare All or Non Bundle 78.6% 100.0% 66.7% 100.0% 100.0% 86.7% 88.9% 92.3% 90.7%
n = 12 n = 16 n = 11 n = 18 n = 11 n = 16 n = 9 n = n = n = n = n =
Clinical Outcome Measures Baseline Target Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 YTD Avg.
1 % of Patients Discharged to Acute Care 6.3% 10.2% 0.0% 6.3% 27.3% 11.1% 0.0% 12.5% 11.1% 7.7%
2 Case Mix Index 1.31 1.54 1.5751 1.3291 1.1231 1.4732 1.1707 1.5338 1.2057 1.3456
3 FIM Change Admission to Discharge 21.97 22.07 28.58 21.06 16.91 22.56 25.18 23.69 22.00 23.46
4 % of Discharges to home 66% 67.96% 42% 56% 64% 61% 73% 63% 44% 77%
5 % of Discharges to a Skilled Nursing Facility 21.17% 58.3% 37.5% 9.1% 27.8% 27.3% 25% 33% 15%
6 ALOS 19.86 14.25 15.33 15.88 11.45 12.73 15.36 15.06 15.89 15.15
7 ALOS O/E Index N/A 0.85 1.03 0.86 0.74 1.10 0.85 1.01 0.96
8 Rehab Unit Patient Satisfaction Percentile 38 80
Financial Outcome Measures Baseline Target Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 YTD Avg.
1 Variable Cost per Case 10,592$ 8,911$ 9,996$ 7,086$ 8,562$ 9,845$ 8,880$
3 Contribution Margin 78,917$ 75,499$ 25,119$ 109,141$ 94,101$ 76,555$
Stroke Rehab
GMC - Davenport
Goal is
98.5%
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Goal is
98.5%
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Sepsis
Physician led – Dr. Dierks
Professionally managed – Lynn Colberg
CMS intervention
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25
26
60
64
60
53
33
94
70
74
100
90
0
10
20
30
40
50
60
70
80
90
100
Jul-2015 Aug Sep Oct Nov Dec Jan-2016 Feb Mar Apr May
PE
RC
EN
T P
OW
ER
PL
AN
U
SA
GE
MONTH
GMC-DAVENPORT - CMS INPATIENT SEPSIS POWER PLAN USAGE
Goal 45%
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GMC - Silvis Sepsis - Mortality O/E - Total Sepsis nowGMC - Silvis Sepsis - Mortality O/E - Secondary SepsisGMC - Silvis Sepsis - LOS O/E - Total Sepsis now
Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample
6 6 3 4 6 5 8 5 5
Compliance to Process Measures Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
All SIRS, potential Sepsis patients
1 % Was SIRS Alert fired
2 % Was suspected Adult Sepsis protocol initiated
All Sepsis patients
3 % Lactate ordered < 3 hrs 100% 86% 100% 100% 17% 100% 100% 100% 100%
4 % Remeasure lactate if initial lactate was elevated < 6 hrs 66% 43% 67% 100% 50% 33% 60% 60%
5 % Patients in which Sepsis Order Set was utilized 83% 67% 86% 50% 50% 60% 50% 60% 100%
% Patients in which Sepsis Order Set was utilized < 3 hrs
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% Sepsis Patients in which 2 Blood cultures are drawn
prior to administration of antibiotics < 3 hrs 100% 86% 67% 100% 17% 80% 100% 100% 80%
7% Sepsis Patients in which broad spectrum antibiotics
were administered < 3 hrs of admit time83% 71% 100% 75% 33% 100% 88% 100% 100%
10% Patients receiving appropriate fluid resuscitation < 3
hrs (Only Septic Shock patients)50% 100% 50% 25% 0% 0%
12% Patients with Focused Exam and/or Hemodynamic
Monitoring < 6 hrs (Only Septic Shock patients)100% 50% 0% 0% 0% 0%
15% Patients given Vasopressor (or other inotrope) < 6 hrs
(only Septic Shock patients)100% 100% 0% 0% 0% 0%
Overall Compliance
All or None Bundle (CMS) 17% 14% 33% 67% 0% 0% 0% 20% 20%
Clinical Outcome Measures (rolling 12 mon.) Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
1 Mortality O/E - Total Sepsis now 0.71 0.70 0.62 0.63 0.65 0.57 0.643 LOS O/E - Total Sepsis now 0.78 0.80 0.74 0.74 0.73 0.75 0.74
5 Readmission O/E - Total Sepsis now 0.76 0.78 0.85 0.86 0.82 0.77
7 Complication O/E - Total Sepsis now 0.83 0.91 0.56 0.58 0.57 0.54 0.56
Financial Outcome Measures Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
1 Variable Cost per Case - Total Sepsis now 3,798$ 4,559$ 3,677$ 5,340$ 4,580$
5 Contribution Margin - Total Sepsis now 65,277$ 57,202$ 54,661$ 174,122$ 53,324$
Generated 05/16/2016
Indicates data not available
Indicates data not yet available but will be later
Sepsis
GMC - Silvis
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Heart Failure (HF)
Physician led - Dr. Rajendran
Professionally managed – Karen Doy / Jacque
Oelerich
Acute Setting - Phase 1 Completed with
some needed improvements
• Will pilot PromiseCare Promise to Heart
Failure Patients
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Condition: Heart Failure
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
Discharges
in sample
n = 12 n = 14 n = 18 n = 11 n = 6 n = 20 n = 6 n = 11 n = 20 n = 22
Compliance to Primary Process Measures Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
1% of ED Patients Who Had a Primary Diagnosis of Heart Failure who received a Loop
Diuretic 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
2 % of ED Heart Failure Patients Admitted to Observation/Outpatient 16.7% 18.2% 5.0% 0.0%
3 % of Heart Failure Patients for which the HF Admission PowerPlan was utilized 75.0% 78.6% 50.0% 100.0% 85.0% 80.0% 83.3% 90.9% 80.0% 81.8%
4% of Heart Failure Patients for whom the PromiseCare Heart Failure Checklist was
utilized91.7% 92.9% 83.3% 100.0% 100.0% 95.0% 100.0% 100.0% 95.0% 100.0%
5 % of Heart Failure Patients for which LVEF was charted 91.7% 85.7% 83.3% 100.0% 100.0% 95.0% 83.3% 90.9% 95.0% 100.0%
6 % of Heart Failure Patients who had a bodyweight measurement taken each day 83.3% 85.7% 83.3% 100.0% 100.0% 95.0% 100.0% 100.0% 90.0% 100.0%
7 % of Heart Failure Patients placed on strict daily Intake & Output. 91.7% 92.9% 83.3% 100.0% 95.0% 95.0% 100.0% 100.0% 90.0% 100.0%
8 % of Heart Failure Patients who received Heart Failure Education. 91.7% 92.9% 77.8% 100.0% 95.0% 95.0% 100.0% 100.0% 95.0% 95.5%
9% of Heart Failure Patients with a 3-5 days post-discharge follow-up appointment
scheduled. 83.3% 57.1% 55.6% 63.6% 75.0% 85.0% 66.7% 72.7% 75.0% 77.3%
10% of Heart Failure Patients on which Medication Reconciliation was completed prior to
discharge58.3% 50.0% 44.4% 90.9% 70.0% 60.0% 83.3% 72.7% 75.0% 68.2%
11 % of Heart Failure Patients with a copy of their Discharge Medication List on their chart 83.3% 64.3% 50.0% 63.6% 80.0% 90.0% 83.3% 72.7% 85.0% 95.5%
12% of Heart Failure Patients who had their Discharge Medication List provided/faxed to
their physician83.3% 64.3% 44.4% 63.6% 80.0% 90.0% 83.3% 72.7% 80.0% 86.4%
13% of Heart Failure Patients with LVEF < 40 who had ACEI or ARB prescribed at
discharge91.7% 78.6% 72.2% 100.0% 90.0% 90.0% 100.0% 90.9% 95.0% 100.0%
14% of Heart Failure Patients for whom the Heart Failure Discharge PowerPlan was
utilized0.0% 0.0% 0.0% 0.0% 5.0% 5.0% 0.0% 9.1% 0.0% 0.0%
Clinical Outcome Measures Baseline Target Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
1 Mortality O/E - Heart Failure 0.83 0.57 0.55 0.76 0.59 0.51 0.37 0.25 0.26 0.33
2 LOS O/E - Heart Failure 0.90 0.68 0.69 0.70 0.72 0.73 0.74 0.74 0.74 0.74
3 Readmission O/E - Heart Failure (30 Day PPR) 1.08 0.74 0.71 0.60 0.64 0.65 0.69 0.62 0.60 0.62
4 Complications - Heart Failure (30 Day PPC) 0.69 0.82 0.76 0.99 0.97 1.11 1.08 1.05 0.97 1.00
5 ALOS
GMC - Silvis
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Diabetes Team
Physician Led – Dr. Figaro
Professionally Managed – Dianna Shie
Expertly Facilitated by Nicole Palmer and Beth Fox
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Total Knee
Physician Led – Drs. Martin and Connolly
Professionally managed – Julie VanDusen
Expertly facilitated by Nicole Palmer and Beth Fox
»
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Heart Failure Phase II
Physician Leader to be determined
Professionally managed – Jacque Oelerich
Expertly Facilitated by Nicole Palmer
»
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PromiseCare Teams in Process
Developing
• PowerPlans / Protocols
• Checklists / Visual Cues
• Diabetes Screening and A1C Results
• Sleep Disorder Screening
• Education for the Patients, Families, Staff and
Medical Staff
• Transitions of Care
• IT Deliverables
• Scorecards
»
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PromiseCare
Integration with HRO, Lean and Baldrige
• Research Best Evidence and Hardwire
• Use of Algorithms, A3’s, Visual Cues, Standard
Work, Value Stream Mapping, Lean the
PromiseCare Process
• Project Management and IT Deliverables
• Education of New Leadership
• Education of New Providers
• Move from Checklists to Care Plans
• Healthcare Team Building
»
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PromiseCare
Questions?
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PromiseCare
Not The End
Only the Beginning
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