Clinical Integration: A Value-Based Model for Better Care

© 2015 Health Catalystwww.healthcatalyst.comProprietary and Confidential

c

Holly Rimmasch2016

Clinical Integration


Objectives● Understand the importance of having a clinically

integrated organizational structure to support systematic improvement and sustainability

● Describe key roles and processes critical to sustained improvement methodology

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© 2015 Health Catalystwww.healthcatalyst.comProprietary and Confidential 3

"Every system is perfectly designed to get the results it gets.” - Dr. Paul Batalden

Organize around process. - William Edwards Deming

... so re-design your system to get better results


Three Systems for Improvement

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What should we be doing? How are we doing?

How do we transform?Clinical Integration


Clinical Integration● What is it?

‒ The organization around clinical processes to facilitate clear accountabilities for care across the continuum

● Why is it important?‒ Our core business is providing value

through better clinical care.

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Another emerging definition-

For many who work on the front lines of delivery system reform, clinical integration is not a generic phrase to describe health care professionals working more closely together. It’s a specific type of legal arrangement that allows hospitals and physicians to collaborate on improving quality and efficiency, while remaining independent entities.

Advisory Board

We are not going to spend time today diving into the legal arrangement

https://www.advisory.com/research/health-care-advisory-board/studies/2010/building-the-performance-focused-physician-network/clinical-integration-investment/legal-context-and-standards/formal-ci-different-from-simple-collaboration


Typical Healthcare System?Just some examples…

Departments

Executive Leadership

Executive CEO

CFO

HR Finance

COO

Departments Departments

Executive Leadership

Executive CEO

CFO

HR Finance

COO

Departments

Hospital or Healthcare system

Clinics


Budgeted Departments- examples• Nursing

• Medical Surgical Units• Intensive Care Units

• Pharmacy

• Respiratory Therapy

• Physical Therapy

• Emergency Department

• IT

• Sourcing (purchasing)

• Care Management

• Medical Group/Physician Division

• Clinics

• Home Care

• Rehabilitation

• Cardiovascular (Cath labs, echo, EKG, etc)

• Radiology

• Quality

• Finance

• Environmental Services

• Medical Group

• Laboratory

• Food & Nutrition

• Health Information Management

Is this enough ?


Heart Failure Readmissions14% reduction in 90-day readmits

21% reduction in 30-day readmits

2X increase in phone calls 48 hours

63% increase in med reconciliation

http://www.healthcatalyst.com/wp-content/uploads/Academic_Medical_Center_HF_Readmissions_3pg.pdf


Reducing Sepsis Mortality

22% reduction in sepsis mortality

$1.3 million in savings

http://www.healthcatalyst.com/wp-content/uploads/2013/05/KC-HealthCatalyst-MultiCare-CaseStudy.pdf


Improved ACO Care CoordinationAdvanced Care Planning

64% increase in high-risk patients with ACPs

1,243 high-risk patients with ACPs

980 physicians and community facilitators engaged

Integrated EDW solution in a heterogeneous EHR environment

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https://www.healthcatalyst.com/wp-content/uploads/2015/01/successstories-quality-improvement-in-healthcare-aco-case-study.pdf


Key Functions of a Clinically Integrated System

● Create a shared vision● Create integrated information systems● Integrate clinical and operations management structure● Integrate incentives and cost structures

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Poll QuestionPlease rate your organization. How integrated are your clinical and operational management structures? – 201 respondents

1. 100%-- we are there! – 2%

2. 75%-- we are getting there! – 11%

3. 50%-- we are well on our way – 33%

4. 25%-- we are not too far on this journey – 34%

5. Don’t know – 20%


Outcomes Improvement Organizational Structure

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Provides domain oversight and recommended prioritiesGUIDANCE

TEAM (S)

Leads specific outcomes improvement discovery intervention design and implementation. Lead unit based change

OUTCOMES IMPROVEMENT

TEAM (S)

Assigned specific discovery and intervention design work by OIT e.g. order set, new workflow

WORKGROUP (S)

Supports developmentof clinical content and

supporting analytics

CONTENT ANDANALYTICS

TEAM (S)

Provides overall governance, prioritization, and cultural change leadership for all outcomes improvement

CLINICAL OUTCOMES IMPROVEMENT

LEADERSHIP TEAM

ENSURETHAT…

• Governance and Teams are appropriately empowered to make decisions• Outcomes Improvement Teams are created based on organizational improvement priorities• Teams are cross discipline, permanent and include the right stakeholders

DATA GOVERNANCE TEAM

Provides overall governance over

the 6 phases of Data Governance


Accountabilities:

• Provides overall governance, prioritization, and cultural change leadership for all outcomes improvement

• Establishes clinical integration (clinical programs, clinical services, patient quality, and safety) and clinical improvement work

• Represents the continuum of clinical services

• Recommends clinical board-levelgoals

• Reviews progress and remove roadblocks

Clinical Outcomes Improvement Leadership Team

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Clinical Outcomes Improvement Leadership TeamMembership should represent key stakeholders in system (e.g., acute, ambulatory, MD division):

• Chief Medical Officer (CMO) or VP of Medical Affairs

• Chief Nursing Officer/Executive or VP for Nursing

• Chief administrators or operational officers

• Other key stakeholders− IT, Finance, Patient Quality, and Safety, ACO, Population Health,

etc.

− Leadership representing Clinical Programs (CV, Pediatrics) and Clinical Support Services (pharmacy, lab)

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Clinical Programs: Ordering of Care

Community Care

Care Process Families

e.g., Diabetes

Cardio-vascular


e.g., Coronary

Artery Disease

General Medicine


e.g., Sepsis

Respiratory


e.g., Obstructive

Lung Disorders

Neuro-sciences


e.g., Back and Neck Pain

Surgery


e.g., Head Injury

Hematology /Oncology


e.g., GI Neoplasm

Behavioral Health


e.g., Depressive Disorders

Women and Newborns


e.g., High-Risk

Pregnancy

Gastro-intestinal


e.g., Pancreatic Disorders

Musculo-skeletal


e.g., Osteoarthritis


Community Care


e.g., Diabetes

Cardio-vascular


e.g., Coronary

Artery Disease

General Medicine


e.g., Sepsis

Respiratory


e.g., Obstructive

Lung Disorders

Neuro-sciences


e.g., Back and Neck Pain

Surgery


e.g., Head Injury

Hematology /Oncology


e.g., GI Neoplasm

Behavioral Health


e.g., Depressive Disorders

Women and Newborns


e.g., High-Risk

Pregnancy

Gastro-intestinal


e.g., Pancreatic Disorders

Musculo-skeletal


e.g,Osteoarthritis

Clinical Support Services: Delivery of Care Ordered

Diagnostic Clinical Support Service (workflow models)(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)

Therapeutic Clinical Support Service (workflow models)(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)

Ambulatory Operations (workflow models)(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)

Capacity Management (workflow models)(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)

Invasive Clinical Support Service (workflow models)(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])


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Heart Rhythm Disorde

rs

Vascular

Disorders

Ischemic Heart Disease

HeartFailure

CARDIOVASCULAR

Level B:Care Process

Families

Level A: Clinical

Program

CardiacValve

DisordersCHF

Cardio-myopath

y

Pulmonary Heart Disease

Level C: Care

Processes

SystolicDysfuncti

onDiastolic

DysfunctionLevel D: Care

Sub-Processes

ICD-9 and ICD-10Diagnosis Codes

ICD-9 and ICD-10

Procedure Codes

CardiacValve

Procedures

Car

e-Le

vel H

iera

rchy


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Heart Rhythm Disorde

rs

Vascular

Disorders

Ischemic Heart Disease

HeartFailure

CARDIOVASCULAR

Level B:Care Process

Families

Level A: Clinical

Program

CardiacValve

DisordersCHF

Cardio-myopath

y

Pulmonary Heart Disease

Level C: Care

Processes

SystolicDysfuncti

onDiastolic

DysfunctionLevel D: Care

Sub-Processes

ICD-9 and ICD-10Diagnosis Codes

ICD-9 and ICD-10

Procedure Codes

CardiacValve

Procedures

Clin

ical

Impl

emen

tatio

n Te

ams Guidance Team

Clinical Implementation Team

Work Groups

CV

CareProcessFamilies

e.g.,coronary artery

disease

=


Care Process Pareto AnalysisCardiovascular Clinical Program

Top 13 Care ProcessesMiddle 27 Care ProcessesBottom 45 Care Processes

Adult_CareProcess Adult_CareProcessFamily Adult_ClinicalProgramNormalized Revenue % of All CPs

Running % of All CPs

Coronary artery disease Ischemic heart disease Cardiovascular $28,516,437 4.47% 4.47%Congestive heart failure Heart failure Cardiovascular $10,935,531 1.71% 6.18%Arterial aneurysm, dissection Vascular disorders Cardiovascular $8,838,347 1.39% 7.57%Cardiac valve disorders Heart failure Cardiovascular $8,095,210 1.27% 8.84%Vascular insufficiency Vascular disorders Cardiovascular $5,918,680 0.93% 9.76%Atrial fibrillation, flutter and other supraventricular tachyarrhythmiasHeart rhythm disorders Cardiovascular $4,972,392 0.78% 10.54%Venous phlebitis, thrombosis, embolismVascular disorders Cardiovascular $2,808,147 0.44% 10.98%Ventricular tachyarrhythmias Heart rhythm disorders Cardiovascular $2,702,363 0.42% 11.41%Pulmonary embolism Heart failure Cardiovascular $2,599,832 0.41% 11.81%Complication of vascular device, implant or graftVascular disorders Cardiovascular $2,304,288 0.36% 12.18%Sick sinus and conduction disordersHeart rhythm disorders Cardiovascular $1,892,212 0.30% 12.47%Peripheral vascular disease Vascular disorders Cardiovascular $1,860,751 0.29% 12.76%

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of Total Cumulative %

Pareto Analysis >> Prioritization

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X-Axis = Care Processes by resources consumed (High to Low)

Y-A

xis

= Pe

rcen

t of t

otal

reso

urce

s co

nsum

ed

Top 85 Care Processes account for 80% of the opportunity (+45)

Top 40 Care Processes account for 62% of the opportunity (+27)

Top 13 Care Processes account for 34% of the opportunity


Internal Variation versus Resource Consumption(Excel Example shown)

Y- A

xis

= In

tern

al V

aria

tion

in R

esou

rces

Con

sum

ed

Bubble Size = Resources Consumed

Bubble Color = Clinical DomainX Axis = Resources Consumed

1

2

3

4


Accountabilities:

• Provides domain oversight and recommended priorities

• Develop and implement best practices across the continuum within domain (i.e. heart failure from prevention through treatment and maintenance)− Each clinical program is assigned accountability for care process families

and related care processes

• Recommend board and clinical program goals

• Prioritize resources

• Determine order and timing for creation of teams to support goals

• Ensure best practices are diffused and sustained systemwide

• Review and report progress; remove barriers

Guidance Team

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Guidance Team

Chaired by physician and nurse director with domain expertise. Team membership should include:

• Physician, nurse director, and administrator from each cluster representing domain

• Knowledge manager, data architect/analyst

• Other key stakeholders:− IT, Finance, Patient Quality, and Safety


Permanent Teams Characteristics

= Subject Matter Expert= Data Capture= Data Provisioning & Visualization= Data Analysis

Women & Children’s Clinical Program Guidance Team

Pregnancy

MD LeadRN SME

Knowledge Manager

DataArchitect

Application Administrator

RN, Clin Ops Director

Guidance Team MD lead

Normal Newborn

MD LeadRN SME

Gynecology

MD LeadRN SME

• Organized permanently for long term improvement• Integrated clinical and technical members• Supports multiple care process families• Choose innovators and early adopters to lead

Innovators

Early Adopters


DATA CAPTURE

• Acquire key data elements• Assure data quality• Integrate data capture into operational

workflow

DATA ANALYSIS

• Interpret data• Discover new information in the data

(data mining)• Evaluate data quality

DATA PROVISIONING

• Move data from transactional systems into the data warehouse

• Build visualizations for use by clinicians• Generate external reports (e.g., CMS)

Knowledge Managers (data quality, data stewardship, and

data interpretation)

Application Administrators (optimization of source systems)

Data Architects(infrastructure, visualization, analysis, reporting)

= Subject Matter Expert= Data Capture= Data Provisioning= Data Analysis

Critical Key Functions to Consider…

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Outcomes Improvement TeamAccountabilities:

• Leads specific outcomes improvement discovery intervention design and implementation. Lead unit based change• Provide broad feedback to smaller workgroup teams on aims,

metrics, and best practices

Membership:

• Broad representation across your system (facilities, clinics, regions) and should include members with deep knowledge and experience:− Physician leader

− Nurse subject matter expert

− Other disciplines (respiratory therapy, finance, lab, etc.)


Workgroup TeamAccountabilities:

• Assigned specific discovery and intervention design work by OIT e.g. order set, new workflow

• Responsible for the “heavy lifting” related to improvement− Targeted on care process or care sub-process

− Integrate best practices; build key metrics

− Report and request input from Outcomes Improvement Team

Membership:

• Small integrated team of domain experts (physicians, nurses, finance) and analytical/technical experts− Data architects/analysts

− Application administrators


Improvement Cycle

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Prerequisites

Recruit team Train team

• Solicit front line plan input

• Finalize analytics dev, testing, and rollout support

• Finalize intervention rollout plan

• Guidance team validation

Rollout

• Review initial results• Identify, approve any

modifications to intervention rollout

• Review lessons learned

• Create next AIM statement

• Repeat process

Results

• Finalize cohort• Identify intervention(s)• Direct observation• Solicit front line input

on AIM and intervention

• Define intervention rollout plan

• Guidance team validation

Intervention

• Review visualized drafts of AIM cohort findings

• Identify data quality issues

• Direct observation• Prioritize and select

AIM #1• Review cohort criteria

and visualizations • Guidance team

validation

AIM

• Confirm team mission, charter, roles

• Review AIM options• Gather best practices• Profile and visualize

preliminary data• Select 2-3 potential

AIMs• Guidance team

validation

Kickoff

Select Build and Refine Build and Refine Build and Refine

Rollout Date

MajorMilestones

Work Streams

7. Measure Progress

1. Best Practices

2. Define Cohort

3. AIM Statement

4. Design Metrics

5. Rollout Plan

6. Rollout

Rollout Date


Identify Potential ImprovementsProcess AIMs and Outcome Goals

Transformation Process

Starter Set Content

Implement Intervention

Measure & Sustain

Review & Select AIM Define Cohort

Iterate on Metrics

Heart Failure: AIM #1

Starter Set Content

Implement Intervention

Measure & Sustain

Review & Select AIM Define Cohort

Iterate on Metrics

Heart Failure: AIM #2

Process Improvement AIM:Improve Follow-up Visit SchedulingFrom 43% to 90% by October 31, 2015

Process Improvement AIM: Improve Medication ReconciliationFrom 58% to 80% by June 30, 2015

Heart Failure Outcome Improvement Goal:Reduce Readmissions = Reduce the readmission rate for the HF population from 30% to 20% by December 31, 2015

2-4 Process Improvement AIMS should produce a significant outcome improvement


Actionable Visualizations

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Permanent Improvement Team Temporary Project Team

Team Structure Options

Pros● Proactive

(strategic investment)● Predictable Cost● Team member establish long

term relationship● Implementation improved● Sustainability improved● Partnership established on

technical priorities

Cons● “Feels” more expensive, actually

saves money long term● True cultural shift

Cons● Difficult to maintain

sustainability● Variable Cost● Speed to trust slower in

temporary teams● Need to reorient team members

don’t always understand context within domain

Pros● “Feels less expensive” one time

cost to fix (not typically true)● Less time to start initially


Priority Management• Intake process to manage strategic and tactical information

requests of EDW team

Data Stewardship• Legislation of standard definitions

• Quality management processes

• Security/authorization

• Master data management

Data Governance Categories

Executive Oversight

IT Leadership


Content & Analytics TeamAccountabilities:

• Supports development of clinical content and supporting analytics• Develop the analytic and knowledge management infrastructure needed to support

process and outcomes improvements in clinical, operational, financial and patient experience across all domains of clinical integration.

• Create consistency across clinical programs and clinical support services• Patient & Provider education related to development of best practices, guidelines, etc.

• Align priorities and resources to system goals

Membership:• Chair examples: CMIO, CQO, chief patient safety officer, chief

knowledge officer• Lead data architects and knowledge mangers• Provider and patient education specialists• Lead administrative and clinical application stewards


Care Improvement MapSepsis and Septic Shock


Are your data governance and content & analytics resources aligned with your improvement outcome goals? – 179 respondents

1. Yes – 6%

2. Mostly – 14%

3. Sometimes – 44%

4. No – 18%

5. Don’t know – 18%

Poll Question


= Subject Matter Expert

= Data Capture

= Data Provisioning & Visualization

= Data Analysis

Small Teams (Designs)• Meet weekly in iteration planning meeting• Build DRAFT processes, metrics, interventions• Present DRAFT work to Broader TeamsOB

Guidance Team

• Meet quarterly to prioritize allocation of resources• Approves improvement AIMs • Reviews progress and removes road blocks• Monitors and tracks progress and sustainability

OB Newborn GYN

W&N

W&N

Broad Teams (Implements)

• Broad RN and MD representation across system• Meet monthly to review, adjust and approve DRAFTs• Lead rollout of new process and measurementOB

W&N

W&N

W&N

Executive Leadership Team

• Prioritizes sequence of formation of Guidance Teams• Approves Board Level Outcomes Goals• Reviews progress and removes road blocks

GUIDANCE TEAM (S)

OUTCOMES IMPROVEMENT

TEAM (S)

WORKGROUP (S)

CLINICAL OUTCOMES IMPROVEMENT

LEADERSHIP TEAM

(Prioritizes Innovations)


Key Success Factors/Lessons Learned• Leadership

• Integration of technical, clinical, and operations

• Dedicated resources− Clinical leadership, domain expertise, operational expertise, Data

Managers, analytic resources

• Permanent structures and processes/systematic approach− Change from “project” to “the way we live”

• Deep culture of quality and improvement; consistent methodologies

• Transparency

• Integrated key concepts into current work/teams/structures

• There are many ways to put this puzzle together

• This is a journey!

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