Weitere ähnliche Inhalte Ähnlich wie Reducing Waste in Healthcare Delivery (20) Mehr von Health Catalyst (20) Kürzlich hochgeladen (20) Reducing Waste in Healthcare Delivery1. © 2013 Health Catalyst
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January 16, 2014 – David A. Burton, MD
Advanced Efforts to Identify and
Reduce Waste in Healthcare Delivery
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1. Constructs for understanding
healthcare waste
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Clinical Integration Construct
Clinical Programs – ordering of care
Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
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Clinical Integration Construct
Clinical Support Services – workflow and defects
Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
ClinicalSupportServices(DeliveryofCare)
Diagnostic Clinical Support Service (work flow models)
(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Service (work flow models)
(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Service (work flow models)
(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Service (work flow models)
(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Service (work flow models)
(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
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Organization of teams
Clinical and technical
Provides steady state
domain governance and
oversight
GUIDANCE
TEAM
Refines Work Group
output and leads
implementation
CLINICAL
IMPLEMENTATION
TEAM
Provides l forum to develop
and/or refine clinical content
and analytics feedback
WORK
GROUP
Supports development
of clinical content and
analytics feedback
Leads data governance
CONTENT AND
ANALYTICS
TEAM
Provides overall governance
and prioritization of initiativesSENIOR EXECUTIVE
LEADERSHIP TEAM
Chief Knowledge
Officer
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Technical support personnel
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=
Organization of clinical teams
Women & Newborn’s Clinical Program Guidance Team
Pregnancy
SAM
Pregnancy
MD Lead
RN SME
Knowledge
Manager
Data
Architect
Application
Administrator
RN, Clinical
Ops Director
Guidance Team MD lead
(e.g., Pregnancy MD Lead)
= Subject Matter Expert
= Data Capture
= Data Provisioning & Visualization
= Data Analysis
Normal
Newborn SAM
NL Newborn
MD Lead
RN SME
Gynecology
SAM
Gyn
MD Lead
RN SME
• Permanent teams
• Integrated clinical and technical members
• Technical personnel support multiple packets
AbNL NB 3-A
SAM
AbNL NB
MD Lead
RN SME
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Repeatable system for deployment
Kickoff AIM Statement
Implementation
Design Launch Approval Results Review
• Mission
• Cohort Discover
• Data Analysis and
Review
• BMJ Best Practices
• Building Multiple
Potential AIM
statements
• Supplement BMJ
content
• Refine Cohort
• Refine Metrics
• Develop Draft
Visualizations
• Develop
Recommended AIM
statement #1
• Cluster Reps Obtain
Front Line Input
• Finalize Cohort
• Develop Additional
metrics based on
feedback
• Develop Additional
Visualizations to
support
• PDSA cycle
• Cluster Reps Obtain
Front Line Input
• Improvement Plan
• Implementation Plan
• Develop cluster rep
assignments, and
deliverables
• Collect cluster rep
feedback
• Prepare Initial
Results from AIM
statement #1
• Summarized report
for historical review
• Refine, recommend
AIM statement #2
Monthly
Tasks and
Checkpoints
7 Steps
(Work Streams)
1. Gather knowledge assets
2. Define cohort
3. Select Aim Statement
4. Select, build & refine metrics
5. Develop implementation plan
6. Implement plan
7. Measure progress
Select Initial Metric Build and Refine Build and Refine Build and Refine
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Population Health Management
construct
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Population Health Management
Medicare fee-for-service payments by venue - 2011
OutpatientClinic Care Inpatient SNF Home Health Hospice
$ 31.7 Billion
11.8%
77.6 Billion
28.8%
90.6 Billion
33.7%
$ 29.7 Billion
11.0%
$ 18.4 Billion
6.8%
$ 10.1 Billion
3.7%
Clinic Care Outpatient Inpatient SNF LTCH/IRF Home Health Hospice
$ 11.1 Billion
4.1%
LTCH/IRF
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Home
(Patient Portal)
* To Invasive
Care Processes
Clinic Care
Non-recurrent
Clinic Care
Chronic
Acute Medical
IP Med-Surg
Acute Medical
IP ICU
Invasive
Medical
Invasive
Surgical
Diagnostic Work-up
Bedside care
Triage to Treatment Venue
Substance
Preparation
Invasive*
Subspecialist
Chronic
Disease
Subspecialist
Screening & Preventive Symptoms
Procedure
Indications for Intervention
Diagnostic algorithms
Indications for Referral
Triage Criteria
Preventive, Diagnostic,
Triage and Clinic Care,
Algorithms; Referral &
Intervention Indications
Population
Utilization
Knowledge Assets
Treatment and
Monitoring
Algorithms
Treatment and Monitoring Algorithms
Health Maintenance and
Preventive Guidelines
Substance Selection
Substance Selection
Clinical Supply Chain Management
Admission Order SetsAdmission Order Sets
Supplementary Order Sets
Pre-Procedure Order Sets
Post-
procedure
Order Sets
Discharge
Bedside care practice guidelines, risk
assessment and patient injury prevention
protocols, bedside care procedures,
transfer and discharge protocols
Standardized
Follow-up
Post-acute
care order sets
IP (SNF, IRF)
Home health
Hospice
Management of Acute
Medical, Invasive & Post-
Acute Care Modules
Per Case
Knowledge
Assets
Clinical ops procedure guidelines and
patient injury prevention
Post-procedure Care
Population Health Management
Anatomy of Healthcare Delivery
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Waste construct
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Utilization management waste and
prevention and treatment waste
Utilization
Management
WastePer capita management
(population focus)
Per encounter and per
case management
(individual patient focus)
Prevention
and
Treatment
Waste
Sample Metrics
Admits/1000 members
IP days/1000 members
OP visits/1000 members
Procedures/1000 members
ED visits/1000 members
Readmissions/1000 members
Sample Metrics
Cost/visit
Cost/case
OR minutes
L&D hours
LOS
# of comorbidities
Population Health Management
Per Capita
Waste
Per Encounter
or Per Case
Waste
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care,
substances and
supplies that do not add
value
Variation in efficiency of
delivering tests, care
and procedures ordered
Patient injuries incurred
in delivering tests, care
and procedures ordered
14
Three forms of waste
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Ordering Waste Workflow Waste Defect Waste
Ordering of tests that are
neither diagnostic nor
contributory
Variation in efficiency of
delivering tests, care
and procedures ordered
Patient injuries incurred
in delivering tests, care
and procedures ordered
Ordering Waste
Ordering tests, care,
substances and
supplies that do not add
value
15
Ordering waste
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Clinical Integration Construct
Clinical Programs – ordering of care
Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
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Ordering of care
Improvement initiative process
Mapping of admin
codes to HC
clinical hierarchy
Basic cohorts –
admin rules
Per Case Key
Process Analyses
Advanced
cohorts - admin
and clinical rules
Care Process
Models for KPA
Care Process list
AIM statement
starter sets
Prevention,
treatment, & UM
starter sets
Process and
outcome metrics
& visualizations
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Wasteful
Cardiac ventriculography to
measure ejection fraction
Contributory
Two-view chest X-ray
Arterial blood gases
Diagnostic
Cardiac echo to measure
ejection fraction
Brain natriuretic peptide (BNP)
Ordering waste example
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care,
substances and
supplies that do not add
value
Variation in OR room
turnover (cycle time) or
Emergency Care wait time
Patient injuries incurred
in delivering tests, care
and procedures ordered
Workflow Waste
Variation in efficiency of
delivering tests, care
and procedures ordered
19
Workflow waste
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Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
ClinicalSupportServices(DeliveryofCare)
Diagnostic Clinical Support Services (work flow models)
(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models)
(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models)
(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models)
(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models)
(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Clinical Integration construct
Clinical Support Services – delivery of care
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Mapping of client
data to HC
clinical hierarchy
Triage of client
data into care unit
& ancillary depts
Clinical
department value
stream maps
Intra- & inter-
departmental
VSMs, A3s, & AIM
statements
Pareto and
opportunity
analyses
Workflow (delivery of care)
Improvement initiative process
Process and
outcome metrics
& visualizations
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Workflow waste – surgical services
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Workflow waste – surgical services
reduce room turnover time
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care,
substances and
supplies that do not add
value
Variation in efficiency of
delivering tests, care
and procedures ordered
ADEs, transfusion
reactions, pressure ulcers,
HAIs, VTE, falls, wrong
surgery
Defect Waste
Patient injuries incurred
in delivering tests, care
and procedures ordered
24
Defect waste (patient injury)
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Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
ClinicalSupportServices(DeliveryofCare)
Diagnostic Clinical Support Services (work flow models)
(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models)
(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models)
(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models)
(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models)
(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Clinical Integration construct
Clinical Support Services – delivery of care
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Hospital-Acquired
Condition (HAC)
cohorts
Analysis of
frequency, costs,
potential savings
Patient injury
Improvement initiative process
Define criteria for
PIPP intervention
Define care units
to which PIPPs
apply
PIPP surveillance
process,
outcome metrics
& visualizations
AIM statement
starter sets
PIPP intervention
protocol starter
sets
Patient Injury
Prevention
Process (PIPP)
starter set maps
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Defect waste – CLABSI prevention
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2. Prioritization – Sample healthcare
industry analyses
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Utilization versus prevention and
treatment waste
Utilization
Management
WastePer capita management
(population focus)
Per encounter and per
case management
(individual patient focus)
Prevention
and
Treatment
Waste
Sample Metrics
Admits/1000 members
IP days/1000 members
OP visits/1000 members
Procedures/1000 members
ED visits/1000 members
Readmissions/1000 members
Sample Metrics
Cost/visit
Cost/case
OR minutes
L&D hours
LOS
# of comorbidities
To be included in future
waste analyses
(at such time as claims
data are available)
Population Health Management
Included in today’s analysis
(a subset of the total waste
in the healthcare system)
Per Capita
Waste
Per Encounter
or Per Case
Waste
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Clinical Programs
Key Process Analysis (KPA)
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Inpatient per case KPA
Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
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Inpatient per case KPA
Clinic Care Outpatient Inpatient SNF LTCH/IRF Home Health Hospice
$ 31.7 Billion
11.8%
77.6 Billion
28.8%
90.6 Billion
33.7%
$ 29.7 Billion
11.0%
$ 18.4 Billion
6.8%
$ 10.1 Billion
3.7%
$ 11.1 Billion
4.1%
OutpatientClinic Care Inpatient SNF Home Health HospiceLTCH/IRF
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Inpatient per case KPA
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Top 10 Care Process
Families account for
over 40% of the
opportunity
Top 32 Care Process
Families account for
80% of the opportunity
X-Axis = Care Process Families by resources consumed (High to Low)
Cumulative Care Process Family % of total resources
Individual Care Process Family % of total resources
Y-Axis=Percentoftotalresourcesconsumed
Inpatient per case KPA
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Y-Axis=InternalVariationinResourcesConsumed
Bubble Size = Case Count Bubble Color = Clinical DomainX Axis = 2012-2013 Variable Direct Cost
1
2
3
4
Inpatient per case KPA
PCI
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~ $20,000 difference in Average Direct Costs between
“highest cost” provider and “lowest cost” provider
for patients with identical intermediate level severity scores
GroupedbyAPRDRG–SeverityScore
Bubble Size = Case
Count for provider
Bubble Color = APRDRG -
Severity Score
X Axis = Average Variable Cost per Case
for provider
Inpatient per case KPA
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Dr. J.
15 Cases
$60,000 Avg. Cost Per Case
Mean Cost per Case = $20,000
$40,000 x 15 cases =
$600,000 opportunity
Total Opportunity = $600,000
Total Opportunity = $1,475,000
$35,000 x 25 cases =
$875,000 opportunity
Total Opportunity = $2,360,000
Total Opportunity = $3,960,000
Cost Per Case, Vascular Procedures
Inpatient per case opportunity analysis
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GroupedbyAPRDRG–SeverityScore
Bubble Size = Case
Count for provider
Bubble Color = APRDRG -
Severity Score
X Axis = Average Variable Cost per Case
for provider
Inpatient per case opportunity
Waste reduction opportunity is calculated based on bringing
the cases in each severity level of each APR-DRG down to
the mean of the severity level
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Inpatient per case opportunity*
Physician variation perspective
* This $97 MM is
based on the
impact of variation
in MD practice
across all types of
relevant inpatient
care units
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IP per case ordering waste
Opportunity analysis
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IP per case ordering waste
Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
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IP per case ordering waste
Sources of ordering variation within a case
• Diagnostics
• Laboratory tests
• Diagnostic imaging studies
• Therapeutics
• Therapies (e.g., respiratory, physical, et al)
• Substances (e.g., antibiotics, blood products)
• Clinical supply chain (e.g., prosthetics, stents,
synthetic bypass grafts, heart rhythm devices)
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Home
(Patient Portal)
* To Invasive
Care Processes
Clinic Care
Non-recurrent
Clinic Care
Chronic
Acute Medical
IP Med-Surg
Acute Medical
IP ICU
Invasive
Medical
Invasive
Surgical
Diagnostic Work-up
Bedside care
Triage to Treatment Venue
Substance
Preparation
Invasive*
Subspecialist
Chronic
Disease
Subspecialist
Screening & Preventive Symptoms
Sources of per case ordering waste
Diagnostic algorithms
Indications for Referral
Indications for Intervention
Triage Criteria
Diagnostic Algorithms,
Triage Criteria, Referral &
Intervention Indications
Utilization
Management
Knowledge Assets
Substance Selection
Substance Selection
Clinical Supply Chain Management
Procedure
Treatment and
Monitoring
Algorithms
Admission Order SetsAdmission Order Sets
Supplementary Order Sets
Pre-Procedure Order Sets
Post-
procedure
Order Sets
Discharge
Bedside care practice guidelines, risk
assessment and patient injury prevention
protocols, bedside care procedures,
transfer and discharge protocols
Treatment and Monitoring Algorithms
Health Maintenance and
Preventive Guidelines
Standardized
Follow-up
Post-acute
care order sets
IP (SNF, IRF)
Home health
Hospice
Management of Preventive,
Ambulatory, Acute Medical,
Invasive & PAC Modules
Prevention and
Treatment
Knowledge
Assets
Clinical ops procedure guidelines and
patient injury prevention
Post-procedure Care
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IP per case ordering waste opportunity
Care Process Family
Total Variable
Cost
Total Variable Cost
Opportunity
%
Opportunity
Arthritis $4,495,738 $1,262,468 28.08%
Pregnancy $3,386,142 $964,935 28.50%
Lower GI disorders $9,223,075 $2,887,678 31.31%
Pulmonary disorders $13,301,079 $4,112,305 30.92%
Ischemic heart disease $16,422,491 $3,830,609 23.33%
Heart failure $10,521,631 $3,151,318 29.95%
Spine disorders $3,667,804 $868,486 23.68%
Abdominal transplant $5,646,849 $1,150,355 20.37%
Sepsis $11,766,105 $4,302,385 36.57%
Infectious disease $9,757,995 $3,359,184 34.42%
Abnormal newborn - 3A $3,633,453 $1,078,333 29.68%
Vascular disorders $10,090,688 $2,978,748 29.52%
GU disorders $5,743,735 $1,790,536 31.17%
Abnormal newborn - 3B $5,504,113 $2,170,518 39.43%
Other gastrointestinal disorders $6,150,878 $2,109,424 34.29%
Heart rhythm disorders $7,745,049 $1,629,037 21.03%
Trauma $5,481,067 $1,784,045 32.55%
Intracranial disorders $4,655,176 $1,479,753 31.79%
Sports medicine disorders $2,212,528 $616,926 27.88%
Upper GI disorders $4,144,179 $1,239,599 29.91%
Bone marrow procedures $6,001,248 $1,662,039 27.69%
Chest procedures $2,943,145 $987,669 33.56%
Heart and lung transplants $2,367,759 $654,981 27.66%
TIA, stroke and paralysis $3,917,114 $1,311,687 33.49%
Normal newborn $934,586 $97,998 10.49%
Renal disorders $3,578,289 $1,306,072 36.50%
Cancer therapeutic procedures $4,966,106 $2,057,475 41.43%
Hematology $4,435,866 $1,839,409 41.47%
Obstructive lung disease $3,598,005 $956,058 26.57%
Biliary tract disorders $3,005,292 $849,573 28.27%
Other cardiovascular disorders $3,084,102 $920,290 29.84%
Liver disorders $3,662,416 $1,256,790 34.32%
Pareto Total $186,043,705 $56,666,685 30.46%
Ordering Waste
* The $57 MM is
based on the impact
of variation in
ordering of tests and
services from
ancillary (non-patient-
care) departments
(e.g., lab, imaging,
pharmacy, therapies,
supply chain, central
services) adjusted by
APR-DRG severity
level
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Reducing per case ordering waste
• Order sets. Evidence-based order sets for the Care
Processes in the Pareto list to reduce variation in the
ordering of simple diagnostic tests (lab, imaging)
• Indications. Evidence-based indications and cost
information to standardize utilization
• Imaging tests (e.g., MRI, CT, US, nuclear scans)
• Substances (e.g., utilization criteria for blood, antibiotics,
total parenteral nutrition)
• Major clinical supplies (e.g., joint prosthetics, cardiac and
vascular stents, synthetic bypass grafts, heart rhythm
devices, neurostimulators)
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Reducing per case ordering waste
• Health Catalyst advanced applications.
• High-level Care Process map laying out the scientific flow
• Aim Packet with 2-5 Aim statements
• Cohort definition to support the Aim Packet
• Common metrics plus additional outcome, process and
balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards,
and/or interactive drill down reports
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Workflow waste
Opportunity analysis
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Primary
Care
Care
Process
Families
e.g.,
Diabetes
CV
Care
Process
Families
e.g.,
Heart
Failure
W&C
Care
Process
Families
e.g.,
Pregnancy
GI
Care
Process
Families
e.g.,
Lower GI
Disorders
Resp-
iratory
Care
Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro
Sciences
Care
Process
Families
e.g.,
Spine
Disorders
Musculo-
skeletal
Care
Process
Families
e.g.,
Joint
Replace-
ment
Surgery
Care
Process
Families
e.g.,
Urologic
Disorders
General
Med
Care
Process
Families
e.g.,
Infectious
Disease
Oncology
Care
Process
Families
e.g.,
Breast
Cancer
Peds
Spec
Care
Process
Families
e.g.,
Peds
CV Surg
Mental
Health
Care
Process
Families
e.g.,
Depression
ClinicalSupportServices(DeliveryofCare)
Diagnostic Clinical Support Services (work flow models)
(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models)
(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models)
(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models)
(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models)
(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Per case workflow waste opportunity
Clinical Support Services
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Source: CA
Office of State-
wide Health
Planning and
Development
(OSHPD)
Annual financial
reports for 2011
351 hospitals
Exclusions:
Kaiser
State hospitals
Small psych H’s
Clinical Support Service Clinical Department
Expenses by
Clinical Department
% of
Total Cum %
Acute Medical Med-Surg Acute Care 8,661,146,370 19.2% 19.2%
Therapeutic Substance Preparation 4,662,386,338 10.3% 29.6%
Therapeutic Clinical Equipment, Supplies & Services* 4,477,744,993 9.9% 39.5%
Acute Medical Med-Surg Intensive Care 3,995,060,038 8.9% 48.3%
Invasive Inpatient Surgery 3,788,458,767 8.4% 56.8%
Diagnostic Laboratory 2,808,517,363 6.2% 63.0%
Diagnostic Diagnostic Imaging 2,730,552,915 6.1% 69.0%
Acute Medical Emergency Care 2,559,406,510 5.7% 74.7%
Ambulatory Clinic Care 2,247,089,922 5.0% 79.7%
Invasive Interventional Medical 1,495,321,329 3.3% 83.0%
Invasive Labor & Delivery 1,159,880,048 2.6% 85.6%
Therapeutic Respiratory Services 1,150,072,297 2.6% 88.1%
Acute Medical Med-Surg Subacute Care 986,656,683 2.2% 90.3%
Therapeutic Rehabilitation Services 912,246,803 2.0% 92.4%
Therapeutic Dietary 616,656,823 1.4% 93.7%
Ambulatory Research 413,491,699 0.9% 94.6%
Therapeutic Other Ancillary Services 410,550,042 0.9% 95.6%
Ambulatory Home Health Care Services 388,565,601 0.9% 96.4%
Therapeutic Renal Dialysis 316,846,172 0.7% 97.1%
Acute Medical Cardiology Services 314,448,422 0.7% 97.8%
Acute Medical Social Services 285,775,151 0.6% 98.4%
Invasive Outpatient Surgery 296,517,893 0.7% 99.1%
Acute Medical Nursery 252,110,537 0.6% 99.7%
Acute Medical Medical Transport 58,853,840 0.1% 99.8%
Acute Medical Neurology Services 55,618,598 0.1% 99.9%
Ambulatory Other Ambulatory 36,537,764 0.1% 100.0%
45,080,512,918 100.0%
* Med supplies sold to pts, DME, central services
Per case workflow KPA - OSHPD
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CA OSHPD Data
Per case workflow KPA - OSHPD
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Per case workflow KPA
Care Process Family
Total Variable
Cost
Total Variable Cost
Opportunity
%
Opportunity
Arthritis $34,257,013 $4,315,132 12.60%
Pregnancy $34,604,134 $3,652,085 10.55%
Lower GI disorders $26,006,611 $5,598,156 21.53%
Pulmonary disorders $21,083,792 $4,592,859 21.78%
Ischemic heart disease $16,680,163 $3,241,204 19.43%
Heart failure $21,605,230 $4,914,260 22.75%
Spine disorders $28,559,591 $5,332,532 18.67%
Abdominal transplant $24,209,074 $1,835,063 7.58%
Sepsis $16,822,816 $4,909,676 29.18%
Infectious disease $17,688,735 $4,145,960 23.44%
Abnormal newborn - 3A $22,057,913 $4,283,595 19.42%
Vascular disorders $13,975,364 $3,505,618 25.08%
GU disorders $17,328,064 $2,730,267 15.76%
Abnormal newborn - 3B $14,361,738 $4,060,365 28.27%
Other gastrointestinal disorders $12,900,700 $2,909,332 22.55%
Heart rhythm disorders $10,963,720 $2,061,714 18.80%
Trauma $12,895,138 $3,498,346 27.13%
Intracranial disorders $13,429,232 $3,017,544 22.47%
Sports medicine disorders $11,905,026 $2,764,691 23.22%
Upper GI disorders $9,088,177 $1,808,059 19.89%
Bone marrow procedures $6,160,908 $862,841 14.01%
Chest procedures $7,842,200 $1,586,223 20.23%
Heart and lung transplants $8,075,094 $1,083,284 13.42%
TIA, stroke and paralysis $6,193,324 $1,373,756 22.18%
Normal newborn $8,898,584 $1,125,381 12.65%
Renal disorders $6,264,978 $1,685,801 26.91%
Cancer therapeutic procedures $4,194,787 $1,187,025 28.30%
Hematology $4,592,082 $1,021,023 22.23%
Obstructive lung disease $5,228,844 $1,220,267 23.34%
Biliary tract disorders $5,775,453 $947,907 16.41%
Other cardiovascular disorders $5,368,812 $1,126,570 20.98%
Liver disorders $4,517,543 $1,097,365 24.29%
Pareto Total $453,534,839 $87,493,901 19.29%
Workflow Waste
* The $87 MM is
based on variation in
efficiency of care
delivery for inpatient
care units (e.g., ICU,
general med-surg
acute care, sub-acute
care, observation)
adjusted by APR-DRG
severity level
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Reducing per case workflow waste
• Value Stream Maps (VSMs). VSMs for the clinical
departments in the Pareto list
• Improved capture of time stamps.
• Today’s Lean/TPS improvement systems are highly
manual – automation is essential to ability to scale
• Timely and complete capture of time stamps is key to
automation of workflow improvement systems
• Success in wringing out workflow waste will depend on
improved focus on completeness and timeliness of time
stamp capture in the EMR
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Reducing per case workflow waste
• Health Catalyst advanced applications.
• Value Stream Map laying out the workflow to be improved
(Health Catalyst has about 70 starter set VSMs)
• Aim Packet with 2-5 Aim statements
• Cohort definition to support the Aim Packet
• Common metrics plus additional outcome, process and
balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards,
and/or interactive drill down reports
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Defect (patient injury) waste
Opportunity analysis
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HAC cohorts/registries
• Ventilator-associated pneumonia (VAP)
• Adverse drug events (ADEs)
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California Data
2,358
1,278
758 739
424 251 212 122 111 13 6
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Hospital Acquired Conditions
2011 California Hospitals
All Payers
Total count 6,272
* Added in 2011
5,921
4,555
3,918
2,735
1,785
555
320 284
34 11
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Hospital Acquired Conditions
2010 Medicare US Hospitals
Total count 20,118
Medicare Data
Count
Count
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Condition Estimated cost
% of
Total Cum % Cases Cost/Case
Vascular Cath-Assoc Infection 405,299,703$ 51.9% 51.9% 2318 174,849$
Pressure Ulcers Stages III and IV 96,917,626$ 12.4% 64.3% 402 241,089$
Iatrogenic Pneumothorax 89,402,081$ 11.4% 75.8% 747 119,682$
Falls and Trauma 67,772,069$ 8.7% 84.4% 1134 59,764$
Cath-Assoc Urinary Tract Infection 59,991,394$ 7.7% 92.1% 720 83,321$
Surgical Site Infection 37,792,448$ 4.8% 97.0% 233 162,199$
Venous thromboembolism (VTE) 8,544,237$ 1.1% 98.1% 204 41,884$
Manifestions of Poor Glycemic Control 6,561,973$ 0.8% 98.9% 119 55,143$
Foreign Object Retained After Surgery 6,347,387$ 0.8% 99.7% 110 57,704$
Air Embolism 1,395,845$ 0.2% 99.9% 13 107,373$
Blood Incompatability 849,397$ 0.1% 100.0% 6 141,566$
780,874,160$ 6,006 130,016$
Cost estimated from gross charges based on cost to charge ratio = 0.254); Savings calculated from cost of DRG with HAC subtracted
from average cost of DRG (for MS-DRGs and HAC with at least 5 cases). Estimated cost per case for all cases in California =
$12,700 (3.7 million cases). Michael Dietzel analysis.
Estimated cost of defects
2011 OSHPD data
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Estimated potential savings
Patient injury (defect) waste
Analytic methodology
For each MS-DRG and Hospital Acquired Condition (HAC)
with at least five cases:
• Define the average total cost for each case which includes a
Hospital Acquired Condition (defect)
• Define the average cost of the base MS-DRG case
(without complication or comorbidity)
• Estimated potential savings (if HAC patient injury were
eliminated) = cost of HAC case minus cost of base case
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-
100,000,000
200,000,000
300,000,000
400,000,000
Hospital Acquired Conditions
Estimated Total Cost of Injury Cases
2011 California Hospitals All Payers
Total count of patients
6,006 without duplicates
*New HAC added in 2011
-
100,000,000
200,000,000
300,000,000
400,000,000
Hospital Acquired Conditions
Estimated Savings of Injury Cases
2011 California Hospitals All Payers
Total count of patients
6,006 without duplicates
Patient injury waste opportunity
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Focus on workflow/defect waste
CMS’s establishment
of penalties weighted
by measurement
domain creates an
incentive to choose
CLABSI and CAUTI
improvement initiatives
(65% of total)
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Reducing per case defect waste
• Define for each type of defect a Patient Injury
Prevention Process (PIPP).
• Screening cohort of patients who may be at risk
• Screening criteria/tool (e.g., Braden Scale) to define patients
who are at risk
• Clinical operations protocol to be implemented with at-risk
patients to prevent injury
• Tracking system to detect injuries and near misses
• Treat patient injury as a “process failure” to be
subjected to root-cause analysis rather than an
“incident” to be reported
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Reducing per case defect waste
• Health Catalyst advanced applications.
• Patient Injury Prevention Process map (combination of
workflow VSM and scientific flow; e.g., Health Catalyst
maps for CLABSI, CAUTI, pressure ulcers)
• Aim Packet with 2-5 Aim statements
• Cohort definitions to support the Aim Packet
• Common metrics plus additional outcome, process and
balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards,
and/or interactive drill down reports
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Why focus on workflow
and defect waste?
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IP per case waste reduction opportunity
Facility perspective Per case ordering waste
Per case workflow waste
Per case defect waste
64
$144 MM
~ 23%
Total IP per case waste
$57 MM*
~ 9 %
(~ 40% of
total of 23%)
$87 MM*
~ 14 %
(~ 60% of
total of 23%)
In Progress
< 1* %
* Preliminary Findings
Work in Progress
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Focus on workflow and defect waste
• Size of the opportunity (14%) and aura of safety
• Payment structure schizophrenia (see next slide)
• Reduction in workflow waste benefits the system under all
forms of payment
• Reduction in defect waste benefits the system for all
Medicare patients
• CMS penalties – helps system reduce or eliminate
penalties under readmission reduction and HAC
• Clinical teams are clinical operations-centric rather than
physician-centric (organizational readiness)
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= Negative Impact = Positive or Negative = Positive Impact
Care Process Family
Knowledge Asset
Discounted
FFS
Per Diem
Per Case Bundled Per Case
Condition
Capitation
Full
Capitation
CMS Commercial CMS Commercial
Workflow
Diagnostic Variation
Standing Orders
MedicationSelection
Triage
Patient Safety
Ambulatory Treatment
and Monitoring
Indications for Referral
Indications for
Intervention
Payment structure considerations
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CMS penalty considerations
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