Healthcare Performance and Measurement Tools

Tom Knoebber

Mission Hospitals

Asheville, North Carolina

POEPursuit of Excellence

DMAICDefineMeasureAnalyzeImproveControl

FOCUS PDCAFindOrganizeClarifyUnderstand

SelectPDCA

PDCA -Plan Do Check Act

12 Step6 Step

Quality

Circles

6 Sigma

“If you don’t know where your going… How will you know when you get

there”

“If you don’t know where you are… How will you know when you’ve left “

“If you don’t measure it... You can’t improve it “

Patients / Community

Departments / Employees

Vision / Strategic Plan Translation & Prioritization

Measures

Voice of the Customer

CommunicationBoard / Leadership

Implementation

Evaluation

What Are The Issues Driving Strategic Planning & Direction ?

•Financial ImpactCosts, Utilization

•Patient/ Consumer Satisfaction Leap Frog, CMS

•SafetyIOM

•LaborShortages

Defining Quality and Efficiency ?

7 Types of WasteOverproduction, Inventory, TransportationWaiting, Excess Processing, Wasted Motion,Defects

IHI - Overuse, Underuse, Misuse

The 5 S’s (Toyota Model - Lean)Sort, Straighten, Shine, Standardize, Sustain

Project Based

Workload

Opportunities

Teams ~ Re-Engineering ~

Process Improvement ~Focused Reviews ~

Education and Facilitation etc...

Data & Information Measurement

Prioritizing System Initiatives and Focus Reporting and MonitoringCharter, Scope and Plan

Review and Verify (GOYA) Focused Data Collection and Analysis

Theories and Testing

Identification and Facilitation

Implementation

Find &Organize

Clarify & Understand

Select

PDCA

Measurement and Analysis

1. Individual Experience

2. Group Experience

3. Graphical Presentation of Observed

4. Statistical Interpretation of Observed

5. Graphical Interpretation of Experiments

6. Statistical Interpretation of Experiments

Cool Tools !!!“Finding” & “Organizing” Opportunity

Surveys - Voice of the CustomerControl Charts - Variation

Special & Common CauseBenchmarkingCharter / Scope Gantt Charts

Cool Tools !!! “Clarifying” & “Understanding”

BrainstormingCause & EffectFlow DiagramsData Collection

Discreet & ContinuousPareto & Histograms & Scatter PlotsStatistical Analysis

ANOVA,Correlation / Regression, Chi Square

Cool Tools !!!“Implementation”

Flow Diagrams (Process Design)FMEA (Prevention)Control Charts

Readmission Reduction

An example

Memorial Mission Hospital, Inc.Mission and St. Joseph's Campuses

Key Internal Process Performance Indicators

Safety - Unplanned Returns to the OR

Effective - Unplanned Readmission's

Timely - Average Length of Stay (ALOS)

0.0

1.0

2.0

3.0

4.0

Oct-Dec 99 Jan-Mar 00 Apr-Jun 00 Jul-Sept 00 Oct-Dec 00 Jan-Mar 01 Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02

Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Safety - Unplanned Returns to OR

0.01.02.03.04.05.06.07.08.09.0

Oct-Dec 99 Jan-Mar 00 Apr-Jun 00 Jul-Sept 00 Oct-Dec 00 Jan-Mar 01 Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Effective - Unplanned Readmission's < 31 Days

3.0

3.5

4.0

4.5

5.0

5.5

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Target (Fixed Budget FY03) Average Length of Stay FY01 Average Length of Stay FY02 Average Length of Stay FY03

Strategic Performance Panel - Dashboard

Unplanned Readmission's within 31 Days

6.455.76 5.97 6.06 6.24 6.29 6.13 5.84 5.74 5.56

10.009.31

0.01.02.03.04.05.06.07.08.09.0

10.011.012.0

Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02 Oct-Dec 02 Jan-Mar 03 Apr-Jun 03 Jul-Sept 03 Oct-Dec 03 Jan-Mar 04

Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Effective - Unplanned Readmission's < 31 Days

Data source changed to reflect Premier actual vs expected rate

Find & Organize - Charter

Problem Statement: Our readmission rate for the MSJ system is 8.01% for the quarter ending 6/00 this represents a quarterly volume of 737 readmission's on 9,198 Discharges (-deaths). This rate is above the 75th percentile of our benchmark peer group. Our current average cost per case for patients being readmitted to the hospital is $5,507. Business Case: For each readmitted patient, reimbursement is reduced or non-existent. Patients who are readmitted occupy bed space that could otherwise be used for patients with a more acute need, Patient who are readmitted due to a failure on our part will have reduced satisfaction that could lead to reduced market share in the region. Prevention of readmission's will improve utilization and reduce costs.

Tips: Defined Business Case, Scope & Boundaries, Champion & Owner, Quantifiable

Clarifying and Understanding - Readmission Rate by Service Line (% of DCs)

15%

12%

4%

9%

4%

23%

7%

8%

10%

8%

Amed

Hsvcs

Woms

Surg

Peds

Onc

Ortho

Neuro

Urol

Trauma

44%

6%

6%

6%

6%

5%

4%

20%

2% 1%

Amed

Hsvcs

Woms

Surg

Peds

Onc

Ortho

Neuro

Urol

Trauma

Clarifying and Understanding -Readmission Volume by Service Line

UNSCHEDULED INPATIENT READMISSIONSFOR ADULT MEDICINE AND HEART SERVICES

FOR APR-JUNE, 2000

37811121617192124313143103

117

99%98%96%94%91%88%84%

80%75%

70%63%

57%

48%25%

0

58

116

174

232

290

348

406

NU

MB

ER O

F PA

TIE

NT

S

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

n=463

Clarifying and Understanding -Analysis of Cause Pareto

Quick ImprovementsOutpatient CHF clinic (see Pareto)Detailed Narrative of each readmission reviewed by each service line for commonalties in practiceReview of Pain Mgmt protocolIncreased DC planning screening for post DC needsPilot Implementation of Case Mgmt model post dischargeEducation and promotion of Medication and Assistance program through the Eblen FoundationReadmission Sepsis team within Infection control to track for cause

Selection & Implementation -

Monitoring (PDCA)

6.67% 6.58%

7.06%7.17%

8.01%

7.01%

6.68%

6.39% 6.46%

6.18%6.04%

6.36%6.12%

6.56% 6.44%

6.08% 6.11%

-

50

100

150

200

250

300

350

04/99-06/99

07/99-09/99

10/99-12/99

01/00-03/00

04/00-06/00

07/00-09/00

10/00-12/00

01/01-03/01

04/01-06/01

07/01-09/01

10/01-12/01

01/02-03/02

04/02-06/02

07/02-09/02

10/01-12/02

01/02-03/03

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Amed Hsvcs Woms Surg Peds Onc Ortho Neuro Urol Trauma Readmit %

Monitoring (PDCA)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

04/99-06/99

07/99-09/99

10/99-12/99

01/00-03/00

04/00-06/00

07/00-09/00

10/00-12/00

01/01-03/01

04/01-06/01

07/01-09/01

10/01-12/01

01/02-03/02

04/02-06/02

07/02-09/02

10/01-12/02

01/02-03/03

04/02-06/03

Amed Hsvcs Woms Surg Peds Onc Ortho Neuro Urol Trauma

Data

Performance Volumes

(Attending Physician Data) (Attribution Physician Data) (Procedural)

Public Reported Quality - Accountability Coded - Decision SupportCoded Readmission SurgeonsBilling Return to the OR

Service Line Assignments Outcomes - Focus Studies

Credentialing CredentialingDenominators NumeratorsMacro indicators Service Line Specific

Focused Studies

Surgiware

Data

77%

94% 94% 93%99%

94% 96%

0%

20%

40%

60%

80%

100%

120%

5/30/03 6/6/03 6/13/03 6/20/03 6/27/03 7/4/03 7/18/03

Outpatient Cases

95%

95%

96%

94.6%

94.8%

95.0%

95.2%

95.4%

95.6%

95.8%

96.0%

Jan/Feb Mar/Apr May/Jun Jul/Aug

Abstracting

Medical Records Attribution Audit Summary

Data & Quality

Premier AffiliationsPremier Affiliations Current Outcomes Initiatives

Current Outcomes Initiatives

1.Core Measures (JCAHO required)

2. 7th Scope of Work (voluntary)

3. AHA Quality Initiative (voluntary)

4. Premier / CMS Quality Initiative (voluntary)

Clinical Performance ReportMISSION ST JOSEPH'S HEALTH SYS

1/1/02 - 12/31/02

Hospital Top Quartile Target

Statistically significant: *** p< 0.01 ** p< 0.05 * p< 0.10

Average Opportunity Totalper Case Opportunity

Aggressive management and/or prevention of new onset post CABG atrial fibrillation reducesoverall LOS.Standardization of case packs and process flows in the OR reduce costs.If the immediate pre-op Hct > 36, consider not setting up blood, just type and hold.

# Hospitals % Female Age % Use IABP

25.7% 64 3.2%

39 29.6% 64 6.3%11,111

Top Quartile Cost Improvement Opportunity

Potential Improvement Actions

# Cases

760

$5,082

How does your hospital compare to the top quartile in clinical and financial performance?

person(s) to whom it is addressed without the written permission of the Hospital and P remier, Inc.

Information in this document is proprietary and may not be photocopied or divulged to parties or persons other than the

Financial PerformanceClinical Performance

Hospital

Top Quartile

CORONARY ARTERY BYPASS GRAFT

$3,862,500

Reporting Period

$11,105

$20,374

$13,985

$25,456

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Avg Variable Cost / Discharge

Avg Total Cost/ Discharge

7.6

7.6

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0

ALOS

1.7%

9.2%

0.8%

2.4%

3.6%

0.6%

1.8%

8.3%

0.7%

3.4%

2.0%

0.8%

0% 5% 10% 15% 20%

Inpatient Mortality

Readmission Rate

Return to OR

PCI during SameAdmission

Hemorrhage/Hematoma

Post-op Infection/Mediastinitis

90.8%

99.0%

82.9%

94.6%

0% 20% 40% 60% 80% 100%

IMA Procedure

ASA duringHospitalization

1.50

2.05

0.0 0.5 1.0 1.5 2.0 2.5

RBCs / Discharge

***

***

***

***

**

*

***

Data & Benchmarking

MSJ Structure

Sonya Greck Ramona Whichello

Heart Services PsychMedical Molly Gouge

Molly Gouge TraumaAdult Medicine Jeff Samz

Critical Care UrologyECC Orthopedics

JCAHO Ramona Whichello Neuro SciencesPatient Safety Oncology Tim Johnston

Lou Hammond Surgical ServicesWomen's General

Pediatrics DentalENTOral

Bob Vassian Plastics

June Beck (MEDICINE) OphthalmologyDana Gibson Anesthesia

Cathy Tremby (SURGICAL)Donna Cravener Sue BradburnKaye Culberson Gus Doescher

Patient Safety Medical StaffSUPPORT: Management Engineering JCAHO Case Managers

Analyst Staff FAAST TeamsMEDICUS Decision Support

ANCILLARY & System

Quality Board

SPT/MAC

DATA OLT

Service Lines

Hospital Board

Patients/Physicians/Bedside Nursing

Hospital Strategic Plan / Vision / Mission

Project Identification and Selection

M

A

C

R

O

P

a

t

i

e

n

t

L

e

v

e

l

(Opportunity I dentification and Facilitation)

Performance I mprovement

(System initiatives directing f ocus studies)

Case / Care Managers

Opportunity I dentifi cation and I mplementation

Identified Opportunities are communicated

through Teams and Service lines

Improvement achieved through PI teams, Focus

studies, Education,

Re- Engineering

System and Various Committee Data Sources Consolidated and Evaluated - Service Line Specific: Sentinel Events, Falls,

Incidents, Med Errors, Clinician Concerns, Credentialing Measures, Complaints, Comments, Satisfaction, Quality Benchmark Measures, Performance Panel Measures,

Financial Performance, Patient Safety,

Strategic Plan, Vision, Mission, Critical Success factors, High Risk,

High Volume, JCAHO, Compliance

Performance

Improvement

Communication and Information Flow

Key Indicators & Measures

OLT

QI Committee

SPT/MAC

Service Lines, Ancillary & Support Departments

Issues brought to QI from SPT / MAC:

Issues brought to QI from SL,

Ancillary and Depts:

Guidance & Issue Resolution: Defining Priorities, Consistency, Completeness

Issues sent to OLT from QI:

Issues brought to SPT from SL, Ancillary and Depts:

Other Committees and Groups:

Questions ?

Tom KnoebberMission Hospitals

828-213-9194