How to put a Health Economic Lens on Quality and Patient Safety Programs

Quality Forum 2013 Breakout Session F3

Friday, March 1st 2013

Stefanie Raschka, Dipl. MA

Health Economist Vancouver Coastal Health

Agenda

1. Background

2. Method

3. Examples

4. Take Aways

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1. Background

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Socio-Economic Challenges

• Increasing quality of care while decreasing costs

• Identifying efficient

methods to use scarce resources AND increasing quality of patient care at

the same time

Resource scarcity

Med-Tech progress

Demographic change

Quality Improvement

Resource Equity

1. Background

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Quality Variables:

Adverse Events & Occurrences, Patient & Employee Satisfaction

Procurement Best practices

Economic variables: Cost and benefits, Return-on-

Investment, Efficiency

Agenda

1. Background

2. Method

3. Examples

4. Take Aways

5

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• Evaluation of costs and

consequences in monetary units

• Opportunity Costs • Cost Avoidance Is an intervention

worthwhile?

Cost-Benefit Analysis

• Competition between resource scarcity and providing the best possible care • Economic outcome measurement, efficient use of resources • Patient focused • Long-term evaluation

Health Economic Evaluation

• Translate results into improved access to the system, e.g.

• Bed days / Patient days

• Wait times • Patient Volume

• Assess the potential of a quality improvement initiative before implementation

Projection Analysis

2. Methods Health Economic Evaluation

System Access

2. Methods Core Measurements

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3. Health Economics • Cost-Benefit Analysis • Return-on-Investment

• Cost Avoidance • Access (e.g. additional patient days, beds freed)

1. Quality Outcomes • Patient/Employee Satisfaction and

Experiences • Adverse Events / Occurrences • Healthcare Acquired Infections

• Mortality & Morbidity

4. Program Costs / Investments • Operational Costs

• Implementation Costs • Training and Education • Consultancy Support

2. Productivity & Efficiency • Length of Stay

• Admissions / Readmissions • Work Flow / Direct Care Time

• Employee Turnover and Staff Absence • Reducing Waste /Clutter-Free

Environment

Making “Cents“

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2. Methods Core Measurements – VCH Releasing Time to Care (RT2C)

Improve Patient Safety and Reliability of Care

• Infection rates (MRSA, UTI, C.diff…) • Hand hygiene compliance rate • In-hospital falls • Timing of meal tray delivery

Improve Patient Experience

• Acute care patient experience • Patient satisfaction survey

Improve Staff Well-Being

• Survey/Dot-voting • QI knowledge • Staff absence • Overtime

Improve Efficiency of Care

• Volume of patient admissions • Direct care time • Length of stay • Readmission rates • Materials and Stocking • Bed moves

Program costs: • Training and education

• Staff appointed to the RT2C program

• Equipment and Materials

Agenda

1. Background

2. Method

3. Examples

4. Take Aways

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3. Examples Surgical Quality Improvement

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1. Quality Outcome

Patient Experience

•30 Day Follow-up: Use of overall satisfaction

question: “How would you rate your overall surgical experience on a scale of 1 (being the

worst) and 5 (being the best) at…”

• Acute Care Inpatient

Survey Results

4.03 4.16

4.3 4.34 4.34 4.36

3.8

4

4.2

4.4

4.6

4.8

5

Mean Surgical Patient Satisfaction VCH

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3. Examples Surgical Quality Improvement

1. Quality Outcome

Physician & Staff Feedback Survey

•Impact of NSQIP* on collaboration, culture,

teamwork and communication

•48 face-to-face interviews

with front-line staff, physicians, administration,

quality coordinators

4.3

4

3.2

5.9

0 1 2 3 4 5 6

NSQIP is improving quality of surgical care

NSQIP has influenced communication

NSQIP has influenced culture

I see value in the program

VCH

Strongly Disagree

Strongly Agree

*National Surgical Quality Improvement Program (NSQIP)

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3. Examples Staff Satisfaction

1. Quality Outcome

Dot-Voting

•Pre- and Post- Implementation Surveys

• Measures the impact of the

quality improvement program on front-line staff

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3. Examples Direct Care Time

2. Productivity & Efficiency

Activity Follows

• Releasing time to patient care

• Reduce interruptions • Using “soft” lean management tools • Identify areas of

improvement • Collaborative team

approach

May - 2012 January - 2013

Direct Care Time 27 % 26 %

Direct Care Minutes 191 (of 720)

158 (of 600)

Interruptions per hour 15.75 10.0

Interrupted by someone else (interruption per hour)

10.65

7.5

Interrupted someone else (interruptions per hour)

5.1 2.5

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3. Examples Reducing Waste

2. Productivity & Efficiency

Clutter-free Environment

•Implementation of a de-clutter template

• The pilot inpatient units of

the CDI program at VGH found

$ 1,181 in supplies and materials wasted

$381

$134

$237

$5

$328

$10

$86

$-

$50

$100

$150

$200

$250

$300

$350

$400

Tape Swabs IV Setsand

Supplies

Gauze PersonalCareItems

Syringes Misc

32.2%

11.3%

20.1% 0.4%

27.8%

0.8% 7.3% Tape

Swabs

IV Sets and Supplies

Gauze

Personal Care Items

Syringes

Misc

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3. Examples Projected Reduction of In-hospital Falls

3. Health Economics

3 Demonstration Sites at Richmond Hospital 2012 Reduced by 50 %

Number of minor falls per year (30% ) 59 30 Number of moderate and severe harm falls (10%) 18 9

Costs (minor harm); $ 11,254 per case $ 663,983 $ 337,619

Costs (moderate and severe harm); $ 30,696 per case $ 552,528 $ 276,264

Total $ 1,216,511 $ 613,883

Cost Avoidance $ 602,629

Bed Days minor falls (extended LOS 4 days) 295 150 Bed Days moderate and severe harm falls (extended LOS 34 days) 612 306 Total Bed Days 907 456

Bed Days Avoided 451

Falls Prevention Actions

• Installed Y-connectors at each bed with bed alarms • Safety checks during each

shift • Risk assessment on

admission • Installation of motion

sensor lights • Family education for fall

prevention

What if we are reaching the goal of reducing falls by 50% ?

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3. Examples Enhanced Recovery After Surgery (ERAS)

3. Health Economics

Service Number of cases Bed days ALOS Reduction of LOS Bed days avoided Additional patients treated

General Surgery 3,235 28,843 9 2 days 6,198 885

Cardiac Surgery 951 10,256 11 4 days 3,599 514

Gyn/urological Surgery 2,748 8,428 4 2 days 2,932 1,466

Total 6,934 47,527 12,729 2,866

Using ERAS to Reduce Length of Stay

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3. Examples Enhanced Recovery After Surgery (ERAS)

3. Health Economics

Using ERAS to Reduce Post-op Complications*

Assumption: Median additional hospital costs for patients with complications = $ 4,000 Based on: Dimick JB, et al. "Complications and Costs after High-Risk Surgery". J Am Coll Surg. 2003. Vol 196, No 5.

Service Number of cases Complications Additional costs for

complications Reduction of complications

∆ Complications

Complications avoided

Costs avoided

General Surgery 2,837 463 $1,851,994 38% 287 176 $703,758 Colorectal 398 178 $710,032 27% 130 48 $191,709 Cardiac Surgery 951 231 $925,513.20 27% 169 62 $249,889 Gyn/urological Surgery 2,748 266 $1,065,124.80 20% 213 53 $213,025 Total 6,934 1,138 $4,552,664 799 340 $1,358,380

*The analysis is based on a one year period (2011/12). The occurrence rate for complication is based on NSQIP data reports.

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3. Examples Cost-Benefit Analysis of an Infection Prevention and Control Program 3. Health

Economics

$1.87

$3.87

$3.36

$1.60

$1.60

$1.80 $1.70

$-

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

$4.50

2007/08 2008/09 2009/10 2010/11

In $

M

Total "savings" Total operational costs IPC

Cost-Benefit Analysis

• $ 65 M spent for the treatment of the selected

HAIs over a four year evaluation period

(incl. MRSA, UTI, SSI, Bacteremias, VRE, CDI)

• Operational costs of

$ 6.7 M and $ 8.1 M in savings from

reducing 4,700 HAI cases

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3. Examples Return-on-Investment of Human Factors in Healthcare Procurement 3. Health

Economics

Return-on-Investment

•5-year lifecycle costs: $ 976,037

(incl. capital costs, costs for sets and replacement of pumps, educational

and costs for performing human factors evaluation)

• 5-year “savings”:

$ 2,314,960 (incl. savings on materials and

equipment, prevented adverse drug events, reduction of maintenance

time)

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

Year 1 Year 2 Year 3 Year 4 Year 5

In $

M

CostsBenefits

ROI ratio = savings : costs

ROI (5-years) = 2:1 ROI (10-years) = 5:1

Agenda

1. Background

2. Method

3. Examples

4. Take Aways

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4. Take Aways Lessons Learned

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Money Talks: • Identifies the economic burden, the potential for “savings” and the

areas of opportunity and priority setting

But, it’s not all about money: • Get the front-line’s experience and opinion (qualitative data) • Making sure the initiatives positively impact patient satisfaction

Use the opportunity to show the improvements: • Identify core measures at the beginning of a program or initiative • Include Before-AND-After evaluations

It’s a learning process and a long-term approach

Stefanie Raschka, MA Dipl. Health Economist

Quality & Patient Safety Vancouver Coastal Health

Email: Stefanie.Raschka@vch.ca Phone: (604) 875-4111 ext. 21491

Cell: (604) 816-9550

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Thank you!

Collaborators • Patrick O’Connor • Linda Dempster • Elizabeth Bryce • Felicia Laing • Mary Cameron-Lane • Sarah Rothwell • VCH Quality & Patient Safety Team

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Backup

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