Measuring Clinical Value at the Bedside

Janice Thalman RCP,MHS-CL, FAARCDuke University Medical Center

thalm001@mc.duke.edu

Objectives

• The evolution of value in healthcare• Eliminating waste and maximizing value• Respiratory care contributions to the success

of our health care system• Critical considerations in staffing and

productivity management

The trouble with the future is that is usually arrives before we’re ready for it.

Value Definition

• Shared goal that unites the interests and activities of all stakeholders

• Defined as health outcomes achieved per dollar spent

• Currently unmeasured and misunderstood

Value

• For patients it must become the overarching goal of health care delivery

• Primary/Preventative care– Measured for a defined patient group with similar

needs• Medical Condition

– Multiple specialties and numerous interventions– Combined efforts over full cycle of care

Value

• Value = results not input• No longer volume of services delivered• May spend more on some services to reduce

the need for others• Mayo: Value = outcomes; quality; safety and

patient satisfaction divided by cost over time.

Value Culture

Add value in quality outcomes, cost, customer satisfaction• Embedding RT in clinical pathways• Protocol based services ( why we don’t need so many

ABG’s with vent patients)• Navigation of high ricks pulmonary patients ( COPD; asthma)• Pt education at Discharge• Smoking Cessation Consults• Pulmonary Rehab Screening

Collaborative• 2012 High Value Healthcare Collaborative was launched• 26 million $ grant funded by the Center of Medicare and Medicaid

Innovation• Decrease utilization & cost by 64 million over 3 years

– patients are engaged and empowered to make health care decisions based on own values and preferences.

• 6 leading health care organizations• 150,000 patients• Improve care and reduce cost

– Collect and exchange data on quality outcomes and cost for expensive high-variation conditions and treatments

– Identify and Evaluate best practice health care models and innovative value based payment

– Share knowledge and lessons learned with the public.

HVHC9 Condition/Disease Areas

• Wide Variations in rates, costs and outcomes nationally– Total knee replacement– Diabetes– Asthma– Hip Surgery– Heart Failure– Perinatal Care– Depression– Spine Surgery– Weight Loss Surgery

MD Collaborative

• Complex delivery with interdependent teams• Identify Practice variation

Outcome Dimensions

• Tier 1. The health status that is achieved or retained

• Survival • Degree of recover

• Tier 2. Recovery Process• Time required and return to normal or best function• Disutility of care or treatment process

• Tier 3. Sustainability of health• Recurrences• New problems as a consequence of treatment

HCAHPS Measures• Nurse Communication

• Doctor Communication

• Pain Management

• Communication about Medications

• Cleanliness and Quietness of Hospital Environment (average of the 2 responses)

• Responsiveness of Hospital Staff

• Discharge Information

• Overall Rating of Hospital (excludes recommend hospital item)

AAA- Local level

• Availability, Affability, Ability– Be here– Answer pages and calls– Be where the action (need) requires– Be nice ( golden rule)– Be a resource – Be responsible to learning and advancing skills

( this is life support, not Wal-Mart )

Hard-Work- Local Level• Scope of care• Relationship with the physicians• Reputation with airway management• Mechanical ventilator management• Consultation service• Technical edge• Research• Stamina• Love of the profession

Respiratory Therapy

Impacting increase in Respiratory Therapy Costs• Nitric Oxide +127%• Ventilator +12%

Service Cost per Discharge

OPCSU FY2008 Q2 FY2009 Q2 Change % ChangeCHILDRENS 3,182,469 3,923,981 741,512 23%HEART 2,347,681 2,692,609 344,928 15%PULMONARY 866,385 1,009,742 143,357 17%GENERAL MED 734,140 761,548 27,409 4%NEUROSCIENCES 603,938 713,854 109,917 18%TRANSPLANT 519,757 798,325 278,568 54%GENERAL SURG 509,017 474,327 (34,690) -7%

All OTHER CSU's 1,166,760 1,131,697 (35,063) -3%TOTAL - RESPIRATORY CARE 9,930,147 11,506,084 1,575,937 16%

COST PER CASE 964 1,204 239 25%

Nitric Oxide D/C Protocols

• Meeting with key physicians– Adult and ICN– Identify clinical objectives

• Agreement on clinical conditions• Communication, education strategies• Rapid wean ( therapist driven)• Reduce total hours on Nitric Oxide• Replace NO with Iloprost

Quality and Patient SafetySpontaneous Breathing Trial PI Project

Project Goal: Improve the % of patients that receive a spontaneous breathing trial to assess readiness for extubation.

Importance: Part of IHI Ventilator Bundle to prevent VAPProject Target: Achieve 90% compliance to fully achieve, 95% to exceed

expectations.

88.4% 88.4%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1st Qtr FY09

2nd Qtr FY09

3rd Qtr FY09

4th Qtr FY09

YTD

SBTTarget FATarget EE

Leadership Focus in Shifting from Volume to Value

• Quality and Safety• Enablers and Provision of Resources• Employee engagement• Service and strategy• Fiscal accountability• Vision and change

Value Culture

Behind Us• Neb Jockey• Concurrent Care• Counting TX’s• Activities• Procedures• Busy Hands• Department success

Take Us Forward• Quality • One-on-one• Protocols• Outcomes• Value Added• Busy Heads• Organization success

…Value is more than a set of skills• Culture• Curiosity• Vision• Values• Passion• Scope• Reputation• Assets• Partnerships-Relationships• Mistakes

Take Us Forward Groups

• Intermediate Care • Core Teams- ICU• Emergency Response• Equipment• Cardio-Thoracic

I don’t want any yes men around me. I want the truth even if it costs them their jobs.

Building the Structure to Support Change

• Redesign care processes based on best practices• IT that will improve access to clinical information

and clinical decision making• Knowledge and skill management• Development of effective teams• Coordination of care across patient conditions,

services and settings over time• Incorporation of performance and outcome

measurements for improvement and accountability

I was going to buy a copy of The Power of Positive Thinking , but thought What the

hell good would that do?

RCPs and Disease Management

• Physical exam and history• Home condition and family capability• Triggers to contact the MD, report to ER• Communication skills across encounters• Application of guidelines and protocols• Measure outcomes across the continuum• Relationship with MD office

COPD- and 30 Day Readmission• Fourth leading cause of 30-day readmission• Significant cost, over 11 billion annually• Readmission cost of $20,757 • 30-day readmission rates as high as 28%• Assessment of care based on adherence to

guidelines suggest numerous opportunities exist to improve COPD outcomes

Gary Brown, Patrick Dunne, COPD In-Patient Care: Time for a New Paradigm. AARC Times November 2011

RCP Role in Avoiding COPD Readmission

• Presence at the point of entry (ER/Clinic)• In-patient protocols/guidelines• Focus on evaluation and education• Discharge readiness and plan• Follow-up once home• Pulmonary rehab and clinic referrals• COPD Team/Specialist

Preparing the workforce for change

• Identify and agree on the steps and content of communication

• Identify the platforms of communication that will be used

• Identify the tree of communication; key people per shift and area

Managing Change…

• Must continue to deliver quality work in the midst of change

• Change has high emotional impact• Phases of change

– Denial, mistakes, chaos, recovery• Navigate change – Supportive communication

– Clarify, Share, engage

Communication Keys

• Clarify direction and expectations• Encourage participation and involvement• Support open communication• Lead by example• Reward and recognize• Support ongoing development• Supervisor and manager blood brothers

Defining Value• Relative worth, merit, importance• Value is often measured by the usefulness or

desirability of something• Elimination of non-value/waste

Usefulness

Need/Desirability

Value 2015• Reimbursement linked to quality• Emergence of Telemedicine• RC to evolve in complexity• Data driven clinical decisions• Protocol will be most common way to deliver RC• RC will need to be increasingly engaged with

research to demonstrate value of what they do• Patients and families will play a greater role• Information management system prevail

Kacmarek, RESPIRATORY CARE • MARCH 2009 VOL 54 NO 3

Reaction of Administrators Beyond to 2012

– Customer satisfaction– Outcomes focused– Partnerships with providers– New interest across the continuum– Information technology– Invest in what adds value– Shift from volume to value

The First Step… Why RCPs• If someone else can do it better or for less cost, you will

not maximize overall efficiency for the hospital, despite how good your productivity system is!

• You need to first define what RCPs do that is of unique and unquestionable value:▫At the bedside 24/7 ▫Flex staffing models▫Cross utilization across procedures, units, sites, etc▫ Intellect- experts in physiology/technology▫Broad legal scope with diverse skills

Hour of Workday1 2 3 4 5 6 7 8

SICU5W

BICU7W

11W5W

6WTotal

0

10

20

30

40

50

60

70

80

Min

utes

of T

hera

py

Total: 6.12 Patient Care Hours

Therapist Workday per Hour per Area

Staff Reductions and Value

• Since value is defined as outcomes relative to cost, cost reduction without regard to outcomes achieved is dangerous and often self-defeating.

• Can lead to short term “false savings” and limiting the ability to provide effective care

• The best approach is often to spend more on those services that reduce others

Porter, What is Value in Health care, NEJM Perspectives December 2010

Protocols

• All would agree that regardless how productive your staff is, that time spent in providing treatments that are not medically necessary is not productive.

• You may be 100% productive in performing 10,000 Med Aerosols per month, but if only 4,000 are indicated, you have wasted resources to provide 6,000 interventions, thus only 40% “effective productivity”.

Effect of Reductions in Respiratory Therapy on Patient OutcomeZibrak JD, NEJM July 1996

• We studied the effect of the reductions in respiratory therapy on patient outcome

• We conclude that consistent application of prescribed guidelines for respiratory therapy results in marked decreases in its use without a reduction in the quality of care.

Value from Patients Perspective

• High-quality, appropriate care• Communicative providers• Human treatment• Access and availability• Environmental factors (Sleep, Food, Privacy)• Billing

Pichert JW, Vanderbilt University, Nashville TN

Bridging the Gap with Respiratory Therapy

UNCC survey results

• 80% were either somewhat or not satisfied with

educational opportunities available to RTs

• 86% were interested in pursuing graduate education

in respiratory care or critical care medicine

• 49% were interested in midlevel practice

RT Gap

• Healthcare is experiencing a shortage of providers in pulmonary

and critical care medicine

• RTs with graduate education and specialized training in

pulmonary/critical care will increase access

• Utilizing RTs to augment the pulmonary/critical care provider

pool can positively effect primary care

• Respiratory care is overdue to academically meet professions

who were once peers

RT Gap

• Targeted outcomes studies

• Financial and economic studies

• Comprehensive comparison studies

• Workforce studies focusing on projected numbers of

midlevel providers needed in pulmonary and critical

care

39.5 Million Discharges Per Year

• 19%-post-discharge event• 20% readmitted within 30 days ( Medicare)

I’ve tried relaxing- but I feel more comfortable tense.

Project Red( Re-Engineered Discharge)

• Patient-centered standardized approach to discharge planning and discharge education.

• Developed thru research funded by the Agency for Healthcare research and Quality.

Resources• High Value Healthcare Collaborative• Medpac - June 2007• J Gen Intern Med- Jan. 2011• Healthcare Cost and Utilization Project• American Journal of Resp. and Critical Care Med.-Jan. 2010• AARCTimes – Nov. 2011• Respiratory Care- March 2009/ vol.54 no 3• Pichert JW, Vanderbilt Univ.• Joint Commission Resources

– http://www.jcrinc.com/ahrq-project-red/• Toffler and Associates

– Creating an agile healthcare organization• New Eng J med 2010 363-2477-2481

• Michael porter PhD.

• Journal of the Royal College of Physicians• Charles RV Tomson