OFFICESummit Specialist Final - app.ihi.orgapp.ihi.org/.../Presentation-12785/...Specialist_Final_Website.pdfRacer Study Nurse, Resident, ... Time Driven Activity Based Costing

IHIOfficeSummit Specialist 3/21/16

Dr. Tony DiGioia 1

www.pfcc.org/IHISpecialist

Tony DiGioia, MD March 21st, 2016 [email protected]

Disclosures Medical Director, Bone and Joint Center and Innovation Center of UPMC Faculty, Institute for Healthcare Improvement Founder, GoShadow LLC President, AMD3 Foundation (not-for-profit)

• $12 billion integrated global health system

• 20+ academic, community, and specialty hospitals

• 400 outpatient sites • 3,200+ physicians

University of Pittsburgh Medical Center (UPMC)

• Share my journey and remember it is a journey

• Everyone starts their journey at a different place

• My experience will help you by providing ways to get started

Try to Answer the “Why’s”

Delivering Value with Volume


Dr. Tony DiGioia 2

We Developed a Patient Focused Care Center

• Care for a specific disease process •  Treatment for a full cycle of care • Reorganize all resources to meet

the needs of patients and families • Accountability for outcomes and

costs •  Implement by design

• Deliver ideal care experiences through the full cycle of care

• Build a sense of community • Focus on wellness and health • Achieve the “Value Trifecta”

Hip and Knee Arthritis and TJR “Home”

The Bone and Joint Center

•  1,725 surgeries CY15 • Only 2 OR’s/day •  90+% of all patients are discharged

directly to home • Lowest LOS • Transparent Outcomes

(www.pfcc.org) • Operational Efficiencies • Lowest (real) cost per case

• Buy-in from executive leadership to realign infrastructure

•  Form multi-functional teams across traditional silos

Challenges

• Refocus existing resources and you do not need new ones

Why Build a Focused Care Center? (…and what’s in it for me)

• Focus on the experience and not the “service line”

• Deliver real value from the perspective of the patients and families as end users

• Set the stage for new payment and care delivery models… Bundling and population health

Our “Operating System” 3 Keys to Deliver Value

1. View All Care as an Experience Through the Eyes of Patients and Families

2. Co-Design 3. Implementation and Teams


Dr. Tony DiGioia 3

5. Shared Vision of the Ideal

Ideal Experience

Current State

2. Guiding Council

3. Shadow, Current State, Urgency

4. Working Group thru Touchpoints

6. PFCC Project Teams Close the Gap

1. Define Care Experience

www.pfcc.org

Patient and Family Centered Care Methodology and Practice (PFCC M/P)

PFCC @ UPMC 70+ Care Experience Working Groups

• Home Health Exp • Mental Health • Dental • ER Registration • Life After Wt Loss • ENT Experience • Imaging • Urgent Care www.PFCC.org/Annual-Reports

• Communication in Ambulatory

• OP Surgery • Urology/Gynecology

• Cancer Treatment • Emergency Dept • Ortho

Population health management

will deliver higher value and

preserve the patient at the

center, which is really

what we are all about.

– David Nash, MD, MBA

“” Darves, Bonnie. "Pushing Population Health Management." (2015): 6-10. American

Association for Physician Leaders. Print.

Triple Aim = Value Trifecta

Experience of Care

Population Health

Per Capita Cost

Why is Population (or Community) Health Important to Specialist? *

1. Enhance health and wellness

2. Improve coordination across “silos”

3. Reduce waste and variation

4. BUNDLING


Dr. Tony DiGioia 4

Patient and Family Activation

•  Patient's knowledge, skills, ability, and willingness to manage his or her own health and care

•  Improves clinical outcomes

• Identifying patients’ needs is crucial

• Team development • Co-design with the community

Population Health

Population Health in Ortho? Crossing the Silos

• Falls Reduction

• Weight No More

• Blues No More

Why? Outcomes and $’s! Programs

BoneandJointHealth.org

Hip, Knee Arthritis, Treatment Options, Exercise and Fall Prevention Fair

Population Health: Falls Prevention

Population Health: “Weight No More”

For nutritional support, ask about WEIGHT NO MORE, the new Magee Bone and Joint Center Program that will help you improve your diet and exercise routine.

•  92 patients have made appointments to see the WNM doctor

• Average age: 63.8 years •  95% made appointments to consult

•  80% attended their scheduled appointment

•  53% have moved onto surgery

Population Health: “Weight No More”


Dr. Tony DiGioia 5

• Collaborating with a mental health team

•  Intervention prior to surgery

•  Improve surgical outcomes

Population Health: Blues No More

Worldwide Population Health: Sample PFCC Projects

Behavioral Health Rapid Admission Process PA, USA

Diabetes Foot Care Newport, Wales Duchenne Muscular

Dystrophy London, UK

Underserved Communities PA, USA Elderly Care Newport, Wales

Pediatric Asthma North Staffordshire, UK

Prenatal Education & Yoga PA, USA Dementia Patient

Experience Northern Devon, UK

Community of Practice

United States: 27 International: 7

The Ideal World What is different between

today’s world and the ideal state – what needs to

change to evolve to the value based world?

The$exis(ng$deficiencies$in$health$care$cannot$be$corrected$simply$by$supplying$more$personnel,$more$facili(es$and$more$money.$These$problems$can$only$be$solved$by$organizing$the$personnel,$facili(es$and$financing$into$a$conceptual$framework$and$opera(ng$system$that$will$provide$op(mally$for$the$health$needs$of$the$popula(on.$

Dr.$Robert$Ebert$

Founder,$Harvard$Community$Health$Pl

an,$1965$

“”


Dr. Tony DiGioia 6

The Value Proposition Patients and Families are the only way for all

of us to understand and deliver value…

Value for Patients and Families Results in Value for

Care Givers and Organizations

• Tightly couple clinical and financial performance

• Develop new delivery and payment systems

• The biggest hurdle is the How to…”

The Bundling

Value = Cost

Outcomes (Important to Patients)

We All Define Value Differently

= Clinical Outcomes

Patients’ Report of Their

Outcomes

Patient Reported Outcomes (PRO’s)

•  Any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else. - National Quality Forum

Independent Assessment of Physical, Mental and Social Well-Being

How can we all

get there?


Dr. Tony DiGioia 7

Opportunities To Get Started…

… NOW!

• Learn What Patients and Families Care About

• Partner in Care and Design

What Matters to You?

What Matters To You?

Quality of Life 36 Outcomes 26

Quality of Care/Staff 22 Reduction in Pain 16

Education 4 Environment of Care 0

Overall % of expectations met within first month of recovery (25 patients): 98%

… In the first 3 months following surgery?

Definitely not

Probably not

Unsure Probably yes

Detractors Passive

Definitely yes

Promoter

How likely are you to recommend us to family and friends?

** Reichheld, Frederick F. "The One Number You Need to Grow." Harvard Business Review (2003): 1-10.

Net Promoter Score

When You Deliver Real Value Patients and Families Become “Evangelists”

Leading Companies NPS

Bone and Joint Center TJR 95

Insurance: USAA 80

Smartphones: Apple 67

Online Shopping: Amazon 66

Airlines: Southwest 62

Cable: DirecTV 34

•  Shadowing is repeated observations of

patients and families as they move through each step of their healthcare journey

•  Shadow the “system”

How We Got Started…


Dr. Tony DiGioia 8

• Determines Your Current State • Continuously Engages

End Users in Real Time: Co-Design

•  Identify Silos • Builds Implementation Teams

By Shadowing the Patient Touchpoints •  Office •  Central Scheduling •  Entrance to Falk •  Waiting Area outside Clinic •  Registration Desk •  Height/Weight Areas •  Exam Room

•  Registration Desk •  Lab •  Registration Desk •  Research Office •  Waiting Area for Imaging •  Entrance to Falk

Example: New Patient Office Visit Care Experience

Care Givers • Office scheduler • Central Scheduling •  Valet •  Information Desk Staff • Registration Staff • MA • Racer Study Nurse, Resident,

Attending Physician and Resident, Resident, Peer Advocate, Study Nurse

• Registration Staff • MA, MA, Phlebotomist • Registration Staff • Case Manager, MA • None •  Valet

Shadowing Changes Care Givers’ Perspective

- Susan P. Ferguson Chief Nursing Officer, Baptist-Collierville

I can’t tell you how impactful Shadowing is; once people Shadow, they talk about care differently—getting to view care through the eyes of patients and families truly provides Care Givers with a different perspective.

iOS App Collection Tool

Cloud-based Collaboration

Platform

GoShadow: Merge Process with Technology

.org

GoShadow: Automatically Generated Reports

• Care Flow Maps • Time Studies • Observational and

Opportunity Reports • Patients’ Stories

.org

Value =

Outcomes

(Important to Patients)

Cost

The Final Frontier: Actual Cost to Deliver Care


Dr. Tony DiGioia 9

Time Driven Activity Based Costing

Robert S. Kaplan and Michael E. Porter “How to Solve the Cost Crisis in Health Care,” HBR 2011

For a full cycle of care: • Personnel • Space • Equipment • Consumables

• All resources for any clinical condition

We Needed a “Connecter”

Accurate and Efficient Real World Example

DiGioia AM; Greenhouse PK; Giarrusso ML; Kress JM. Determining the True Cost to Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for Bundling and Reference-Based Pricing. The Journal of Arthroplasty, 31(1)1-6, (2016).

Physician

Office

Determine the Actual Costs for TJR Over Four Month Bundle

Follow the Patient *What is the total # of provider categories?

Health

Insurance

Pharmacy

Home Health

Outpatient Therapy

Rehab or

Killed Nursing Facility

Home

Acute Hospital

27 14 Personnel Categories Number of Organizations

5 4 23 3


Dr. Tony DiGioia 10

0% 10% 20% 30% 40% 50% 60% 70%

1.  Pre-Op/Office 2.  Pre-Op

Testing & Consults

3.  Day of Surgery/OR

4.  PACU 5.  Hospital Stay 6.  Therapy 7.  Follow-Up

Visits

Care Segments

3%

12%

17%

2%

58%

7%

1%

3%

16%

20%

2%

51%

7%

1%

0% 10% 20% 30% 40% 50% 60% 70%

TKR THR

1.  Pre-Op/Office 2.  Pre-Op

Testing & Consults

3.  Day of Surgery/OR

4.  PACU 5.  Hospital Stay 6.  Therapy 7.  Follow-Up

Visits

Distribution of Costs

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Facility #1

Facility #2

Outpatient THR

Inpatient vs. Outpatient TJR

Pre-Op + Office

Pre-Op Testing + Consults

Day of Surgery

+ OR

PACU Hospital Stay

Therapy Follow Up

Visits

Patient Centered Value System

Outcomes Cost

Experiences ^

^ ^

Aligns the Catalyst for Change with

Our Mission

• Population Health • Bundling • ACO’s/PCMH’s • Cost Reduction Tool

The Patient Centered Value System


Dr. Tony DiGioia 11

Transform Care for Patients and Families

View care through the eyes of patients and families to improve outcomes and experiences while reducing costs.

Ready, Set, GoShadow… Transform the Way You Deliver CareSign up at goshadow.org

goshadow.org

GoShadow is the simple, easy-to-learn solution that will enable you to

make direct, real-time observations of patients and their families as they

move through each step in their care journey. You and your teams will

identify opportunities for improvement and generate the sense of urgency

needed to redesign care delivery.

© 2015 GoShadow, LLC. All rights reserved.

Merging the Arts and Sciences of Improvement

Community of Practice myPFCC.org

Questions

Documents

OFFICESummit Specialist Final - app.ihi.orgapp.ihi.org/.../Presentation-12785/...Specialist_Final_Website.pdfRacer Study Nurse, Resident, ... Time Driven Activity Based Costing