Using Multi-Hospital Laboratory Integration to Improve Lab

Outreach SuccessJohn Waugh

Henry Ford Health System, DetroitExecutive War College, New Orleans 4/28/09

Henry Ford Health System

Integrated HealthcareDelivery System

Integrated HealthcareDelivery System

Financing of Health CareFinancing of Health CareHealth, Lifestyle & Alternative Med ServicesHealth, Lifestyle & Alternative Med Services

Home Health ServicesHome Health ServicesPrimary & Preventive CarePrimary & Preventive Care

Ambulatory CareSpecialty, Multi-specialty

High Technology

Ambulatory CareSpecialty, Multi-specialty

High Technology

Long-Term CareLong-Term CareSpecialized HospitalsSpecialized Hospitals

Acute CareHospitalization

Acute CareHospitalization

TertiaryCare

Hospitalization

TertiaryCare

Hospitalization

Research & Education

Now: Henry Ford Health SystemNow: Henry Ford Health System• Southeast Michigan• 22,000 employees• 7 hospitals, 40 ambulatory cntrs • 11 million billed lab tests (2008)

• Beds: 2,495 Admissions: 88,984 • 3 million clinic visits• 1100 physicians, 3rd largest multi-specialty group in US• >1500 partner community docs• HAP insurance, 540,000 members• $62M research funding, 3rd largest NIH $ in Michigan• Leap Frog Group- ‘Top 41 safest hospitals’• Thompson Reuters ‘100 Top Hospitals- Performance Improvement• 101 ‘Best & Brightest Places to Work’• Crain’s Detroit Business- ‘Coolest Place to Work’

HFHS Alignment - LEAP 2008Henry Ford Health System is a unified, integrated organization bringing

value to its patients, communities, members, physicians, employees and business units through:

Delivery of the highest quality of clinical care and personal service with aligned goals and standards of performanceA focus on coordination of services across the continuum of care to achieve a patient care experience that is appropriate, aligned and seamlessA culture of innovation and learningCoordinated growth strategies and brandingInformation technology that enhances patient care, increases theefficiency of administrative processes and supports clinical integration across the SystemProviding a world-class environment for employees and physiciansto practice their professions, expand their skills and talents and develop their careersMarket strength with a unified contracting strategy

HF-WBH

24/7

24/7

HF-COT

HF-MWARHF-KG

HF-MAC

24/7

HFH

HF-WH

Current Service Locations

Hospital24 Hr. Med CenterMedical Clinic

24/7

Integration NO

• Advertising• Signage• Annual Report• Insurance Products

Integration YES

It takes systems to integrate Systems

Pathology Billed Test vs Labor Equivalents

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

Mar-02

Jun-0

2Sep

-02

Dec-0

2Mar-

03Ju

n-03

Sep-0

3Dec

-03

Mar-04

Jun-0

4Sep

-04

Dec-0

4Mar-

05Ju

n-05

Sep-0

5Dec

-05

Mar-06

Jun-0

6Sep

-06

Dec-0

6Mar-

07Ju

n-07

Sep-0

7Dec

-07

Mar-08

Jun-0

8

Bille

d Te

sts

by Q

uarte

r

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Labo

r Equ

ival

ents

billed test LEQ

2002 2008

HFHS Pathology Financials75 CLIA Certificates, 663 FTEs

(millions) ServiceLine

HFH HFMG COT WBLM WAR WYAN CL TWP

Gross Rev $575 $346 $24 $6.8 $0 $32 $75 $55

Net Rev $207 $125 $8.4 $2.4 $0 $12 $27 $20

Sal/Beni $49 $28 $6 $1.0 $0 $3 $4.4 $4

Non-Labor $46 $22 $3 $1.5 $0 $3 $5.8 $5.5

Tot Exp $93 $48 $9 $2.5 $0 $6.1 $10.3 $9.3

Net Inc/GC $114 $77 ($0.5) ($0.1) $0 $5.4 $17 $11

HFH/HFMG Lab Retirements & HFWBH Hires - 2002 to 2049

0

5

10

15

20

2520

02

2004

2006

2008

2010

2012

2014

2016

2018

2020

2022

2024

2026

2028

2030

2032

2034

2036

2038

2040

2042

2044

2046

Year

Num

ber o

f FTE

sW. Blm Hosp Hires

HFH / HFMG RetirementsIncremental Certified Technical Staff Only

NOW

Pathology & Laboratory MedicineService Line (PALM)

Pathology & Laboratory MedicineService Line (PALM)

• All hospital Lab Service Line created 2001• Extension across system- 2008• “Accelerate one lab enterprise across system”• Corporate entity, CEO Liaison• Under leadership R. Zarbo, Senior VP• “Centralize to every extent possible”• Single capital pool• Cascading approach as LIS permits, on a timeline• New Hospital Lab now a ‘Stat Lab’ concept, space,

capital costs

Hail Augustus

HF-WBH

24/7

24/7

HF-COT

HF-MWARHF-KG

HF-MAC

24/7

HFH

HF-WH

Current Service Locations

Hospital24 Hr. Med CenterMedical Clinic

24/7

HF-WBH

24/7

24/7

HF-COT

HF-MAC

24/7

HFH

Hospital24 Hr. Med CenterMedical Clinic

24/7

Hub & Spoke Design

HF-MWAR

HF-WH

HF-KG

Molecular Pathology and Genomic MedicineMolecular Pathology and Genomic Medicine

Laboratory Director , PhD

Division Head,, MD

Advisory Members-Division heads and section chiefs

TransplantationInfectious Diseases Hematopathology Oncology IdentityPharmacogenomics

GonorrheaChlamydiaHIV quantHCV quantHCV qualMyco TB

Myco Av IntMyco

GordoniCMV

HSV 1 & 2MRSA

HLA class I & II

genotyping

Warfarin*CYP2C9-2CYP2C9-3VKORC1

NeoplasticJAK2

BCR-ABL major &

minor brkptsPML-RARA

CBFb-MYH11AML-1ETO

FLT3B cell IGH

TCR-gammaBCL2-JH

CoagulationFactor V (Leiden)Factor II

(Prothrombin)MTHFR

BrainMGMT

1p19q LOHLungEGFR

Ob/GynGestational

disease Colorectal

MSIMLH1

Tumor AssocEBV

Tissue &Patient Identity

HFWBH

24/7

24/724/7

HFCOT

HFMWARHFKG

HFMAC

HFHS LABTri-County

OUTREACH RING

P.A.L.M.SYSTEMCORE

&ESOTERIC

LAB MODEL24/7

CORE

HFWH

Laboratory Outreach Brand

Pathology & Laboratory MedicineService Line (PALM)

• PALM Principles

• Business Plan,

• Timeline & Schedule

Value Drivers

Focus on 20% of actions that will drive 80% of the economic value for the organization.

- With highest probability of success- In shortest period of time

Value Drivers• Requests for new tests should be reviewed for clinical value

and economic impact.

• Compare all hospital test menus with W. Bloomfield Hosp Menu

• Align proficiency testing orders with test menus

• Realign position management to PALM Service Line

• Review consumable contracts for aggregation and price protection.

• Catalogue all existing Lab Outreach testing

Value Drivers• Review and approve Capital needs as a Service Line

• Develop and trend internal Quality Management Metrics

• Review and understand professional staff duties by site

• Roll-up financial reporting and craft fair transfer pricing

• Create targeted communication to stakeholder groups

• Consider recommendations from Wellspring Partners

Value Drivers• Review and approve personnel requisitions at the PALM level

• Reassign professional staff contracts to PALM

• Unify all Laboratory Outreach under one brand….HFML

• Build-out Lab Portal to support Lab Outreach

• Review all service contracts for effectiveness and savings

• Redefine best practices in the new conditions

Value Drivers• Repatriate revenue from reference laboratory testing

• Repatriate revenue from prof Pathology contracts: Part A

• Repatriate revenue from prof Pathology contracts: Part B

• Migrate Clinton Twp to enterprise-wide LIS systems

• Tie LIS to Macomb choice of Careplus or Powerchart

• LEAN management to all PALM Service Line

Valu

e Driv

ers

1 CETAC review for new test services

2 Test Menu Review HF-WB as baseline

3 Realign position management to PALM Service Line

4 Consumable contracts PALM review & approval

5 Catalog all existing Lab Outreach

6 Capital PALM review & approval

7 Quality management metrics

8 Professional Staff Duties

9 Financial roll-up corporate with transfer pricing

10 Communication to Stakeholders

11 Wellspring Partners report

12 Personnel requisition approval

13 Professional staff contracts, reassign to PALM

14 Unified Lab Outreach to HFML

15 Service contract review

16 Best Practices redefined for New Conditions

17 Build-out Lab Portal

18 Repatriate $$ Revenue from Reference Lab Tests

19 Repatriate $$ Revenue from Professional Referrals

20 Align Proficiency Testing orders with test menus

21 Repatriate $$ Revenue from Part B to HFHS

22 LEAN management to ALL PALM Service Line

23 Macomb Clinton to Shared LIS

24 Clinton Lab results to CarePlus or Cerner Powerchart

SvcLine

IT $$$

• Value Drivers (24): Quality, Cost, Service– Economic Impact vs. Probability of Success

• Timeline– 20% of activities that drive 80% of Value

• 90 days• 180 days• 365+ days

• Implementation Drivers– No items require new $$ in 1st 150 days

Value Drivers

$

Probability of Success

Economic Impact vs. Success Probability

$ $ $

probability probability probability

90 days 180 days 365+ days

12

34 7

5 8 9

6

10

11

1215

14

13

1617 19

24

18 20 22

21

23

Establish 3 fast moving teams

257

Test menu reviewCatalog existing OutreachQuality management metrics

Establish 2 teams

14 Unified Lab OutreachBest Practices16

Establish 1 team

22 LEANManagement

Pathology Service Line Launch

• Communication to Stakeholders– Internal

• Staff, physicians, leadership– External

• Physicians, vendors

• Savings Strategies & Growth Strategies

• Quality Management

Customers

• If Customers are not on the top of your priority list, re-do the list.– We can’t grow new customers and discard

old customers – Every customer is unique– Emphasizing customer satisfaction is a

common concern for all of us and a way to align us

Service Commitment• On-site pathologists• 24X7 pathologist and supervisor on-call• Sub-specialty coverage and consultation

– Surgical pathology• double read breast & prostate, 2nd opinions

– Clinical pathology• microbiology, chemistry, blood bank, hematopathology

• Common trended quality metrics• Centralize esoteric tests & autopsies• Implement LEAN management• Expand Outreach

HF-WBH

24/7

24/7

HF-COT

HF-MAC

24/7

HFH

Hospital24 Hr. Med CenterMedical Clinic

24/7

Centurions, Legion Commanders & Legionaries

HF-MWAR

HF-WH

HF-KG

Centurions

Fixed & Mobile Army

ALL ROADS LEAD TO ROME

TURN-AROUND TIME (TAT)

CAP ACCREDITATIONREQUIRED

Emergency Room TATCBC, Troponin, BMP, PT, PTT

STAT TEST TATChem, Heme, Coag, Urinalysis

Frozen Section TAT

Biopsy TAT (Small or Simple)Resection TAT (Large or Complex)

Cytology Non-Gyn TAT

Cytology PAP Smear TAT

Cytology ASCUS/HG PAP + HPVBlood Culture Contamination

Critical Value Reporting

Customer & Staff Satisfaction

Quality Management Metrics

Growing Outreach

• Start with Large In-Reach Base

• Lower Unit Cost for All

Mass ProductionMass Production

•Continuous Production

•Conveyor belt assembly line

•Division of labor

•Simple repetitive tasks

•Integrated supply chain

•Standardized parts

•Reducing waste

Lab Outreach

• Market Opportunity Assessment• Gap Analysis (fresh set of eyes)• Web Portal• Legal Structure• Add New Talent to lead Outreach

You can train a dog to climb a tree, or you can hire a squirrel

Sr. VP & Chair,

Pathology & Lab Medicine

EVP & COO HFHS

Office of PALM

Med & Admin Directors

System DirectorAnatomic Pathology

System DirectorClinical Pathology

Vice Chair, HFH

EVP & CEO HFMG

System Director Laboratory

Operations / COO

PATHOLOGY AND LABORATORY MEDICINE

HF CottageManager

HF Macomb Clinton Twp

Med. Dir.HF Macomb

Clinton Admin Director

HF W. Bloomfield

Admin Director

HFMG Regional

LaboratoriesMed. Dir.

HFMG Regional Labs

Manager

HF Macomb Warren

Med. Dir.HF Macomb

Warren Admin Director

CEO Liaison

HFH Admin

DirectorHFML

Manager

HF WyandotteMed. Dir.

HF WyandotteAdmin

Director

System Director Lab Operations / COO

Lab OutreachHenry Ford

Medical Laboratories

Med. Dir.

HF HospitalMed. Dir.

HF Cottage Hosp

Med Dir

HF W. Bloomfield Med. Director

Lab System Org StructureLab System Org Structure

Advisory Groups: Strategic Planning, Leadership, Quality Mgt, New Technology, Informatics,CLIA Lab Directors, New Test Services (CETAC), Accreditation

Administrative Leads Focus On: Human Resources Finance/Budget Purchasing, Info Technology

Sunquest / CoPath Histotrak

MASAqueduct

Middleware

LAB PORTAL Atlas

APOLLO Pathpacs

Scantron

LAB USER’S GUIDE

pathology.hfhs.org/lug

TELEPATHOLOGYLeica

− Store AP Req Scans− Store Clin Path Req Scans− Integrate External AP Results− Telepath Integration− Associate Imaging to Reports− Interface to acquisition devices

Cameras (1-2 M records/yr)- Gels- Microbiology

− Surg Path Reqs− Cytopath Reqs− Clin Path Reqs− Outreach Documents

− HFWBH

PathInformatics 032309

SCANNING

TISSUE BIOREPOSITORY

DOCUMENT CONTROL

Master Control

HEALTHSTREAMTraining

Competency

Wired

Seamlessness Seamlessness Pathology Service Line

Attributes

COT HFH HFMG HFMacomb

HFMacombWarren

WYH

Common Trended Quality Metrics X X X X X X

Enterprise-wide Lab Info System X X X X X

Lab Courier Shared X X X X X X

Esoterics to HFH Core Lab X X X x AP X X

Reporting to Common EMR X X X X X

Common Reference Lab – MCL X X X X X X

Centralized Blood Sourcing X X X X X X

Lab OutreachHenry Ford Medical Labs

X X X X X X

Pathology Consult In-Source X X X X X X

LEAN Management X X X X X X

Electronic Document Control X X X

Common Web Presence X X X

On-Line Lab Test Catalog X X X X X

Capital and Consumable Contracts X X X X X X

Key Changes 2004-2008Key Changes 2004-2008Organized visual, workflow, priority specimen workstreams

Key Changes 2004-2008Key Changes 2004-2008Laboratory structural redesign, work cell design & standardization

•Linear flow•U-shapedindividualworkcells

2

1

4

3

Requisition

Specimen container

Tissue cassette

Glass slide

Current Gross Lab Process Map

PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

BucketsProblem

Specimens

PCPC

PCCassettePrinter

To Histology

Storage

Storage

Transcription

1 4

2 3

StorageCutting Station 2ComputersSpecimen BucketsCassette PrintersCutting Station 4

Delays

Cutting Station 3Cutting Station 1

To Gross Lab

To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Scanner

Accession #1Scanner Cassette

PrinterCassettePrinter

Accession #2

Specimen Rehab

Specimen Tracking

Cutting StationsSort Station

Color CodedBuckets

Histology

Storage

Accession & Gross Lab Process Flow Map“following the work”

Next Steps

• What we need from you as leaders– Your behavior is a role model, your shadow– Embrace & champion the change, THINK BIGGER– Communicate extra positive messages

• To your staff• To your clients

– Rid rumors & fear…Communicate– Contribute to transition teams– Be patient, we will get there together, playing well

on a larger team

Lessons Learned• It takes systems to integrate Systems• Value Drivers, move quickly• Align incentives, follow the money• Economy: We’re all running at redline

• Challenges: – Traditional Return to Silo response– Couriers, IT, Capital availability

Q & AHenry Ford Hospital Detroit Campus