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Surgical Directions © 2015
Why Focus on Perioperative Services?
Perioperative services drive hospitals’ performance.
• Over 68% of better performing hospitals’
revenue
• 60% of margin is derived from better performing
perioperative services.
• Successful system under Value-Based
Purchasing/ACO provides both surgeons and
payors more value for surgical services.
Equation: Outcome/Cost
By helping our clients tackle the complexities and
minimize the political and cultural barriers, our
clients have experienced significant improvements
in surgeon, staff, and patient satisfaction, which has
resulted in improved access to the OR, sustainable
growth in surgical volume, and increased market
share.
Surgical Directions © 2015
Healthcare Leaders Role
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As healthcare leaders our goal is to improve the value of
Perioperative Services
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Surgical Directions © 2015
Bridging Worlds
Bridging worlds provide insight in overcoming barriers and taking your
organization to a new level.
• Integrate Co-Create:-Collaborative governance
-Pre surgical optimization
• Nimble Exceed Rate of Change:-Bundled payment-Surgical home
• Generate Data / Give Insight:-Surgical dashboard-Monitoring key processes
• Tell Stories/ Create Experiences
ERASE BOUNDARIES / SILOS
-INTEGRATE, CO CREATE
-NEW GOVERNANCE AND DELIVERY MODEL
Surgical Directions © 2015
Case Study:
Beaumont Royal Oak
Flagship Tertiary Level I Trauma Center
Underperforming:
– Financially
– Clinically
– Operationally
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Surgical Directions © 2015
Case Study: Beaumont Royal Oak
Flagship hospital in trouble and struggling:
• Not meeting financial goals:
• Merger talks with Henry Ford terminated• Merger discussion with Oakwood
• Bond refinancing
• CRNAs employed by hospital meeting to discuss unionization
• Anesthesiologist had only a marginal role in operational leadership andless than optimal relationship with surgeons, nurses, and CRNAs.
• Leadership goal is to be the top surgical hospital in the nation
o Exceed UHC hospital benchmarks
Surgical Directions © 2015
Royal Oak Has Opportunities for
Improvement
Metric Benchmark Royal Oak Rating
SharedGovernance
SSEC: Multi-disciplinary approach to operational leadership
Surgeon as Chair
Matrix organization with traditional ‘nurse in
charge’ model
Medical Director
Anesthesiologist / CRNA Co-manages OR with nursing
RespectedClinically Active
Surgeon and anesthesia
chair at each tower
Lack of collaboration and
cross coverage
Daily HuddleMulti-disciplinary approach to proactively manage the schedule
1, 3 and 5 days out
M, W, F Scheduling Meeting lacking depth
and scope in proactive schedule management
Accountability
Strong and decisive leadership
Metrics, Dashboards and KPIs to
monitor performance and objectives
Culture of Accommodation
Surgical Directions © 2015
Royal Oak Has Opportunities for
Improvement
Metric Benchmark Royal Oak Rating
Block Schedule8 hr blocks plus open time;
75%-85% utilization
Current utilization under 50%
Cases per ORMain OR
IP 950 cases x 50% = 475 casesOP 1,400 cases x 50% = 700 cases
Total: 1,175 cases per ORCV 400
732 cases per OR
Day of Surgery Cancellations
<1%~1% Staff indicate much higher
Turnover TimeIP: 20-30 minutes
OP: 10-20 minutesNot Tracked
First Case On-Time Starts
90% or greater within 5-7 minutes of start time
Not Tracked
NA
NA
Notation: Excludes 4 CV OR’s and CV Case Volume
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Surgical Directions © 2015
Royal Oak Has Opportunities for
Improvement
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Metric Benchmark Client Rating
LeadershipDrive perioperative performanceDaily Huddle
Not involved in OR management
SafetyCreate a culture of safetyConsensus on protocols
Has a culture of safety but no consensus on protocols
PATProtocol drivenPatient optimized prior to surgery
Not protocol driven patients
Service Orientation
Service focusedWorking in silos and not in collaboration with nursing
Anesthesia
Surgical Directions © 2015
Case Study
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Block Utilization
Benchmark
Actual
Surgical Directions © 2015
Overview of Beaumont Royal Oak
Hospital Perioperative Improvement
Governance Structure and
Leadership
Process Improvement
Efficiency Initiatives
Anesthesia /
Pre-Anesthesia Testing
Surgeon Scorecards &
AccessStrategic Growth
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Surgical Services Executive Committee
• How do you build trust and a sense of joint ownership between
surgeons, anesthesia, and administrations/hospital staff?
• The Surgical Services Operations
Committee
• The committee membership
includes:
– Surgeons
– Anesthesia
– Nursing
– Senior Administration
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Surgical Directions © 2015
A “New” Hospital Surgical Organizational
Structure that Aligns Incentives
SSEC(Administration Sponsored)
Nursing
Leadership
Business Director/
Manager
PreOp
Main OR (Hosp)
Data Analysis
Budgeting/
Financial Analysis
Business
Development
Medical
Directors
Performance
Improvement
Teams
PACU
Surgical Directions © 2015
Balancing Surgeons’ needs for Access, Efficiency, Safety
and Quality Care and Hospital’s need for OR Value /
Productivity
Effective OR Leadership:
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Surgical Directions © 2015
Daily Huddle
Participants
‒ OR Director‒ Anesthesia
‒ PAE‒ Central Sterile Supply
‒ Materials‒ Scheduling
‒ Case Management‒ Ancillary Services, when needed (radiology, lab,
etc.)
Task
Review Schedule for next 72 hours‒ Patient Risk Factors
‒ Equipment‒ Supplies
‒ Sequence of Patients‒ Staff Assignment
Outcome
• Minimize Cancellations <1%• Improve On-Time Starts >80%
• Decrease Case Delays <5%• Improve Profitability
• Improve Clinical Outcomes
Surgical Directions © 2015
Anesthesia Helps Drive
Perioperative Performance
Driving Perioperative Performance
Effective Medical Director
Strong leader
Stipend based on service
standards
Incentives aligned
Available effective regional blocks
PAT
Protocoldriven and evidenced-
based
Surgical Home & Bundled
Payments
Participate in Daily Huddle
On-time starts
Quick procedural turnover
time
Respected clinically
Well-positioned
for the future
Growth in Case Volume & Improved Bottom Line
Surgical Directions © 2015
Case Study: Pre-Anesthesia Testing
Effective PAT
Medical Director
Telephone Questionnaire
Single Pathway Scheduling
Risk Management
Strategies
Testing Protocols
Systems to treat patients
with co-morbid conditions
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Surgical Directions © 2015
Beaumont Royal Oak
Key Performance Indicators
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Metric Current State Best Practice
Block Time / Prime Time Utilization 76% 70% - 85%
Cases per Operating Suite 838 1,219
Turnover Time 25 25 - 35
Same Day Case Cancellation 2.62% <1%
First Case On Time Start 65% >90%
Review Elective Cases 1, 2, & 3 Days Prior 100% >70%
Metric Jan-14 As of Jan-15 Variance
Improvement
Variance %
Block Time / Prime Time Utilization <50% 76% 26% 52%
Cases per Operating Suite 733 838 105 14%
Turnover Time 40 25 -15 38%
Same Day Case Cancellation 3.71% 2.62% -1.09% 29%
First Case On Time Start 29% 65% 36% 124%
Review Elective Cases 1, 2, & 3 Days Prior 25% 100% 75% 300%
Surgical Directions © 2015
Results: Beaumont Royal Oak
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IMPACT ON VOLUME: 24%
IMPACT ON NET INCOME: $20M
Surgeons Engaged
Improvement in Clinical Outcomes
Hospital well-positioned and
functioning efficiently
Surgical Directions © 2015
Bundled Payments are Here!
• Hospital Joint Discourse
• Bundled Payment Early Adoption 2012
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Surgical Directions © 2015
Be Nimble Exceed Rate of Change
• CMS Goal 2018
– 50% Quality/Cost Initiatives
• 2016 Bundled Payment- Joint Replacement
• 75 Markets
• 800 Hospitals
• 90 day episode
• Cost
• Quality Measures
– Complications
– Readmission
– Patient Experience
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Surgical Directions © 2015
Any services
72 hours
prior to
Admission
such as…
PAT
Physician Visits
(surgeon and other)
ED Visits
Any services
during the
Acute Stay
such as…
Hospital
Surgeon
Anesthesiologist
Consulting
Physicians
Any services during the 90-Day
Post-Acute Period
such as…
What is Included in the Target Price?
Inpatient Rehab
Skilled Nursing
Facilities & LTACH
Home Health
Agencies
Outpatient
Therapy Services
Readmissions
(to NYU or others)
Outpatient Services
Lab Services
DME
Physician Visits
(surgeon and other)
Part B Drugs
Days 91-120
CMS will be monitoring
the period immediately
following to ensure that
services are not being
shifted outside the
bundle.
NYULMC will be
financially responsible
if such behavior is
observed and may be
removed from the
program.
Surgical Directions © 2015
CLINICAL PATHWAYS & WORKFLOW
STRATEGIES
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Surgical Directions © 2015
Clinical Management Pathway
The Importance of Care Coordination
• Enforces best practices / standardization of pathways, workflows, and order sets
• Improves communication between providers and to the patient
• Ensures follow-up after care transitions
• Optimizes Patient Expectations and Outcomes
Surgical Directions © 2015
Goal
Develop a pathway that can be used for
90% of the patients with exclusions
determined by pathway criteria, not
physician preference
Surgical Directions © 2015
Preventing Hospital Readmissions
• Often suboptimal outcomes are tied to comorbidities or
complications associated with their TJA.
• Preoperative optimization of risk factors for suboptimal
outcomes is the best method of prevention.
• The use of an integrated preadmission testing and
clearance center utilizing the patient’s internist or a
hospital affiliated internist associated with a TJA specific
education and comorbidity identification process is
critical for medically complicated patients.
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Results
• Average of length of stay was decreased to 3.58
days from 4.27 days (Median LOS 3 days).
• Discharge to inpatient facilities has decreased
on average from 63% to 44% on average.
Surgical Directions © 2015
Conclusions
• Decreased length of stay
• Decreased discharges to inpatient facilities
• Decreased the cost of the episode of care
• Decreased readmission rate
• Positive margin
Surgical Directions © 2015
Fundamentals of Co-Management
Surgical Home
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Surgical Directions © 2015
Gain Sharing Metrics
• Patient Satisfaction
• LOS
• Unplanned 30 day readmission
• Compensation
– Fee Based on hours work
– Gain sharing tied to a percentage physician base
compensation if quality and lost metrics are achieved
Surgical Directions © 2015
Generate Accurate Data
Define Current State:
Generate Insight!
Surgical Directions © 2015
Elephant in the OR
IMPROVING OR PRODUCTIVITY
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Surgical Directions © 2015
Issue
Hospital for joint disease has limited capacity
Has initiatives to grow volumeBUT
Reducing case time is KEY to delivering
strategic objectives
Surgical Directions © 2015
Issue
Surgeons complain about turn over
time and same day cancellations
Most hospitals are afraid to address
case timeBUT
Cost per minute: $30 - $80
Surgical Directions © 2015
PUBLISHED OR METRICS DRIVE
CHANGE!
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Surgical Directions © 2015
Case Time Data
Driving Organizational Change
Patient In
Anesthesia Ready
CutClose
Patient Out
Surgical Directions © 2015
Physician Scorecard
Surgical Directions © 2015
Physician Scorecard (cont’d)