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Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital
 

Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital

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In this presentation, Daniel May, Huron Healthcare managing director, and Mark Mullarkey, Texas Children’s Hospital Senior Vice President, share: insights into tracking the initiative’s progress, ...

In this presentation, Daniel May, Huron Healthcare managing director, and Mark Mullarkey, Texas Children’s Hospital Senior Vice President, share: insights into tracking the initiative’s progress, strategies for engaging physicians, and real-world lessons learned from the initiative.

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Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital Presentation Transcript

  • Delivering On The Vision: Keys To Achieving Breakthrough Operational Performance 2013 Children’s Hospital Association Annual Leadership Conference October 14, 2013 Mark Mullarkey, Senior Vice President, Texas Children’s Hospital Dan May, Managing Director, Huron Healthcare
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 2
  • Summary  In late 2012 Texas Children’s Hospital (TCH) identified the need to improve financial performance of the health system by over $50M.  TCH launched a health system wide performance improvement initiative name “Delivering on the Vision.”  Partnering with Huron Healthcare, TCH identified over $60M of improvements in labor, non-labor, clinical operations, clinical documentation, and physician services.  Over the past year, the TCH team worked with Huron to successfully implement the identified improvement. © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 3
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 4
  • Background Texas Children’s Hospital (TCH) identified the need to improve financial performance of the health system by reducing costs, increasing revenue, and improving quality. • $50 million gap between projected 2013 profitability and target operating margin • Federal and state funding reductions driving most of this gap • Higher margins crucial for replenishing capital and expanding TCH facilities • Competitive threats driving expected gap closer to $75M © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 5
  • Project Background & Scope  The TCH leadership team initiated a health system wide performance improvement project named “Delivering on the Vision” in reference to the their “Vision 2010 Initiative”  Project assessed and addressed performance in every key operational area: – Labor Expenses – Non-Labor Expenses – Clinical Operations – Clinical Documentation Improvement – Physician Services © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 6
  • Business Imperative of $50M identified Today's Operating Margin Gap $'s in 000 $120,000 $100,000 Estimate higher margins will be required to maintain an Aa2 rating, replenish capital and expand facilities $80,000 $60,000 $40,000 2013 Estimate $50 MM $20,000 $- June 12 YTD $75MM $(20,000) $(40,000) $(60,000) 2011 June 2012 YTD Run Rate Target Operating Margin 2013 2014 2015 2016 2017 Projected Operating Margin 7
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 8
  • Executive Steering Committee PROJECT GOVERNANCE – IMPLEMENTATION TCH Executive Sponsors Susan MacDonald, EVP, RN Randy Wright, EVP & COO Huron Client Services Executive Project Management TCH: Mark Mullarkey Huron: Robert Donnert Daniel May Executive Steering Committee Randy Wright, EVP & COO Dr. Mark Kline, MD, Physician in-Chief Dr. James Versalovic, MD Pathology Dr. Gordon Schutze, MD Peds Lori Armstrong, SVP & CNO Mary Jo Andre, VP Quality Michelle Riley-Brown, SVP West Sherry Fultz, AVP Chanda Cashen, AVP OB/Gyn Susan MacDonald, EVP Dr. Michael Belfort, MD, Ob/Gyn in-Chief Dr. George S Bisset, MD Radiology Dr. Manju Monga, MD OB/Gyn Linda Aldred, SVP HR John Nickens, VP Supply & Hosp Based Cris Daskevich, SVP Women’s Pavilion Mark Mullarkey, SVP Ambulatory & OR Diane Scardino, AVP Medical Practice Ben Melson, EVP & CFO Dr. Charles Fraser, MD Surgeon in-Chief Dr. Dean Andropoulos, MD Anesthesia Dr. David Wesson, MD Surgery Mallory Caldwell, SVP Strategy Tabitha Rice, VP Alec King, VP Finance Matt Girotto, AVP Surgical Services Labor Non-Labor Physician Svc Clinical Ops CDI Huron: Greg Bryan TCH: Lori Armstrong Huron: Dan May TCH: John Nickens Huron: Chris Smedley TCH: Mallory Caldwell Huron: Larry Burnett TCH: Tabitha Rice Huron: Gerri Berg TCH: Dan DiPrisco © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary 9
  • Executive Steering Committee PROJECT GOVERNANCE – WORK TEAMS Labor Solution Team Non-Labor Solution Team Physician Svc Solution Team Clinical Ops Solution Team CDI Solution Team Huron: Greg Bryan Huron: Irene Walsh TCH: Lori Armstrong TCH: M. Riley-Brown Coord: L. Toures Huron: Dan May Huron: P. Zimmerman TCH: John Nickens TCH: D. Scardino TCH: Dr. D. Roth Coord: J. Estes Huron: C. Smedley TCH: Mallory Caldwell TCH: T. Johnson MD Leaders: Dr. Shutze, Dr. Wesson, Dr. Monga Coord: M. Wilrich Huron: Larry Burnett Huron: Brad Stater TCH: Tabitha Rice TCH: G. Parazynski Coord: G. Erwin Huron: Gerri Berg Huron: S Manierre TCH: Dan DiPrisco Coord: J. Austin Nursing Work Team Perioperative Work Team Clinical Ancillary Work Team Support Services Work Team Corporate Work Team Nursing Work Team Pharmacy Work Team Pediatrics Work Team Lab Work Team OB/Gyn Work Team Surgical Work Team Surgery Work Team Cath Lab Work Team Non-Clinical Work Team Case Management Work Team Patient Placement Work Team Physician Education Work Team Coding – Reconciliation Work Team Care Variation Work Team Care Coordination Work Team Food/EVS Work Team Surgical Work Team © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary 10
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 11
  • Assessment: Key Findings  TCH’s growth in spending had been greater than its growth of revenue over the past year, creating an imperative to reduce spending; early intervention is TCH’s motto.  The following elements have prompted TCH to reduce spending:  Staffing levels had risen faster than what has been budgeted  Annual non-labor /supply chain spending had risen faster than what has been budgeted  Funding of the Baylor College of Medicine had increased faster than what has been budgeted  TCH lacked standardization in key areas of operations, vendor contracting, and clinical processes of care.  TCH lacked a long term plan that integrated physician capacity and recruitment, support staff needs, facility space needs, and required capital expenditures. 12
  • Assessment: Key Findings  TCH lacked an integrated care management program, consistent coordinated interdisciplinary meetings, and regular adherence to evidence based standards of care for length of stay management.  TCH lacked a productivity management tool to help department leaders and providers to manage their labor costs and flex their staffing to changes in volume.  TCH lacked an effective position control process to manage the hiring decisions across the organization and an effective process for monitoring and managing premium labor.  TCH’s management to staff ratio was inconsistent across different areas.  TCH lacked a clinical documentation management process for optimizing coding and reimbursement of future Medicaid APR-DRG patients. 13
  • Total Opportunity Identified from Assessment TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY Area Low Mid-Point High Non-Labor $7,330,000 $8,847,500 $10,365,000 Labor $8,412,000 $12,297,000 $16,182000 Clinical Documentation $6,772,500 $9,030,000 $11,287,500 Clinical Operations $5,900,000 $9,350,000 $12,800,000 Physician Services $15,433,000 $20,651,150 $25,869,300 $43,847,500 $60,175,650 $76,038,800 Annualized Total © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 14
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives I. II. III. IV. V. Non-Labor Labor Clinical Documentation Clinical Operations Physician Services V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 15
  • Executive Summary: Non-Labor Strengths  GPO Compliance  Clinical practice and product choices are strongly influenced by evidence based literature and research  Texas Children’s Hospital performs innovative, cutting-edge procedures. These procedures often require extensive supply resources Opportunities  Majority of savings are related to standardization and utilization of supplies and services  Some of the cost savings opportunities may require administrative support and leadership © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 16
  • Non-Labor Opportunity Identified NON-LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY Area Low Midpoint High Medical/Surgical $660,000 $705,000 $950,000 Surgical Services $700,000 $850,000 $1,000,000 Cath Lab & Imaging $270,000 $330,000 $390,000 Laboratory $800,000 $1,000,000 $1,200,000 Pharmacy $2,000,000 $2,250,000 $2,500,000 Purchased Services $1,700,000 $2,100,000 $2,500,000 IT $550,000 $687,500 $825,000 Food Services/EVS $650,000 $825,000 $1,000,000 $7,330,000 $8,847,500 $10,365,000 Annualized Total © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 17
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives I. II. III. IV. V. Non-Labor Labor Clinical Documentation Clinical Operations Physician Services V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 18
  • Labor Opportunity Identified LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY AREA LOW MIDPOINT HIGH Nursing $2,326,000 $3,757,500 $5,189,000 Clinical Ancillary $2,720,000 $4,025,500 $5,331,000 Non-Clinical Support $1,825,000 $2,727,000 $3,629,000 Administrative/Financial $1,541,000 $8,412,000 $1,787,000 $12,297,000 $2,033,000 $16,182,000 Annualized Total Strengths  Management is open and supportive of change and improvement  Quality of talent is strong  Passionate about Texas Children’s Hospital Opportunities  Implement discipline and tools for successful productivity management  Design an organizational structure, span of control and accountability process to support strategic plans  Review/revise/support system-wide position requisition and control process © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 19
  • Labor Opportunity by Facility FTEs Total Main Campus Pavilion West Campus Key Operational Areas Low High Low High Low High Low High Nursing 24.0 53.5 16.0 45.5 4.0 4.0 4.0 4.0 Clinical Ancillary 33.8 66.1 28.2 57.7 0.6 0.8 5.1 7.6 Support Services 29.4 50.5 17.7 34.1 7.1 11.2 4.6 5.2 Financial/Administrative 21.5 28.8 21.5 28.8 0.0 0.0 0.0 0.0 TOTAL 108.7 199.0 83.4 166.1 11.7 16.0 13.7 16.9 Dollars Key Operational Areas Total Low Main Campus High Low High Pavilion West Campus Low High Low High Nursing $2,326,000 $5,189,000 $1,467,000 $4,330,000 $480,000 $480,000 $379,000 $379,000 Clinical Ancillary $2,720,000 $5,331,000 $2,276,000 $4,689,000 $26,000 $34,000 $418,000 $608,000 Support Services $1,825,000 $3,629,000 $1,200,000 $2,717,000 $348,000 $596,000 $277,000 $316,000 $0 $0 $0 $0 Financial/Administrative $1,541,000 $2,033,000 $1,541,000 $2,033,000 TOTAL $8,412,000 $16,182,000 $6,484,000 $13,769,000 $854,000 © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. $1,110,000 $1,074,000 $1,303,000 20
  • Flexing Staffing to Demand KEY IMPLEMENTATION APPROACH Flexing Staffing to Volume Volume to staffing regression correlations indicate 77% of patient care units are not flexing efficiently to census Note: R2 of 1.0 indicates the regression line perfectly fits the data © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 21
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives I. II. III. IV. V. Non-Labor Labor Clinical Documentation Clinical Operations Physician Services V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 22
  • Clinical Documentation Improvement Opportunity CLINICAL DOCUMENTATION IMPROVEMENT - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY Area Low Midpoint High Improved Reimbursement After CDI $6,772,500 $9,030,000 $11,287,500 Annualized Total $6,772,500 $9,030,000 $11,287,500 Strengths  The coding staff has an awareness that chart documentation needs improvement  The coding staff desires to embrace change Opportunities  Coding opportunities were found that would significantly affect reimbursement with APRDRGs  Coding opportunities were found that would affect severity of illness and risk of mortality which would increase the case mix index (CMI) © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary 23
  • Case Review CLINICAL DOCUMENTATION IMPROVEMENT The following summary provides the results of an analysis conducted on 75 cases reviewed during the assessment: Total Charges of the 75 Charts $ 7,316,055 TCH’s Reimbursement at Current Rate of 36% of Charges TCH’s Reimbursement at APR-DRG Rate Improved Reimbursement (APRDRG) After Implementation Incremental Change With Improved Documentation $2,633,781 $2,403,722 $3,191,981 $788,259 © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 24
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives I. II. III. IV. V. Non-Labor Labor Clinical Documentation Clinical Operations Physician Services V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 25
  • Clinical Operations Assessment Opportunity CLINICAL OPERATIONS - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY Area Annual Length of Stay Benefit Low Midpoint High $5,900,000 $9,350,000 $12,800,000 Strengths  Organization has been primed for change by the current leadership  Leaders at all levels expressed interest in obtaining data to support decision making and increase accountability  Case Management leadership has outlined an appropriate vision for the future of their department Opportunities  Patients are staying longer than medically necessary and are not transitioning to a lower level of care in a timely manner  Without operational process improvement and a bed allocation analysis, TCH will not have the ability to serve additional inpatients without operating above 85% utilization, which hinders patient throughput  No centralized tool is being used to track key throughput metrics. These metrics should be used daily/weekly to support comprehensive patient flow improvement. © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 26
  • Length of Stay Opportunity MAIN CAMPUS Average Length of Stay for Top 10 APR-DRGs 50 Opportunity Days: 446 Volume: 14 Opportunity Days: 280 Volume: 10 45 Average Length of Stay (Days) 40 35 30 Opportunity Days: 303 Volume: 27 25 Opportunity Days: 340 Volume: 27 20 Opportunity Days: 660 Volume: 90 15 Opportunity Days: 728 Volume: 200 10 5 Opportunity Days: 920 Volume: 891 Benchmark TCH Opportunity Days: 415 Volume: 186 Opportunity Days: 585 Volume: 216 Opportunity Days: 512 Volume: 698 0 Appendectomy Post-Op, Post-Traumatic, Other Device InfectionsFailureCardiac Cath Cardiac Valve Procedures without to Thrive & other Nutiritional Cardiac Defibrillator & Heart Assist ImplantProcedure withwith Circulatory Disorder Hepatobiliary, Contact withAbdominal Procedures Malnutrition, Seizure Disorders Craniotomy, except for Trauma Diagnosis, Rehab, Aftercare or Other Pancreas & Heath Service Cardiac Cath Other except for Ischemic Heart Disease Notes: Listed in order of descending opportunity days TCH Date Timeframe: June 1, 2011 to May 31, 2012 Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry Benchmark: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle) © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary 27
  • Length of Stay Opportunity MAIN CAMPUS 35% of TCH patients have excess days. The delineation of those patients by number of excess days is outlined below. Excess Days Variance over Benchmark Length of Stay 60% 50% 49% 40% of cases have a variance of 2 to 11 days 40% 30% 20% 20% 10% 10% 4 to < 6 Days 6 to < 11 Days 10% 6% 5% 11 to < 20 Days 20+ Days 0% > 0 to < 2 Days 2 to < 4 Days Notes: Timeframe: June 1. 2011 to May 31, 2012 Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry DRGs: APR – DRGs Source: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle) © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary 28 28
  • Length of Stay Benefit Opportunity MAIN CAMPUS Clinical Operations Financial Benefit Low High Length of Stay Benefit • Reduction in 4,800 to 9,700 patient days results in the following benefit: • Capacity created to serve an additional 450 to 930 patients annually (50% backfill) • Cost savings associated with reducing 2,400 to 9,700 patient days (50% cost savings) $5.9 M $12.8M Demand Backfill Percentage Cost Savings Percentage Backfill (Number of Cases) 50% 50% 700 60% 40% 70% Patient Days Reduction Opportunity Opportunity Low High 3,600 $5.9 M $12.8 M 800 3,000 $8.3 M $17.7 M 30% 1,000 2,200 $10.6 M $22.6 M 80% 20% 1,100 1,400 $13.0 M $27.6 M 90% 10% 1,200 700 $15.4 M $32.5 M 100% 0% 1,400 0 $17.7 M $37.4 M (Associated with Cost Savings) Notes: Benefit model incorporates lost revenue associated with reducing length of stay of patients with payers who reimburse based on percent of charges (except Medicaid given the upcoming reimbursement change), which includes 70% of the total patient days Alec King, Vice President of Finance, reviewed and approved the benefit model methodology 50% backfill estimate is based on conversations with several TCH senior executives Includes Medical/Surgical patients (excludes NICU, newborns, chemical dependency, psychiatry, rehabilitation and ungroupable) who discharged 6/1/ 2011 – 5/31/2012 © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2013 Huron Consulting Group. All rights Proprietary Proprietary 29
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives I. II. III. IV. V. Non-Labor Labor Clinical Documentation Clinical Operations Physician Services V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 30
  • Physician Services Opportunity PHYSICIAN SERVICES - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY Area Low Midpoint High Clinical Efficiency $15,000,000 $20,000,000 $25,000,000 Non-Provider Labor (1) $ $ $ Annualized Total $15,433,000 433,000 651,150 $20,651,150 869,300 $25,869,300 Opportunities  Continue support of the TCH/Baylor mission through process improvements including, but not limited to:  Increase provider throughput and revenue  Improve patient flow and access in clinics by improving scheduling templates, utilization of support staff and standardizing staffing models where appropriate  Refine CART model to tie revenue to expenses  Align labor costs, revenue and production to directly correlate with appropriate cost centers (1) Non Provider Labor does not include Baylor staff as they were not accounted for in the Labor Analysis © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 31
  • Clinical Efficiency Department wRVU Gap to Potential Net wRVU Gap to Number of New full time Sullivan Potential Net Clinical Total wRVUs Collections to FPSC FTE Physicians in Total FTEs FTES (hired Cotter FTE Collections to FTEs Annualized Sullivan Cotter Adjusted analysis After 7/1/2011) adjusted FPSCr Median Median Median Median Pediatrics 617 489.89 290.14 63.00 1,066,278 329,140 $18,309,820 666,620 $36,840,622 Surgery 58 56.27 43.13 8.00 300,896 29,243 $2,005,042 80,772 $5,979,215 Obstetrics/ Gynecology – Baylor 36 33.90 25.55 22.00 77,223 77,596 $4,943,768 103,576 $6,748,980 Obstetrics/ Gynecology - TCH 13 13.00 13.00 **0 112,137 5,187 $523,101 9,476 $923,837 Anesthesiology 51 49.71 40.48 3.00 408,697 74,476 $2,276,571 * * Pathology 21 21.00 9.20 6.00 42,108 8,859 $535,666 11,628 $706,526 Pediatric Radiology 26 23.90 20.00 0.60 109,555 15,963 $1,374,537 56,545 4,585,666 822 687.67 441.50 102.60 2,116,894 540,464 $29,968,505 928,617 $55,784,846 Total * Providers were all acquired after 7/1/2011 but because the practice was already established all providers were included in analysis ** No benchmark for anesthesiology available in FPSC survey © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 32
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 33
  • Timeline   ACTIVITIES      Organize project teams Establish baseline measurement criteria Identify and quantify financial benefit initiatives Complete detailed operational analysis Build business case for specific initiatives Obtain approval to implement initiatives Implement detailed improvement ideas and plans Monitor Benefits Months 9 – 12+ Implement Initiatives Months 3 - 12 Develop Initiatives Months 1 - 3        Compile improvement documentation Train and educate staff Implement improvement plans and initiatives Implement management tools and reporting Empower management and drive accountability Align organization structure to support changes Begin measuring results     Implement residual program Ensure management has accepted accountability Monitor financial results Transition project management office DELIVERABLES Knowledge Transfer, Empower Management and Drive Accountability  Work steps completed for high priority initiatives   © 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential. © 2012 Huron Consulting Group. All rights Proprietary Proprietary Work steps completed for additional initiatives Benefits tracking and monitoring tool    Residual work steps completed for all initiatives Benefits tracking and monitoring tool Monitoring of savings 34
  • Project Scorecard - Example Delivering on the Vision Project Scorecard Area Savings Timeline Issues Non Labor Labor Clinical Documentation Clinical Operations Physician Services Proceeding as planned At risk for trending off plan © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. Require immediate attention 35
  • Non-Labor Project Scorecard (partial example) Key Updates Status Summary Issues /Barriers Action/ Next Steps  Monitored initiatives at a confirmed value of $13M  All teams working to complete implementation and monitoring of remaining initiatives  None  None  Identified to 179% of high goal  Implemented to 166% of mid-point goal  $1M in additional identified initiatives being completed  None  Monitor remaining initiatives Information Technology  Identified to 505% of high-goal  Implemented to 605% of mid-point goal  All initiatives have been implemented  None  None Laboratory  Identified to 64% of high goal  Implemented to 6% of mid-point goal  $700K in additional identified initiatives remaining to be implemented  Delays to a number of initiatives being resolved  Implement and monitor remaining initiatives Non-Labor Purchased Services Proceeding as planned At risk for trending off plan © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. Require immediate attention 36
  • Summary of Key Project Results  Improved margin by $32M in FY 13 YTD  Improved flexing of staff, reduced FTEs, and developed and implemented a new labor productivity system; also developed worked hours per unit of service (WHPUOS) standards for key departments  Reduced non-labor supply and purchased services costs and improved 340B benefits  Reduced length of stay, implemented interdisciplinary care rounds, implemented Teletracking and other tools © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 37
  • Summary of Key Project Results  Improved clinical documentation producing an increase in severity adjusted case mix index  Improved physician productivity  Increased transparency with physicians and staff  Improved quality by standardizing staffing levels and reducing care variation © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 38
  • Benefit Scorecard – Overall Project (as of 09/ 2013) Solution Group Non-Labor Labor Clinical Doc. Physician Services Clinical Operations Target Benefits $17,786,447 $14,011,071 $7,558,869 $12,297,000 $9,030,000 $20,651,150 $9,350,000 $13,725,177 $9,030,000 $14,263,000 $9,350,000 $9,382,125 $ TBD $9,540,200 $11,874,500 $5,276,000 $ TBD $8,089,000 $11,874,500 7250 7250 10,560 10,560 $60,175,650 $64,154,624 $44,807,896 $32,789,369 % of Target • Implemented Realized Benefits Benefits FY 13 YTD $8,847,500 LOS Reduction (Days) Total Identified Benefits 107% 72% 52% Clinical Documentation tracking begins in 10/2013 following Medicaid APR-DRGs start in TX on 9/1/13 © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 39
  • Labor – FTE’s © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 40
  • Labor – Salary & Benefit as % of NPSR • • © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. Net Patient Service Revenue is up 11.9% Salary and Benefit Expense is up just 5.9% 41
  • Labor – Control of Temp Expense © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 42
  • Estimated Financial Impact ACTUAL PAYROLL DATA VS FY13 BUDGET Average Paid FTE Variance from FY13 Budget= 386.7 paid FTE Cumulative Paid Dollar Variance by Pay Period (FY13 to PPE 4/13/13) = $16,013,200 Notes: In scope labor depts only; Dollars estimated based on avg wage rate per dept and include a 15% benefit factor © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 43
  • Project Results: Clinical Operations Realization Schedule Projected Annual Benefit includes: + Demand Backfill + Cost Savings – Revenue Loss Confidential. 44
  • Physician Services COUNTS Overall Specialty OBG BCM POGC/WSH OBG MFM A&I ADO AGP CAR DER DEV END HEM/ONC INF NEP NEU NGI PMR PSY PUL RHE CHS NSU OPH ORT OTO PLA PSU SYSTEM WIDE TOTALS %AGES COMPLETE Overall Not In Started Process Past Due Complete 1 5 0 0 2 0 0 5 0 10 0 0 0 0 0 0 0 0 0 0 0 10 0 1 3 0 1 38 4 5 5 1 1 0 4 0 0 10 6 0 0 1 0 0 0 5 4 5 0 0 3 4 0 3 12 73 0 0 0 0 2 0 0 0 0 0 0 0 2 1 2 0 0 0 0 0 0 0 3 0 1 0 2 13 6 5 8 7 10 0 9 7 0 1 6 0 14 12 12 0 0 6 3 0 6 0 10 9 4 11 16 162 Total 11 15 13 8 15 0 13 12 0 21 12 0 16 14 14 0 0 11 7 5 6 10 16 14 8 14 31 286 Not In Started Process Past Due Complete 9% 33% 0% 0% 13% 36% 33% 38% 13% 7% 0% 0% 0% 0% 13% 55% 33% 62% 88% 67% 0% 42% 31% 0% 0% 0% 69% 58% 48% 0% 48% 50% 0% 0% 5% 50% 0% 0% 0% 0% 7% 0% 13% 7% 14% 88% 86% 86% 0% 0% 0% 0% 100% 0% 7% 38% 0% 3% 13% 45% 57% 100% 0% 0% 19% 29% 0% 21% 39% 26% 0% 0% 0% 0% 0% 19% 0% 13% 0% 6% 5% 55% 43% 0% 100% 0% 63% 64% 50% 79% 52% 57% Updated as of 7.17.13 © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 45
  • Access - 3rd Available Specialties Tracked and Included: Renal Physical Medicine Clinic Rheumatology Allergy & Immunology Endocrine GI & Nutrition Otolaryngology Adol/Sports/Med/Yng Womens Neurology Psychology Service Orthopaedics Urology Ophthalmology Pulmonary Medicine Psychiatry - 17O Gynecology © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. Genetics Plastic Surgery Pediatric Surgery Retrovirology Orthodontics Res. Primary Care Neurosurgery Inf. Disease Development Pedi Dental Congenital Heart Surgery Dermatology Cardiology Hematology/Oncology 46
  • Internal Texas Children’s Pediatrics Referral Rate © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 47
  • TCH: Mid-Project Experience Survey Results Clinical Operations Update - June 2013 Patient Day Accumulation for Project Period (Nov-May FY13) 10,000 9,000 7,250 8,000 7,000 5,531 6,000 5,000 76% of goal 4,000 3,000 2,000 1,000 Results at a Glance … Most Recent Three-Month Period (Mar-May ‟13) vs. Historic Period (June ‟11-May „12) Severity-adjusted average length of stay decreased by 15.9 hours per patient, an 11% reduction compared to historic period! • Patient flow efforts increased capacity to serve 5,531 more patient days, cumulatively • 51% decrease in Red Acute Care Census Alert hours (34 in Mar-May „13 vs. 69 in Mar-May „12) • 9% decrease in EC boarding time average (Mar-May „13 vs. Mar-May „12) • 14% decrease in readmissions within 48 hours (38 in Mar-May „13 vs. 44 in Mar-May „12) Key Accomplishments to Date Care Management Engaged over 20 care managers in weekly Clinical High Risk meetings to collaboratively address and resolve barriers to efficient patient flow, efficient care, transitions to the next level of care and hospital reimbursement • Implemented Morrisey, a Care Management software tool for discharge planning, utilization review, and other work flow management Care Progression • Established 11 daily and multidisciplinary Care Progression Rounds (CPR) across over 35 services to proactively plan for patient's discharge with the care team and the patient/family • Conducted over 1,200 CPRs (and counting) since project start, with participation by over 500 physicians, nurses, and supporting care team members Room Management • Centralized Main campus bed assignment process which included the implementation of TeleTracking (TT), an electronic bed board; Trained over 600 nurses, unit clerks, EVS, and Patient Escort staff members on TT tool • Redesigned the EVS & Patient Escort staffing model to support a dedicated discharge cleaning team and discharge transportation process; automated discharge cleans and transportation requests with use of the TT tool • Year End Goal Net Days Saved Delivering on the Vision: Care Process Updates 7,250 5,531 The focus of the Care Process (CP) initiative is on creating a foundation and work processes to support physician adoption of evidence-based standards of care. • Pneumonia Care Process team is developing a care pathway which supports earlier discharge preparation, cohorted beds, and respiratory support • DKA Care Process team is developing a business case for a Diabetes Center for Excellence which includes pathway and education and translator availability; initiating hospital benchmarking for insulin pen vs. insulin vial only on formulary “It's incredible when I think about the results we've had recently…it is making a big difference.” -Executive Leadership “I’m on service this week and I have to tell you about how much the energy has changed on the floors! Everyone’s talking about and planning for discharges.” -Hospitalist © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. TeleTrackingXT TM : An Update on the Centralized Bed Assignment Process • Room Management has placed approximately 1,500 patients in beds since go-live (5/29) • EVS has conducted over 1,200 discharge cleans since go live • Patient Escort has performed over 300 discharge trips since go live “[Requesting a bed] through TeleTracking makes my job so much easier. I can trust that things will happen without me interfering and getting on the phone.” -Charge Nurse 48
  • Clinical Documentation Initiative – Main Campus BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 49
  • Clinical Documentation Initiative - West Campus BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 50
  • © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. ‹#›
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 52
  • Physician Engagement Strategies  Physician leaders should be involved from the beginning  Transparency is important when working with the physicians  Accurate data presentation and interpretation is key to get the physicians engage  Inclusion of medical staff at all levels and particularly in all work teams  Communicate, communicate, communicate © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 53
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 54
  • “Leadership always impacts and influences outcomes, not some of the time, but all of the time.” Labor Non-Labor Michelle Riley-Brown SVP TCH West Campus Lori Armstrong, MSN, RN CNO, SVP John Nickens VP Hospital Based Services and Supply Chain Clinical Operations Tabitha Rice SVP Clinical Support Services Diane Scardino AVP Ambulatory Servcies Clinical Documentation Jackie Ward, RN Director Cancer Center Joan Shook, MD Chief Safety Officer Dan Diprisco Director Physician Revenue Cycle Physician Services Mallory Caldwell SVP Strategy © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. Trent Johnson Director Ambulatory Services 55
  • But it takes a team…..a very large team! Jennifer Upshaw Dr. Carol Altman Sherry Fultz Dr. Michael Braun John Henderson Dr. Charles Gay Sandra Tillis Dr. Scott Dorfman Mike Towne Dr. Doug Ris Sarah McMaster Mari Trace Dr. Al Hergendroeder Dr. Jed Nuchtern Robert Turner Dr. Peter Hiatt Kara Lenahan Kim Nguyen Dr. Ryan Himes Matt Timmons Cindy Miley Ryan Breaux Dr. Jake Kushner Diane Scardino Dr. Brigetta Meuller Binta Baudy Dr. Ellen Friedman Travis Crum Stephanie Ramirez Dr. Theresa Wright Dr. David Roth Dr. Gordon Schutze Helen Currier Dr. Robert Zeller Dr. Monju Monga Tina Ninan Dr. Thomas Shaw Dr. Daniel Penny Lorraine Cogan Mary Kana Jeff Reinhart Matt Girotto Trent Johnson Laura Hardy Jackie Ward Dr. Jennifer Deitrich Dr. Jordan Orange Dr. Gary Clark Dr. David Coats Barkha Chandwani Daniel Fischer Jennifer Evans Dr. Angelo Giardino Tuhin Pakaj Dr. Efrain Bleiberg Chanda Cashen Dr. William Phillips Dr. Thomas Luerssen Dan Diprisco 56
  • Lessons Learned  Successfully implementing enterprise-wide performance projects requires: • Executive engagement and support • Physician engagement and support • Transparency and accountability • Setting realistic improvement goals for each solution • Communicating savings targets per initiative to all affected parties • Communication and early buy-in from all stakeholders to ensure timely implementation • Effective benefit realization monitoring and presentation – measure, measure, measure. Data and trends as “pictures” © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 57
  • Lessons Learned  Once redesign efforts are completed the organization must invest in resources to continue monitoring to hold the gains - Ongoing (although maybe modified) governance structures - Hardwired reporting mechanisms © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 58
  • Agenda I. Summary II. Texas Children’s Hospital’s Opportunities & Challenges III. Governance Approach IV. Transforming the Organization: Key Initiatives V. Tracking Progress & Measuring Benefit VI. Physician Engagement Strategies VII. Lessons Learned VIII. Questions © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 59
  • Today’s Presenters Mark Mullarkey Senior Vice President Texas Children’s Hospital mwmullar@texaschildrens.org 1-832-824-1262 Dan May Managing Director Huron Healthcare dmay@huronconsultinggroup.com 678-576-0408 © 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 60