0
Operationalizing Clinical Excellence:
Lessons Learned
May 14, 2014
Speakers:
•James Stein, M.D., Associate Chief of Surger...
Learning Objectives
• Identify keys to improving clinical operations with
DRG-based reimbursement
• Understand foundationa...
Presentation Outline
I. Children’s Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
About CHLA
• Founded in 1901, oldest freestanding children’s hospital in California
• By the numbers:
– 347 active beds ov...
About CHLA – Affiliations and Accolades
• The Saban Research Institute of CHLA is among the largest and most
productive pe...
Opportunities & Challenges
• Children’s Hospital Los Angeles (CHLA) was forecasting a
significant impact to financial stab...
Opportunities & Challenges
Prior to July 1st
, 2013 After July 1st,
2013
MedicaidMedicaid Medicaid Managed CareMedicaid Ma...
Presentation Outline
I. Children’s Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
9
Leveraging Change Across the Continuum
of Inpatient Care
10
Process Improvement, Accountability, and
Operational Transparency
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
Which area does your organization struggle with the most?
A. Patient Placement
B. Case Management
C. Interdisciplinary Car...
Clinical Operations Key Areas
13
Restructure 
patient flow
Clinical Operations
Patient Placement Model Changes
14
Inconsistency
Variability
BEFORE AFTER
Case by Case
Clinical Operations
Centralized
Coo...
Patient Placement Metrics
15
Time Stamp Area Responsible
Bed Request
Sending Area and/or Patient
Placement
Bed Clean Envir...
Clinical Operations Key Areas
16
Improve Care
Coordination,
Redesign
Best Practice Case Management Model
17
 Psychosocial
assessments
 Abuse, neglect, domestic
violence interventions
 Cris...
Physician Advisor Program
18
The Physician Advisor is a CHLA physician who facilitates the safe and
efficient flow of pati...
Clinical Operations Key Areas
19
Improve Care
Coordination
Interdisciplinary Care Coordination Model
20
Clinical Operations
Anticipated Date of Discharge Process
21
• Define patient-centered, team approach to align anticipated
date of discharge (...
Clinical Operations Key Areas
22
Streamline
Clinical Care
Reduce variation, decrease LOS and unnecessary resource
consumption and enhance timely care for patients
Care Variation Ma...
Appendectomy, Pneumonia, Neutropenia and Cystic Fibrosis
Workshops, Clinical Pathway Redesign and Medical Milestone
Tools
...
• Best/consensus practice
• Education - patient and staff
• Designation of appropriate metrics
• Medical, Clinical and Phy...
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
• Defined and Actionable Leadership Structure
• Patient Flow Meeting
Governance
27
Governance
Leadership Structure
28
Governance
Approval and Monitoring Process
Objective: Retrospectively review performance on key metrics and identify and address root...
Referral Process
30
Governance
Patient Flow Meeting
• Weekly meeting to promote the use of data and metrics in identifying,
monitoring, managing and impr...
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
What systems/processes have you used, or are you
considering for improving clinical operations?
1)Bed Board
2)Case Managem...
• Bed Board Optimization
• Case Management System Implementation
• Operational Metrics
• Clinical Benchmarking Data Progra...
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
Project Results
• Decreased severity-adjusted and straight length of stay
• Created the capacity to serve additional patie...
• Severity Adjusted Average LOS has decreased by 1.45 days for all
in-scope patients
• Severity Adjusted Average LOS has d...
Revenue Enhancement & Cost Savings Benefit
Clinical Ops Improvement Outcomes
Preliminary Draft Benefit Model
(Currently Be...
Medi-Cal/ Medicaid LOS Trends vs. Case Mix Index
Clinical Ops Improvement Outcomes
Updated as of March 31, 2014
39
CDI Go-...
Significant Mortality Rate Reduction since Fiscal Year 2004
Expected vs. Observed Mortality Rates
40
Expected vs. Observed Mortality Rate Continuing Favorably Trend
Updated as of March 31, 2014
41
CDI Go-Live
ClinOps Go-Liv...
Medi-Cal/ Medicaid Direct Cost Per Case % Reduction
Clinical Ops Improvement Outcomes
Updated as of March 31, 2014
42
Clinical Ops Improvement Outcomes
Average Daily Census Fiscal Year 2013 vs. 2014
43
Updated as of March 31, 2014
Clinical Ops Improvement Outcomes
Admissions Fiscal Year 2013 vs. 2014
6.3% Increase In
Admissions FY14
6.3% Increase In
A...
In addition to the strong LOS reduction, CHLA:
•Created the capacity to treat more patients which is reflected in the sign...
46
Readmission Data
46
Readmission Rates Remain Stable
Updated as of March 31, 2014
47
• LOS reduction achieved while maintaining or improving patient satisfaction
comments/scores
• How would you rate the o...
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
Critical Success Factors
1. Focusing on Quality Before Financials
2. Leadership At All Levels
3. Transparent and Consisten...
Next Steps
1. Evolution of Clinical Operations
• Service based inpatient case management
• Increased physician participati...
Presentation Outline
I. Children's Hospital Los Angeles Opportunities & Challenges
II. Transforming the Organization: Key ...
Today’s Speakers
52
Larry Burnett, R.N.
Managing Director
Huron Healthcare
Mary Dee Hacker, R.N.
Vice President, Patient C...
APPENDIX
53
Project Timeline
Project Initiatives May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
Refresh Data Analysis, Finalizing Ini...
Medi-Cal/ Medicaid Average LOS trends by severity
Clinical Ops Improvement Outcomes
Updated as of March 31, 2014
55
Medi-Cal/ Medicaid Average LOS trends by severity
Clinical Ops Improvement Outcomes
Updated as of March 31, 2014
56
Medi-Cal/ Medicaid Direct Cost Per Case trends by severity
Clinical Ops Improvement Outcomes
Updated as of March 31, 2014
...
Significant reduction in mortality rates since Fiscal Year 2004
Expected vs. Observed Mortality Rates
58
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Operationalizing Clinical Excellence: Lessons Learned

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From the CHA conference, Huron Healthcare’s Larry Burnett and Paul Kane present tactical steps toward operational excellence for children’s hospitals.

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  • Improved Access to Care: Ensures patients access the right care setting and provider at the right time to improve outcomes and maximize the use of valuable resources.
    Proactive Case Management: Proactive management of patients across the continuum driving quality and cost effective care. Strong case management reduces avoidable admissions and minimizes delays in clinical settings.
    Interdisciplinary Care Coordination: Increases communication with the care team, ensures continuity of care, provides seamless transitions for patients.
    Care Variation Management: Clinical practice redesign that improves the reliability, quality, and safety of patient care by integrating and coordinating medical, nursing, and ancillary practice while decreasing process variation.
  • Process Improvement:
    Establish consistent processes that minimize artificial variability
    Clarify individual roles and performance expectations
    Improve timeliness and effectiveness of communication (e.g., tools, key medical record inputs, policies)
  • to support bus clinicians and care managers
    to troubleshoot care variation and obstacles to throughput
    problem-solving role and advocate. very clear that this job function must be filled by a physician
  • Speak to some examples relative to units
  • Why Is this Important?
    Improve Care Team communication
    Improve Care Coordination
    Enable RN to leverage ADOD and care plan discussions to advance the progression of patients through the continuum of care
    Continue optimizing Interdisciplinary Care Coordination discussions
    Align process for integrating ADOD into daily capacity planning and staffing infrastructure
    Align ADOD processes with key metrics
    How does it work?
    Physician/Provider completes anticipates date of discharge at time of patient admission
    Bedside RN updates anticipated date of discharge during day as aligned with changes to patient plan of care and patient/family communication
  • [JIM]
  • Revenue Enhancement = Volume Increase x Contribution Margin Per Day
    Cost Savings = Payer Mix Adjusted Patient Day Reduction x Direct Variable Cost
  • 8% cost reduction on average
  • Transcript of "Operationalizing Clinical Excellence: Lessons Learned"

    1. 1. Operationalizing Clinical Excellence: Lessons Learned May 14, 2014 Speakers: •James Stein, M.D., Associate Chief of Surgery and Chief Medical Quality Officer Children’s Hospital Los Angeles •Mary Dee Hacker, R.N., Vice President, Patient Care Services, Chief Nursing Officer Children’s Hospital Los Angeles   •Larry Burnett, R.N., Managing Director Huron Healthcare •Paul Kane, Senior Director Huron Healthcare  
    2. 2. Learning Objectives • Identify keys to improving clinical operations with DRG-based reimbursement • Understand foundational strategies to support interdisciplinary communication and accountability • Understand how to measure outcomes and sustain high quality care 2
    3. 3. Presentation Outline I. Children’s Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 3
    4. 4. About CHLA • Founded in 1901, oldest freestanding children’s hospital in California • By the numbers: – 347 active beds overall – 106 pediatric critical care beds (more than any other hospital in the western U.S.) – More than 5,200 employees and nearly 600 medical staff – Average length of stay: 7.4 days • Annual statistics: – Admits 13,800 inpatients – Nearly 319,000 outpatient visits – More than 70,000 Emergency Department visits – More than 104,000 individual patients – More than16,000 pediatric surgeries performed 4
    5. 5. About CHLA – Affiliations and Accolades • The Saban Research Institute of CHLA is among the largest and most productive pediatric research centers in the Western US • One of the country’s premier teaching hospitals, CHLA is affiliated with the Keck School of Medicine of the University of Southern California • Children’s Hospital Los Angeles ranks among the top five in the nation on the U.S. News & World Report Honor Roll of children’s hospitals • Children’s Hospital Los Angeles is one of just 13 children’s hospitals to be designated a “Top Hospital” for 2013 by The Leapfrog Group • The hospital is designated a Magnet Hospital by the American Nurses Credentialing Center—an honor held by only 7 percent of hospitals nationwide 5
    6. 6. Opportunities & Challenges • Children’s Hospital Los Angeles (CHLA) was forecasting a significant impact to financial stability and needed to take immediate steps to transition to a DRG-based payment structure • The organization embarked on a significant, organization-wide transformative journey, which included major changes to care delivery processes • CHLA fully engaged all members of the care team in innovative ways, enabling them to work in a results-focused, mutually accountable, symbiotic manner, maintaining focus on the patient 6
    7. 7. Opportunities & Challenges Prior to July 1st , 2013 After July 1st, 2013 MedicaidMedicaid Medicaid Managed CareMedicaid Managed CareCommercialCommercial Percentages are based on percentage of patient days. Percentages are based on percentage of patient days. 7
    8. 8. Presentation Outline I. Children’s Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 8
    9. 9. 9 Leveraging Change Across the Continuum of Inpatient Care
    10. 10. 10 Process Improvement, Accountability, and Operational Transparency
    11. 11. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 11
    12. 12. Which area does your organization struggle with the most? A. Patient Placement B. Case Management C. Interdisciplinary Care Coordination D. Inappropriate Variation in Care Delivery E. Governance & Accountability 12 Audience Question Clinical Operations
    13. 13. Clinical Operations Key Areas 13 Restructure  patient flow Clinical Operations
    14. 14. Patient Placement Model Changes 14 Inconsistency Variability BEFORE AFTER Case by Case Clinical Operations Centralized Coordinated Measurable
    15. 15. Patient Placement Metrics 15 Time Stamp Area Responsible Bed Request Sending Area and/or Patient Placement Bed Clean Environmental Services Bed Assigned Patient Placement Patient Ready To Move Sending Area (i.e. Portals, Nursing Units, ICU, Admitting, etc.) Bed Occupied Receiving Unit Clinical Operations
    16. 16. Clinical Operations Key Areas 16 Improve Care Coordination, Redesign
    17. 17. Best Practice Case Management Model 17  Psychosocial assessments  Abuse, neglect, domestic violence interventions  Crisis interventions and counseling for issues such as bereavement and end of life  Patient/family support and conferences  Interventions to help resolve barriers to care progression and facilitate discharge  Post-hospital care referrals  Paperwork assembly/transportation arrangements  Authorizations  Clinical assessment Level of Care / Discharge Planning  Utilization Review  Case escalation / referral to resolve barriers to care progression  Discharge Planning Clinical Operations Case Manager Assistant Case Manager Assistant Case Manager Case Manager Social Worker Social WorkerPatient/ Family Patient/ Family
    18. 18. Physician Advisor Program 18 The Physician Advisor is a CHLA physician who facilitates the safe and efficient flow of patients by providing guidance to the care team Typical issues addressed by the physician advisor: • Delays in ancillary services (i.e. MRI delay), consults, discharge planning, or discharge orders • Secondary review (after Case Manager) and follow-up for non-adherence to Clinical Pathway/Care Sets • Communication challenges or disagreements amongst the care team • Guidance and planning on care issues that may be more appropriate for the outpatient setting • Payer requests for further information to authorize care or prevent denials • Participates in yellow/red census alerts and works to improve throughput during high capacity • Clarification and follow-up for the Clinical Documentation Improvement (CDI) program Clinical Operations
    19. 19. Clinical Operations Key Areas 19 Improve Care Coordination
    20. 20. Interdisciplinary Care Coordination Model 20 Clinical Operations
    21. 21. Anticipated Date of Discharge Process 21 • Define patient-centered, team approach to align anticipated date of discharge (ADOD) process with • Daily care team communication forums • Proactive communication with patient/family about their course of care, discharge plans, goals for stay/day and medical milestones • Why is this important? • How does it work? Clinical Operations
    22. 22. Clinical Operations Key Areas 22 Streamline Clinical Care
    23. 23. Reduce variation, decrease LOS and unnecessary resource consumption and enhance timely care for patients Care Variation Management 23 Clinical Operations
    24. 24. Appendectomy, Pneumonia, Neutropenia and Cystic Fibrosis Workshops, Clinical Pathway Redesign and Medical Milestone Tools Care Variation Management DRGs Selected 24 Appendectomy, Pneumonia Workshop & Re- design Appendectomy/ Pneumonia Clinical Intervention/ Go-live & Neutropenia Approvals Cystic Fibrosis Workshop Cystic Fibrosis Clinical Approvals Oct-Dec March MayAprilJan Neutropenia Initiative Education, Training and Go-live Feb Appendectomy/ Pneumonia Clinical Approvals & Neutropenia Workshop Prioritization of future CVM Initiatives June Clinical Operations
    25. 25. • Best/consensus practice • Education - patient and staff • Designation of appropriate metrics • Medical, Clinical and Physician Dashboards Care Variation Management 25 Clinical Operations
    26. 26. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 26
    27. 27. • Defined and Actionable Leadership Structure • Patient Flow Meeting Governance 27 Governance
    28. 28. Leadership Structure 28 Governance
    29. 29. Approval and Monitoring Process Objective: Retrospectively review performance on key metrics and identify and address root causes for unnecessary variation Key Impact: Optimal, reliable performance on outcome and process metrics increasingly available in the public domain 29 Governance
    30. 30. Referral Process 30 Governance
    31. 31. Patient Flow Meeting • Weekly meeting to promote the use of data and metrics in identifying, monitoring, managing and improving issues in patient flow throughout the hospital using: – Focused, structure conversation – Identification/resolution of barriers – Measurement and goal-setting • Analyze performance (PatientONTRAC™, Care Variation Management , Quality, Patient Satisfaction, Readmissions, Operational and Other Metrics) • Address patient flow barriers and discuss performance improvement activities • Set and manage to key performance indicator goals • Celebrate successes and share best practices 31 Governance
    32. 32. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 32
    33. 33. What systems/processes have you used, or are you considering for improving clinical operations? 1)Bed Board 2)Case Management System 3)Operational Metrics 4)Clinical Benchmarking Data Program 33 Audience Question Enabling Technologies
    34. 34. • Bed Board Optimization • Case Management System Implementation • Operational Metrics • Clinical Benchmarking Data Program Implemented New and Optimized Existing Technology to Improve Operations 34 Enabling Technologies
    35. 35. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 35
    36. 36. Project Results • Decreased severity-adjusted and straight length of stay • Created the capacity to serve additional patients • Continued re-enforcement of the historical decreasing mortality rate trends • Reduced overall cost per case significantly • Reduced capacity-related admission denials • Mitigated negative readmissions impact to the hospital • Improved patient satisfaction • Enhanced overall clinical operations efficiency 36
    37. 37. • Severity Adjusted Average LOS has decreased by 1.45 days for all in-scope patients • Severity Adjusted Average LOS has decreased by 1.94 days for Medi-Cal patients Clinical Ops Improvement Outcomes Estimated Range of Results 3 Month Results Annualized ConfirmedLow Mid High Average LOS Reduction (Days) 0.3 0.45 0.6 1.45 1.45 Patient Day Reduction 3,300 5,000 6,700 5,115 20,462 Updated as of March 31, 2014 37
    38. 38. Revenue Enhancement & Cost Savings Benefit Clinical Ops Improvement Outcomes Preliminary Draft Benefit Model (Currently Being Validated/Finalized) Estimated Range of Results Estimated AnnualizedLow Mid High Revenue Enhancement/ Backfill Benefit (Based on Incremental Discharges in Nov Projected to April) $5.5M $8.4M $11.3M $6.5M Dark Green (Excluding Nursing/Tech Labor) Cost Savings Benefit $6.2M Subtotal Benefit $12.7M Light Green (Nursing/Tech Labor) Cost Savings Benefit $6.6M Total Potential Benefit $19.3M Updated as of March 31, 2014 38
    39. 39. Medi-Cal/ Medicaid LOS Trends vs. Case Mix Index Clinical Ops Improvement Outcomes Updated as of March 31, 2014 39 CDI Go-Live ClinOps Go-Live Physician Advisor/CM Tool Go-Live
    40. 40. Significant Mortality Rate Reduction since Fiscal Year 2004 Expected vs. Observed Mortality Rates 40
    41. 41. Expected vs. Observed Mortality Rate Continuing Favorably Trend Updated as of March 31, 2014 41 CDI Go-Live ClinOps Go-Live Physician Advisor/CM Tool Go-Live Expected vs. Observed Mortality Rates
    42. 42. Medi-Cal/ Medicaid Direct Cost Per Case % Reduction Clinical Ops Improvement Outcomes Updated as of March 31, 2014 42
    43. 43. Clinical Ops Improvement Outcomes Average Daily Census Fiscal Year 2013 vs. 2014 43 Updated as of March 31, 2014
    44. 44. Clinical Ops Improvement Outcomes Admissions Fiscal Year 2013 vs. 2014 6.3% Increase In Admissions FY14 6.3% Increase In Admissions FY14 44 Updated as of March 31, 2014
    45. 45. In addition to the strong LOS reduction, CHLA: •Created the capacity to treat more patients which is reflected in the significant decrease in capacity related admission denials •On track for an 75% in comparison to FY 2013 Clinical Ops Improvement Outcomes 45 Updated as of March 31, 2014
    46. 46. 46 Readmission Data 46 Readmission Rates Remain Stable Updated as of March 31, 2014
    47. 47. 47 • LOS reduction achieved while maintaining or improving patient satisfaction comments/scores • How would you rate the overall teamwork between doctors, nurses, and staff? Improving the Patient Experience 47 Rating Total Responses Excellent 3152 58% Very Good 1244 23% Good 656 12% Fair 304 6% Poor 69 1% Totals 5425 100% Rating Total Responses Excellent 1754 73% Very Good 384 16% Good 166 7% Fair 69 3% Poor 22 1% Totals 2395 100% November 2011-June 2013 July 2013 – March 2014
    48. 48. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 48
    49. 49. Critical Success Factors 1. Focusing on Quality Before Financials 2. Leadership At All Levels 3. Transparent and Consistent Communications 4. Staff and Stakeholder Engagement and Buy-in 5. Strategic Investments (e.g., IT Systems, Physician Advisors, Case Management Assistants, External Implementation Expertise) 49
    50. 50. Next Steps 1. Evolution of Clinical Operations • Service based inpatient case management • Increased physician participation in care coordination rounds • Implementation of best practices in out of scope areas (NICU/Rehab) 1. Full Care Continuum Management • Ambulatory/outpatient redesign • Case management • Access • Clinic operations 1. Data Analytics and Performance Improvement Investments 2. Labor/ Staffing Management 3. Re-negotiating Contractual Arrangements 50
    51. 51. Presentation Outline I. Children's Hospital Los Angeles Opportunities & Challenges II. Transforming the Organization: Key Initiatives A. Clinical Operations B. Governance & Accountability C. Enabling Technologies III. Tracking Progress & Measuring Benefit IV. Lessons Learned V. Questions 51
    52. 52. Today’s Speakers 52 Larry Burnett, R.N. Managing Director Huron Healthcare Mary Dee Hacker, R.N. Vice President, Patient Care Services, Chief Nursing Officer Children's Hospital Los Angeles   James Stein, M.D. Associate Chief of Surgery and Chief Medical Quality Officer Children's Hospital Los Angeles   Paul Kane Senior Director Huron Healthcare
    53. 53. APPENDIX 53
    54. 54. Project Timeline Project Initiatives May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Refresh Data Analysis, Finalizing Initiatives & Reporting Metrics Develop Workplans, Team Charters and Workgroups Complete design sessions Implement Clinical Operations (CO) Management Tools & Execute on Implementation Plans Improve CO Work Process to Drive Results Monitor Realization and Sustain Value Conduct CO Training and Knowledge Transfer Implementation Timeline 12 MonthsImplementation Timeline 12 MonthsMonth CM CM CVM PP and CC CM=Case Management, CVM=Care Variation Management, PP=Patient Placement, CC = Care Coordination 54
    55. 55. Medi-Cal/ Medicaid Average LOS trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 55
    56. 56. Medi-Cal/ Medicaid Average LOS trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 56
    57. 57. Medi-Cal/ Medicaid Direct Cost Per Case trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 57
    58. 58. Significant reduction in mortality rates since Fiscal Year 2004 Expected vs. Observed Mortality Rates 58
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