HFMA Presentation March 31 2014

© 2015, MedAssets, Inc. All rights reserved. MedAssets®. Not to be reprinted without permission. For non-commercial use ONLY.
Financial Impact of Quality,
Safety and Reliability
Efforts in a Healthcare
Organization
Rick Beaver, Lean Healthcare Consulting, MedAssets
Healthcare Financial Management Association
Texas Chapter Meeting
March 31, 2015

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All About
MedAssets

3
MedAssets is a healthcare performance improvement company focused
on helping providers realize financial and operational gains.
Offerings: Cost and clinical resource management; purchasing and
revenue cycle solutions; change management consulting; embedded
management and process improvement services; and data and analytics
tools
Clients: Serves four out of five U.S. hospitals: 4,500 hospitals and 123,000
non-acute healthcare providers, as well as payers and healthcare
information technology vendors
Reach: Manages on behalf of clients more than $59 billion in total spend,
$2.5 billion in labor expense and $400 billion in gross revenue
Employees: 3,200 employees and 15 office locations
Headquarters: Alpharetta, Ga.

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• In a perversion of the fee-for-service system, hospitals fared
better financially when patients needed follow-up care after an
error occurred.
• A hospital was encouraged by the payment system to harm a
patient just enough without killing him or her and perform
some additional services, for which it received additional
payments.
• Not much incentive to improve care or save Medicare money.
• Of course, no hospital’s leadership consciously decided to
hurt patients to make more money, but the system did not
encourage and reward better and more efficient care.
Journal of Health Care Finance, Vol. 39, No. 1, Fall 2012, published by Wolters
Kluwer Law & Business
The Economics of Health Care Quality and Medical Errors

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• Allegedly, from 2001 to early 2009, Syracuse basketball
Coach Jim Boeheim did not follow the written drug-testing
policies as required by the NCAA.
• THE EXCUSE:
Athletics director Daryl Gross admitted they didn't follow the
policy and said:
"The department followed an 'unwritten
policy' because the written policy was
confusing.“
USA Today News, March 7, 2015
Adherence to Procedure (Sports Team)

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Adherence to Procedure (Health System)
“Our procedures reflected the most recent Central Line Infection
prevention strategies”, i.e.:
• Minimize use of femoral vein
• Maximal barrier protection during insertion
• Scrub or protect the hub
• Change the dressing if breached
• We didn’t follow our procedure because “we were missing the
how to implement, measure compliance and sustain
adherence to Procedure”.
• Dressings only changed on Monday,
regardless of condition
• Procedure said scrub the hub but they
used Curos™ caps
• Everyone had their own interpretation of
“the policy”

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It’s interesting that a sports team today is being held to a
higher level of accountability for not following established
procedure when we continue to experience patient harm
as a direct result of not following established harm
prevention strategies!

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• The Centers for Medicare & Medicaid Services (CMS)
has for the first time will stop reimbursing hospitals for
three major problems
1) Preventable Readmissions
2) Low Performing Value Based Performance and Patient
Experience Metrics
3) Health Care Facility Acquired Conditions
Journal of Health Care Finance, Vol. 39, No. 1, Fall 2012, published by
Wolters Kluwer Law & Business

9
What is CMS’ Excess Readmissions Program?
• Congress authorized CMS to reduce the reimbursement of
over 3,000 hospitals in the Affordable Care Act to reinforce
improving healthcare quality, including the patient experience
and efficiency.
• Hospitals have an incentive to reduce excess readmissions
and avoid a penalty of up to 3% of its entire annual Base
Operating DRG Reimbursement as with VBP.
• Hospitals with readmissions on selected disease states greater
than expected will get a graduated penalty of up to 3%.

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What is CMS’ Healthcare Acquired Conditions (HAC)
Penalty Program?
• Congress authorized CMS to reduce the reimbursement of over
3,000 hospitals in the Affordable Care Act to reinforce improving
healthcare quality, including the patient experience and efficiency.
• Hospitals have an incentive to reduce the number of HAC
incidences to avoid a penalty of 1% of its entire annual Base
Operating DRG Reimbursement as with VBP. The top 25%
(Worst) of hospitals will be penalized the full 1%.
• This program is to encourage hospitals to eliminate the incidence
of HACs that could be reasonably prevented by applying
evidence-based strategies.

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VBP Rewards or Penalties Increase Annually

12

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Texas Health System - Projected to Lose 50% of the total
losses projected for all acute care hospitals in their city
eligible for VBP.
$2.457M lost in reimbursement from CMS VBP, Readmissions,
and HACs with $837,000 in excess cost from HACs in ICU
events.
Lost incentives results = $1.3M in addition to the costs and
penalties.

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• Health care leaders are focusing on quality and patient safety
in ways they never have before because the economics of
quality have changed substantially.
• However: Health reform legislation does not require hospitals
to implement comprehensive quality improvement and patient
safety programs
• Improvement programs involving Lean or Six Sigma have had
a significant affect at Intermountain Healthcare, Advocate
Good Samaritan Hospital, Poudre Valley Health System, and
the University of Illinois at Chicago Medical Center
Real improvement in care of patients begins today

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Harm Prevention: Strategies vs Practice
It was noted in the August, 2014 issue of Infection Control Today
digital issue that:
“Despite advancements in HAI prevention strategies, there are still
persistent gaps between Recommendations and Practice.”
“We heard loud and clear that facilities need practical guidance into
how to implement the infection prevention strategies, references and
materials about the implementation science behind preventing
Hospital Acquired Infections.”
MedAssets consultants provides the “HOW” to implement the
strategies that have been in publication for years.
Let’s talk about improvement in patient care

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The MedAssets strategy for prevention of healthcare-
associated infection involves a Playbook to Implement Harm
Prevention strategies and a Management Systems “bundle” to
sustain gains achieved
Adding a Management Systems strategy provides critical
guidance to physicians, clinical managers, and hospital leaders
as they work to prevent healthcare-associated infections.

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MedAssets Playbook: Strategy & Practice
• Most organizations have the Harm Prevention key strategies
(IHI, ICT, APIC etc.) in place within their procedures.
• Without an Implementation approach (MedAssets Playbook i.e.)
improvements are not achieved
• Without “Management Systems”, improvements achieved are
not sustained.
• The approach:
– Prioritize the solutions
– Playbook implementation of the key solution strategies
– Build a “Management System” to sustain the improvements gained
– Utilize Operations Score Boards (Linked to C-Suite goals)
– Supported by Leadership rounding (Gemba Walks)

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MedAssets Playbook: Prioritize the Solutions
• Relative to CLABSI Prevention:
– A focus on Dressing, Hub and Flush Compliance eliminates ~ 90+% of
CLAB Infections
By addressing compliance to Dressing
remaining in-tact, hubs clean before access
and line flushes are completed, 90+% of
CLABSI is eliminated

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MedAssets Playbook: Implement Key Strategies
• 80:20 Rule (Dressing, Hub and Flush Protocol Compliance)
• Nursing Units Complete Daily Audits
– Audits conducted by any personnel including charge nurse, unit clerk etc
– Follow-up Audits support unit audits (IC specialist, Q staff, unit manager)
• Audit Process
– ICU’s conduct an audit of dressing, flush and hub cleaning compliance
– ICU & MICU: 4x per day on each patient with an indwelling central line
– In-Patient Unit: 2x per day on each patient with an indwelling central line
– Results entered into database with auto-graph generation
– Results shared daily in nurse huddles (2 minutes)
– Results reviewed and discussed by leaders
– Management Systems rounding occurs to discuss results with staff

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MedAssets Playbook: Implement Daily Metrics
• Daily Metrics taken by operations
• Results Shared daily with staff
• Leader rounding needed for
sustainment of gains achieved

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CLABSI Trending (pre and post)
• Statistically significant improvement in CLABSI rate across 5 hospitals
achieved immediately. From start of work, ZERO CLABSI
• MedAssets process approach demonstrated the effectiveness of the
CLABSI elimination process
• Next steps (The other 10%): Evaluate ability to sustain gains
• Work with physicians to achieve 100% insertion technique
• Address long indwelling lines and poor site selection

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VBP Metric Trending (pre and post engagement)
• Statistically significant improvement in VTE-2 metric
• MedAssets process approach demonstrated the effectiveness of
our approach to strategy implementation

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• Statistically significant improvement SCIP-2 Metric
• MedAssets process approach demonstrated the effectiveness of a
specific implementation plan

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• Statistically significant improvement in SCIP-9 Foley Removal Metric
• Positively affects the prevention of Urinary Tract Infection (UTI)

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Urinary Tract Infection (UTI) Trending (pre and post)
• UTI rate significantly improved as a result of SCIP-9, early removal
of Foley Catheter, metric improvement
• Led to development of a Medical Patient Foley Removal protocol
and additional UTI reduction

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CLABSI Trending and Management Systems
• “Management Systems needed to Sustain Gains”
• Ability to “recover” by following Playbook Sustainment Plan
• 3 of 4 CLABSI’s related
to site selection

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Some hospitals get it right and sustain the gains without added
support

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• Never previously achieved 5 months at ZERO CLABSI
• Using In-Depth Root Cause Analysis, determined the 1
infection in December caused by the “Final 10%”
• It’s easy to investigate 1 infection in 6 months

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• Demonstrated early improvement but returned to previous levels
• Hospital lacked the leadership follow-up, i.e. Manage to the Measure,
approach to sustaining gains

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Management Systems Sustain Results
Lean Management Core Skills
• Visual Management Controls
• Playbook for Strategy Implementation
• Leadership Standard Work
• Daily Accountability Mechanisms
• Disciplined Adherence To Process
• Root Cause Problem Solving
How do you
sustain your
improvements

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Lean Approach – Reduce Nurse Time
Required to Manage Central Lines
Use best dressing product on all Central Lines (CL)
Common dressing placed on all lines prevents nurse accessing the site
upon admission, thereby reducing infection risk
• Previously, all lines had non-compliant dressings at insertion
• Caused unit nurses to change the dressing on every CL patient
Best available dressing product can last on average 5 days
• Old dressing used had a life of
about 1-3 days
• Significantly reduces infection risk
• Reduces nursing hours to manage
dressings
In addition to Harm Elimination, a
Lean-Six Sigma Approach to Process
Improvement Provides Added Gains

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IJ Line Needing Line Securement
32

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Assurance of an Intact Dressing
No rolled
edges opening
to the
insertion site
Dressing not
wet or soiled
Occlusive around
lumens with no
large openings
Hair clipped away
from dressing site
INCLUDING
whiskers!

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Improved Dressing Product
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Withstands 8 Pounds Pulling Force
Reduces Nurse Time to Manage Dressing***
Should be Used on All Lines @ Time of Insertion

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MedAssets’ Quality, Safety, Reliability, and
Patient Satisfaction Assessment Solution
• Unique and proprietary consulting solution
• Finds even more important measures than just the Value-
based Purchasing measures used by CMS
• Intense assessment and onsite root cause analysis to patient
outcome issues
• Includes a strategic in-depth voice of the patient and
stakeholder analysis.

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Value-Based Purchasing Executive Summary
FY2017 Pro Forma
Hospital System # XXXX

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FY17 Outcomes Target Improvement Areas
Hospital System XX
$728K additional savings beyond VBP by reducing CLABSI 100%,
CAUTI 50%, and SSIs by 50%.

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Qualifying Questions to See Need for QSR
1. Need to prevent Harm and Death? Of course – everyone does.
a) Must improve quality, safety, reliability and/or patient experience
b) Reduce readmissions and cost
c) And, continuously improve - CMS Reimbursement reduced in Value-Based Purchasing
d) Department of Health requests/requires outside unbiased experts
2. Leaders want to design-in reliability of the processes vs. react to failure?
3. Want more value from the Quality Department?
a) Tired of waste of auditing and inspection – want prevention and value from this team as in High
Reliability Organizations (HROs)
4. Leadership wants to go to the next level of performance improvement?
5. How much are you losing in patients and reimbursement due to quality?

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Preventing Death and Harm - Reliability Solutions Model
Recovered $3.2 Million in Future Unreimbursed Revenue through Harm
Prevention and Elimination

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Neighbor went for cataract surgery. Private Surgeon Surgery Center had
one room on the right side of the hall for only surgeries on right eyes.
Same for left eye surgeries in the room on the left side of the hall.
This center is designed to “fly”.
By: John J. Nance, JD

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Summary
• MedAssets Harm Prevention Playbook an effective approach to
implementing proven strategies
• Critical component of sustaining gains is deploying a Management
Systems structure to sustain improvement beyond the engagement
• Hospitals have achieved improvement and in some cases
elimination of harm
– At several hospitals, reinforcing the Sustainment Plan was required
• Lean Healthcare approach also improves the supporting processes
to minimize cost and staff time
For more information about the MedAssets Harm Prevention approaches,
contact: rbeaver@medassets.com

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Every organization needs higher
reliability to prevent harm

HFMA Presentation March 31 2014

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