Operationalizing Clinical Excellence: Lessons Learned
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Children's Hospital Los Angeles faced financial challenges under new DRG-based reimbursement and embarked on an organization-wide transformation. Key initiatives included improving clinical operations through initiatives like standardized patient placement, interdisciplinary care coordination, and reducing clinical variation. Governance was strengthened with a defined leadership structure and patient flow meetings. Enabling technologies such as an optimized bed board and case management system were implemented to improve operations. Tracking progress showed benefits like reduced length of stay, increased capacity to serve patients, continued decreasing mortality trends, and improved financial and patient satisfaction outcomes. Lessons learned emphasized focus on quality, leadership engagement, communications, and strategic technology investments.
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Operationalizing Clinical Excellence: Lessons Learned
- 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. 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. 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. 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. 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. 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. 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. 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 Leveraging Change Across the Continuum of Inpatient Care
- 10. 10 Process Improvement, Accountability, and Operational Transparency
- 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. 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. Clinical Operations Key Areas 13 Restructure patient flow Clinical Operations
- 14. Patient Placement Model Changes 14 Inconsistency Variability BEFORE AFTER Case by Case Clinical Operations Centralized Coordinated Measurable
- 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. Clinical Operations Key Areas 16 Improve Care Coordination, Redesign
- 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. 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. Clinical Operations Key Areas 19 Improve Care Coordination
- 20. Interdisciplinary Care Coordination Model 20 Clinical Operations
- 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. Clinical Operations Key Areas 22 Streamline Clinical Care
- 23. Reduce variation, decrease LOS and unnecessary resource consumption and enhance timely care for patients Care Variation Management 23 Clinical Operations
- 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. • Best/consensus practice • Education - patient and staff • Designation of appropriate metrics • Medical, Clinical and Physician Dashboards Care Variation Management 25 Clinical Operations
- 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. • Defined and Actionable Leadership Structure • Patient Flow Meeting Governance 27 Governance
- 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
- 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. 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. 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. • 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. 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. 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. • 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. 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. 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. Significant Mortality Rate Reduction since Fiscal Year 2004 Expected vs. Observed Mortality Rates 40
- 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. Medi-Cal/ Medicaid Direct Cost Per Case % Reduction Clinical Ops Improvement Outcomes Updated as of March 31, 2014 42
- 43. Clinical Ops Improvement Outcomes Average Daily Census Fiscal Year 2013 vs. 2014 43 Updated as of March 31, 2014
- 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. 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 Readmission Data 46 Readmission Rates Remain Stable Updated as of March 31, 2014
- 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. 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. 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. 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. 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. 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. APPENDIX 53
- 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. Medi-Cal/ Medicaid Average LOS trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 55
- 56. Medi-Cal/ Medicaid Average LOS trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 56
- 57. Medi-Cal/ Medicaid Direct Cost Per Case trends by severity Clinical Ops Improvement Outcomes Updated as of March 31, 2014 57
- 58. Significant reduction in mortality rates since Fiscal Year 2004 Expected vs. Observed Mortality Rates 58
Editor's Notes
- 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