a model for co-management 4-19-2011

7/29/2019 A Model for Co-Management 4-19-2011

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Presented by:

Dr. Stephen Taylor, PresidentWest Hospital Ortho Co-Management

Laurie M. Johnson, RNExecutive Director - Orthopaedics


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Total Joint Replacement (TJR) has been the

most effective treatment for advancedarthritis since the 1970s

Goal of TJR Quality Results

Relieve Pain

Restore Function

Long Lasting (>25 years)

Avoid Complications

More than 700,000 TJRs arecurrently performed each year


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INCREASING DEMAND FOR

TOTAL JOINT REPLACEMENT

Increasing senior population

Greater desire for active lifestyle

Greater acceptance of TJR bypopulation

700% increase in TJR inthe next 20 years


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INCREASED DEMAND FOR TJR

Success Requires:

1) Adequate physician supply

2) More efficient care process3) Care process must emphasize VALUE


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Reality:

Healthcare dollars spent

must be controlled and

appropriately allocated

Allocation must be determinedby value of product or service

In TJR we must maintain andimprove quality, but we mustalso control costs

VALUE IN TOTAL JOINT

REPLACEMENT


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IOWA HEALTH-DES MOINES

COMMITMENT

IH-DM committed to meet the increased patient

need for TJR

Current facilities at IMMC couldnt meet growingdemand for ORs and patient beds

MWH was designed to

emphasize orthopaedictotal joint care dedicating

4 of the 6 ORs and 50%

of the patient beds


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MWH ORTHOPAEDIC SERVICES

Focused, specialized care

Mutual project between IH-DM and

Des Moines Orthopaedic Surgeons, PCAligned incentives of both organizations

to improve QUALITY and VALUE for our

patientsCo-Management organization was

formed to manage the entire process


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WEST HOSPITAL ORTHOPAEDIC

CO-MANAGEMENT COMPANY, LLC

The WHOCC oversees the entire

orthopaedic service line at MWH

emphasizing quality, patient safety &

convenience, efficiency and

cost containment

Equal representation from IH-DM & DMOS

Medical Director from DMOS


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WHOCCMANAGEMENT

ACTIVITIES

Developcomprehensiveplan of care forall orthopaedic

patientsImplement anddirect strategic,

financial andoperational plans

Assist infacilities

management

Evaluate andrecommendequipmentpurchases

Assist indeveloping

operational andcapital budgets

Superviseand/or train

managementstaff

Develop andoversee all cost

containmentactivities


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WHOCC BUSINESS MODELExecutive Committee

Meets bi-weekly

Working committee

Includes the OrthoExecutive Director

Reports to the

Governing Board

Finance Committee

Meets quarterly

Reviews financialsand makes

recommendations

Reports to theGoverning Board

WHOCC GOVERNING BOARDOversees all committee activities

Reviews & approves meeting minutes

Makes final decisions


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CO-MANAGEMENT COMPANY

Initial project was to interview and select thefollowing key personnel:

Orthopaedic service-line Executive Director

Inpatient department Nurse Manager

Surgical Services department Nurse Manager

Physical Therapy department Manager

All personnel are employees of IH-DM


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All physicians expected

to comply at MWHNo significant exceptionsare allowed

All physicians are invitedand encouraged to

participate in the process

WHOCC TEAM REVIEWS

AND SETS ALL PROCESSES


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STANDARDIZED, UNIFORM

PROCESSES AND PROCEDURES

Rationale: Repetitive, focused process andprocedures maximizes efficiency and minimizes therisk of error or oversight.

Examples:OR nurses comfortable working with any surgeon due tostandardized draping, supplies and instructions

Nursing unit care doesnt vary by physician (common pain

management regimen, blood transfusion protocol, dressing,etc)

One standard Physical and Occupational therapy regimenfor all surgeons that can be tailored to the individual needsof each patient


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EXAMPLES OF UNIFORM PROCESSES

CREATED AND IMPLEMENTED BY WHOCC1. Pre-op medical clearance request form

2. Standardized scheduling process and form

3. Pre-op orders

4. Regional anesthesia

5. Demand matching of implants

6. Comprehensive uniform post-op orders,

including pre-emptive multi-modal painmanagement

7. Uniform activity and physical therapy goals


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WHOCC ACTIVITIES

VALUE IN TJR

New techniques, equipment and implants must

be critically evaluated by hospital and physicians

Those new techniques or implants that add cost

without significant improvement in quality should

be avoided


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Is there enoughscientific

evidence towarrant a trial?

Trial withdefined

evaluation andresults

Review bycommittee to

assessquality and

value oftechnique

Confirm ordeny use of

technique orproduct

EVALUATION OF NEW TECHNIQUES

AND SURGICAL PRODUCTS


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EVALUATION PROCESS EXAMPLES

Floseal deny (evidence didnt support) V-lock suture confirm (all use)

Participated in Draping Boot Camp tostreamline, trial and standardize surgical

drapes confirm (all use) Surgical prep (Chloraprep) confirm (all use)

Eliminated many trays by developing commoninstrument sets for all physicians by procedure confirm (all use)

Covaderm Surgical Dressing future trial

Cold therapy/DVT wrap future trial


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1. Base Management Fee

Hourly at Fair Market Value

2. Incentives Quality of service

Operational efficiency

Financial/budgetary

New program development

WHOCC PHYSICIAN COMPENSATION


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Measurable Controllable

Realistic Bound bytime limits

INCENTIVE COMPENSATION DEVELOPMENT


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2010 INCENTIVES

Quality of Service (50%)

SCIP Core Measures

Patient Satisfaction

Demand Matching

Operational Efficiency (20%)

On-time starts

OR turnaround time

Financial/Budgetary(20%)

Length of StayCost per Case

New Program

Development (10%)Expanded Patient Education


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2011 INCENTIVES

Quality of Service (50%)

SCIP Core Measures

Patient Satisfaction

Demand Matching

Financial/Budgetary(30%)

Cost per case (Goal4%)

Vendor negotiations for

spinal implants

New Program Development (20%)

Hip and Knee scoring

Infection rates (within 60 days)Readmission rate (within 30 days)

Revision rate (within 1 year)


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INCENTIVE STRUCTURE

2011 INCENTIVE FOR SCIP CORE MEASURES (15% OF TOTAL)RANGE FROM: TO: ANNUAL PAYOUT:


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1. All implants placed in category basedon technology Cemented femoral stem

Tapered non-cemented stem

Revision stem2. Each category included substantially

similar implants

3. Target price established by WHOCC

4. All vendors allowed to participate

VENDOR NEGOTIATIONS


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5. Implants that meet target price for eachcategory become preferred andpermitted to use at MWH

6. Use of outliers is strongly discouraged

7. In a few select categories competitivebidding utilized only one implant fromsingle vendor allowed

eg. Modular revision femoral stem (onevendor, one price for all components)

eg. Revision segmental hinged knee

VENDOR NEGOTIATIONS,

continued


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DEMAND MATCHING

All implants categorized by

Quality Level and Cost

A Level Lowest cost

B Level Intermediate costC Level High cost


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DEMAND MATCHING cont

Three Patient Variables Considered

1. Patient Age

2. Patient Health

3. Patient EXPECTED activity level


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(scanned copy of form here)


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DEMAND MATCHING cont

>90% Compliance expected

Results are reported by

Individual Physician

All Physicians

Transparency is a great motivator!


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WHOCC - SUMMARY

1. Aligned incentives of hospital andsurgeons that are required for success

2. Emphasis on Quality and Cost = Value

3. Recognize importance and contributionof ALL team members:Surgical Techs & Nurses Therapists

Patient Care Facilitators Patient Care Techs

Management Staff Physicians

Ultimate winners:

Patients All team members


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CO-MANAGEMENT COMPANY

OUR COMPANY

Is COMMITTED toFRESH THINKING

and

INNOVATIVE CARE

THAT ADDS


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DATA COLLECTION

Information received monthly from various systems Finance Purchasing

ORSOS Clinical Quality

Review, calculate and report Incentive Metric datamonthly to Executive Committee

Determine if there is other data outside of the metricsthat needs to be reported On-time starts, turnover times, and Average Length of Stay

(ALOS) are not part of the 2011 metrics, but continue to bemonitored monthly for significant changes

Volume and cost data from broken, lost and (not) foundinstruments in Central Sterile is reported to the ExecutiveCommittee & the staff each month

The cost of implants that are opened but unused are reported inconjunction with the demand-matching metrics


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DATA COLLECTION continued

Whenever possible, total volumes are reviewed rather than

randomized selections 100% of all total joint procedures are reviewed for correct implants

Over 90% of all eligible patients are included in the SCIP Core Measure

data review

In addition to the overall patient

satisfaction score, each physiciansscores are calculated and reported

Direct variable cost-per-case is

reported/reviewed by surgeon

All data is presented as an

overall score and also byeach physician and procedure

Transparency has been a key motivator for physician change


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QUALITY OF SERVICE 2010 GOAL2010

ACTUAL2011 GOAL

2011

CURRENT

DVT Prophylaxis within 24 hours

before/after surgery99.8% 100%

Appropriate antibiotics within

1 hour prior to surgery98.7% 99.4%

Antibiotics stopped within 24 hours

after surgery ends98.8% 100%

% of patients who are normothermic

after 15 minutes in PACUn/a n/a 85%

SCIP Overall Average 97% 99.3% 97% 96.1%

Patient Satisfaction 87 91.2 92.3 90.4

Implant Demand Matching 90% 88.7% 90% 89.2%


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NEW PROGRAM

DEVELOPMENT

2010 GOAL2010

ACTUAL

2011 GOAL2011

CURRENT

Expand Patient EducationAll total joints patients at MWH

New program written by Patient

Care Facilitatorsn/a n/a

Hip and Knee ScoringPrimary hips & knees only

n/a n/aForms have been developed,

data collection begins 5/1/2011

Infection rates (w/in 60 days)Primary hips & knees only n/a Still calculating


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AVERAGE

LENGTH OF STAY2008 2009 2010

2011

CURRENT

Primary total hip and knee

pts, commercial payers only4.17 days 3.94 days 2.81 days 2.84 days

4.17

3.94

2.81 2.84

2.5

3

3.5

4

4.5

2008 2009 2010 2011

current

2010 goal

3.45 days


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8,7038,847

8,959 8,972

8,772

8,573

8,186

7,834 7,720

7,400

7,800

8,200

8,600

9,000

9,400

2008 2009 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11

DIRECT VARIABLE

COST-PER-CASE2008 2009 2010

2011

CURRENT

2011

GOAL

Primary total hip and

knee pts, commercialpayers only

$8,703 $8.847 $8,186 $7,720 $7,939

2010 goal

$8,1962011 goal

$7,939


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SUMMARY

DO recognize that consistent, substantiated data is a key factor in

engaging the physicians and staff to achieve success DONT underestimate the value of immersing yourself in the details

DOplan to be in this for the long haul Success doesnt happen overnight

DONT hesitate to build relationships with people who can help you

The advantage of a large organization is that many people are there toassist, but you may have to search for them

DO communicate results regularly with front-line staff They will be very engaged in the process

They can have a big impact on achieving positive outcomes

DONT overlook the small successes These are most important when things are progressing slowly

DO celebrate every milestone along the way, and DONTforget to have fun!


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a model for co-management 4-19-2011

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