delivering on the vision: keys to achieving breakthrough operational performance at texas...

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

2

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.

3

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.


4

Agenda

I. Summary







VIII. Questions


5

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


6

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


Business Imperative of $50M identified

7

2011 June 2012 YTDRun Rate

2013 2014 2015 2016 2017 $(60,000)

$(40,000)

$(20,000)

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

Today's Operating Margin Gap$'s in 000

Target Operating Margin Projected Operating Margin

2013 Estimate$50 MM

Estimate higher margins will be re-quired to maintain an Aa2 rating, replenish capital and expand facili-ties

June 12 YTD $75MM

8

Agenda

I. Summary







VIII. Questions


Executive Steering Committee PROJECT GOVERNANCE – IMPLEMENTATION

9

Huron Client Services Executive

Daniel May

TCH Executive Sponsors

Susan MacDonald, EVP, RNRandy Wright, EVP & COO Project Management

TCH: Mark MullarkeyHuron: Robert Donnert

Labor

Huron: Greg BryanTCH: Lori Armstrong

Non-Labor

Huron: Dan MayTCH: John Nickens

Physician Svc

Huron: Chris SmedleyTCH: Mallory Caldwell

Clinical Ops

Huron: Larry BurnettTCH: Tabitha Rice

CDI

Huron: Gerri BergTCH: Dan DiPrisco

Executive Steering Committee

Randy Wright, EVP & COO Susan MacDonald, EVP Ben Melson, EVP & CFO Dr. Mark Kline, MD, Physician in-Chief Dr. Michael Belfort, MD, Ob/Gyn in-Chief Dr. Charles Fraser, MD Surgeon in-Chief Dr. James Versalovic, MD Pathology Dr. George S Bisset, MD Radiology Dr. Dean Andropoulos, MD AnesthesiaDr. Gordon Schutze, MD Peds Dr. Manju Monga, MD OB/Gyn Dr. David Wesson, MD SurgeryLori Armstrong, SVP & CNO Linda Aldred, SVP HR Mallory Caldwell, SVP StrategyMary Jo Andre, VP Quality John Nickens, VP Supply & Hosp Based Tabitha Rice, VPMichelle Riley-Brown, SVP West Cris Daskevich, SVP Women’s Pavilion Alec King, VP FinanceSherry Fultz, AVP Mark Mullarkey, SVP Ambulatory & OR Matt Girotto, AVP Surgical ServicesChanda Cashen, AVP OB/Gyn Diane Scardino, AVP Medical Practice

© 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential.© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential.

Executive Steering Committee PROJECT GOVERNANCE – WORK TEAMS

10

LaborSolution Team

Huron: Greg BryanHuron: Irene WalshTCH: Lori ArmstrongTCH: M. Riley-Brown

Coord: L. Toures

Non-LaborSolution Team

Huron: Dan MayHuron: P. ZimmermanTCH: John NickensTCH: D. ScardinoTCH: Dr. D. Roth Coord: J. Estes

Physician SvcSolution Team

Huron: C. SmedleyTCH: Mallory Caldwell

TCH: T. JohnsonMD Leaders:

Dr. Shutze, Dr. Wesson, Dr. MongaCoord: M. Wilrich

Clinical OpsSolution Team

Huron: Larry BurnettHuron: Brad StaterTCH: Tabitha Rice

TCH: G. ParazynskiCoord: G. Erwin

CDISolution Team

Huron: Gerri BergHuron: S ManierreTCH: Dan DiPrisco

Coord: J. Austin

Nursing Work Team

Pharmacy Work Team

Lab Work Team

Surgical Work Team

PediatricsWork Team

OB/GynWork Team

SurgeryWork Team

Case Management Work Team

Patient Placement

Work Team

Care Coordination Work Team

Care Variation

Work Team

Physician Education Work Team

Coding – Reconciliation

Work Team

Cath Lab Work Team

Surgical Work Team

Non-Clinical Work Team

Food/EVSWork Team

Nursing Work Team

Perioperative Work Team

Corporate Work Team

Clinical Ancillary

Work Team

Support Services

Work Team


11

Agenda

I. Summary







VIII. Questions


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.

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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

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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

Annualized Total $43,847,500 $60,175,650 $76,038,800

Total Opportunity Identified from Assessment


15

Agenda

I. Summary



IV. Transforming the Organization: Key InitiativesI. Non-LaborII. LaborIII. Clinical DocumentationIV. Clinical OperationsV. Physician Services



VII. Lessons Learned© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential.

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

16© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential.

17

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


Non-Labor Opportunity Identified


18

Agenda

I. Summary







LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

AREA LOW MIDPOINT HIGH

Nursing $2,326,000 $3,757,500 $5,189,000Clinical Ancillary $2,720,000 $4,025,500 $5,331,000Non-Clinical Support $1,825,000 $2,727,000 $3,629,000Administrative/Financial $1,541,000 $1,787,000 $2,033,000Annualized Total $8,412,000 $12,297,000 $16,182,000

Labor Opportunity Identified

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Strengths Management is open and supportive of change and improvement Quality of talent is strong Passionate about Texas Children’s HospitalOpportunities 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


Dollars Total Main Campus Pavilion West Campus

Key Operational Areas Low High Low High 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

Financial/Administrative $1,541,000 $2,033,000 $1,541,000 $2,033,000 $0 $0 $0 $0

TOTAL $8,412,000 $16,182,000 $6,484,000 $13,769,000 $854,000 $1,110,000 $1,074,000 $1,303,000

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

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Labor Opportunity by Facility


Flexing Staffing to DemandKEY IMPLEMENTATION APPROACH

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Note: R2 of 1.0 indicates the regression line perfectly fits the data

Flexing Staffing to Volume

Volume to staffing regression correlations indicate 77% of patient care units are not flexing efficiently to census

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Agenda

I. Summary







23

CLINICAL DOCUMENTATION IMPROVEMENT - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY


Improved Reimbursement After CDI $6,772,500 $9,030,000 $11,287,500


Clinical Documentation Improvement Opportunity

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 APR-

DRGs Coding opportunities were found that would affect severity of illness and risk of mortality

which would increase the case mix index (CMI)


Case Review CLINICAL DOCUMENTATION IMPROVEMENT

24

Total Charges of the 75 Charts

TCH’sReimbursement

at Current Rate of 36% of Charges

TCH’s Reimbursement at

APR-DRGRate

Improved Reimbursement (APR-

DRG) After Implementation

Incremental Change With Improved Documentation

$ 7,316,055 $2,633,781 $2,403,722 $3,191,981 $788,259

The following summary provides the results of an analysis conducted on 75 cases reviewed during the assessment:


25

Agenda

I. Summary







26

CLINICAL OPERATIONS - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY


Annual Length of Stay Benefit $5,900,000 $9,350,000 $12,800,000

Clinical Operations Assessment Opportunity

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.


Length of Stay Opportunity

Append

ectom

y

Post-O

p, Post

-Traumatic

, Othe

r Dev

ice Inf

ectio

ns

Cardiac

Valve P

rocedu

res with

out Card

iac Cath

Malnutri

tion, F

ailure

to Thriv

e & oth

er Nutir

itiona

l Diso

rders

Seizure

Cardiac

Defibrilla

tor & Hear

t Ass

ist Im

plant

Craniot

omy,

except

for Trau

ma

Cardiac

Cath with

Circula

tory Diso

rder

excep

t for Is

chemic H

eart D

isease

Proced

ure with

Diagnos

is, Reh

ab, After

care o

r Othe

r Cont

act with

Heath S

ervice

Other H

epatob

iliary,

Pancrea

s & Abdo

minal P

rocedu

res05

101520253035404550

Opportunity Days: 920

Volume: 891

Opportunity Days: 728Volume: 200



Opportunity Days: 512 Volume: 698




Opportunity Days: 303 Volume: 27


Average Length of Stay for Top 10 APR-DRGs

BenchmarkTCH

Aver

age

Leng

th o

f Sta

y (D

ays)

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)

MAIN CAMPUS

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> 0 to < 2 Days 2 to < 4 Days 4 to < 6 Days 6 to < 11 Days 11 to < 20 Days 20+ Days0%

10%

20%

30%

40%

50%

60%

49%

20%

10% 10%6% 5%

Excess Days Variance over Benchmark Length of Stay

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)

Length of Stay OpportunityMAIN CAMPUS

35% of TCH patients have excess days. The delineation of those patients by number of excess days is outlined below.

40% of cases have a variance of 2 to 11 days

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Length of Stay Benefit Opportunity

Demand Backfill

Percentage

Cost Savings

Percentage

Backfill(Number of

Cases)

Patient Days Reduction

(Associated with Cost Savings)

OpportunityLow

OpportunityHigh

50% 50% 700 3,600 $5.9 M $12.8 M

60% 40% 800 3,000 $8.3 M $17.7 M

70% 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

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

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

MAIN CAMPUS

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30

Agenda

I. Summary







PHYSICIAN SERVICES - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY


Clinical Efficiency $15,000,000 $20,000,000 $25,000,000

Non-Provider Labor (1) $ 433,000 $ 651,150 $ 869,300


Physician Services Opportunity

31

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


Clinical Efficiency

DepartmentNumber of

Physicians in analysis

Total FTEs Clinical FTEs

New full time FTES (hired

After 7/1/2011)Total wRVUs Annualized

wRVU Gap to Sullivan

Cotter FTE adjusted Median

Potential Net Collections to Sullivan Cotter

Median

wRVU Gap to FPSC FTE Adjusted Median

Potential Net Collections to FPSCr 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

Total 822 687.67 441.50 102.60 2,116,894 540,464 $29,968,505 928,617 $55,784,846

32

* 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


33

Agenda

I. Summary







VIII. Questions


ACTIVITIES

DELIVERA

BLES

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

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

Work steps completed for high priority initiatives 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

Develop Initiatives

Months 1 - 3

Implement Initiatives

Months 3 - 12

Monitor Benefits

Months 9 – 12+

Timeline

34

Knowledge Transfer, Empower Management and Drive Accountability


35

Delivering on the Vision Project Scorecard

Area Savings Timeline Issues

Non Labor

Labor

Clinical Documentation

Clinical Operations

Physician Services

Project Scorecard - Example

Proceeding as planned At risk for trending off plan Require immediate attention


Non-Labor Project Scorecard (partial example)

36

Key Updates

Status Summary Issues/Barriers

Action/ Next Steps

Non-Labor Monitored initiatives at a confirmed value of $13M All teams working to complete implementation and

monitoring of remaining initiatives

None None

Purchased Services

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


Proceeding as planned At risk for trending off plan Require immediate attention

37

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


38

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


Benefit Scorecard – Overall Project (as of 09/ 2013)

39

• Clinical Documentation tracking begins in 10/2013 following Medicaid APR-DRGs start in TX on 9/1/13

Solution Group Target Benefits

Identified Benefits

Implemented Benefits

Realized Benefits

FY 13 YTD

Non-Labor $8,847,500 $17,786,447 $14,011,071 $7,558,869

Labor $12,297,000 $13,725,177 $9,382,125 $5,276,000 Clinical Doc. $9,030,000 $9,030,000 $ TBD $ TBDPhysician Services $20,651,150 $14,263,000 $9,540,200 $8,089,000 Clinical Operations $9,350,000 $9,350,000 $11,874,500 $11,874,500

LOS Reduction (Days) 7250 7250 10,560 10,560

Total $60,175,650 $64,154,624 $44,807,896 $32,789,369

% of Target 107% 72% 52%


Labor – FTE’s


Labor – Salary & Benefit as % of NPSR

41

• Net Patient Service Revenue is up 11.9%

• Salary and Benefit Expense is up just

5.9%


Labor – Control of Temp Expense


Estimated Financial ImpactACTUAL PAYROLL DATA VS FY13 BUDGET

43

Notes: In scope labor depts only; Dollars estimated based on avg wage rate per dept and include a 15% benefit factor

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


Project Results:Clinical Operations Realization Schedule

44Confidential.

Projected Annual Benefit includes:

+ Demand Backfill

+ Cost Savings

– Revenue Loss

45

Physician Services

Updated as of 7.17.13

Specialty

Not Started

In Process Past Due Complete Total

Not Started

In Process

Past Due Complete

OBG BCM 1 4 0 6 11 9% 36% 0% 55%POGC/WSH 5 5 0 5 15 33% 33% 0% 33%OBG MFM 0 5 0 8 13 0% 38% 0% 62%

A&I 0 1 0 7 8 0% 13% 0% 88%ADO 2 1 2 10 15 13% 7% 13% 67%AGP 0 0 0 0 0CAR 0 4 0 9 13 0% 31% 0% 69%DER 5 0 0 7 12 42% 0% 0% 58%DEV 0 0 0 0 0END 10 10 0 1 21 48% 48% 0% 5%

HEM/ONC 0 6 0 6 12 0% 50% 0% 50%INF 0 0 0 0 0NEP 0 0 2 14 16 0% 0% 13% 88%NEU 0 1 1 12 14 0% 7% 7% 86%NGI 0 0 2 12 14 0% 0% 14% 86%PMR 0 0 0 0 0PSY 0 0 0 0 0PUL 0 5 0 6 11 0% 45% 0% 55%RHE 0 4 0 3 7 0% 57% 0% 43%CHS 0 5 0 0 5 0% 100% 0% 0%NSU 0 0 0 6 6 0% 0% 0% 100%OPH 10 0 0 0 10 100% 0% 0% 0%ORT 0 3 3 10 16 0% 19% 19% 63%OTO 1 4 0 9 14 7% 29% 0% 64%PLA 3 0 1 4 8 38% 0% 13% 50%PSU 0 3 0 11 14 0% 21% 0% 79%

SYSTEM WIDE 1 12 2 16 31 3% 39% 6% 52%TOTALS 38 73 13 162 286 13% 26% 5% 57%

Overall%AGES COMPLETE

OverallCOUNTS


Access - 3rd Available

Specialties Tracked and Included:Renal Neurology Genetics Development Pedi Physical Medicine Clinic Psychology Service Plastic Surgery Dental Rheumatology Orthopaedics Pediatric Surgery Congenital Heart Surgery Allergy & Immunology Urology Retrovirology Dermatology Endocrine Ophthalmology Orthodontics Cardiology GI & Nutrition Pulmonary Medicine Res. Primary Care Hematology/Oncology Otolaryngology Psychiatry - 17O NeurosurgeryAdol/Sports/Med/Yng Womens Gynecology Inf. Disease


Internal Texas Children’s Pediatrics Referral Rate



TCH: Mid-Project Experience Survey Results

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

Year End Goal

Net Days Saved

7,250 5,531

Patient Day

Accumulation

for Project Period

(Nov-May FY13)

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

76%

of goal

7,250

5,531

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)

Results at a Glance …

Most Recent Three-Month Period (Mar-May ’13)

vs. Historic Period (June ’11-May ‘12) 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

“It's incredible when I think about the results

we've had recently…it is making a big

difference.”

-Executive Leadership

Delivering on the Vision:

Care Process Updates

Key Accomplishments to Date

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“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

“[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

Clinical Operations Update - June 2013

Clinical Documentation Initiative – Main CampusBASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION


Clinical Documentation Initiative - West CampusBASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION


Business Imperative of $50M identified

51

2011 June 2012 YTDRun Rate

2013 2014 2015 2016 2017 $(60,000)

$(40,000)

$(20,000)

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

Today's Operating Margin Gap$'s in 000

Target Operating Margin Projected Operating Margin

2013 Estimate$50 MM

Estimate higher margins will be required to maintain an Aa2 rating, replenish capital and expand facilities

June 12 YTD $75MM

For the 11 months ended August, the Hospital had an operating margin of $55.8M on a budget of $37.9M. Hospital operating margins

have improved from the prior year by $72.7M.

52

Agenda

I. Summary







VIII. Questions


53

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


54

Agenda

I. Summary







VIII. Questions


“Leadership always impacts and influences outcomes, not some of the time, but all of the time.”

© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 55

Labor

Clinical DocumentationClinical Operations

Physician Services

Non-Labor

Lori Armstrong, MSN, RN

CNO, SVP

Michelle Riley-Brown

SVP

TCH West Campus

John Nickens

VP

Hospital Based Services and

Supply Chain

Diane Scardino

AVP

Ambulatory Servcies

Tabitha Rice

SVP

Clinical Support Services

Jackie Ward, RN

Director

Cancer Center

Joan Shook, MD

Chief Safety Officer

Dan Diprisco

Director

Physician Revenue Cycle

Trent Johnson

Director

Ambulatory Services

Mallory Caldwell

SVP Strategy

But it takes a team…..a very large team!

56

Dr. Jordan Orange

Kim Nguyen

Mari Trace

Dr. Peter Hiatt

Dr. Charles Gay

Dr. Gary Clark

Dr. Robert Zeller

Tuhin Pakaj

Dr. Thomas Luerssen

Lorraine Cogan

Ryan Breaux

Dr. David Coats

Dr. William Phillips

Binta Baudy

Dr. David Roth

Dr. Ellen Friedman

Dr. Al Hergendroeder

Mary Kana

Dr. Jed Nuchtern

Cindy Miley

Dr. Michael Braun

Sandra Tillis

Helen Currier

Tina Ninan

Dr. Jennifer Deitrich

Dr. Gordon Schutze

Dr. Ryan HimesKara Lenahan

Stephanie Ramirez

Dr. Jake Kushner Dr. Angelo Giardino

Matt GirottoLaura Hardy

Diane Scardino

Trent Johnson

Chanda Cashen

Dr. Monju Monga

John Henderson

Mike Towne

Sherry FultzDr. Carol Altman

Sarah McMaster

Matt Timmons

Dr. Daniel Penny Jackie Ward

Dr. Brigetta Meuller

Physicia

n Service

sRobert Turner

Jennifer Upshaw

Dan Diprisco

Travis Crum

Daniel Fischer

Jeff Reinhart

Dr. Efrain Bleiberg

Dr. Doug Ris

Jennifer Evans

Barkha Chandwani

Dr. Theresa Wright

Dr. Thomas Shaw

Dr. Scott Dorfman

57

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”


58

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


59

Agenda

I. Summary







VIII. Questions


60

Today’s Presenters

Mark Mullarkey

Senior Vice President

Texas Children’s Hospital

[email protected]

1-832-824-1262

Dan May

Managing Director

Huron Healthcare

[email protected]

678-576-0408


delivering on the vision: keys to achieving breakthrough operational performance at texas...

Health & Medicine

scardino tch

tch team

zimmerman tch

huron consulting group

lori armstrong tch

mallory caldwell tch

john nickens tch

greg bryan tch