Healthcare Performance and Measurement Tools
Tom Knoebber
Mission Hospitals
Asheville, North Carolina
POEPursuit of Excellence
DMAICDefineMeasureAnalyzeImproveControl
FOCUS PDCAFindOrganizeClarifyUnderstand
SelectPDCA
PDCA -Plan Do Check Act
12 Step6 Step
Quality
Circles
6 Sigma
“If you don’t know where your going… How will you know when you get
there”
“If you don’t know where you are… How will you know when you’ve left “
“If you don’t measure it... You can’t improve it “
Patients / Community
Departments / Employees
Vision / Strategic Plan Translation & Prioritization
Measures
Voice of the Customer
CommunicationBoard / Leadership
Implementation
Evaluation
What Are The Issues Driving Strategic Planning & Direction ?
•Financial ImpactCosts, Utilization
•Patient/ Consumer Satisfaction Leap Frog, CMS
•SafetyIOM
•LaborShortages
Defining Quality and Efficiency ?
7 Types of WasteOverproduction, Inventory, TransportationWaiting, Excess Processing, Wasted Motion,Defects
IHI - Overuse, Underuse, Misuse
The 5 S’s (Toyota Model - Lean)Sort, Straighten, Shine, Standardize, Sustain
Project Based
Workload
Opportunities
Teams ~ Re-Engineering ~
Process Improvement ~Focused Reviews ~
Education and Facilitation etc...
Data & Information Measurement
Prioritizing System Initiatives and Focus Reporting and MonitoringCharter, Scope and Plan
Review and Verify (GOYA) Focused Data Collection and Analysis
Theories and Testing
Identification and Facilitation
Implementation
Find &Organize
Clarify & Understand
Select
PDCA
Measurement and Analysis
1. Individual Experience
2. Group Experience
3. Graphical Presentation of Observed
4. Statistical Interpretation of Observed
5. Graphical Interpretation of Experiments
6. Statistical Interpretation of Experiments
Cool Tools !!!“Finding” & “Organizing” Opportunity
Surveys - Voice of the CustomerControl Charts - Variation
Special & Common CauseBenchmarkingCharter / Scope Gantt Charts
Cool Tools !!! “Clarifying” & “Understanding”
BrainstormingCause & EffectFlow DiagramsData Collection
Discreet & ContinuousPareto & Histograms & Scatter PlotsStatistical Analysis
ANOVA,Correlation / Regression, Chi Square
Cool Tools !!!“Implementation”
Flow Diagrams (Process Design)FMEA (Prevention)Control Charts
Readmission Reduction
An example
Memorial Mission Hospital, Inc.Mission and St. Joseph's Campuses
Key Internal Process Performance Indicators
Safety - Unplanned Returns to the OR
Effective - Unplanned Readmission's
Timely - Average Length of Stay (ALOS)
0.0
1.0
2.0
3.0
4.0
Oct-Dec 99 Jan-Mar 00 Apr-Jun 00 Jul-Sept 00 Oct-Dec 00 Jan-Mar 01 Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02
Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Safety - Unplanned Returns to OR
0.01.02.03.04.05.06.07.08.09.0
Oct-Dec 99 Jan-Mar 00 Apr-Jun 00 Jul-Sept 00 Oct-Dec 00 Jan-Mar 01 Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Effective - Unplanned Readmission's < 31 Days
3.0
3.5
4.0
4.5
5.0
5.5
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Target (Fixed Budget FY03) Average Length of Stay FY01 Average Length of Stay FY02 Average Length of Stay FY03
Strategic Performance Panel - Dashboard
Unplanned Readmission's within 31 Days
6.455.76 5.97 6.06 6.24 6.29 6.13 5.84 5.74 5.56
10.009.31
0.01.02.03.04.05.06.07.08.09.0
10.011.012.0
Apr-Jun 01 Jul-Sept 01 Oct-Dec 01 Jan-Mar 02 Apr-Jun 02 Jul-Sept 02 Oct-Dec 02 Jan-Mar 03 Apr-Jun 03 Jul-Sept 03 Oct-Dec 03 Jan-Mar 04
Target (75th Percentile)* Target (50th Percentile)* Target (25th Percentile)* Effective - Unplanned Readmission's < 31 Days
Data source changed to reflect Premier actual vs expected rate
Find & Organize - Charter
Problem Statement: Our readmission rate for the MSJ system is 8.01% for the quarter ending 6/00 this represents a quarterly volume of 737 readmission's on 9,198 Discharges (-deaths). This rate is above the 75th percentile of our benchmark peer group. Our current average cost per case for patients being readmitted to the hospital is $5,507. Business Case: For each readmitted patient, reimbursement is reduced or non-existent. Patients who are readmitted occupy bed space that could otherwise be used for patients with a more acute need, Patient who are readmitted due to a failure on our part will have reduced satisfaction that could lead to reduced market share in the region. Prevention of readmission's will improve utilization and reduce costs.
Tips: Defined Business Case, Scope & Boundaries, Champion & Owner, Quantifiable
Clarifying and Understanding - Readmission Rate by Service Line (% of DCs)
15%
12%
4%
9%
4%
23%
7%
8%
10%
8%
Amed
Hsvcs
Woms
Surg
Peds
Onc
Ortho
Neuro
Urol
Trauma
44%
6%
6%
6%
6%
5%
4%
20%
2% 1%
Amed
Hsvcs
Woms
Surg
Peds
Onc
Ortho
Neuro
Urol
Trauma
Clarifying and Understanding -Readmission Volume by Service Line
UNSCHEDULED INPATIENT READMISSIONSFOR ADULT MEDICINE AND HEART SERVICES
FOR APR-JUNE, 2000
37811121617192124313143103
117
99%98%96%94%91%88%84%
80%75%
70%63%
57%
48%25%
0
58
116
174
232
290
348
406
NU
MB
ER O
F PA
TIE
NT
S
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
n=463
Clarifying and Understanding -Analysis of Cause Pareto
Quick ImprovementsOutpatient CHF clinic (see Pareto)Detailed Narrative of each readmission reviewed by each service line for commonalties in practiceReview of Pain Mgmt protocolIncreased DC planning screening for post DC needsPilot Implementation of Case Mgmt model post dischargeEducation and promotion of Medication and Assistance program through the Eblen FoundationReadmission Sepsis team within Infection control to track for cause
Selection & Implementation -
Monitoring (PDCA)
6.67% 6.58%
7.06%7.17%
8.01%
7.01%
6.68%
6.39% 6.46%
6.18%6.04%
6.36%6.12%
6.56% 6.44%
6.08% 6.11%
-
50
100
150
200
250
300
350
04/99-06/99
07/99-09/99
10/99-12/99
01/00-03/00
04/00-06/00
07/00-09/00
10/00-12/00
01/01-03/01
04/01-06/01
07/01-09/01
10/01-12/01
01/02-03/02
04/02-06/02
07/02-09/02
10/01-12/02
01/02-03/03
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
Amed Hsvcs Woms Surg Peds Onc Ortho Neuro Urol Trauma Readmit %
Monitoring (PDCA)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
04/99-06/99
07/99-09/99
10/99-12/99
01/00-03/00
04/00-06/00
07/00-09/00
10/00-12/00
01/01-03/01
04/01-06/01
07/01-09/01
10/01-12/01
01/02-03/02
04/02-06/02
07/02-09/02
10/01-12/02
01/02-03/03
04/02-06/03
Amed Hsvcs Woms Surg Peds Onc Ortho Neuro Urol Trauma
Data
Performance Volumes
(Attending Physician Data) (Attribution Physician Data) (Procedural)
Public Reported Quality - Accountability Coded - Decision SupportCoded Readmission SurgeonsBilling Return to the OR
Service Line Assignments Outcomes - Focus Studies
Credentialing CredentialingDenominators NumeratorsMacro indicators Service Line Specific
Focused Studies
Surgiware
Data
77%
94% 94% 93%99%
94% 96%
0%
20%
40%
60%
80%
100%
120%
5/30/03 6/6/03 6/13/03 6/20/03 6/27/03 7/4/03 7/18/03
Outpatient Cases
95%
95%
96%
94.6%
94.8%
95.0%
95.2%
95.4%
95.6%
95.8%
96.0%
Jan/Feb Mar/Apr May/Jun Jul/Aug
Abstracting
Medical Records Attribution Audit Summary
Data & Quality
Premier AffiliationsPremier Affiliations Current Outcomes Initiatives
Current Outcomes Initiatives
1.Core Measures (JCAHO required)
2. 7th Scope of Work (voluntary)
3. AHA Quality Initiative (voluntary)
4. Premier / CMS Quality Initiative (voluntary)
Clinical Performance ReportMISSION ST JOSEPH'S HEALTH SYS
1/1/02 - 12/31/02
Hospital Top Quartile Target
Statistically significant: *** p< 0.01 ** p< 0.05 * p< 0.10
Average Opportunity Totalper Case Opportunity
Aggressive management and/or prevention of new onset post CABG atrial fibrillation reducesoverall LOS.Standardization of case packs and process flows in the OR reduce costs.If the immediate pre-op Hct > 36, consider not setting up blood, just type and hold.
# Hospitals % Female Age % Use IABP
25.7% 64 3.2%
39 29.6% 64 6.3%11,111
Top Quartile Cost Improvement Opportunity
Potential Improvement Actions
# Cases
760
$5,082
How does your hospital compare to the top quartile in clinical and financial performance?
person(s) to whom it is addressed without the written permission of the Hospital and P remier, Inc.
Information in this document is proprietary and may not be photocopied or divulged to parties or persons other than the
Financial PerformanceClinical Performance
Hospital
Top Quartile
CORONARY ARTERY BYPASS GRAFT
$3,862,500
Reporting Period
$11,105
$20,374
$13,985
$25,456
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000
Avg Variable Cost / Discharge
Avg Total Cost/ Discharge
7.6
7.6
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0
ALOS
1.7%
9.2%
0.8%
2.4%
3.6%
0.6%
1.8%
8.3%
0.7%
3.4%
2.0%
0.8%
0% 5% 10% 15% 20%
Inpatient Mortality
Readmission Rate
Return to OR
PCI during SameAdmission
Hemorrhage/Hematoma
Post-op Infection/Mediastinitis
90.8%
99.0%
82.9%
94.6%
0% 20% 40% 60% 80% 100%
IMA Procedure
ASA duringHospitalization
1.50
2.05
0.0 0.5 1.0 1.5 2.0 2.5
RBCs / Discharge
***
***
***
***
**
*
***
Data & Benchmarking
MSJ Structure
Sonya Greck Ramona Whichello
Heart Services PsychMedical Molly Gouge
Molly Gouge TraumaAdult Medicine Jeff Samz
Critical Care UrologyECC Orthopedics
JCAHO Ramona Whichello Neuro SciencesPatient Safety Oncology Tim Johnston
Lou Hammond Surgical ServicesWomen's General
Pediatrics DentalENTOral
Bob Vassian Plastics
June Beck (MEDICINE) OphthalmologyDana Gibson Anesthesia
Cathy Tremby (SURGICAL)Donna Cravener Sue BradburnKaye Culberson Gus Doescher
Patient Safety Medical StaffSUPPORT: Management Engineering JCAHO Case Managers
Analyst Staff FAAST TeamsMEDICUS Decision Support
ANCILLARY & System
Quality Board
SPT/MAC
DATA OLT
Service Lines
Hospital Board
Patients/Physicians/Bedside Nursing
Hospital Strategic Plan / Vision / Mission
Project Identification and Selection
M
A
C
R
O
P
a
t
i
e
n
t
L
e
v
e
l
(Opportunity I dentification and Facilitation)
Performance I mprovement
(System initiatives directing f ocus studies)
Case / Care Managers
Opportunity I dentifi cation and I mplementation
Identified Opportunities are communicated
through Teams and Service lines
Improvement achieved through PI teams, Focus
studies, Education,
Re- Engineering
System and Various Committee Data Sources Consolidated and Evaluated - Service Line Specific: Sentinel Events, Falls,
Incidents, Med Errors, Clinician Concerns, Credentialing Measures, Complaints, Comments, Satisfaction, Quality Benchmark Measures, Performance Panel Measures,
Financial Performance, Patient Safety,
Strategic Plan, Vision, Mission, Critical Success factors, High Risk,
High Volume, JCAHO, Compliance
Performance
Improvement
Communication and Information Flow
Key Indicators & Measures
OLT
QI Committee
SPT/MAC
Service Lines, Ancillary & Support Departments
Issues brought to QI from SPT / MAC:
Issues brought to QI from SL,
Ancillary and Depts:
Guidance & Issue Resolution: Defining Priorities, Consistency, Completeness
Issues sent to OLT from QI:
Issues brought to SPT from SL, Ancillary and Depts:
Other Committees and Groups:
Questions ?
Tom KnoebberMission Hospitals
828-213-9194