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“Quality and Safe Respiratory
Care: Does it Work in a
Productivity Model?”
Timothy R. Myers MBA, RRT-NPS, FAARC Associate Executive Director, Brands Management
American Association for Respiratory Care
Adjunct Faculty, Assistant Professor Department of Pediatrics,
Case Western Reserve University
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Healthcare is Getting Serious About
Safety, Benchmarks & Productivity
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Why Benchmark?
In a 2006 AARC survey of managers that
drew over 200 respondents:
• Within the past two years 64% had been
asked by their administrators to compare
their department to other hospitals.
• 71% expected their administrator to ask
them to make this comparison within the
coming year!
• The next round of consultants and cost
cutting is here…
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What is Benchmarking?
• Definition
– Process of comparing performance against
other groups (or self over time) for the purpose
of improving performance
• Process
– Define metrics (measured values)
– Select compare group and see how you rank
• Purpose
– Identify best performers
– Describe and emulate best practices
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What “performance” do we
measure?
• Quality of care
– Difficult to define
– Expensive to track (labor intensive data
collection)
• Efficiency and productivity
– Easy to define
– Data available from billing records (CPT)
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The United States is worse on key measures
American College of Physicians, Ann Intern Med 2008;148:55-75
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Definitions
Example:
# billed procedures / variable labor hour
Problem:
• not all procedures take the same time
• efficiency depends on mix of procedures
not how well they are performed
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Definitions
Where do we get standard times?
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AARC Uniform Reporting
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Definitions (productivity vs efficiency)
Highest clinical productivity comes from
the highest treatment efficiency combined
with the leanest organizational structure
Problem: we don’t know how productivity
is related to quality
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Take-Home Message
• Increase clinical productivity by:
– Increasing efficiency (less time to do the job)
• Use nebulizers that give unit dose in shorter time
• Q8 vs Q2 hour vent checks
• Vest or IPV instead of manual chest physiotherapy
– Increasing utilization (more focus on clinical)
• Decrease number of non-clinical activities
• Decrease number of non-clinical FTEs
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So How Do YOU Measure It?
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The AARC Benchmarking Service
• Designed by respiratory therapy managers for
respiratory therapy departments
• Allows you to compare your operations with any
hospital currently enrolled in the service
• Provides you with complete access to
– operational characteristics and
– data entered by all subscribed hospitals
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Purpose of Website
• Collect & report data
– compare departments on productivity
– identify outstanding performance
• Explain best practices supporting outstanding performance
• Provide a network & forum for discussion of benchmarking issues
• Provide education on benchmarking
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Desirable Workload Data
• Represent majority of workload
– Not practical report all workload
• Common to all respiratory care departments
• Raw data easily obtainable
– do not require reliance on finance department
– based on billing volume by CPT codes
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Raw Data Used by AARC
• Mechanical ventilation days (including CPAP)
– 94002 (first day)
– 94003 (subsequent day)
– 94660 (CPAP)
• Aerosol treatments
– 94640 (nebulizer, MDI, IPPB treatment)
– 94664 (nebulizer, MDI, IPPB instruction)
• Airway clearance
– 94667 (chest PT –initial)
– 94668 (chest PT –subsequent)
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Percentage of Total Workload Captured by
AARC Benchmarking System
69 6350
58 5368 66
51
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A B C D E F G H
Benchmarked Other
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Benchmarking Metrics
• Primary
– standard hours/variable hour (efficiency)
– variable hours/unit of service (efficiency)
– fixed hours/total hour (administrative load)
• Secondary
– PRN hours/variable hour (staffing
flexibility)
– agency hours/variable hour (staffing cost)
– missed aerosol treatments (quality)
– annual units of service (total workload)
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Purpose of Metrics
• Identify leaders in compare group
• Guide secondary analysis
– (“drill down”) into profile of benchmark
department to identify best practices
• Allow “data mining” to support future
research
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Interpretation Issues
• Low values for productivity metrics due to:
– low efficiency
– high percentage of total workload made up
of non-benchmarked procedures
• Essential that benchmark group be comparable
departments
– comparable quality and scope of practice
– procedures not included in metrics are
similar
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6 categories: 62 questions
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data entered
data calculated
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= volume x URM standard time
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A New Paradigm
In God We Trust, All Others
Must Bring Data
W. Edwards Deming
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The Default Compare Group
• Not based on department specific
characteristics
• Based on hospital demographics:
– Number of beds within 25%
– Number of ICU beds within 50%
– Organizational type must match • Academic, Childrens, Community
– Classification type must match • Rural, Suburban, or Urban
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Current Summary Report
terms linked to glossary
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Current Summary Report
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Trend Report
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Trend Report
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Trend Report
links to raw data
limited data set
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Resources on the Website (tools)
• AARC Benchmarking Users Guide
• Data entry template (Excel spreadsheet)
• Benchmarking listserve
– Automatic registration with membership
• CPT code URM crosswalk
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Resources (AARTimes reprints)
• Overview of benchmarking service
• Setting up comparison groups
• Pitfalls of benchmarking
• Understanding the metrics
• Administrators point of view
• Frequently asked questions
• Case study
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Resources (webcasts)
• Benchmarking for success
• Optimal staffing
• Data entry made easy
• Compare groups and repors
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Why AARC Benchmarking?
Allows you to:
• Trend your own data from quarter to quarter
• Generate standard and custom reports
• Establish multiple comparison groups with other
hospitals based on mutual operational
characteristics, staffing and size
• Verify the accuracy of data through direct contact
with the hospital that provided their data
• Most user friendly of any commercial system
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Quality and Safety
• Quality and safety are in a sense inseparable
• Creating a culture of safety is part of building a system of continuous quality improvement
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Emphasis on improving quality of health care
Focus on quality improvement in healthcare organizations
Improves patient care outcomes
Helps improve the work environment: people want to work in organizations that emphasize quality
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The Institute of Medicine
To Err Is Human (1999)
Safety In Healthcare Delivery
Institute of Medicine. (1999). To Err Is Human. Washington, DC: National Academies Press.
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A Safety Crisis
• The IOM report on safety opened the door to acknowledge there is a healthcare safety crisis, for example data indicated in 1999: Approximately 44,000 to nearly 100,000 patients die annually in U.S. hospitals due to error.
• What is your reaction to this?
Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery
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AARC Congress 2012
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Key Terms
• Safety: Freedom from accidental injury
• Error: Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery
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Safe Care=Quality Care?
Just because care is considered safe does not mean that it is of a higher quality.
BUT
There is a greater chance that the care is of higher quality.
Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery
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Quality and Safety
Partnership- Guiding Principles • IOM 6Aims for Improvement- Patient care that:
• Safe- avoidance of unintended pt. harm
• Effective- evidence-based
• Patient-centered- focused on needs and rights of the individual patient
• Timely- avoidance of delays & barriers to patient care flow
• Efficient- elimination of waste
• Equitable- fair access to comparable health care services for all
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Internal Benchmarking:
Productivity & Safety
Rainbow Babies & Children’s
Hospital Experience
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Respiratory Scorecard:
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Service Excellence
0
1
2
3
4
5
6
1 2 3 4 5 6 7 8 9 10 11 12
Po
ints
(m
ax.=
5)
Months
Service Excellence
Non-Billable Workload
Consult Service
Missed Treatments
Service Time
2008 Average
Non-Billable=
82% Target
2008 Average
Consult =
31% Target
2008 Average
Missed Tx=
82% Target
2008 Average
Service Time=
82% Target
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Consult Service
71%
66%
71%
52%
57%
68% 70%
80%
75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Monthly Compliance %
Monthly Compliance %
5 4 3 2 1
Consult
Service overall QA audit
score (pct)
71
% > 95% 95-85% 85-75% 75-70% < 70%
Quarterly
Compliance
1st 70%
2nd 59%
3rd 75%
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Productivity
Procedures x Operating Standard = Productive Hours
Productive Hours / Total Product Hrs = Productivity Index
Procedures Total
Productive Hrs
Operating
Standard
Productive
Hrs
Productivity
Index
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Productivity Index
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1 3 5 7 9 11 13 15 17 19 21 23 25
Vo
lum
e
Pay Periods
Respiratory Care Productivity
Procedures
Actual Worked Hours:
Total Target Worked Hours:
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Productivity Percentage
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
110.0%
1 3 5 7 9 11 13 15 17 19 21 23 25
Ta
rge
t P
ct
Pay Periods
Productivity Percentage
Productivity Index:
Monthly Productivity Index
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Supplemental Hours to Regular Hours
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Pct
of
To
tal H
ou
rs
Pay Periods
Extra Paid Hours Pct
Overtime Hrs %
PRN Hrs %
Total Hrs %
OT Average
= 4.6%
PRN Average
= 7.7%
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Know your Financials
• How much Medicaid does your institution cover?
• What areas or diseases are potentially at financial
risk?
• What is your average reimbursement per billing?
• What does your expense portfolio look like?
• What are the key service lines that generate a positive
net income?
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Rainbow Experience
• Medicaid has average 60-67% over last decade
– Cardiac, NICU, Cystic Fibrosis, Complex
Surgeries are positive financial service lines
– Most other respiratory diseases are potential
financial risks (asthma, pneumonia, RSV)
• Average “net billable” for Rainbow discharges was
approximately 46% in 2011-12
– Example: $100 charge (revenue) typically returned
$46 dollars (Not including expenses)
![Page 55: “Quality and Safe Respiratory - Indiana Society for ... Fall Seminar/iSRC.pdf · “Quality and Safe Respiratory Care: Does it Work in a Productivity Model?” Timothy R. Myers](https://reader031.vdocument.in/reader031/viewer/2022022419/5a7788457f8b9ad22a8e3f4c/html5/thumbnails/55.jpg)
Expense Portfolio
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Things to Worry About
• Consultants (con and insult)
– Con your boss
– Insult your intelligence
• Labor Shortage
– The “global warming” of our profession
– Lack of staff forced increased productivity
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Why Benchmark?
• To document your efficiency
• Have real data from comparable
departments to respond to
recommendations of consultants who will
recommend downsizing your staff
• To determine “best practice” in specific
areas of operations by communicating
directly with managers at benchark
facilities
![Page 58: “Quality and Safe Respiratory - Indiana Society for ... Fall Seminar/iSRC.pdf · “Quality and Safe Respiratory Care: Does it Work in a Productivity Model?” Timothy R. Myers](https://reader031.vdocument.in/reader031/viewer/2022022419/5a7788457f8b9ad22a8e3f4c/html5/thumbnails/58.jpg)
What to Do When Consultants Come to YOUR
HOSPITAL!!!
• Stay involved and informed
• Know your department and all it’s
processes
• Lose the defensiveness!
• Be suspect of consultant data
• Know your data, identify opportunities
• Identify reason for variances
• Network with other RC directors
![Page 59: “Quality and Safe Respiratory - Indiana Society for ... Fall Seminar/iSRC.pdf · “Quality and Safe Respiratory Care: Does it Work in a Productivity Model?” Timothy R. Myers](https://reader031.vdocument.in/reader031/viewer/2022022419/5a7788457f8b9ad22a8e3f4c/html5/thumbnails/59.jpg)
Social Media 2.0
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Other Outlets