Emergency Department Directors Academy Phase I Spring 2020 Containing Cost While Providing Prudent Care DESCRIPTION The effective ED leader must understand cost appropriate care and efficient utilization of critical resources. Financial realities place pressure on all participants in the healthcare environment and frequently necessitate a critical review of utilization. Too many CTs, admitting patients eventually denied by third party payors, unnecessary laboratory tests, staff cutbacks, etc., are all areas of frequent ED review. Critical review, peer comparisons (locally and nationally), and effective communication all play a role in defining appropriate utilization. The presenter will describe methods of encouraging practitioner (utilization) behavior change, when appropriate. OBJECTIVES

• Define resource utilization and cost containment. • Identify the major types of over-utilized resources in the delivery of ED services (imaging studies, staff,

inpatient services, laboratory studies, etc.) • Describe several tools available to the ED director and management team to assist with demand

forecasting and cost management. • List institutional leaders traditionally most concerned about over-utilization. • Describe successful methods of demonstrating findings and creating behavior change. • Describe the potential risk of under-utilization. • Containing Cost While Providing Prudent Care

2/4/2020, 4:15 PM - 5:15 PM FACULTY: Jay A. Kaplan, MD, FACEP DISCLOSURE: (+) No significant financial relationships to disclose

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Containing Cost While Providing Prudent Care

Jay Kaplan, MD, FACEP

Medical Director of Care Transformation, LCMC Health

Clinical Associate Professor of Medicine, Section of Emergency Medicine,

LSU Health Sciences Center University Medical Center New Orleans

Caveat #1: What Brought Us to this Dance . . .

Ain’t Going to Get Us to the Next One . . . .

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To keep doing things

the same way

and expect different results . .

.

Caveat #2 –The Best Definition of Madness is

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Caveat #3 How Most of Us Approach Change

Social Philosopher Eric Hoffer

“In times of change, learners will inherit the earth while the learned find themselves beautifully equipped to deal with a world that no longer exists.”

-

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Outline

Definition of “Resource Utilization” and “Cost Containment”

Major types of over-utilized resources: Staff/Imaging/Lab/Inpatient admissions

“Wasted Bed Capacity”

Tools available to assist in this process

Physician profiling and change management

Definitions

Resource Utilization:

The percentage of time a resource is busy

Use compared to availability

Cost Containment:

A wide variety of strategies or methods whose primary goal is to control the rising cost of health care. These strategies and methods may include, but are not limited to government regulation, managed care programs, payment policies, global budgets, rate setting, consumer education, and utilization management

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Capacity Vs. Demand - IHI

Matching capacity and demand by making minor adjustments in the availability of health care providers or the scheduling of elective surgeries is often sufficient to reduce delays. If the demand for care is greater than the capacity of the system, there will be a delay in providing care. If the capacity is greater than demand, then resources are being wasted. When capacity and demand are matched, delays in care are reduced. Whenever a quantitative analysis indicates that the system has the capacity to meet the demand during normal functioning, then specific change concepts can be implemented relatively quickly to help align capacity and demand during predicted or unpredicted periods of high demand.

Cost = $$ Spent – Benefit = “ROI”

Systems People

Techs/UC’sNursesProcess Outcomes

Physicians/APP’sEfficient Flow

ScribesED Inpatient

Effective useSNF

Transitions of Care

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Transitions of Care & Handoffs

Setting to SettingPCP to ED

ED to Inpatient

Inpatient to Acute Rehab to SNF

Person to PersonPhysician to Physician

Nurse to Nurse

Physician to Nurse and vice-versa

Why Is This Important?Example #1: Workforce Shortage

Average cost to replace:Med-Surg $50-55,000

Critical Care $70-80,000

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2030 ratio expected to be 2.0

“Here you go…thought youmight like this”

Not . . .

Example #2: Revenue Maintenance

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Problems:

We are still viewed as “the most expensive place in the health care system to receive care.”

We are the #1 target for ACO’s and organizations committed to value-based payment.

And . . . Medicaid in most states is the single largest line item in the budget!

AND . . . In terms of admissions and other costs, EP’s control 32%!

An Interesting Study by Myles Riner

20% of least costly non-admitted ED visits account for 4% of the total cost of all non-admitted ED visits.

Could save as much $ if reduce CT scans 1/12.

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In Terms of $ Cost, the Real Questions Are

Do you need to order that imaging study on that patient?

Do you really need to admit that patient?

Status: Observation or Inpatient?

Level of Care: Med/Surg or Tele or ICU?

and . . .

Are all of your clinicians making those decisions in a consistent way?

Are you giving your clinicians individual feedback on their:

Resource utilization

Throughput metrics

Admission/Observation %’s

Patient experience

Relationship with staff

Relationship with peers

Relationship with medical staff/resident staff?

In Terms of $ Cost, the Next Question Is

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Questions

Is ordering the appropriate study equivalent to quality?

Is not ordering the unneeded study equivalent to quality?

Is working fully staffed more likely to produce quality?

Is working short less likely to produce quality?

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Choosing Wisely 2013

The 5 Initial Recommendations

1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.

2. Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience.

3. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

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The 5 Recommendations

4. Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

5. Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children.

Choosing Wisely 2015: The Second 5

6. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.

7. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.

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The Second 5

8. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis.

9. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.

The Second 5

10. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasispresenting with symptoms consistent with uncomplicated kidney stones

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So . . . Questions for You

What have you done to implement the Choosing Wisely recommendations?

What have you done to make your clinicians’ practice more consistent?

How have you demonstrated to your leadership (hospital, health system, state legislators) how you are containing cost while providing prudent/quality care?

The Real Question is not . . .

“Quality vs Cost”but rather

“How to Engender Quality and Generate $through

Cost-Effective Throughput andEffective Use of Resources”

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The Real Issue is Not $ Spent . . . But

What Do You Get

for the $$

You Spend?

The Real Issue is Not $ Spent . . . But

You have to learn to talk

the language of ROI . . .

Return on Investment

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• Charity Hospital flooded by Katrina; did not reopen• Interim LSU Public Hospital opened in 2006• Joined LCMC Health in June 2013• UMCNO opened August 2015

Transition to Talking About ROI –University Medical Center New Orleans

• 446 licensed inpatient beds

• 60 behavioral health beds

• Over 2,000 full-time employees

• 640 physicians

• 1.3 million square feet for healthcare services

• 2.3 million square feet overall in UMC New Orleans

• 19 operating rooms

• 5-story Ambulatory Care Building with 276 exam rooms

• 56 emergency department exam rooms

– 9 rapid treatment rooms in the Emergency Department

– 5 trauma rooms

– 9 acute treatment rooms

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Emergency Department Statistics2017• 90,462 visits (up 7.0%)

• 14,157 admissions/obs (up 15.6%)

• LWOBS 4.4% (down 5.1%)

2018 (through June)• Visits up 2.4% (1064 patients)

• Admissions/Obs up 11.2% (764 patients)

• LWOBS down 15%

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Hospital and ED Innovations• Converted “ED Throughput Committee” to the

“Hospital Throughput Committee” – meets monthly

• Attended by COO, CNO, CMO, as well as representatives of Nursing, Behavioral Health, ED, Hospitalists, Intensivists, EVS, Transport

• Individual core meetings with ED, Behavioral Health, Hospitalists and Intensivists to share data and solicit each group’s perspective to generate commonly agreed upon Saturation triggers and potential actions

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Inpatient Actions/Innovations• Emphasis on early discharges of all teams – 2 before 10am

• Earlier Behavioral Health faculty presence on predictable high volume days

• Trigger notification by phone alert to all providers when Med Surg and ICU Saturation triggers are met and reinforced every 12 hours

• ICU Team responsible for ICU downgrade order writing and following patients until Hospitalist Teams can transition patient to their care

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ED Actions/Innovations• Opened one 14 bed pod as a Faculty only pod

• Passed a nursing protocol order set through Med Exec to enable nurses to order common diagnostics & meds.

• Put PA’s/NP’s in our Rapid Treatment Area

• Instituted SORT – when ED beds filled, Provider in Triage

• Put PA’s/NP’s in Behavioral Health ED during peak hours

• Opened a second CT scanner for high volume times.

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Results – Door to Provider

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0

20

40

60

80

100

120

30-O

ct6-

Nov

13-N

ov20

-Nov

27-N

ov(S

OR

T S

TA

RT

) 4-

Dec

11-D

ec18

-Dec

25-D

ec1-

Jan

8-Ja

n15

-Jan

22-J

an29

-Jan

5-F

eb

12-F

eb19

-Feb

26-F

eb5-

Mar

12-M

ar19

-Mar

26-M

ar2-

Apr

9-A

pr16

-Apr

23-A

pr30

-Apr

7-M

ay14

-May

21-M

ay28

-May

4-Ju

n11

-Jun

18-J

un25

-Jun

2-Ju

l

Door to Provider: Pre and Post Sort

Door to Provider

Linear (Door to Provider)

SORT start

Results – Imaging TAT

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0

20

40

60

80

100

120

140

160

2017 Nov 2017 Dec 2018 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun

Head Order to Final (min)

0

50

100

150

200

250

2017 Nov2017 Dec2018 Jan2018 Feb2018 Mar 2018 Apr 2018May

2018 Jun

Abd/Pel Order to Final (min)

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Results – Saturation

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Return on Investment UMC (2018)

Increased Admissions/ Observation

Increased Visits/Patients treated

Additional patients seen who didn’t

LWOBS

1436 patients

374 patients

1.6%

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RETURN ON INVESTMENT - UMC (2018)

Of Admissions/ Observations

• 55.2% Admissions

• 31.3% Observations

• 13.5% Psychiatric Admissions

AVERAGE COLLECTED REVENUE (2018)

• Inpatient $16,873

• Observation $2,376

• Psych inpatient $4,699

• Discharged $442

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RETURN ON INVESTMENT (2018)• Inpatients: 1436 x 55.2% = 793 patients x $16,873 = $13,380,289

• Obs: 1436 x 31.3% = 449 patients x $2,376 = $1,066,824

• Psych IP: 1436 x 13.5% = 194 patients x $4,699 = $911,606

Total for Admits/Obs = $15,358,719

Plus

• Treated-and-Released: 374 patients (decreased LWOBS) = 374 x $442 = $165,308

Total increase in revenue = $15,524,027

RETURN ON INVESTMENT (2018)

Total increase in revenue =

$15,524,027

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RETURN ON INVESTMENT 2019 (through August)

• Inpatients: 763 x 55.2% = 421 patients x $16,873 = $7,103,533

• Obs: 763 x 31.3% = 239 patients x $2,376 = $567,864

• Psych IP: 763 x 13.5% = 103 patients x $4,699 = $483,997

Total for Admits/Obs = $8,155,394

Plus

• Treated-and-Released: 809 patients (decreased LWOBS) = 809 x $442 = $357,578

Total increase in revenue = $8,512,972

RETURN ON INVESTMENT (2018 & 1st 8 months 2019)

Total increase in revenue =

$24,036,999

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The Cost-Effective Use of Human Resources . . .

Ensure that no one is doing

something that could be done by

someone who costs less!

(but has the skills and knowledge to

get the job done well)

Patient Care Technicians

The Care Pair Concept: Nurses

• Transport• Do EKG’s• Draw blood• Take/document vital signs• Document “patient resting

comfortably”• Change stretcher linen• Take bedpans• Enter orders/write order slips

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Clinical Information Managers - Scribes

The Care Pair Concept: Physicians

• Transcribe• Document• Gather lab results• Know when x-rays are completed• Follow up on consultants called• Change stretcher linen• Take bedpans• Enter orders/write order slips

More Techs, APP’s, Scribes

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Staffing – Resource Allocation

Dedicated Consistent Charge RN

Charge/Lead Physician

Flexibility:– Floats– Liberal use of extenders– CIM’s/Medical scribes– On-call

Geographic allocation?:– Nurse, Physician, both?

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Clinical Information Managers = Scribes

Go to bedside with you

Document history and physical exam

Follow up and alert you re: outstanding lab/ x-ray

Follow up on requested communication

Discharge instructions

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CIM’s implemented

Saint Barnabas Medical CenterAvg Patients per Physician Service Hour

y = 0.0078x + 2.1561

2.00

2.05

2.10

2.15

2.20

2.25

2.30

2.35

2.40

2.45

2.50

1999/Feb

1999/Mar

1999/Apr

1999/May

1999/Jun

1999/Jul

1999/Aug

1999/Sep

1999/Oct

1999/Nov

1999/Dec

2000/Jan

2000/Feb

2000/Mar

2000/Apr

Month of Service

Pts

Per

Hou

r

y = 0.0187x + 2.1884

Quality of Life for Emergency PhysiciansPre- and Post-Implementation of Clinical Information Managers

May 1999/February 2000

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Efficiencypatient flow

MD<10mins aware labresults

pt fordisposition

aware xraysdone

time withpatients

time spenton charting

chart doneby shift end

job apleasure

Questions

Avera

ge S

atisfa

ction S

core

pre-CIM

post-CIM

5 = very good4 = good3 = fair2 = poor1 = very poor

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Quick Registration Intake, not Triage Immediate BeddingRME: Treat-&-Street from

Front/Initiate Care on OthersAdvanced Nurse Protocols

Quick Registration Intake, not Triage Immediate BeddingRME: Treat-&-Street from

Front/Initiate Care on OthersAdvanced Nurse Protocols

Door to Doc

Patient Sat

Door to Doc

Patient Sat

The Cost-Effective Use of Space - Throughput

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RME and Effective Bed Utilization

RME and Change in Annual Patients / ED Bed

1,7741,647

1,870

1,3671,189

2,5482,433

2,843

2,387

2,094

-

500

1,000

1,500

2,000

2,500

3,000

St. Mary - Apple Valley Pioneer MemorialHospital

St. Bernardine MedicalCenter

Madera CommunityHospital

Rideout MemorialHospital

PreRME Current

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Impact of a Rapid Medical Evaluation Program on Patient Satisfaction(5 point scale)

3.9

4.03

3.88

4.12

4.23

3.91 3.93

4.01

3.75

4.03 4.01 4.034.054.10

4.494.42

4.23

4.13

4.434.47

4.15

4.31

4.06

4.21

3

3.4

3.8

4.2

4.6

5

A B C D E F G H I J K L

Emergency Department

Pt. S

atisfa

ction

Satisfaction Pre-Implementation Satisfaction Post-Implementation

Re-Look at Your Space & Align It to Your Process

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Transformation

Collaborative team working together to improve outcomes

Changed Process – enforced changes with leader rounding

Build out of triage into old waiting room

Old triage became internal RAP room

Old storage area became new stretchers

Team out front: APP’s, nurses, techs

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40

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The Emergency Department

Metric Then Now

Door to Doc/PA 68 mins 26 mins

Patients LWBS 4.6% 1.5%

LOS Pts D/C’d 260 minutes 196 minutes

LOS Pts Admitted 720 mins 524 mins* (-)71 mins

Patient Satisfaction 3rd percentile 31st percentile (11/12 58th)

Core Measures Near 100% Near 100%

* With Transition Orders

Service goals for Lab, Imaging and Consultants

All rooms multi-purpose

Chairs instead of stretchers

Extenders

ChargeRN/Physician

Board Rounds

Systems - While Patients Are InSystems - While Patients Are In

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Systems - Getting Patients Out

p y

Early Inpatient Discharge

No delay nurse report

Weekend Discharges

“Zero Tolerance” on Hidden beds

Transition orders

Full Capacity Protocol

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•Time physician order to discharge to patient out

•Patient out to call to housekeeping

•Call to housekeeping to bed clean

•Bed clean to assignment of new patient to bed

•Time of bed assignment to new patient in bed

ChecklistTime Order to Patient Out

Call to Housekeeping to Room Clean

Time Order to Patient Out

Call to Housekeeping to Room Clean

Key:•Inpt performance indicators•Goals and timeframes•Data collection process•Accountability

Measurement – “Inpatient Metrics”

Inpatient Patient Flow Performance Dashboard

Slide courtesy of D2I

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The Inpatient Process

Metric Then Now

% Pts D/C by 11 am 31% 66%

D/C order to Pt Departure 168 mins 189 mins167 mins (3200)

Departure to Room Clean 84 mins 75 mins

ED Admit Request to Orders Received

163 mins 129 mins*

Orders Received to Bed Assignment

280 mins 129 mins

Bed Assign to Pt in Bed 88 mins 69 mins

* Almost Immediate with Transition Orders

Individual Physician Profiles

If you do not measure by the individual, no one will ever admit that their practice is not A+ the best . . .

The excuses are:

My patients are different.

The data must be wrong.

It’s not statistically valid.

. . .

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The American Journal of Medicine (2012) 125, 356-364.

Variation in Clinical Practice is Rampant

Head CT examinations were ordered in 8.9% of emergency department visits

Two-fold variation in overall head CT ordering (6.5–13.5%),

Three-fold variation in head CT ordering for atraumatic headache (21.2–60.1%).

Summary

What reserve we had is gone – efficient practice is essential.

Careful resource utilization with appropriate cost containment is crucial to success.

Consistency is crucial . . . Measurement is a must, individual as well as group.

Use of technology is an imperative.

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Questions?

Thank you.

Jay Kaplan, MD, FACEPjkaplan@acep.org