Genesis Health System

PromiseCare

Research Summit – June 8, 2016

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PromiseCare - Concepts

The PromiseCare process is known by many

titles, and in summary is focused on:

• Re-designing clinical care to achieve these

goals

• Reducing variation in care

• Increasing reliability of outcomes

• Increasing efficiencies in the use of

resources

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Almost all studies that investigate the reliability of the application of clinical science in healthcare

conclude that there are significant opportunities for improvement.

Volume 348(26) 26 June 2003 pp 2635-2645

The Quality of Health Care Delivered To Adults In the United States

McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer:

DeCristofaro, Alison: Kerr, Eve A.

BACKGROUND

We have little systematic information about the extent to which standard processes involved in healthcare—a key element of quality—are delivered in the United States.METHODS

We telephoned a random sample of adults living in 12 metropolitan areas in the United States and…received written consent to copy their medical records…to evaluate performance on 439 indicators of quality of care

for 30 acute and chronic conditions as well as preventative care…RESULTSParticipants received 54.9 percent of recommended care.

CONCLUSIONSThe deficits we have identified in adherence to recommended processes for basic care pose serious threats

to the health of the American public. Strategies to reduce these deficits are warranted.

Reliability in HealthCare

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PromiseCare - Origins

The concept of decreasing variation in care is

not new.

It has been successfully implemented by

organizations such as Geisinger Health

System and Intermountain Health Care.

They have documented success in achieving

the desired results.

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Geisinger Model – Proven Care

Developed a process one procedure / DRG at

a time.

About 10 years in the making so far

Originally started with CABG

Led by a Cardiac Surgeon to start with

Currently about 17 projects in place

CABG Ave. LOS fell 0.5 days (6.2 vs. 5.7)

CABG 30-day readmission rate fell 44%

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GHS - Performance Excellence as Strategy

Physician Led - Professionally Managed

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The Promise in PromiseCare

Right Patient

Equitable Care Every time

Every patient

Right Time

Right Setting

Right Resources

Right Care

Safe Patient-Centered

Timely

Effective/Efficient

Crossing the Quality Chasm 2001 –

Institute of Medicine

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PromiseCare - Objectives

Differentiate Genesis based on quality outcomes

Reduce the overall cost to treat

• Research current best evidence

• Hardwire care delivery processes

• Reduce unwanted variation to deliver high clinical

reliability

• Reduce operational inefficiencies

• Provide effective and efficient clinical care

Develop the internal infrastructure (people, process and

technology) that will ensure sustained improvements,

maintain consistency and provide ongoing cost-effective care

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PromiseCare - Operational Structure

GHS Performance

Excellence

Leadership

Committee PromiseCare

Steering Committee Chair: CMO

Medical, Clinical &

Administrative Leadership

PromiseCare Project Support Team: IT, BIC, Finance, Quality, Nursing Education, Pharmacy,

and others

PromiseCare Coordinator and Specialist

GMC-Davenport MOC

GMC – Illini MOC

CAH MEC

Sepsis

Leadership

Team and

Workgroups

HF Leadership

(Phase I &

II)Teams and

Workgroups

Stroke

Rehab

Leadership

Team and

Workgroups

Condition Specific Leadership Committee Physician, Nurse & Administrative Champions

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Total Knee

Procedure

(Sleep Apnea )

Diabetes

(Phase I &

II)Teams and

Workgroups

PromiseCare - Steering Committee

Essential governance to make the process

consistent

Reports to the MOC and MEC on progress

and state of the program

Needs multidisciplinary input

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PromiseCare - Steering Committee

Differentiate Genesis based on quality outcomes

• Receive and review ongoing requests for PromiseCare

initiatives

• Approve selection criteria

• Select DRG / Diagnosis for Promise Care

• Charter DRG & Clinical Redesign Teams

• Monitor progress of PromiseCare projects

• Monitor attainment of metrics for Promise Care

initiatives (process and outcomes)

• Oversee communication plan

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Criteria Rank

(1 – 5 high)

Percentage

Weighting

Total

Availability of Evidence

Base Medicine

25%

Physician Leadership in

Area/Condition

20%

Quality Opportunity 20%

Sufficient Volume for

Change

15%

Availability of Data 10%

Financial Opportunity 10%

PromiseCare - Selection Criteria for Care

Redesign

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PromiseCare – What are We Doing?

Agreeing on what the right care is (Best Practice

Elements)

Designing the processes to ensure the right care

happens every time

Measuring compliance to the process measures

Measuring the outcomes

Expecting improved outcomes with less cost

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PromiseCare - Structure & Relationships

A methodology to bring the optimal coordination of

resources to a clinical situation in a consistent, quality

oriented, cost effective manner

Requires the utmost collaboration between all

components of patient care

Needs extensive resources

• Medical Oversight

• Nursing

• Pharmacy and other Disciplines

• Education

• IT

• BIC / Finance review

• Quality

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Stroke Rehab

Physician led - Dr. Chin

Professionally managed – Suzanne Schalber

Stroke Rehab process is fully implemented

and the model for the rest of the System to follow

Will promise future Stroke Rehab patients they will

deliver specific best practice elements

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Condition: GMC - Davenport Stroke Rehab - Variable Cost per Case

Discharges in

sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

n = 14 n = 17 n = 9 n = 18 n = 12 n = 15 n = 9 n = 12 n = n = n = n =

Compliance to Process Measures Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 YTD Avg.

PromiseCare Admit Stroke Rehab Power

Plan Percentage100.0% 100.0% 81.8% 100.0% 100.0% 93.8% 88.9% 92.3%

1% of Patients Assessed by Therapies within 24 Hours

of Receipt of Initial Rehab Order100% 100% 100% 100% 100% 100% 100% 100% 100%

2% of Patients Who Received a Dietary Consult within

24 hours of Receipt of Initial Rehab Order100% 100% 100% 100% 100% 93% 100% 100% 99%

3% of Patients Who received Bowel and Bladder

Training 100% 100% 100% 100% 100% 100% 100% 100% 100%

4% of Patients Who Completed Depression Screening

within 48 Hours of Receipt of Initial Rehab Order86% 100% 100% 100% 100% 100% 89% 100% 97%

5% of Patients Who Had Swallowing Assessment

Completed100% 100% 100% 100% 100% 100% 100% 100% 100%

6% of Patients With Communication Disorder Who

Received Training by SLP100% 100% 100% 100% 100% 100% 100% 100% 100%

7% of Patients With Cognitive Deficit Who Received

Training100% 100% 100% 100% 100% 100% 100% 100% 100%

8% of Patients Who Have Neurofeedback Assessment

Completed100% 100% 100% 100% 100% 100% 100% 100% 100%

9% of Patients Who Have Daily Monitoring for Skin

Integrity100% 100% 100% 100% 100% 100% 100% 100% 100%

10 % of Patients Who Receive 3 Hours of Therapy Daily 93% 100% 89% 100% 100% 100% 100% 100% 98%

11% of Patients Who Have Mobility Issues AND

Received PT Training100% 100% 100% 100% 100% 100% 100% 100% 100%

12% of Patients Who Have Self Care Issues AND

Received OT Training100% 100% 100% 100% 100% 100% 100% 100% 100%

13% of Patients Who Were Discharged by Estimated

Discharge Date100% 100% 78% 100% 100% 93% 100% 85% 94%

PromiseCare Stroke Rehab Bundle 98.1% 100.0% 97.2% 100.0% 100.0% 98.9% 99.1% 99.3% 99.2%

PromiseCare All or Non Bundle 78.6% 100.0% 66.7% 100.0% 100.0% 86.7% 88.9% 92.3% 90.7%

n = 12 n = 16 n = 11 n = 18 n = 11 n = 16 n = 9 n = n = n = n = n =

Clinical Outcome Measures Baseline Target Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 YTD Avg.

1 % of Patients Discharged to Acute Care 6.3% 10.2% 0.0% 6.3% 27.3% 11.1% 0.0% 12.5% 11.1% 7.7%

2 Case Mix Index 1.31 1.54 1.5751 1.3291 1.1231 1.4732 1.1707 1.5338 1.2057 1.3456

3 FIM Change Admission to Discharge 21.97 22.07 28.58 21.06 16.91 22.56 25.18 23.69 22.00 23.46

4 % of Discharges to home 66% 67.96% 42% 56% 64% 61% 73% 63% 44% 77%

5 % of Discharges to a Skilled Nursing Facility 21.17% 58.3% 37.5% 9.1% 27.8% 27.3% 25% 33% 15%

6 ALOS 19.86 14.25 15.33 15.88 11.45 12.73 15.36 15.06 15.89 15.15

7 ALOS O/E Index N/A 0.85 1.03 0.86 0.74 1.10 0.85 1.01 0.96

8 Rehab Unit Patient Satisfaction Percentile 38 80

Financial Outcome Measures Baseline Target Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 YTD Avg.

1 Variable Cost per Case 10,592$ 8,911$ 9,996$ 7,086$ 8,562$ 9,845$ 8,880$

3 Contribution Margin 78,917$ 75,499$ 25,119$ 109,141$ 94,101$ 76,555$

Stroke Rehab

GMC - Davenport

Goal is

98.5%

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Goal is

98.5%

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Sepsis

Physician led – Dr. Dierks

Professionally managed – Lynn Colberg

CMS intervention

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24

25

26

60

64

60

53

33

94

70

74

100

90

0

10

20

30

40

50

60

70

80

90

100

Jul-2015 Aug Sep Oct Nov Dec Jan-2016 Feb Mar Apr May

PE

RC

EN

T P

OW

ER

PL

AN

U

SA

GE

MONTH

GMC-DAVENPORT - CMS INPATIENT SEPSIS POWER PLAN USAGE

Goal 45%

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GMC - Silvis Sepsis - Mortality O/E - Total Sepsis nowGMC - Silvis Sepsis - Mortality O/E - Secondary SepsisGMC - Silvis Sepsis - LOS O/E - Total Sepsis now

Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample Disch in sample

6 6 3 4 6 5 8 5 5

Compliance to Process Measures Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

All SIRS, potential Sepsis patients

1 % Was SIRS Alert fired

2 % Was suspected Adult Sepsis protocol initiated

All Sepsis patients

3 % Lactate ordered < 3 hrs 100% 86% 100% 100% 17% 100% 100% 100% 100%

4 % Remeasure lactate if initial lactate was elevated < 6 hrs 66% 43% 67% 100% 50% 33% 60% 60%

5 % Patients in which Sepsis Order Set was utilized 83% 67% 86% 50% 50% 60% 50% 60% 100%

% Patients in which Sepsis Order Set was utilized < 3 hrs

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% Sepsis Patients in which 2 Blood cultures are drawn

prior to administration of antibiotics < 3 hrs 100% 86% 67% 100% 17% 80% 100% 100% 80%

7% Sepsis Patients in which broad spectrum antibiotics

were administered < 3 hrs of admit time83% 71% 100% 75% 33% 100% 88% 100% 100%

10% Patients receiving appropriate fluid resuscitation < 3

hrs (Only Septic Shock patients)50% 100% 50% 25% 0% 0%

12% Patients with Focused Exam and/or Hemodynamic

Monitoring < 6 hrs (Only Septic Shock patients)100% 50% 0% 0% 0% 0%

15% Patients given Vasopressor (or other inotrope) < 6 hrs

(only Septic Shock patients)100% 100% 0% 0% 0% 0%

Overall Compliance

All or None Bundle (CMS) 17% 14% 33% 67% 0% 0% 0% 20% 20%

Clinical Outcome Measures (rolling 12 mon.) Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

1 Mortality O/E - Total Sepsis now 0.71 0.70 0.62 0.63 0.65 0.57 0.643 LOS O/E - Total Sepsis now 0.78 0.80 0.74 0.74 0.73 0.75 0.74

5 Readmission O/E - Total Sepsis now 0.76 0.78 0.85 0.86 0.82 0.77

7 Complication O/E - Total Sepsis now 0.83 0.91 0.56 0.58 0.57 0.54 0.56

Financial Outcome Measures Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

1 Variable Cost per Case - Total Sepsis now 3,798$ 4,559$ 3,677$ 5,340$ 4,580$

5 Contribution Margin - Total Sepsis now 65,277$ 57,202$ 54,661$ 174,122$ 53,324$

Generated 05/16/2016

Indicates data not available

Indicates data not yet available but will be later

Sepsis

GMC - Silvis

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Heart Failure (HF)

Physician led - Dr. Rajendran

Professionally managed – Karen Doy / Jacque

Oelerich

Acute Setting - Phase 1 Completed with

some needed improvements

• Will pilot PromiseCare Promise to Heart

Failure Patients

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30

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Condition: Heart Failure

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

Discharges

in sample

n = 12 n = 14 n = 18 n = 11 n = 6 n = 20 n = 6 n = 11 n = 20 n = 22

Compliance to Primary Process Measures Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

1% of ED Patients Who Had a Primary Diagnosis of Heart Failure who received a Loop

Diuretic 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

2 % of ED Heart Failure Patients Admitted to Observation/Outpatient 16.7% 18.2% 5.0% 0.0%

3 % of Heart Failure Patients for which the HF Admission PowerPlan was utilized 75.0% 78.6% 50.0% 100.0% 85.0% 80.0% 83.3% 90.9% 80.0% 81.8%

4% of Heart Failure Patients for whom the PromiseCare Heart Failure Checklist was

utilized91.7% 92.9% 83.3% 100.0% 100.0% 95.0% 100.0% 100.0% 95.0% 100.0%

5 % of Heart Failure Patients for which LVEF was charted 91.7% 85.7% 83.3% 100.0% 100.0% 95.0% 83.3% 90.9% 95.0% 100.0%

6 % of Heart Failure Patients who had a bodyweight measurement taken each day 83.3% 85.7% 83.3% 100.0% 100.0% 95.0% 100.0% 100.0% 90.0% 100.0%

7 % of Heart Failure Patients placed on strict daily Intake & Output. 91.7% 92.9% 83.3% 100.0% 95.0% 95.0% 100.0% 100.0% 90.0% 100.0%

8 % of Heart Failure Patients who received Heart Failure Education. 91.7% 92.9% 77.8% 100.0% 95.0% 95.0% 100.0% 100.0% 95.0% 95.5%

9% of Heart Failure Patients with a 3-5 days post-discharge follow-up appointment

scheduled. 83.3% 57.1% 55.6% 63.6% 75.0% 85.0% 66.7% 72.7% 75.0% 77.3%

10% of Heart Failure Patients on which Medication Reconciliation was completed prior to

discharge58.3% 50.0% 44.4% 90.9% 70.0% 60.0% 83.3% 72.7% 75.0% 68.2%

11 % of Heart Failure Patients with a copy of their Discharge Medication List on their chart 83.3% 64.3% 50.0% 63.6% 80.0% 90.0% 83.3% 72.7% 85.0% 95.5%

12% of Heart Failure Patients who had their Discharge Medication List provided/faxed to

their physician83.3% 64.3% 44.4% 63.6% 80.0% 90.0% 83.3% 72.7% 80.0% 86.4%

13% of Heart Failure Patients with LVEF < 40 who had ACEI or ARB prescribed at

discharge91.7% 78.6% 72.2% 100.0% 90.0% 90.0% 100.0% 90.9% 95.0% 100.0%

14% of Heart Failure Patients for whom the Heart Failure Discharge PowerPlan was

utilized0.0% 0.0% 0.0% 0.0% 5.0% 5.0% 0.0% 9.1% 0.0% 0.0%

Clinical Outcome Measures Baseline Target Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

1 Mortality O/E - Heart Failure 0.83 0.57 0.55 0.76 0.59 0.51 0.37 0.25 0.26 0.33

2 LOS O/E - Heart Failure 0.90 0.68 0.69 0.70 0.72 0.73 0.74 0.74 0.74 0.74

3 Readmission O/E - Heart Failure (30 Day PPR) 1.08 0.74 0.71 0.60 0.64 0.65 0.69 0.62 0.60 0.62

4 Complications - Heart Failure (30 Day PPC) 0.69 0.82 0.76 0.99 0.97 1.11 1.08 1.05 0.97 1.00

5 ALOS

GMC - Silvis

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Diabetes Team

Physician Led – Dr. Figaro

Professionally Managed – Dianna Shie

Expertly Facilitated by Nicole Palmer and Beth Fox

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Total Knee

Physician Led – Drs. Martin and Connolly

Professionally managed – Julie VanDusen

Expertly facilitated by Nicole Palmer and Beth Fox

»

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Heart Failure Phase II

Physician Leader to be determined

Professionally managed – Jacque Oelerich

Expertly Facilitated by Nicole Palmer

»

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PromiseCare Teams in Process

Developing

• PowerPlans / Protocols

• Checklists / Visual Cues

• Diabetes Screening and A1C Results

• Sleep Disorder Screening

• Education for the Patients, Families, Staff and

Medical Staff

• Transitions of Care

• IT Deliverables

• Scorecards

»

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PromiseCare

Integration with HRO, Lean and Baldrige

• Research Best Evidence and Hardwire

• Use of Algorithms, A3’s, Visual Cues, Standard

Work, Value Stream Mapping, Lean the

PromiseCare Process

• Project Management and IT Deliverables

• Education of New Leadership

• Education of New Providers

• Move from Checklists to Care Plans

• Healthcare Team Building

»

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PromiseCare

Questions?

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PromiseCare

Not The End

Only the Beginning

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