reducing practice variation · case study severe sepsis care path team. many thanks to the entire...

Reducing Practice Variation

WORKSHOP

Seth Podolsky, MD, MS, FACEPCMO, Ambulatory & Integration

Banner Health System

May 2, 20191:00 pm – 2:15 pm

“We do not come to fear the FUTURE. We

come here to shape it.”

– Barack Obama

DisclosuresPatient Forecaster, Inc., Denver, CO

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Objectives

• Explore existing and future clinical care paths / guidelines to improve clinical processes and patient outcomes

• Discuss assets of technology that can support clinical decision making, as well as potential barriers

• Share process improvement best practices and projects that reduce practice variation

• Have fun!

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Agenda – Reducing Practice Variation Workshop

• Case study• Work sessionAimsProcess & OutcomesChange ideasPilot Study

• Debrief

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What are we trying to accomplish?How will we know if change is an improvement?

What change can we make that will result in an improvement?

Plan

Do

Study

Act

Improvement Model

Langley et al., The Improvement Guide7

Process Improvement Worksheet

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1) Aims• What is your goal?• Who is your population?

Adapted from Nelson et al., The Joint Commission Journal on Quality Improvement, Vol 22, Issue 8: Aug 1996, 531-548

2) Process & Outcomes• What is your current process?• How do you measure success?

Access System Assessment Diagnosis Treatment

Patient with need for “x”

Follow-Up

3) Change Ideas• What process redesign might get better results?

Clinical OutcomesMorbidity & Mortality

FunctionalHealth Status

Patient Satisfaction

CostsDirect & Indirect

4) Pilot Study• Timeline, stakeholders, next steps

Case Study Severe Sepsis Care Path Team

Many thanks to the entire improvement team for their time, effort, slides and success …Drs. Guzman, Gullett, Reddy, and Podolsky, as well as Virginia Foster, Lisa Smith, and all the personnel who improved care for our patients in the Emergency Services Institute and the

Respiratory Institute at the Cleveland Clinic Health System

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Severe Sepsis Care Path

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1. Care Path Guide

2. Pilot Implementation

3. Pilot Results

Nationally

• Incidence ↑83%

• Mortality 30-45%

• $25,000-$50,000 per episode

• 2/3 of patients > 65 years

• 1 of top 5 ED malpractice claims

Sepsis: Target Opportunities

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CCHS

• Surviving Sepsis Guidelines est. in 2003

• No standard screening process or method

• No tracking of adherence to sepsis bundles

• ED average length of stay > 5 hours

Severe Sepsis Care Path Guide

Early screening of patients for

sepsis

Compliance with 3- and 6-

hr sepsis bundles

Expedited admission

process

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1. Care Path Guide


3. Pilot Results

Sepsis Pilot Plan

• Pilot Scope ED to MICU

o Screening

o Throughput

o Compliance with 3- and 6-hr bundles

Academic hub

Regional hub

• Project Team ED ICU RT Pharmacy Lab Throughput CSO CI

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Sepsis Pilot Training

• Sense of urgency• Disease• Process • Overcoming bias• Leadership support• 100% caregivers

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Sepsis Pilot Monitoring

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Sepsis Pilot Implementation

• Real-time data

• Continuing education

• Cycles of improvement

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1. Care Path Guide


3. Pilot Results

278293

232

100

150

200

250

300

350

Feb-Apr2013

Oct-Dec2013

Feb-Apr2014

ED Length of StaySepsis ICU Admissions

319

283

241

100

150

200

250

300

350

Feb-Apr 2013 Oct-Dec2013

Feb-Apr 2014

ED #1 ED #2

Feb-Apr 2014 compared to:o Feb-Apr 2013 - ↓ 24% (78 min)o Oct-Dec 2013 - ↓ 15% (42 min)

Feb-Apr 2014 compared to:o Feb-Apr 2013 - ↓ 17% (46 min)o Oct-Dec 2013 - ↓ 21% (61 min)

(median time in min)(median time in min)

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Estimated Observed Inpatient LOSSepsis Admissions

15.312.3

0

5

10

15

20

2013n=205

2014n=235

Days

ED #1 ED #2

9.27.2

0

5

10

15

20

2013n=177

2014n=185

Days

↓ 3 days

↓ 2 days

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Sepsis Pilot: Summary of Results

Pilot Timeframe: Feb-Apr 2014

ED #2

↓ 1 hr. ED LOS

↓ > 24 hr. Hospital LOS

↑ 21% ICU pts. d/c home

ED #1

↓ 1 hr. ED LOS

↓ > 24 hr. Hospital LOS

↑ 11% ICU pts. d/c home

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Sepsis Care Path: Next Steps

Informatics Changes

Order sets

Screening alert

BI reports

Process Expansion

Emergency Departments

Inpatient Floors

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Explore existing and future clinical care paths / guidelines to improve clinical processes and patient outcomes

Objective 1

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What are opportunity areas in your ED?Where does evidence exist, yet practice varies?

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Examples

• Spine• Stroke• STEMI• Pulmonary embolism• Pediatric mild head injury

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Discuss assets of technology that can support clinical decision making, as well as potential barriers

Objective 2

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How are clinical decision support tools incorporated into your work flow?Any example of shared decision making with your patients?

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Share process improvement best practices and projects that reduce practice variation

Objective 3

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Be so good they can’t ignore you.

- Steve Martin

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Let’s Get To WorkRight after this commercial message and a bathroom break …

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Workshop

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Case Study

Project Aims

Process Mapping & Outcomes

Change Ideas

Pilot Study

Debrief

What is the problem to solve?Where does variability exist across your system?

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Follow-Up








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Follow-Up







What are your aims?Think S.M.A.R.T. 5 min break out

(SMART = specific, measurable, achievable, relevant and time-bound)

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Follow-Up







Clinical Process & Outcome Model

From Dr. Paul Batalden 37

Multiple Patients

From Dr. Paul Batalden 38

BiologicalMorbidity & Mortality




Outcomes = Results of Care

© Trustees of Dartmouth College 39

What is your current process? Clear outcomes measures?15 min group work5 min report out

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Follow-Up







1. ModifyInput

2. CombineSteps

3. Eliminatehand-off failures

4. EliminateStep

5. Reorder sequence

7. Replace with better value step

6. Arrange to changeprocess concept

8. Based on output,redesign production

9. Based on use of output, redesign product

10. Based on need, redesign

Clinical Improvement Action Guide, Nelson et al., JCAHO, 1998, p. 109-110

ChangeConcepts

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Travel

Unnecessary movement or relocation of items

I have orders to run some tests.I’ll bring the patient

right over.

Waiting Area

Sigh…..!!

© Cleveland Clinic 43

Underutilized Human Talent

Not asking the staff that works the process how to improve it© Cleveland Clinic

I’ve made a few changes to the

process.

Staff

Staff

Staff

Manager

I wish someone would ask OUR opinion…!

Staff

Staff

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What process redesign might get better results?10 min group work5 min report out

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Follow-Up







Steps for a pilot study?Timeline, stakeholders, etc.10 min group work5 min report out

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How Do You Replicate Across A Health System?

Replication Methods

Burst – by Care Path• One care path spread across the

region simultaneously• Lower likelihood of index care

path patient• Support may be enormous

Cluster – by Hospital• Multiple care paths at one site• Higher likelihood of index Care

Path patient• 24/7 support of onsite IT

specialist• BenefitsSingle education for 4 care pathsLess travelLess fatigueTargeted supportLess confusion

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Cluster ApproachFour Care Paths• Spine

• Stroke

• PMHI

• Sepsis

Replication Team• Physician

• Physician Specialist

• Project Manager

• Support Team (trainers)

• *Medical Director (site specific)

• *Super User (site specific)

Pre-meeting•Medical Director•Nurse Manager

Education•2 sessions per day/2-3 days•Case for change•Current State•Demo/Slides

Launch•GTM – 30 min. daily check-ins (1st week)

•1 week support 24/7

30 day check-in

Performance monitoring •Ongoing

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Next Steps

Vet plan with ESI Care Path Committee &

key stakeholders

Secure approval from IT to provide support staff

(trainers)

Create and send

communication plan to ED

Medical Directors

Select dates & schedule sessions

Launch first two sites

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November 2014Care Path Replication Calendar

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

1

2 3 4 5 6 7 8

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

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ED 1 & 2

• Pre-meeting• Medical Director Nurse

Manager• Education (2 sessions per day)

• Case for Change• Current State• Demo/Slides

• Launch/Support• GTM – 30 min. check-ins

(1st week)• 1 week support 24/7

• 30 Day Check-In

ED #3 ED #3 ED #3

ED #3

ED #3

ED #3

ED #3

ED #3

ED #3

ED #3

ED #4

ED 1 & 2

ED 1 & 2

ED 1 & 2

ED 1 & 2

ED #3

ED #4 ED #4 ED #4

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DebriefWhat is one part of the workshop that you enjoyed and why?

What is one thing that you would change and why?

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THANK YOU!!Dr. Seth Podolsky

[email protected]

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Making health care easier, so life can be better.

mailto:[email protected]

reducing practice variation · case study severe sepsis care path team. many thanks to the entire...

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