Presented by:
Dr. Stephen Taylor, President
West Hospital Ortho Co-Management
Laurie M. Johnson, RN
Executive Director - Orthopaedics
Total Joint Replacement (TJR) has been the
most effective treatment for advanced
arthritis since the 1970’s
Goal of TJR → Quality Results
 Relieve Pain
 Restore Function
 Long Lasting (>25 years)
 Avoid Complications
More than 700,000 TJR’s are
currently performed each year
INCREASING DEMAND FOR
TOTAL JOINT REPLACEMENT
Increasing senior population
Greater desire for active lifestyle
Greater acceptance of TJR by
population
700% increase in TJR in
the next 20 years
INCREASED DEMAND FOR TJR
Success Requires:
1) Adequate physician supply
2) More efficient care process
3) Care process must emphasize VALUE
VALUE IN TOTAL JOINT
REPLACEMENT
Reality:
Healthcare dollars spent
must be controlled and
appropriately allocated
Allocation must be determined
by value of product or service
In TJR we must maintain and
improve quality, but we must
also control costs
IOWA HEALTH-DES MOINES
COMMITMENT
IH-DM committed to meet the increased patient
need for TJR
Current facilities at IMMC couldn’t meet growing
demand for OR’s and patient beds
MWH was designed to
emphasize orthopaedic
total joint care dedicating
4 of the 6 OR’s and 50%
of the patient beds
MWH ORTHOPAEDIC SERVICES
 Focused, specialized care
Mutual project between IH-DM and
Des Moines Orthopaedic Surgeons, PC
Aligned incentives of both organizations
to improve QUALITY and VALUE for our
patients
“Co-Management” organization was
formed to manage the entire process
WEST HOSPITAL ORTHOPAEDIC
CO-MANAGEMENT COMPANY, LLC
The WHOCC oversees the entire
orthopaedic service line at MWH
emphasizing quality, patient safety &
convenience, efficiency and
cost containment
Equal representation from IH-DM & DMOS
Medical Director from DMOS
Develop and
oversee all cost
containment
activities
Supervise
and/or train
management
staff
Develop
comprehensive
plan of care for
all orthopaedic
patients
Implement and
direct strategic,
financial and
operational plans
WHOCC
MANAGEMENT
ACTIVITIES
Assist in
developing
operational and
capital budgets
Evaluate and
recommend
equipment
purchases
Assist in
facilities
management
WHOCC BUSINESS MODEL
Executive Committee
Finance Committee
•Meets bi-weekly
•Meets quarterly
•Working committee
•Includes the Ortho
Executive Director
•Reviews financials
and makes
recommendations
•Reports to the
Governing Board
•Reports to the
Governing Board
WHOCC GOVERNING BOARD
•Oversees all committee activities
•Reviews & approves meeting minutes
•Makes final decisions
WEST HOSPITAL ORTHOPAEDIC
CO-MANAGEMENT COMPANY
Initial project was to interview and select the
following key personnel:
Orthopaedic service-line Executive Director
Inpatient department Nurse Manager
Surgical Services department Nurse Manager
Physical Therapy department Manager
All personnel are employees of IH-DM
WHOCC TEAM REVIEWS
AND SETS ALL PROCESSES
All physicians expected
to comply at MWH
No significant exceptions
are allowed
All physicians are invited
and encouraged to
participate in the process
STANDARDIZED, UNIFORM
PROCESSES AND PROCEDURES
Rationale: Repetitive, focused process and
procedures maximizes efficiency and minimizes the
risk of error or oversight.
Examples:
OR nurses comfortable working with any surgeon due to
standardized draping, supplies and instructions
Nursing unit care doesn’t vary by physician (common pain
management regimen, blood transfusion protocol, dressing,
etc…)
One standard Physical and Occupational therapy regimen
for all surgeons that can be tailored to the individual needs
of each patient
EXAMPLES OF UNIFORM PROCESSES
CREATED AND IMPLEMENTED BY WHOCC
1.
2.
3.
4.
5.
6.
7.
Pre-op medical clearance request form
Standardized scheduling process and form
Pre-op orders
Regional anesthesia
Demand matching of implants
Comprehensive uniform post-op orders,
including pre-emptive multi-modal pain
management
Uniform activity and physical therapy goals
WHOCC ACTIVITIES
VALUE IN TJR
New techniques, equipment and implants must
be critically evaluated by hospital and physicians
Those new techniques or implants that add cost
without significant improvement in quality should
be avoided
EVALUATION OF NEW TECHNIQUES
AND SURGICAL PRODUCTS
Is there enough
scientific
evidence to
warrant a trial?
Trial with
defined
evaluation and
results
Review by
committee to
assess
quality and
value of
technique
Confirm or
deny use of
technique or
product
EVALUATION PROCESS EXAMPLES







Floseal → deny (evidence didn’t support)
V-lock suture → confirm (all use)
Participated in ‘Draping Boot Camp’ to
streamline, trial and standardize surgical
drapes → confirm (all use)
Surgical prep (Chloraprep) → confirm (all use)
Eliminated many trays by developing common
instrument sets for all physicians by procedure
→ confirm (all use)
Covaderm Surgical Dressing → future trial
Cold therapy/DVT wrap → future trial
WHOCC PHYSICIAN COMPENSATION
1. Base Management Fee
 Hourly at Fair Market Value
2. Incentives




Quality of service
Operational efficiency
Financial/budgetary
New program development
INCENTIVE COMPENSATION DEVELOPMENT
Measurable
Controllable
Realistic
Bound by
time limits
2010 INCENTIVES
Quality of Service (50%)
SCIP Core Measures
Patient Satisfaction
Demand Matching
Operational Efficiency (20%)
On-time starts
OR turnaround time
Financial/Budgetary (20%)
Length of Stay
Cost per Case
New Program
Development (10%)
Expanded Patient Education
2011 INCENTIVES
Quality of Service (50%)
SCIP Core Measures
Patient Satisfaction
Demand Matching
Financial/Budgetary (30%)
Cost per case (Goal – 4%↓)
Vendor negotiations for
spinal implants
New Program Development (20%)
Hip and Knee scoring
Infection rates (within 60 days)
Readmission rate (within 30 days)
Revision rate (within 1 year)
INCENTIVE STRUCTURE
2011 INCENTIVE FOR SCIP CORE MEASURES (15% OF TOTAL)
RANGE FROM:
TO:
ANNUAL PAYOUT:
<95%
$0
≥95%
<96%
60% of SCIP incentive
≥96%
<97%
80% of SCIP incentive
≥97%
Full Incentive
2011 INCENTIVE FOR PATIENT SATISFACTION (20% OF TOTAL)
RANGE FROM:
TO:
ANNUAL PAYOUT:
<91.1
$0
≥91.1
<91.9
50% of Pt. Sat. Incentive
≥91.9
<92.3
75% of Pt. Sat. Incentive
≥92.3
Full Incentive
VENDOR NEGOTIATIONS
1.
All implants placed in category based
on technology
•
•
•
2.
Cemented femoral stem
Tapered non-cemented stem
Revision stem
Each category included “substantially
similar” implants
3.
Target price established by WHOCC
4.
All vendors allowed to participate
VENDOR NEGOTIATIONS,
continued…
5.
Implants that meet target price for each
category become “preferred” and
permitted to use at MWH
6.
Use of outliers is strongly discouraged
7.
In a few select categories competitive
bidding utilized – only one implant from
single vendor allowed
eg. Modular revision femoral stem (one
vendor, one price for all components)
eg. Revision segmental hinged knee
DEMAND MATCHING
All implants categorized by
Quality Level and Cost
A Level – Lowest cost
B Level – Intermediate cost
C Level – High cost
DEMAND MATCHING cont…
Three Patient Variables Considered
1. Patient Age
2. Patient Health
3. Patient EXPECTED activity level
(scanned copy of form here)
DEMAND MATCHING cont…
>90% Compliance expected
Results are reported by
Individual Physician
All Physicians
Transparency is a great motivator!
WHOCC - SUMMARY
1. Aligned incentives of hospital and
surgeons that are required for success
2. Emphasis on Quality and Cost = Value
3. Recognize importance and contribution
of ALL team members:
•Surgical Techs & Nurses
•Patient Care Facilitators
•Management Staff
•Therapists
•Patient Care Techs
•Physicians
Ultimate winners:
•Patients •All team members
WEST HOSPITAL ORTHOPAEDIC
CO-MANAGEMENT COMPANY
OUR COMPANY
Is COMMITTED to
FRESH THINKING
and
INNOVATIVE CARE
THAT ADDS
DATA COLLECTION
 Information received monthly from various systems
• Finance
• ORSOS
• Purchasing
• Clinical Quality
 Review, calculate and report Incentive Metric data
monthly to Executive Committee
 Determine if there is other data outside of the metrics
that needs to be reported
 On-time starts, turnover times, and Average Length of Stay
(ALOS) are not part of the 2011 metrics, but continue to be
monitored monthly for significant changes
 Volume and cost data from broken, lost and (not) found
instruments in Central Sterile is reported to the Executive
Committee & the staff each month
 The cost of implants that are opened but unused are reported in
conjunction with the demand-matching metrics
DATA COLLECTION continued…
 Whenever possible, total volumes are reviewed rather than
randomized selections
 100% of all total joint procedures are reviewed for correct implants
 Over 90% of all eligible patients are included in the SCIP Core Measure
data review
 In addition to the overall patient
satisfaction score, each physician’s
scores are calculated and reported
 Direct variable cost-per-case is
reported/reviewed by surgeon
 All data is presented as an
overall score and also by
each physician and procedure
Transparency has been a key motivator for physician change
QUALITY OF SERVICE
2010 GOAL
2010
ACTUAL
2011 GOAL
2011
CURRENT
DVT Prophylaxis within 24 hours
before/after surgery
99.8%
100%
Appropriate antibiotics within
1 hour prior to surgery
98.7%
99.4%
Antibiotics stopped within 24 hours
after surgery ends
98.8%
100%
n/a
n/a
85%
SCIP Overall Average
≥97%
99.3%
≥97%
96.1%
Patient Satisfaction
≥87
91.2
92.3
90.4
≥90%
88.7%
≥90%
89.2%
% of patients who are normothermic
after 15 minutes in PACU
Implant Demand Matching
OPERATIONAL
EFFICIENCY
On-time starts
OR turnaround time
NEW PROGRAM
DEVELOPMENT
Expand Patient Education
All total joints patients at MWH
Hip and Knee Scoring
Primary hips & knees only
Infection rates (w/in 60 days)
Primary hips & knees only
Readmission rates (w/in 30 d)
Primary hips & knees only
Revision rates (w/in 1 year)
Primary hips & knees only
2010 GOAL
2010
ACTUAL
2011 GOAL
2011
CURRENT
≥93%
91.8%
n/a
n/a
≤20 min
16 min
n/a
n/a
2010 GOAL
2010
ACTUAL
2011 GOAL
2011
CURRENT
n/a
n/a
New program written by Patient
Care Facilitators
Forms have been developed,
data collection begins 5/1/2011
n/a
n/a
n/a
Still calculating
<1.5%
Still calculating
n/a
n/a
<5.0%
0.5%
n/a
n/a
<2.0%
Still calculating
AVERAGE
LENGTH OF STAY
Primary total hip and knee
pts, commercial payers only
4.5
2008
2009
2010
2011
CURRENT
4.17 days
3.94 days
2.81 days
2.84 days
4.17
3.94
4
3.5
2010 goal
3.45 days
3
2.81
2.84
2010
2011
current
2.5
2008
2009
DIRECT VARIABLE
COST-PER-CASE
Primary total hip and
knee pts, commercial
payers only
2008
2009
2010
2011
CURRENT
2011
GOAL
$8,703
$8.847
$8,186
$7,720
$7,939
9,400
9,000
8,703
8,847
8,959
2010 goal
$8,196
8,972
8,772
2011 goal
$7,939
8,573
8,600
8,186
8,200
7,834
7,800
7,720
7,400
2008
2009
Feb-10
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
SUMMARY
 DO recognize that consistent, substantiated data is a key factor in
engaging the physicians and staff to achieve success
 DON’T underestimate the value of immersing yourself in the details
 DO plan to be in this ‘for the long haul’
 Success doesn’t happen overnight
• DON’T hesitate to build relationships with people who can help you
 The advantage of a large organization is that many people are there to
assist, but you may have to search for them
 DO communicate results regularly with front-line staff
 They will be very engaged in the process
 They can have a big impact on achieving positive outcomes
 DON’T overlook the small successes
 These are most important when things are progressing slowly
DO celebrate every milestone along the way, and DON’T
forget to have fun!