A Value-Based Model for Reduction of
Preventable Harm in Medical/Surgical
Inpatients
Thanjavur S Ravikumar, Cordelia Sharma, et al.
HIMSS ME-PI Community Meeting
November 5, 2010
Geisinger Health System, Wilkes-Barre, PA; LIJ Medical Center, New Hyde Park, NY; Albert Einstein College of Medicine, Bronx, NY;
Montefiore Medical Center, Bronx, NY; Feinstein Institute for Medical Research, Manhasset, NY
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Case #1
58 yr old man following colon resection proceeds to
have a massive AMI – Cardiogenic Shock
Issues:
*Despite young age, patient had clinical evidence of
cardiac disease
- risk under estimation
*Post op EKG shows changes, wrong evaluation by
junior resident
- cognitive dissonance
- co-management vs. consultation
*Junior resident Senior resident Attending hierarchy
- power distance
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Case #2
55 yr old morbidly obese woman with sleep apnea
undergoes bowel resection complicated by severe
aspiration, pneumonia & respiratory arrest.
Issues:
* Failure to rescue
* Inter-team communication/care coordination
* Knowledge gap
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Case #3
88 yr old female undergoes radical surgery for pelvis
tumor. On POD # 2 at 6:45 PM patient developed
respiratory distress and decreased oxygen saturation.
Surgical rapid response called. SICU attending as well
as the surgical PA and residents respond. It is quickly
determined that patient requires intubation. Pt is
intubated by the intensivist while plans for transfer to
SICU are made.
Seemingly appropriate traditional mode of care.
Is this sufficient?
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Effective Methods/Factors on
Outcome
• Multidisciplinary focus
• Critical event training/simulation
• Effective communication process
• Physiologically based early warning systems
and intervention
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Hypothesis & Objectives
• Building safe hospital systems to improve valuebased surgical outcomes is predicated on workflow
redesign for dynamic risk stratification, coupled
with “real time” mitigation of risk
– Co-management model for hospitalized surgical
cohort
– Iterative process redesign adaptable to
disparate systems
– Outcome-based; cost-effective = value
paradigm
– Multidisciplinary teams, patient-centered
– Applicability to medical/surgical adult inpatients
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Perioperative Deterioration:
Outcome Depends on Patient Status
Compensated
Stability
Decompensating
Pseudo Stability
Physiologic
Derangement
- - - Lives Saved/QOL
― Disease Progression
Critical Event
Acute Care System Redesign: 3 Zones vs. ROI
ROI / DISEASE PROGRESSION
ROI In Disease Progression Management
Continuum of
Care
Rapid
Response
Zones of Intervention
- - - Return on Investment
― Disease Progression
Code
Team
Continuum of Care:
Program Description and Domains
R & D/Education
Quality
CER
Simulation
Complications
Glossary
SS 360 Scoring
Financials
Unit Specific
Costs
DRG/Program
Based Cost
Total Cost Analysis
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Targeted Response
Preventable Harm Reduction
Workflow Redesign
Co-management of Hospitalized Patients
Intensivist/Hospitalist with Medical/Surgical Teams
Multidisciplinary Rounds
Acuity Stratified HAWK Rounds
Real time communication
Hospital Anatomy Redesign
Hospitalist Led Floor-based Teams
Aggregation of Patients
Formation of safety net – PCU
Mortality
Reduction
Efficiency
Bed Mgmt
Throughput
ED, OR, ICU Impact
Enabling Technologies
EHR
Vocera
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Acuity Based
Rounds
(Hawk/Dove/
Risk Score)
Discharge Planning;
Transition of Care
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Study Design and Methods
Pilot SCoC
1998
A
Validation SCoC
2001
B
C
2001
2005
2004
PHAMIS
Hospital-wide CoC
Medical
Center
Surgery
TSI
SPARCS
Premier
2008
Metrics & Analysis
Dec 2008
Mortality, LOS, Cost, Readmission
Jun 2009
D
Multi-Hospital
Database
Nov 2009
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Linear Regression, Chi-Sq, t-Test,
Fisher, Mann-Whitney U-Test
Siemens
CareScience
QUEST
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Implementation Steps
• Engagement of Stakeholders
• Multidisciplinary Structure:
- Floor based team building/cohorting
- Restructure Hospitalist role/enhance ownership
- One CoC MD – weekly rotation
• Redesign Process Flow
-
Concurrent multidisciplinary CoC rounds in a.m.
CoC morning report
Hawk rounds, TOC, task assignment, TRT
Real time team and external communication
Creation of PCU
• Tools
-
MDRT in Epic
Vocera build out
Mortality analysis, simulation
FCCS training
Protocols, care maps, algorithms
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A Day in the Continuum
7:30PM – 7:00AM
Periodic Hawk Rounds
(10PM, 2AM, 6AM)
AM Discharge Prep
7:00PM – 7:30PM
Hospitalist Handoff
Communication
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20
19
22
“Right
Care”
“Right
Team”
17
16
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2
“Right
Sequence” “Right
Time”
“Right
“Right
Rounding”
Handoffs”
3
4
5
6
Efficient Discharges -11:00AM
Reduce holding – ED and PACU
Real time Communication
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9:30AM – 7:00PM
Hospitalist Patient Care
& Continuum of Care
Hawk Rounds
23 00
15
7
RRT & Code Calls
8
Hawk Rounding
Acuity Stratified Targeted
Response
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13 12 11
9
10
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7:00AM – 7:30AM
Hospitalist Handoff
Communication
7:30AM – 8:00AM
Hospitalist PreRounding on the
Patient Floors
8:00AM – 9:00AM
Simultaneous
CoC Rounds
9:00AM – 9:30AM
Hospitalist & Continuum
of Care MD Hawk Huddle
& Nursing Bed Huddle
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Rounding Tool Domains
Patient List
History
Icon&&Alerts
HAWK List
Provider
Nursing
PT / OT
Pharmacy
Nutrition & Care Management
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Pilot SCoC: Mortality
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Pilot SCoC
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Pilot SCoC: Outcome Summary
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Validation SCoC
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Validation SCoC
*
* Mortality Odds Ratio Index: LIJMC vs. LIJMC - Surgery
2005 vs. 2007
1.2
1.6
Significant at 95% confidence level
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Validation SCoC: LOS
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Validation SCoC: Readmissions
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Hospital-wide CoC: Mortality
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Mortality
CareScience - Confidential Information
Hospital-wide CoC: Mortality
Discharge Dates: 11-01-2008 thru 05-312009
Facilities: GEISINGER WYOMING
VALLEY
Report By: Month
Date Range
Total Outcome
Actual Expected Deviation
Cases
Cases
O/E Ratio
Dec-2008
945
931
3.4%
3.0%
0.5%
1.16
Jan-2009
914
900
3.2%
3.0%
0.2%
1.07
Feb-2009
879
867
2.8%
2.3%
0.4%
1.18
Mar-2009
906
894
2.6%
2.7%
-0.1%
0.96
Apr-2009
1,018
1,005
2.7%
2.7%
0.0%
1.00
922
914
3.0%
2.5%
0.4%
1.16
6,440
6,351
3.0%
2.8%
0.2% *
1.09
May-2009
Totals:
Mortality Rate Comparison -- Geisinger Health System
Discharge Dates: 06-01-2009 thru 11-30-2009
Date Range
Total Outcome
Actual Expected Deviation
Cases
Cases
Jun-2009
916
898
2.7%
2.8%
-0.1%
0.95
Jul-2009
999
984
2.9%
Aug-2009
923
912
2.1%
2.8%
0.1%
1.04
2.5%
-0.4%
0.83
Sep-2009
984
974
2.1%
2.6%
-0.6% *
0.78
Oct-2009
1,045
1,033
2.1%
2.6%
-0.5%
0.83
930
918
2.4%
2.6%
-0.2%
0.92
5,797
5,719
2.4%
2.7%
-0.3% *
0.89
Nov-2009
Totals:
* Significant at 75% confidence level
** Significant at 95% confidence level
Source: CareScience Quality Manager
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Cost Savings
Pilot SCoC
• Cost saved from decreased LOS in PCU
• $851,511 - $2,007,388
Validation SCoC
• ALOS and direct costs by CMS surgical DRG
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Summary
• Hospital Care Delivery Redesign:
– Real time acuity stratification and mitigation of risk
• Applicability to disparate hospital systems /
patient populations
• Cost saving outweighs resource requirement
• Limitations:
– Not an RCT
– Administrative data reliance
– SMR: Constant risk fallacy
“Differential measurement error”
“Inconsistent proxy measures of risk”
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ROI / DISEASE PROGRESSION
Acute Care System Redesign
Patient Safety Strategies
Continuum of
Care
Rapid
Response
Shift to
the Left
Zones of Intervention
- - - Return on Investment
― Disease Progression
Code
Team
Future Initiatives
• FCCS course for hospitalists/mid level
providers/nurses at GWV
• Education using simulation of real case scenarios
• Floor based data on outcomes
• Readmission analysis
• Predictive modeling
- Mortality analysis
- Implementation of SS360 score
- Development of risk stratification score for
medical pts
- Bio markers
• DRG based protocols/algorithms
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Proven Care®
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Case #1
58 yr old man with known CAD/HTN/DM/smoker
undergoes elective colon resection
WHAT HAPPENED
12 PM – Pt comes out of OR
1 AM – Intern evaluates pt for chest pain.
Orders EKG and labs: notifies senior
resident that there are no new EKG
changes - pt’s pain resolves.
4 AM – Nurse calls intern for ↑ HR
intern orders beta-blocker and HR ↓
7 AM – Chief resident notes during rounds
that earlier EKG had significant changes
that intern missed. Cardiology consult
called STAT.
8 AM – Cardiologist diagnoses massive MI. Pt
becomes hypotensive
9 AM – Pt moved to ICU – deteriorates and
expires from cardiac arrest.
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WHAT CONTINUUM OF CARE
COULD DO
12 PM – Pt identified as “HAWK” by
risk stratification thru review of OR
pts with surgical team
2 AM – Pt seen during Hawk rounds.
Intern and CoC review EKG and
identify new changes.
Surgical chief resident and Attg
called. Cardiology consulted.
Cardiologist evaluates pt.
Pt taken to cath lab emergently.
Survives
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Case #2
45 yr old morbidly obese woman develops emesis after
bowel resection: Resp Ther places pt on BIPAP at
night without knowledge of emesis. Pt aspirates
massively due to positive pressure and expires:
Knowledge gap
Lack of inter team communication
Solution: CoC develops simulation based scenario to
demonstrate contraindication of BIPAP and
incorporates in the curriculum of all stake holders
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Case #3
WHAT HAPPENED
POD #1 –
2 AM – Confusion fever
9 AM – O2Sat 79% 2L 02
11 AM – Weaned to RA
1 PM – Labored respirations confusion 02Sat
83%--02 Restarted
5 AM – Multiple episodes of confusion –
psych consulted
POD #2
3 PM – Labored respirations, CXR bilateral
effusions
8 PM – Pt found unresponsive in chair. RRT
called. Pt intubated, TX to SICU
POD # 5 – Extubated
POD # 7 – Transfer to floor
POD # 7 & 8 –Continuum of Care f/u
POD # 9 – D/C to Rehab
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WHAT CONTINUUM OF CARE
COULD DO
POD #1
9 AM –Primary team calls Continuum of
Care team
- Attending/PA Pt evaluated diagnostic
and Tx recommendations made and
Pt triaged to appropriate setting.
Hawk rounding avoids RRT call and
reintubation
Continuum of Care F/U after transfer
from ICU or PCU to floor and
available to surgical team.
POD #7 D/C to Rehab/home
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