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!