3 Strategies for Maximizing Service Line Efficiency, Quality and Profitability
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The document discusses strategies for enhancing the efficiency, quality, and profitability of orthopedic service lines, emphasizing the importance of surgical first assists, operational alignment, and data transparency. It outlines methodologies for identifying operational and clinical indicators, closing gaps in service delivery, and implementing change management strategies. The document also highlights the criticality of sustaining improvements through effective governance, patient-centered care, and the integration of metrics and dashboards.
3 Strategies for Maximizing Service Line Efficiency, Quality and Profitability
- 1. 3 Strategies for Maximizing Service Line Efficiency, Quality, and Profitability Miki Patterson PhD RNFA ONP Vince Capasso, MSF, FACHE, MBB 1
- 2. Speakers Miki Patterson PhD RNFA ONP • Certified Orthopedic Nurse Practitioner • Over 30 years of clinical experience in healthcare, consulting, RNFA, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing • Past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care • Dr Patterson has done extensive work with hospital leadership desiring to improve their clinical quality and process issues while teaching change management and giving voice to clinicians and hospital personnel. • PhD in Nursing Research from University of Massachusetts Medical School, a Master’s Degree from Boston College, and her B.S. in Nursing at Fitchburg State University Miki Patterson, PHD ONP Senior Director, Intralign Intelligent CareDesign 2
- 3. Speakers Vince Capasso • Certified Six Sigma Master Black Belt and Fellow in the American College of Healthcare Executives • Over 30 years of Business, Process Design, Strategy Deployment, and Balanced Scorecard experience in a broad variety of organizations that include consulting, government, manufacturing, service, and healthcare. His business experience includes executive leadership positions in Accounting, Finance, IT, and Supply Chain functions. • Vince has managed hundreds of complex Process Improvement and Strategy Deployment projects. He has taught extensively on Lean Six Sigma, Human Centered Design, and Strategy Deployment; has developed Lean-Six-Sigma and Change Management courses for many global organizations, and has been published in national journals on the subject. • Master of Finance degree from Bentley University and Vincent Capasso, MSF, FACHE, Six Sigma Master Black Belt Senior Director, Operational Process CareDesign a B.S. of Accounting degree from Southern New Hampshire University 3
- 4. Objectives As a participant, you will be able to: • Identify key operational and clinical indicators of orthopedic service line efficiency • Describe how Surgical First Assists can add value in the OR • List the steps in developing and/or evaluating or building an orthopedic service line • Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line 4
- 5. Healthcare in Transition Providers must increase efficiency and control 5 When outcomes are linked to reimbursement, providers must drive towards value based care.
- 6. Sample of Total Joint Service Line Cost • Roughly 45% of Episode costs are incurred in the intra-operative space • Controlling the intra-operative space is key to improving efficiency, reducing cost and • Control begins in the Operating Room with efficient surgeon extension • To gain Total Joint Service Line Excellence status, data transparency, process refinement, Rehab $5,000 (10%) Acute Post-Op $5,000 (10%) marketing and supply chain excellence are also needed Intra-Operative $22,500 (45%) Implant 41% Hospital 45% increasing quality Clinic/ “Pre-hab” $15,000 (30%) Admission/ Pre-Op $2,500 (5%) 6 Episode of care costs
- 7. Bending the Cost Curve • Alignment of surgeons and hospitals; clinical and operational goals • Integration of tools and strategies to enhance transparency and accountability • Change management – Strength and capability to affect lasting, sustained change 7 Innovative Vision
- 8. 1. Alignment Alignment of Surgeons, Clinicians, and Hospital with Patient Needs
- 9. Alignment Why isn’t everyone on the same page? The right tools can bring clarity to goals and objectives and create a common purpose. 9 It takes some work!
- 10. 3Ps of Alignment Process Purpose People Purpose • Is Direction Clear? • Is the message Heard & Understood? • Are we using the right metrics? • Do we have a Strategy Deployment Process? Process • Are staff and managers trained in problem solving? • Is there a structured Process Improvement Methodology? • What is the level of Efficiency? • Does the Organization utilize standard work? People • What is the level of Staff Satisfaction? • Are we Patient-Centric? • Are there Appropriate Resources? 10
- 11. First, understand the various voices you will hear. Each has a different perspective. Voice of the Customer (VOC) • Used to describe customers’ needs and their perceptions of your services, product, or process. Voice of the Business (VOB) • Used to describe your business’ needs in creating the service or product. Voice of the Process (VOP) • Used to describe the current state of the process; how is the process performing. Is it capable of meeting customer needs? 11
- 12. Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Management & Staff 12 Education and Staff Equipment Development Culture Trust/Cohesiveness/Accountability Teamwork Intra Dept. Financials ROSE / Positive BUD / Opportunities THORN / Problems C-Suite Leadership “Revolving door” Patients Surgeons IT Systems MD Engagement Staffing Levels Facilities Engagement Efficiency New Ventures Teamwork Inter Dept. Culture Autonomy & Environment New “learning” Leadership Staff Flexibility Surgeons not Engaged
- 13. Gather Voices and Affinitize the “Themes” Rose, Bud, Thorn Exercise | Patients 13 The Doctor is not always listening Not answering call-bells promptly Great Nurses ROSE / Positive Room has a View Surgery went Well Food is Very Bad Was in Pain Waited a LONG Time Nurse did Not Listen Crowded and Loud Hallways Would Like to have Facilities need meal time flexibility upgrading Lots of noise Receptionist was Rude Great PT Staff My Surgeon is Abrupt BUD / Opportunities THORN / Problems
- 14. Summarize the “Voices” and Synchronize with Strategy Voice of The Business Voice of The Process Voice of The Customer 14
- 15. 2. Closing Operational Gaps Understanding Gaps Between Current State vs. Desired Future State
- 16. Service Line Excellence The Drivers of Service Line Excellence Clinical & Operational Excellence: Pre-Op, Intra-Op, Post-Op Service Line Integration & Efficiency: Patient Care Journey Supply Chain Best Practices Infrastructure and Practices in Place to Drive Continuous Improvement Effective Governance within a Just & Safe Culture Effective Information Systems Structure & Analytics Optimized Financial Management Alignment of Partners Across the Continuum of Care 16
- 17. 17 Clinical and Operational Excellence Efficient, Safe, High Quality Processes Appropriate/Optimized Staffing Effective/Efficient Sterile Processing Employ Best Clinical Practices Patient-Centered Care % of patients with medical clearance 14 days prior to surgery % charts with History & Physical complete 10 days prior to surgery 85% + On Time First Case Starts Time patient waits in holding area Frequency of same OR team operating together Staffing levels are appropriate based on predictive modeling Avg Turn Around Time < 21 min Standard process in place and followed for OR set-up Defect-free transfer of patient to PACU Patient assessment complete and documented within 30 minutes of arrival in PACU and every hour thereafter Driver Critical to Success Indicator Critical to Success Metrics
- 18. How Does The Critical-to-Success Tool Work? Goal Drivers Critical to Success Indicators Big Goal Goal Driver #1 Goal Driver #2 Goal Driver #3 Critical to Success Indicator 1 Critical to Success Indicator 2 Critical to Success Indicator 3 18
- 19. Building the Critical-to-Success Tree Drivers are like themes. They frame and compartmentalize the goal. Goal Drivers Increase Ortho Margin Strong Surgeon Alignment Surgical Process Efficiency Best Practice Implant Management Standardized Processes Patient-Centered Care 19
- 20. Building the Critical-to-Success Tree Goal Drivers Critical to Success Indicators Critical to Success Indicator (CTSI) These are another layer of compartmentalization. They break down the drivers into measurable areas. Increase Ortho Margin Strong Surgeon Alignment Surgical Process Efficiency Best Practice Implant Management Standardized Processes Patient-Centered Care 20
- 21. Building the Critical-to-Success Tree Goal Drivers Critical to Success Indicators Increase Ortho Margin Strong Surgeon Alignment Surgical Process Efficiency Co-Management Agreement in Place Surgeons Are Engaged Best Practice Processes Hospital provides consistent surgical teams 21
- 22. Building the Critical-to-Success Tree Critical to Success Indicators Critical to Success Metrics Co-Management Agreement in Place Surgeons Are Engaged Best Practice Processes Hospital provides consistent surgical teams 20-30% of compensation is tied to gain sharing On Time Starts at 85% + 75%+ of Surgeons participate in shared governance activity 22
- 23. Timeline: Knee Replacement Observation 23 Illustrating Pain Points 7:45 8:15 8:45 9:15 9:45 10:15 10:45 11:15 11:45 12:15 12:45 1:15 1:45 2:15 2:45 Pt. in Room 10:22 Tourniquet Off 12:05 Time Out 10:26 Incision 10:56 Surgeon Exit 12:35 Dressing On 12:49 Pt. Arrives in Pre-Op 8:30 Anes. Arrives for Nerve Patient Waits 67m Block 8:57 Patient Waits 27m 2nd Time Out 10:53 Nerve Block Induction 9:15 Patient Wheeled Out 12:56
- 24. Spaghetti Diagram: Hip Surgery 24 Metric Mapping Key | # of In & Outs Surgeon: 1 RN Circulator: 16 Device Rep: 9 Scrub Tech 1: 1 Scrub Tech 2: 6 Scrub Tech 3: 5 PA: 1 Anesthesia 1: 0 Anesthesia 2: 1 Other: 2 Total: 42
- 25. Value Stream Map : Flows and Waste 25
- 26. 3. Implementing Change Using the Correct Tools and Approach to Move the Organization to a New Reality
- 27. Identify “Quick Wins” First 27 Quick Wins 1 Update white Boards - room and Central (time slots for discharge and rehab) 2 Discharge Education Class - Pilot 3 Night before discharge call to family for transport 4 ON-Q ordering process / Improve 5 Nursing pain management assessment/training (i.e. heel slide to check pain) 6 Room discharge clearing for cleaning: belongings, CPM, tubes, meds, etc.. 7 “Room Dirty” notification process 8 Sleeper sofa/plan around overnight 9 Potential for CPM install in AM/tech - day of discharge 10 Unit TV with Ortho-specific media content 11 Consider switching rehab gym with waiting room gym 12 PACU and TJ Floor use dual monitors | PACU needs Teletracker monitor, TJ Floor needs PICIS monitor
- 28. Plot projects based on Resources and ROI 28 What will give you most benefit for least effort? Roadmap of High-Impact Tactical Projects | Example High Med Low Improve Discharge Process Streamline Surgical Flow Reduce Case Time Late Starts Staff Resource Planning Low Med High Return on Investment: Hard $ only Resources Required (time, effort, staff, cost) Improve Time Out Disposable Supply Improvement – Outside OR Core Cell Saver Analysis/Redesign Antibiotic Cement Analysis/ Redesign Maintenance and Equipment Improvement Surgical Set Analysis/Flow Improve Surgical Scheduling Disposable Supply Improvement – OR Core Medicare TJA Bundled Care Data Mapping Revenue Cycle Assessment TDABC Model TJA Supply Chain Implant Cost Medicare Pricing Accuracy Improve TJA Education
- 29. Week 1-3 Week 4 Week 5 Week 4-15 Week 16 Assessment Project Kick-Off Roadmap Remaining Projects Onsite Remote Coaching Onsite Remote Coaching Onsite Remote Coaching Co-creation, Recommendations, & Pilots Dashboard Implementation 100 Day Sprint Methodology 29
- 30. Process Transformation: Project Examples Sample Results: Peri-Op Infection Rate Reduction Problem Result Total Joint infection rates were at 3% vs a national average of .72%. After 6 months the total joint infection rate was 0% resulting in a projected savings of $1.4 million per year through avoidance of extended length of stay/treatment and readmission. 30
- 31. Process Transformation: Project Examples Sample Results: Surgical Cancelation Rate Reduction Problem Result The cancellation rate dropped to 6% and identified the potential to improve margin by 1.4M with estimated margin impact for FY 2013 of $500K. 31 The surgery cancellation rate was consistently high for three years, at 13% at the time of engagement.
- 32. Intelligent Process Transformation Sample Results: Supply Chain Efficiency Problem Result The hospital was experiencing high supply cost, increasing OR supply chain labor cost, stock-outs and excess inventory. Reduced total supply inventory by $670K. Reduced supplies on specialty carts by $70K and reduced labor cost of $80K. Before Before After After 32
- 33. “Sales reps have created this necessity for themselves with the surgeon, and we’re saying it’s not as necessary as everyone thinks it is.” Justin Freed, Executive Director of Supply Chain at Loma Linda University Medical Center Source: Lee, Jaimy. "Devicemaker Sales Reps Being Replaced in the OR." Modern Healthcare 16 Aug. 2014
- 34. The Role of the Sales Rep Influencing the Cost of Orthopedic Implants • Lack of price transparency and rep presence leads to unnecessary up-sell • Rep or multiple reps in OR slows room turnover • Clinical support provided by the rep is not free – charged through hefty SG&A implant cost The result: Loss of control, reduced efficiency and higher supply costs. 34
- 35. Effective Support of Operational & Clinical Efficiency Specialized SFAs – the Smarter Alternative Low High Doctors assisting Partners Practice Employed SFAs Freelance SFAs Hospital Employed SFAs Specialized SFAs Advanced Surgical Support Adds Value in the OR 35 Skill Level / Efficiency
- 36. Consider Advanced Surgical Support Specialized Surgical First Assists are a Highly Skilled Group of Surgeon Extenders Experience Matters: University of MD St. Joseph Medical Center Case Study / 2013 data Procedure Actual procedure time Typical procedure time* # of 2013 procedures Minutes freed General Surgery 100 138 1123 42,674 Urology 205 270 117 7,605 GYN 128 138 80 800 *Estimated average surgery time without SFA is based on 2012 Medicare data and top HCPCS codes associated with each procedure area. 36
- 37. Sustaining the Gains Maintaining Accountability, Automating Dashboards and Linking Metrics to Projects
- 38. Maintaining the Gains / Strategy Execution 38 Use Dashboards to track key metrics Strategy Goals Metrics Projects Responsible
- 39. Maintaining the Gains / Strategy Execution Using your Critical to Success Metrics focus your data collection on the metrics that drive success Strategy Goals Metrics Projects Responsible 39
- 40. Thank You