Launch Kickoff Meeting April 15 2015 Welcome Dr Judith Steinberg MD MPH Deputy Chief Medical Officer Commonwealth Medicine University of Massachusetts Medical School 2 PSH Pilot Launch Kickoff Meeting Objectives ID: 908213
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Slide1
Perioperative
Surgical Home Pilot
Launch Kick-off Meeting
April 15, 2015
Slide2WelcomeDr. Judith Steinberg, MD, MPHDeputy Chief Medical Officer
Commonwealth Medicine University of Massachusetts Medical School2
Slide3PSH Pilot Launch Kick-off Meeting Objectives
Present overall goals, team processes for change and team process measures for the PSH PilotPresent Pilot outcomes measure slate and process for data collectionIdentify next steps for implementation of the PSH Pilot3
Slide4AgendaWelcome Pilot Goals
Pre-op TeamIntra-op TeamPost-op TeamPost Discharge TeamOutcomes TeamNext Steps4
Slide5“I have a Dream”5
Slide6Perioperative Surgical HomePSH™
Urology Pilot Kick-off RetreatJan 13th 2015
Slide77
Slide88
Slide9Perioperative Surgical HomePSH™
Urology Pilot Launch MeetingApril 15th 2015
Slide10Shubjeet Kaur MD, M.Sc.HCM
Professor and
Chair of AnesthesiologyUniversity of Massachusetts Medical School
UMass Memorial Medical CenterWorcester, MA 10
Slide11HARD Work
11
Slide12Thank You
12
Slide13What is the PSH?
The PSH is a patient-centered, physician-led interdisciplinary, and team-based system of coordinated patient careSpans the entire experience from decision of the need for any invasive procedure—surgical, diagnostic, or therapeutic—to discharge from the acute-care facility and beyond 13
Slide14PSH Overview14
Slide15Creating Consistent, Seamless Care
Patient-Centered Medical
Home TeamPerioperative Surgical Home Process15
Slide16Key Components of the PSHPatient ExperienceCost Analysis
Quality MetricsPerformance ImprovementData Management Collaboration: Surgeons, Hospital Administration, Other StakeholdersOutcomes Tracking 16
Slide17ASA National Learning Collaborative
Launched July 201417
Slide18Learning Collaborative Members18
A diverse group of health care organizations that includes:18 Academic Medical Centers16 Community Hospitals7 Group Practices/ASCs3 Pediatric Hospitals
Slide19Pilot PSH ProjectsOrtho/Total Joint (18)Colorectal/ERAS/ERIN (5)Idiopathic Spinal Fusion (4)
Urology (2)Adenoidectomy-Tonsillectomy (1)19
Slide20Measuring the Impact of the Model
Selected common metrics with the goals of:
Quantifying the impact of the model on costs, quality, and patient experienceIdentifying high-performing models and best practicesDriving performance improvement across pilot projectsIdentified potential metrics for the following domains:Clinical and safety
outcomesPatient centered outcomesInternal efficiency outcomesEconomic outcomesClassified the metrics by surgical phase:Pre-operativeIntra-operativePost-
operativePost-dischargeAcross the surgical stages20
Slide21Identifying the PSH Primary Metrics
Evaluated the 148 identified metrics and narrowed the list down to the 20 most meaningful and feasible metrics
Clinical & Safety Outcomes
Patient Centered OutcomesInternal Efficiency OutcomesEconomic OutcomesTOTALPre-Operative11
103Intra-Operative02103
Post-Operative31105Post-Discharge1
1103Across the Surgical Stages300
36TOTAL85432021
Slide22PSH Primary MetricsPSH Primary Metrics: 13 metrics – 11 clinical; 2 survey
24 sub-metrics – 16 clinical; 8 surveyID NamePSH-IE1 PSH First Case Delayed on Day of Surgery (IP and OP)PSH-IE2 PSH Day of Surgery Case Cancellations (IP and OP)PSH-IE3 Timeliness of Outpatient PSH Surgical Case Discharge PSH-IE4 Average Length of Stay for Inpatient PSH Surgical CasesPSH-CS1 Outpatient PSH Surgical Case Mortality
PSH-CS2 Discharge Disposition of Inpatient PSH Surgical Cases PSH-CS3 Unplanned Upgrade of Care for Inpatient PSH Surgical CasesPSH-CS4 Unplanned Upgrade of Care for Outpatient PSH Surgical CasesPSH-CS5 Non-mortality Complications for Adult Inpatient PSH Surgical CasesPSH-CS6 Non-mortality Complications for Pediatric Inpatient PSH Surgical CasesPSH-CS7 Inpatient PSH Surgical Case MortalityPSH-PC1 PSH Patient Experience at DischargePSH-PC2 PSH Patient Experience 30 Days Post-discharge22
Slide23Local Context- Alignment23
Slide2424
UMMHC 2020 Vision We will become the best academic health system in New England based on measures of patient safety, quality, cost, patient satisfaction, innovation, education and caregiver engagement.
Slide25Staying Focused25
Slide26Driver Diagram26
Slide27Perioperative
Surgical Home Pilot
Pre-operative Team
Slide28Pre-Operative TeamSuzanne AshtonJane BaronAlexander Berry
Edward CluneAlok KapoorTheofilos MatheosMelinda Miville
Barbara Steadman28
Slide29Goals of TeamCoordinated carePatient centered care Systems improvement
29
Slide30Process Improvement or Change #1
Surgeon VisitPSE appointment bookedScheduling department instructed to give PSE appointment at least 10-14 days out prior to surgerySurgeon’s office provides patient informational sheetSheet describes purpose of PSE, length of PSE appointment, directions to PSE, instructions centered around anticoagulation drugs, instructions to notify PCP of upcoming surgeryPrior to patient arrival surgeon’s office faxes down surgical consent and pre-operative order sets ( to be placed in patient’s chart in PSE)Pre-op team documents receipt of above
30
Slide31Process Improvement or Change #2
Standardize the pre-operative work-ups and lab ordering.The team will do periodic chart reviews to determine this was done.31
Slide32Process Improvement or Change #3
Anesthesiologist to evaluate patientAny outstanding issues or pending labs/studies to be followed up by pre-op team“Green Sheet” on patient chart will designate missing information that needs to be addressedSurgeon to be notified of any potential problem which needs to be followed up
Completed chart to be hand delivered to SACU for others to review it.Recommend assigned anesthesiologist call patient ahead of surgery32
Slide33Process Improvement or Change #4
Patient teaching materials are being compiledpaper handouts on surgeryPower point on a videoMaterials on mindfulness and stress reductionInstructions for incentive spirometer
and smoking cessation33
Slide34Process Improvement or Change #5
Patient questionnaire: SF-12To be given to patient to be filled out while in PSE waiting room and at 1 month follow-up at surgeon visitEither paper/pencil version or on iPADInclude patient experience questions in 1 month follow-up
Compare results of pre-op survey with 1 months follow-up34
Slide35Preparation for LaunchWhat we need:
Finalize patient materials and power pointQuestionnaire set up35
Slide36Perioperative
Surgical Home Pilot
Intra-operative Team
Slide37Intra-Operative Team
Pamela BentonJoann GeslakAndrea GraberPamela HaggertyMichael PuimMitchell SokoloffMaksim
Zayaruzny
Slide38Goals
Systems Improvement: Increase OR EfficiencyDecrease OR Times: operative and turnaroundDecrease CostEnhance Patient Safety and ExperienceImprove Surgical OutcomesDiminish Complication RateReduce LOS, ReadmissionIncrease Physician and Staff Satisfaction
Coordination with Pre-op and Post-op Processes
Slide39Process Improvement
InstrumentsEquipmentAnesthesiaAntibioticsPositioning
Prep and DrapeDVT ProphylaxisInstrumentsEquipmentProcedure
HousekeepingDedicated Teams
Slide40Finalization Prior to Launch
Finalize OR Instruments and EquipmentStandardize Some Parts of Operative CasesDedicated OR Staff EducationCreate Time Study Checklist
Slide41Metrics/Measures
Team Process MeasuresTime and EfficiencyPilot Outcome MeasuresOR Utilization (Collection Methods Established)OR Expense (Collection Methods Established) Patient Outcomes (Chart Review)Physician and Staff Satisfaction
(Questionnaires Need to be Developed)
Slide42Perioperative
Surgical Home Pilot
Post-Operative Team
Slide43Post-OperativeTeamGus Angaramo
Lauren BerseyKhaldoun FarisWendy HodgerneyJohnny IsenbergerErin Legier Jenna
L'HeureuxChristopher St AmandNikol VarvaresouKimberly WilliamsJennifer Yates43
Slide44Address urology service coverage gapsStandardize postoperative patient careImprove communication:Between providers
Between patient and providersStreamline dischargeMinimize risk of readmissionCreate educational program for providersPost-operative Team Goals44
Slide45Process ImprovementsOptimizing coverageStandardized orders for post-op patientsStaff education
Patient and family educationStreamlining discharge45
Slide46Optimizing Coverage
Completed:Dedicated urologic coverage weekdays 7am-7pmIn Process:Improving weekend dedicated daytime coverageWeekend coverage resources: - Urology midlevel providers - Hospitalist NP providers - Residents
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Slide47Standardized Orders
Standardized orders created forCystectomy Radical Prostatectomy NephrectomyReview processNext step:Forms Committee
47
Slide48Staff educationPACU and SACUSouth 5
Urology clinic staffHospitalist NPMeasureDelivery of lecture topicsStaff satisfactionStaff Education
48
Slide49Staff Education
Educational Outreach to Perioperative StakeholdersSouth 5 Educational Sessions:Bladder cancer and Cystectomy (2 sessions in January and February)Prostate Cancer and Radical Prostatectomy
Kidney Cancer, Radial and Partial NephrectomyUrology Clinic Lunch and Learn:Bladder cancer and Cystectomy (December 2014)Renal cancer and Radical/Partial Nephrectomy
(scheduled April 2015)Prostate cancer and Radical ProstatectomyPACU Staff Educational Sessions – pending new PACU/SACU managerBladder cancer and CystectomyProstate Cancer and Radical ProstatectomyKidney Cancer, Radial and Partial NephrectomyUreteroscopy and Shock wave lithotripsyBPH Surgical Management: Hospitalist Nurse Practitioner TeamCare of the Urologic Postoperative Patient
(scheduled and delivered March 11, 5:30 pm)49
Slide50Patient and Family Education
Patient and family educationPost-discharge instructions sheetsMeasure:Patient satisfactionReadmissionsStaff satisfaction50
Slide51Anticipate needs for dischargePrepare caretakersPreoperative teaching
MeasuresPatient satisfactionCaretaker satisfactionComplication riskOverall flow for hospitalized patientsDischarge readiness vs. Actual dischargeAlign with institutional initiativesOptimizing Discharge Flow
51
Slide52Optimize postoperative educationPatients and ProvidersRecord complications to pinpoint areas for improvement
Minimize Risk of Readmission52
Slide53Preparation for LaunchPlatform for communicationPreoperative patient education
Our team process measures vs. pilot outcome measures53
Slide54Perioperative
Surgical Home Pilot
Post-discharge Team
Slide55Post Discharge TeamChristine Coulombe
Tess GesslerMasilo GrantCraig Lilly55
Slide56Goals of Post Discharge TeamCoordinated and continuous care
Collaboration with the other PSH teams to develop continuityEnsure continuity with PCP and Surgeon follow-upsPatient centered careQuestionnaires designed to monitor: post-discharge progressearly detection of complicationspatients’ experienceImproving patient outcomes
Early detection and reporting of complications and care coordinationSystems improvement Track follow up appointments and readmissions56
Slide57Process Improvement or Change #1
Coordinated and Continuous CareCollaborating with other PSH groups to ensure continuity of care Examining areas in which there is overlap/ lack of overlap between groups to ensure agreementDeveloping a universal tracking system to monitor patient progress through the Perioperative
Surgical HomeTracking PCP and Surgeon follow-upsQuestionnaires at follow-up appointmentsQuestions about follow-up appointments
57
Slide58Process Improvement or Change #2
Patient Centered CarePost Discharge QuestionnairesPost-discharge day 1-2 questionnaire will assess for potential issues early in the discharge course and cover such issues as pain, activities of daily living, medications, etc.Post-discharge one month questionnaire for follow-upPatient satisfaction questions added to post-discharge questionnaires
Reporting of issues to providers Specific highlighted answers are triggers to notify the surgeon, so that issues are managed early, to avoid complications and potentially decrease hospitalizationsProgress will be measured by:Quantifying the response rate and results of our questionnaires in conjunction with the Outcomes group58
Slide59Process Improvement or Change #3
Systems ImprovementDeveloping a means to track hospital readmissionsDischarge planning records and checking EMR – enter into RedcapTracking follow up appointments Document follow-up appointments in EMR
Ensure Primary Care follow up 2-3 day and 4-6 weeks follow-up Progress will be measured by:Quantifying percentage follow-up attained59
Slide60Preparation for LaunchWhat we will need:Collaboration with other teams:
pre-op: questionnaires, follow-up appointments and initial patient assessmentpost-op: discharge date, assessment, contact information, updated PCP name and numberQuestionnaire from pre-op to match (as best possible) post-discharge questionsTool to document patient responses, such as RedcapA means to track patients who are discharged directly to home (as opposed to SNF, Rehab, etc)60
Slide61REDCap may be used to:Monitor a patients progress through the Perioperative Surgical Home
Create surveys or questionnairesUse as a collection tool for our pilot outcome and team process measures dataCreate reports Using REDCap for the Pilot61
Slide62Perioperative
Surgical Home Pilot
Outcomes Team
Slide63Arlene AshAlok Kapoor
Ellie DuduchSharyn DeMangoKhaldoun FarisStephen HeardShubjeet KaurOutcomes Team
Ann LawthersChristine Motzkus-FeagansMary NaplesMitchell SokoloffSpiro SpanakisMatthias Walz63
Slide64Goals: Determine measures for overall pilotDevelop data collection processAnalyze data and create reports
Outcomes Team64
Slide65Outcome MeasuresPatient QuestionnairesPre-op: SF12
1-2 days post discharge questionnaire plus patient experience questionsOne month post discharge: SF12, plus post discharge questions, plus patient experience questions3 months post discharge?65
Slide66Outcome MeasuresTeam to collect Clavien-dindo
classification Deviations from normal postoperative course 66
Slide67Outcome MeasuresTeam to collect NSQIP complicationsPneumonia
Unplanned intubationProlonged mechanical ventilation (>48 hours)DVTPESSIAKIMIStrokeUTISeptic shockBleeding – transfusionFailure to rescue
Delirium67
Slide68Pain ScoresFrom Inpatient EMRFrom post discharge questionnaire
Outcome Measures68
Slide69From Inpatient EMRLength of StayRe-admission rateMortality 30 day
Discharge LocationOutcome Measures69
Slide70Cost of Care from FinanceOutcome Measures
70
Slide71Staff experience questionnaireExercise fitnessTransfusions
Time to ambulation and full nutritionOutcome Measures Parking Lot71
Slide72Analysis of DataRecord data into RedCap
Assistance from Christine Motzkus-FeagansSome data can be compared to historical controlsOther data will be tracked over time and examined for signs of improvement (e.g. Poisson test)IRB submission72
Slide73Perioperative
Surgical Home Pilot
Next Steps
Slide74Launch Date 5-4-15Teams to implement processesDevelop Redcap system to monitor implementation of processes: collect data
Finalize patient questionnaires and steps for collectionPilot Outcomes Measures data collection and reportingNext Steps74
Slide75MeetingsIndividual Team Meetings every other week
Leadership meetings every other week All team monthly meetings for shared learningNext Steps75