Session 15 Improved Outcomes and a Proven ROI Model for Quality Improvement: Transforming Diabetes Care

Transcription

1 Session 15 Improved Outcomes and a Proven ROI Model for Quality Improvement: Transforming Diabetes Care Charles G Macias MD, MPH Chief Clinical Systems Integration Officer Director of Evidence-Based Outcomes Center Texas Children s Hospital

2 Learning Objectives Understand how to improve diabetes care using data and process improvement. Define the basic clinical and operational elements of a comprehensive diabetes improvement program. Verbalize the role of standardized care based on evidence-based treatments, processes, and education in improving diabetic outcomes.

3 We believe in improving the lives of our patients by focusing improvement initiatives on care processes for complex conditions like diabetes with significant variability and high costs.

4 Poll Question #1 How effective are your organization s efforts to improve the care of diabetics? 1) We are not focusing on it 2) Not at all effective 3) Somewhat effective 4) Moderately effective 5) Very effective 6) Unsure or not applicable 4

5 About 208,000 children and adolescents have been diagnosed with diabetes; approximately 0.25% of the U.S. population. 5

6 Texas Children s Hospital (TCH) Internationally renowned. Committed to creating a community of healthy children through excellence in patient care, education, and research. Provides primary and tertiary care for children through the hospitals, affiliated practices, and a health plan. Manage more than 1 million patient encounters each year. 6

7 Background Of the discharges with diabetes as the first listed diagnosis were for DKA. 64% Children and adolescents admitted with diabetic ketoacidosis (DKA) are at risk for serious complications, longer hospital stays, and poorer outcomes. 7

8 The Problem and Opportunity TCH leaders noted a measurable degree of variation in its management of DKA patients. This variation had been increasing over several years, leading to gaps in quality of care for patients admitted with DKA. Diabetes care met criteria for a focused improvement effort: Large population of patients. High degree of variation in care. Measurable gaps in the consistency and quality of care. Organizational readiness. TCH determined to reverse this trend by launching an enterprise-wide campaign to drive diabetes care improvement. 8

9 TCH Inpatient Diabetes Care FY inpatient encounters $11.3 million in patient charges DKA, a metabolic crisis of type 1 diabetes, accounted for ~60% of all inpatient activity Average length of stay (LOS) of 2.9 days 30-day same cause readmission rates of 2.8%

10 Substantial Variation in Practice and Processes for Children with Diabetes at TCH with a huge opportunity to reduce LOS Benchmark (2.2 Days)

11 Inefficiencies in Current Care Delivery Diabetes patients admitted across the hospital Infused insulin for DKA only in intensive care beds Transfer time introduces delays in care and medical errors Lack of specialized nursing care Bedside education is delivered by a vast number of bedside nurses Insufficient standardization in care/education Uncoordinated care by a multidisciplinary team New onset education classes delivered by ambulatory CDE and only held on weekdays

12 The Turning Point TCH recognized that incremental change would not suffice to transform DKA care. 12

13 A Balanced Report Card DKA Scorecard Category Classification Metrics IOM Domain Utilization of EBP Process Utilization of tools (order sets) for all patients meeting criteria for DKA Effective Process Time from arrival to intravenous administration of insulin Efficiency, Timely Total length of stay (hospital admissions) Throughput Outcome Admission to PICU/PCU until bed request for acute care (= medical special care LOS) Time from admission until physically placed in acute care (= physical special care LOS) Physical LOS medical LOS (= delay in getting bed waiting in special care) Patient Centered, Timely Avoidable Events Outcome Readmission rates for patients with DKA Efficiency, Timely Education Outcome Competencies were assessed using education checklist Patient Satisfaction Outcome Patient satisfaction with quality of care Efficiency, Equitable Equitable, Patient Centered

14 Project Aims Inpatient Diabetes Center of Excellence Provide DKA and diabetes care in a specialized acute care unit. Utilize dedicated bedside nurses to deliver DKA therapy and diabetes education. Employ standardized evidence-based care. Decrease LOS and readmission rates to outperform benchmark. Enhance patient satisfaction. Optimize decision support in EHR. Utilize care process team to define and implement additional aims, metrics, and rapid cycle improvements.

15 Results Standardization of Care Hospital Throughput Length of Stay Patient Satisfaction Financial 81% DCU & CDN. Ketone recognition in EC increased to 70%. 17% increase in order set use. 19% increase in IV insulin within 1 hour. Quick transition to subcutaneous insulin. Enhanced patient throughput from EC to PICU to acute care to discharge. 33% decrease in LOS for DKA patients. Patient satisfaction increased from ~80% to over 90%. Net revenue savings of $460,000/year. 53% ROI. 15

16 The How

17 Outcome: Patient Volume by Admission Location ICU Path PCU Path Acute Care Path DCU 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Qtr1 Qtr2 Qtr3 Qtr4 Qtr ICU PCU Acute Care Bed ICU PCU DCU

18 Quick Recognition of DKA Inpatient Team Aim: 75% of established diabetes patients who received care in the EC will have a POC Ketones testing in EC.

19 Quick Initiation of IV Insulin Aim A: Initial dose of IV insulin will be administered within 2 hours following triage in at least 80% of DKA patients. Aim B: Initial dose of IV insulin will be administered within 1 hour following insulin order in at least 80% of DKA patients during Q3 FY 2015.

20 If POC Ketones Have Increased, Why No Change in Insulin Timeliness? Reductions in average overall time. Total time 2.4 to 2.3 hours (orange). Time to order insulin 1.5 to 1.3 hours (green). # encounters receiving Insulin Insulin Timing Q Q Q Q4 # encounters receiving insulin Mean time from triage to insulin order Mean time from insulin order to administration Mean time from triage to insulin administration

21 If POC Ketones Have Increased, Why No Change in Insulin Timeliness? Reductions in proportion that had insulin >180 minutes from triage (yellow). From 22% to 12% More work still needs to be done. 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 38% 30% 34% 35% 22% 6% IV Insulin Timing Triage Start to IV Insulin Administration TriageArrivalToInsulinAdmitRate 25% 10% 41% 29% 22% 8% 46% 33% 2015-Q Q Q Q minutes minutes minutes Greater than 180 minutes 9% 12%

22 Quick Transition to Subcutaneous Insulin Aim: 80% of DKA patients who meet medical criteria for transition will transition from IV insulin to SQ insulin within 4 hours of meeting medically appropriate criteria in FY2016 Q2. No baseline data at present. (Criteria defined as no emesis/no nausea/no vomiting, bicarb >15, and patient wants to eat). Revised DKA admission order sets to include a one-time Lantus and Humalog dose. o Approval obtained from pharmacy SQ insulin to bedside while continuous IV insulin in progress. o Nutrition can provide meal regular tray OK for first meal. o EC, ICU, Diabetes Unit Nurse training October o EC, ICU, Endocrine Physician training in October Decrease time by decreasing steps in communication. Discussion with dietician for food availability completed.

23 Outcome: Transition to Acute Care

24 Outcome: Decreased LOS Phase 1: DCU Opens Phase 2: DKA management in DCU

25 Care Shifted to DCU Delivered by CDNs 120% Shift-Level CDN and DCU Bed Utilization 100% CDN Contact DCU Bed Assignments + CDN contact DCU Bed Assignments 97.6% 80% 60% 55.8% 80.0% 81.4% 40% 20% 0% 55.8% 22.2% 19.0% 19.1% 25.7% 38.7% 29.4% 22.9% 14.1% 1.8% 5.1% 6.3%

26 Outcome: Improved Satisfaction

27 Outcome: Financial Savings $70K $60K $50K $40K $30K $20K $10K $K Q Q Net Revenue: Defined as gross revenue minus cost. Assuming full census and turnover of beds. $460,000 per year ($10K) ($20K) ($30K) DCU opens DKA management in DCU

28 Model Financial Results 53% ROI $140K $120K Quarterly $120K $100K $88K $80K $60K $40K $20K $0K ($20K) $4K $26K ($2K) ($40K) ($38K) ($38K) ($38K) ($38K) ($38K) ($60K) Net Revenue CPT Cost

29 Poll Question #2 How would you rate the quality of care your organization delivers for diabetic ketoacidosis (DKA)? 1) Poor 2) Fair 3) Good 4) Very good 5) Excellent 6) Unsure or not applicable 29

30 How? People/Place Process improvement team to improve care and reduce variability in order sets, treatment, workflows, and LOS. Recognized that transformative change required for success. Changed where care was delivered. Created a highly specialized Diabetic Care Unit (DCU); opened in March Changed who delivered care. 22 specialized Core Diabetic Nurses (CDNs) and other ancillary support staff with extensive training in the management of diabetes mellitus (DM) by October 2014.

31 Goals of Diabetic Care Timely and patient-centered delivery of inpatient diabetes care by removing the inefficiencies across the continuum. Quick recognition of DKA in ECs Quick initiation of IV insulin in DKA Quick transition to SQ when medically ready Timely outpatient follow up Communication with PCP

32 How? Evidence-Based Guidelines & Education Patient education Comprehensive training materials developed for patient and family. IV insulin administration standardized Changed how care was delivered Standard, evidence-based protocol for dose, method, and approach. Standardized care on evidence-based treatments, process, and education existing order sets were reduced to a standard group of four evidence-based order sets developed by a multidisciplinary team. Goal to make it near impossible to deliver care without use of standard order sets. Order sets built into EHR. Clinical decision support.

33 How? Analytics Availability of data. Implemented an enterprise data warehouse (EDW) with integrated data from clinical, operational, financial, and other systems. Implemented a pediatrics analytical application to provide reliable, near real-time information to decision makers. Improved ability to identify and manage diabetes patients. Risk predictor model to identify and risk stratify DM patients. Stratified into low, medium, and high risk to apply appropriate care.

34 Summary of How We Achieved Our Results All ingredients standardized care based on evidence-based treatments, process improvement, analytics and education came together first on the DCU where highly trained and specialized care providers could provide the best possible care and achieve the best possible outcomes.

35 Lessons Learned Establishing a specific department or team to handle diabetes cases is an effective method to lower costs, manage care, and meet deliverables. The use of existing infrastructure to develop a comprehensive unit enabled TCH to deliver guaranteed care and support for patients affected by DM. Educating all individuals involved in DM care through relevant materials is essential for the benefit of diabetics at TCH and worldwide. Building a quality program takes time. Requires engagement from all directions. Most successful when directly aligned to institutional mission. Infrastructure is essential. 35

36 Future Plans: Expansion High Risk Predictor Model Risk Adjusted Shared Saving Plan Behavioral Health Assessment and Assistance Education Diabetes Education Material CDE Education Tracking Outpatient Education Pathway No Shows/Cancellation Diabetes Comorbidity Screening Diabetes Action Plans Patient Satisfaction Diabetes Care Process Team Hospital Follow-up Insulin Timeliness TCP Education Flu Shots School Packets

37 Analytic Insights Questions & AnswersA 37

38 What You Learned Write down the key things you ve learned related to each of the learning objectives after attending this session.

39 Thank You 39