Healthcare Innovation

1. Healthcare Innovation Robert Monte, Director of SR and VERC October , 2012 Pitt School of Pharmacy

2. Presentation Outline • The Healthcare Dilemma • VA Pittsburgh Healthcare System Overview • VAPHS VERC and OSR Overview • Game Based Learning

3. The Healthcare Problem Maternity Unit Philippines Emergency Room Canada Clinic Capetown South Africa Clinic Waiting Area Sydney Australia UCLA Emergency Room

4. The Healthcare Problem: Cost of Poor Quality • Broken health care processes and system failures result in the deaths of more than 98,000 Americans and injuries to more than 1 million patients every year (IOM, 2000) • 75 % of patients describe the health care system as fragmented and fractured (Picker Institute, 2000). • Health care costs have been rising at double-digit rates since the late 1990s

5. The Healthcare Problem • Estimated $.30 to $.40 of every dollar spent on health care, more than half a trillion dollars per year, is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.” • 43 million, more than one-sixth of the U.S. population under the age of 65 have no health insurance (IOM, 2004a). • Uninsured receive little preventive care and tend to require a disproportionate share of costly chronic and acute care.

6. VAPHS and VERC/OSR Overview VA Pittsburgh Healthcare System | Veterans Engineering Resource Center

7. VA Pittsburgh Healthcare System • 60, 141 total uniques • 583 operating beds • 538,436 outpatient visits • 43 liver & 40 kidney transplants • 171,985 bed days of care • Budget > $450 million • 3011.2 full time equivalent employees • 1,152 total volunteers • Research > $20 million • 5 contract community-based outpatient clinics • MCCF Collections >$21.3 million VA Pittsburgh Healthcare System | Veterans Engineering Resource Center

8. VAPHS – UD Hospital Processes IE-1106 OPERATIONS IMPROVEMENT IN HEALTHCARE

9. 4 Major Hospital Work Streams • Enrollment Process • Inpatient Process • Discharge Process • Outpatient Process IE-1106 OPERATIONS IMPROVEMENT IN HEALTHCARE

10. About VAPHS VERC & OSR

11. VERC – Program Offices Heather Woodward-Hagg VA-CASE VERC Director Peter Woodbridge MWM VERC Director Janis Hersh New England VERC Director Robert Monte VAPHS VERC Director Robert.monte@va.gov IE-1106 OPERATIONS IMPROVEMENT IN HEALTHCARE

12. Organizational Structure VERC and OSR • Staffing • 9 Full Time VA Staff • 3 Fellows • 1 Graduate Research Intern • 25 Part time Contract Staff

13. Our Mission The mission of the VAPHS VERC and OSR is to lead the continuous improvement of healthcare in Veterans Health Administration (VHA) through the application of knowledge and expertise in Systems Engineering and Operations Management.

14. Building Blocks Mission Framework Pillars Foundations

15. Strategic Focus

16. Office of Systems Redesign • Train and coach staff to improve systems and process performance • VA TAMMCS training seminars • Improvement Workshops • VISN and VHA training and mentoring • Keys to success • VA TAMMCS • Staff engagement • Passionate champions • Clear return on investment • Continuous monitoring

17. Academic Partners • Partnerships with the academic community greatly expand our level of knowledge and expertise • Continue to grow our academic affiliations and leverage the expertise of these partnerships to foster innovative healthcare solutions in VHA and new funding streams

18. Awards and Recognition FY 08 Inpatient Flow Team Systems Redesign Champion Award North-Eastern Inpatient Flow (FIX) FY 09 Dermatology Clinic Systems Redesign Champion Award Team Outpatient Clinical Care Systems Redesign FY 10 Lung Cancer Team -Federal Executive Board (FEB) Chairman’s Gold Award1st Place -Hospital and Health System Association of Pennsylvania (HAP) -National Systems Redesign Award 1st Place Outpatient Clinical Care Outstanding Supervisor/Manager Gold Award Robert Monte Rookie of The Year Silver Award Adam Critchlow FY 11 TeleDermatology Program FEB Clinical Team Chairman's Gold Award 1st Place VISN 4 Lung Cancer Collaborative FEB Outstanding Team Silver Award FY 12 Purdue University Lean Healthcare Black Belt Certification Adam Critchlow

19. Major Projects

20. National Initiate to Reduce Missed Opportunity (NIRMO) • Deliverables • Reduction of the National MO rate to 10% or less in the Top 50 Clinics • National Voice of the Customer Questionnaire, Analysis, and Report • National Implementation of Strategies Questionnaire, Analysis and Report • Predictive Model to identify probability of a no-show and target patients for reminder calls • Missed Opportunities Toolkit • Incentive Programs to reduce MO • Clinic Simulation to Test Impact of Access Strategies on MO • NIRMO National Virtual Collaborative • NIRMO VISN Collaboratives • NIRMO Facility RPIWs

21. National Initiate to Reduce Missed Opportunity (NIRMO) • Milestones by Fiscal Year • FY2010 • Charter and approval August 2010 • Initial planning for the Voice of the Customer and Reminder Call pilot • FY2011 • NIRMO Kicked off • National Voice of the Customer developed (January) Implementation of Strategies developed (February) Development of No Show predictor models by: • University of Pittsburgh Katz School of Business • Wayne State University • FY2012 • Virtual Collaborative started spreading strategies and best practices • Completed 6 face-to-face VISN Collaboratives and 15 Rapid Process Improvement Workshops (RPIWs) Timeline

22. (NIRMO) Results 20 of 154 VA Facilities Meeting Goal – Aug 2012

23. National Initiate to Reduce Missed Opportunity (NIRMO)

24. VISN MO Collaboratives and RPIWs

25. Operating Room Scheduling • Goals and Objectives • Develop an analytical modeling framework for the OR suite • Use several years of real and de-deintifed data from actual surgical procedures at an existing OR suite in order to calibrate the model accurately • Develop a decision support system based on the calibrated model that could be easily maintained and have its underlying data dynamically updated • Develop a suitable software interface within which the system would reside

26. Intensive Care Unit Flow • Detailed computer simulation and stochastic optimization models for patient flow • Develop methods for calibrating the models • Implement use of simulation models • Support VA decision making • Application of model

27. Error Proofing Reprocessing ofReusable Medical Equipment (RME) • The goals of this effort are to understand the endoscope cleaning process, evaluate factors that influence endoscope cleaning, and make recommendations to improve the endoscope cleaning process • Project generated national recommendation for the use of AERs

28. Transformational Initiative T21 Projects

29. Develop Specialty Pact Care Models • Background: Current relationship between specialists and existing primary care PACT teams is not well understood • Project Goal • Develop, implement and analyze a three tiered approach using e-consults, same day access, and traditional face to face visits to provide specialist services to an existing Primary Care PACT • Increase access to specialists, while reducing long travel distances for Veterans • Methods: Voice of Customer and Process, Three Tier Pilot, Geospatial Modeling to guide decisions for best allocation of specialist resources to high impact clinical areas in order to significantly reduce Veteran travel times and distances • Accomplishments: VOC and VOP 75% complete, pilots established, preliminary Geospatial models • Future Directions: Analyze pilots, improve process, disseminate to VHA

30. Develop Specialty Pact Care Models

31. Improving the Investigation Review Board Process (VAPHS Pilot) • Background: Data demonstrate substantial variation in IRB review quality and efficiency, and this variation is likely due to inconsistent and inefficient application of relevant regulations • Project Goal: Improve the variation in the efficiency and effectiveness of IRB review processes at VAPHS • Methods: VERC utilized VA-TAMMCS and Systems Engineering to develop process flow maps, simulation model, process re-engineering. CHERP conducting quality reviews, data collection and analysis, and developing change package • Accomplishments • Data entry program to capture and analyze the information • A codebook to guide coders in extracting data IRB records • Simulation model to test improvement scenarios • Future Directions • HSRD grant awarded and work began April 2012

32. Optimizing Remote Technologies • Background: Healthcare Systems have little guidance as to how to structure remote monitoring of care. The VHA Care Coordination Home Telehealth Program offer a method to provide care in the Veterans home • Project Goal: Develop mathematical models that capture the tradeoffs involved in remote health care monitoring (e.g., frequency of in-office visit vs. remote data transmission). These models can be used to generate policy recommendations for current and future remote monitoring practices to increase utilization of CCHT. • Methods: Data mine and analyze CCHT records to determine care patterns that optimize clinical outcomes. Stakeholder focus groups • Accomplishments • Initial collection review of CCHT data • Stakeholder interviews and focus groups • Future Directions • Develop pilots to test effectiveness of model and policy recommendations at increasing CCHT utilization • Develop predictive models to determine patient factors that predict positive clinical outcomes and use to identify patients to enroll in CCHT

33. National Products and Tool Kits

34. Geospatial Organization of Dialysis: Optimizing Networks(GORDON) Decision Tools • GORDON was used by VHA National Leadership and Central Business Office to inform national Dialysis Contract negotiations • Geoeconomics of Chronic Disease (GEODE) • Ensemble of geospatially fluent tools for forecasting severity-specific growth in the Veteran CKD population and identifying optimal strategies for construction of VA based dialysis units • Dialysis Modalities and Disposition (DIAMOND) • Ensemble of geospatial analytic tools addressing consequences of changes in policy, contracting rates or costs, and demographics on the prevalence of major modes of renal replacement therapy and the financial liabilities of VA

35. Return on Investment Geospatial Organization of Dialysis: Optimizing Networks • Central Business Office restructured contracts in FY11 to save VHA approximately $75 million per year in negotiated reimbursements. As End Stage Renal Disease incidence escalates in the next 10 years, total cost savings could reach over $600 dollars 11 10 12 $0 $0 $0 $0 $0 $68,394 $0 $0 $75,000,000 $0 $273,578 $75,000,000 $0 $0 $0 Expenses| Projected Hard . Soft | Actual Hard . Soft

36. Lung Cancer Care Database • Alpha testing completed in June 2011 • New Revision January 2012 • Data tracking and analysis facilitates reduction in time from Diagnosis to Treatment • Goal to link the Database to the Corporate Data Warehouse retrieve available data automatically from CPRS templates • Used currently by 10 facilities

37. Patient Aligned Care Team(PACT) Tools • Used by PACT teams across VHA to collect, organize, and analyze data • VAPHS developed the original Practice Redesign tool and later collaborated with the Midwest Mountain and VA CASE VISN 11 VERCs to embed macro logic to improve the usability of the tool. • VAPHS VERC PACT Industrial Engineer holds a weekly “office hours” call via VANTs and LiveMeeting on use of tool and data analysis • A national PACT tool help desk was developed through the MWM VERC and is maintained by the PACT IE group

38. NIRMO Predictive Model • Pitt built five separate models built using logistic regressions that are specific to the type of care • The model was used to identify patients for targeted reminder calls • The pilots reduced MO rates by 50% • VAPHS VERC can send reports to VA Facility shared drives on request • Finalizing VSSC report template to all VA Facilities to retrieve their own list

39. NIRMO Toolkit • The National Missed Opportunities Toolkit is a SharePoint site devoted to training and education about Missed Opportunities • The purpose of the toolkit • Provide ongoing in depth support for MO reduction efforts • Enable teams to spread techniques and expertise nationally • Provide a training reference • Provide interactive tools and reference documents • Be your MO project one stop shop • VA TAMMCS and Tool Based schemes

40. Staffing Models The VAPHS VERC worked with the Tampa VAMC during the period November 2010 to January 2011 to help them develop staffing tools to align personnel resources with workload. The tools enabled departments beginning with Chaplain Services and Environmental Management Services to calculate their workload, task time, and required FTEE while allowing for leave, breaks, and administrative time.

41. Education and Fellowship

42. Education Programs • Advanced Systems Engineering Fellowship • University of Pittsburgh Industrial Engineering Senior Projects • Graduate School of Public Health Students • Katz Graduate School of Business Senior Project • Health Systems Engineering (HSE) Course • Healthcare Innovations Pitt Pharmacy

43. VERC/OSR Training • Provide facility and VISN Level Trainings • Systems Redesign Project Training (Lean Yellow Belt) • Systems and Process Improvement (SPI) Workshops • Improving Our Work is Our Work : All employee introduction to TAMMCS/Lean

44. Fellowship and Graduate Research Program • The OAA Health Systems Engineering Fellowship program provides a strong and extended exposure to the application of systems engineering principles in the health care environment • The Graduate Research Program is sponsored with an academic affiliate to provide an experience in health systems engineering research Jahan Taheri Elizabeth May Brittany Green John Bennett Lanxi Tang

45. Game Based Learning

46. Concept • Game based learning was popularized in the 1960s with The Beer Game”, a role-playing simulation developed at MIT to clarify the advantages of taking an integrated approach to managing the supply chain • Demonstrates the value of sharing information across the various supply chain components. • Advanced Clinic Access principles echo supply chain components and the “player” would have to choose strategies to improve access to care.

47. Theme Hospital

48. Early Prototypes • The VAPHS VERC modified a clinic simulation model to develop a rapid prototype game to teach Advanced Clinic Access Principles in August 2011 using Microsoft Visio and Process simulator. • The game was a combination of the modified prototype simulation and “game pieces” and was played in teams led by an instructor.

49. Game Prototype 1 Simulation

50. Prototype II