Individual Task Variability: Linking Process Improvement to Patient and Hospital Outcomes

1. Individual Task Variability: Linking Process Improvement to Patient and Hospital Outcomes Susan Meyer Goldstein & Rachna Shah Cincinnati Innovations in Healthcare Delivery 2006

2. Scenario… Treatment of ST-elevation mycardial infarction (STEMI) in Greater Minnesota

3. Current Evidence Medical Science Balloon angioplasty (PCI) is preferred treatment for heart attack (based on numerous global studies) Practice Less than half receive primary balloon treatment; often delayed

4. Pilot Study Source: Henry et al., American Heart Journal Vol 150, Issue 3, 2005

5. Standardized Protocol 95 minutes Community hospital MHI Every patient, every time (24/7 coverage); no exclusions. Source: Henry et al., American Heart Journal Vol 150, Issue 3, 2005

6. Patient arrives at rural hospital with STEMI symptoms Arrive at MHI Security holds elevator and escorts patient to cath lab Give 2 more doses of metoprolol during transport MHI’s Standardized Treatment Protocol for STEMI Remove patient shirt; put on gown Move patient onto imaging table Load patient into ground or air ambulance Perform ECG within 5 min. of arrival A cardiologist explains procedure to patient; another cardiologist preps patient Give sedation Is STEMI diagnosed? yes no End of process Is patient anxious? no Perform angiogram (image the blockage) yes Activate team (MD, nurse, technician) Attach defibrillation pads Does angiogram confirm blockage? no Contact transport Start second IV yes Contact MHI Perform chest x-ray Perform PCI Locate pre-stocked kit Give aspirin, clopidogrel, nitroglycerin, heparin, metoprolol (all in kit) Complete procedure and transfer patient to recovery room Start IV and monitors, draw blood for testing (all in kit)

7. Outcomes – Patient Mortality

8. Research Problem Practitioners’ questions: ·Can we further improve an already well-performing system? · Are the community hospitals doing everything they can? Researchers’ questions: · Are there systematic factors within process-level activities that can be improved? What is the impact of hospital-level task activity on the outcomes of interest? Patient-level task activity?

9. Research Propositions • Is the impact of variability in task activity on process performance (cost, quality) observable? • What is the relative importance of hospital-level versus patient-level task activity in predicting performance? • What are the impact of process handoffs?

10. Literature Base • Service process variability • Frei et al. (1999), Management Science • Tsikriktsis & Heineke (2004), Decision Sciences • Field et al. (2006), Decision Sciences • Process improvement • Zantek et al. (2002), Management Science • Rust & Metters (1996), EJOR • Process handoffs • Hammer (re-engineering) • Shingo (set-ups)

11. Sample Characteristics • 27 Minnesota community hospitals • Average 81 miles from MHI (range 17-149 miles) • Data collection period: March 2003 – Feb. 2006 • Total 720 patients • Exclusions: 54 false positives, 4 extreme time outliers (2 for weather delay; 1 for diagnostic dilemma; 1 for LOS), 11 intentional protocol deviations/missing partial data • Final data set for analysis: 651 patients

12. Outcomes of Interest • Patient hospital length of stay – proxy for cost • Sample mean = 3.8 days (range 0-34) • Mortality cases excluded due to truncation • Skewed distribution; 90% of patients hospitalized 6 days or fewer • Logarithmic function used in analysis • Patient in-hospital mortality – proxy for quality • Sample mean = 3.2% • 21 deaths in sample

13. Data Structure Patient i Patient i Patient i etc. Community Hospital j MHI Community Hospital j Community Hospital j etc. i = 1, … 651 j = 1, … 27

14. Process Description Interval CHosp Transpt MHI 0. Pt arrives at CHosp 1. EKG started 2. Transport called 3. Transport arrives 4. Pt departs CHosp 5. Pt arrives at MHI 6. Pt arrives at Cath Lab 7. Procedure begins 8. Normal blood flow

15. Independent Variables: Hospital-Level • From ‘Know what’ to ‘Do what’ • Proportion of 4 drugs given • From ‘Know how’ to ‘Do how’ • Hospital median time intervals

16. Independent Variables: Patient-Level • From ‘Know what’ to ‘Do what’ • Proportion of 4 drugs given • From ‘Know how’ to ‘Do how’ • Difference from hospital median time intervals • Reduces multi-collinearity • Keeps VIFs below 2.0 Patient Raw Minutes Interval 1ij Median Hospital Interval 1j Patient Interval 1ij - =

17. Systolic blood pressure Age Heart rate Killip class 4 Killip class 3 Killip class 2 Hypercholesterolemia Diabetes Hypertension Prior congestive heart failure Anterior MI Control Factors – Patient Characteristics

18. Regression Model: Length of Stay Baseline with control factors: ln(length of stay)ij = β0 + β1-3[Patient risk factorsij] + εij Full model: ln(length of stay)ij = β0 + β1-3[Patient risk factorsij] + β4-8[Hosp median intervalj] + β9Hosp drug scorej + β10-17[Pt intervalij] + β18Pt drug scoreij + εij

19. Length of Stay Results Baseline Model Full Model

20. Hospital-Level Effects: LOS

21. Patient-Level Effects: LOS

22. 1 2 3 4 5 6 7 8 Length of Stay Results Interval CHosp Transpt MHI ? EKG → call transport Patient ‘Do how’ Transport call → arrive CHosp → transport handoff Transport → MHI handoff Hospital ‘Do what’ Drug score

23. Logistic Regression: Mortality Results Baseline Model Full Model

24. Hospital-Level Effects: Mortality

25. Patient-Level Effects: Mortality

26. 1 2 3 4 5 6 7 8 Mortality Results Interval CHosp Transpt MHI Hospital ‘Do how’ Arrive CHosp → EKG ? EKG → call transport ? Depart CHosp → arrive MHI Patient ‘Do how’ Transport → MHI handoff

27. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Conclusions Is the impact of variability in task activity on process performance (cost, quality) observable? Length of Stay Mortality Hospital ‘Do what’ Drug score

28. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Conclusions What is the relative importance of hospital-level versus patient-level task activity in predicting performance? Length of Stay Mortality Hospital ‘Do what’ Drug score

29. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Conclusions What are the impact of process handoffs? Length of Stay Mortality Hospital ‘Do what’ Drug score

30. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Conclusions In practice… Length of Stay Mortality Hospital ‘Do what’ Drug score