Improving Clinical Performance Through Knowledge and Capability Transfer

1. Improving Clinical Performance Through Knowledge and Capability Transfer Premier Inc. Annual Breakthrough Conference 2005 H. Douglas Sears Six Sigma Master Black Belt, Director of Performance Improvement Bon Secours Health System Douglas Goldstein eFuturist Lead…Innovate…Transform President – Medical Alliances

2. Sharing Better for Performance Excellence

3. M I NY PA NJ MD KY VA SC FL Health System Overview • 21 Acute Care Hospitals • 1 Psychiatric Hospital • 9 Nursing Care Facilities • 8 Assisted Living Facilities • 2 Retirement Communities • Home Care and Hospice Providers A $2.4 billion not-for-profit Catholic health system, Bon Secours owns, manages, or joint ventures: Bon Secours’ more than 28,000 caregivers help people in 15 communities in 9 states

4. BSHSI Performance ExcellenceOverview BSHSI Board BSHSI Performance Excellence BSHSI Operations

5. BSHSI Performance ExcellenceDetail BSHSI Performance Excellence LEADERSHIP Organizational Efficiency Clinical Excellence (CMS/HQI, Pay for Performance, LOS IHI 100k Lives, Patient Safety, Loss Prevention) (Productivity, Revenue Cycle Enhancement, Materials Management) CULTURE PROCESS Quality Improvement Science & Techniques Data Management (Measurement, reporting and prediction) (Six Sigma, Rapid Cycle,) TECHNOLOGY

6. Accelerating Knowledge Transfer, Innovation & Communities of Performance - People, Process and Technology Supporting Intelligent Information Technology - Strategy, Intranet, ROI, EMR and RHIO

7. 1. Overview Case Study and Demonstration Six Sigma + Quality-Care Management / CMS HQI Initiative ____________________________________ Knowledge & Capabilities Transfer Services for Performance Excellence

8. Clinical Strategy Overview Service Enhancement • Outcomes • Patient safety • High quality care • Better than expected outcomes • Appropriate resource utilization • Physician provider of choice • Market recognition for quality Clinical Vision: A Culture of Quality Clinical Improvement Physician Alignment Information Technology

9. CMS Quality Initiative • CMS HQI Demonstration Project – “Pay for Performance” • Community Acquired Pneumonia • Congestive Heart Failure • Acute Myocardial Infarction • Coronary Artery Bypass Graft • Hip / Knee Replacement • Clinical Performance Measurement • Premier Perspective Database • Indicators • Targets • Program Incentives and Scoring • Role of Care Management / CIS • Multi-Dimensional Knowledge Transfer Effort

10. Care Management QI Strategy Status Grid[Status as of Site Visit Date]

11. 2. Improving Clinical Performance Through Knowledge and Capability Transfer Case Study and Demonstration Quality -Care Management / CMS HQI Initiative KTPE Services for Clinical Performance Excellence

12. How Well Do You Share? …knowledge, best practices, capabilities, etc. on a scale between 1 (great) to 10 (poorly)

13. Strategy Statement BSHSI KTPI Knowledge Transfer for Performance Improvement • KTPI accelerates the effective diffusion of innovations and best practices - essential to Building a Unified Bon Secours and achieving operational, clinical and community excellence • KTPI supports better capabilities transfer through Web services technology and tools (Intranet project) • KTPI saves time and money and improves accountability for improvement The BSHSI ‘Knowledge Transfer for Performance Improvement’ is a strategic imperative that optimizes the integration of human resources, processes, and technology to liberate the potential of our people

14. Analyze Phase: Explore Causes of Process Variation Collect Data Identify Evidence Best Practices Measure: Diagnostic Assessment Finalize Clinical & Financial Objectives Revise Project Plan Control: Develop Standard Operating Procedure Monitor Process and Result Performance Measures by Condition Improve: Select Solutions Develop Execution Plan Conduct Pilot Implement Plan Key Deliverables / Benefits: Review Composite Quality Scores by Condition on a Monthly Basis Key Deliverables / Benefits: Identify Clinical “Best Practices” Develop Knowledge Transfer Work Book Key Deliverables / Benefits: Share Best Practices Across BSHIS Share Results with Senior Leadership at the Local System Level CMS Clinical Improvement Methodology Develop Charter: Problem Statement Mission Statement Baseline Measures Project Plan Status Report Identify Project Champion Analysis Action Clinical Improvement Accountability

15. Knowledge Transfer Efforts to Date Strategy, Design, Business Plan, Pilots… • Online Communities of Excellence • Nursing Collaborative – Nurse Agency Reduction • Supply Chain • Care Management – Quality • LOS • Six Sigma • KT Workshops: Launched Operational Best Practice efforts to achieve targeted savings • Intranet – Integrate KTPE requirements and BSHSIShare.org lessons learned/features into next generation BSHSI Intranet - IRIS • Building a Quality Culture: Clinical Excellence – support achievement of Premier CMS objectives, patient safety and SQP goals with a multi-dimensional KTPE effort

16. Do It Better…Online! Beyond Paper & Email… Email shares one to one, but not one to everyone! Email Addiction = Loss Knowledge to the Organization

17. KTPE - Quality Improvement Strategies • Leadership Engagement • Site Visits – Assessment and Support • BSHSIShare.org – Beyond Email & Paper • Virtual Teams within BSHSI Share – Quality Care Management • Data Management • AMI • Great Performance Data available ASAP online • Process Redesign • Enhanced case management • ED workflow • Automated tracking • Clinical Informatics Transformation • Bar coding • CPOE • Concurrent reporting

18. CMS Composite Scores - BSHSI Weighted Average for All Clinical ConditionsQuarters Ending December 2003 – September 2004 Overall BSHSI 9/04 – 77.7% 6/04 – 76.7% 3/04 – 75.3% 12/03 – 74.2%

19. KTPE Deployment Strategy ‘Best Practices’ Diffusion Models Start with Formal, Centralized Best Practice Adoption –Expand According to SQP Priorities Dedicated execution resources Performance linked to transfer success Mandated targets Mgt endorsed best practice Proscribed approach Centralized: SQP Goals, performance incentives Tools and resources posted on intranet HSO, Peer SME, and external consultation Performance Reporting on intranet to SQP targets Decentralized: CoPs “vet” best practices FY 04: Focus on Centralized diffusion: KT workshop best practice areas and critical clinical excellence topics (push; top-down) 05-06: Expand functions and number of KTPI efforts based on SQP priorities – use mix of diffusion strategies (with focus on push) 07: Fully deployed KTPI model: Decentralized (pull; peer-to-peer)

20. BSHSI Share Online Pilot Communities • Nursing Collaborative • Quality & Care Management • Supports CMS Pay for Performance • Supply Chain • BSHSIShare.org launched in 30 days after completion of the KTPE Business Plan with a Nurse Agency Community Pilot • Technology: Open Source Content Management System (www.phpnuke.org) • No license fees, no annual maintenance • Minimal investment in custom programming to meet the needs of health care and BSHSI

21. BSHSIShare – Care Management • The e-fficient place to… • Share improvements, innovations, tools and resources • Report results • View quarterly reports • Access best practices • Get CMS and CM News • Register for Webinars • Participate in Clinical Webinars • Supporting offline / conference call processes • BSHSI Share vs Web Ex • Deliver external ‘Health News’ feeds daily • Multi-media packaging of ‘knowledge’ and ‘tools’ • Connecting people with documents/tools and connecting people with experience for rapid cycle improvement

22. BSHSIShare – Care Management: Online Tool Features • Best Practices Knowledge Library • Enhanced Content Organization • Real-time Knowledge and Tool Sharing through – ‘Share Resource’ • Online Reporting: • Access to Navigator reports • One click Monthly Status Report • Expanded Search – same time BSHSIShare and Web search • Much more…

23. Premier/CMS Data Collection and Submission Flow - CURRENT • Hospital Concurrent Process • HIS Census report used to identify patients that may be candidates for CMS program • Collect CMS indicator data via automated Tool B daily on these patients • Daily CMS indicator data sent to nursing units, CMO, CM or other hospital defined persons for review to ensure compliance with indicators • Report sent to hospital management weekly for compliance review • Generic Submission Process • After discharge, HIS system sends data to Trendstar • Data from Trendstar submitted to Premier • Premier sends list of patients to be included back to hospital • Medical records pulls charts from list and searches through charts to abstract data • Data is entered on Premier Web tool (Tool A) • Premier cleanses data and sends back to hospital for approval to submit • Premier submits data to CMS • Premier sends scores to hospital • Reliability Validation • Hospital is asked by CDAC (under contract with CMS) to pull charts, copy and send to CDAC - about 7 identified charts per quarter per diagnosis • CDAC compares their abstracted data results with hospital submission results and provides hospital an interreliability score • Score must be 90% or better to stay in CMS program 1 month 30 – 60 days • Hospital Discharge Data Collection Process • Use automated ToolC to enter CMS indicators on every patient discharged with relevant diagnosis including indicators hospital wants to collect (e.g., nursing unit) • Upload data to Premier Web tool • Analyze data immediately to determine scores and process improvement ? 6 months later • Related Hospital Processes Not Linked • Medical Records abstracting on all patients (Tool D) • JA Thomas data collection on patients (Tool E) • Other clinical data collection and analysis (Tools?)

24. Premier/CMS Data Collection and Submission Flow - IDEAL • Hospital Concurrent Process • HIS Census report used to identify patients that may be candidates for CMS program • Collect CMS indicator data via automated Tool daily on these patients • Daily CMS indicator data sent to nursing units, CMO, CM or other hospital defined persons for review to ensure compliance with indicators • Report sent to hospital management weekly for compliance review • Generic Submission Process • After discharge, HIS system or Tool sends data to Trendstar • Data from Trendstar or Tool submitted to Premier • Premier sends list of patients to be included back to hospital • Medical records pulls charts from list and searches through charts to abstract data (Step not needed) • Data is uploaded on Premier Web tool • Premier cleanses data and sends back to hospital for approval to submit • Premier submits data to CMS • Premier sends scores to hospital • Reliability Validation • Hospital is asked by CDAC (under contract with CMS) to pull charts, copy and send to CDAC - about 7 identified charts per quarter per diagnosis • CDAC compares their abstracted data results with hospital submission results and provides hospital an interreliability score • Score must be 90% or better to stay in CMS program 1 month 30 – 60 days • Hospital Discharge Data Collection Process • Use automated Tool to review CMS indicators on every patient discharged with relevant diagnosis including indicators hospital wants to collect (e.g., nursing unit) • Upload data to Premier Web tool • Analyze data immediately to determine scores and process improvement ? 6 months later • Related Hospital Processes Linked • Medical Records abstracting on all patients (Tool) • JA Thomas data collection on patients (Tool) • Other clinical data collection and analysis (Tool)

25. Quality Content Review Process Classification of Practices • Franchise Practice: Practice that all BSHSI facilities will incorporate as quickly as possible to improve performance. All hospital Administrators will be advised to implement the practice. • Best Practice: Practice that BSHSI facilities should incorporate unless there are specific circumstances that will limit the effectiveness of the practice. • Established Practice: Practice that has been shown to be effective in at least one facility and may be considered for replication. • Discouraged Practice: Practice that has been shown to be ineffective or harmful in improving outcomes. Hospital Administrators will be notified of such practices.

26. Criteria • Established Practice: A process or practice that has been implemented and there is a relationship between the practice and improved outcomes. There is no data or expert consensus that there is a cause and effect between the practice and the improved outcome. Example: An indicator score is generally increasing and physician educational campaign is begun. The scores continue to increase at the same rate and no “special cause” effect is demonstrated on the run chart. • Best Practice: A process or practice about which there is data to demonstrate a relationship between the practice and improved outcomes or there is expert consensus that the practice should be replicated in BSHSI facilities. An example of a best practice is employing an additional nurse practitioner to follow every cardiac patient and write discharge orders. There is data to support this practice causes an improvement in the score for complete discharge orders for CHF patients. It may not be an efficient and robust practice (see below). • Franchise Practice: A best practice which is also efficient and robust. An efficient practice is one which requires minimal change in behavior (a so called “hard wired” change) and requires less than $5,000 in additional expenditures to implement. A robust practice in one which all hospitals can implement with little disruption of other processes. An example of an efficient and robust practice is implementing smoking cessation counseling to the patient registration process such as BSHR has done. • Discouraged Practice: A process or practice about which there is data to suggest the practice may be ineffective or result in poorer outcomes or there is consensus among expert opinion that the practice is ineffective or detrimental. An example of a discouraged practice is the institution of a process change that increases “door to balloon” time.

27. Clinical Practice Classification Grid • Each process/practice identified for each of the clinical conditions (AMI, HF, PN, CBG, Ortho) will be classified according to the schema above and categorized by practice and focus area as below.

28. AMI Pick Up the Beat Campaign Problem Statement: Based the second quarter results of 04 HQI composite scores it appears that many of the Bon Secours acute care facilities have opportunities for improvement with the evidence based indicators for Acute Myocardial Infarction (AMI).  Listed below are the indicators that represent our largest opportunities for improvement: • Smoking Cessation • ACE Inhibitor Use • Aspirin Prescribed at Discharge • Thrombolytic received within 30 minutes of hospital arrival • Mortality Rates • Improving these indicators will result in greater gains in overall composite scores for AMI, and will result in greater improvement in decile performance. Strategies Stage 1 – Build Awareness of Problem and Initial Directions for Solutions Stage 2 – Accelerated Sharing of Solutions & Problem Solving Stage 3 – ‘Deeper Dives’ Into AMI Strategies & Resources

29. Tactic: AMI Pick Up the Beat Webinar

30. Intranet interface supports the seamless delivery of multiple Web services Intranet tool needs to be able to integrate other Web appli-cations effectively Search Virtual meetings BP Database Share Etc. Next Step: BSHSI KTPEIntranet Integration with KTPE & eLearning Intranet Hub Knowledge Transfer for PE eLearning System BSHSI Best Practice & Innovation Database (Web)

31. Next Steps: Increasing Sharing Literacy of Healthcare Associates Best Practice & Innovation DB: • Central knowledge resource Robust Search: • Internal • Resources & Assets • SMEs • External Web Share: • Submit an effective practice or improvement of core strategy • Adaptations to market conditions • Enhance collaboration eCollaboration: • Accelerated problem solving • Save time and money

32. Support Share Search Community of Excellence (multi-dimensional) Innovate Six Sigma Knowledge Collaborate Next Steps: e-Sharing Requires Personal Change The online Community of Excellence extends teams 365 x 7 x 24 • Shared Learning/Working Environment with Aligned Purpose • Knowledge @ Point of Need • Support Member Behavior Change from Email Centric Communication to Web Centric Sharing

33. CMS Composite Scores – Bon Secours Richmond Health System Weighted Average for All Clinical ConditionsQuarters Ending December 2003 – September 2004 Overall BSHSI 9/04 – 77.7% 6/04 – 76.7% 3/04 – 75.3% 12/03 – 74.2%

34. Hospital Compare.hhs.gov Percent of Heart Failure Patients Given ACE Inhibitor for LVSD

35. Hospital Compare.hhs.gov (continued) Percent of Pneumonia Patients Given Initial Antibiotic Timing

36. Hospital Compare.hhs.gov (continued) Percent of Heart Attack Patients Given Aspirin at Arrival

37. Performance Results: Year One • Compliance with Evidence-Based Medicine: The “Composite Score” • Compliance Benchmarks / Targets • BSHSI • Bon Secours Richmond • State and National: Examples from Medicare’s public website

38. Key Bytes • It’s a ‘KNOWLEDGE’ not information economy! • From Knowledge to …‘Know How’ • Knowledge is Social • …the power of social and informal networks in your organization • Have an Enterprise Knowledge Management and Innovation Strategy and Plan • Capturing and Packaging Critical Quality Knowledge & capabilities requires multi-year investment • Fund the treasure hunt! • Capability transfer depends on multi-media support • Audio & video online and live interactions! • Virtual community building takes dedicated human resources with experience

39. Future State Innovation

40. Community Operations and Support Tracking and Performance Results Exchange and Support Center Knowledge Packaging & Content Management Knowledge and Capability Transfer BSHSI’s Knowledge Transfer Model: Core Competencies and Program Components LEADERSHIP CULTURE TECHNOLOGY PROCESS