Measuring Clinical Value at the Bedside

1. Measuring Clinical Value at the Bedside Janice Thalman RCP,MHS-CL, FAARC Duke University Medical Center thalm001@mc.duke.edu

2. Objectives • The evolution of value in healthcare • Eliminating waste and maximizing value • Respiratory care contributions to the success of our health care system • Critical considerations in staffing and productivity management The trouble with the future is that is usually arrives before we’re ready for it.

3. Value Definition • Shared goal that unites the interests and activities of all stakeholders • Defined as health outcomes achieved per dollar spent • Currently unmeasured and misunderstood

4. Value • For patients it must become the overarching goal of health care delivery • Primary/Preventative care • Measured for a defined patient group with similar needs • Medical Condition • Multiple specialties and numerous interventions • Combined efforts over full cycle of care

5. Value • Value = results not input • No longer volume of services delivered • May spend more on some services to reduce the need for others • Mayo: Value = outcomes; quality; safety and patient satisfaction divided by cost over time.

6. Value Culture Add value in quality outcomes, cost, customer satisfaction • Embedding RT in clinical pathways • Protocol based services ( why we don’t need so many ABG’s with vent patients) • Navigation of high ricks pulmonary patients ( COPD; asthma) • Pt education at Discharge • Smoking Cessation Consults • Pulmonary Rehab Screening

7. Collaborative • 2012 High Value Healthcare Collaborative was launched • 26 million $ grant funded by the Center of Medicare and Medicaid Innovation • Decrease utilization & cost by 64 million over 3 years • patients are engaged and empowered to make health care decisions based on own values and preferences. • 6 leading health care organizations • 150,000 patients • Improve care and reduce cost • Collect and exchange data on quality outcomes and cost for expensive high-variation conditions and treatments • Identify and Evaluate best practice health care models and innovative value based payment • Share knowledge and lessons learned with the public.

9. HVHC9 Condition/Disease Areas • Wide Variations in rates, costs and outcomes nationally • Total knee replacement • Diabetes • Asthma • Hip Surgery • Heart Failure • Perinatal Care • Depression • Spine Surgery • Weight Loss Surgery

10. MD Collaborative • Complex delivery with interdependent teams • Identify Practice variation

11. Outcome Dimensions • Tier 1. The health status that is achieved or retained • Survival • Degree of recover • Tier 2. Recovery Process • Time required and return to normal or best function • Disutility of care or treatment process • Tier 3. Sustainability of health • Recurrences • New problems as a consequence of treatment

13. HCAHPS Measures • Nurse Communication • Doctor Communication • Pain Management • Communication about Medications • Cleanliness and Quietness of Hospital Environment (average of the 2 responses) • Responsiveness of Hospital Staff • Discharge Information • Overall Rating of Hospital (excludes recommend hospital item)

15. AAA- Local level • Availability, Affability, Ability • Be here • Answer pages and calls • Be where the action (need) requires • Be nice ( golden rule) • Be a resource • Be responsible to learning and advancing skills ( this is life support, not Wal-Mart )

16. Hard-Work- Local Level • Scope of care • Relationship with the physicians • Reputation with airway management • Mechanical ventilator management • Consultation service • Technical edge • Research • Stamina • Love of the profession

17. Respiratory Therapy • Impacting increase in Respiratory Therapy Costs • Nitric Oxide +127% • Ventilator +12%

18. Nitric Oxide D/C Protocols • Meeting with key physicians • Adult and ICN • Identify clinical objectives • Agreement on clinical conditions • Communication, education strategies • Rapid wean ( therapist driven) • Reduce total hours on Nitric Oxide • Replace NO with Iloprost

19. Quality and Patient SafetySpontaneous Breathing Trial PI Project Project Goal: Improve the % of patients that receive a spontaneous breathing trial to assess readiness for extubation. Importance: Part of IHI Ventilator Bundle to prevent VAP Project Target: Achieve 90% compliance to fully achieve, 95% to exceed expectations.

20. Leadership Focus in Shifting from Volume to Value • Quality and Safety • Enablers and Provision of Resources • Employee engagement • Service and strategy • Fiscal accountability • Vision and change

21. Value Culture Behind Us Take Us Forward Quality One-on-one Protocols Outcomes Value Added Busy Heads Organization success • Neb Jockey • Concurrent Care • Counting TX’s • Activities • Procedures • Busy Hands • Department success

22. …Value is more than a set of skills • Culture • Curiosity • Vision • Values • Passion • Scope • Reputation • Assets • Partnerships-Relationships • Mistakes

23. Take Us Forward Groups • Intermediate Care • Core Teams- ICU • Emergency Response • Equipment • Cardio-Thoracic I don’t want any yes men around me. I want the truth even if it costs them their jobs.

24. Building the Structure to Support Change • Redesign care processes based on best practices • IT that will improve access to clinical information and clinical decision making • Knowledge and skill management • Development of effective teams • Coordination of care across patient conditions, services and settings over time • Incorporation of performance and outcome measurements for improvement and accountability

33. I was going to buy a copy of The Power of Positive Thinking , but thought What the hell good would that do?

40. RCPs and Disease Management • Physical exam and history • Home condition and family capability • Triggers to contact the MD, report to ER • Communication skills across encounters • Application of guidelines and protocols • Measure outcomes across the continuum • Relationship with MD office

41. COPD- and 30 Day Readmission • Fourth leading cause of 30-day readmission • Significant cost, over 11 billion annually • Readmission cost of $20,757 • 30-day readmission rates as high as 28% • Assessment of care based on adherence to guidelines suggest numerous opportunities exist to improve COPD outcomes Gary Brown, Patrick Dunne, COPD In-Patient Care: Time for a New Paradigm. AARC Times November 2011

42. RCP Role in Avoiding COPD Readmission • Presence at the point of entry (ER/Clinic) • In-patient protocols/guidelines • Focus on evaluation and education • Discharge readiness and plan • Follow-up once home • Pulmonary rehab and clinic referrals • COPD Team/Specialist

44. Preparing the workforce for change • Identify and agree on the steps and content of communication • Identify the platforms of communication that will be used • Identify the tree of communication; key people per shift and area

45. Managing Change… • Must continue to deliver quality work in the midst of change • Change has high emotional impact • Phases of change • Denial, mistakes, chaos, recovery • Navigate change – Supportive communication • Clarify, Share, engage

46. Communication Keys • Clarify direction and expectations • Encourage participation and involvement • Support open communication • Lead by example • Reward and recognize • Support ongoing development • Supervisor and manager blood brothers

47. Defining Value • Relative worth, merit, importance • Value is often measured by the usefulness or desirability of something • Elimination of non-value/waste Usefulness Need/Desirability

48. Value 2015 • Reimbursement linked to quality • Emergence of Telemedicine • RC to evolve in complexity • Data driven clinical decisions • Protocol will be most common way to deliver RC • RC will need to be increasingly engaged with research to demonstrate value of what they do • Patients and families will play a greater role • Information management system prevail Kacmarek, RESPIRATORY CARE • MARCH 2009 VOL 54 NO 3

49. Reaction of Administrators Beyond to 2012 • Customer satisfaction • Outcomes focused • Partnerships with providers • New interest across the continuum • Information technology • Invest in what adds value • Shift from volume to value

50. The First Step… Why RCPs • If someone else can do it better or for less cost, you will not maximize overall efficiency for the hospital, despite how good your productivity system is! • You need to first define what RCPs do that is of unique and unquestionable value: • At the bedside 24/7 • Flex staffing models • Cross utilization across procedures, units, sites, etc • Intellect- experts in physiology/technology • Broad legal scope with diverse skills