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A Brief History of Tufts Medical Center
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  1. A Brief History of Tufts Medical Center 1796: Boston Dispensary founded 1981: World’s first pediatric trauma center established at the Floating Hospital 1894: Floating Hospital takes ill children & mothers out on Boston Harbor • Notable benefactors: Sam Adams & Paul Revere • First permanent medical facility in New England 1997: Creation of Neely House, a first-of-its-kind B&B-style home for cancer patients & their families 1938: 100-bed Pratt Clinic constructed, largest in the world ca.1919: Similac invented 1852: Tufts University founded 1992: First, full-service private teaching hospital created, with addition of the maternity service 1979: Graduate School of Nutrition created, first in the US 1886: Instructive District Nursing Association formed, the forerunner of the VNA 2009:Adopted the BCBSMA Alternative Quality Contract Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  2. Combining Art and Science to Create Value for Patients and Staff Margaret M. Vosburgh, EVP, COO June 19, 2009

  3. What is value1? A fair return or equivalent in good and services, or money for something exchanged 1 value. (2009). In Merriam-Webster Online Dictionary.Retrieved June 16, 2009, from http://www.merriam-webster.com/dictionary/value Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  4. Defining our Value Proposition Patients and Families • Access to world-class healthcare • Welcoming, calm environment Physicians • Cases • Reliable processes • Educational experiences for medical students, residents, and fellows Staff • Predictable environment • Support to provide top-notch service Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  5. Trust Relationships Safety Compassion Best Practices Voice of the Customer Lean and Six Sigma Outcomes Science Art The ART and SCIENCE Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  6. Throughput Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  7. Previous State of Hospital Throughput ? ? ? ? ? Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  8. Obstacles to Throughput Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  9. Optimization Task Force Purpose • To fast track organizational change by having process owners analyze current systems and propose alternatives. Participants • MD, RN, and Staff leaders from across the hospital Process • Standing meetings and agenda report outs • Formal template, complete for presentation Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  10. Operational Assessment & Plan Where we are • Inverse correlation between cost of care and quality outcomes • Unfocused management team • Patient volumes do not support our current operational and financial structure Where we want to be • Over the next 12 months, the Hospital & Physician’s Organization must focus on measurable outcomes: • Increase quality • Grow volume • Reduce the cost of care • Increase productivity How we are going to get there • Improve the operational and financial landscape • Create high expectations: • Educate staff & drive accountability • Measure outcomes regularly & relentlessly • No excuses Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  11. 2009 Operational Plan Create infrastructure to increase volume, decrease cost & improve quality outcomes INCREASE VOLUME DECREASE COST Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  12. Clinical Excellence / Quality Profitability Staff Development Summary of 2009 Goals • Infuse quality & patient safety principles into all clinical & business decisions: establish & monitor unit-specific goals • FY09 Q4: Meet Leapfrog ICU Staffing goals • Dedicated ICU Intensivist • Pharmacist rounding with team daily • FY09 Q4: Meet Leapfrog CPOE implementation goal • FY09 Q1: Implement decentralized clinical & profitability responsibility to the quality triad • FY09 Q2: Improve CMS & IHI measures to meet or exceed required goals • Increase discharges to 17,832 – an additional 2 patients per day • Reduce the ALOS to 5.5 days – decrease of 0.2 days per unit • Reduce Cost per Discharge – Unit-specific UHC Benchmarking • Reduce clinical denials to less than 10% - accurate charting • Reduce administrative denials to less than 15% - accurate charting • Establish & implement leadership competencies • FY09 Q1: Managers complete initial Manager Training modules • FY09 Q1: Graduate 1 Lean Six Sigma Green Belt class Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  13. Structure and Goals of the Quality Triads Physician The mission of the Quality Triad is to ensure quality within the organization by understanding, measuring and managing key metrics and processes. Quality Staff Development Profitability $ Administration Nurse Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  14. Foster a Culture of Quality • Lean / Six Sigma is a data-driven methodology(DMAIC) to solve issues, eliminate waste and improve processes. • Lean / Six Sigma is an integrated set of tools that produce breakthrough performance improvements. • Lean / Six Sigma will make it possible for the hospital to pursue leadership among our competitors through continuous quality improvement. Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  15. Optimization Initiatives ADT Center OR Leadership Forum Critical Care Task Force Optimization Task Force Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  16. Solutions • ADT Center • Optimization Task Force • Outpatient Scheduling Project • Phlebotomy Improvement Project • OR Leadership Forum • Critical Care Task Force Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  17. Goals Design/How Targets Mission I. ADT Center • Decrease ALOS to Medicare GLOS • Increase patient, staff & referring MD’s satisfaction • Eliminate OR, PACU holds • Eliminate ED diversion hours • Decrease interval between referral &bed placement • Coordinate diagnostic & treatment modalities • Communicate with MD’s to foster movement to an alternative level of care in a timely fashion • Prioritize access to beds based on patient care need and relationship with referring party • Establish a seamless, one-stop admission process for all non-scheduled and appropriate admissions. • Eliminate OR, PACU holds and ED diversions The ADT Center facilitates the right level of patient care in the right setting at the right time with the right service Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  18. ADT Team Medical Director 2100Nurse Bed Coordinator Proposed Coverage: Weekdays, 7am – 7pm Beeper other times • Radiology • Lab • Pharmacy • PT – PTT • QSS ADT Center Design ADT Team facilitates a disease mgmt model Patient’s case enters the ADT Center • Hospital Departments • Outside Sources • Physicians • Other ADT Team consults with appropriate resources 877 - OK - TUFTS Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  19. II. Discharge Optimization Scheduling Improvement Enhancements to Discharge Order Plan • Tufts Medical Center Clinics Follow-up Appointments • Space for 3 appointments • Can designate clinic, visit type, follow-up timeframe, type of clinician, and any comments needed to ensure continuity of care • Tufts Medical Center Ancillary Testing • Space for 3 appointments • Can designate test, test type, follow-up timeframe and the reason for the test/instructions Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  20. Discharge Orders Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  21. III. Phlebotomy Improvement Project Note: This reflects “report – to – work” in lab; arrival at patient units typically 10 to 15 minutes later, which constitutes the start of AM draw. Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  22. A.M. Lab Result Completion Times By improving Phlebotomist staffing patterns & prioritizing floors AM lab result times decreased. Implementation Date Instrument Problems June 4 & 5 Sick Calls Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  23. IV. OR Throughput Improvements Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  24. Model of Care

  25. The Need to Re-evaluate the Current Care Model • Consumers are not satisfied with current care models • Current systems do not work • Dissatisfaction of clinical staff – moving away from the bedside • Need to deliver care in a more efficient and less costly manner • Need to reduce variation and improve outcomes • Public mandate / Pay for Performance • Current service delivery model has not been able to provide desired outcomes Creating a new Model of Care is the most sustainable long-term strategy for Tufts Medical Center Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  26. New Model of Care Patient Centered Environmentally Aware Forward Looking Professionally Rewarding Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  27. Master Staffing Plan Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  28. Results: Increase Volume

  29. Discharges Are Up April YTD Discharges: Above budget by 742 or 7.2% and above prior year 974 or 9.6% Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  30. Clinic Visits Are Up April YTD Clinic Visits: Above budget by 3.494 or 1.8% and above prior year by 11,733 or 6.3% Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  31. Operating Room Cases (IP & OP) Are Up April YTD OR cases are up 462 or 6.9% over prior year and above budget by 407cases or 6.0% Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  32. ED Visits are down & Admissions from ED Are Up April YTDED visits YTD are 502 or 2.3% above budget but (748) or (3.3%) below prior YTD Pedi ED visits were down (289)or (7.0%) from prior YTD Adult ED visits were down (459)or (2.5%) from prior YTD Inpatient admissions from the ED are above last year by11.6% Emergency Department Visits-April YTD Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  33. INCREASE VOLUME: Reduce Emergency Room Diversion Elimination of ED diversion1 Hour ED Diversion = 1 Lost Inpatient Admission 2008 Dec YTD = $1.3 million lost revenue FY 2009 April YTD: Lost Revenue due to ED Diversion = $0 Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  34. INCREASE VOLUME: Manage of Length of Stay March 2008 ALOS peaked at 6.12 April 2009 YTD ALOS = 5.21 withLOS down by ~1 day ADT Center Co-Director began working 1-on-1 with physicians New Director Case Management implements process reducing ALOS Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  35. INCREASE VOLUME: Increase OR Volume Redirected block time to realize a15% increase in surgical cases to target or ninety (90) additional cases/month Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  36. Volume Has Grown April YTD discharges are 742 over budget and 974 over prior YTD April YTD surgery cases are 407 over budget and 462 over prior YTD Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  37. Results: Decrease Cost

  38. DECREASE COST: Operation Room Skill Mix Shifting RN:Tech skill mix ratio from 85:15 to 66:341 Operating Room labor annualized savings of$1 million Savings = $1,014,852 1 AORN Skill Mix Standard is 67% RN to 33% Tech Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  39. DECREASE COST: Inpatient Nursing Skill Mix RN:Tech skill mix ratio 3:1 to 4:1 SALARY SAVINGS = $1.7 million Savings Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  40. DECREASE COST: Reduction of Contract Labor FTEs 77% reduction in Nursing Contract Labor FTEs from high of 73 FTEs in May 2008 to 17 FTEs in April 2009 Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  41. DECREASE COST: Reduction of Contract Labor Expense Total Contract Labor savings since May 2008 = $740K Combining Art & Science, Innovations in Healthcare II, June 19, 2009

  42. Summary Successful outcomes occur when Art and Science are combined. Involving people, providing data & encouraging innovation will always lead to success. Combining Art & Science, Innovations in Healthcare II, June 19, 2009