Healthcare Innovation

1. Healthcare Innovation Robert Monte, VAPHS VERC Director September 2013 University of Pittsburgh 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 VERC Overview

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

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

12. Organizational Structure VERC and OSR • Staffing • 10 Full Time VA Staff • 5 Fellows • 25 Part time Contract Staff

13. VERC: Mission and Vision

14. VERC National Activity Map

15. Building Blocks Mission Framework Pillars Foundations

16. Strategic Focus

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 PA -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 • Physical Therapy Missed Opportunities Reduction Team • FEB Chairman’s Bronze Award • Total Parenteral Nutrition Improvement Team • FEB Chairman's Bronze Award

19. Innovation

20. Game Based Learning The concept of developing a game to teach principles to improve access was suggested by Flo Hutchinson, Chief of Staff, Charleston VA Medical Center and Ro Hurley, Associate Director Systems Redesign, VA Central Office in June 2011. The VAPHS VERC & OSR was very interested in the concept and began work on a prototype in July 2011. The game objective is to implement Access Strategies to reduce waiting times for an appointment while keeping a balance of at least $5 .

21. Results

22. Telemedicine Solution: Aphasia Treatment Aphasia is a language disorder resulting from brain damage that impairs communication. The Program for Intensive Residential Aphasia Treatment and Education (PIRATE) provides treatment to Veterans with aphasia. The PIRATE program requires patients to travel to VA Pittsburgh and be housed in residential living facilities to receive this intensive face to face therapy. The prototype was built using a smart phone and i-pad.

23. Geospatial ORganization of Dialysis: Optimizing Networks (GORDON)

24.   Access and Missed Opportunities Data Tool • Data related to Advanced Clinic Access (ACA) measures are located in many different places on the VHA Support Service Center (VSSC) website. • To address this need, we created an Excel tool that creates a report using Pivot Tables to provide this information for the clinics at the stop code level.

25. National and VISN Support

26.   FTEE Resource Assessment and Staffing Tool • VERC worked with the Tampa VA Medical Center from November 2010 to January 2011 to help them develop staffing tools to align personnel resources with workload. • The tools enabled departments to calculate their workload, task time, and required FTEE while allowing for leave, breaks, and administrative time.

27. Wilmington VAMC Operating Room Simulation Model The goals and objectives of the project were to develop a current state simulation model of the Wilmington VA Medical Center’s four existing Operating Rooms and the new Endovascular Suite that would accurately model the workload, procedure durations, probability distributions for the process flow, and resource utilization. The model was used to test variable scenarios to optimize OR utilization and minimize late cases, overtime usage, and procedure backlogs.

28. Transplant Mapping • The first communication until the decision to develop a referral packet is variable and needs to be supported more formally. • The Transplant Referral Dialog template is a good tool that needs more resources applied on the referring side to fully optimize its use. • Communication needs to be improved between transplant teams and transplant teams and NSO.

29. Major Projects

30. 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

31. 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 • FY2013 • Virtual Collaboratives • NIRMO Training Modules • Site Visits • Toolkit development and deployment

32. 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

33. 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

34. National Initiate to Reduce Missed Opportunity (NIRMO)

35. VISN MO Collaboratives and RPIWs

36. (NIRMO) Results

37. 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

38. 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

39. Minor Projects

40. 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

41. Develop Specialty Pact Care Models

42. 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

43. Education and Fellowship

44. 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

45. 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 • Courses – Pitt Engineering, Business, Pharmacy

46. 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

47. Summer Internships

48. Thank you Questions?