1. science
2. medicine
3. surgery

4/16/2015
Agenda
Challenges at Advocate Lutheran General Hospital in
implementing the PSH and… what happens to the
PSH when CMS unbundles surgical care in 2017?
• How to get started in a private practice group with limited
resources
• Discussion on steps to implement
• LEAN- where are we in the process
• Challenges
• Early results
• Making it work even in less than optimal situations
• Next Steps
Challenges at Advocate Lutheran General Hospital in
2
Advocate Lutheran General
Hospital
Anesthesia Group (PRAA) Structure
• ALGH
• Pure private practice group staffing:
700 beds NW Chicago
Part of 12 soon to be 15 hospital system (largest in ILL)
30K cases
Truven’s top 100 16 times
Truvens top 5 academic systems 6 times
Cerner IP, Allscrips OP,eClinical Works OP, Compass, Crimson,
NSQIP, Midas, OR business mgr spreadsheets
USNWR recognized
1000 MDs on staff
250 surgeons
Profit 60M/System endowment 3.5B soon to be 5.5B under
management
36% MC/MC
26 OR rooms, 8gi rooms, OB, OOR, plus 5 surgery
centers and 12 bed SICU managing 46K anesthetics
36 full time docs and 9 part time docs and soon to be 8
CRNAs, 38MDs, 10part time docs
No support staff, outsourced billing and management
Zero stipend
7 x14 “library” and 1 office shared by medical director and
non-MD coordinator
Chairman’s office outside of OR
FES pay per case and no pay for “extra work”
Cardiac, SICU, OB, PAT, PEDS coordinator provide
service with no comp.
3
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4/16/2015
Getting started…Our Process
• Applied for ASA Surgical Home study group
• Support from Competent management and C
level support is essential
• Hired our savior “Flo”
• Set goals
• Divided process into various parts
• PAT, pre-intra, post, case management and post
D/C snif, LTAC all “lead” by different docs
OR Directors scope covers all except post D/C
Metrics
• LOS
• Unplanned 30 day readmission
• Financial– Total inpatient stay cost
– Total intra-op cost
– Total direct supply cost per case
• Clinical
– NSQIP
Chose Colorectal Service
because
• Single group of 3 surgeons doing 750 cases and
almost no co-other surgeons doing these cases
• Very difficult players..but as compared to others,
maybe not
No clinical staff in their office
Lots of issues with their preop processes
• Yet, they appeared to want to improve….
• Several outcomes drove us to choose this
service line
LOS and Readmission
METRICS
2013
2014
Surgeons
Top Decile
Surgeons
Top Decile
% of Readmission within 30 Days
8.43%
12.19%
10.33%
11.99%
ALOS
6.80
7.07
6.03
6.70
Source: Crimson
• Data-Enhance Recovery Colectomy
• SSI
– On time 1st case starts
– Surgery time- ERAS < 3 hour anesthesia time
• Patient Satisfaction Scores
7
8
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4/16/2015
Average LOS- 2013 to 2014 Trend
% 30 Readmission- 2013 to 2014 Trend
Source: Crimson
Source: Crimson
9
10
Top 5 Reasons for Readmission within
30 days
Early challenge: not all data matches chosen
procedures
Direct Supply Cost per Case by ICD-9 FY2014
Advocate Lutheran Performance
ICD-9 Primary Px
Top 5 Reasons for Readmission Jan 2012-June 2014
Cohort Performance
Case Volume
variance to
Direct Supply Cost per Case
75th Opportunity
percentile
$2,159 $791
$26,103
1733-LAP RIGHT HEMICOLECTOMY
33
4593-SMALL-TO-LARGE BOWEL NEC
10
$2,069
4594-LG-TO-LG BOWEL ANASTOM
5
$2,397
N/A
N/A
$37,777
$1,110
$11,097
4863-ANTERIOR RECT RESECT NEC
72
$2,434
$525
4869-RECTAL RESECTION NEC
9
$3,043
$2,013
$18,118
129
$2,376
XXX
$93,096
TOTAL
Jan 2012 to June 2014 (DRG)
Value %
Total # cases
90th
75th
50th
25th
# of facilities
389-G. I. Obstruction W Complication
6.9%
8
$1,070
$648
N/A
$1,190
$483
$1,368
$959
N/A
$1,909
$1,030
$1,830
$1,557
N/A
$2,445
$2,315
$2,389
$2,086
N/A
$3,105
$2,850
82
43
392-Esophagitis, Gastroent & Misc. Digest Disorders W/O
Major complication
5.17%
6
862-Postoperative & Post-traumatic infections W Major
complication
5.17%
6
393-Other digestive system diagnosis W Major complication
5.17%
6
394-Other digestive system diagnosis W Complication
4.31%
5
74
49
Source: Advisory Board
Notes: Benchmark values calculateion cases fro Nov 2013-Oct 2014
TOTAL # of CASES= 111 in Crimson
31
Source: Crimson Clinical Advantage
11
12
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4/16/2015
A Big Challenge-no single
source
Surgeon challenges and
Ulterior Motives
• All the data lives in different data bases with
different structures and personnel
• NSQIP
• Cerner registry
• Compass
• Crimson and Midas for quality
• HCAHPS for patient satisfaction
• Compass for some surgery financial data
• Business manager spread sheets for some
financial data not always matching our
designated PSH group
• Initially we found the surgeons were willing to
participate BUT….
They really wanted to improve turn over time
Epidurals done out of the OR
More consistent service from Anesthesia
• Then they would play
13
Advocate Lutheran General
PSH/ERAS Mission
• Promote coordinated care
• Reduce
–
–
–
–
Setting Goals
Cost of care
LOS
Complication rates
Re-admissions
•
•
•
•
Promote optimal patient safety
Standardize practice using evidence based practices and research
Improve the patient experience and satisfaction
Improve overall satisfaction of Patients, Surgeons, Anesthesia,
Nursing and other clinical staff
• Provide quality & improvement measures demonstrating success,
outcomes based on research (NSQIP, SCIP)
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16
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4/16/2015
SharePoint Site
What is the Goal?
• The goal of the PSH is to enhance value and help
achieve the Triple Aim: a better patient experience,
better health care, and lower costs.
17
18
Lean Methodology
Act
STUDY
Study
DO
Step 8
Step 7
Step 6
Plan +
Step 5
Step 4
Step 3
Step 2
Step 1
Interview
Staff
19
Assemble
steering
teamSelected a
physician
leader for
each
phase and
its
members
Gathered
literature.
Collected
quality
baseline
data
Collected
list of
protocols
for each
phase
Observed
current
state.
Value –
stream
Mapping.
Develop
protocols
and
clinical
pathways
Trial
protocols
And
Clinical
Pathways
Step 10
PSH/ERAS Steering Team
Step 9
Analyze
the
pathways
and
protocols
and new
Workflows
and
handoffs.
Monitor
Data
Implement
finalized
processes
Finalize
protocols, and clinical
pathways.
processes Finalize
and clinical physician
pathways. scorecards
Develop
and
Physician dashboard
Ad HOCAdvocate
Home health
Nutrition
Geriatric MD
Nursing
Education
Scorecards
and
Colorectal
dashboard.
Anesthesia
Pre-op-Dr. Young
Intra-op-Dr. Nishant
Shah/ Pain- Dr.
Adanin and Dr.
Hennes
Post-op-Dr. Bissing
Post Discharge-Dr.
Bissing
Surgeons:
Dr. Park
Dr. Prasad
Dr. Marecik
Lead
Anesthesiologist
Dr. Bissing
Surgeon in
Chief
Dr. White
Administrator
Cindy van
Brenk
Post Discharge
Care
Coordinators
IT
Suzzie Kwon
Marketing
Evonne W
Post-Op
Tammy
Burrows
PSH Project
Team
Pharmacist
Noreen Kelly,
Amish Doshi
Quality
Mary
Fleming
Intra-op RN
Marta
Tobolski
Service
Erin Pangallo
POCU
Lynn Nolan &
Steve Jermeay
Hospitalists
Dr. Kushner
Dr. Affinitti
Finance
Stephanie
Xanthopoulos
20
Physical
Therapist
Doug Reed
Researcher
Suela Sulo
PST
Steve Jermeay
& Lynn Nolan
Project
Manager
Flo
Ostomy RN
Marina
Makovetskaia
Kiokemeister
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4/16/2015
Perioperative Surgical Home Protocols
PERIOPERATIVE SURGICAL HOME PROVIDES A ROBUST
INTEGRATION OF THE ENTIRE PATIENT CARE
CONTINUUM
Each phase of care has a well-defined series
of care elements and protocols
Preoperative
Phase(Scheduling from
office & PST)
Intraoperative Phase
Postoperative Phase
Post Discharge Phase
(POCU/MOR)
(Phase 1 PACU, 7 Tele)
(Home/Facility)
Education & Expectation Management
Pain Management
Diabetes Optimization
Preoperative
Phase
(Scheduling from the
office and PST)
Skin Prep (SSI Bundle)
Wound Care
Intraoperative
Phase
Postoperative
Phase
Post Discharge
Identify Risk Factors
Co- Morbidities Screening
Intraop Analgesia- Epidurals
Early feedings /diet
Phase
Anesthesia clinical pathways
Early Ambulation
(POCU/MOR)
(Phase I PACU, 7 Tele)
(Home/facility)
Lab orders
Goal Directed Fluid Therapy
Physical/OT Therapy Consult
Use of Pre-op Meds
Nausea and vomiting control
Primary Care Follow-up
Bowel Prep
Early removal of NG tubes/catheters
Arrangements made for
SNF/LTC if needed
What are the metrics in each phase that will be measured?
Each phase of care has a well-defined series of
care elements and protocols- each with an
emphasis on patient centered care and shared
decision
making
21
Stoma Care
Prescriptions
Standardize nursing care
Transition Phone Call Center
Risk for Readmission Interview
Transfusion Therapy
PIC Line Placement
Anemia
evaluation/management
DVT preventive Therapy
Post-op Analgesia
Home visit by Home Health
Normothermia
Stoma Education
Follow-up phone calls from RN
Nutrition Optimization
Alcohol consumption
Smoking Cessation
Strength and Conditioning
Inclusion of Hospitalist
D/C of Antibiotics
Chemical Prophylaxis
22
Colorectal Procedures for PSH
Why these procedures?
• Laparoscopic Right Hemi colectomy
• Laparoscopic Left Hemi colectomy
• Low Anterior Resection
• Current research focuses on these
procedures and there is a lot ERAS protocols
that are in the literature
• Research has shown that patients that are
under anesthesia 3 hours or less have a
faster recovery and shorter LOS
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24
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4/16/2015
Top 5 Procedures (Jan 2014- Dec 2014)
SOURCE:SURGINETStephanie
Xanthopoulos
25
Abdominal Perineal Resection
Abdominal Perineal Resection Laparoscopic
Anoplasty
Anoscopy
Anus Botox Injection
Bowel Resection
Bowel Resection Left Hemicolectomy
Bowel Resection Left Hemicolectomy Laparoscopic
Bowel Resection Right Hemicolectomy Laparoscopic
Coloanal Pull-Through
Coloanal Pull-Through Laparoscopic
Colon Resection Low Anterior Laparoscopic
Colonoscopy Laparoscopic Assisted
Colonoscopy OR
Colostomy Closure
Colostomy Revision
da Vinci Abdominal Perineal Resection Laparoscopic
da Vinci Bowel Resection Left Hemicolectomy Laparoscopic
da Vinci Bowel Resection Right Hemicolectomy Laparoscopic
da vinci Bowel Resection Ultra Low Laparoscopic
da Vinci Coloanal Pull-Through Laparoscopic
Exam Under Anesthesia
Fistulectomy
Gastrostomy Tube Insertion
Hemorrhoidectomy
Hernia Repair Inguinal
Hernia Repair Umbilical
Hernia Repair Ventral
Hernia Repair Ventral Laparoscopic
Ileoanal Pull - Through
Ileoanal Pull - Through Laparoscopic
Ileostomy Closure
Ileostomy Revision
Lesion Excision Rectal
Lesion Excision Torso
Mini Procedure - GEN
Neuro Stimulator Insertion Stage II
Neuro Stimulator Lead Insertion Stage I
Pilonidal Cyst Excision
Rectal Prolapse Repair
Rectal Vaginal Fistula Repair
Rectocele Repair
Sphincterotomy
Transanal Excision of Rectal Tumor
Grand Total
Total of Top 5 Bowel Resection Procedures
2
1
10
10
19
23
13
100
58
2
6
1
1
25
3
1
5
9
8
10
7
19
153
1
34
1
1
4
16
2
6
26
4
46
2
1
12
12
9
17
3
4
10
3
700
204
Office Changes
Pre-operative Phase
Office and Pre-Surgical Testing
26
Surgery-Colonoscopy Check list
• Surgery-Colonoscopy Checklist Form
• Scheduling- to identify the ERAS Patients
with and without Epidural placementPENDING
• Introduction to the New Pre-Surgical Clinic
27
28
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4/16/2015
Pre-Surgical Clinic
• Meet 2 afternoon sessions per week (Tuesday and
Thursdays 12pm-4pm) in current PST space
• Multidisciplinary clinic- “one stop shopping” concept
• Serves as the home base for the patient and a point of
contact before and after surgery
• Allows for proactive planning for post-discharge
transitional care, and active follow-up with high-risk
patients.
• Patients will be prepared for discharge before their
admission
• Patients will be educated on postop expectations and
their healing process
29
Serves all five of the major goals of the PSH:
• Provides a portal of entry to perioperative care and
ensures continuity.
• Stratifies and manages patient populations
according to acuity, comorbidities, and risk
factors.
• Delivers evidence-informed clinical care.
• Manages and coordinates the follow up of the
perioperative care across specialty lines.
• Measures and improves performance and costefficiencies.
30
Providers and Clinicians in
Clinic- Plan- DRAFT
•
•
•
•
•
•
Goals of Pre-Surgical Clinic
Hospitalist
PST Nurse
Ostomy RN- AD HOC basis
Lab
Discharge Planner- TBD
Nutritionist- TBD
Risk Assessment-Reduction Tools
(used in Clinic)
•
•
•
•
•
•
•
•
NSQIP Cardiac Risk Calculator
POP-Pulmonary risk calculator
PONV screening tool
Delirium tool- Mini Cog Assessment
Nutritional status tool- in Cerner
Anemia/blood count protocol
OSA - STOP Bang screening tool
Risk of readmission tool- currently used only
by the Case Manager
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4/16/2015
Other screenings
Education Booklet
•
•
•
•
•
• The booklet is a guide to help patients and
their families understand what to expect
during the entire surgical and hospital
experience.
• The goals of the booklet are:
Diabetes –HbA1c test
Albumin and Creatinine levels
Alcohol use
Smoking cessation
Preconditioning/exercise
– To help the patient understand and prepare for
surgery
– Explain how the patient can be an active
participant in their care and decision making
– Provide daily goals to recover faster
33
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Pre op steps
Intra-operative Phase
POCU and OR
•
•
•
•
•
•
•
•
•
•
•
•
Home
NPO after midnight for solids and nonclear liquids
Clear liquids until 4 hrs. preop
Carbohydrate drinks 4 hrs. prior to surgery
POCU
Celecoxib 400mg po
Pregabalin 75mg po
Tylenol 1000 mg po
(All to be part of preop order set initiated by colorectal service)
Epidural placement T7-10 (to be placed by Anesthesiology)
35
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4/16/2015
Intra-op steps
Intra-op steps
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Operating Room
Epidural specifics:
Lidocaine 2% bolus 20 min prior to incision in increments of 3-4 cc to test correct placement and to cover
incisional pain
Bolus epidural at the end of the case with 4-5 cc 0.25% bupivacaine to cover incision as patient awakens
Epidural to be activated after bolus at the end of the case at 4-10 cc/hr and run with 0.125% bupivacaine with 2
mcg fentanyl at the end of the case
Rate to be determined by anesthesiologist
General notes on epidural usage. Keep in mind epidural activation can and usually results in a decrease in
venous capacitance and sometimes a drop in SVR. These changes also result in changes on a device such as
the Flo Trac that may direct the clinician to administer more fluid because preload has decreased. As a result, we
would like to only use the epidural at the beginning to test and simultaneously cover the pain associated with
incision and later when the patient is awakening.
Narcotics
Discretion of Anesthesiologist. Minimal use preferred so as to decrease the amount of time it takes for bowel
function to return.
Discretion of Surgeon. Please ask PPM if Toradol 15 mg can be administered. If yes, then administer
approximately 30 minutes before the end of the case. Do not administer Toradol if the patient has significant renal
impairment.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Fluids
Use PIV started in preop to infuse 1 liter crystalloid prior to incision
Start basal rate and connect to pump. Fluid rate based on lean body weight; max 80kg
1cc/kg/hr for laparoscopic cases
3cc/kg/hr for open cases
Decrease rate to 1cc/kg/hr when transferring to PACU
2nd PIV to be placed in the OR
Flo-Trac mediated fluids will be administered through this IV
Flo-Trac
Arterial Line to be placed after patient is induced and intubated
No arterial lines for short cases such as right hemicolectomies. Use best judgment and place if needed for patient
safety
We may have other noninvasive monitoring that functions similar to the Flo-Trac to assist with fluid administration
in those cases
SVV better than SV because of increased compliance of heart in most patients under 65 years of age and without
any signs of heart failure
Must wait 5-10 minutes to make sure the values are not an aberration. Use clinical judgment when deciding to
infuse fluids based on values.
Correlate decision making with position changes such as T-burg and other changes such as insufflation
Intra-op steps
Intra-op steps
•
•
•
Follow SVV protocol
– SVV values should be consistent for 5-10 minutes before following protocol
treatment options.
• Also one must always keep in mind the other factors that can cause a change in stroke
volume variation that does not relate to fluid responsiveness. This includes cardiac
arrhythmias (more than 4 times a minute), non-controlled ventilation, and fluctuations in
intra-abdominal pressure or thoracic pressure.
• If there are frequent cardiac arrhythmias than one will not be able to use stroke volume
variation and should not follow this protocol
•
– SVV Guided Fluid Intervention
• If the stroke volume variation is greater than 12 % for an appropriate amount of time
and everything else has been deemed appropriate than one should give a 250ml bolus.
• This bolus SHOULD NOT affect blood product administrations in either transfusion
thresholds or for amount of products. After the bolus has been administered one should
go back to reassess the SVV again looking for the percent change.
• If the value is now less than 12%, then this is showing that one is making an
improvement in the patients stroke volume optimization
•
–
–
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
.
Ventilate at about 8cc/kg IBW
Decrease tidal volumes as needed for patient safety
If BMI >30, then decrease actual body weight by approximately 30%. If you use other methods to calculate approximate IBW, that
will be appropriate as well
PONV prophylaxis
Dexamethasone 4mg at start of case
Ondansetron 4mg at end of case
Add scopolamine patch for high risk cases preoperatively
Post Operative Delirium
Give little to no versed if patients are slightly altered or cannot answer simple questions such as why they are
getting their procedure
Give muscle relaxant at beginning of case and small to no dose of reversal. Try to avoid reversal as much as
possible.
Miscellaneous
Place OG tube at the beginning of case and remove it at the end of the case
Epidurals will not be placed for right hemicolectomies
Dr. Prasad will label which cases need epidurals and they will be listed as such on the schedule
An attempt will be made to have the CRNAs staff these cases to help facilitate epidural placement in the preop
area
•
10
4/16/2015
Epidural
Placement
Workflow
Intra-op Status
• Implementation of:
– Epidural placement in the POCU
– SSI Colorectal Bundle
• Utilize CHG Sage wipes in the POCU the day of
surgery
• Closing Mayo Tray
• Changing gloves and gowns
– Consistent Colorectal Team in the OR
41
42
POCU Time Audit Analysis with
Epidural
INTRAOP Time Audit Analysis with
Epidurals
2:52
6:00
2:36
2:24
2:13
2:06
2:04
30% decrease in
total me in
POCU from 1/7
to 2/4
1:55
4:48
2:09
4:35
1:48
Average Times
3:45
1:26
0:59
3:36
4:04
3:53
3:313:30
3:22
3:05
2:49
2:32
2:20
2:24
2:20
0:57
0:37
1:23
0:30
0:28
0:230:22
0:070:09
0:00
43
0:150:13
0:09
0:04
0:18
0:10
0:03
0:08
0:05
0:05
0:17
0:29
0:16
0:10
1:12
0:58
0:04
0:03
0:13 0:10
0:030:05 0:03 0:06
1/7/15
1/14/15
1/21/15
1/28/15
2/4/15
Total Avg.
Hand off me
0:07
0:04
0:03
0:05
0:03
0:04
Epidural Placement
0:09
0:09
0:37
0:08
0:17
0:16
Anesthesia me in POCU
0:23
0:15
0:59
0:18
0:30
0:29
End of epidural to pt to OR
0:22
0:13
0:10
0:05
0:10
0:12
Total me in POCU
2:36
2:13
2:06
2:04
1:48
2:09
0:31
0:26
0:18
0:17 0:20
0:11
0:080:080:110:050:100:08
0:090:07
0:02
1:13
1:06
0:59
0:42
0:12
0:56
0:48
0:46
0:40
0:06
0:040:05
0:00
Total me for line and
foley placement
Total me for prep and
posi oning
1/7/15
Total drape me
1/14/15
Time from end of drape
me to surgeon arrival
1/21/15
Time from pt in OR to
surgeon arrives
1/28/15
Total anesthesia me
2/4/15
Total room me
Turnover me (1st to 2nd
pt)
Total Avg.
44
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4/16/2015
Summary- Results and Opportunities
Wins
•
•
•
•
All staff showed up on time for
epidural placements in the
POCU
Average total time for patients in
the POCU decreased by 30%
from Jan 7th to Feb 4th
Right hemi-colectomy patients
on the average under
anesthesia for < 3 hours. Left
hemi-colectomy and LAR
patients are under anesthesia on
the average >3.5 hours.
Turnover decreased by 40% on
average from first and 2nd
weeks. (3 people are now
available for turnover)
Need to work on
• Decreasing total anesthesia
time.
• Resident delays
• OR staff not sure which
resident is assigned to
their room
• Residents are not
consistently present
during positioning.
• Delay between end of epidural
placement to transfer to OR
Post-Op Phase
Phase 1 PACU
7 Telemetry
46
Post-op status
• In PACU-Monitor epidural fails
• On 7 Tele
– No PICC lines delays- patients are getting screened
24-48 hours after surgery if they need a PICC line
– PT- need to develop an algorithm for patients that
need PT. Needs to be based on age and pre-surgical
clinic assessment
– Ostomy education on the weekends
47
48
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4/16/2015
Revised Post–op Protocols
Daily goals are developed for patients
regarding:
• Activity and early mobilization
• Early feeding and diet
• Early removal of Foley catheter
• Post-op analgesia
Post-Discharge Phase
Home or Facility
50
49
Post Discharge
• Transition care- currently 24 hour phone calls
done only once
• Looking at software system to help with postop discharge calls- vendor meeting with
surgeons in March
• Follow-up to find out top 5 SNIF’s the
colorectal patients go to after discharge
• Meet with Advocate Home Health
51
Next Steps
• Pilot Pre-Surgical Clinic- tentative start date March 1st
• Build risk assessment tools and place on SharePoint
Site for all to access.
• All protocols to be placed on the SharePoint Site
– Icon to be placed on PC’s
•
•
•
•
Complete education booklet for patients
Office staff to utilize revised surgery checklist
Anesthesia intra-op protocols
Anesthesia analgesia protocols
– Work with pharmacy to trial Exparel and IV Tylenol on select group of
patients-need algorithms
– Build order sets
52
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4/16/2015
Project Timeline
Next Steps (cont.)
T arget Date
Deliverables
ST AT US
PERFORM INTERVIEWS IN A LL A REA S
Aug-Sept.2014
DEVELOP A SHA REPOINT SITE
• Begin development and implementation of post-op
protocols
– Educate staff and build order sets
• Clinician 3 RN’s to assist with Ostomy education for
patients on weekends and off-shifts- education and
training being developed
• Work with Case Management on how changes in their
role will effect the ERAS patients
OVERVIEW OF PROJECT MEETING WITH SURGEONS
KICK-OFF MEETING WITH STEERING COMMITTEE
Oct. 14
VA LUE STREA M MA PPING-CURRENT STA TE
PERFORM WA STE A SSESSMENT
EVIDENCED BA SED A SSESSMENT
GA THER PROTOCOLS FROM A LL A REA S
Nov./ Dec.
Jan.- Feb 2015
DEVELOP CLINICA L PA THWA YS
BEGIN IMPLEMENTA TION OF NEW PROCESSES A ND
PROTOCOLS
IDENTIFY METRICS
REPORT OUT TO LEA DERSHIP- UPDA TE
BRA INSTORM A ND IDENTIFY SOLUTIONS WITH TEA MS
BUILD RISK A SSESSMENT TOOL
UPDA TE A ND REVISE PROTOCOLS
DEVELOP EDUCA TIONA L MA TERIA LS FOR PA TIENTS
PILOT PRE-SURGICA L CLINIC- DEVELOP PROCESS
DEVELOP A ND PLA N OUT SOLUTIONS- need leadership
approval
MARCH/APRIL 15
PLA CE PROTOCOLS A ND A LGORITHMS ON SHA REPOINT SITE
ROLL OUT PROTOCOLS IN EA CH PHA SE
May/ June 2015
Jul-14
DEVELOP EDUCA TIONA L MA TERIA LS FOR STA FF
DEVELOP A ND PILOT NURSE NA VIGA TOR ROLE/ TRA NSITION
NURSE
IMPLEMENT/EXECUTE SOLUTIONS (develop Future State
Map)
FINA LIZE CLINICA L PA THWA YS
PSH SHOWCA SE- WA LK-THRU'S
IMPLEMENT/EXECUTE SOLUTIONS (develop Future State
Map)
FINA LIZE REVISIONS TO FUTURE STA TE
FINA LIZE CLINICA L PA THWA YS COSTS
FUTURE PROCESSES REPORT OUT
FINA LIZE EDUCA TION MA TERIA LS
Jul-14
TEA M CELEBRA TION
NEEDS ATTENTION
COMPLETE
PENDING
53
Barriers Summary
• Anesthesia has no paid time to develop program
• Limited hospital support with high threshold for
ROI
• Clinical and quality systems are a mess
• Surgeons still paid on volume (anesthesia too)
• Disparate primary care and surgeon referral
• Every department is overburdened and over
measured for productivity
• Burn out by same providers doing all the
projects
• Show me the money/ROI, (NSQIP)
55
What happens in 2017?
UNBUNDLED SURGICAL CARE
56
14
4/16/2015
Questions??
57
15