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Patient Safety ROI Calculations The business case for preventing inpatient falls
Eric Crawford
Eric.crawford@imail.org
Pascal Briot pascal.briot@imail.org
Intermountain Healthcare
IHI Seminar – From the Bedside to the Balance Sheet
Intermountain Medical Center – March 13, 2013
Why does the business case matter
1. Intermountain Healthcare’s mission:
Excellence in the provision of healthcare services to the community at the
lowest sustainable cost
2. Establish internal and external benchmark:
You cannot improve what you do not measure
3. Maximize the opportunities and strengths of performing as a
system through standardized processes:
Homogeneous system-wide application of best practice
4. Payment reform:
From FFS to capitation
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Challenges 1. How to identify rate and severity of falls
Impact of information measurement system and professional cultures
2. How to identify savings associated with reduction in rate of falls
Matched cohort comparison of length of stay, labs, imaging and Rx utilization
3. How to track intervention “cost”
Identification of intervention & accounting methodologies
4. How to “put it all together”
From the bedside to the balance sheet
Benefits – Costs = ROI
Benefits(costs of poor quality or service)
Costs (costs of improvement intervention)
ROI (Case for Change)
Intermountain ROI Tactical Initiatives
• Led by Asst. VP for Quality & Patient Safety and reported to CNO / VP for Clinical Operations
• Mission: – To build a partnership between clinical and financial experts to use the best
available data and expertise
– To provide careful ROI analysis of quality and patient safety initiatives in order to give leadership insight into strategic opportunities
– To build a standardized approached to calculating ROI that can be “exported” to other initiatives on a system, regional or facility levels
– To quantify existing quality improvement projects that may assist in meeting Intermountain’s goal of maintaining a low rate of cost increases to CPI+1%
• Initial areas of concentrations: – Falls
– Adverse Drug Events (ADE)
– Central Line Associated Blood Stream Infection (CLABSI)
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Tracking of interventions
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Rate of Falls with Injury per 1000 Patient Days
Injury No Injury
Leadership & refined /measurement system Organizational structure
Strategy for organization, robust measurement, multi level QI structure
1998-2004
Creation of Patient Safety Team
Meeting Prep and Follow-up
Nursing Falls Education
Develop protocol
2005 - 2007
Creation Safe Patient Handling team (earned
Magnet status, gait belts & lift system,
awareness signs)
Standardize Fall definition
Added electronic risk scoring/protocol
to event system
Developed web reports for front line
Inclusion of falls on nurse manager dashboard
2010 - 2011
Board Goal (2010)
Designated Fall Champions
Post Falls Assessment Implementation
Mini-RCA for Falls (Falls Assessment Huddle)
Patient Safety Index
Skill Pass Off for bed types
New Bed (with integrated bed alarm)
Nurse Call System Integration
Intermountain strategy to reduce falls
1998 - 00: Identification of falls as a strategic objective within patient safety Institution wide systematic tracking of falls
2002 – 04: Institution objective to achieve Magnet Status
What was done ?
2005 – 06: Doing better (going above and beyond Magnet Status)
Electronic reporting & risk screening
2008 – 10: Feedback of information to front line personnel and manager
Nurse manager dashboard
2011 – 12: Senior leadership & board engagement
Reduction of all falls & falls with injury become “board goals”
Resources allocation towards goals
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Intermountain’s interventions as compared to other institutions
Dimensions Intermountain
1998 - 2010 Kaiser
2007-2010 NHS
2009-2011
Leadership Teams and Champions • Creation of Patient Safety Team (1998) • Creation Safe Patient Handling Team (2005) • Board Goal & Designated Fall Champions (2010)
HEROES (Hospital & Emergency Dept Reliability & Operational Excellence for Safety) • Create reliable clinical practices in all 21
medical centers • Standards of practice & successful
practices shared on Monthly Collaborative Calls (2009)
The Strategic Team • Improvement Leader • Trust Chief Executive/Senior Sponsor • Medical Director • Finance Director • Dir of Nursing and Clinical Governance • Head of Health Informatics
Process improvement
Education & Assessment • Develop Protocol & Nursing Falls Education
(1998) • Standardize Fall Definition (2005) • Post Falls Assessment Implementation &
Patient Safety Index (2010)
Fall Prevention Bundle 2007 • Start-of-shift huddle • Schmid assessment • Purposeful hourly rounding • Toileting assistance • Alignment with Pharmacy and PT • Staff, patient, and family education • Vital Behaviors Falls Prevention Bundle May 2009 • Schmid Plus ABCs Age, Bone, Coagulation,
Recent Surgery • Ongoing requirement for nurses to attend
yearly training
Multi-faceted Fall interventions Checklist
(March 2010) • Toilet & Mobility • Environment • Assessment • Medication
• Raising Awareness • Education & Training
Infrastructure Patient Equipment & Staff Awareness • Magnet status, gait belts & lift system,
awareness signs (2005) • New Bed (with integrated bed alarm) • Nurse Call System Integration (2010)
Patient Equipment & Staff Awareness • Specialty low beds • Gait Belts • Chair alarms, bed alarm s • Door signs, yellow armbands • Care board
Patient Equipment & Staff Awareness • Low profile beds • New bed rails • Care board
Information system & reporting
Electronic Reporting • Added electronic risk scoring /protocol to event
system • Developed web reports for front line. Inclusion
of falls on nurse manager dashboard (2005)
Electronic Reporting • Electronic Responsible Reporting Form • KP Health Connect (Kaiser Permanente
electronic medical record)
Data Intelligence & Review System • Develop and integrate the safety fields in
clinical , administrative and financial patient level costing) data electronically
• Improve data availability and accessibility to frontline staff
• Regular audits to review performance and update protocols
Exercise I – What are your strategies and interventions?
Strategy Intermountain 1998 - 2012
Intervention Intermountain 1998-2012
Senior leadership and board engagement and objectives
Full System Engagement • Board of trustees to individual nurses • Mandatory Computer-based Training • Board Goal & Designated Fall Champions (2010)
Leadership
Teams and Champions • Creation of Patient Safety Team (1998) • Creation Safe Patient Handling Team (2005) • Board Goal & Designated Fall Champions (2010)
Continuous feedback information loop
Education & Assessment • Develop Protocol & Nursing Falls Education
(1998) • Standardize Fall Definition (2005) • Post Falls Assessment Implementation &
Patient Safety Index (2010)
Process improvement
Process Improvement Cycles • Falls risk assessment • EMR improvements • Updated and universal protocols
External Benchmarking
Achieving “accreditation” standard • Magnet status awarded in 2004-2005 • Required improvement in nursing sensitive areas
Infrastructure
Patient Equipment & Staff Awareness • Magnet status, gait belts & lift system,
awareness signs (2005) • New Bed (with integrated bed alarm) • Nurse Call System Integration (2010)
Accurate measurement of falls / No blame culture
Electronic Measurement Systems • Risk Management System (Late 1990’s) • Web Event Report(2005)
Information system & reporting
Electronic Reporting • Added electronic risk scoring /protocol to
event system • Developed web reports for front line.
Inclusion of falls on nurse manager dashboard (2005)
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Intermountain fall with injury rate
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Fall
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Falls with Injury Intermountain System
Average Falls with Injury LCL UCL
Fall risk calculator
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Methodology for ROI calculation Savings:
– Decrease payment on legal claims
– Decrease variable cost due to
• reduction in complication associated with fall reduction
• reduction in LOS
Potential impact on revenue stream?
Expenses:
– Costs of implementation of falls prevention initiatives • Personnel (new staff, education, training, …)
• IT / information / measurements (Risk event system, data tracking and reporting, …)
• Infrastructure (equipment, supply, …)
How to allocate capital expenditure?
Decreased Payment on Legal Claims
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Reduced Patient Costs
Savings = 𝑉𝑐𝑜𝑠𝑡 𝑤/𝑓𝑎𝑙𝑙 − 𝑉𝑐𝑜𝑠𝑡 𝑤/𝑜𝑢𝑡𝑓𝑎𝑙𝑙 ∙ #𝑅𝑒𝑑𝑢𝑐𝑒𝑑 𝐹𝑎𝑙𝑙𝑠
∆𝑁𝑂𝐼 =
𝐹𝑖𝑥𝑒𝑑 𝑃𝑎𝑦𝑒𝑟𝑠 𝑆𝑣𝑛𝑔𝑠
𝐹𝐹𝑆 𝑃𝑎𝑦𝑒𝑟𝑠 𝑆𝑣𝑛𝑔𝑠 − 𝑆𝑣𝑛𝑔𝑠𝑃𝑎𝑦𝑚𝑒𝑛𝑡
𝐶𝑜𝑠𝑡
Approximation of Financial Outcome
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Exercise II – Identify Components of an ROI
Savings Costs
Legal Liability Personnel
Variable cost (Extended LOS, additional labs, imaging, Rx)
IT/ Information / Measurement
Impact on revenue stream (NOI) Infrastructure
Other types of savings (personnel injuries, …)
Other costs
NPV Total Costs
Lessons learned
1. Leadership engagement and support
From middle management to senior management and the board
Leverage relationships in different departments to achieve a common goal
1. Accurate and consistent identification of falls
Risk event reporting system
No blame culture
3. Track and cost your intervention to reduce fall
Quality Improvement culture to track intervention: clinical and finance teams need to find ways to
share data and work together for creating the ‘business case for safety’ and achieving sustainable
outcomes.
Need a good activity based cost accounting system and capital cost allocation methodology.
Need to track ROI at facility and departmental budget level
4. Establish the business case for patient safety and quality improvement
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Intermountain Next Steps 1. Refine Patient Cost Reduction Calculations
• Verify whether charges related to falls are billable
• Determine appropriate comparison I. No Falls : Falls
II. No Falls : Falls with Injury
2. Investigate employee injury claims
3. Refine allocation of capital costs
• Beds, remodeling
• Across applicable risk events (pressure ulcer,…)
4. Create methodology for budgeting utilization changes at dept. level
5. Apply ROI methodology to other risk events
Questions
Thank you!