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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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2007 2008 2009 2010 2011 2012

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!