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Reducing Practice Variation: Creating System-Wide Clinical Care Paths Seth Podolsky, MD, MS, FACEP CMO, Ambulatory & Integration Banner Health System May 1, 2019 3:15 pm – 4:00 pm
Reducing Practice Variation:Creating System-Wide Clinical Care Paths
Seth Podolsky, MD, MS, FACEPCMO, Ambulatory & Integration
Banner Health System
May 1, 20193:15 pm – 4:00 pm
Why Does This Matter?
• Quality matters!• We can do better• Data should drive practice• The whole is greater than its parts• Systems have replaced solo shops
1 in 2.5 MILLION2
High Reliability
www.mpkelley.com
3
© Dartmouth Atlas
Chronic Illness – Last 2 Years Of Life
Bend, Oregon 10.6 days
Manhattan, NY 34.9 days
© Dartmouth Atlas
How many people in your shop?Everybody have a similar… Cat Scan rate?… admission rate?… opioid prescription rate?
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Times they are a changin’ …
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Case StudyThanks to my friends and colleagues at the Cleveland Clinic Health System!
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A Day In The Life …
• Avon = 108• Brunswick = 65• Euclid = 117• Fairview Adult = 216• Fairview Peds = 83• Hillcrest Adult = 154• Hillcrest Peds = 43• Lakewood = 55
• Lutheran = 121• Main = 215• Marymount = 142• Medina = 87• South Pointe = 109• Twinsburg = 73• Weston = 121• Some acquistions not included
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Cleveland Clinic Health System
12 Hospital EDs, 2 Pediatric EDs, 6 FSED11
What your parents think you doWhat friends think you do What your colleagues think you do
What you think you doWhat society thinks you do What you really do
ED Leader
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Objectives
• Describe how clinical care paths/guidelines can improve patient outcomes
• Discuss how technology can play a role in clinical decision support tools
• Review shared-decision making models to incorporate patient and family preferences into clinical process
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Financial DisclosuresPatient Forecaster, Inc., Denver, CO
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to walk through the process.
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Describe how clinical care paths/guidelines can improve patient outcomes
Objective 1
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Care Paths
150 Developed
© Cleveland Clinic
Pediatric Mild Head InjuryImproved appropriate use of brain CT based on validated decision support tool.
Pediatric Mild Head Injury
• How many of you …Treat kids with mild head injuries?Have rules that govern your decisions?What are they?
Have colleagues that follow different rules?Created forcing functions with embedded evidence?
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Pilot Objectives
• Reduce unnecessary pediatric head CTsReduce radiation exposure
• Evidence based practice for mild head injuriesPECARN Study 42,412 children Identified clinically important traumatic brain injuries (ciTBI) Validated
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Process Changes
• Documentation ToolUtilized evidence based criteria (PECARN)
• Best Practice Alert in EPIC“Forcing function” for providers Patient arrival (based on chief complaint) Pediatric Head CT order
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Pilot Findings
• High risk factors100% of patients received head CT as recommended
• Moderate risk factors53% of patients received head CT
• Low risk factors98% of patients did NOT receive a head CT as recommended
• 80% of providers utilized the Care Path documentation tool25
Pilot Results
28%
22%
0%
5%
10%
15%
20%
25%
30%
Baseline Pilot
Head CT Utilization
Cost reduced $215.00 per patient encounter
26© Cleveland Clinic
Summary
• Reduced radiation exposure• Reduced cost per encounter• Reduced practice variation
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Are all physicians, PAs, NPs, and nurses following best practice at your shop?
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Count The Black Dots
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“The difference between success and failure is a great
CAREGIVER TEAM.” – Anonymous
© Cleveland Clinic
STEMI RedesignImproved standardization by decreasing variability.
Primary EndpointCan process redesign improve outcomes?
Weak Strong
Hospital Process/ Systems
Call To Action
• Align focus• Leadership support• Drive accountability • Protocol as standard of care
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• ED Physician Activates Cath Lab• Standardize Care Process• Cath Lab Readiness
Key Steps
Serial Versus Parallel Processing
35Umesh N. Khot et al. Circulation. 2007;116:67-76
Umesh N. Khot et al. Circulation. 2007;116:67-76
Figure 2. Serial vs parallel processing in achieving door-to-balloon time. Simultaneous performance of catheterization laboratory activation, physical transfer to catheterization laboratory, initial catheterization laboratory setup, and cardiology evaluation leads to a reduction in door-to-balloon time.
Initial Checklist
3 separate checklists • ED physician • Nursing• Cardiology Fellow
© Cleveland Clinic
Handoff Signatures
Phone Numbers
Standardized Care:Safe STEMI Handoff Checklist
• Provides instructions
• Provides phone numbers
• Defines roles
• Assigns accountability
• “Time Out” to ensure completion
ED Physician Nursing Cardiology
Checklist Drives Process
© Cleveland Clinic
PCI Within 90 Minutes For STEMI
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40%
60%
80%
100%
120%
Q12014
Q22014
Q32014
Q42014
Q12015
Q22015
Q32015
Q42015 Q12016
Q22016
Q32016
Q42016
Q12017
Q22017
Q32017
Q42017
Q12018
© Cleveland Clinic
Pre Care Path Post Care Path
Heart Attack Mortality6.3%
2.9% 54%
© Cleveland Clinic
“You will either step forward into GROWTH,
or you will step backward into safety.”
- Abraham H. Maslow
Discuss how technology can play a role in clinical decision support tools
Objective 2
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Pulmonary EmbolismImproved appropriate use of chest CT to rule out pulmonary embolism.
Embedded clinical decision rules as forcing functions.
Pulm
onar
y Em
bolis
m
44© Cleveland Clinic
Spine Care PathImproved appropriate use of diagnostic imaging for spine complaints.
Embedded clinical decision rules as forcing functions to support evidence.
Embedded Spine Care Path
46© Cleveland Clinic
Acute StrokeImproved appropriate clinical decision making and use TPA for acute stroke.
Embedded clinical decision rules as forcing functions to drive process.
Acut
e St
roke
48© Cleveland Clinic
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Review shared-decision making models to incorporate patient and family preferences into clinical process
Objective 3
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Low
Risk
Che
st P
ain
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Pediatric Mild Head Injury
52© Cleveland Clinic
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Pare
nt To
ol
© Cleveland Clinic
Leverage Technology
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“We do not come to fear the FUTURE. We
come here to shape it.”
– Barack Obama
V = QCalueuality
ost
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It’s just the right thing to do!
Key Takeaways
• Improve patient outcomes with clinical pathways Good for your Mom and mine
• Leverage technology for support Embed clinical decision support tools
• Shared-decision making models are useful Patient and family preferences help drive process
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It’s all about quality and patient safety …
Mom should get the same great care here, there, everywhere!!
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How wonderful it is that nobody need wait a single moment before
starting to improve the world.- Anne Frank
THANK YOU!!Dr. Seth Podolsky
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Making health care easier, so life can be better.
mailto:[email protected]
Reducing Practice Variation:�Creating System-Wide Clinical Care PathsWhy Does This Matter?High ReliabilitySlide Number 4Chronic Illness – Last 2 Years Of LifeHow many people in your shop?Times they are a changin’ …Case StudyA Day In The Life …Cleveland Clinic Health SystemWhat your parents think you doSlide Number 15ObjectivesFinancial DisclosuresSlide Number 18Describe how clinical care paths/guidelines can improve patient outcomesCare PathsPediatric Mild Head InjuryPediatric Mild Head InjuryPilot ObjectivesProcess ChangesPilot FindingsPilot ResultsSummaryAre all physicians, PAs, NPs, and nurses following best practice at your shop?Count The Black DotsSlide Number 30STEMI RedesignSlide Number 32Call To ActionKey StepsSerial Versus Parallel ProcessingInitial Checklist�Standardized Care:�Safe STEMI Handoff Checklist�Checklist Drives ProcessPCI Within 90 Minutes For STEMIHeart Attack MortalitySlide Number 41Discuss how technology can play a role in clinical decision support toolsPulmonary EmbolismPulmonary EmbolismSpine Care PathEmbedded Spine Care PathAcute StrokeAcute StrokeSlide Number 49Review shared-decision making models to incorporate patient and family preferences into clinical processLow Risk Chest PainPediatric Mild Head InjurySlide Number 53Leverage TechnologySlide Number 55Slide Number 56It’s just the right thing to do!Key TakeawaysIt’s all about quality and patient safety …Slide Number 60THANK YOU!!���Dr. Seth Podolsky�[email protected]�602-747-7507
