Presented by: Dr.

Stephen Taylor, President

West Hospital Ortho Co-Management

Laurie M. Johnson, RN
Executive Director - Orthopaedics

Total Joint Replacement (TJR) has been the most effective treatment for advanced arthritis since the 1970s
Goal of TJR Quality Results Relieve Pain Restore Function Long Lasting (>25 years) Avoid Complications

More than 700,000 TJRs are currently performed each year

INCREASING DEMAND FOR TOTAL JOINT REPLACEMENT

Increasing senior population
Greater desire for active lifestyle Greater acceptance of TJR by population

700% increase in TJR in the next 20 years

INCREASED DEMAND FOR TJR

Success Requires: 1) Adequate physician supply 2) More efficient care process 3) Care process must emphasize VALUE

VALUE IN TOTAL JOINT REPLACEMENT

Reality:
Healthcare dollars spent must be controlled and appropriately allocated Allocation must be determined by value of product or service

In TJR we must maintain and improve quality, but we must also control costs

IOWA HEALTH-DES MOINES COMMITMENT

IH-DM committed to meet the increased patient need for TJR Current facilities at IMMC couldnt meet growing demand for ORs and patient beds
MWH was designed to emphasize orthopaedic total joint care dedicating 4 of the 6 ORs and 50% of the patient beds

MWH ORTHOPAEDIC SERVICES

Focused, specialized care Mutual project between IH-DM and Des Moines Orthopaedic Surgeons, PC Aligned incentives of both organizations to improve QUALITY and VALUE for our patients Co-Management organization was formed to manage the entire process

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY, LLC

The WHOCC oversees the entire orthopaedic service line at MWH emphasizing quality, patient safety & convenience, efficiency and cost containment Equal representation from IH-DM & DMOS
Medical Director from DMOS

Develop and oversee all cost containment activities

Develop comprehensive plan of care for all orthopaedic patients

Implement and direct strategic, financial and operational plans

Supervise and/or train management staff

WHOCC MANAGEMENT ACTIVITIES

Assist in facilities management

Assist in developing operational and capital budgets

Evaluate and recommend equipment purchases

WHOCC BUSINESS MODEL

Executive Committee Meets bi-weekly
Working committee

Finance Committee
Meets quarterly Reviews financials and makes recommendations Reports to the Governing Board

Includes the Ortho Executive Director

Reports to the Governing Board

WHOCC GOVERNING BOARD

Oversees all committee activities Reviews & approves meeting minutes Makes final decisions

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY

Initial project was to interview and select the following key personnel:
Orthopaedic service-line Executive Director Inpatient department Nurse Manager Surgical Services department Nurse Manager Physical Therapy department Manager

All personnel are employees of IH-DM

WHOCC TEAM REVIEWS AND SETS ALL PROCESSES

All physicians expected to comply at MWH No significant exceptions are allowed All physicians are invited and encouraged to participate in the process

STANDARDIZED, UNIFORM PROCESSES AND PROCEDURES

Rationale: Repetitive, focused process and procedures maximizes efficiency and minimizes the risk of error or oversight.
Examples: OR nurses comfortable working with any surgeon due to standardized draping, supplies and instructions Nursing unit care doesnt vary by physician (common pain management regimen, blood transfusion protocol, dressing, etc) One standard Physical and Occupational therapy regimen for all surgeons that can be tailored to the individual needs of each patient

EXAMPLES OF UNIFORM PROCESSES CREATED AND IMPLEMENTED BY WHOCC

1. 2. 3. 4. 5. 6.
7.

Pre-op medical clearance request form Standardized scheduling process and form Pre-op orders Regional anesthesia Demand matching of implants Comprehensive uniform post-op orders, including pre-emptive multi-modal pain management Uniform activity and physical therapy goals

WHOCC ACTIVITIES
VALUE IN TJR
New techniques, equipment and implants must be critically evaluated by hospital and physicians Those new techniques or implants that add cost without significant improvement in quality should be avoided

EVALUATION OF NEW TECHNIQUES AND SURGICAL PRODUCTS

Is there enough scientific evidence to warrant a trial?

Trial with defined evaluation and results

Review by committee to assess quality and value of technique

Confirm or deny use of technique or product

EVALUATION PROCESS EXAMPLES

Floseal deny (evidence didnt support) V-lock suture confirm (all use) Participated in Draping Boot Camp to streamline, trial and standardize surgical drapes confirm (all use) Surgical prep (Chloraprep) confirm (all use) Eliminated many trays by developing common instrument sets for all physicians by procedure confirm (all use) Covaderm Surgical Dressing future trial Cold therapy/DVT wrap future trial

WHOCC PHYSICIAN COMPENSATION

1. Base Management Fee Hourly at Fair Market Value 2. Incentives

Quality of service Operational efficiency Financial/budgetary New program development

INCENTIVE COMPENSATION DEVELOPMENT

Measurable

Controllable

Realistic

Bound by time limits

2010 INCENTIVES
Quality of Service (50%) SCIP Core Measures Patient Satisfaction Demand Matching
Financial/Budgetary (20%) Length of Stay Cost per Case

Operational Efficiency (20%) On-time starts OR turnaround time

New Program Development (10%) Expanded Patient Education

2011 INCENTIVES
Quality of Service (50%) SCIP Core Measures Patient Satisfaction Demand Matching Financial/Budgetary (30%) Cost per case (Goal 4%) Vendor negotiations for spinal implants

New Program Development (20%) Hip and Knee scoring Infection rates (within 60 days) Readmission rate (within 30 days) Revision rate (within 1 year)

INCENTIVE STRUCTURE
2011 INCENTIVE FOR SCIP CORE MEASURES (15% OF TOTAL)
RANGE FROM: TO: <95% ANNUAL PAYOUT: $0

95%
96% 97%

<96%
<97%

60% of SCIP incentive

80% of SCIP incentive Full Incentive

2011 INCENTIVE FOR PATIENT SATISFACTION (20% OF TOTAL)

RANGE FROM: 91.1 91.9 92.3 TO: <91.1 <91.9 <92.3 ANNUAL PAYOUT: $0 50% of Pt. Sat. Incentive 75% of Pt. Sat. Incentive Full Incentive

VENDOR NEGOTIATIONS
1. All implants placed in category based on technology
Cemented femoral stem Tapered non-cemented stem Revision stem

2.
3. 4.

Each category included substantially similar implants

Target price established by WHOCC All vendors allowed to participate

VENDOR NEGOTIATIONS, continued

5. Implants that meet target price for each category become preferred and permitted to use at MWH
Use of outliers is strongly discouraged In a few select categories competitive bidding utilized only one implant from single vendor allowed
eg. Modular revision femoral stem (one vendor, one price for all components) eg. Revision segmental hinged knee

6. 7.

DEMAND MATCHING

All implants categorized by Quality Level and Cost

A Level Lowest cost B Level Intermediate cost C Level High cost

DEMAND MATCHING cont

Three Patient Variables Considered

1. Patient Age 2. Patient Health 3. Patient EXPECTED activity level

(scanned copy of form here)

DEMAND MATCHING cont

>90% Compliance expected

Results are reported by

Individual Physician All Physicians

Transparency is a great motivator!

WHOCC - SUMMARY
1. Aligned incentives of hospital and surgeons that are required for success 2. Emphasis on Quality and Cost = Value 3. Recognize importance and contribution of ALL team members:
Surgical Techs & Nurses Patient Care Facilitators Management Staff Therapists Patient Care Techs Physicians

Ultimate winners: Patients All team members

WEST HOSPITAL ORTHOPAEDIC CO-MANAGEMENT COMPANY

OUR COMPANY Is COMMITTED to FRESH THINKING and INNOVATIVE CARE THAT ADDS

DATA COLLECTION
Information received monthly from various systems
Finance ORSOS Purchasing Clinical Quality

Review, calculate and report Incentive Metric data monthly to Executive Committee Determine if there is other data outside of the metrics that needs to be reported
On-time starts, turnover times, and Average Length of Stay (ALOS) are not part of the 2011 metrics, but continue to be monitored monthly for significant changes Volume and cost data from broken, lost and (not) found instruments in Central Sterile is reported to the Executive Committee & the staff each month The cost of implants that are opened but unused are reported in conjunction with the demand-matching metrics

DATA COLLECTION continued

Whenever possible, total volumes are reviewed rather than randomized selections
100% of all total joint procedures are reviewed for correct implants Over 90% of all eligible patients are included in the SCIP Core Measure data review In addition to the overall patient satisfaction score, each physicians scores are calculated and reported Direct variable cost-per-case is reported/reviewed by surgeon

All data is presented as an overall score and also by each physician and procedure
Transparency has been a key motivator for physician change

QUALITY OF SERVICE
DVT Prophylaxis within 24 hours before/after surgery Appropriate antibiotics within 1 hour prior to surgery Antibiotics stopped within 24 hours after surgery ends % of patients who are normothermic after 15 minutes in PACU

2010 GOAL

2010 ACTUAL
99.8% 98.7% 98.8%

2011 GOAL

2011 CURRENT
100% 99.4% 100% 85%

n/a

n/a

SCIP Overall Average Patient Satisfaction Implant Demand Matching

97% 87 90%

99.3% 91.2 88.7%

97% 92.3 90%

96.1% 90.4 89.2%

OPERATIONAL EFFICIENCY
On-time starts OR turnaround time

2010 GOAL 93% 20 min

2010 ACTUAL 91.8% 16 min

2011 GOAL n/a n/a

2011 CURRENT n/a n/a

NEW PROGRAM DEVELOPMENT

Expand Patient Education
All total joints patients at MWH

2010 GOAL

2010 ACTUAL

2011 GOAL n/a

2011 CURRENT n/a

New program written by Patient Care Facilitators

Hip and Knee Scoring

Primary hips & knees only

n/a
n/a n/a n/a

n/a
Still calculating

Forms have been developed, data collection begins 5/1/2011

Infection rates (w/in 60 days)

Primary hips & knees only

<1.5% <5.0% <2.0%

Still calculating

Readmission rates (w/in 30 d)

Primary hips & knees only

n/a n/a

0.5%
Still calculating

Revision rates (w/in 1 year)

Primary hips & knees only

AVERAGE LENGTH OF STAY

Primary total hip and knee pts, commercial payers only

2008
4.17 days

2009
3.94 days

2010
2.81 days

2011 CURRENT
2.84 days

4.5 4 3.5 3 2.5

4.17 3.94

2010 goal 3.45 days

2.81

2.84

2008

2009

2010

2011 current

DIRECT VARIABLE COST-PER-CASE

Primary total hip and knee pts, commercial payers only 9,400 9,000 8,703 8,600 8,200 7,800 8,847

2008

2009

2010

2011 CURRENT
$7,720

2011 GOAL
$7,939

$8,703

$8.847

$8,186

8,959

8,972 8,772

2010 goal $8,196

8,573
8,186

2011 goal $7,939

7,834

7,720

7,400
2008 2009 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11

SUMMARY
DO recognize that consistent, substantiated data is a key factor in engaging the physicians and staff to achieve success DONT underestimate the value of immersing yourself in the details DO plan to be in this for the long haul
Success doesnt happen overnight

DONT hesitate to build relationships with people who can help you
The advantage of a large organization is that many people are there to assist, but you may have to search for them

DO communicate results regularly with front-line staff

They will be very engaged in the process They can have a big impact on achieving positive outcomes

DONT overlook the small successes

These are most important when things are progressing slowly

DO celebrate every milestone along the way, and DONT forget to have fun!