Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital

Delivering On The Vision:
Keys To Achieving Breakthrough
Operational Performance
2013 Children’s Hospital Association
Annual Leadership Conference
October 14, 2013
Mark Mullarkey, Senior Vice President, Texas Children’s Hospital
Dan May, Managing Director, Huron Healthcare

Agenda
I.

Summary

II.

Texas Children’s Hospital’s Opportunities & Challenges

III. Governance Approach

IV. Transforming the Organization: Key Initiatives
V. Tracking Progress & Measuring Benefit
VI. Physician Engagement Strategies

VII. Lessons Learned
VIII. Questions

© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential.

2

Summary
 In late 2012 Texas Children’s Hospital (TCH) identified the need to
improve financial performance of the health system by over $50M.
 TCH launched a health system wide performance improvement
initiative name “Delivering on the Vision.”
 Partnering with Huron Healthcare, TCH identified over $60M of
improvements in labor, non-labor, clinical operations, clinical
documentation, and physician services.
 Over the past year, the TCH team worked with Huron to successfully
implement the identified improvement.


3

Agenda
I.

Summary

II.




VIII. Questions


4

Background
Texas Children’s Hospital (TCH) identified the need to improve financial
performance of the health system by reducing costs, increasing revenue,
and improving quality.
• $50 million gap between projected 2013 profitability and target
operating margin
• Federal and state funding reductions driving most of this gap
• Higher margins crucial for replenishing capital and expanding TCH
facilities
• Competitive threats driving expected gap closer to $75M


5

Project Background & Scope

 The TCH leadership team initiated a health system wide performance
improvement project named “Delivering on the Vision” in reference to
the their “Vision 2010 Initiative”
 Project assessed and addressed performance in every key
operational area:

– Labor Expenses
– Non-Labor Expenses
– Clinical Operations
– Clinical Documentation Improvement
– Physician Services

6

Business Imperative of $50M identified
Today's Operating Margin Gap
$'s in 000
$120,000
$100,000
Estimate higher margins will be
required to maintain an Aa2
rating, replenish capital and
expand facilities

$80,000

$60,000
$40,000

2013 Estimate
$50 MM

$20,000
$-

June 12 YTD
$75MM

$(20,000)
$(40,000)
$(60,000)

2011

June 2012 YTD
Run Rate
Target Operating Margin

2013

2014

2015

2016

2017

Projected Operating Margin

7

Agenda
I.

Summary

II.




VIII. Questions


8

Executive Steering Committee
PROJECT GOVERNANCE – IMPLEMENTATION

TCH Executive Sponsors
Susan MacDonald, EVP, RN
Randy Wright, EVP & COO

Huron Client Services Executive

Project Management
TCH: Mark Mullarkey
Huron: Robert Donnert

Daniel May

Randy Wright, EVP & COO
Dr. Mark Kline, MD, Physician in-Chief
Dr. James Versalovic, MD Pathology
Dr. Gordon Schutze, MD Peds
Lori Armstrong, SVP & CNO
Mary Jo Andre, VP Quality
Michelle Riley-Brown, SVP West
Sherry Fultz, AVP
Chanda Cashen, AVP OB/Gyn

Susan MacDonald, EVP
Dr. Michael Belfort, MD, Ob/Gyn in-Chief
Dr. George S Bisset, MD Radiology
Dr. Manju Monga, MD OB/Gyn
Linda Aldred, SVP HR
John Nickens, VP Supply & Hosp Based
Cris Daskevich, SVP Women’s Pavilion
Mark Mullarkey, SVP Ambulatory & OR
Diane Scardino, AVP Medical Practice

Ben Melson, EVP & CFO
Dr. Charles Fraser, MD Surgeon in-Chief
Dr. Dean Andropoulos, MD Anesthesia
Dr. David Wesson, MD Surgery
Mallory Caldwell, SVP Strategy
Tabitha Rice, VP
Alec King, VP Finance
Matt Girotto, AVP Surgical Services

Labor

Non-Labor

Physician Svc

Clinical Ops

CDI

Huron: Greg Bryan
TCH: Lori Armstrong

Huron: Dan May
TCH: John Nickens

Huron: Chris Smedley
TCH: Mallory Caldwell

Huron: Larry Burnett
TCH: Tabitha Rice

Huron: Gerri Berg
TCH: Dan DiPrisco

© 2013 Huron Consulting Group. All rights reserved.reserved. & Confidential.& Confidential.
© 2012 Huron Consulting Group. All rights Proprietary Proprietary

9

PROJECT GOVERNANCE – WORK TEAMS
Labor
Solution Team

Non-Labor
Solution Team

Physician Svc
Solution Team

Clinical Ops
Solution Team

CDI
Solution Team

Huron: Greg Bryan
Huron: Irene Walsh
TCH: Lori Armstrong
TCH: M. Riley-Brown
Coord: L. Toures

Huron: Dan May
Huron: P. Zimmerman
TCH: John Nickens
TCH: D. Scardino
TCH: Dr. D. Roth
Coord: J. Estes

Huron: C. Smedley
TCH: Mallory Caldwell
TCH: T. Johnson
MD Leaders:
Dr. Shutze, Dr.
Wesson, Dr. Monga
Coord: M. Wilrich

Huron: Larry Burnett
Huron: Brad Stater
TCH: Tabitha Rice
TCH: G. Parazynski
Coord: G. Erwin

Huron: Gerri Berg
Huron: S Manierre
TCH: Dan DiPrisco
Coord: J. Austin

Nursing
Work Team
Perioperative
Work Team

Clinical
Ancillary
Work Team
Support
Services
Work Team
Corporate
Work Team

Nursing
Work Team
Pharmacy
Work Team

Pediatrics
Work Team

Lab
Work Team

OB/Gyn
Work Team

Surgical
Work Team

Surgery
Work Team

Cath Lab
Work Team
Non-Clinical
Work Team

Case
Management
Work Team
Patient
Placement
Work Team

Physician
Education
Work Team
Coding –
Reconciliation
Work Team

Care
Variation
Work Team
Care
Coordination
Work Team

Food/EVS
Work Team
Surgical Work
Team

10

Agenda
I.

Summary

II.




VIII. Questions


11

Assessment: Key Findings
 TCH’s growth in spending had been greater than its growth of revenue over the past
year, creating an imperative to reduce spending; early intervention is TCH’s motto.
 The following elements have prompted TCH to reduce spending:


Staffing levels had risen faster than what has been budgeted



Annual non-labor /supply chain spending had risen faster than what has been budgeted



Funding of the Baylor College of Medicine had increased faster than what has been
budgeted

 TCH lacked standardization in key areas of operations, vendor contracting, and
clinical processes of care.
 TCH lacked a long term plan that integrated physician capacity and recruitment,
support staff needs, facility space needs, and required capital expenditures.

12

Assessment: Key Findings
 TCH lacked an integrated care management program, consistent coordinated
interdisciplinary meetings, and regular adherence to evidence based standards of
care for length of stay management.
 TCH lacked a productivity management tool to help department leaders and
providers to manage their labor costs and flex their staffing to changes in volume.
 TCH lacked an effective position control process to manage the hiring decisions
across the organization and an effective process for monitoring and managing
premium labor.
 TCH’s management to staff ratio was inconsistent across different areas.
 TCH lacked a clinical documentation management process for optimizing coding
and reimbursement of future Medicaid APR-DRG patients.
13

Total Opportunity Identified from Assessment

TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area

Low

Mid-Point

High

Non-Labor

$7,330,000

$8,847,500

$10,365,000

Labor

$8,412,000

$12,297,000

$16,182000

Clinical Documentation

$6,772,500

$9,030,000

$11,287,500

Clinical Operations

$5,900,000

$9,350,000

$12,800,000

Physician Services

$15,433,000

$20,651,150

$25,869,300

$43,847,500

$60,175,650

$76,038,800

Annualized Total


14

Agenda
I.

Summary

II.


I.
II.
III.
IV.
V.

Non-Labor
Labor
Clinical Operations
Physician Services



15

Executive Summary: Non-Labor
Strengths
 GPO Compliance
 Clinical practice and product choices are strongly influenced by evidence based literature and
research
 Texas Children’s Hospital performs innovative, cutting-edge procedures. These procedures
often require extensive supply resources

Opportunities
 Majority of savings are related to standardization and utilization of supplies and services
 Some of the cost savings opportunities may require administrative support and leadership


16

Non-Labor Opportunity Identified
NON-LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area

Low

Midpoint

High

Medical/Surgical

$660,000

$705,000

$950,000

Surgical Services

$700,000

$850,000

$1,000,000

Cath Lab & Imaging

$270,000

$330,000

$390,000

Laboratory

$800,000

$1,000,000

$1,200,000

Pharmacy

$2,000,000

$2,250,000

$2,500,000

Purchased Services

$1,700,000

$2,100,000

$2,500,000

IT

$550,000

$687,500

$825,000

Food Services/EVS

$650,000

$825,000

$1,000,000

$7,330,000

$8,847,500

$10,365,000

Annualized Total


17

Agenda
I.

Summary

II.


I.
II.
III.
IV.
V.

Non-Labor
Labor
Clinical Operations
Physician Services



18

Labor Opportunity Identified
LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
AREA

LOW

MIDPOINT

HIGH

Nursing

$2,326,000

$3,757,500

$5,189,000

Clinical Ancillary

$2,720,000

$4,025,500

$5,331,000

Non-Clinical Support

$1,825,000

$2,727,000

$3,629,000

Administrative/Financial

$1,541,000
$8,412,000

$1,787,000
$12,297,000

$2,033,000
$16,182,000

Annualized Total

Strengths
 Management is open and supportive of change and improvement
 Quality of talent is strong
 Passionate about Texas Children’s Hospital
Opportunities
 Implement discipline and tools for successful productivity management
 Design an organizational structure, span of control and accountability process to support strategic plans
 Review/revise/support system-wide position requisition and control process

19

Labor Opportunity by Facility
FTEs

Total

Main Campus

Pavilion

West Campus

Key Operational Areas

Low

High

Low

High

Low

High

Low

High

Nursing

24.0

53.5

16.0

45.5

4.0

4.0

4.0

4.0

Clinical Ancillary

33.8

66.1

28.2

57.7

0.6

0.8

5.1

7.6

Support Services

29.4

50.5

17.7

34.1

7.1

11.2

4.6

5.2

Financial/Administrative

21.5

28.8

21.5

28.8

0.0

0.0

0.0

0.0

TOTAL

108.7

199.0

83.4

166.1

11.7

16.0

13.7

16.9

Dollars
Key Operational Areas

Total
Low

Main Campus
High

Low

High

Pavilion

West Campus

Low

High

Low

High

Nursing

$2,326,000 $5,189,000 $1,467,000 $4,330,000

$480,000

$480,000

$379,000

$379,000

Clinical Ancillary

$2,720,000 $5,331,000 $2,276,000 $4,689,000

$26,000

$34,000

$418,000

$608,000

Support Services

$1,825,000 $3,629,000 $1,200,000 $2,717,000

$348,000

$596,000

$277,000

$316,000

$0

$0

$0

$0

Financial/Administrative $1,541,000 $2,033,000 $1,541,000 $2,033,000
TOTAL

$8,412,000 $16,182,000 $6,484,000 $13,769,000 $854,000


$1,110,000 $1,074,000 $1,303,000

20

Flexing Staffing to Demand
KEY IMPLEMENTATION APPROACH

Flexing Staffing to Volume

Volume to staffing regression correlations indicate 77% of patient care units are
not flexing efficiently to census

Note: R2 of 1.0 indicates the regression line perfectly fits the data

21

Agenda
I.

Summary

II.


I.
II.
III.
IV.
V.

Non-Labor
Labor
Clinical Operations
Physician Services



22

Clinical Documentation Improvement Opportunity

CLINICAL DOCUMENTATION IMPROVEMENT - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area

Low

Midpoint

High

Improved Reimbursement After CDI

$6,772,500

$9,030,000

$11,287,500

Annualized Total

$6,772,500

$9,030,000

$11,287,500

Strengths
 The coding staff has an awareness that chart documentation needs improvement
 The coding staff desires to embrace change
Opportunities
 Coding opportunities were found that would significantly affect reimbursement with APRDRGs
 Coding opportunities were found that would affect severity of illness and risk of mortality
which would increase the case mix index (CMI)


23

Case Review
CLINICAL DOCUMENTATION IMPROVEMENT

The following summary provides the results of an analysis conducted
on 75 cases reviewed during the assessment:

Total Charges
of the 75 Charts

$ 7,316,055

TCH’s
Reimbursement
at Current Rate of
36% of Charges

TCH’s
Reimbursement at
APR-DRG
Rate

Improved
Reimbursement (APRDRG) After
Implementation

Incremental Change
With Improved
Documentation

$2,633,781

$2,403,722

$3,191,981

$788,259


24

Agenda
I.

Summary

II.


I.
II.
III.
IV.
V.

Non-Labor
Labor
Clinical Operations
Physician Services



25

Clinical Operations Assessment Opportunity
CLINICAL OPERATIONS - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area

Annual Length of Stay Benefit

Low

Midpoint

High

$5,900,000

$9,350,000

$12,800,000

Strengths
 Organization has been primed for change by the current leadership
 Leaders at all levels expressed interest in obtaining data to support decision making and increase
accountability
 Case Management leadership has outlined an appropriate vision for the future of their department
Opportunities
 Patients are staying longer than medically necessary and are not transitioning to a lower level of care
in a timely manner
 Without operational process improvement and a bed allocation analysis, TCH will not have the ability
to serve additional inpatients without operating above 85% utilization, which hinders patient
throughput
 No centralized tool is being used to track key throughput metrics. These metrics should be used
daily/weekly to support comprehensive patient flow improvement.

26

Length of Stay Opportunity
MAIN CAMPUS

Average Length of Stay for Top 10 APR-DRGs
50

Opportunity Days: 446
Volume: 14

Volume: 10

45

Average Length of Stay (Days)

40
35
30
Volume: 27

25
Volume: 27

20
Volume: 90

15
Volume: 200

10
5

Opportunity Days:
920
Volume: 891

Benchmark
TCH

Volume: 186

Volume: 216
Volume: 698

0
Appendectomy
Post-Op, Post-Traumatic, Other Device InfectionsFailureCardiac Cath
Cardiac Valve Procedures without to Thrive & other Nutiritional Cardiac Defibrillator & Heart Assist ImplantProcedure withwith Circulatory Disorder Hepatobiliary, Contact withAbdominal Procedures
Malnutrition,
Seizure
Disorders
Craniotomy, except for Trauma Diagnosis, Rehab, Aftercare or Other Pancreas & Heath Service
Cardiac Cath
Other
except for Ischemic Heart Disease

Notes:
Listed in order of descending opportunity days
TCH Date Timeframe: June 1, 2011 to May 31, 2012
Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry
Benchmark: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle)

27

Length of Stay Opportunity
MAIN CAMPUS

35% of TCH patients have excess days. The delineation of those patients by number of excess
days is outlined below.
Excess Days Variance over Benchmark Length of Stay

60%
50%

49%
40% of cases have a variance of 2 to 11 days

40%
30%

20%

20%

10%

10%

4 to < 6 Days

6 to < 11 Days

10%

6%

5%

11 to < 20 Days

20+ Days

0%
> 0 to < 2 Days

2 to < 4 Days

Notes:
Timeframe: June 1. 2011 to May 31, 2012
Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry
DRGs: APR – DRGs
Source: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle)

28
28

Length of Stay Benefit Opportunity
MAIN CAMPUS
Clinical Operations Financial Benefit

Low

High

Length of Stay Benefit
•
Reduction in 4,800 to 9,700 patient days results in the following benefit:
•
Capacity created to serve an additional 450 to 930 patients annually (50% backfill)
•
Cost savings associated with reducing 2,400 to 9,700 patient days (50% cost savings)

$5.9 M

$12.8M

Demand
Backfill
Percentage

Cost
Savings
Percentage

Backfill
(Number of
Cases)

50%

50%

700

60%

40%

70%

Patient Days
Reduction

Opportunity

Opportunity

Low

High

3,600

$5.9 M

$12.8 M

800

3,000

$8.3 M

$17.7 M

30%

1,000

2,200

$10.6 M

$22.6 M

80%

20%

1,100

1,400

$13.0 M

$27.6 M

90%

10%

1,200

700

$15.4 M

$32.5 M

100%

0%

1,400

0

$17.7 M

$37.4 M

(Associated with
Cost Savings)

Notes:
Benefit model incorporates lost revenue associated with reducing length of stay of patients with payers who reimburse based on percent of charges (except Medicaid given
the upcoming reimbursement change), which includes 70% of the total patient days
Alec King, Vice President of Finance, reviewed and approved the benefit model methodology
50% backfill estimate is based on conversations with several TCH senior executives
Includes Medical/Surgical patients (excludes NICU, newborns, chemical dependency, psychiatry, rehabilitation and ungroupable) who discharged 6/1/ 2011 – 5/31/2012

29

Agenda
I.

Summary

II.


I.
II.
III.
IV.
V.

Non-Labor
Labor
Clinical Operations
Physician Services



30

Physician Services Opportunity
PHYSICIAN SERVICES - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area

Low

Midpoint

High

Clinical Efficiency

$15,000,000

$20,000,000

$25,000,000

Non-Provider Labor (1)

$

$

$

Annualized Total

$15,433,000

433,000

651,150

$20,651,150

869,300

$25,869,300

Opportunities
 Continue support of the TCH/Baylor mission through process improvements including, but not limited to:
 Increase provider throughput and revenue
 Improve patient flow and access in clinics by improving scheduling templates, utilization of support staff
and standardizing staffing models where appropriate
 Refine CART model to tie revenue to expenses
 Align labor costs, revenue and production to directly correlate with appropriate cost centers

(1) Non Provider Labor does not include Baylor staff as they were not accounted for in the Labor Analysis

31

Clinical Efficiency

Department

wRVU Gap to
Potential Net wRVU Gap to
Number of
New full time
Sullivan
Potential Net
Clinical
Total wRVUs
Collections to
FPSC FTE
Physicians in Total FTEs
FTES (hired
Cotter FTE
Collections to
FTEs
Annualized
Sullivan Cotter
Adjusted
analysis
After 7/1/2011)
adjusted
FPSCr Median
Median
Median
Median

Pediatrics

617

489.89

290.14

63.00

1,066,278

329,140

$18,309,820

666,620

$36,840,622

Surgery

58

56.27

43.13

8.00

300,896

29,243

$2,005,042

80,772

$5,979,215

Obstetrics/
Gynecology – Baylor

36

33.90

25.55

22.00

77,223

77,596

$4,943,768

103,576

$6,748,980

Obstetrics/
Gynecology - TCH

13

13.00

13.00

**0

112,137

5,187

$523,101

9,476

$923,837

Anesthesiology

51

49.71

40.48

3.00

408,697

74,476

$2,276,571

*

*

Pathology

21

21.00

9.20

6.00

42,108

8,859

$535,666

11,628

$706,526

Pediatric Radiology

26

23.90

20.00

0.60

109,555

15,963

$1,374,537

56,545

4,585,666

822

687.67

441.50

102.60

2,116,894

540,464

$29,968,505

928,617

$55,784,846

Total

* Providers were all acquired after 7/1/2011 but because the practice was already established all providers were included in analysis
** No benchmark for anesthesiology available in FPSC survey

32

Agenda
I.

Summary

II.




VIII. Questions


33

Timeline




ACTIVITIES







Organize project teams
Establish baseline measurement
criteria
Identify and quantify financial benefit
initiatives
Complete detailed operational
analysis
Build business case for specific
initiatives
Obtain approval to implement
initiatives
Implement detailed improvement
ideas and plans

Monitor Benefits
Months 9 – 12+

Implement Initiatives
Months 3 - 12

Develop Initiatives
Months 1 - 3








Compile improvement
documentation
Train and educate staff
Implement improvement plans
and initiatives
Implement management tools and
reporting
Empower management and drive
accountability
Align organization structure to
support changes
Begin measuring results







Implement residual
program
Ensure management
has accepted
accountability
Monitor financial results
Transition project
management office

DELIVERABLES

Knowledge Transfer, Empower Management and Drive Accountability


Work steps completed for high
priority initiatives





Work steps completed for
additional initiatives
Benefits tracking and
monitoring tool





Residual work steps completed
for all initiatives
Benefits tracking and
monitoring tool
Monitoring of savings
34

Project Scorecard - Example

Delivering on the Vision Project Scorecard
Area

Savings

Timeline

Issues

Non Labor
Labor
Clinical Operations
Physician Services

Proceeding as planned

At risk for trending off plan


Require immediate attention

35

Non-Labor Project Scorecard (partial example)

Key
Updates

Status

Summary

Issues
/Barriers

Action/ Next Steps

 Monitored initiatives at a confirmed value of $13M
 All teams working to complete implementation and
monitoring of remaining initiatives

 None

 None

 Identified to 179% of high goal
 Implemented to 166% of mid-point goal
 $1M in additional identified initiatives being completed

 None

 Monitor remaining
initiatives

Information
Technology

 Identified to 505% of high-goal
 All initiatives have been implemented

 None

 None

Laboratory

 Identified to 64% of high goal
 $700K in additional identified initiatives remaining to be
implemented

 Delays to a
number of
initiatives being
resolved

 Implement and monitor
remaining initiatives

Non-Labor

Purchased
Services

Proceeding as planned

At risk for trending off plan


Require immediate attention

36

Summary of Key Project Results
 Improved margin by $32M in FY 13 YTD
 Improved flexing of staff, reduced FTEs, and developed and implemented
a new labor productivity system; also developed worked hours per unit of
service (WHPUOS) standards for key departments
 Reduced non-labor supply and purchased services costs and improved
340B benefits
 Reduced length of stay, implemented interdisciplinary care rounds,
implemented Teletracking and other tools


37

Summary of Key Project Results

 Improved clinical documentation producing an increase in severity
adjusted case mix index
 Improved physician productivity
 Increased transparency with physicians and staff
 Improved quality by standardizing staffing levels and reducing care
variation


38

Benefit Scorecard – Overall Project (as of 09/ 2013)

Solution Group

Non-Labor
Labor
Clinical Doc.
Physician Services
Clinical Operations

Target
Benefits

$17,786,447

$14,011,071

$7,558,869

$12,297,000
$9,030,000
$20,651,150
$9,350,000

$13,725,177
$9,030,000
$14,263,000
$9,350,000

$9,382,125
$ TBD
$9,540,200
$11,874,500

$5,276,000
$ TBD
$8,089,000
$11,874,500

7250

7250

10,560

10,560

$60,175,650

$64,154,624

$44,807,896

$32,789,369

% of Target

•

Implemented Realized Benefits
Benefits
FY 13 YTD

$8,847,500

LOS Reduction (Days)
Total

Identified
Benefits

107%

72%

52%

Clinical Documentation tracking begins in 10/2013 following Medicaid APR-DRGs start in TX on 9/1/13


39

Labor – FTE’s


40

Labor – Salary & Benefit as % of NPSR

•
•


Net Patient Service Revenue is up
11.9%
Salary and Benefit Expense is up
just 5.9%

41

Labor – Control of Temp Expense


42

Estimated Financial Impact
ACTUAL PAYROLL DATA VS FY13 BUDGET

Average Paid FTE Variance from FY13 Budget= 386.7 paid FTE
Cumulative Paid Dollar Variance by Pay Period (FY13 to PPE 4/13/13) =
$16,013,200

Notes: In scope labor depts only; Dollars estimated based on avg wage rate per dept and include a 15% benefit factor

43

Project Results:
Clinical Operations Realization Schedule

Projected Annual
Benefit includes:
+ Demand Backfill
+ Cost Savings
– Revenue Loss

Confidential.

44

Physician Services
COUNTS
Overall
Specialty
OBG BCM
POGC/WSH
OBG MFM
A&I
ADO
AGP
CAR
DER
DEV
END
HEM/ONC
INF
NEP
NEU
NGI
PMR
PSY
PUL
RHE
CHS
NSU
OPH
ORT
OTO
PLA
PSU
SYSTEM WIDE
TOTALS

%AGES COMPLETE
Overall

Not
In
Started Process Past Due Complete
1
5
0
0
2
0
0
5
0
10
0
0
0
0
0
0
0
0
0
0
0
10
0
1
3
0
1
38

4
5
5
1
1
0
4
0
0
10
6
0
0
1
0
0
0
5
4
5
0
0
3
4
0
3
12
73

0
0
0
0
2
0
0
0
0
0
0
0
2
1
2
0
0
0
0
0
0
0
3
0
1
0
2
13

6
5
8
7
10
0
9
7
0
1
6
0
14
12
12
0
0
6
3
0
6
0
10
9
4
11
16
162

Total
11
15
13
8
15
0
13
12
0
21
12
0
16
14
14
0
0
11
7
5
6
10
16
14
8
14
31
286

Not
In
Started Process

Past
Due

Complete

9%
33%
0%
0%
13%

36%
33%
38%
13%
7%

0%
0%
0%
0%
13%

55%
33%
62%
88%
67%

0%
42%

31%
0%

0%
0%

69%
58%

48%
0%

48%
50%

0%
0%

5%
50%

0%
0%
0%

0%
7%
0%

13%
7%
14%

88%
86%
86%

0%
0%
0%
0%
100%
0%
7%
38%
0%
3%
13%

45%
57%
100%
0%
0%
19%
29%
0%
21%
39%
26%

0%
0%
0%
0%
0%
19%
0%
13%
0%
6%
5%

55%
43%
0%
100%
0%
63%
64%
50%
79%
52%
57%

Updated as of 7.17.13


45

Access - 3rd Available
Specialties Tracked and Included:
Renal
Physical Medicine Clinic
Rheumatology
Allergy & Immunology
Endocrine
GI & Nutrition
Otolaryngology
Adol/Sports/Med/Yng Womens

Neurology
Psychology Service
Orthopaedics
Urology
Ophthalmology
Pulmonary Medicine
Psychiatry - 17O
Gynecology


Genetics
Plastic Surgery
Pediatric Surgery
Retrovirology
Orthodontics
Res. Primary Care
Neurosurgery
Inf. Disease

Development Pedi
Dental
Congenital Heart Surgery
Dermatology
Cardiology
Hematology/Oncology

46

Internal Texas Children’s Pediatrics Referral
Rate


47

TCH: Mid-Project Experience Survey Results

Clinical Operations Update - June 2013
Patient Day
Accumulation
for Project Period
(Nov-May FY13)
10,000
9,000
7,250

8,000
7,000

5,531

6,000
5,000

76%
of goal

4,000
3,000
2,000
1,000

Results at a Glance …
Most Recent Three-Month Period (Mar-May ‟13)
vs. Historic Period (June ‟11-May „12)

Severity-adjusted average length of stay
decreased by 15.9 hours per patient, an 11%
reduction compared to historic period!

• Patient flow efforts increased capacity to
serve 5,531 more patient days, cumulatively

• 51% decrease in Red Acute Care Census

Alert hours
(34 in Mar-May „13 vs. 69 in Mar-May „12)
• 9% decrease in EC boarding time average
(Mar-May „13 vs. Mar-May „12)
• 14% decrease in readmissions within 48
hours
(38 in Mar-May „13 vs. 44 in Mar-May „12)

Key Accomplishments to Date
Care Management
Engaged over 20 care managers in weekly Clinical High Risk meetings to
collaboratively address and resolve barriers to efficient patient flow, efficient care,
transitions to the next level of care and hospital reimbursement
• Implemented Morrisey, a Care Management software tool for discharge planning,
utilization review, and other work flow management
Care Progression
• Established 11 daily and multidisciplinary Care Progression Rounds (CPR) across over
35 services to proactively plan for patient's discharge with the care team and the
patient/family
• Conducted over 1,200 CPRs (and counting) since project start, with participation by
over 500 physicians, nurses, and supporting care team members
Room Management
• Centralized Main campus bed assignment process which included the implementation
of TeleTracking (TT), an electronic bed board; Trained over 600 nurses, unit clerks,
EVS, and Patient Escort staff members on TT tool
• Redesigned the EVS & Patient Escort staffing model to support a dedicated discharge
cleaning team and discharge transportation process; automated discharge cleans and
transportation requests with use of the TT tool

•

Year End
Goal

Net Days
Saved

Delivering on the Vision:
Care Process Updates

7,250

5,531

The focus of the Care Process (CP) initiative is on creating a
foundation and work processes to support physician adoption of
evidence-based standards of care.
• Pneumonia Care Process team is developing a care pathway which
supports earlier discharge preparation, cohorted beds, and respiratory
support
• DKA Care Process team is developing a business case for a Diabetes
Center for Excellence which includes pathway and education and
translator availability; initiating hospital benchmarking for insulin pen vs.
insulin vial only on formulary

“It's incredible when I think about the
results we've had recently…it is making
a big difference.”
-Executive Leadership
“I’m on service this week and I have to tell
you about how much the energy has
changed on the floors! Everyone’s talking
about and planning for discharges.”
-Hospitalist


TeleTrackingXT

TM

: An Update on the Centralized Bed
Assignment Process

• Room Management has placed approximately 1,500 patients in beds
since go-live (5/29)

• EVS has conducted over 1,200 discharge cleans since go live
• Patient Escort has performed over 300 discharge trips since go live
“[Requesting a bed] through TeleTracking makes my job so
much easier. I can trust that things will happen without me
interfering and getting on the phone.”
-Charge Nurse
48

Clinical Documentation Initiative – Main Campus
BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION


49

Clinical Documentation Initiative - West Campus
BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION


50


‹#›

Agenda
I.

Summary

II.




VIII. Questions


52

Physician Engagement Strategies
 Physician leaders should be involved from the beginning
 Transparency is important when working with the physicians
 Accurate data presentation and interpretation is key to get the physicians
engage
 Inclusion of medical staff at all levels and particularly in all work teams
 Communicate, communicate, communicate


53

Agenda
I.

Summary

II.




VIII. Questions


54

“Leadership always impacts and influences outcomes, not
some of the time, but all of the time.”
Labor

Non-Labor
Michelle Riley-Brown
SVP
TCH West Campus

Lori Armstrong, MSN, RN
CNO, SVP

John Nickens
VP
Hospital Based Services and
Supply Chain

Clinical Operations

Tabitha Rice
SVP
Clinical Support
Services

Diane Scardino
AVP
Ambulatory Servcies


Jackie Ward, RN
Director
Cancer Center

Joan Shook, MD
Chief Safety Officer

Dan Diprisco
Director
Physician Revenue Cycle

Physician Services

Mallory Caldwell
SVP Strategy


Trent Johnson
Director
Ambulatory Services

55

But it takes a team…..a very large team!
Jennifer Upshaw

Dr. Carol Altman

Sherry Fultz
Dr. Michael Braun

John Henderson

Dr. Charles Gay

Sandra Tillis

Dr. Scott Dorfman

Mike Towne

Dr. Doug Ris

Sarah McMaster

Mari Trace

Dr. Al Hergendroeder
Dr. Jed Nuchtern

Robert Turner

Dr. Peter Hiatt

Kara Lenahan

Kim Nguyen

Dr. Ryan Himes

Matt Timmons

Cindy Miley

Ryan Breaux
Dr. Jake Kushner
Diane Scardino

Dr. Brigetta Meuller

Binta Baudy

Dr. Ellen Friedman

Travis Crum

Stephanie Ramirez
Dr. Theresa Wright

Dr. David Roth

Dr. Gordon Schutze

Helen Currier

Dr. Robert Zeller
Dr. Monju Monga

Tina Ninan

Dr. Thomas Shaw

Dr. Daniel Penny

Lorraine Cogan

Mary Kana
Jeff Reinhart

Matt Girotto

Trent Johnson

Laura Hardy

Jackie Ward

Dr. Jennifer Deitrich

Dr. Jordan Orange
Dr. Gary Clark

Dr. David Coats

Barkha Chandwani

Daniel Fischer

Jennifer Evans

Dr. Angelo Giardino

Tuhin Pakaj

Dr. Efrain Bleiberg

Chanda Cashen

Dr. William Phillips
Dr. Thomas Luerssen

Dan Diprisco
56

Lessons Learned
 Successfully implementing enterprise-wide performance projects
requires:
• Executive engagement and support
• Physician engagement and support
• Transparency and accountability
• Setting realistic improvement goals for each solution
• Communicating savings targets per initiative to all affected parties
• Communication and early buy-in from all stakeholders to ensure timely
implementation
• Effective benefit realization monitoring and presentation – measure,
measure, measure. Data and trends as “pictures”

57

Lessons Learned
 Once redesign efforts are completed the organization must invest in
resources to continue monitoring to hold the gains
- Ongoing (although maybe modified) governance structures
- Hardwired reporting mechanisms


58

Agenda
I.

Summary

II.




VIII. Questions


59

Today’s Presenters

Mark Mullarkey
Senior Vice President
Texas Children’s Hospital
mwmullar@texaschildrens.org
1-832-824-1262

Dan May
Managing Director
Huron Healthcare
dmay@huronconsultinggroup.com
678-576-0408


60

Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital

Delivering on the Vision: Keys to Achieving Breakthrough Operational Performance at Texas Children’s Hospital

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