QBP. Focus on COPD. Presentation to OHA : HealthAchieve Bonnie Burnes, William Osler Health System November 5th, 2014

Transcription

1 QBP Focus on COPD Presentation to OHA : HealthAchieve Bonnie Burnes, William Osler Health System November 5th, 2014

2 Agenda Overview 1. Organizational Strategic and Clinical Context 2. QBP Governance & Phased Approach 3. COPD Case Study 4. Key Successes and Lessons Learned 2

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4 A Typical Day at Osler More than Emergency Visits Babies born Dialysis clinic visits Surgeries 4

5 Osler s Corporate Strategic Plan Create health services with an unwavering commitment to patient inspired care Deliver exemplary care in the eyes of our patient and peers Foster bold innovative partnerships to create a unified health system SD 2 - Priorities: 1. Continually refine services to meet the needs of target populations 2. Ensure clinical best practices across the organization 3. Ensure sustainability by meeting the challenges of new funding models Create impact beyond our immediate community through education and innovation 5 5

6 Osler s Clinical Priorities Plan A system designed to support timely access to appropriate care, across the continuum of care. Effort to prevent onset and/or exacerbation of chronic diseases, such as diabetes, COPD and CHF. 6 6

7 Osler s Clinical Priorities Plan se Increased Scheduled Outpatient Activity Reduce Unscheduled/ Avoidable Emergency Visits & Inpatient Admissions 7 7

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9 QBP Governance Structure Quality Improvement Plan Corporate Quality Governance Council Senior Leadership Team (SLT) QBP Steering Committee Dr. Tamara Wallington, Co-Chair Bonnie Burnes, Co-Chair Corporate Chief of ED Director of Quality, Practice & Patient Safety (HHCC) Director of Client Services & Clinical Analytics (CW CCAC) Hospitalist Lead General Internist Lead Director of Nursing and Professional Practice Finance/Case Costing Decision Support Coding & Transcription COPD Expert Panel CHF Expert Panel Stroke Expert Panel Hip Fracture Expert Panel Endoscopy Expert Panel 9 9

10 Osler Expert Panel Core Team CCE Rep Pharmacy Educator Resource Nurse Front line MD, Nurse Nurse practitioner Allied Health OT/PT/SLP CCAC Decision Support Discharge Planner Clinical Informatics Administrative support Coding Ad Hoc Finance Headwaters Health Care Centre Palliative Care Telehomecare ED Chief and educators Library staff Lab Palliative Care Research 10 10

11 QBP Phases of Development Phase 1 Current State Assessment Phase 2 QBP Assessment Phase 3 Gap Analysis Phase 4 Closing the Gap Phase 5 Monitor Implementation Accountability/ Sustainability 11 11

12 Osler s Progress with QBPs Phase 1 Current State Assessment Phase 2 QBP Assessment Phase 3 Gap Analysis Phase 4 Closing the Gap Phase 5 Implementation/ Accountability/ Sustainability COPD CHF Jan 2014 Feb 2014 Mar 2014 May 2014 Aug 2014 Feb 2014 Mar 2014 Apr 2014 Jun2014 Aug 2014 Hip Fracture Stroke May 2014 Jun 2014 Jul 2014 Aug 2014 Oct 2014 May 2014 Jul 2014 Aug 2014 Sep 2014 GI Endoscopy Aug 2014 Oct

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14 Current State and QBP Assessment How do we create sustained improvement? 14

15 Current State and COPD Process Map Medical Unit MAU Emergency % of Pt with short breath/chest complain/ COPD history Typically COPD Patients are CTAS 2/3 COPD Patient sits in waiting area with other Patients Patient arrives Emergency (Walk-in/EMS/Transferred from Outpatient Clinic) Patient assessed by Triage Nurse Patient taken to ED (Placement based on CTAS score*) Isolation beds shortage Longer stay in ED may cause Patient not receiving appropriate care; Patient could end to Critical Care Unit instead Waiting time As blend unit (GIM/Resp), Respirology receives a lot of non-resp patient Respirology Educuation Primary Care Nurse initiates Medical Directive % of Discharge home Patient assessed by ED Physician Order written Respirology Patient goes to other medical unit Admission decision cohorts Patient to appropriate unit Patient goes home % of Diagnosed % of Admitted Discharge home % of admitted to Medical Unit Yes Patient transferred to Medical Unit Regular Inpatient Process followed (ALC Team: OT/PT/RT/Dietician) Discharge Planning Referral to CCAC Referral to West Park Order executed Investigation and treatment initiated Decision made based on result Decision? Referred to Internal Medicine Patient admitted to Medical Unit Bed available? Delay in ED depletes 48 hr time limit Care Connect NRT CCAC Responsible Nurse No Patient with COPD automatically referred to Respirology Consultant GIM/Respirologist involves in decision-making Patient stays in ED Patient admitted to Medical Unit Admit to MAU No OR Waiting time MAU is 48 hours Unit run by MD and supported by NP Patient stays maximum 48 hrs starting from Triage point Connection to Telehomecare Referral to Pulmonary Rehab RT Consultant Order Set Utilization Having Respirologist on the floor Pulmonary baseline Develop COPD Order Set Patient stays in ED Develop Order Set for Discharge Referral to COPD Education Clinic Patient transferred to Medical Unit Bed available? % of admitted to MAU Patient daily assessed by MD/NP * Patient Placement CTAS score RESUS Acute OR Sub-Acute OR ATC Patient transferred to MAU with handwritten order Yes OR Patient transferred to MAU with Order Set filled by ER Physician Patient seen by ALC team (PT/OT/RT/ Dietician/SW/Pharmacist/COPD Educator) Discharge Planning: Transportation arrangement CCAC PFT referral Referral to other outpatient clinic Give Patient the copy of Lab/DI test result for revisit NP consultant notes sent to FP For Patient without FP: provide resource package and ask Patient come back to Urgent Care Clinic/ED Admit to Medical Unit Inconsistent process Patient may/may not Come with Resp. Order Set Assigned to Resp. Hospitalist Have RT consultation Referred to Respirologist Get PFT Refer to COPD Education Clinic/ Pulmonary Rehab Clinic CTAS 1 Decision? CTAS 2 CTAS 3 CTAS 4/5 Discharge home Confusion around the Primary Care Physician: FP or Walk-in Clinic? Patient goes home With family By EMS By alternative transportation Measurements Issues & Hot spots OR Potential Leverage Points 50% Patient with Order Set UCC Pharmacy Tech sees patient in MAU for BPMH Transportation Issues 15

16 Closing the Gap Leverage Points Streaming to Respirology Cluster Spirometry: baseline Consults: RT, Dietitian Greater involvement with Specialists/ Referral to Respirologists Nicotine Replacement Therapy Module & Smoking Cessation COPD Order Set Pulmonary Rehab Clinic COPD education Pharmacist consult for med rec Vaccines: influenza and pneumococcal Automatic referral to CCAC for Rapid Response Nurse program Automatic referral to Telehomecare Standardization of antibiotic ordering practices 16

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18 Order Set Implications to Referrals 40.0% Proportion of QBP COPD visits receiving interventions 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% COPD Education Telehomecare Referral Respirology Referral Order set implementation 0.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Time 18

19 Order Set Implications to RIW and Readmissions Resource Intensity Weight RIW Order Set Implementation Readmission Rate 0.90 Readmissions 0.80 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 0 Time 19

20 COPD Average LOS and Readmission Average LOS 6.02 days 7.24 days 0.20 ALC 30 day Readmission 0.12 ALC 5.90 Acute 7.04 Acute 16% 18% Order Set Used Order Set Not Used Order Set Used Order Set Not Used Discharges between December 18, 2013 and June 30,

21 COPD Telehomecare 6 months Before & After Enrollment (Sept 2014) 21

22 Sustainability Outcome Measures: 1. Readmissions to Osler within 28 days post discharge for COPD 2. Average total LOS for acute inpatients 3. Volumes of COPD QBP acute inpatients 4. Resource Intensity Weights Process Measures: 1. Number of patients enrolled in Telehomecare 2. Number of referrals to the Rapid Response nurse (24 hrs. discharge) 3. % patients admitted to Respirology unit 4. Order set utilization 5. Referral to COPD education and Pulmonary Rehab 22

23 Osler Lessons Learned Team and front line ownership is critical Broad team representation is necessary to achieve buy in Changing behaviours is challenging It takes time to implement and sustain change Benefits to having a structured governance approach across all QBP s Standardized process has provided tremendous learning and consistency for the organization 23

24 Questions and Comments 24

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