Using Multi-Hospital Laboratory Integration to Improve Lab Outreach Success John Waugh Henry Ford Health System, Detroit Executive War College, New Orleans 4/28/09
Henry Ford Health System
Integrated Healthcare Delivery System
Tertiary Tertiary Care Care Hospitalization Hospitalization Acute Acute Care Care Hospitalization Hospitalization
Specialized Specialized Hospitals Hospitals Long-Term Long-Term Care Care Ambulatory Ambulatory Care Care Specialty, Specialty, Multi-specialty Multi-specialty High High Technology Technology Primary Primary && Preventive Preventive Care Care Home Health Services Home Health Health, Health, Lifestyle Lifestyle && Alternative Alternative Med Services Services Financing Financing of of Health Health Care Care Research & Education
Now: Henry Ford Health System • • • • • • • • • • •
Southeast Michigan 22,000 employees 7 hospitals, 40 ambulatory cntrs 11 million billed lab tests (2008) Beds: 2,495 Admissions: 88,984 3 million clinic visits 1100 physicians, 3rd largest multi-specialty group in US >1500 partner community docs HAP insurance, 540,000 members $62M research funding, 3rd largest NIH $ in Michigan Leap Frog Group- ‘Top 41 safest hospitals’
• Thompson Reuters ‘100 Top Hospitals- Performance Improvement • 101 ‘Best & Brightest Places to Work’ • Crain’s Detroit Business- ‘Coolest Place to Work’
HFHS Alignment - LEAP 2008 ¾
Henry Ford Health System is a unified, integrated organization bringing value to its patients, communities, members, physicians, employees and business units through: ¾ Delivery of the highest quality of clinical care and personal service with aligned goals and standards of performance ¾ A focus on coordination of services across the continuum of care to achieve a patient care experience that is appropriate, aligned and seamless ¾ A culture of innovation and learning ¾ Coordinated growth strategies and branding ¾ Information technology that enhances patient care, increases the efficiency of administrative processes and supports clinical integration across the System ¾ Providing a world-class environment for employees and physicians to practice their professions, expand their skills and talents and develop their careers ¾ Market strength with a unified contracting strategy
Current Service Locations
HF-MAC HF-WBH
24/7 HF-MWAR
HF-KG
HFH
HF-COT
24/7
24/7
HF-WH
Hospital 24 Hr. Med Center Medical Clinic
24/7
Integration Î NO • • • •
Advertising Signage Annual Report Insurance Products
Integration Î YES
It takes systems to integrate Systems
Pathology Billed Test vs Labor Equivalents billed test
LEQ
1800000
120.0
1600000 100.0 1400000
80.0
1000000 60.0 800000
600000
Labor Equivalents
Billed Tests by Quarter
1200000
40.0
400000 20.0 200000
2002
2008
0.0
M ar Ju -02 n Se -0 2 p De -02 c M -0 2 ar Ju 03 n Se -0 3 p De -03 c M -0 3 ar Ju 04 n Se -0 4 pDe 04 cM 04 ar Ju -05 n Se -0 5 p De -05 c M -0 5 ar Ju 06 n Se -0 6 p De -06 c M -0 6 ar Ju 07 n Se -0 7 p De -07 cM 07 ar Ju -08 n08
0
HFHS Pathology Financials 75 CLIA Certificates, 663 FTEs (millions)
Service Line
HFH
HFMG
COT
WBLM
WAR
WYAN
CL TWP
Gross Rev
$575
$346
$24
$6.8
$0
$32
$75
$55
Net Rev
$207
$125
$8.4
$2.4
$0
$12
$27
$20
Sal/Beni
$49
$28
$6
$1.0
$0
$3
$4.4
$4
Non-Labor
$46
$22
$3
$1.5
$0
$3
$5.8
$5.5
Tot Exp
$93
$48
$9
$2.5
$0
$6.1
$10.3
$9.3
Net Inc/GC
$114
$77
($0.5)
($0.1)
$0
$5.4
$17
$11
HFH/HFMG Lab Retirements & HFWBH Hires - 2002 to 2049 W. Blm Hosp Hires
Incremental Certified Technical Staff Only
HFH / HFMG Retirements 25 NOW
15
10
5
Year
Pathology & Laboratory Medicine Service Line (PALM) • • • • • • • • •
All hospital Lab Service Line created 2001 Extension across system- 2008 “Accelerate one lab enterprise across system” Corporate entity, CEO Liaison Under leadership R. Zarbo, Senior VP “Centralize to every extent possible” Single capital pool Cascading approach as LIS permits, on a timeline New Hospital Lab now a ‘Stat Lab’ concept, space, capital costs
2046
2044
2042
2040
2038
2036
2034
2032
2030
2028
2026
2024
2022
2020
2018
2016
2014
2012
2010
2008
2006
2004
0 2002
N u m b er o f F T Es
20
Hail Augustus
Current Service Locations
HF-MAC HF-WBH
24/7 HF-MWAR
HF-KG
HFH
HF-COT
24/7
24/7
HF-WH
Hospital 24 Hr. Med Center Medical Clinic
24/7
Hub & Spoke Design
HF-MAC HF-WBH
24/7 HF-MWAR
HF-KG
HFH
HF-COT
24/7
HF-WH
24/7
Hospital 24 Hr. Med Center Medical Clinic
24/7
Molecular Pathology and Genomic Medicine Division Head,, MD Laboratory Director , PhD
Advisory MembersDivision heads and section chiefs
Infectious Diseases
Gonorrhea Chlamydia HIV quant HCV quant HCV qual Myco TB Myco Av Int Myco Gordoni CMV HSV 1 & 2 MRSA
Transplantation
HLA class I & II genotyping
Pharmacogenomics
Warfarin* CYP2C9-2 CYP2C9-3 VKORC1
Hematopathology
Neoplastic JAK2 BCR-ABL major & minor brkpts PML-RARA CBFb-MYH11 AML-1ETO FLT3 B cell IGH TCR-gamma BCL2-JH Coagulation Factor V (Leiden)
Factor II (Prothrombin)
MTHFR
Oncology
Brain MGMT 1p19q LOH Lung EGFR Ob/Gyn Gestational disease Colorectal MSI MLH1 Tumor Assoc EBV
Identity
Tissue & Patient Identity
HFHS LAB Tri-County OUTREACH RING HFMAC HFWBH
24/7
24/7
HFMWAR HFKG
CORE
24/7
24/7
HFWH
HFCOT
P.A.L.M. SYSTEM CORE & ESOTERIC LAB MODEL
Laboratory Outreach Brand
Pathology & Laboratory Medicine Service Line (PALM) • PALM Principles • Business Plan, • Timeline & Schedule
Value Drivers Focus on 20% of actions that will drive 80% of the economic value for the organization. - With highest probability of success - In shortest period of time
Value Drivers • Requests for new tests should be reviewed for clinical value and economic impact.
• Compare all hospital test menus with W. Bloomfield Hosp Menu • Align proficiency testing orders with test menus • Realign position management to PALM Service Line • Review consumable contracts for aggregation and price protection.
• Catalogue all existing Lab Outreach testing
Value Drivers • Review and approve Capital needs as a Service Line • Develop and trend internal Quality Management Metrics • Review and understand professional staff duties by site • Roll-up financial reporting and craft fair transfer pricing • Create targeted communication to stakeholder groups • Consider recommendations from Wellspring Partners
Value Drivers • Review and approve personnel requisitions at the PALM level • Reassign professional staff contracts to PALM • Unify all Laboratory Outreach under one brand….HFML • Build-out Lab Portal to support Lab Outreach • Review all service contracts for effectiveness and savings • Redefine best practices in the new conditions
Value Drivers • Repatriate revenue from reference laboratory testing • Repatriate revenue from prof Pathology contracts: Part A • Repatriate revenue from prof Pathology contracts: Part B • Migrate Clinton Twp to enterprise-wide LIS systems • Tie LIS to Macomb choice of Careplus or Powerchart • LEAN management to all PALM Service Line
Value Drivers •
1
CETAC review for new test services
2
Test Menu Review HF-WB as baseline
3
Realign position management to PALM Service Line
4
Consumable contracts PALM review & approval
5
Catalog all existing Lab Outreach
6
Capital PALM review & approval
7
Quality management metrics
8
Professional Staff Duties
9
Financial roll-up corporate with transfer pricing
10
Communication to Stakeholders
11
Wellspring Partners report
12
Personnel requisition approval
13
Professional staff contracts, reassign to PALM
14
Unified Lab Outreach to HFML
15
Service contract review
16
Best Practices redefined for New Conditions
17
Build-out Lab Portal
18
Repatriate $$ Revenue from Reference Lab Tests
19
Repatriate $$ Revenue from Professional Referrals
20
Align Proficiency Testing orders with test menus
21
Repatriate $$ Revenue from Part B to HFHS
22
LEAN management to ALL PALM Service Line
23
Macomb Clinton to Shared LIS
24
Clinton Lab results to CarePlus or Cerner Powerchart
cL Sv
e in
IT
$ $$
Value Drivers (24): Quality, Cost, Service – Economic Impact vs. Probability of Success
•
Timeline – 20% of activities that drive 80% of Value • 90 days • 180 days • 365+ days
•
Implementation Drivers – No items require new $$ in 1st 150 days
Value Drivers $
Probability of Success
Economic Impact vs. Success Probability 90 days
180 days
1
21
13
6
$
365+ days
$
2 4 7 3 8 5 10 9 probability Establish 3 fast moving teams
2 Test menu review 5 Catalog existing Outreach 7 Quality management metrics
11
$
14 12 15
16 17
probability
18 20 22 24
23
19 probability
Establish 2 teams
Establish 1 team
14 Unified Lab Outreach 16 Best Practices
22 LEAN Management
Pathology Service Line Launch • Communication to Stakeholders – Internal
• Staff, physicians, leadership
– External
• Physicians, vendors
• Savings Strategies & Growth Strategies • Quality Management
Customers
• If Customers are not on the top of your priority list, re-do the list. – We can’t grow new customers and discard old customers – Every customer is unique – Emphasizing customer satisfaction is a common concern for all of us and a way to align us
Service Commitment • • •
• • • •
On-site pathologists 24X7 pathologist and supervisor on-call Sub-specialty coverage and consultation – Surgical pathology • double read breast & prostate, 2nd opinions – Clinical pathology • microbiology, chemistry, blood bank, hematopathology
Common trended quality metrics Centralize esoteric tests & autopsies Implement LEAN management Expand Outreach
Centurions, Legion Commanders & Legionaries Centurions
ALL ROADS LEAD TO ROME
HF-MAC HF-WBH
24/7 HF-MWAR HF-KG
HFH
HF-COT
24/7
24/7
HF-WH
Hospital 24 Hr. Med Center Medical Clinic
Fixed & Mobile Army
24/7
Quality Management Metrics TURN-AROUND TIME (TAT)
CAP ACCREDITATION REQUIRED
Emergency Room TAT CBC, Troponin, BMP, PT, PTT STAT TEST TAT Chem, Heme, Coag, Urinalysis Frozen Section TAT Biopsy TAT (Small or Simple) Resection TAT (Large or Complex) Cytology Non-Gyn TAT Cytology PAP Smear TAT Cytology ASCUS/HG PAP + HPV Blood Culture Contamination Critical Value Reporting Customer & Staff Satisfaction
Growing Outreach • Start with Large In-Reach Base • Lower Unit Cost for All
Mass Mass Production Production •Continuous Production •Conveyor belt assembly line •Division of labor •Simple repetitive tasks •Integrated supply chain •Standardized parts •Reducing waste
Lab Outreach • • • • •
Market Opportunity Assessment Gap Analysis (fresh set of eyes) Web Portal Legal Structure Add New Talent to lead Outreach
You can train a dog to climb a tree, or you can hire a squirrel
Lab System Org Structure PATHOLOGY AND LABORATORY MEDICINE EVP & CEO HFMG
EVP & COO HFHS
Sr. VP & Chair, CEO Liaison
Advisory Groups: Strategic Planning, Leadership, Quality Mgt, New Technology, Informatics, CLIA Lab Directors, New Test Services (CETAC), Accreditation
Office of PALM
System Director Laboratory Operations / COO
Med & Admin Directors
System Director Anatomic Pathology
HF Macomb Clinton Twp Med. Dir. HF Macomb Clinton Admin Director
Pathology & Lab Medicine
HF Wyandotte HF Macomb Med. Dir. Warren HF Wyandotte Med. Dir. Admin HF Macomb Director Warren Admin Director
System Director Lab Operations / COO
HFMG Regional Laboratories Med. Dir. HFMG Regional Labs Manager
Administrative Leads Focus On: Human Resources Finance/Budget Purchasing, Info Technology
System Director Clinical Pathology Vice Chair, HFH
HF Hospital Lab Outreach Med. Dir. Henry Ford Medical HFH Laboratories Admin Med. Dir. Director HFML Manager
HF W. Bloomfield Med. Director HF W. Bloomfield Admin Director
HF Cottage Hosp Med Dir HF Cottage Manager
Sunquest / CoPath
Wired
Histotrak MAS Aqueduct Middleware
APOLLO Pathpacs
SCANNING
LAB PORTAL Atlas
TELEPATHOLOGY Leica
Scantron − Store AP Req Scans − Store Clin Path Req Scans − Integrate External AP Results − Telepath Integration − Associate Imaging to Reports − Interface to acquisition devices Cameras (1-2 M records/yr) - Gels - Microbiology
− Surg Path Reqs − Cytopath Reqs − Clin Path Reqs − Outreach Documents
HEALTHSTREAM Training Competency
DOCUMENT CONTROL Master Control
− HFWBH
LAB USER’S GUIDE
TISSUE BIOREPOSITORY
pathology.hfhs.org/lug
PathInformatics 032309
Seamlessness COT
HFH
HFMG
HF Macomb
HF Macomb Warren
Common Trended Quality Metrics
X
X
X
X
X
X
Enterprise-wide Lab Info System
X
X
X
X
X
Pathology Service Line Attributes
WYH
Lab Courier Shared
X
X
X
X
X
X
Esoterics to HFH Core Lab
X
X
X
x AP
X
X
Reporting to Common EMR
X
X
X
X
X
Common Reference Lab – MCL
X
X
X
X
X
X
Centralized Blood Sourcing
X
X
X
X
X
X
Lab Outreach Henry Ford Medical Labs
X
X
X
X
X
X
Pathology Consult In-Source
X
X
X
X
X
X
LEAN Management
X
X
X
X
X
X
Electronic Document Control
X
X
X
Common Web Presence
X
X
X
On-Line Lab Test Catalog
X
X
X
Capital and Consumable Contracts
X
X
X
X
X
X
X
X
Key Key Changes Changes 2004-2008 2004-2008 Organized visual, workflow, priority specimen workstreams
Key Key Changes Changes 2004-2008 2004-2008 Laboratory structural redesign, work cell design & standardization
•Linear flow •U-shaped individual workcells
1
Requisition
2
Specimen container
3
Tissue cassette
4
Glass slide
Accession & Gross Lab Process Flow Map “following the work” Histology Micro scope
Table To Histology
Transcription Storage
22
Specimen Rehab
3
Cutting Stations
Cutting Stations
Sort Station Color Buckets
3
Problem Specime ns
4 4
11
Coded Current Gross Lab Process Map
Buckets SMART
Specimen Tracking PC
Tags
Accession #1 PC
PC
Accession #2
Cassette Printer
T o Gross Lab
Accession PC
Scanner PC
Cassette Cassette Printer Printer
PC
Scanner PC
Cassette Scanner Printer Tag Entry
Storage Cutting Station 2
T o Gross Lab
Cutting Station 3 Cutting Station 1
Computers Specimen Buckets Cassette Printers
Delays
Cutting Station 4
Storage
Storage
Next Steps •
What we need from you as leaders – Your behavior is a role model, your shadow – Embrace & champion the change, THINK BIGGER – Communicate extra positive messages • To your staff • To your clients – Rid rumors & fear…Communicate – Contribute to transition teams – Be patient, we will get there together, playing well on a larger team
Lessons Learned • • • •
It takes systems to integrate Systems Value Drivers, move quickly Align incentives, follow the money Economy: We’re all running at redline
• Challenges: – Traditional Return to Silo response – Couriers, IT, Capital availability
Q & A Henry Ford Hospital Detroit Campus