Using Multi-Hospital Laboratory Integration to Improve Lab Outreach Success

Using Multi-Hospital Laboratory Integration to Improve Lab Outreach Success John Waugh Henry Ford Health System, Detroit Executive War College, New Or...
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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 ƒ Organized visual, workflow, priority specimen workstreams

Key Key Changes Changes 2004-2008 2004-2008 ƒ 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