Clinical Integration: A Value-Based Model for Better Care

© 2015 Health Catalyst
www.healthcatalyst.com
Proprietary and Confidential
c
Holly Rimmasch
2016
Clinical Integration

Objectives
● Understand the importance of having a clinically
integrated organizational structure to support systematic
improvement and sustainability
● Describe key roles and processes critical to sustained
improvement methodology
2

Proprietary and Confidential 3
"Every system is perfectly
designed to get the
results it gets.”
- Dr. Paul Batalden
Organize around process.
- William Edwards Deming
... so re-design your system to get
better results

Three Systems for Improvement
4
What should we be doing? How are we doing?
How do we transform?

Clinical Integration
● What is it?
‒ The organization around clinical processes
to facilitate clear accountabilities for care
across the continuum
● Why is it important?
‒ Our core business is providing value
through better clinical care.
8

Another emerging definition-
For many who work on the front lines of delivery
system reform, clinical integration is not a generic
phrase to describe health care professionals working
more closely together. It’s a specific type of legal
arrangement that allows hospitals and physicians to
collaborate on improving quality and efficiency, while
remaining independent entities.
Advisory Board
We are not going to spend time today diving into
the legal arrangement
6

Typical Healthcare System?
Just some examples…
7
Departments
Executive
Leadership
Executive CEO
CFO
HR Finance
COO
Departments Departments
Executive
Leadership
Executive CEO
CFO
HR Finance
COO
Departments
Hospital or Healthcare
system
Clinics

Budgeted Departments- examples
• Nursing
• Medical Surgical Units
• Intensive Care Units
• Pharmacy
• Respiratory Therapy
• Physical Therapy
• Emergency Department
• IT
• Sourcing (purchasing)
• Care Management
• Medical Group/Physician
Division
• Clinics
8
• Home Care
• Rehabilitation
• Cardiovascular (Cath labs,
echo, EKG, etc)
• Radiology
• Quality
• Finance
• Environmental Services
• Medical Group
• Laboratory
• Food & Nutrition
• Health Information
Management

Heart Failure Readmissions
9
14% reduction in 90-day readmits
21% reduction in 30-day readmits
2X increase in phone calls 48 hours
63% increase in med reconciliation

Reducing Sepsis Mortality
22% reduction in sepsis mortality
$1.3 million in savings

Improved ACO Care Coordination
Advanced Care Planning
64% increase in high-risk
patients with ACPs
1,243 high-risk patients with
ACPs
980 physicians and community
facilitators engaged
Integrated EDW solution in a heterogeneous
EHR environment
5

Key Functions of a Clinically
Integrated System
● Create a shared vision
● Create integrated information systems
● Integrate clinical and operations management structure
● Integrate incentives and cost structures
11

Poll Question
Please rate your organization. How integrated are
your clinical and operational management
structures? – 201 respondents
1. 100%-- we are there! – 2%
2. 75%-- we are getting there! – 11%
3. 50%-- we are well on our way – 33%
4. 25%-- we are not too far on this journey – 34%
5. Don’t know – 20%
13

Outcomes Improvement Organizational
Structure
14
Provides domain oversight and
recommended prioritiesGUIDANCE
TEAM (S)
Leads specific outcomes improvement
discovery intervention design and
implementation. Lead unit based
change
OUTCOMES
IMPROVEMENT
TEAM (S)
Assigned specific discovery and
intervention design work by OIT
e.g. order set, new workflow
WORK
GROUP (S)
Supports development
of clinical content and
supporting analytics
CONTENT AND
ANALYTICS
TEAM (S)
Provides overall governance, prioritization,
and cultural change leadership for all
outcomes improvement
CLINICAL OUTCOMES IMPROVEMENT
LEADERSHIP TEAM
ENSURE
THAT…
• Governance and Teams are appropriately empowered to make decisions
• Outcomes Improvement Teams are created based on organizational improvement priorities
• Teams are cross discipline, permanent and include the right stakeholders
DATA GOVERNANCE
TEAM
Provides overall
governance over
the 6 phases of
Data Governance

Accountabilities:
• Provides overall governance, prioritization, and cultural
change leadership for all outcomes improvement
• Establishes clinical integration (clinical programs, clinical
services, patient quality, and safety) and clinical
improvement work
• Represents the continuum of clinical services
• Recommends clinical board-level
goals
• Reviews progress and remove
roadblocks
Clinical Outcomes Improvement
Leadership Team
14

Clinical Outcomes Improvement
Leadership Team
Membership should represent key stakeholders in
system (e.g., acute, ambulatory, MD division):
• Chief Medical Officer (CMO) or VP of Medical Affairs
• Chief Nursing Officer/Executive or VP for Nursing
• Chief administrators or operational officers
• Other key stakeholders
− IT, Finance, Patient Quality, and Safety, ACO, Population Health,
etc.
− Leadership representing Clinical Programs (CV, Pediatrics) and
Clinical Support Services (pharmacy, lab)
16

Clinical Programs: Ordering of Care
Community
Care
Care Process
Families
e.g.,
Diabetes
Cardio-
vascular
Care Process
Families
e.g.,
Coronary
Artery
Disease
General
Medicine
Care Process
Families
e.g., Sepsis
Respiratory
Care Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro-
sciences
Care Process
Families
e.g., Back and
Neck Pain
Surgery
Care Process
Families
e.g., Head
Injury
Hematology
/Oncology
Care Process
Families
e.g., GI
Neoplasm
Behavioral
Health
Care Process
Families
e.g.,
Depressive
Disorders
Women and
Newborns
Care Process
Families
e.g., High-
Risk
Pregnancy
Gastro-
intestinal
Care Process
Families
e.g.,
Pancreatic
Disorders
Musculo-
skeletal
Care Process
Families
e.g.,
Osteoarthritis

Community
Care
Care Process
Families
e.g.,
Diabetes
Cardio-
vascular
Care Process
Families
e.g.,
Coronary
Artery
Disease
General
Medicine
Care Process
Families
e.g., Sepsis
Respiratory
Care Process
Families
e.g.,
Obstructive
Lung
Disorders
Neuro-
sciences
Care Process
Families
e.g., Back and
Neck Pain
Surgery
Care Process
Families
e.g., Head
Injury
Hematology
/Oncology
Care Process
Families
e.g., GI
Neoplasm
Behavioral
Health
Care Process
Families
e.g.,
Depressive
Disorders
Women and
Newborns
Care Process
Families
e.g., High-
Risk
Pregnancy
Gastro-
intestinal
Care Process
Families
e.g.,
Pancreatic
Disorders
Musculo-
skeletal
Care Process
Families
e.g,
Osteoarthritis
18
Clinical Support Services:
Delivery of Care Ordered
Diagnostic Clinical Support Service (workflow models)
(e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Therapeutic Clinical Support Service (workflow models)
(e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Ambulatory Operations (workflow models)
(e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)
Capacity Management (workflow models)
(e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Service (workflow models)
(Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

19
Heart
Rhythm
Disorders
Vascular
Disorders
Ischemic
Heart
Disease
Heart
Failure
CARDIOVASCULAR
Level B:
Care Process
Families
Level A:
Clinical
Program
Cardiac
Valve
Disorders
CHF
Cardio-
myopathy
Pulmonary
Heart
Disease
Level C:
Care
Processes
Systolic
Dysfunctio
n
Diastolic
Dysfunction
Level D: Care
Sub-
Processes
ICD-9 and ICD-10
Diagnosis Codes
ICD-9 and ICD-10
Procedure Codes
Cardiac
Valve
Procedures
Care-LevelHierarchy

20
Heart
Rhythm
Disorders
Vascular
Disorders
Ischemic
Heart
Disease
Heart
Failure
CARDIOVASCULAR
Level B:
Care Process
Families
Level A:
Clinical
Program
Cardiac
Valve
Disorders
CHF
Cardio-
myopathy
Pulmonary
Heart
Disease
Level C:
Care
Processes
Systolic
Dysfunctio
n
Diastolic
Dysfunction
Level D: Care
Sub-
Processes
ICD-9 and ICD-10
Diagnosis Codes
ICD-9 and ICD-10
Procedure Codes
Cardiac
Valve
Procedures
ClinicalImplementationTeams
Guidance Team
Clinical Implementation
Team
Work Groups
CV
Care
Process
Families
e.g.,
coronary
artery
disease
=

Care Process Pareto Analysis
Cardiovascular Clinical Program
Top 13 Care Processes
Middle 27 Care Processes
Bottom 45 Care Processes
Adult_CareProcess Adult_CareProcessFamily Adult_ClinicalProgram
Normalized
Revenue % of All CPs
Running %
of All CPs
Coronary artery disease Ischemic heart disease Cardiovascular $28,516,437 4.47% 4.47%
Congestive heart failure Heart failure Cardiovascular $10,935,531 1.71% 6.18%
Arterial aneurysm, dissection Vascular disorders Cardiovascular $8,838,347 1.39% 7.57%
Cardiac valve disorders Heart failure Cardiovascular $8,095,210 1.27% 8.84%
Vascular insufficiency Vascular disorders Cardiovascular $5,918,680 0.93% 9.76%
Atrial fibrillation, flutter and other supraventricular tachyarrhythmiasHeart rhythm disorders Cardiovascular $4,972,392 0.78% 10.54%
Venous phlebitis, thrombosis, embolismVascular disorders Cardiovascular $2,808,147 0.44% 10.98%
Ventricular tachyarrhythmias Heart rhythm disorders Cardiovascular $2,702,363 0.42% 11.41%
Pulmonary embolism Heart failure Cardiovascular $2,599,832 0.41% 11.81%
Complication of vascular device, implant or graftVascular disorders Cardiovascular $2,304,288 0.36% 12.18%
Sick sinus and conduction disordersHeart rhythm disorders Cardiovascular $1,892,212 0.30% 12.47%
Peripheral vascular disease Vascular disorders Cardiovascular $1,860,751 0.29% 12.76%
24

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of Total Cumulative %
Pareto Analysis >> Prioritization
22
X-Axis = Care Processes by resources consumed (High to Low)
Y-Axis=Percentoftotalresourcesconsumed
Top 85 Care Processes account
for 80% of the opportunity (+45)
for 62% of the opportunity (+27)
for 34% of the opportunity

Internal Variation versus Resource Consumption
(Excel Example shown)
Y-Axis=InternalVariationinResourcesConsumed
Bubble Size = Resources
Consumed
Bubble Color = Clinical DomainX Axis = Resources Consumed
1
2
3
4

Accountabilities:
• Provides domain oversight and recommended priorities
• Develop and implement best practices across the continuum
within domain (i.e. heart failure from prevention through treatment
and maintenance)
− Each clinical program is assigned accountability for care process families
and related care processes
• Recommend board and clinical program goals
• Prioritize resources
• Determine order and timing for creation of teams to support goals
• Ensure best practices are diffused and sustained systemwide
• Review and report progress; remove barriers
Guidance Team
30

Guidance Team
Chaired by physician and nurse director with domain
expertise. Team membership should include:
• Physician, nurse director, and administrator from each
cluster representing domain
• Knowledge manager, data architect/analyst
• Other key stakeholders:
− IT, Finance, Patient Quality, and Safety
25

Permanent Teams Characteristics
= SubjectMatter Expert
= Data Capture
= Data Provisioning & Visualization
= Data Analysis
Women & Children’s Clinical Program Guidance Team
Pregnancy
MD Lead
RN SME
Knowledge
Manager
Data
Architect
Application
Administrator
RN, Clin Ops Director
Guidance Team MD lead
Normal Newborn
MD Lead
RN SME
Gynecology
MD Lead
RN SME
• Organized permanently for long term improvement
• Integrated clinical and technical members
• Supports multiple care process families
• Choose innovators and early adopters to lead
Innovators
Early Adopters

DATA CAPTURE
• Acquire key data elements
• Assure data quality
• Integrate data capture into operational
workflow
DATA ANALYSIS
• Interpret data
• Discover new information in the data
(data mining)
• Evaluate data quality
DATA PROVISIONING
• Move data from transactional systems into
the data warehouse
• Build visualizations for use by clinicians
• Generate external reports (e.g., CMS)
Knowledge Managers (data
quality, data stewardship, and
data interpretation)
Application Administrators
(optimization of source systems)
Data Architects
(infrastructure, visualization, analysis, reporting)
= Subject Matter Expert
= Data Capture
= Data Provisioning
= Data Analysis
Critical Key Functions to
Consider…
41

Outcomes Improvement Team
Accountabilities:
• Leads specific outcomes improvement discovery
intervention design and implementation. Lead unit based
change
• Provide broad feedback to smaller workgroup teams on aims,
metrics, and best practices
Membership:
• Broad representation across your system (facilities, clinics,
regions) and should include members with deep
knowledge and experience:
− Physician leader
− Nurse subject matter expert
− Other disciplines (respiratory therapy, finance, lab, etc.)
28

Workgroup Team
Accountabilities:
• Assigned specific discovery and intervention design work by OIT
e.g. order set, new workflow
• Responsible for the “heavy lifting” related to improvement
− Targeted on care process or care sub-process
− Integrate best practices; build key metrics
− Report and request input from Outcomes Improvement Team
Membership:
• Small integrated team of domain experts (physicians, nurses,
finance) and analytical/technical experts
− Data architects/analysts
− Application administrators
29

Improvement Cycle
30
Prerequisites
 Recruit team
 Train team
• Solicit front line plan
input
• Finalize analytics dev,
testing, and rollout
support
• Finalize intervention
rollout plan
• Guidance team
validation
Rollout
• Review initial results
• Identify, approve any
modifications to
intervention rollout
• Review lessons
learned
• Create next AIM
statement
• Repeat process
Results
• Finalize cohort
• Identify intervention(s)
• Direct observation
• Solicit front line input
on AIM and
intervention
• Define intervention
rollout plan
• Guidance team
validation
Intervention
• Review visualized
drafts of AIM cohort
findings
• Identify data quality
issues
• Direct observation
• Prioritize and select
AIM #1
• Review cohort criteria
and visualizations
• Guidance team
validation
AIM
• Confirm team mission,
charter, roles
• Review AIM options
• Gather best practices
• Profile and visualize
preliminary data
• Select 2-3 potential
AIMs
• Guidance team
validation
Kickoff
Select Build and Refine Build and Refine Build and Refine
Rollout Date
Major
Milestones
Work Streams
7. Measure Progress
1. Best Practices
2. Define Cohort
3. AIM Statement
4. Design Metrics
5. Rollout Plan
6. Rollout
Rollout Date

Identify Potential Improvements
Process AIMs and Outcome Goals
Transformation Process
Starter Set
Content
Implement
Intervention
Measure &
Sustain
Review &
Select AIM Define Cohort
Iterate on
Metrics
Heart Failure: AIM #1
Starter Set
Content
Implement
Intervention
Measure &
Sustain
Review &
Select AIM Define Cohort
Iterate on
Metrics
Heart Failure: AIM #2
Process Improvement AIM:
Improve Follow-up Visit Scheduling
From 43% to 90% by October 31, 2015
Process Improvement AIM:
Improve Medication Reconciliation
From 58% to 80% by June 30, 2015
Heart Failure Outcome Improvement Goal:
Reduce Readmissions = Reduce the readmission rate for the HF population
from 30% to 20% by December 31, 2015
2-4 Process Improvement AIMS should produce a significant outcome improvement

Actionable Visualizations
47

Permanent Improvement Team Temporary Project Team
Team Structure Options
Pros
● Proactive
(strategic investment)
● Predictable Cost
● Team member establish long
term relationship
● Implementation improved
● Sustainability improved
● Partnership established on
technical priorities
Cons
● “Feels” more expensive,
actually saves money long term
● True cultural shift
Cons
● Difficult to maintain
sustainability
● Variable Cost
● Speed to trust slower in
temporary teams
● Need to reorient team
members don’t always
understand context within
domain
Pros
● “Feels less expensive” one
time cost to fix (not typically
true)
● Less time to start initially

Priority Management
• Intake process to manage strategic and tactical
information requests of EDW team
Data Stewardship
• Legislation of standard definitions
• Quality management processes
• Security/authorization
• Master data management
34
Data Governance Categories
Executive Oversight
IT Leadership

Content & Analytics Team
Accountabilities:
• Supports development of clinical content and supporting analytics
• Develop the analytic and knowledge management infrastructure needed to support
process and outcomes improvements in clinical, operational, financial and patient
experience across all domains of clinical integration.
• Create consistency across clinical programs and clinical support services
• Patient & Provider education related to development of best practices, guidelines, etc.
• Align priorities and resources to system goals
Membership:
• Chair examples: CMIO, CQO, chief patient safety officer, chief
knowledge officer
• Lead data architects and knowledge mangers
• Provider and patient education specialists
• Lead administrative and clinical application stewards
35

Care Improvement Map
Sepsis and Septic Shock

Are your data governance and content & analytics
resources aligned with your improvement outcome
goals? – 179 respondents
1. Yes – 6%
2. Mostly – 14%
3. Sometimes – 44%
4. No – 18%
5. Don’t know – 18%
37
Poll Question

= Subject Matter Expert
= Data Capture
= Data Provisioning & Visualization
= Data Analysis
Small Teams (Designs)
• Meet weekly in iteration planning meeting
• Build DRAFT processes, metrics, interventions
• Present DRAFT work to Broader TeamsOB
Guidance Team
• Meet quarterly to prioritize allocation of resources
• Approves improvement AIMs
• Reviews progress and removes road blocks
• Monitors and tracks progress and sustainability
OB Newborn GYN
W&N
W&N
Broad Teams (Implements)
• Broad RN and MD representation across system
• Meet monthly to review, adjust and approve DRAFTs
• Lead rollout of new process and measurementOB
W&N
W&N
W&N
Executive Leadership Team
• Prioritizes sequence of formation of Guidance Teams
• Approves Board Level Outcomes Goals
• Reviews progress and removes road blocks
GUIDANCE
TEAM (S)
OUTCOMES
IMPROVEMENT
TEAM (S)
WORK
GROUP (S)
CLINICAL OUTCOMES IMPROVEMENT
LEADERSHIP TEAM
(Prioritizes Innovations)

Key Success Factors/Lessons
Learned
• Leadership
• Integration of technical, clinical, and operations
• Dedicated resources
− Clinical leadership, domain expertise, operational expertise, Data
Managers, analytic resources
• Permanent structures and processes/systematic approach
− Change from “project” to “the way we live”
• Deep culture of quality and improvement; consistent methodologies
• Transparency
• Integrated key concepts into current work/teams/structures
• There are many ways to put this puzzle together
• This is a journey!
59

Clinical Integration: A Value-Based Model for Better Care

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