Category Archives: Ideas and innovation

$8 Billion healthcare transformation in New York State

The New York State government has defined a goal to reduce avoidable hospital use by 25% over 5 years for the Medicaid population,nygov-logo which it will achieve through an innovative program called the Delivery System Reform Incentive Payment.

In 2012 New York State spent $53 billion on Medicaid beneficiaries, the most of any state in the country. In an effort to control costs, a Medicaid Redesign Team was struck in 2011 leading to greater enrolment of patients in Managed Care Organizations, reduced waste, and a global Medicaid spending cap that will result in an estimated $10 billion of savings in 2016 (based on original cost projections).

Better care, lower costs
Turning attention to sustainability and improved quality of care, the state entered into an agreement with the federal government in 2014 to reinvest $8 billion of savings through the Delivery System Reform Incentive Payments program. The primary goal is to reduce avoidable hospital use by 25% over 5 years.

Pay-for-Performance-PPCThis will be achieved by organizing hospitals and community care providers together in new integrated care organizations (called Performing Provider Systems), and by transitioning to performance-based funding system (focusing on pay-for-outcome, rather than fee-for-service).

The program is expected to improve care and reduce costs for the state’s 5.8 million Medicaid patients, and to encourage extending health insurance coverage to an estimated 1.5 million uninsured citizens.

KPMG will be supporting the New York State Department of Health during this program and providing assistance and guidance to care providers in Performing Partner Systems. Apix Performance is working as an expert advisor to KPMG, with a specific focus on design and development of the Medicaid Accelerated eXchange (MAX) Series during which care teams in all twenty-five Performing Providers Systems will undertake rapid-cycle process improvement projects.

More information is available here…

A practical approach to eliminating triage

This article is Part II of a 2-part series on triage. Click here for Part I – “The trouble with triage”.

Triage is a band-aid solution for long wait times for specialist care, ensuring that scarce resources are allocated where they are most needed.Hospital-1 But perversely, triage is one of the reasons that specialist wait times are getting longer in the first place.

The use of triage must be curtailed, and in parallel we must solve the problem of increasing wait times. A practical, seven-step approach can help us achieve this:

1. Triage only when appropriate
Occasionally triage is necessary, when two criteria are present:

i) There is a clear relationship between the speed of access to medical care and patient outcomes, and
ii) Demand temporarily exceeds capacity.

In these situations, difficult decisions are required. Triage is used to focus efforts where they will provide the greatest benefit. For instance, in emergency departments, patients are triaged to ensure that someone with urgent care needs, such as a trauma victim, is seen without delay. Even in the emergency department, however, recent evidence suggests that waiting increases mortality and many hospitals are trying to reduce or eliminate triage.

2. Manage urgent and non-urgent care differently
If triage is required, then only two triage categories should be defined; urgent and non-urgent. Patient demand and specialist capacity should be managed separately for these two groups of patients. Continue reading

The trouble with triage

This article is Part I of a 2-part series on triage. Click here for Part II – “A practical approach to eliminating triage”.

I frequently work with specialists who have long wait times for new referrals, a result of inadequate capacity to meet the demand for their services. Many try to manage high patient demand by triaging referrals, so that the most urgent patients are seen first. However, triage is a flawed solution that increases wait times and ultimately makes things worse instead of better.

TriageThe Oxford dictionary defines triage as: “the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties”. It originated in the 1930’s when it was used to assess wounded on the battlefield. The definition implies the use of triage in exceptional circumstances, such as military conflict. It is a method of assessing urgency for patients for whom treatment would be appropriate.

Modern triage has expanded significantly beyond these battlefield origins to encompass almost all forms of medical prioritization. As patients, we are now triaged not just in exceptional circumstances, but for nearly all of our routine healthcare needs. This has serious consequences for our health. The use of triage must be curtailed to be more in line with its original use – as an assessment tool for exceptional circumstances – and in parallel we must solve the problem of increasing wait times. Continue reading

Medical scribes… A low-tech solution to a high-tech problem?

In my medical practice, I frequently find myself balancing conflicting priorities of accurate, comprehensive documentation versus face-to-face time with my patients, gathering information and making shared treatment plans.

I’m an advocate for electronic medical records, but these have only made the documentation process more cumbersome. I frequently have to wait until I can find and log-in to a computer before I can complete my work, and in a busy day this time comes at the expense of my time with patients.

The introduction of medical records may have many benefits, but data-entry is difficult and time-consuming for everyone – not only for physicians who can’t type. While introducing electronic records productivity can drop by 30%, and it is estimated that physicians now spend up to two-thirds of their time on clerical work that could be done by others.

Medical ScribeI’ve often thought of the perfect scenario, where relevant clinical documentation is generated without interrupting my time with patients, and available in real-time in an electronic medical record. Apparently, I’m not the only one. Continue reading

E-Trigger tool identifies potentially missed cancer diagnoses

Electronic trigger-tools utilize electronically stored health data to generate clinical alerts that can improve the quality and efficiency of healthcare.

A recent report demonstrates that this can be successfully done. An automated trigger-tool scanned electronic health records to identify patients at risk of delayed cancer diagnosis. Clinicians were alerted to patients with a high-likelihood of cancer diagnosis who had not been appropriately followed-up. The tool was studied on approximately 300 000 patients over a 1-year period with abnormal test results that were suspicious for prostate and colo-rectal cancer. Continue reading

Improving patient access at a movement disorder clinic

The results of a Performance Clinic Program with the Neurology Department at Memorial University have been published in the BMJ Quality Improvement Reports journal, available here…

The clinical team participated in a 2-day Performance Clinic, implemented improvements and presented their initial results to Senior Management at Eastern Health after 3 months. Apix Performance facilitated the process improvement workshop and provided project support. No additional time or resources were provided to the team, who achieved very impressive results…

“Our multi-disciplinary neurology team were dissatisfied with long access times for consultation for new referrals. We participated in a rapid process improvement workshop and a structured improvement process. Over a six-month period we were able to reduce our access time for initial appointment for patients with suspected movement disorders from 133 to 20 days. We implemented a ‘carousel’ multi-disciplinary appointment and a standardised clinic form that improved the flow of patients and that we estimate will save 150 hours of physician time and 320 hours of administrative time per year.” Continue reading

Cycle time: The new wait time

Bill is an elderly patient living independently at home, who recently fell and was admitted to the hospital where I work (name and minor details changed to protect his identity). Bill clearly indicated his wish to spend as much time at home as possible.

For some time we had been measuring our length of stay in hospital, and more recently we had been monitoring our readmission rate.clock-and-stethoscope But Bill presented us with a dilemma. On the one hand we could achieve the shortest length of stay by sending Bill directly home from the emergency department, without assessment or home services and with the high likelihood that he would soon be re-admitted. Alternatively, keeping him in hospital indefinitely would eliminate the chance of re-admission. However, optimal care for Bill would produce mediocre scores on both measures. What we did not have was a single measurement that would reflect best care for Bill, and help us to meet his goal of spending as much time as possible at home.

Every industry faces the challenge of simultaneously optimizing both efficiency and quality. Before medicine, I worked as a manufacturing engineer at a company producing circuit boards. Despite our best efforts during the production process (the “length of stay” at our factory), a small number circuit boards would require repairs before shipping or be returned by customers for repairs (“readmissions”). We therefore measured the cycle time, meaning the total time that a circuit board was in our factory for production (length of stay) and repairs (readmissions). If our average cycle time was low, then we knew that we were manufacturing efficiently and achieving high quality.

In health care, cycle time – the time that it takes from beginning to end of a treatment process, including if necessary, the treatment of complications – should replace wait time as a key measure of health system performance. Continue reading