1. Pursuing High Value Healthcare Optimizing Laboratory Testing Webinar #6 July 16, 2015 1

2. Agenda Welcome Data Team Updates  Current data and reports  Discussion Team Status Reports o Progress/Activities Since Learning Session  Phase 2 of Collaborative Meeting Time Reminders ● Next Steps  Action Period 2

3. Our First Collaborative: Global Aim We aim to reduce harm to patients and conserve system resources by optimizing the use of laboratory tests for patients cared for in our region’s hospitals. We will use a collaborative approach considering the best medical evidence and quality improvement science. It begins with an evaluation of current test ordering profiles and patterns followed by an organized plan to optimize testing and ends with a plan to sustain these practices. By doing this we expect to reduce cost and improve satisfaction and quality of care for patients and the health system. It is important to work on this now because as health care professionals we can play an important role in health care reform by designing more patient-centered, efficient and high value inpatient care. 3

4. Quality Improvement Process Assessment Theme Global Aim Specific Aim Change Ideas Measure(s) PDSA SDSA 1 2 3 1 2 3 Success Measure Global Aim Modified from Quality By Design, A Clinical Microsystems Approach Nelson, Batalden and Godfrey© Trustees of Dartmouth College Step 1- Form Team Step 2- Get Baseline Data Step 3- Create Global Aim Step 4- Create Specific Aim Step 5 –Determine Cause and Effects Step 6- Brainstorm Change Ideas Step 7 –Determine Process Measures Step 8- Test Your Changes 4 We are here!

6. Data Update Site visit findings Institution specific data reports Consolidated database reports Next steps

7. Project Target Population All adults with an inpatient hospital stay > 24 hours in length, excluding maternity, inpatient psych and swing bed patients What does “inpatient” mean? When does admission time start? Inpatient > 24 hours ER visit > 24 hours? Observation bed > 24 hours? Same Day Surgical care > 24 hours? ER Observation Inpatient?

8. Project Target Population All adults with an inpatient hospital stay > 24 hours in length, excluding maternity, inpatient psych and swing bed patients Excluding Patients Maternity & childbirth related, excluded using MDC codes 14 & 15 or DRG codes 765-795 Inpatient psych, excluded prior to data submission when possible. Additionally, excluded using DRG code 885 Swing bed, excluded using discharges with no DRG code assigned

9. Dropping Missing DRG codes Swing bed patients are typically not assigned a DRG code What other patients are typically not assigned a DRG code?  Observation only patients?  Other? What patients might we inadvertently drop if we exclude all discharges with a missing DRG code?  DISCUSSION

10. Defining Length of Stay Length of Stay in hours = (discharge timestamp – admit timestamp) Length of Stay in CDC days = (discharge date – admit date) Length of Stay in calendar days = ((discharge date – admit date) + 1)

11. Defining Length of Stay For example, suppose a person gets admitted at 10:02am on June 2 nd and discharged at 4:10pm on June 3 rd Length of Stay in hours = (6/3/2014 16:10 – 6/2/2014 10:02) = 29.13 hours Length of Stay in CDC days = (6/3/2014 – 6/2/2014) = 1 day Length of Stay in CDC days = ((6/3/2014 – 6/2/2014) + 1) = 2 days

12. Defining Length of Stay For example, suppose a person gets admitted at 10:02am on June 2 nd and discharged at 4:10pm on June 3 rd But what does “admitted” mean? Was the patient admitted to the ER at 10:02am? Was the patient assigned a bed as on “observation” patient at 10:02am? Was the patient admitted as an inpatient at 10:02am?

13. Defining Admit Time 1. Identify individual discharges  using a unique visit number in the admission data file, unique visit number 2. Link all labs associated with an individual discharge unique visit numbers  Sometimes the unique visit number is in the Lab data file  Sometimes we link on MRN and dates of service 3. Labs are associated with a visit if they are within 24 hours of the available admit timestamp

14. Labs Within 24 hours of Admit Timestamp Goal: to ensure we obtain labs that were collected when a patient was in the ER or an observation bed prior to being admitted as an inpatient If labs were collected within 24 hours prior to the available admit timestamp, the earliest collection time is used as the “admit time” when calculating length of stay For example, suppose a person goes to the ER on June 2 nd at 6:11am and has a CBC drawn at 8:01am. The patient then gets admitted as an inpatient at 10:02am on June 2 nd and discharged at 4:10pm on June 3 rd. The “admit time” used to calculate length of stay will be 6/2/2014 08:01.

15. Labs Within 24 hours of Admit Timestamp By only including labs that were collected within 24 hours prior to the available admit timestamp, what issues might come up? If a patient has labs for an elective surgery done 7 days prior to the admission they will not be included. BUT if the are done the day before surgery they might be…..  Other concerns? DISCUSSION

16. CBC rates per patient day (HGB)

17. CHEM rates per pt day (CREAT)

18. CHEM rates per pt day (K)

19. CBC rates per first 24 hours of visit (HGB)

20. CHEM rates per first 24 hours of visit (CREAT)

21. CHEM rates per first 24 hours of visit (K)

22. Next Steps 1. Finalize length of stay definitions 2. Finalize inclusion/exclusion criteria 3. Support sites to continue monthly data uploads 4. Define monthly DRG severity values 5. Include LFT and Cardiac Biomarker lab tests 6. Support Year 2 of the Collaborative (explore lab values? Explore DRG specific ordering patterns?)

23. Team Progress Reports RRMC Brattleboro NVRH Bennington Porter DHMC CVMC UVMMC Any updates from the teams to share on advances since our Learning Session at Dartmouth? 4

24. 24 Learning Session 1 Oct. 25 8:30 to 3:30 Learning Session 1 Oct. 25 8:30 to 3:30 Learning Session 4 Jun. 9 TBD 8:30 to 3:30 Learning Session 4 Jun. 9 TBD 8:30 to 3:30 Learning Session 2 Jan.14, TBD 8:30 to 3:30 Learning Session 2 Jan.14, TBD 8:30 to 3:30 Kick-Off Week 1 Sept 10, 2PM Kick-Off Week 1 Sept 10, 2PM Learning Session 3 Apr. 14 TBD 8:30 to 3:30 Learning Session 3 Apr. 14 TBD 8:30 to 3:30 Action Period 5-6 weeks Action Period 5-6 weeks Conference Call / Webinar Nov 19, 2PM Conference Call / Webinar Dec 17, 2PM Conference Call/ Webinar Feb. 18, 2PM Conference Call / Webinar Mar 24, 2PM Conference Call / Webinar May 12, 2PM Continuous Coaching/Faculty Support Collaborative Timeline

25. Next Steps Action Period  Continue to review and submit data  Test change ideas  Measure results  Adjust as needed  Test again or try new change idea Support  Faculty and Data Team are here to support you! Next Webinar- August 13 th, 2PM 14