1. Clinical Analytics for Quality Improvement Initiatives Paul Henchey October 5, 2015

2. ABOUT ARBORMETRIX MISSION To deliver the most advanced healthcare performance measurement platform ROOTS Founded by surgeons and researchers Funded by venture capital FOCUS Acute Care Scientifically rigorous clinical analysis Advanced cloud-based technology CLIENTS Collaboratives & specialty societies Hospitals & health systems Accountable care organizations

3. AGENDA Context for Quality Improvement – National – Regional – Local Implementing clinical analytics to – Drive quality improvement locally – Leverage national and regional initiatives Case Studies

4. CONTEXT FOR QUALITY IMPROVEMENT

5. COMPLEMENTARY INITIATIVES NATIONAL Research Database REGIONAL Collaboration LOCAL Process Improvement National societies like ACS and STS have been successful in aggregating broad research databases. More specialized registries now being developed. State-wide and regional CQI initiatives are big enough for data-driven learning and small enough that the players can know each other and can collaborate effectively on best practices. Individual health systems are where quality improvements must ultimately be organized, funded and implemented.

6. EXAMPLE: BROAD NATIONAL INITIATIVE American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) 50 clinical variables captured for surgical cases Includes 30 day outcomes 660 Participating Hospitals Clinical abstraction of 1,680 sample cases per hospital per year Semi-annual benchmarking reports

7. EXAMPLE: SPECIALIZED NATIONAL INITIATIVE Americas Hernia Society Quality Collaborative (AHSQC) Focus on ventral hernia repair Continuous data collection and online benchmarking Captures details of technique, mesh utilization Patient outcomes including readmission Quarterly QI meetings Coaching on surgical technique AHSQC Medical Director: Michael J. Rosen, MD, FACS Professor of Surgery, Cleveland Clinic Foundation, Comprehensive Hernia Center AHSQC Director for Quality and Outcomes: Benjamin K. Poulose, MD, MPH, FACS Assistant Professor of Surgery, Vanderbilt University Medical Center

8. EXAMPLES: REGIONAL INITIATIVES 10 percent reduction in mortality 34 percent reduction in sepsis 29 percent reduction in pneumonia 33 percent reduction in cardiac arrest 15 percent reduction in length of stay 18 percent reduction in surgical site infections Saved $11 million statewide in total episode payments for Post-CQI treated patients in one year, through the Michigan Trauma Quality Improvement Program (MTQIP) Saved $27.8 million statewide over four years, through the Michigan Bariatric Surgery Collaborative (MBSC) $85.9 million saved statewide over two years by reducing adverse events, through the Michigan Surgical Quality Collaborative (MSQC) Regional CQI model now being replicated in states such as Pennsylvania and North Carolina…

9. EXAMPLES: LOCAL INITIATIVES Vanderbilt Section of Surgical Sciences Surgeon-led Surgical Value Improvement Initiative Leveraging national registry data (NSQIP, AHSQC, etc.) Focus on unwanted variation in cost and quality University of Michigan Department of Surgery Leadership for several regional initiatives Implementing process improvements internally Tracking ROI Feedback loop for surgeons

10. IMPLEMENTING CLINICAL ANALYTICS

11. FRAGMENTED DATA OPPE RVUS CFO OR DIRECTOR SECTION CHIEF Block time Quality Supply cost Revenue Cost DRG CPT

12. COLLABORATIVE CLINICAL ANALYTICS Integrated system provides credible, consistent performance metrics Eliminates ‘spreadsheet wars’ Supports the alignment of goals, processes Targeted Improvement Strategic Planning Monitoring & coaching

13. DATA MODEL Professional Claims CPT RVU Surgeon Facility Claims & Cost Accounting ICD9 Facility Cost LOS OR System Case Minutes Supply Cost CPT, RVU, Surgeon ICD9, Facility Cost, LOS Case Minutes, Supply Cost Clinical Outcomes Clinical Registries Clinical Outcomes

14. CLINICAL SCOPE National Surgical QIP (ACS) Metabolic and Bariatric Surgery Accreditation and QIP (ACS) American Hernia Society Quality Collaborative (AHSQC) Collaborative Endocrine Surgery QIP Michigan Surgical Quality Collaborative (MSQC) Michigan Trauma QIP Michigan Urological Surgery Improvement Collaborative (MUSIC) CLINICAL REGISTRIES Acute Care Bariatric Colorectal Endocrine HPB Minimally Invasive DEPARTMENTS Surgical Oncology Cardiac Thoracic Vascular Urology Orthopaedic

15. CORE METRICS QUALITYPRODUCTIVITY EFFICIENCYFINANCIAL Post-operative complications Mortality Reoperations Readmissions LOS Surgical cut-to-close time Supply cost Hospital direct cost Work RVUs Procedures Visits Cases Net revenue Net income Total cost Contribution margin

16. ARBORMETRIX RISK-ADJUSTMENT Why Risk-Adjust? Because an 85-year-old female undergoing cardiac surgery is more likely to suffer adverse outcomes compared to an otherwise healthy 50-year-old male undergoing the same procedure. Because some hospitals and physicians treat more high-risk patients than others. Without Risk adjustment physicians will not trust your reports.

17. ARBORMETRIX RELIABILITY ADJUSTMENT 0 deaths out of 2 patients 0 deaths out of 200 patients Which surgeon would you refer a family member to?

19. CASE STUDIES

20. REGIONAL EXAMPLE: MSQC A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Ann Surg. 2014 Feb;259(2):310-4. doi: 10.1097/SLA.0b013e3182a62643. Kim EK1, Sheetz KH, Bonn J, DeRoo S, Lee C, Stein I, Zarinsefat A, Cai S, Campbell DA Jr, Englesbe MJ. “In the state of Michigan, full bowel preparation is associated with decreased infectious complications after elective colectomy. Within this context, the Michigan Surgical Quality Collaborative recommends full bowel preparation before elective colectomy.”

21. MICHIGAN SURGICAL QUALITY COLLABORATIVE SCREEN SHOT Bundle 3way with Mech Bowel Prep selected. Chart shows level of compliance with each of six best practices. Wide variation in bundle compliance across hospitals. Data altered to protect confidentiality

22. Chart shows correlation between bundle compliance and SSI rates. Cases with 5 of 6 best practices have only 1/5th the complications compared to those with 0 or 1 best practices. Chart shows correlation between bundle compliance and SSI rates. Cases with 5 of 6 best practices have only 1/5th the complications compared to those with 0 or 1 best practices. Data altered to protect confidentiality

23. LOCAL EXAMPLE: VANDERBILT SECTION OF SURGICAL SERVICES “We have been able to gain new intelligence regarding value that we did not have prior to implementing the SurgicalMetrix solution.” “We are able to evaluate each surgeon in their own clinical space and identify surgeons who deliver high quality care at low cost.” “We are then planning to engage those surgeons and apply their processes to those who may not be performing as well.”

24. Reports quantify the financial impact of surgical complications. Here we see a $9,000 swing in net income between complicated and uncomplicated colorectal surgery cases. Reports quantify the financial impact of surgical complications. Here we see a $9,000 swing in net income between complicated and uncomplicated colorectal surgery cases. Data altered to protect confidentiality

25. Chart shows correlation between poor quality and reduced margins Surgeon in lower right quadrant has high complication rates and low net income per case Chart shows correlation between poor quality and reduced margins Surgeon in lower right quadrant has high complication rates and low net income per case Data altered to protect confidentiality

26. This surgeon’s rate of pneumonia complications is much higher than her peers. This may provide a coaching opportunity. This surgeon’s rate of pneumonia complications is much higher than her peers. This may provide a coaching opportunity. Data altered to protect confidentiality

27. LOCAL EXAMPLE: MICHIGAN DEPARTMENT OF SURGERY “How can we track the results from our investment in a new staffing model for Acute Care Surgery?” New staffing model intended to improve quality and reduce cost per case. SurgicalMetrix put in place to track actual impact over time.

28. Now using dedicated Acute Care surgeons in place of rotating staff for most Non-Trauma Emergency (NTE) cases. Data altered to protect confidentiality

29. Dashboards track cost and quality for NTE cases: Complication rate has dropped from about 20% to 12% Direct Costs reduced from about $18,000 to $12,000 per case LOS also reduced by about 0.5 Dashboards track cost and quality for NTE cases: Complication rate has dropped from about 20% to 12% Direct Costs reduced from about $18,000 to $12,000 per case LOS also reduced by about 0.5 Data altered to protect confidentiality

30. COMPLEMENTARY INITIATIVES NATIONAL Research Database REGIONAL Collaboration LOCAL Process Improvement National societies like ACS and STS have been successful in aggregating broad research databases. More specialized registries now being developed. State-wide and regional CQI initiatives are big enough for data-driven learning and small enough that the players can know each other and can collaborate effectively on best practices. Individual health systems are where quality improvements must ultimately be organized, funded and implemented.

31. ADDITIONAL INFORMATION http://www.arbormetrix.com/whitepapers http://www.arbormetrix.com/blog phenchey@arbormetrix.com https://twitter.com/ArborMetrix