Faculty Bibliography

BACKGROUND:Reducing costs while increasing or maintaining quality is crucial to delivering high value care. OBJECTIVE:To assess the impact of a hospital value-based management programme on cost and quality. DESIGN/METHODS:Time series analysis of non-psychiatric, non-rehabilitation, non-newborn patients discharged between 1 September 2011 and 31 December 2017 from a US urban, academic medical centre. INTERVENTION/METHODS:NYU Langone Health instituted an institution-wide programme in April 2014 to increase value of healthcare, defined as health outcomes achieved per dollar spent. Key features included joint clinical and operational leadership; granular and transparent cost accounting; dedicated project support staff; information technology support; and a departmental shared savings programme. MEASUREMENTS/METHODS:Change in variable direct costs; secondary outcomes included changes in length of stay, readmission and in-hospital mortality. RESULTS:The programme chartered 74 projects targeting opportunities in supply chain management (eg, surgical trays), operational efficiency (eg, discharge optimisation), care of outlier patients (eg, those at end of life) and resource utilisation (eg, blood management). The study cohort included 160 434 hospitalisations. Adjusted variable costs decreased 7.7% over the study period. Admissions with medical diagnosis related groups (DRG) declined an average 0.20% per month relative to baseline. Admissions with surgical DRGs had an early increase in costs of 2.7% followed by 0.37% decrease in costs per month. Mean expense per hospitalisation improved from 13% above median for teaching hospitals to 2% above median. Length of stay decreased by 0.25% per month relative to prior trends (95% CI -0.34 to 0.17): approximately half a day by the end of the study period. There were no significant changes in 30-day same-hospital readmission or in-hospital mortality. Estimated institutional savings after intervention costs were approximately $53.9 million. LIMITATIONS/CONCLUSIONS:Observational analysis. CONCLUSION/CONCLUSIONS:A systematic programme to increase healthcare value by lowering the cost of care without compromising quality is achievable and sustainable over several years.

Statement of Problem Or Question (One Sentence): As communication among patient care team members is often dangerously fragmented and effective collaboration becomes essential to provide safe hospital care for patients, we implemented the Daily Medicine Rounding Tool (DMeRT) that improved collaboration between the physician and nurse. Objectives of Program/Intervention (No More Than Three Objectives): 1. We aimed to promote a patient-centered, highly reliable rounding tool to reduce hospital adverse events by streamlining real time communication between nurses and physicians. 2. We hypothesize that this tool will decrease the need for frequent calls throughout the day, ultimately improving team productivity and overall staff satisfaction. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In our institution, the Epic's default patient dashboard columns included patient name, venous thromboemboli (VTE) prophylaxis, Medical Orders for Life Sustaining Treatment (MOLST) completion, glycemic control, and medication reconciliation completion. Expanding upon these prior default columns, we partnered with information technology and nursing to create a customized dashboard that included additional informational columns extracted from the documentation in the charts, to include the administration of intravenous fluids, oxygen supplementation, last bowel movement recorded and high risk medications (anti-coagulants, anti-epileptics, furosemide, opioids, and benzo-diazepines). We then trained the physicians and nurses to discuss each patient using the customized DMeRT dashboard during interdisciplinary rounds. The average time spent on the DMeRT is 15 minutes for a total 10 patients. This helps as a reminder and the identification of potential pitfalls and safety concerns. The DMeRT was instituted on a 30 bed medical unit (5500) on June 1, 2018 with iterative improvements to content. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will analyze data pre and post intervention to assess for impact on reducing medication errors during hospitalization, hospital acquired VTE events and improvement in glycemic control. Finally we will track MOLST completion, medication reconciliation compliance, constipation and fluid overload events added to the patient's problem list 48 hours prior to discharge. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): To date, the unit which implemented the intervention had an improvement in the Quality Hyperglycemia Scores (method used to evaluate inpatient glycemic management) from 56 in 4/2018 to 95 in 12/2018. There was an improved MOLST completion from 14% in 4/2018 to 83% in 12/2018. A Preliminary survey of 15 nurses on unit 5500 showed that 80% reported that they rarely need to call house staff within 2 hours of completing the rounding tool and 66% of nurses were satisfied with the DMeRT. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): During hospitalization, multiple aspects of patient care are overlooked while we focus on the admitting diagnosis, necessary diagnostics and treatments. Medication errors during hospitalization are commonly caused by breakdowns in communication and associated with substantial risk. This is a simple tool that utilizes information technology to efficiently and systematically review standardized aspects of care

Statement of Problem Or Question (One Sentence): As the lack of a 'face-to-face' interaction between the full team and the patient led to a downtrend in patient experience scores, we were inspired to design a patient centered communication tool that standardizes the multi-disciplinary bedside rounds. Objectives of Program/Intervention (No More Than Three Objectives): 1. To improve our patients' hospital experience in regards to care transitions and discharge planning by implementing standard bedside rounds that center around the patient's health care needs. 2. To create a daily scheduled opportunity for the patient to be involved in medical decisions and discharge planning which enhances patients' understanding of their own care plan. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): Our medical-surgical units did not have a standardized approach to ensure clear communication from a patient's multidisciplinary team, comprised of physicians, nurses, case managers and social workers. To this end, we implemented a communication plan based on the acronym "WE CARE" 1) Who was present (who was at bedside in addition to the patient); 2) Everyone on same page (language and literacy barriers); 3) Connect with patient and family (promote patient-centeredness and compassionate care through eye contact, introducing the full team); 4) Assessing understanding (explanation of changes to medications, key lab and test Results, and post-discharge plans); 5) Response from patient and/or caregivers (ensuring understanding); 6) Educate/empathy/end of conversation. Centered on the WE CARE model, we gathered all members of the care team and visited each patient at a standardized time every day. The intervention was started on one medical-surgical, unit 5600 on July 2018. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores for care transitions and discharge information pre and post intervention will be evaluated for the study group (unit 5600). We will also compare these scores to med/surg units who did not receive the intervention. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): We compared our pre-intervention 1/1/2018-4/31/2018 (approximately 54 surveys) and post-intervention (approximately 42 surveys) scores. In the domain of care transitions, e. g., patient had a good understanding of things patient was responsible for in managing his/her health; patient had a good understanding of purpose of each medication; staff consideration of patient and caregiver preferences post-discharge, there was an increase from 28% in our top-box (an answer of always) composite HCAHPS score to 58%. Scores for "discharge information delivered" remained high with a top-box response above 85% both pre-and post-intervention. In addition, during the post-intervention time, the study group unit had the highest "care transition" and "discharge information" top box responses compared to all control units. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): A focused, structured communication tool WE CARE, implemented as a part of daily standardized multidisciplinary bedside rounds led to an improvement in patient satisfaction scores around care transitions and discharge information delivered

The Accreditation Council for Graduate Medical Education requires integration of quality improvement and patient safety education into graduate medical education (GME). The authors created a novel "Swiss Cheese Conference" to bridge the gap between GME and hospital patient safety initiatives. Residents investigate a specific patient safety event and lead a monthly multidisciplinary conference about the case. Resident presenters introduce the Swiss cheese model, present the case and their findings, and teach a patient safety topic. In groups, participants identify contributing factors and discuss how to prevent similar events. Presenters and stakeholders immediately huddle to identify next steps. The Swiss Cheese Conference has increased participants' comfort analyzing safety issues from a systems perspective, utilizing the electronic reporting system, and launching patient safety initiatives. The Swiss Cheese Conference is a successful multidisciplinary model that engages GME trainees by integrating resident-led, case-based quality improvement education with creation of patient safety initiatives.

Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies' Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.

Background: Paper-based Early Recovery after Surgery (ERAS) path-ways have been shown to reduce length of stay, but there have been limited evaluations of electronic health record (EHR) based pathways. The objective of this study was to evaluate whether ERAS processes implemented with a novel pathway activity integrated with the EHR (E-Pathway) can reduce costs without resulting in increased 30 day readmissions. Methods: We performed a retrospective cohort study of surgical patients age>= 18 years hospitalized at an academic medical center from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing elective procedures with similar length of stay as colon surgery (3-5 days). The E-Pathway was based on a pathway template developed by a common EHR vendor (Epic Systems, Verona, WI) with content developed by a multidisciplinary team based on ERAS principles. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay (O:E LOS) and 30 day readmissions to our hospital. For both groups, we performed an interrupted time series with segmented regression analysis with month being the unit of time. We used gamma regression for cost models and logistic models for the secondary outcomes. Results: We included 823 (470 and 353 in the pre-and post-intervention, respectively) colon surgery patients and 3415 (1,819 and 1,596 in the pre-and post-intervention) surgical control patients. Among the colon surgery cohort, we observed no changesin cost eitheratbaseline [-0.1% (95% CI-0.8%, 0.5%) per month] or with immediate introduction of the pathway. However, there was statistically significant (p = 0.040) decrease in costs of 1.3% (0.6% to 2.5%) per surgical encounter per month over the 18 month post intervention period. The surgical comparator group had no change in cost either at baseline or at the time of intervention and had a nonsignificant decrease in monthly costs of 0.6% (p = 0.231) post-intervention. There was statistically significant (p = 0.039) decrease in the O:E slope after the intervention of 1.49% per surgical encounter per month. The surgical comparator group had a nonsignificant (p = 0.761) increase in slope of 1.87%. For the 30 day readmission rates, there were no statistically significant changes in either the colon surgery or control groups. Conclusions: Our study is the first, to our knowledge, to report on the outcomes of a novel sophisticated E pathway integrated into an EHR. Following implementation of the E-pathway for colon surgery patients, we observed decreasing direct variable costs and O:E LOS over time. These improvements were not observed among comparable surgical patients. Consequently, as institutions continue to place increased emphasis on standardization of best practice care, E-pathways can be powerful vehicles to support those changes in the new EHR-centric care model