LEAN SIX SIGMA WORLD CONFERENCE
Bundles of CABG: Preparing Cardiac Surgery for Value Based Pay
Presenter: Melina Darby, Senior Project Manager, Michigan Medicine, Ann Arbor, MI, USA
Co-Presenter: Jamie MacLaren, Continuous Improvement Engineer, Michigan Medicine, Ann Arbor, MI, USA
Keywords:Healthcare, Root Cause Analysis, Implementation
The Michigan Medicine Samuel and Jean Frankel Cardiovascular Center (CVC) is located in Ann Arbor at the University of Michigan. It is nationally recognized in the diagnosis and treatment of heart and vascular diseases. The division of Cardiac Surgery performs approximately 2,000 heart surgeries each year. In Fall of 2018, the CVC enrolled in two cardiac surgery bundled payment episodes, Coronary Artery Bypass Graft (CABG) and Mitral Valve, as part of the Bundled Payments for Care Improvement (BPCI) Advanced program. This program looks at the patient’s continuum of care until 90-days post-discharge and includes all healthcare resource cost utilization into one payment. To prepare for bundled payments, the Clinical Design and Innovation (CDI) team was tasked to work on process improvement within Cardiac Surgery in the summer of 2017. The overall goal of this work was to increase patient days at home post-procedure. This includes reducing patients’ length of stay (LOS) in the hospital, Skilled Nursing Facility (SNF) utilization, and readmissions. A project manager and industrial engineer from CDI facilitated working sessions with a multidisciplinary team from Cardiac Surgery to understand current state and opportunities for improvement. This multidisciplinary team consisted of cardiac surgeons, anesthesiologists, nurses, perfusionists, administrators, and others involved in the patients’ care. Once current state was understood, potential opportunities were inserted into an impact effort matrix and the team then voted on the top three areas to improve upon (i.e., subgroups). The areas selected were 1) operating room (OR) efficiency, 2) clinical pathway, and 3) barriers to discharge. Within the three subgroups, the team did a deeper dive into current state to determine which areas to focus on and to analyze root causes. For the OR efficiency subgroup, the case length was divided into five procedural segments: 1) patient in room to patient positioned, 2) patient positioned to incision, 3) incision to close, 4) close to patient out of room, and 5) turnover. These times were also benchmarked against ten external institutions and the Society of Thoracic Surgeons (STS) database. After swimlane mapping, benchmarking, and Gembas, we found that the incision to close segment had the most opportunity for improvement to decrease case time and increase OR efficiency. For the clinical pathway subgroup, the team determined a clinical pathway would be beneficial to show which steps need to occur each day in the ICU and step-down units.
This pathway serves as a reference guide for nursing, residents, and other members of the care team. It includes guidelines on the back of the pathway that provide criteria for extubation, line removal, and other patient care milestones. The pathway enables staff on the units to be autonomous as the whole care team will be clear on where the patient is on the pathway and when to move forward. This eliminates delays in patient care as staff no longer need approvals to move forward at each step. The barriers to discharge subgroup implemented expectations for a Support Coach. A Support Coach is someone close to the patient (e.g., family member, friend, neighbor) who the patient can count on for assistance during recovery, both in the hospital and after discharge. Additionally, a pilot began in October 2019 to have a Care Manager and Physical Therapist see patients during their History and Physical (H&P) assessment to provide expectations for going home, rehabilitation exercises, and to prepare patients and their Support Coaches for SNF decisions, if needed.
The hope is that patients seen preoperatively will have an increase in patient days at home, post-procedure. During the team’s work on each subgroup, leadership became more involved in the process. In order to truly implement and sustain well, leadership determined they would need to engage and own the work. A team consisting of CVC and unit leadership, called ACTIVATE (Advancing Care, Treatment Efficiency, Innovation, Value and Teamwork for Cardiac Episodes) was formed. The CVC ACTIVATE team is multidisciplinary and focuses on innovation, quality improvement, and communication to achieve the best possible outcomes for patients.
ACTIVATE and CDI worked closely to implement countermeasures and analyze data. ACTIVATE has continued to track data and has seen improvement in LOS, SNF utilization, and readmissions for CABG procedures. For calendar year 2018, the median LOS, SNF utilization, and 30-day readmissions were 6 days, 18.6%, and 11.8%, respectively.
Currently, the median LOS is 5 days with 5.7% SNF utilization and 2.0% 30-day readmissions. ACTIVATE and each member of the multidisciplinary team were key components of the success of this program. Utilizing lean techniques, such as Gembas, value stream mapping, and swimlanes, were pivotal in its success. We are now working closely with ACTIVATE to sustain and spread these efforts.