Using Data to Drive Dramatic Improvement in Houston

1. Using Data to Drive Dramatic Improvement in Houston A Special Innovation Project Funded by the Centers for Medicare & Medicaid Services Facilitated by TMF Health Quality Institute Julie Nguyen, Program Manager

2. Community Data • Medicare paid $5.2 billion on care furnished in an estimated 412 LTCHs nationwide. • About 118,300 Medicare beneficiaries had almost 134,700 LTCH stays.

3. Community Data • LTCH discharges are concentrated in a relatively small number of diagnosis groups. • Top 25 LTCH diagnoses made up 62 percent of all LTCH discharges • 9/25 diagnoses were respiratory, representing 33 percent of LTCH patients

4. Community Data • Medicare admissions -> acute care hospital ICUs fell 14 percent, while the number of Medicare ICU patients discharged to LTCHs almost tripled. • For Medicare ICU patients receiving mechanical ventilation: • Only 16 percent of patients discharged alive were discharged to LTCHs • 46 percent were discharged to SNFs or IRFs

5. Community Data

6. Community Data • Medicare pays more for patients using LTCHs than for similar patients in other settings. • The payment differences were not statistically significant when LTCH care was targeted to the most severely ill patients. • About 13 percent of LTCH cases were of minor or moderate severity, as measured by all patient refined DRGs. Lower severity cases tend to be concentrated in some LTCHs.

7. Community Data • Medicare LTCH beneficiaries are disproportionately under age 65, over age 85, disabled, and diagnosed with end-stage renal disease. • They are also more likely to be African American.

12. Admissions per 1000 Benes overall bar chart comparing National, Texas and Houston

13. Readmissions per 1,000 Benes Overall bar chart comparing National, Texas and Houston

14. Community Data bar chart showing Medicare beneficiaries, long-term care hospital beds and payments in Houston, Dallas and outside of Houston and Dallas

20. Patient A

21. Patient B

22. Questions to Consider • Are acute care hospitals discharging patients to LTCHs so that services paid under the acute care hospital PPS are not included? • If so, Medicare pays twice for the same service — once to the acute care hospital and once to the LTCH. • Are early discharges from acute care hospitals distorting the acute inpatient PPS relative weights by reducing the costs of caring for certain types of cases in acute care hospitals that routinely discharge to LTCHs?

23. Community Root Cause Analysis Data Analysis and Fishbone Diagram

24. Fishbone Diagram

25. Fishbone Diagram Problem: Achieve Higher Bowling Scores Problem: Achieve Higher Bowling Scores

26. Fishbone Diagram showing the bowling process inputs beginning with People People Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Problem: Achieve Higher Bowling Scores Bowling Process Inputs

27. Fishbone Diagram People Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Problem: Achieve Higher Bowling Scores Bowling Process Inputs Ball Cleaner — Machines

28. Fishbone Diagram People Methods Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Curve or straight ball — Use wrist band? — Length of arm swing — Amount of ball lift — Use of alley arrows — # of steps on approach — Amount of practice — Use rag to wipe off ball— Problem: Achieve Higher Bowling Scores Bowling Process Inputs Ball Cleaner — Machines

29. Fishbone Diagram People Methods Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Curve or straight ball — Use wrist band? — Length of arm swing — Amount of ball lift — Use of alley arrows — # of steps on approach — Amount of practice — Use rag to wipe off ball— Problem: Achieve Higher Bowling Scores Bowling Process Inputs Type of wrist band — Ball material — Shoes used — Ball weight — Lane oil — Rag clean — Ball Cleaner — Machines Materials

30. Fishbone Diagram People Methods Measurement Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Curve or straight ball — Use wrist band? — Length of arm swing — Amount of ball lift — Use of alley arrows — # of steps on approach — Amount of practice — Use rag to wipe off ball— Scorekeeper — - Manual or auto Problem: Achieve Higher Bowling Scores Bowling Process Inputs Type of wrist band — Ball material — Shoes used — Ball weight — Lane oil — Rag clean — Ball Cleaner — Machines Materials

31. Fishbone Diagram People Methods Measurement Attitude — Alcohol intake — How many on team? — -Pace Everyone show up? — Curve or straight ball — Use wrist band? — Length of arm swing — Amount of ball lift — Use of alley arrows — # of steps on approach — Amount of practice — Use rag to wipe off ball— Scorekeeper — - Manual or auto Problem: Achieve Higher Bowling Scores Bowling Process Inputs Type of wrist band — Ball material — Shoes used — Ball weight — Lane oil — Rag clean — Temperature — Noise from other bowlers — Time of year — Humidity — Ball Cleaner — Machines Materials Environment

32. Community Root Cause Analysis Breakout Sessions

33. Fishbone Diagram Team A Problem: Geographic Variation of Data Community/ Culture Provider Patient Problem: Geographic Variation of Data Inputs Communication/Coordination Comfort Measures Policy/Payment

34. Fishbone Diagram Team B Community/ Culture Provider Patient Problem: Geographic Variation of Data Inputs Communication/Coordination Comfort Measures Policy/Payment

35. Fishbone Diagram Team C Community/ Culture Provider Patient Problem: Geographic Variation of Data Inputs Communication/Coordination Comfort Measures Policy/Payment

36. Fishbone Diagram – What are the causes of the geographic variation in the data? Community/ Culture Provider Patient Problem: Geographic Variation in the Data Inputs Communication/Coordination Comfort Measures Policy/Payment

37. Ground Rules • Be respectful • Silence your cell phones • Let others speak • Be open

38. Breakout Session • Brainstorm Strengths and Weaknesses for each category for your team (30 min) • Multi-Vote to reach consensus on the top 5 strengths and weaknesses (15 min) • TMF staff will facilitate each team and act as time keepers • Identify a team member to report back to the group