| Are you wondering what your physicians can do to facilitate cost reduction? Mary Washington Hospital used a single physician to demonstrate the impact of a practice change on patient care AND cost position for DRG 148: Major Small and Large Bowel Procedure >17 with Complications. |
| The Challenge |
 | FROM 2000 BENCHMARK:
DRG 148 was cited among the DRGs with the most savings potential for the organization.
- Total Excess: $239 K
- Excess per Case: $1,811
- Excess Days per Case: .8
- Clinical cost per Day: $9,192
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Getting on Board |
| One physician looked at the data and claimed that there was no way anyone could provide quality care at $1,800 per case less (the HMC target) and in that short a time period. So, he turned to the HMC Knowledge Web and asked around. He discovered practices and plans of care that cost less and were better for the patient in the long term. |
New, Innovative Practices Replace Traditional Beliefs |
| Clarifying the process:
- Is current Pathway meeting our needs?
- Is the Pathway user friendly?
- Where is the Pathway being initiated?
- How is the Pathway being utilized?
- Used as MD order set (95% in past 6 months)
- Not currently used for variance tracking
- Not generally used as a guide nursing relies on for tracking landmarks, plan of care, or LOS
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| Understand the process:
- Audited retroactive cases among MD’s for best practice opportunities
- D/C on liquid diet at times, with follow up in office
- NGT removal dates (POD 1-2, POD 5-6)
- Pain management practice (Epidural/PCA/Oral/Times of switching)
- Abt. usage variances (types/frequency)
- OR cost variation in staplers
- Research Articles: (Education Research)
- Best Pain Management with Bowel Motility
- Protocols for Decreasing LOS after Colon Surgery
- When to Start Clear Liquids
- When to D/C NGT
- MWH lead a conference call July 17, 2001 through HMC with 7 participating hospitals
- Questions sent out prior to call
- Pain management preferences/duration
- D/C criteria
- NGT removal times
- Patient education
- F/U call on OR specific issues
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| Select specific processes to improve:
- Pharmacy: Reduce pharmacy costs by a minimum of 10%
- LOS: Reduce Dr. Daniel's elective patient LOS a total of 3 days
- Improve OR variation costs in staplers by 15%
- Formulate and sustain patient education, beginning in the Dr's Office, intensifying education in PAT, through the home recovery phase
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| Do the plan:
- Pharmacy: Best cost efficient drug combination (Abts/PCA/Epidural/ anti-emetics) without affecting quality of care (per Dr. Daniel)
- LOS Cost Driver:
- Brochure for PAT
- Pre-op colon cleansing
- Ostomy education
- VS, NGT, TCDB, IS, SCD's, Foley, Ambulation
- Pain management information
- Dietary expectations
- Home/after care instructions
- Living Will information
- Pre-op Video (To be shown in PAT)
- To include visual component of bowel education
- OR: The Surgeon group agreed to a 6 month trial to use Ethicon internal staplers (August, 2001). They had been using US Surgical, a non-contract stapler.
- Pilot of Dr. Daniel's patients: 15 cases over 90 day trial period
- PAT orders and pre-op colon education (brochure and video)
- NGT removed post-op day 1
- Clear liquid on day of BS
- Advance to food on day of flatus
- Epidural out early (post-op day 2-3) and switch to PCA
- Best cost efficient combination Abts/PCA/Epidural/ anti emetics without affecting
- quality of care
- 100% interdisciplinary education by 9/30 on study expectations
- Performance Improvement MD order set for Dr. Daniel's patients
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Cost Position Shows Marked Improvement |
| "I think that everyone on the team did a lot of work towards making things happen for DRG 148. I simply remained open minded to change...I think there are a lot of other DRGs that need looking into and hope DRG 148 may set the example for those workgroups to succeed." James Daniel, MD
Mary Washington Hospital |
| GOAL: Pharmacy cost reductions in Dr. Daniel's patients of 10% ($180/case)
- Examples: Flagyl -> Cefotax; Cipro -> Gentamycin; Unasyn -> Clindamycin
- Costs reduced $358/case (20%) from Sept '01 to June '02.
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| GOAL: LOS decrease of 3 days for Dr. Daniel's patients
- Dr. Daniel has gone from a 11.3 day LOS to a 7.6 day LOS from Sept 01 – June 02 (3.7 day decrease)
- The overall DRG 148 LOS has gone from an 11 day LOS in 3rd Q '01 to a 9.2 day LOS for 2nd Q '02 (1.8 day decrease)
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| GOAL: OR cost decrease of 15% ($317/case)
- The Surgeon group agreed to a 6 month trial to use Ethicon internal staplers which is a part of our VHA contract (a $318/case savings)
- The OR has improved costs by $665/case or 31.5%
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| FUTURE GOALS:
- Continued communication among Physicians, PAT, SDS, OR, and floors (all disciplines) regarding improvements needed on orders or pathway usage
- Monitor patient evaluations and consider input for changes to care provided
- Monitor outcomes sheets watching for patterns that may need changes
- Continue to educate staff in all areas about DRG 148 forms, education, and practices
FROM 2001 BENCHMARK:
- **Off Top 10 DRG List**
- Total Excess: $80 K ($158 K less)
- Excess per Case: $594 ($1,215 less)
- Excess Days: .22 (.64 fewer days)
- Clinical cost per Day: $8,825 ($367 less)
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