Again, welcome to the Beth Israel Deaconess Family! Agenda - - PDF document

10/29/2018 1

Department of Anesthesia, Critical Care and Pain Medicine

AJH Orientation

October 22, 2018

Patient Engagement, Systems Science, and the Elimination of Preventable Harm

Again, welcome to the Beth Israel Deaconess Family!

Agenda

• Introductions
• Department Overview
• Faculty Development
• Quality, Safety, Innovation, and Information Technology
• Compliance
• Billing and Coding
• Key Contacts
• CME/PDA
• What’s coming and Questions

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Our Mission

• Improve the quality of our patients’ lives by

providing compassionate, state-of-the-art care.

• Advance the field of perioperative medicine by

– Generating new knowledge – Educating the next generation of leaders in anesthesia – Driving expansion, improvement, innovation, and integration across the system of perioperative care delivery.

• Support personal and professional development

and fulfillment for Department members.

Beth Israel Deaconess: Today

Our System Today

A premier, $2+ billion academic health system including

• BIDMC and 3 community member

hospitals

• 1,500 member faculty practice

through Harvard Medical Faculty Physicians

• 6 additional affiliated hospitals
• 2,600 physicians in BIDCO
• Affiliated Physician Group
• Strategic partnerships with Atrius,

Joslin & Hebrew SeniorLife

Why BID + Lahey Health

• Our missions are aligned
• We share the same values
• We complement one another
• We will secure and strengthen our legacies
• We can be transformative together

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Metric / Statistic

NewCo

Operating Revenue $2,263 M $2,091 M $254 M $449 M $156M $5,213 M Hospitals 4 6 1 1 1 13 Beds 1,035 960 118 192 140 2,445 Physician Network Adult PCPs 519 336 N/A 85 44 984 Specialists 1,875 1,092 92 400 137 3,596 Total 2,394 1,428 92 485 181 4,580

Combined Scale: BID + Lahey + NEBH + MAH + AJH

Notes and Sources: BIDMC includes BIDMC, BID‐M, BID‐N, BID‐P, and APG; BIDMC 2017 budget; Lahey 2017 budget. NEBH 2017 budget; MAH 2017 budget; NEBH staffed bed count from 2016 CareGroup filing; MAH staffed bed count from 2016 CareGroup bond filing. MAH physician count from MACIPA website and physician directory. AJH physician count from AJH website – includes BIDCO numbers previously represented in the BIDMC/BIDCO column. NewCo+ revenue does not include HMFP

Our Department

• BIDMC

– 39 ORs – Numerous remote sites – 16 Labor and Delivery suites – 41 ICU beds

• BID Needham
• BID Milton- OR and ICU
• BID Plymouth- OR and ICU
• Anna Jaques - OR
• Ambulatory sites
• Pain- AWPC, Spine Center, BIDN, BIDM, Chestnut Hill,

Chelsea, Lexington

Department Structure

Chair Chair VC for Operative Anesthesia VC for Operative Anesthesia East Campus Director East Campus Director West Campus Director West Campus Director Chief Milton Chief Milton Chief Needham Chief Needham Chief Plymouth Chief Plymouth Chief AJH Chief AJH Divisions Divisions VC of Research VC of Research CARE CARE VC Education and Faculty Development VC Education and Faculty Development Residency Program Director Residency Program Director Fellowship Directors Fellowship Directors Medical Student Education Medical Student Education Internship Internship VC Perioperative Medicine VC Perioperative Medicine Director of PAT Director of PAT VC Quality Improvement and Innovation VC Quality Improvement and Innovation Director of Innovation Director of Innovation Director of Patient Safety Director of Patient Safety Director of Informatics/IT Director of Informatics/IT VC Faculty Development VC Faculty Development Chief Administrative Officer Chief Administrative Officer Executive VC Executive VC

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Department Staff

66% increase over 8 years

2010 2012 2014 2016 2018 Faculty 70 81 86 89 107 Research Faculty/Staff 21 23 17 24 37 CRNAs 10 15 21 37 38 Fellows 11 15 14 15 23 Residents 54 54 54 54 54 Interns 3 6 6 6 12 Nurse/PA/MA 15 17 17 24 32 Engineers/IT/Techs 18 19 19 28 29 Administrative 30 31 31 31 54 Totals 232 261 265 308 386

Faculty Development

Matthias Eikermann, MD Vice Chair, Faculty Affairs Professor of Anaesthesia

Faculty Affairs

Susan Kilbride Administrative Director Faculty Affairs Nora Mc Carthy Project Administrator Faculty Affairs and Recruitment Letisha Phillips Project Administrator Credentialing, Privileging and Enrollment Taneshia D. Pina Administrative Coordinator Faculty Affairs and Recruitment

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Grand rounds lectures

Opportunity Grand Round lecture series

• Target audience: Attending physicians, residents,

CRNA, research staff.

• Focus on anesthesia and perioperative medicine.
• Every Wednesday Morning 7-8 AM
• CME credit
• Streaming to BIDMC affiliated hospitals
• O

t iti t t/ t

Grand rounds agenda topics

Opportunity Grand Round lecture series

• Division specific aspects:

Cardiac, vascular, thoracic, vascular, obstetrics, pain, critical care.

• Important topics across Divisions:

Faculty development, research, QI, management, inter-professional relations.

Faculty affairs - Discussion

• Professional growth
• Mentorship
• Lecture series
• Case presentations
• Guidelines
• Clinical pathways

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Quality, Safety, Innovation and Information Technology

Quality, Safety and Innovation

World‐class standards & processes measurably enhance individual and organizational value

Satya Krishna Ramachandran, MD

Associate Professor of Anaesthesia, Harvard Medical School Vice-Chair for Quality, Safety, Innovation and Informatics Department of Anesthesia, Critical Care & Pain Medicine

skrama@bidmc.harvard.edu Structure How well does our system allow us to deliver high quality safe care? Ext/Int standards (e.g. TJC,CMS,DEA) Compliance Process How well do we perform the process of patient care? Procedural Non-procedural Outcome How well do our patients fare during

• r after our care?

Technical outcomes Functional outcomes

Outcomes that matter!

Define & Measure Quality

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Health Care Quality Dimensions

Seven Pillars of Quality

Donabedian 1990

Efficacy Effectiveness Efficiency Optimality Acceptability Legitimacy Equity Six Dimensions of Quality

Bengoa 2006

Effective Efficient Patient Centered Equitable Safe Timely Six Aims of Quality Management

IOM 2001

Effective Efficient Patient Centered Equitable Accessible Safe

Define & Measure Quality

Outcome

Structure Process

Individual Organization Outcome

What Outcomes?

Challenge for Quality Systems

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Objectives

Ambition: World-class standards & processes that measurably enhance individual and organizational value

• Describe the framework for implementing a network-wide

Quality, Safety and Innovation (QSI) program

• Discuss the critical steps involved in achieving this ambition

Organizational Excellence - I

1‐Year Objective: Framework for site‐level Q&S assessment is in place Critical Measures: 1. Priority Q&S outcomes (safety, efficiency and effectiveness) and relevant process measures are defined for each site 2. Site directors identify and discuss barriers for performance of high quality and safe care 3. The policies, guidelines and standard operating procedures are defined and accessible across all operating sites

Sample Workflow for Event Review

Review Closed & Secured

QA Concern

Confidential Discussion: Provider & Division Head QA Committee Discussion Senior Review Subcommittee

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Professional Standards

Organizational responsibility: 1. Defining measures of competence – FPPE/OPPE 2. Determining SOC/reasonable care standards for AE 3. Defining domains and concepts of excellence 4. Culture of respect – supporting individual quality journeys Individual responsibility: 1. Reporting AE and close calls 2. Participate in critical site and network training 3. Commit to respect, learning environments and organizational goals 4. Present AE to group at M&M/protected forums

Organizational Excellence - III

3‐Year Objective: Continuous learning environment framework in place Critical Measures: 1. Established process for Q&S assurance is functional 2. The individual and departmental all‐payer performance improvement (PI) dashboards are active 3. Performance improvement teams are active at sites 4. Integration of patient and family perspectives in CQI

Tracking Relevant Outcomes

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Project Communication Project Communication Organizational Excellence - V

5‐Year Objective: Dynamic benchmarking of Perioperative Q&S measures and processes across multiple hospital systems in the network Critical Measures:

• 1. Daily feedback delivered to the site chiefs on interactive dashboard

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Summary

Structure, Process, Outcome

• Renewed energy for aligning and enhanced focus on excellence
• Support for framework from BIDMC QSII
• Readiness for regulatory body visits

Learning environment

• Respect
• Use technology and innovative methodology
• Openness to change

5.A1. Define common and aspirational network structures, processes and outcomes 5.A2. Enable data structures for shared views 3.A.1. Allocate adequate resources development and maintenance: IT, manpower, leadership, time 3.A.2. Experiment with technology – mobile, industry partnership, enhanced data visualization 3.A.3. Q&S measures are embedded in regular Divisional Reports 3.A.4. Directors are accountable for monthly meetings with division staff where Q&S reports are disseminated, division level PI, Q&S assurance, and workplace safety 3.A.5. Pair faculty making presentations with peer champions from PSC and Safety Committees to enhance clinician learning experience 3.A.6. Partner with patient advocacy groups and other community resources on Safety and CQI committees 1.A.1. Collect division level feedback to define processes, measures and outcomes 1.A.2. Analyze and define the Electronic Tracking (DataMart) structure and sources for the data 1.A.3. Identify taskforce to align departmental measures and processes with BIDMC on job safety 1.A.4. Conduct and review “culture of safety” and “readiness‐for‐change” surveys and identify priority areas with division directors 1.A.5. Create divisional feedback system for front‐line reports of Q&S concerns 1.A.6. Establish Task force to define policies, SOPs, and guidelines pertaining to department, division, operating site, regulatory and professional bodies 1.A.7. Review and define SOP for reporting and follow‐up of adverse events occurring during or after clinical care 1.A.8. Review and define the SOP for regulatory body visit readiness 1.A.9. Use innovative technology solutions to enhance access and knowledge transfer of policies, guidelines & SOPs 1.A.10. Identify process owners who will establish the SOPs for ownership, maintenance and change in policies

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5.B.1. Perform resilience and culture surveys and demonstrate meaningful improvement 5.B.2. Establish a mature resilience training program for clinicians 5.B.3. Implement robust systems to enhance error reporting 5.B.4. Ensure at least one QI and Safety projects each are undertaken by every division to provide opportunities for faculty members to be part of meaningful change 3.B.1. Establish individual or group education/coaching tools 3.B.2. Commit appropriate departmental resources 1.B.1. Establish the workgroup that defines domains of excellence for the individual clinician 1.B.2. Benchmark high value domains within departmental pillars 1.B.3. The workgroup publishes measures of excellence, based on high‐value to outcomes of interest (patient, clinician, organization) and publishes the methodology 1.B.4. Define the prioritization of measures

Compliance

Policy for Anesthetic Care Compliance with:

• Governmental organizations

– CMS (Medicare & Medicaid) – FDA – OSHA – DPH

• Non-governmental Organizations

– The Joint Commission – USP – ACGME – Insurance companies

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Billing Compliance

Patient care Medical chart Coding (ICD-10 & CPT) Billing Denial & rebilling Office of the Inspector General (OIG)

• Ensure

compliance with all Federal rules and regulations

• 2016 Anesthesia

billing compliance became a focus

What’s covered?

Perioperative care Regional OB GI Not covered here

• Pain
• APS
• CPS
• ICU

Types of Billing

Personally perform - continuously and personally present throughout the entire procedure Medical direction – coverage of 2 to 4 simultaneous cases (teaching rule exception for only 2 locations) Medical supervision – cannot meet demands of Medical direction

• Each coverage is a modifier added to the

submitted bill

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Medical Direction – 7 requirements

• Performs a pre-anesthetic examination and evaluation;
• Prescribes the anesthesia plan;
• Personally participates in the most demanding procedures

in the anesthesia plan, including, if applicable, induction and emergence;

• Ensures that any procedures in the anesthesia plan that he
• r she does not perform are performed by a qualified

anesthetist;

• Monitors the course of the anesthesia administration at

frequent intervals;

• Remains physically present and available for immediate

diagnosis and treatment of emergencies;

• Provides indicated post-anesthesia care.

Medical Direction – 7 requirements Personally participates in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence

• Induction and Emergence should be defined in

policy Medical Direction – 7 requirements

Induction

– Occurs with GA and Regional anesthesia (e.g. spinal anesthesia, nerve block) – Does not occur as a discrete event with MAC / analgesia

Emergence

– Continuum of emergence from decision to PACU (GA only, ?MAC)

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Medical Direction – 7 requirements Monitors the course of the anesthesia administration at frequent intervals

• CMS makes no statement on the frequency,

but…

– Should be more often for higher acuity cases – Should be more often for sicker patients

Medical Direction – 7 requirements Remains physically present and available for immediate diagnosis and treatment of emergencies

• Physical proximity

– Allows the anesthesiologist to return – Reestablish direct contact with the patient – Meet medical needs, urgent, or emergent clinical problems

Breaks Short duration breaks are given for personal privileges and must be of brief duration Long duration breaks include relief for other reasons

– Provider being given the break is not available – Left the peri-anesthetic area

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Breaks When the documentation of a break is ‘EASY’ “Like” breaking “like”

– No problem!

Break during room turnover

– No problem!

Name of break person with times of break placed in the record Breaks Not defined by time but by availability The anesthesiologist who gives a Long duration break

– Is temporarily personally performing (for some time) – Identify and communicate to an available staff anesthesiologist to cover their directed locations – Group practice allows coverage by available staff

Backup Backup anesthesiologist will be

– Physically present and available for immediate diagnosis and treatment of emergencies, and – Responsible for the provision of anesthesia services

Name and coverage times must be in the chart

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The medical record

Things that can be done to ensure accurate and compliant medical records:

– When personally performing – ensure that the A- time and the D-time do not overlap with any other

• case. The D-time must be at least 1 minute earlier

than the A-time of the next case – If you receive a Long duration break, make sure the name of the clinician and time of coverage are recorded. – Self-breaks when the turnover is prolonged are fully compliant.

The medical record Things that can be done to ensure accurate and compliant medical records:

– When medically directing – ensure you are covering no more than four cases at once. Even

• ne minute overlap is a problem.

– If you provide a Long duration break, identify which anesthesiologist is your backup for your

• ther location(s).

– Provide breaks between cases, when appropriate.

Billing and Coding

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Anesthesia Financial Solutions

• Central Billing Office located in Needham, MA
• Full Revenue Cycle Management (Chart acquisition, coding, billing,

backend AR):

– Anesthesia – Pain – Critical Care

• Executive Director, (CPC Certified)

– January 8, 2018

• Management (4)

– (1) Coding Manager (CPC Certified) – (1)Revenue Cycle /Project Manager (CPC Certified) – (1) AR Manager – (1) Operations Manager (CPC Certified)

• Practice Management Billing Software

– CONNECT -10/1/18 (former PM software PPM)

Coding Department

• Coding Staff

– (1) Coding Manager – (7) Full time coders – (1) RCM Manager support – All Coding staff CPC certified- requirement*

• Ongoing Coder Training & Quality Assurance

Assessments

– Monthly QA per coder –scorecard + goals (QA & Productivity) – Monthly Lunch & Learn Code Specific training – Continual feedback

Accounts Receivable

• AR Staff

– 16 accounts receivable specialists

• Ongoing training

– Ongoing training & feedback – Scorecard & goals – Certified Professional Biller Certification (CPB) – New

• Via Lunch & Learn sessions
• Ongoing cross-training of staff

– Maximization of productivity

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Provider Education

• Onboarding Orientation
• Monthly staff meetings & performance feedback
• Quick Reference Tools
• Monthly Anesthesia Department Newsletter

– Current trends & industry news per coding & documentation

• Online MyPath Training (coming soon)
• Monthly utilization reports for E&M specific (New)

– Pain & ICU

• How can we best help Anna Jaques providers?

Key Contacts

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Compensation and Benefit Summary

Department of Anesthesia, Critical Care and Pain Medicine

APHMFP Compensation and Benefit Summary

October 11, 2018

Patient Engagement, Systems Science, and the Elimination of Preventable Harm

Compensation and Benefits

• Compensation
• Call Theory and Compensation
• Bonus
• Highlight of Benefits
• Scheduling and Anesthesia Record
• Questions

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APHMFP Physician Compensation Model

• Total Compensation:
• Base + Call Points + Bonus
• Base Structure

Rewards Tenure

• Year 1

$255,000

• Year 2

$265,000

• Year 3

$280,000

Physician Call/OT Pay Construct

• Call and OT are paid on a points basis
• 1 Point = $100
• Points are paid out quarterly
• MD OT

After 5pm and callback

Physician Call/OT Compensation

Call/OT Estimates Points (1 Point = $100) MD CRNA Per Day Per Day Daily Daily SUN‐THU 7.50 SUN‐THU FR 17.00 FR SA 30.00 SA HOL 7.50 HOL HOL Eve Weekday 17.00 HOL Eve Sun 30.00 Beeper Beeper M‐F 1.50 M‐F 1.25 SA 3.50 SA 2.50 Sun 3.50 Sun 2.50 HOL 3.50 HOL 2.50 OT (After 5pm) Per Hour OT (After Shift or 40 hours and call back) Per Hour M_F 1.50 Weekday 1.25 SA 1.50 SA 1.25 SU 1.50 SU 1.25 HOL 1.50 HOL 1.25 Post‐Call 2.00

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APHMFP CRNA Compensation Model

• Total Compensation:
• Base + Call Points + Bonus
• Base Structure

Rewards Tenure

• Year 0-2

$165,000

• Year 3-5

$175,000

• Year 5+

$180,000

CRNA Call/OT Pay Construct

• Call and OT are paid on a points basis
• 1 Point = $100
• Points are paid out quarterly
• CRNA OT

After Shift and/or 40 Hours/Week and callback

CRNA Call/OT Compensation

Call/OT Estimates Points (1 Point = $100) MD CRNA Per Day Per Day Daily Daily SUN‐THU 7.50 SUN‐THU FR 17.00 FR SA 30.00 SA HOL 7.50 HOL HOL Eve Weekday 17.00 HOL Eve Sun 30.00 Beeper Beeper M‐F 1.50 M‐F 1.25 SA 3.50 SA 2.50 Sun 3.50 Sun 2.50 HOL 3.50 HOL 2.50 OT (After 5pm) Per Hour OT (After Shift or 40 hours and call back) Per Hour M_F 1.50 Weekday 1.25 SA 1.50 SA 1.25 SU 1.50 SU 1.25 HOL 1.50 HOL 1.25 Post‐Call 2.00

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Physician Paid Time Off

PTO construct rewards tenure

Year 0-2: 5 weeks PTO and 1 Week Meeting/Conference Year 3: 6 Weeks PTO and 1 Week Meeting/Conference Year 5: 7 Weeks PTO and 1 Week Meeting/Conference

• Scheduled 1 year in advance
• 5 days maximum carryover otherwise cash-out at base pay
• Eligible to convert points up to 2 weeks of additional

vacation (points valued at 15 per day) and vice versa

• Paid Holidays Aligned with Individual Hospitals

CRNA Paid Time Off

PTO construct rewards tenure

Year 0-2: 5 weeks PTO and 1 Week Meeting/Conference Year 3+: 6 Weeks PTO and 1 Week Meeting/Conference

• Scheduled 1 year in advance
• 5 days maximum carryover otherwise cash-out at base pay
• Eligible to convert points up to 2 weeks of additional

vacation (points valued at 15 per day) and vice versa

• Paid Holidays Aligned with Individual Hospitals

Physician CME/PDA

• CME/PDA (pro-rated for partial year and FTE)
• Physician: $4500
• Department Paid: ASA, MSA, BIDCO dues
• CME/PDA Paid: Staff Dues, Initial and Reappointment

Fees, Fed DEA, MACS, Mass Medical

• Must use in current fiscal year (Oct 1-Sept 30)
• Paid out per HMFP Accountable Spending Plan

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Physician CME/PDA Summary

Physician Community Anesthesia ‐ CME/PDA $4,500 Dept Paid ASA $750 MSA $400 BIDCO Dues $1,100 Total Dept $2,250 CME/PDA Paid Staff Dues $$$ Initial Appt $$$ Reappointment $$$ Fed DEA $731 MACS $150 Mass Medical License $600 Total CME/PDA Varies

CRNA CME/PDA

CME/PDA (pro-rated for partial year and FTE)

• CRNA: $2500
• Department Paid: AANA Dues
• CME/PDA Paid: Staff Dues, Initial and Reappointment

Fees, NBCRNA, CRNA License

• Must use in current fiscal year (Oct 1-Sept 30)
• Paid out per HMFP Accountable Spending Plan

CRNA CME/PDA Summary

CRNA Community Anesthesia ‐ CME/PDA $2,500 Dept Paid Fed DEA ‐ MACS ‐ AANA Dues $645 Dept Paid Varies CME/PDA Staff Dues $$$ Initial Appt $$$ Reappointment $$$ NBCRNA $180 CRNA License $150 Total CME/PDA Varies

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Bonus

Guaranteed in Year 1 Metrics Based** in Year 2 and beyond ** Metrics TBD

Benefits Summary Scheduling and Anesthesia Record

Scheduling

• Existing scheduling practice will remain during transition
• Move to Qgenda post transition

Anesthesia Record

• Existing record maintained during transition
• Goal: Integrate record across Network

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Questions?

CME/PDE Process

CME/PDA

• Primary Contact: Trish Stevens

(pstevens@bidmc.harvard.edu)

• Community Intranet Features:

– Instructions and Accountable Spending Plan policies posted – Ability to check your balance – Relevant Forms posted

• Important Reminders:

– Deadline for submitting is 60 days from date expense is paid or last day of your trip – Finance team needs 7 days to process – Need to submit within 53 days to get paid

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Points, Scheduling, and Anesthesia Record

Points

– Document via Anesthesia Intranet

Scheduling

– Existing scheduling practice will remain during transition – Move to Qgenda in 2019 – exact date TBD

Anesthesia Record

– Existing record maintained during transition – Move to Shareable Forms in 2019 – exact date TBD

What’s Coming and Questions

What’s Coming

– Intranet Tutorial

Questions?