Ti Time Cr Critical al Diagn agnosi sis P s Plan anning State - - PowerPoint PPT Presentation

Ti Time Cr Critical al Diagn agnosi sis P s Plan anning

State of Missouri

May 17, 2019

Age genda

• Introductory Remarks
• Dr. Randall Williams, Director, Missouri Department of Health and Senior Services
• Review TCD History and Current State
• Dean Linneman, Director, Division of Regulation and Licensure, DHSS
• Methodologies and Innovative Strategies “Time is of the Essence”
• Dr. David Marcozzi, MD, MHS-CL, FACEP
• Review Missouri’s Forward Plan of Action
• Douglas Havron, RN, BSN, MS
• Question & Answer Session
• Closing Remarks
• Dean Linneman, Director, Division of Regulation and Licensure, DHSS

Introd

• ductor
• ry R

Remarks

• Dr. Randall W

l Williams, D Direc ector

• r

Missouri D i Dep epartment of

• f Hea

ealt lth a and S Sen enio ior S Ser ervic ices

Re Review TC TCD Hist story & & Current State

De Dean L Linne neman an, Di Director Di Division o

• f Regulation a

and L Licensure, DHS DHSS

Methodologies and Innovative Strategies “Ti Time i is of s of the Es Esse sence”

Dr

• Dr. Da

David M Marcozzi, M MD, MHS HS-CL, FA FACEP

Disclaimer

• The presenter has no financial relationships to disclose regarding time

critical illnesses, the State of Missouri, or the Maryland Hospital Association

• The views presented do not represent the Department of Defense of

the the University of Maryland

• A honorarium was received for this presentation from Harvon &

Associates, LLP

Agenda

• Who the heck is this guy
• What this is/is not
• How did you get here
• IMO
• Emergency care
• A suggestion

What this is

• A perspective from a provider, policy maker and administrator
• Honest thoughts to Missouri’s healthcare leaders
• Potential paths forward based on lessons learned

What this is not

• Cheerleading
• Filtered
• Easy solutions

TIME CRITICAL DIAGNOSIS SYSTEM OVERVIEW AND FACT SHEET

• Missourians expect timely and appropriate emergency medical

treatment when suffering from an injury, stroke or heart attack. Missouri has launched an exciting new initiative – the Time Critical Diagnosis System – to improve health outcomes for patients who suffer trauma, stroke or heart attacks known as ST-Elevation Myocardial Infarction, or STEMI.

Prehospital Healthcare is Healthcare The walls of a hospital are artificial boundaries

The ‘They Don’t Care’ Game

• About meetings
• About conference calls
• About emails
• About the organizational structure
• About silos
• About the state vs the locals vs the feds
• About why it was so hard
• About why it didn’t get done

This work is needed-right now

• Captain Obvious
• The optimal care for patients with time critical patients isn’t needed

tomorrow, it was needed yesterday and needs to be maintained

• With any crisis, there is opportunity
• Missouri is at a critical juncture
• Leadership is essential
• Cooperation is needed
• Openness catalyzes change
• Innovation is fundamental

"A Pessimist Sees The Difficulty In Every Opportunity; An Optimist Sees The Opportunity In Every Difficulty."

– Winston Churchill

25

Paymen ent T Taxonomy Framework

Payment Taxonomy Framework Category 1: Fee for Service— No Link to Quality Category 2: Fee for Service—Link to Quality Category 3: Alternative Payment Models Built on Fee- for-Service Architecture Category 4: Population-Based Payment Description Payments are based on volume

• f services and not

linked to quality or efficiency At least a portion of payments vary based on the quality or efficiency

• f health care delivery

Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment is not directly triggered by service delivery so volume is not linked to

• payment. Clinicians and
• rganizations are paid and

responsible for the care of a beneficiary for a long period (e.g. >1 yr) Medicare FFS

• Limited in

Medicare fee- for-service

• Majority of

Medicare payments now are linked to quality

• Hospital value-

based purchasing

• Physician Value-

Based Modifier

• Readmissions/Hosp

ital Acquired Condition Reduction Program

• Accountable care organizations
• Medical homes
• Bundled payments
• Comprehensive primary care

initiative

• Comprehensive ESRD
• Medicare-Medicaid Financial

Alignment Initiative Fee-For-Service Model

• Eligible Pioneer

accountable care

• rganizations in years 3-

5

26

Target p per ercentage o

• f M

f Med edicare F FFS p payments l linked t to q quality ty a and alter ternative p e payment m model els i in 2016 a and 2 2018

2016

All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4)

2018 50% 85% 30% 90%

Four MIPS Categories Make up Total Performance Score

Merit-Based Incentive Payment System. Electronic Health Records. Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians. 25% 25% 25% 15% 15% 15% 10% 15% 30% 50% 45% 30% 2019 2020 2021+

Quality Cost/Resource Use Clinical Practice Improvement Advancing Care Information

Relative Weight of Each MIPS Category Over Time

Category Description Relative Difficulty Quality

Clinicians must select 6 measures of the over 200+ available to report to CMS; score in this category not just awarded for reporting, but for high performance

Resource Use

Points awarded for cost savings; clinician scores based

• n Medicare claims, no

reporting required

Clinical Practice Improvement

New category that rewards clinicians for clinical practice improvement activities; over 90 activities to choose from

Advancing Care Information

Tracks clinicians EHR2 use

• ffering partial credit, can

report as individual or group Score based on peer performance benchmarks Score based on Eligible Clinicians’3 own performance

28

Systems of Healthcare Delivery

Trauma Stroke Mental Health Pediatric Cardiac

Emergency Care System

Washington, D.C., 1966.

30

31

Inefficiency= Sub-Optimal Care

• Prolonged ED boarding =  mortality by 5%
• When >6h delay, 5% increased mortality (Chalfin DB, et al. Crit Care Med 2007;35:1477-83.)
• Delayed transfer of floor patients =  mortality by 9%
• When >6h delay, hosp 9% mortality incr & 3% hourly incr (Churpek MM, et al. J Hosp Med 2016; Jun 28.)
• Delayed transfer of PACU boarders =  mortality (OR 5.32)
• When ≥6h delay, ICU mortality increase, with OR 5.32 (Bing-Hua YU. Am J Surg 2014; 208:268-74.)
• Patients recovered in OR put “CODE 1” patients at risk
• O’Leary DP, et al. Int J Surg 2014; 12:1333-6.
• Delayed transfer of outside hospital patients with time-sensitive

tertiary care and trauma needs at risk

• Faine BA, et al. Crit Care Med 2015; 43:2589-96.

32

Ann Emerg Med. 2014 May;63(5):572-9. doi: 10.1016/j.annemergmed.2013.11.018. Epub 2013 Dec 22.

“We are better, but we aren’t ready.”

David Marcozzi, MD, MHS-CL, Testimony to the Blue Ribbon Panel Meeting on the State, Local, Tribal, and Territorial Ability to Respond to Large Scale Biological Events: Challenges and Solutions, Wednesday, January 17, 2018

39

Time is muscle-Door to Balloon time

• ED physician activates
• Single-call activation system
• Response team is available

within 20–30 minutes

• Prompt data feedback
• Senior management

commitment

• Team based approach
• Paramedics perform pre-

hospital tests

• The Imperative
• The U.S. service members the nation sends into harm’s

way and every American should have the best possible chance for survival and functional recovery after injury.

• The Urgency
• Military burden: ~6,850 service member deaths in Iraq and
• Afghanistan. Nearly 1,000 from potentially survivable

injuries.

• Civilian burden: 147,790 U.S. trauma deaths in 2014 - as

many as 30,000 may have been preventable with optimal trauma care.

• Threats from active shooter and other mass casualty

incidents.

• As wars end and service members leave the military, the

knowledge, experience and advances in trauma care gained over past decade are being lost.

43

• The Opportunity

– Existence of a military trauma system built on a learning system framework that has achieved unprecedented survival rates for casualties. – Organized civilian trauma system that is well positioned to assimilate recent wartime trauma lessons learned and serve as a repository and incubator for innovation during the interwar period.

Traumatic injury accounts for nearly half of all deaths for Americans under 46 years of age and cost the nation $670B in 2013.

Contex ext

Donald Berwick (Chair), Institute for Healthcare Improvement Ellen Embrey, Stratitia, Inc., and 2c4 Technologies, Inc. Sara F. Goldkind, Goldkind Consulting, LLC Adil Haider, Brigham and Women’s Hospital, and Harvard University COL (Ret) John Bradley Holcomb, University of Texas Health Science Center Brent C. James, Intermountain Healthcare Jorie Klein, Parkland Health & Hospital System Douglas F. Kupas, Geisinger Health System Cato Laurencin, University of Connecticut Ellen MacKenzie, Johns Hopkins University School of Hygiene and Public Health David Marcozzi, University of Maryland School of Medicine

• C. Joseph McCannon, The Billions Institute

Norman McSwain, JR., (until July 2015), Tulane Department of Surgery John Parrish, Consortia for Improving Medicine with Innovation and Technology (CIMIT); Harvard Medical School Rita Redberg, University of California, San Francisco Uwe E. Reinhardt, (until August 2015), Princeton University James Robinson, Denver Health EMS-Paramedic Division Thomas Scalea, R. Adams Cowley Shock Trauma Center, University of Maryland

• C. William Schwab, University of Pennsylvania

Philip C. Spinella, Washington University in St. Louis School of Medicine 44

Commit ittee on

• n Milit

litary T ry Trauma C Care’s L Learnin ing H Healt lth System a and I Its Transla latio ion t to

• the C

Civilia ilian Se Sect ctor

• Preventable deaths after injury: Those casualties whose lives could have been

saved by appropriate and timely medical care, irrespective of tactical, logistical, or environmental issues.

• Focused empiricism: An approach to process improvement under circumstances

in which: (1) high-quality data are not available to inform clinical practice changes, (2) there is extreme urgency to improve outcomes because of high morbidity and mortality rates, and (3) data collection is possible. A key principle of focused empiricism is using the best data available in combination with experience to develop clinical practice guidelines that, through an iterative process, continue to be refined until high-quality data can be generated to further inform clinical practice and standards of care.

• Expert trauma care workforce: Each interdisciplinary trauma team at all Roles of

care includes an expert for every discipline represented. These expert-level providers oversee the care provided by their team members, all of whom must be minimally proficient in trauma care (i.e., appropriately credentialed with current experience caring for trauma patients).

45

Definitions

“Military and civilian trauma care will be optimized together, or not at all.”

46

A national strategy and joint military–civilian approach for improving trauma care is lacking. A unified effort is needed to ensure the delivery of optimal trauma care to save the lives of Americans injured within the United States and on the battlefield. A national learning trauma care system would ensure continuous improvement of trauma care best practices in military and civilian sectors.

The V Vision: A A National Trauma Care S System

47

The Aim (Rec 1) The Role of Leadership

– National-Level Leadership (Rec 2) – Military Leadership (Rec 3) – Civilian Sector Leadership (Rec 4)

An Integrated Military–Civilian Framework for Learning to Advance Trauma Care

– Improving the Collection and Use of Data (Rec 5) – A Collaborative Research Infrastructure in a Supportive Regulatory Environment (Recs 7 and 8) – Systems and Incentives for Improving Transparency and Trauma Care Quality (Recs 9 and 10) – Developing Expertise (Recs 6 and 11)

Findings a and R Recommendations

Without an aim, there is no system (Deming). Recommendation 1: The White House should set a national aim of achieving zero preventable deaths after injury and minimizing trauma-related disability.

• The 75th Ranger Regiment demonstrated that achieving zero preventable

deaths is an achievable goal when leadership takes ownership of trauma care and data is used for continuous reflection and improvement.

48

Th The A Aim

Key Finding: – The absence of any higher authority to encourage coordination, collaboration, standardization, and alignment in trauma care across and within the military and civilian sectors has resulted in variations in practice, suboptimal outcomes for injured patients, and a lack of national attention and funding directed at trauma care.

Recommendation 2: The White House should lead the integration

• f military and civilian trauma care to establish a national trauma

care system. This initiative would include assigning a locus of accountability and responsibility that would ensure the development of common best practices, data standards, research, and workflow across the continuum of trauma care.

49

Full list of actions detailed in bullets that follow the recommendation

Nati tion

• nal-Level L

Leadership

Key Findings:

• Responsibility, authority, and accountability for battlefield care are diffused

across central and service-specific medical leadership, as well as line leadership.

• There is no overarching authority responsible for ensuring medical readiness to

deliver combat casualty care.

50

Recommendation 3: The Secretary of Defense should ensure combatant commanders and the Defense Health Agency (DHA) Director are responsible and held accountable for the integrity and quality of the execution of the trauma care system in support of the aim of zero preventable deaths after injury and minimizing disability.

• The Secretary of Defense also should ensure the DHA Director has the responsibility and

authority and is held accountable for defining the capabilities necessary to meet the requirements specified by the combatant commanders with regard to expert combat casualty care personnel and system support infrastructure.

• The Secretary of Defense should hold the Secretaries of the military departments accountable

for fully supporting DHA in that mission.

• The Secretary of Defense should direct the DHA Director to expand and stabilize long-term

support for the Joint Trauma System so its functionality can be improved and utilized across all combatant commands, giving actors in the system access to timely evidence, data, educational

• pportunities, research, and performance improvement activities.

Full list of actions detailed in bullets that follow the recommendation

Milit itary Lea Leadership ip

Key Findings:

• Authority and accountability for civilian trauma care capabilities are

fragmented and vary from location to location, resulting in a patchwork of systems for trauma care in which mortality varies twofold between the best and worst trauma centers in the nation.

• There is no federal civilian health lead for trauma care (including

prehospital, in-hospital, and post-acute care), despite past recommendations that such a lead agency be established.

51

Recommendation 4: The Secretary of HHS should designate and fully support a locus of responsibility and authority within HHS for leading a sustained effort to achieve the national aim of zero preventable deaths after injury and minimizing disability. This leadership role should include coordination with governmental (federal, state, and local), academic, and private-sector partners and should address care from the point of injury to rehabilitation and post-acute care.

Full list of actions detailed in bullets that follow the recommendation

Civilia ilian Sect ector Lea Leadership ip

Recommendation 5: The Secretary of HHS and the Secretary of Defense, together with their governmental, private, and academic partners, should work jointly to ensure that military and civilian trauma systems collect and share common data spanning the entire continuum of care. Within that integrated data network, measures related to prevention, mortality, disability, mental health, patient experience, and other intermediate and final clinical and cost outcomes should be made readily accessible and useful to all relevant providers and agencies.

Specifically:

• Congress and the White House should hold DoD and the VA accountable for

enabling the linking of patient data stored in their respective systems.

52

Key Findings:

– The collection and integration of trauma data across the care continuum is incomplete in both the military and civilian sectors. – Data are fragmented across existing trauma registries and other data systems, and data sharing within and across the military and civilian sectors is impeded by political, operational, technical, regulatory, and security-related barriers.

Full list of actions detailed in bullets that follow the recommendation

Improving t the C Collection a and U Use of D Data

Recommendation 7: To strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient

• utcomes, the White House should issue an executive order mandating

the establishment of a National Trauma Research Action Plan requiring a resourced, coordinated, joint approach to trauma care research across DoD, HHS (NIH, AHRQ, CDC, FDA, PCORI), DOT, the VA, and others (academic institutions, professional societies, foundations).

53

Full list of actions detailed in bullets that follow the recommendation

Key Findings:

• Despite its significant societal burden, civilian investment in trauma

research is not commensurate with the importance of injury.

• Sustainment of DoD’s trauma research program is threatened by funding

reductions though previously identified gaps in combat casualty care capabilities remain less than 50 percent resolved.

A Colla llaborative M Milit ilitary ry–Civilian R Research Infrastruct cture

Key Findings: – The ambiguity between quality improvement and research slows and even impedes quality improvement and research activities. – FDA and DoD requirements for informed consent impede needed trauma research.

Recommendation 8: To accelerate progress toward the aim of zero preventable deaths after injury and minimizing disability, regulatory agencies should revise research regulations and reduce misinterpretation

• f regulations through policy statements (guidance).

Points of consideration:

• Amend the FDA’s authority so as to allow the FDA to develop criteria for waiver
• r modification of the requirement of informed consent for minimal-risk research.
• For nonexempt human subjects research that falls under HHS or FDA human

subjects protections, DoD should consider eliminating the need to also apply 10 U.S.C. 980 to the research.

• Distinction between QI and research needs to support pragmatic learning

methods that align with a learning health system (e.g., focused empiricism).

54

Full list of actions detailed in bullets that follow the recommendation

A Supportive R Regulatory En Envi vironment

Recommendation 9: All military and civilian trauma systems should participate in a structured trauma quality improvement process.

• ACS should expand TQIP to encompass measures from point-of-

injury/prehospital care through long-term outcomes, for its adult as well as pediatric programs.

• CMMI should pilot, fund, and evaluate regional, system-level models of trauma

care delivery.

55

Key Findings: – In both the military and civilian sectors, performance transparency at the provider and system levels is lacking. – No process exists for benchmarking trauma system performance across the entire continuum of care within and between the military and civilian sectors. – Military participation in national trauma quality improvement collaboratives is minimal; only a single military hospital participates in an ACS TQIP.

Full list of actions detailed in bullets that follow the recommendation

Systems a and Ince centives f for Improvi ving Transpar arency

Key Findings:

• The greatest opportunity to save lives after injury is in the prehospital setting.
• Prehospital care is not currently linked to health care delivery reform efforts.
• Variable standards of care, a paucity of universal protocols and current reimbursement

practices for civilian EMS (i.e., pay-for-transport) are major impediments to the seamless integration of prehospital care into the trauma care continuum.

Recommendation 10: Congress, in consultation with HHS, should identify, evaluate, and implement mechanisms that ensure the inclusion of prehospital care (e.g., emergency medical services) as a seamless component of health care delivery rather than merely a transport mechanism.

Possible mechanisms that might be considered include:

• Amendment of the Social Security Act such that emergency medical services is

identified as a provider type enabling establishment of conditions of participation.

• Modification of CMS’s ambulance fee schedule to better link the quality of prehospital

care to reimbursement and health care delivery reform efforts.

• Establishing responsibility, authority, and resources within HHS to ensure that

prehospital care is an integral component of health care delivery, not merely a provider

• f patient transport.

56

Full list of actions detailed in bullets that follow the recommendation

Systems a and Ince centives f for Improvi ving Trauma C Care Quality

Key Findings:

• The military’s teleconsultation programs in theater are jeopardized by a lack of

funding and institutionalization.

• While best practices in telemedicine exist within the United States (e.g., Project

ECHO), this tool is not used to its full potential in military or civilian trauma care.

• More formal methods for military-civilian collaboration could better translate military

best practices and its agile approach into civilian guideline development processes.

57

Recommendation 6: To support the development, continuous refinement, and dissemination of best practices, the designated leaders

• f the recommended national trauma care system should establish

processes for real-time access to patient-level data from across the continuum of care and just-in-time access to high-quality knowledge for trauma care teams and those who support them.

Full list of actions detailed in bullets that follow the recommendation

De Develop

• ping E

g Expertise: Timely Dissemination o

• f K

Knowledge

Key Findings:

• Policy and operational barriers—variable trauma workload, beneficiary care

responsibilities, and the lack of defined trauma care career paths—impede the military’s ability to recruit, train, and retain an expert trauma care workforce.

• Reliance on just-in-time (e.g., trauma courses, short-duration predeployment training

programs) and on-the-job training does not provide the experience necessary to ensure an expert trauma care workforce.

• DoD lacks validated, standardized trauma training and skill sustainment programs.

58

Recommendation 11: To ensure readiness and to save lives through the delivery

• f optimal combat casualty care, the Secretary of Defense should direct the

development of career paths for trauma care. Furthermore, the Secretary of Defense should direct the Military Health System to pursue the development of integrated, permanent joint civilian and military trauma system training platforms to create and sustain an expert trauma workforce.

Specifically:

• Assign military trauma teams to civilian trauma centers and ensure the verification of

a subset of MTFs as Level I, II, or III trauma centers.

• Hold DHA accountable for standardizing the curricula, skill sets, and competencies

for military physicians, nurses, and allied health professionals.

Full list of actions detailed in bullets that follow the recommendation

De Develop

• ping E

g Expertise: En Ensuring an Ex Expert W Workforce ce

5 9

Is Change Needed?

Don’t manage to a budget. Instead, set the vision

Kotter's approach to change management

• Step 1: Urgency Creation
• Step 2: Build a Team
• Step 3: Create a Vision
• Step 4: Communication of Vision
• Step 5: Removing Obstacles
• Step 6: Execute
• Step 7: Let the Change Mature
• Step 8: Integrate the Change

Time to Be Bob

A Learning Health System

• Have leaders who are committed to a culture of continuous learning

and improvement

• Systematically gather and apply evidence in real-time to guide care
• Employ IT methods to share new evidence with clinicians to improve

decision-making

• Promote the inclusion of patients as vital members of the learning

team

• Capture and analyze data and care experiences to improve care
• Continually assess outcomes refine processes and training to create a

feedback cycle for learning and improvement

9 Key Tasks

• Oversight/Leadership
• System engineering foundation
• Population Health approach
• Integrated and seamless IT platform
• Data collection, analysis, sharing,

transparency

• Economic valuation
• Continual performance improvement
• Measure development
• Structure
• Process
• Outcome

$

• “Show me your budget and I’ll tell you your priorities”
• VP Joe Biden
• Maryland Trauma Physician Services Fund
• The Maryland Trauma Physician Services Fund provides payments to offset

the costs of uncompensated and undercompensated medical care provided by trauma physicians to patients at Maryland's designated trauma centers; stipends to trauma centers to offset the trauma centers' on-call and standby expenses; and grant funding to trauma centers for certain equipment.

• The Fund is financed by a $5 surcharge on motor vehicle registrations.

Homeland Security Presidenti tial D Directi tive 21 HSPD-21

• Within 180 days after the date of this directive, the Secretary of Health and

Human Services, in coordination with the Secretaries of Transportation and Homeland Security, shall establish within the Department of Health and Human Services an Office for Emergency Medical Care.

• Under the direction of the Secretary, such Office shall lead an enterprise to

promote and fund research in emergency medicine and trauma health care; promote regional partnerships and more effective emergency medical systems in order to enhance appropriate triage, distribution, and care of routine community patients; promote local, regional, and State emergency medical systems’ preparedness for and response to public health events.

• The Office shall address the full spectrum of issues that have an impact on

care in hospital emergency departments, including the entire continuum of patient care from pre-hospital to disposition from emergency or trauma care.

The Missouri Emergency Care Learning Health System

Strategically Proactive and Rapidly Reactive-Saving Lives When Moments Matter

Review M Missou souri’s Forward P Plan of Action

• n

Douglas H Havr vron

• n, R

RN, B BSN, M MS

Primary Planning Team

Douglas Havron, RN, BSN, MS Lynn Colson, Project Manager

Proj

• jec

ect P Plan

• Evaluate and Make Recommendations
• Identification of Stakeholders & Data Sources
• Gathering TCD Information
• Data Component Recommendations
• Funding Structures
• Missouri TCD Initial Report
• Missouri TCD Workgroup Meetings
• In-person Meeting 1
• In-person Meeting 2
• Summary Report (In-Person)

Evaluate and M Make Recommendations

• Identification of Stakeholders & Data Sources
• Gathering TCD Information
• Data Component Recommendations

Funding S Structures

Missouri ri TCD Initial Report rt

Missouri TCD D Workgroup M Meetings

• In-person Meeting 1
• In-person Meeting 2

Final Report (In-Per erson

• n)

Project Task

• Est. Delivery Date
• 1. Evaluate and Make Recommendations
• Identification of Stakeholders & Data Sources

Q3 2019

• Gathering TCD Information

Q4 2019

• Data Component Recommendations

Q2 2020

• 2. Funding Structures

Q1 2020

• 3. TCD Report

Q2 2020

• 4. TCD Workgroup Meetings
• In-person Meeting 1

Q2 2019

• In-person Meeting 2

Q4 2019

• 5. Summary Report (In-person)

Q2 2020

Questions? s?

Cl Clos

• sing R

Remarks

De Dean L Linne neman an, Di Director Di Division o

• f Regulation a

and L Licensure, DHS DHSS

Th Than ank y k you

• u!