 Welcome everyone, we had a fascinating discussion today, but before we get to that, I'm going to turn it over for the Executive Director's Report to Susan Barrett, before I do that. I do want to recognize a number of the audiences. It's always great to have a member from the General Assembly and attendance, so one of the newest members, Lucy Rogers, is here. Welcome. Come more often. So that's Susan. Great. So I just have one announcement and it's an agenda change. We had planned to have a healthcare workforce presentation this afternoon starting at 2.50. We are taking that item up the agenda, where we've already rescheduled it to January 30th, and so that will be posted on our website. That's it. And I see no minutes to approve. There are. Okay. So the minutes of Wednesday, January 9th is our motion. It's been moved and seconded to approve the minutes of Wednesday, January 9th. Without any additions, deletions, or corrections. Any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Okay. So with that, I'm going to turn it over to Board Member Dr. Jessica Holmes, who has really been the driving force behind the discussion today. And it's one that I think is going to be a fascinating one, so Jessica. Great. Thank you. So before I introduce some of our panelists today, I just want to get a little background into where this came about while I decided to have this. Obviously, everybody knows that we're sort of entering this great new world of healthcare payment delivery reform, and this is a world we're moving away from cost-plus volume-based fee-for-service reimbursement towards value-based reimbursement. Our all-pair model is already moving us in that direction, where delivering high-quality cost-effective care is effectively going to be acquainted around. So we need to learn all we can about ways to reduce waste, improve efficiencies, and ultimately improve health outcomes for the laundry. And Gundersen Health Systems in Wisconsin has taken some really impressive steps towards in this direction in the past few years. Some of you may have seen, there was a Wall Street Journal article in August 2018 that basically highlighted some of the intriguing process that Gundersen went through to really identify ways to improve efficiencies in their orthopedic practice and actually improve health outcomes. They took on an 18-month review with an efficiency expert that followed all the doctors and nurses and looked at all the resources that were used to do a knee replacement and a very, very detailed cost-accounting exercise. And then the article that describes how the list price for a knee replacement was about $50,000, and the actual cost amounted to about $10,000 once they really analyzed the true cost of it. And through efficiency gains identified about 20% more savings that could be achieved and help outcomes for their patients. So it was a fascinating article. I gave one of our speakers today a phone call, had a wonderful conversation with Rachel about this process. Rachel Albrecht is on the phone and is going to give a presentation to share with us some of the warnings that they had in this process. She's the administrative director of orthopedics, podiatry, and outpatient therapies units at Gundersen. But I recognize in this conversation that some of the things that I've heard from Rachel, I had been hearing from other providers in the state realizing that our entire state is going through innovative changes to how we deliver payment, how we deliver health care. And so we've also invited Drs. Macy and Arrows, I think Dr. Macy will hopefully be here soon, to talk about what they're doing at Coplick and at Mansfield Orthopedics, which is known throughout the state at the Center of Excellence Orthopedics. So we want to learn from what they're doing, the innovative reforms that they are doing as well. And then Dr. Steven Lefler and I have had several conversations in the context of the all-care model and had wonderful conversations about some of the innovative reforms that are happening at the health network around delivery reform, how do we improve outcomes for patients and reduce inefficiencies. And so some of the things that Gundersen was doing with respect to orthopedics is being done at UVM Health Network in areas of cardiac units. So lots of learning, lots of exciting things to learn about today. And so that's the point of this session and I'm very excited about it. And I'm very, very thankful that all of you took time out of your days to come here, especially those of you who are saving people's lives by the minute. So very, very appreciative. And Dr. Mel Boynton was very interested in being on this panel as well. I had a wonderful phone call with him learning about some of the work that's being done and brought along these lines. He is probably right now doing a new replacement. So he was going to try and call in after that was over. We didn't want to interrupt any of that. So yeah, we didn't want to do that. So if he could, he was going to try and call in. So there might be some point where he jumps on the line. I don't know. So with that, I think I'm going to turn it over to Rachel. If that's okay, can you hear me, Rachel? Yes, I can hear you. Thank you. Okay, so why don't we turn it over to you, maybe you can start us off and tell us about all the learnings that you guys had and what you did there. Absolutely. Well, thank you for having me. This is exciting work. I'm excited to share the learnings we've had thus far. But I also want to say that we are nowhere close to the end of our journey and we are excited to learn from others that have had other successes as we are to share our own successes. So I'm here to share some learnings from our journey. I hope it's valuable to you. But I'm also very interested in hearing your feedback. You've also been pursuing to enhance the value to our patients and to our communities from a healthcare perspective. A little bit about me. I've been with Sundersend about 12 years. My background is entirely in business. I have no clinical background at all. Sundersend has a Diane leadership model where each department has both an administrative director and a medical director or department chair so that we are co-leading together. We are a physician-led organization. Our CEO is a physician. And at every level of leadership, we have businesses engaged in those leadership roles. So while I am at this core level for the administrative side, everything we've done is in our partnership with our provider group. So I just need to make sure to say that. Right now I have spent two years with our orthopedic dietary and therapies department. I have previously left our Heart Institute and also our vision services department ophthalmology and optometry. So a little bit about me but if I can get now into... How am I supposed to be working? There's a little bit about Sundersend Health System. So we are literally right down the Mississippi River. You can see the picture on the bottom right below. You'll see the Mississippi River is less than a mile from our main campus in La Crosse County. As a system we see over a million clinics of this a year have about a quarter of a million unique patients. Our tertiary care center in La Crosse County and our main hospital has 325 beds. We have five personal access hospitals, affiliate partners. We have affiliate pharmacies, emergency transportation services, skilled nursing facilities. We serve over 21 counties in three states. So we serve patients from Wisconsin, Minnesota and Iowa. Primarily with close to 20,000 surgeries a year in our 6th hospital location. So that's just a bit about us in the system. We are a level 2 trauma center. We are a teaching hospital. We have over 30 regional medical and specialty clinics also connected to our system. We do, something important to note that I get a lot of questions on when I talk about our system is that we do have an employee position and provider model. So for the most, once we have a handful of contracted providers, for the most part all of our positions and associate staff are employed. Which definitely sometimes changes your approach to how you move this kind of work forward. So why do we exist? We rely heavily on our strategic plan and our mission, vision and purpose to drive our work. And a little over a year ago in 2017, we transitioned our strategic plan to mirror the Institute for Healthcare Improvement's triple aim. To focus on population health. We've read some of things to better align with our culture. But to improve the health of our communities really does our population health work. So operating outstanding experience of care is our patient satisfaction, patient experience and quality work. And use the financial burden of health care, which is the cost of care capital work you hear from us. Some of us may have heard of the quadruple aim. We have incorporated that through the center of our strategic plan. We talk about every life we touch. That includes our providers, our staff, our patients, their families and our community. So you can see that the middle of our strategic plan is also in our vision that we will enhance the health and wellbeing of our communities while enriching every life we touch, including patients, families and staff. And so when you come to Gunnerston, for the most part you ask someone what our purpose is, our purpose is to enrich every site. So orthopedics has been on the journey. And I have been to the department of close figures now, but this journey started many years ago and before my time. And I am carrying on this journey. But the department was very engaged in wanting to talk about value to our patients. How do we continue to enhance our quality and our safety and enhance the patient experience but reduce costs? Because our primary goal always is quality and safety for our patients. And supporting our providers and our staff to deliver high quality and safe patient care. But we knew we had to start working on the value side of the equation. And why did we have to start doing that? I think you heard from Susan in the beginning that the differences in the reimbursement environment, we are looking at having a significant portion of our patients migrating to a capacitated model of care. So we, like many across the healthcare industry, have our feet into canoes. We still have close to 70% volume based reimbursement in our fee for service patients. But we are moving to evaluate the system with some capacitated contracts. We are participating in several of the BPCIA Medicare bundles. And so we find ourselves with the challenge as many do across the country in tackling this and knowing that we have our feet into canoes. But our philosophy here at Gunderson is that we will treat patients the same regardless of payer. And actually I don't want my providers to know what insurance the patient has when they're making treatment decisions. I want them to always make the best decisions for the patients in the care they need. So our philosophy is that we need to drive quality safety but also value for all of our patients. And so we do not take different approaches by care and I think that's very important. And I think that's one of the reasons why it's been so easy for my provider groups to get engaged in this as they know that it is primarily about the patients and about our patients. And I think that's a very important part of the conversation. So our approach has been that we knew if we wanted to embark on this journey we needed solid data. We didn't need averages or estimates or looking at RBU valuing. We wanted real data. And to get real data we needed to focus on time driven activity-based costing. We needed to help our provider see really truly what is the cost of what we're doing. Because all day long you can look at averages and estimates and bake numbers but that isn't really what's meaningful to drive and change for us. And so we embarked on a journey of one to two year journey of engaging our quality and improvement folks practice organization to come in and for providers step by step through their processes. And the initial focus was totally and totally replacement primary. And so we looked at two factors. We looked at quality and we looked at cost. And we looked at cost from a couple different angles. We looked at it from a time and resource perspective from a people perspective. And we looked at it from a supply cost perspective. So this time driven activity-based costing is a very time and resource intensive process. But it took the detail and the trust in the level of detail in the process for us to really get all of our providers on board to drive this change. On the left-hand side of this slide is some different kind of process math. So we spent a lot of time mapping out processes, looking for deviation in processes and deciding what deviation and variation of process we would continue to support and what deviation we would look at standardizing. So there was a lot of time spent, a lot of provider time spent coming to this table talking about the deviation and talking about where they were willing to come together and standardize. And I'll talk about that a little bit more approach to that. We spent a lot of getting real cost for things. Looking at the real purchase price of supplies, looking at the real cost of our staff did a lot of time stamp methodology and who is in the OR wheeled in who is still in the OR wheels out, what are they paid per hour and so what is the cost of that case from our personnel perspective. So we did a lot of that really real costing to compute the total cost and that's what we used as our driver. There are barriers certainly to holding this up. Very costly, very resource intensive and you're looking at a very micro level versus a macro level and there are pros and cons certainly to that. It's hard to roll things out on a large scale when you're looking at it in such a detail and there are system limitations to having the support to do that. I think though that despite all of those challenges the biggest challenge is the culture shift. So when I talk about this I always look at people and ask how comfortable would you be if your boss followed you around all day and looked over your shoulder and timed you and everything you said. Most people don't feel like that's something that they want to do or would feel comfortable doing this but we really did. We had people follow staff and time everything they did and that's how the culture shift is trust. That we're not pursuing this from a judgment perspective we're pursuing this so that we can improve care for our patients and improve the resources we have for our staff to deliver and provide to deliver that care. But the biggest challenge and barrier is culture. Having folks being willing to engage in the process to trust in the process and to know that it's not about judgment. And I think laying the groundwork for that and making sure that everyone is on board from that perspective is probably the most important part of being successful in this work. So this is an improvement system we call our GEM model and on the left side you'll see the leading change and the right side you'll see the managing change. And I always tell my managers when we're leading change the first two points you'll see on the left side are the most critical. They're creating the shared need and the shaping the vision. I call the creating the shared need is the why. Why do we even care about this? Why should our providers care? Why should our staff care? We all need to be on board and understand the why so that we can get past that this isn't about judgment this is about improvement. And so I recently presented with a colleague at the Institute for Healthcare Improvement on a similar topic and we handed out copies of this. Because I carry this around with me every day to talk through with my managers and my staff what it means to lead change, to manage change, to drive change. And I think this has been a valuable tool for our organization. So some examples of process maps. They can be very simple here. It's just being straightforward and simple and you can see in yellow the timestamps for each of these areas. And when we looked at total hips and total knees there were many, many process maps. There was the prior to pre-op process there was the intra-op process the hospital stay, the post-op so many different processes that we had to tackle when we were looking at improvement in this area. And here's another example with many storm clouds so you can see each of those clouds would really potentially be a product and it had to tackle. We had the right piece at the table. We had a strong Y and F strong need for change when we had folks engaged in understanding that this wasn't about improvement. So needed to know what our goals were and where we were going. So we started looking for benchmark and metrics to gauge our success. We are currently participating with two different collaborative cohorts to look at benchmarking our success and are we making the progress we should be making and do we have the right goals and views. And so we are keeping the Y firmly in view and each time we meet to talk about this we start the why. Why are we here? Why does this feel important to us and why is it important to our patients and our community? We follow the PDSA or PDCA cycle and I think that helps to bring people to the table because when we launch an improvement project or launch a change it is not set in stone and we try to let folks know that this is a constant evaluation cycle of change. We plan to study or check and act and then we look again and say did we get the outcomes we thought we would get from that change and do we need to revisit it. And so it's a constant cycle of evaluating these changes, what's working, what's not. Something that might be working from the staff perspective isn't working from the surgeons perspective and so we need all voices at the table to reevaluate what we're doing but always we start with the why. Why are we here? And so how did we get those folks to the table? We had a couple avenues to do this. We started a monthly multi-disciplinary orthopedic leadership team meeting. It was over the noon hour so that folks could try to get away for lunch and we tried to have representatives from every point of care about orthopedic patient with touch in our system. Surgeons, Associate Staff, Anesthesia, Hospitalist, PCOT, staff from the floor, Social Work, staff from the OR, staff from PREOC to come to the table and the goal of that was to get everyone aligned with the why, to keep us aligned with the why but to be able to talk about deviation of practice and potential standardization opportunities. So we need every month and it's a live open discussion about where we still seem deviation and where can we still improve and those meetings are incredibly valuable and every time we meet new things come up and we tackle new objectives so in that meeting we keep a running list of all the projects and initiatives that we are working but really we assign the doers and it's their chance to take a lot of this work out to own it, to push it forward and go back to this big group on the progress. So it's been an incredibly valuable meeting where it's a safe place, it's an open place where we know we're all trying to tackle the same thing and we're on the same page and that has been incredibly valuable. The other meeting we have is quarterly all of the total joint surgeons we go up to dinner, we go off campus so that's our instructions take them to dinner, down through and all of the activities or practices, these basins or variations that come up in that monthly orthopedic leadership meeting we bring to this surgeon dinner and we give them a safe place to talk to their colleagues about these variations and deviations and to hash out where do we go from here. So we have a multidisciplinary team but we also have a quarterly surgeon meeting in that meeting they review how are we tracking on our average length of stay patients, our readmission our other key goals such as ET day of surgery one of our goals was to get all of our patients up and moving, day of surgery but there were some barriers to that that we felt were being driven by the pain management strategy that was used in TROP so our surgeons talked about different pain management strategies they could try so our patients are able to get up and do ET day of surgery So those surgeon dinners while it's a time commitment and if we take them off site we buy dinner pectoproof and pectons they've been incredibly valuable because they've been relationship builders but also they've talked about practice variation and a safe place to get everyone to agree to the standard of care So recently we got all of our seven surgeons that are doing total joints to agree on their anti-cohex management protocol co-stop which we've never had all of them on the same page from that perspective in the past So that will help our nurses on the floor know how to better educate our patients about their anti-cohex co-stop that will help our staff and the clinic to know how to talk to our patients about their medications co-stop when they're calling and making the co-stop co-calls to check on the patient there's an incredible value of getting those all of those surgeons are on the same page with their co-stop anti-cohex management strategies So just some examples of some outcomes of those meetings So here you see some of the some of the spectacular those quarterly surgeon dinners they are very engaged and I will say unless one is on vacation or wants on fall and we try to avoid those they do all show up they all come, they're all incredibly engaged usually we start meeting at 30 I don't know that there's ever been a time where we've left before eight years they all are usually at least three hours long we discuss practice variations we discuss any new literature or best practices any of them have identified and what we should think about rolling out in our organization The monthly leadership team meetings are the truly multidisciplinary meetings, there's usually at least 20 people in those meetings the focus is that it's a constant plan to study act for our change management and we open that meeting with this wife and again to align along our purpose, why are we here our purpose of these meetings is to make sure we are delivering quality and safe patient care and excellent service to our patients and their families that is our primary goal to support our staff and providers in doing that and to decrease the financial burden for our patients and so this meeting is to ensure alignment collaboration and engagement to achieve those things the focus all orthopedic related issues and topics we started with a focus on total needs, total hips ongoing work we are now taking on more intentionally primary shoulder placements and hip fractures because those are two of the VCCIA bundles we are participating in but really any ortho related issue or topic is a fair game for this meeting I think another important factor here in the success we've had is transparency and status at the certain dinner we put up all the resistance and all the accomplishments on the screen we put the patient information and we put the surgeons information and we talk about them very transparently all the surgeons have been open to that we also share surgeon level data at the ortho leadership team meeting again to say we're in the variation it's not at all most judgment from a place of how do we all get better together so I think that the culture around that is pretty significant when we talk about putting re-emission data complication data or comparing surgeon supply costs in the OR that those are that's significant for all the surgeons to get on board and say I'm comfortable with you sharing my data at that level we try to have very real time data so we have monthly uploads into the tool we're using to kind of crunch our own data but also compare to our peer group and we use a tool that gives us the ability to quickly dig into the details if we see outliers what do those mean but again I can't emphasize enough how important it is to consistently layer that this is about improvement and it's not about judgment and any most of the bones would come across when it starts to feel more like judgment than about it and so we're always trying to layer and remind ourselves that it is about it so we've had a lot of projects done that have come of this we have had supply costs for all of our organization projects several years ago even when this was more informal than a formal process all of our total joint surgeons agreed to a 6 to 1 vendor for all of their knee and hip it was a revision or a special case that they did to CPA so that was a significant impact to our supply costs getting all of our surgeons on the same page with their implant another example would be so our surgeons all decided to move away from using drains to move away from using CAD so that was another data innovation opportunity practice changes the AS-COA was a significant practice change PT data surgery that was a practice change we had to have our PT and OT groups at the table because some of our patients were going to the OR later they had to work with our PT and OT departments and they had to change their shifts to staff PT and OT later to have patients that were going to the floor later and so now we go back and forth between being at 80 to 90% PT data surgery and we track every single patient that wasn't able to do PT on data surgery and why we feel like they weren't able on going from a practice change perspective we have ongoing trials related to intratocaine management strategies using blocks and different things to try to maximize our patient's comfort from a certain perspective but also to what will allow them to get up and be successful in PT data surgery so we have ongoing trials on intratocaine management that are going on there surgeons are meeting with anesthesia as a partner from a process change perspective we've done a lot of work on our patient education process so we have gotten a lot of our information online we have created TTS we have a PhD OT to be a part of our total joint scan of our class and I think a lot of organizations are doing that but an innovation that came from our floor nurses was that they felt one of the most important factors and success of patients going home and being successful at home was that their care givers were educated on the care they would need when they got home and so our floor nurses started holding a caregiver class every morning at 8.45 they pull all of the caregivers together they let them know that they need them at 8.45 the next morning and they talk about medications they talk about incision care they talk about constipation what to do they talk about all of their questions so they cover five or six very key areas that really need those caregivers to be very clear on before they leave the hospital with their loved ones we are discharging the disparity of our patients I think we're up to close to 60% home on day one so day after surgery and that is a significant shift from where we were two years ago I say two years ago we were sending no one home day one almost and now we're sending almost 60% of our patients home day one so that's been a significant shift for us we have a lot of areas that are a work in process or progress we are working very hard on developing a plan to better engage our post acute care partner we are participating in several bundles and it's a 90 day all-in-suit bundle and post acute care the critical piece of the picture for our patients and the success of our patients post discharge so we are working on potential plan for partnership with our post acute care partner so those are just some examples of some of the projects and changes we have worked through this process of things so some of our results actually this data is a bit older you can see our things on the inpatient cost side much of that is those 106A we've been able to reduce our post acute care cost by encouraging patients to go home and not to go to nursing homes trying to get them optimized in the right resources prior to surgery so that they are successful in going home instead of to a post acute care facility you can see that we've reduced our length of space quite significantly and we're tracking it less than a two day length of space to be significantly now pretty regularly and consistently we are up to 80-90% each day of surgery before we were doing no PT day of surgery so that has been a shift and that has been one of the greatest drivers in our patients being able to go home day one and you can see that we've reduced our utilization of skilled nursing facilities quite significantly as well by trying to get ahead of education with our patients to set them up for success going home so we have had a lot of positive outcomes from this work from a cost perspective but we have had challenges and we do have a lot of plans to continue to work forward in this project but a lot of the most significant challenges are related to culture and culture takes time to shift and trust takes time to build so when you talk about shifting from a judgment model to an improvement model that takes time and so we are still on that journey I would say we are much better than where we were we are sharing data openly and apparently we're talking about it but we have the right people at the table but that is an ongoing journey resource management and allocation a lot of the work we've done has been very resource intensive we are an integrated health system there are a lot of big service lines looking for similar support so of course resource management and allocation is always a challenge in working through these these kinds of changes the changing landscape of healthcare I think is a challenge for all of us and we want to keep that firmly in view anything we do we talk about what is the potential impact for our patients and we try to keep that in view both from a care quality outcome perspective but from a financial perspective as well and spreading change and improvements across the system can be challenging we know that many start here at our main campus in La Crosse performing totally in here for placement we have several surgeons working out in our region performing these same surgeries at our critical access hospitals and even some at non gunders and hospitals so how do we spread the change to our critical access partners but also to our non gunders and partners that are also supporting us and delivering the same kind of care to our patients so that is an ongoing journey on how we keep everyone aligned I will go back and say we have tried some things that haven't worked and I think a lot of times when we talk about these things we talk a lot about what has worked but we don't always talk about what has worked and so I can share an example with you of something we tried that didn't work and that was asking the hospitalist to manage our knee patients so typically our orthopedic teams are attending and take on primary management of our total knee patients we did a trial of the hospitalist taking this on thinking that that may impact length of stay they could get to the hospital sooner we weren't waiting on the provider team to get out of the OR and get to the floor to rate the charge orders and we found that that change was counterproductive we were very busy the hospitalists already had a lot on their place and a lot on their cars and they were very willing to be partners with us in this but it did not positively impact length of stay or impact of quality and that we were able to deliver to our patients so we reversed that change so we have had learning that has tried and that didn't work and I think that's part of the trust and improvement culture we need to build is that if something isn't working it doesn't mean we can commit to it forever and it really is a PDSA planning to study that cycle of looking at the changes we've made so we are still solidly on this journey we are close to a maintenance phase right now but our total shifts and total needs are focusing right now on our processes around hip fractures and shoulder replacements but we found communities in other areas so I could share a couple of learnings that we've had that we're trying to spread to other areas our total joint surgeons brought literature forward that talked about value of using antibiotic cement and premium standard biotech cement is more expensive than plain cement or plain cement plus adding something like a bank powder and mixing in the OR so my total joint surgeons agreed they would trial moving from antibiotic cement to the plain cement with the bank powder in the OR that worked very well it saved about 60 some dollars a case or something like that extrapolated out based on our volume it was $40,000 to $50,000 savings a year and I asked for a report on who else in the OR was using antibiotic cement and learned that pediatry was which is also my scope of leadership and so I went to my pediatrics and shared the data with them and said would you consider moving to a different model of cement and they were fully onboard immediately when I put the cost and put the data in front of them and told them what the conversation was with the orthopedic total joint surgeon so we are still looking at how we roll up these changes more broadly across our organization and I think that that is a good thing we still want to maintain a level of autonomy for care providers we know that we are not a factory we know that we need to take care of our patients on pieces and allow surgeons and physicians and providers to have autonomy and discretion in their processes so my department chair right now is one of my shoulder surgeons was two surgeons here at Anderson that do total shoulders and his cost per case was higher than my other shoulder surgeon's cost per case so I brought the data to him and he talked about it from a supply cost perspective and he felt like the implant he was using he could defend why he was using it and so said okay can I move forward with renegotiating our contract on those implants see if we can get data from that perspective if you are not interested in standardizing our implant right now with the other surgeons so we took that approach we were allowing the differences for our shoulder surgeons but renegotiated our contract and had a significant amount of savings from that perspective purple tunnels we saw that one of our hand surgeons purple tunnels were costing about twice as much as the other so I sent my program manager to the OR and said I need you to go and see what's happening in the OR and I need you to take a notebook and write down what's going on and the learning in going to the OR and seeing what was happening one surgeon was using a blade it was about a $90 blade a specialized blade but it was only needing it 50% of the time he only needed it when he was doing a patient's right hand and he didn't need it when he was doing the left but the OR staff in an effort of course the surgeon and have everything ready when he needed it was opening it every time so there was a way to close to $100 on 50% of the cases because this blade wasn't utilized and so we went to the surgeon talked about the situation he was very okay with that being TRN on his preference part we did some education with the OR staff on what it meant to something with TRN and making sure we're not opening things unless we know we need them and so that it's close to $100 a case on 50% of this hand surgeon's cases my manager going to the OR seeing what was actually happening and talking to the staff and the surgeon to drive that change so those are just some other examples of changes we've driven in other areas that has been successful so that's a little bit about our journey again we're still possibly on this journey we still have a lot to learn and we still have a long way to go but I think the key to our success thus far has been the engagement of providers and staff at all levels the willingness to share and the willingness to come to the table from a place of improvement and not judgment and telling our why is that we all care about our patients and we all care about our community and we all care about driving value from that perspective so with that I will take any questions or comments and I am very excited to learn anything I can from you as well well thank you Rachel this is Jessica speaking thank you so much that was fascinating and interesting on so many levels I appreciate it and we all are sure appreciated hearing about the process the successes and even some of the failures I thought I would actually before we turn it over to the board and public questions I thought I would actually invite the panelists if you have questions to the extent this is a shared information session we said that you have questions for Rachel I bet we would learn from those questions as well so if you have any questions I would welcome you to ask them hi Rachel this is Dr. John Macy can you hear me yes I can that was a great presentation thank you very much so I am really encouraged with how you start with why that is hugely important and the cultural shift that you emphasize is key to this whole process so some specific questions that I have one is what electronic medical record system do you currently use and what do you use for data analytics because that is a make or break for all of us it is so we are on epic epic and so we are on epic both on in all of our criticalized hospitals except one I think is going live this month last month we are in epic in the hospital this month yes from a data analytics perspective we have tackled that a couple different ways gonderson participates in a Wisconsin state collaborative called about health and I am happy to send Christine and Susan the link that they can share about the goal of about health but about health is six organizations across the state of Wisconsin some names you might use in there Aurora, theta, pro health Valin, aspirus gonderson those are the six and the whole the entire goal of about health is to drive improvement in healthcare and state of Wisconsin so while we are technically competitors in some areas we don't approach that collaborative from a think of competition we approach it from a place of quality and value and so all six institutions upload their data on the areas that they have agreed to tackle either monthly or quarterly we talk about who is improving the fastest who has strong outcomes we share best practices and that has been an incredible process to share with other folks in the Midwest on what they are doing that has been helpful so one of the first about health collaborative tackled totally and so that is something that has been very valuable I am happy to send the link on more about about health and data analytics we are utilizing is a Harvard startup that came from the Institute for Health Improvement it is a project that started at IHI and was turned over to Harvard Business School and they started an organization called Avangard and I can send a link to them with their information as well Avangard started with building a platform to look at analytics related to orthopedics and neuroscience because two areas that has kind of the most in this initial mandatory and voluntary CMS bundle for orthopedic and neuro and so Gundersen was one of the initial partners of Avangard to help them build this tool and in Avangard I can look at any of my orthopedic procedures and see what my costs are and how I and what my outcomes are so and how I'm tracking on those things against our collaborative and that is a nationwide collaborative that is not a geographic specific it's not just the Midwest so many organizations across the country are participating in that then we we upload all of our data including epic timestamps and it's Avangard that came on site with us and did all of the process tracking and so far when wheels in and what are they all paid at our who's still in the hour wheels out and time stamping all these things and we update upload all of our supply costs Avangard too so they directly map our costs for each case based on the epic timestamps and the supply costs we're uploading so very real data so if we are not finding that we are in the top for Thailand specific area I can reach out to my Avangard contacts and say I'm really interested in what other organizations are doing related to length of stay because we are tracking at only the 20th percentile and they will hook me up on a conference call with those that are at the 90th percentile so that I can learn from them and so Avangard has been the tool we've chosen now there are many that they can use for that same thing but I would say that part of why we've been able to get our surgeons and providers on board with looking at Avangard data is because it was such an intensive process to get the data uploaded and get it validated on the front line Hi Rachel, my name is Brian Arrow someone of the orthopedic docs at Mansfield, thanks for your presentation I just have a question with the Avangard and the project you completed and have ongoing how did you finance the analytics and pay for the potential increased cost to look at this information? Right, that was not cheap I think at the time that would not be that pursued that but I think knowing that the reimbursement model in our industry will be changing significantly from a volume to value base we knew we needed to get our arms around this and orthopedics I think volunteers to be a starting place for that organization we knew that needs and hips if bundles came out it would likely be bundles and we knew we had a high enough volume of needs and hips that if we could get our arms around cost we could drive significant change so yes was there and is there an ongoing investment in that tool? Absolutely, have we seen the return of an investment over and over again? Yes, we have Hi Rachel, it's Steve Leffler and so I just wondered do you have a process for how you pick the next project you're going to do? Do you do some kind of analysis? Do you just have to notice that shoulders were expensive and your boss uses an expensive joint or is there a mechanism to use to make your decisions? I look at this from two perspectives when I'm looking at my data I look at high volume procedures and I look at high dollar procedures so you can have something that's a low volume but very high dollar and even if you only do it 20 times a year if you can save $3,000, 20 times a year that's significant my purple tunnel cost was anywhere from $100 to $300 the potential savings was $100 to $150 being small but when I'm doing hundreds of them a year that adds up so I started by looking at what are my high volume areas and what are my high dollar areas and where do I have engagement from my surgeons to look at these things and that's how I started but you're the one making the decision it doesn't go in front of a committee or something it's my department chair Dr. Steve Klein who is a shoulder surgeon and myself looking at the data and making the decisions on who we want to talk to now I say just because Dr. Klein and I identified as something maybe a very good thing to do we always put it in front of the providers and the surgeons to say are you willing to look at this and most of the time they are very infrequently have I heard no but we don't take it to them and say you have to look at this or you have to change we bring the data to them and many times there's an element of competition and so if there's a surgeon that has a much higher cost than another typically they're willing to come to the table and talk about that especially because again we're approaching it from a place of improvement and not judgment and so for the most part they know that if it comes down to while they're using a more substantive implant and they're not willing to concede on that right now that we likely will not wish the end to look up so I think it starts from a place of trust as well and that we all know that we're doing that to improve care and that I care for our patients so I I can't recall if I'm actually where I brought this forward to a provider surgeon for consideration and have just said no Rachel I'm a shoulder surgeon I did two shoulder replacements this morning before this meeting. What implant system does he use? I'm just kidding I'm just kidding Well he's in a case right now he was going to try to explain me here but he's in a case also so I actually don't think so on a more serious note one of the biggest problems we have in Vermont is we have two academic medical centers one at Dartmouth one in Burlington and we have several community hospitals around and trying to get everybody on the same page or even in the same canoe is extremely difficult it's worse than herding cats I know you're embarking on trying to move your project outwards into the community and how do you engage these the community physicians with your group or even the your non-Gundersen providers? Yeah that's a challenge and so in a lot of ways we're very lucky that all of the surgeons I'm working with right now are employed surgeons and even the surgeons that we have employed out in our regional locations are they're employed so when we have these regular quarterly dinners it's not just my surgeons here at main campus it's also my regional surgeons that come to the table and actually those regional surgeons don't even report my service line they report to a regional service line so I have even less control and Dr. Klein has less control but they've seen the value that the collaboration and the multidisciplinary approach has had and so they do make it a priority to come to these meetings and they do work very hard to bring forward literature, best practices and to implement change across the system and not just here at main campus now I will say the part I think of getting them engaged is we do take them off site we take them to a very nice dinner it's a three hour dinner and I think that helps and they look forward to that collegiality the respectful challenging of one another but it's a place they can safely talk about their practices not the judgment and they feel very supported in that so we haven't engaged any non-employed physicians or surgeons because frankly we don't have any, our biggest competitor here actually in town is Mayo Clinic so Mayo runs our competing local lacrosse hospital and Rochester, Minnesota is a little over an hour away but all of the orthopedic surgeons in our region for the most part are employed there by Mayo or another so to follow up on that how do you incentivize employed physicians do you, is there some part of their salary that is secondary to quality metrics or is there are there bonuses or I don't need specifics but I'm just wondering to get these people to the table and engage and incentivize them, right so I'm wondering so I, yeah great question and I will answer that with a story two years ago Avangard put on an annual conference and advised all of their co-workers to come together in Boston and it said two days list of what is everyone doing, what's working, what's not what are best practices it's incredibly valuable and two years ago I went to the first time and the very last section was about game sharing so we had a day and a half of theory exciting engaging, empowering invigorating conversation about value for our patients, outcomes for our patients all of the things that we get excited to talk about and the very last conference was around game sharing so if you're successful in the fund bill and you're getting the bonuses who gets that money or if the surgeons come together and agree to standardize their implants and you're saving $2,000 in implants how much of that savings goes to the surgeons and I can tell you my department chair at the time which is a different department chair than I have right now there was very very lively conversation about this and he raised his hand and he said I don't understand we will be even passing the savings along to our patients and to our community so there isn't an incentive except that our surgeons feel like this is the right thing to do because our patients are their neighbors and they live in these communities too and they want to see us reducing the cost of healthcare for our communities and not pass along financial burden to our patients and so our orthopedic surgeons are on a production model for their compensation but there has been no financial incentive for them to participate in this project does that answer your question? yes thank you alright so I think what I'll do is any questions from the board? I just have one question in terms of the three areas that you emphasized practice changes process changes and supply cost standardization do you have any rule of generalization you can make in terms of what proportion each of those contribute to the results that you're getting? well I think the practice change probably is the greatest contributor because that drives the process and the supply change if our surgeons are willing to change their processes then likely this won't be very successful in changing the process of supply cost so you know I think that probably is the biggest opportunity what's our process for deciding on an exchange vendor what's our process for post-op management or the practice of post-op management that the surgeons are willing to support because that impacts the process of our nurses our surgeons recently moved away from using warfarin and their post-op anti-coids that is a significant change in the process for our nurses who are having spent a lot of time managing I&R so the supply cost savings and process savings is driven by the certain degree of practice I hope that answers your question it does, thank you yeah I just said one I think this has been a great analysis and I love the conversation that we're having here because I had a lot of the same questions that John was asking about you know how do you incentivize people and you know what are the analytics and how do you support this from the staffing so I think it's going to be things that we'll be looking at but one of the questions I had for you when you talked about the gain sharing I was a little surprised that I would expect when you have these significant cost savings that a portion goes back to the patient but you would think a portion was going either to invest in new initiatives or to offset inflation costs or to offset other things because I do think you kind of need that way to incentivize everybody to participate and usually when you do a cost savings program there's a piece that you pass on to the consumer and there's a piece that gets shared throughout the organization to get everybody invested in participating so I was a little surprised that you're saying that wasn't necessarily going back that way but it's one to one at Godderson so because we saved X number of dollars in our total needs we haven't decreased the price of the total need necessarily by that X dollars any cost savings we have as an organization I'll say essentially get spread across the organization and allows us to have less fee increases over time as a system or even in some cases to decrease our fees across the system we have a strategy to one of our key drivers is reducing the cost of care for our community one of our goals is to keep our fees steady and in some cases reduce our fees it might not mean that that's the case for total needs specifically but for a system so savings and total needs may help us reduce the cost of a procedure in another area so I think that's important though that kind of work from a system perspective not from a procedure or departmental perspective so that may be a bit of a difference we have not done being sharing with providers we think that that when we entered into the PCIA you had to outline how you would distribute the incentives or what your contract was with your positions we said well we don't have one they're employed and there's no incentive to drive quality or value or cost reduction so I think my and I'm very proud to say that all of my surgeons are very very invested in the Y the Y of our organization is here for our community for our Christian and that's a key driver for them and that's a culture we're building here at Gunderson that we're doing these things to improve the health of our community and by the health of our community we mean the financial health also and that's part of our role we are one of the biggest employers in the La Crosse community so our staff are our patients and that drives a lot of the conversation thank you I think what we'll do is hold the public comment towards the end to keep moving through these presentations I think Dr. Aronson I'm thrilled that you're here I think I'd love to hear you know, Mansfield of the Pudigs and Cotwe are well known as a center of excellence for the Pudigs in the state so hearing some of the innovative things that you all are doing is helpful and also if you could share a little bit about obviously and you pointed to a little bit to this you're a critical access hospital you don't have the deep pockets that a Gunderson health systems has to do the sorts of data analytics I'm wondering a little bit if you could talk to speak to how might we learn from other hospitals or can it be applied to a critical access hospital what are the innovations that you are already doing we'd love to hear about so thank you one of the first things that we've done is trying to really make our OR more efficient and we started about a year and a year ago we formed a new committee called the torque committee the OR committee, it's real original but what it does is it gets surgeons it gets a perioperative director it gets CSP people it gets implant people at the table talking about all of these different problems and issues and trying to synthesize some standardization and trying to put some to make it more efficient particularly from a cost standpoint so we're really excited about the results that we've seen from some decreased costs, from improved efficiency, from higher use of our OR from being extremely busy it's a difficult problem to deal with so we are very strapped with the demand for our services it's huge and our ability to provide those services is limited and that's due to essentially our facilities and our ability to utilize our staff appropriately trying to manage that is a very difficult task given the demand if we didn't, if we had half the demand it would be a different story so that's been very beneficial for us and I think Brian is actually on that committee as the chairman of our surgery department things we've done to really improve our outcomes is really starts with patient education we do a tremendous amount of patient education setting their expectations early joint classes, as Rachel described, education at the bedside, nursing education, caregiver education is a big part of that some of them do go to joint classes, all the patients go, at least for knees and hips not for shoulders, it's a little more difficult and you have to have the numbers you can't do 50 joint replacements a year and expect to have a joint class once a week that's going to provide efficiency so you need to have a certain number of procedures to say you need 200, 300 knee replacements a year to be able to set up a joint class that's actually make some sense that you can get 10, 12, 20 people going to from a financial standpoint we use home health and VNA services less our patients are getting more educated in the hospital preoperatively during their stay and immediately afterwards and our services our use of those services are less so that's one place we've saved money, we're sending patients less to inpatient rehab that has saved a lot of money, post-acute inpatient care is hugely responsive if you look at these bundled payments and the whole cost of a service implants is a huge portion of it post-acute care is a huge portion of it hospital services is another big portion the surgeon's fee by the way is only about 8% so you know it's just just a little I think there are several less things that we've been working on we're very fortunate that we do have a small community hospital with an incredibly talented staff and a culture that makes it work it drives it, our culture all the way from our CEO down through our COO down through our surgeons to our staff level people is awesome we had people in the other day some financial people looking at the OR looking at how things were working and the comment at the end by the business guy was this was an amazing visit for many reasons but the number one reason was everybody here is smiling the employees and the patients obviously were too so that really drives home the point I think as Rachel said it's all about the culture it's about determining the why and then sticking to that I think those are some of the specific things and we have lots of other things planned but we have some constraints that we'd love to talk about so good afternoon Brian Eros and one of the ortho partners at Mansfield so I echo what John has said in addition the TORC committee which is the OR committee of COPLI actually came about and one of the important things I think it has total buy-in from our administration and I think that's why it works and so we sit around providers and discuss exactly what John's talking about utilization, costs where are we now, where do we think we should go, where do we need to go and I think that's important since I joined Mansfield in 2011 I've been employed there since and since 2011 I can just say and I don't have a slide with specific numbers our length of stay has decreased now where I can be pretty confident and say that it is definitely greater than 60% of our patients go home by post-up day one our partial knee replacements near 98% of them go home the same day and so some of what has allowed that to occur is a quarterly group meeting that's multidisciplinary set up initially and headed by one of our partners currently unfortunately unable to be here, Brian Huber would sit down with our nursing staff health therapist, OT actually nursing staff to discuss the care processes that we would need to go through in order to make that that length of stay shortened and so these have been ongoing discussions that have started way back in 2011 as far as meeting quarterly with our group including the PAs that are part of the team and I think that has been and we're now seeing this now, I've been there eight years over the past two to three years really reducing. John's comment on SNF care, I actually in the last six months probably can count less on one hand the number of times a patient of mine gets discharged to an inpatient acute facility after leaving their hospital and the information that we have gotten from some of the SCIT measures as far as the readmission rate is lower than what the national averages would be so not only do I feel we are moving forward with regular meetings and discussions with the team members but I think I do feel and we can definitely report back with numbers that our length of stay has reduced. Our readmission rate is less than national average and I think as we move forward with the committee that we have in place teaming with our administrative staff I just see very good positive outcomes for us down the road and trying to nail down where these costs are and looking at trying to hopefully reduce the overall costs for our arthroplasty care, hip knees and then shoulders at Copley. I will say I did learn as far as the presentation by Gundersen we do have a joint replacement class and we are fortunate enough that we do have enough volume that we can hold this and I know that John and I have brainstormed but just looking at ways of utilizing online resources I think the caregiver class is a wonderful idea at something that we don't specifically have at Copley it's more joint with the patient but we have caregivers that are visiting our patients when they're there all week and that's actually an interesting idea so I guess what I'm getting at is these conversations where we learn from another system I'll be able to take this back and actually talk with our nurses because there are ways during the week when our patients are there although it's a short period of time that morning after there could be a quick meeting that all the caregivers get together and disseminate some of that same information I can actually just see that being more efficient so each nurse instead of going through it with each patient and their caregiver they get it in one session and so I think just looking at as we move forward having a forum where hopefully we could get together with other programs to share ideas I speak with colleagues across the country and mainly I end with one comment most of them are doing arthroplasty what is the single most thing that you've done in the last six months that's given you the most bang for your buck and it could be something simple to how they express their gratification how one hospital system decided to hang a magnet next to the handicap plates where anyone from the birthing center could park here so you could park in the front row for the next three weeks and so I think that's helpful and what that's just getting at is I think ongoing communication even across state lines to look at what other healthcare systems are doing hopefully we can develop a model future we'll enable to foster that cost savings reduction and ultimately improve quality thank you I'd like to just talk about one example that really improves the patient experience that nine out of ten patients on that first post-operative visit talk about Karen our perioperative director started this thank you for choosing Copley card it's a blank card that starts in the clinic and is signed by everybody that sees that patient it comes to registration in the hospital it goes to the pre-op area it goes to the OR and it goes to the PACU and every nurse every staff member anybody that signs these things and then it's mailed to the patient they get about three or four days after their surgery they open it up it's personalized by about ten to fifteen to sometimes twenty different people all the best whatever glad you're all the best on your recovery it personalizes it so much we've done this now for I don't know six months or so maybe more and the number of patients that comment on it is incredible the other thing I do is I call my patients two days after surgery every single patient not every patient but most of my patients I learned this from Doug Campbell one of my mentors in the hospital practice a call from a surgeon a couple of days afterwards is incredible for patients they love it oh my god you're calling me I've never had a doctor call me at home before why not and I call them on my phone without my number blocked right if there's a problem I want to hear about it I want them to call me we live in a small enough state as Rachel was saying these people are our neighbors hanging on my door I do home visits I've taken people to surgery it's a great place that we live in and I think we need to appreciate that this day is about your patients I wonder I don't know Dr. Lefler or Rachel do you have any questions for the folks from Hopley thought I'd open that up in case you do Rachel I appreciate it wrote down some of the things you're doing about the heart sensitivity and the surgeon calling the patients I learn things with every system I talk to and learn things that we can talk about doing here you know I think we're all trying to tackle the same thing I think learning from each other is incredible so I just appreciate the opportunity to be here I don't know if I have any questions I think we're all challenged with the same things heard from you about layering education do you think that's important we don't have classes for all our patients our children are patients like yours don't go through a class because of volume we only think of 80 to 180 years so have similar challenges but anything I can learn from anyone I will take back to my group as an opportunity so just really appreciate this opportunity to hear what you are doing as well and I will take those and learn from you I guess I would just throw out there how do we, this has been one more thing, continue these conversations I wonder actually if there is a role in the boss or how do we start to have these conversations even internally in Vermont for learning and I think boss is already doing that but how do we do more I guess I will just throw that out there but any questions alright so I think Christina needed a minute just to change some of the PowerPoint right that is Rachel Rachel you are on now in a big skull screen so I know there is going to be I don't know if you are muted now we just had a big U it's a movie screen we are just moving to the PowerPoint presentation are you going to be able to stay on the line that's okay with you of course we definitely want you to stay on the line great helpful alright thank you so I am going to change the focus a little bit we are going to talk a little bit about emergency medicine I am going to ER doc by training so this is a project we worked on and I will say that we are working on a joint project right now working on the same issues where do people get discharged to how do you standardize the process how do you make sure people get PT on the floor all the things that we are hearing are the things that are on our plate so that was very helpful I want to just mention that we are doing this am I driving this is that going to work now alright yay so from a UVM health network perspective I just wanted to outline what is the imperative and so clearly in a fee for service model that pays for volume incentivizes doing more cases and so if you can drive down your cost of care so you can reduce your cost you may be able to drive more cases but the all payer model really is a value based system and it allows for investments to keep the population healthier so when the question came where could money come from to do this I would argue pretty strongly that when you are under capitation or a fixed payment perspective there is dollars in the system to drive process improvement and change and just to repeat that the all payer model margin is not generated by volume not by doing more cases but it really comes from quality on the right patients at the UVM health network we have a network quality council it meets every other month on the committee we have clinical leaders chairs we have quality directors we have chief medical officers chief nursing officers project improvement leaders across the network and we have a tool right now called peak it's a tool from Kauffman hall that really lets us see the cost that we do across the network at all of our sites and it mixes with clinical data so we can combine them together and the network quality council is very focused on care variation and cost data so you look at that every month on a dashboard to help us make decisions about what we are going to look at so how do we choose projects so there is really four different areas that we focus on the first one is utilization it may be that one area is doing a lot more particular diagnosis one of the ERs maybe or is using more of a certain antibiotic for certain kinds of cases there may be variation within the specialty around what kind of stents cardiology is using is something we are looking at right now we do look at overall cost data for episode of care and then quality outcomes and once again we have a tool I was asking about the tool to help us pick and choose our projects one of the first projects that we picked on is we noted that in emergency medicine we were admitting a lot of people with chest pain who within 24 to 36 hours would go home to the back home and not have a diagnosis of heart disease very common issue and so we knew I will show you some data that in 2014 we were admitting about 30% of people who presented to the University of Vermont Medical Center emergency department with chest pain 1 out of 3 of them were getting admitted and a relatively small amount of those people actually had heart disease so you could call those admissions waste people coming in the hospital getting extensive testing it's expensive, the patients don't want to stay overnight most importantly I was using that bed we needed for other people we're full almost all the time and so I thought I would just talk quickly about how in 2014 if someone showed up at our ED and had chest pain most of them get an EKG and they were getting a blood test and then based on those two pieces of information the doctor was making a decision often times with cardiology to admit those people for what we call serial enzymes they're getting a number of blood tests over 20, 40, 36 hours at the end of that testing they would often times undergo some further cardiac test and then be discharged and we knew that of that 30% of people being admitted 5 to 8% actually have heart disease so a small number so we knew there was a big opportunity there so the network quality council said those admissions are not adding value to any part of the system and so we built a project where we wanted to see if we could streamline that process so as I said we knew in 2014 that 32% of our patients were being admitted and most of them are going home within 36 hours and in 2014 and 15 a better test was developed so the test we were using became much more sensitive and there was a paper that came out that said if you could do this test twice over 3 hours that was negative both times and a couple other things came together that most of these people could go home and so we worked with cardiology to make sure that we were using the right test and pathology helped us so we could get 2 tests back in 3 hours 24-7 that was some work we had to do and in 2018 utilizing this new process we only admitted 15% of chest pain patients careful follow up we've carefully tracked every person we've sent home and we really not found any missed heart attacks so we know this new procedure works 99.8% of the time so sooner or later there will be a miss but it's been very successful so far and we actually think there's even ways to mitigate even that risk percentage because we don't force you to follow the protocol you can still admit people around the protocol if necessary so what exactly did we do so in 15 this better test comes out we meet with our cardiology colleagues make sure they agree with this process of sending more people home we work with pathology to make sure the test is available 24-7 we're using the right one we have a good mechanism to get it back in a timely fashion and we realize that this protocol doesn't mean that no one needs to have further testing it means it's safe to go home tonight from the ER so we wanted to be certain that we had really robust cardiology follow up so in 18, once we're going to send someone home I can click an order at discharge that gets them a cardiology appointment within three days that's really important in this this doesn't work if you don't have cardiology saying we'll always see the patient within three days and we pick three days so if you come in Friday evening you could be seen Monday that's how we do it in 16 we start testing the system we're using the new blood test we're doing the test twice as the protocol says and we're starting to send very select patients home we're starting to look who do we think is really okay to go home are they really getting a follow up appointment is it really happening are they getting good testing when they leave is cardiology able to get them in and get timely test scheduled and it really goes very smoothly in 2017 we trained all the providers in the new protocol and we make some changes in our EMR which is epic to make this change durable and so that as I always say it's easier to do it right than it is to do it wrong and in 2018 we have full implementation across our emergency department so this is a quick slide so I just told you in 14 we're admitting about one out of three chest pain patients who presented to the University of Vermont in 2018 we admitted 15% this is important because as I told you there still may be reasons even if someone has two negative tests to get admitted and we didn't tell the providers you have to send the patient home and so if you look across the bottom here here is the emergency department doctors at the University of Vermont they've all seen this they're comfortable if you look right in the middle they're left-legged and so in 2014 I was admitting about 15% of my patients and that sounds really great but I have to tell you the truth I work mostly day shifts now it's very easy for left-legged to get a cardiology consult on a day shift so someone I was worried about even in 15 I could get a consult they could come down they could do a stress test so I was able to send more people home than my partner Dr. Weimersheimer and he's still seeing some people who he's worried about who can't get a cardiology test at 3 o'clock in the morning so what I want you to understand from the slide is we didn't say we expect everyone to be at 15% or whatever we said we're going to drive out unnecessary variation and what I'm most interested on this slide is if you look in 14 the blue lines there's a lot of variability amongst us if you look on the orange lines in 18 we've really reduced variation we've really squeezed that down we're not looking for no variation there may be a very good reason for someone to stay even with a negative test but we were able to drive out a lot of excess variation by following this protocol closely and when we show this in our meetings we say look you can see some people are doing it a little different what's going on next steps we're going to continue robust follow up we need to really track these patients and make sure we're not having people go home there's lots to follow if we don't go to cardiology who are getting tests in cardiology that meant they should have stayed in the hospital we want to test treadmill testing in the ED I won't say 24-7 but for more hours because that is a way to even eliminate the necessary cardiology follow up but that could have a big length of stay issue and we have other issues going on in the EDs right now with borders and so on so we want to be smart about doing that but when you can do that on that initial visit it's extremely efficient and the patients love it and then you can be done with the complete work up in that one quick visit as we said in every presentation you have to have good data you have to have data that the providers believe that they can test and poke their fingers at and they can look at and play with I will tell you that as we're rolling out Epic across the network we can't wait because once we have Epic for all of our hospitals and Epic has a lot of tools in it and then in real time providers will be able to build their own dashboards and easily compare themselves against their colleagues and then in real time learn from each other and we're like I said it's important to know your local dynamics so if you looked at that last slide you'd say it looks like Leffler's great and Weinersheimer's bad but that's totally not true it depends on knowing what's going on with other issues we may have a longer life to stay that may be totally reasonable so you have to combine this data with local expertise and we're already applying some of this work to other pathways like for blood clots in the lung and so on summary, in 2018 we saved 270 bed nights that's a hard number we know that we kept people out of the hospital who didn't need to stay overnight we freed up beds for other patients who needed to be in the hospital we saved $750,000 if you look at Medicare reimbursement for hospital admission Medicaid, in a commercial inpatient testing cost more than outpatient testing so we're confident that's a conservative number we allowed for much more outpatient testing freeing up our inpatient capacity for other patients and most importantly as you move towards capitation part of that really important Holy Grail is to do as much care out of the hospital as possible and so this was a great example where we could provide hospital level care in an outpatient setting Ian, I'll stop there and be happy to take questions Thank you, that's another glimpse in a different area where this obviously important work to be done so I guess the first thing I'll do is obviously open it up to our other panelists if you have questions for Dr. Leffler So that sounds like a great test but I think it's really important as you pointed out is to have the services like getting somebody into cardiology in two to three days that is key to make this innovation work, right? Yes and so how do you approach your cardiologists and you know, herd your cats and get them all online So what really helped us a lot is that we were able to say to our cardiologists look, if you're willing to see people nine to five Monday through Friday we'll consult you less to the ED we'll ask for less consults and as soon as we said that they were all on board they couldn't wait until they called less so the way we do it now if you have two of this test, troponin test, negative twice an unerarchable EKG and no other concerning factors we don't consult cardiology in the ED which also saves a lot of money and we send the person home with a three day follow up and as long as that's working seamlessly we're doing many less consults which is good for the cardiologists good for the patients and good for the system Steve, that was a nice presentation one question I have if you save 750 bed nights it potentially allows you to provide access to care to other patients so other service lines in your hospital and over the time since you've implemented this change have you had like a discussion with the other service lines as far as easier to get patients transferred in from an outside facility allowing further ease for patients to egress out of the OR to the floor if you have any comments if you've been trying to transfer it into us recently you know that we are constantly having issues right now with capacity we desperately need the Miller building to come on board and we can't wait but we have right now every single day issues with managing how many patients need our services so this was just immediately consumed with other people I would like to tell you I think we're able to accept more transfers from this extra 270 bed nights but it just got sucked up in all the other need right now to be honest with you anybody else have any other is this a program that you would recommend to the community setting, community hospitals it's a great question John without question and so I would say that OneCare Vermont is aware of this project and they're having Dr. Harrington who is our ED leader and one care learning collaborative to roll it out across the state and the work you're exactly right in a community hospital you have to make sure you have the right test it's available 24 seven you can do it twice and that you can arrange close follow up but really it's not a high technology change it's really having appropriate resources available so we're hopeful that most OneCare hospital systems and health service areas will adopt this program because we think there's a big opportunity across the state of Vermont to get anybody from the board just along that I think that the first thing you know a couple things that Rachel said that really stuck out to me was improvement not judgment and I think your chart shows that right because if you looked at that and you say oh this person is better than another it's not about that it was about everybody had improvement and the other thing was that I really think we can take across the whole system you were just touching on is you know collaborate and compete and how do we do that across the system with this is one example which hopefully will go through OneCare but you know the examples that you gave at Copley you know there are examples throughout the whole system and you know it would really be great to see the hospitals you know having whether it's a consortium or something where you know like like to like you can compare things and look at how do we how do we do better to make quality decisions throughout all the systems you know and obviously to some degree UVM has more resources to be able to you know attack some of these problems and some of the other hospitals but you know it sounds like Copley you guys are talking you know throughout the country to people about how do you improve but it would be great to have forums to kind of share that you know at least through Vermont so we can get some of those savings in the system and you know I love because it showed $750,000 of savings but you know we don't see that in the hospital budget presentation because it's not there right so you know but it's a good thing to be able to illustrate you know we would have had higher costs in our system you know without these types of things so you know I think you guys shouldn't be shy about sharing a lot more of those because it really helps to see you know what you're doing along these lines I thought it was you know this whole thing thanks I'd love to open up to public comment but I just want to echo Maureen's comments but this has been very inspiring I mean I think we keep you know hearing about this all-hair model and hope that we're starting to see the kinds of delivery reform changes that we think is incentivized by the new payment system and these are examples of exactly that changes that we hope would make improvements in population health under these costs which are the goals of the model more forum more opportunities to share this kind of information across providers across the network I think one care and bonds have fantastic roles for that so I would love to open it up to public comment Dale did I hear your name correctly Rachel? sorry Rachel yes Rachel yeah yes I'm still here I can almost hear you oh I'm not the only one that has hearing problems so you mentioned macro and micro can you hear me now? yeah there's also what they call meso so you have macro, micro, meso is right in between the two and it's got to do with that like meso culture so I was looking at you've got 21 counties you've got three states you've got a very diverse culture or cultures that you're serving and I see you shared in different oh you shared in a different way the cultural shift or what is a cultural shift it sounds like it's also a community cultural shift it's not just in the hospital in the setting it's also was there a shift within the community as far as their perception what is the depth of persons within the community because you said it went back to the community as far as their savings and they weren't so interested in how like the incentive was not that they did some of that savings themselves but that doesn't answer the question of where are they at in their own personal costs where are they at in the costs within the community and you mentioned a three hour meal we have a two foot snowstorm coming maybe we could probably do a three hour meal cultural thinking there was a shift in time management I was wondering did you slow down and that actually made things better did your time management change did your perception of it change that's a lot of questions in there Dale for Rachel did you get all of those sure I can give it a shot I think their thunderstorm has had a shift and if you do plan in that we do have an intentional focus on population health and to do that it means engaging our community our partners our patients differently and so I think you're right there we can have an institutional cultural shift but it also takes a community cultural shift and it's a shift on the part of our patients to be successful in some of these things I heard from one of the panelists I think about clarifying or trying to best define patient expectation on the front end and so we are focusing not just on orthopedics but I know across the system on patient education and community education so that our patients know what to expect and what is reasonable and why we're trying to do what we're doing and how it impacts them so we aren't just engaging our team in the Y we're trying to meet the community in the Y and I think that's important I'm sorry can you clarify the rest of your question I think there was a question about time management yeah I think if I would have brought this plan to the surgeons and said this will flip you down that would probably not have gone well so in anything we do we try to be very respectful of the practices and productivity and the processes of our providers this is a time intensive process but the point was to get the right data on how long things took so we didn't our intention wasn't to slow things down in this have we done something that sometimes take more time to then have better outcomes on the back end sure I think the caregiver class is one thing that nurses might have been able to offer that same education in the room in the midst of doing other things but we thought having intentional time pulling resources aside to have an actual dedicated caregiver class for that education was delivered without the patients in the room so the caregivers could focus that we felt like was an investment and maybe it's taking a bit more time but we're seeing strong outcomes and feedback from our patient caregivers on the back end so you know I think we also from a time management perspective we tried to invest a lot of administrative resources to not get in the way of the provider resources engaged in this project so I think that's important that we're just very respectful of the providers in these things and you know I just I love the presentation about cardiology I just think that's incredible and I can put my heart institute hat back on and a lot of changes we're making in a deeper service model negatively impact us so we made a change of we were doing the blood type of screen on every patient pre-op for a while and then we started looking at our blood transfusion rates and talking to our blood bank about blood availability and realized that that thing was unnecessary cost that was being passed to all the patients. Our transfusion rate was so low almost all the patients we were transfusing were anemic so we knew that ahead of time for that and we weren't transfusing the case it was usually there to have the case and the blood bank hadn't had because the blood we needed went in those cases so that's something that was a savings to our patients and to our community but actually in a deeper service world cost us money but that's our commitment right but that's a culture change so I don't know if I fully answered your entire question Yes you did, thank you Dan Richter on family physician also in Cambridge, Vermont also Chair of Vermont Health Care for All I actually have a question sort of more to the board because I think these are all excellent wonderful presentations and I admire these physicians greatly and I think it's wonderful except that we still have a tremendous access problem so a lot of these problems could be prevented and I would ask that you would widen the scope of looking for cost savings by looking around the world realizing that the rest of the industrialized world covers everyone for half the cost with better outcomes they live longer and they go to the doctor more often in fact they have more hospital days, there are more admissions and some even have more transplants so clearly we're doing a lot wrong in this country and of course there's the article of Ubi Reinhardt it's the price is stupid, we have a much more expensive infrastructure probably more intensive hospital beds than we need for a population etc but the other thing is the whole idea of public funding and budgeting and all there's many other ways that these countries save money and spend less and it's not about fee for service because again most of them are fee for service so that is really not a problem not a great way to pay doctors and certainly we and I think the idea of the salaries is clearly one of the reasons this is working so well but also that they are able to do health planning for a population and I am getting to a question but I also want to make the point that our administrative costs in the healthcare system are around 31% of total we've seen in the last since 1975 a 32% a 3200% increase in the number of healthcare administrators at the same time 150% increase in the number of doctors since 1970 we've not looked at that, we're not looking at the ground beneath our feet, we're adding more administration to the healthcare system so that is my one thing is that for us to examine the administrative costs in healthcare as one way to look at how can we reduce that it's driving doctors absolutely nuts with all of the administration and the administrative tasks that we have to deal with the second is primary care is dying, primary care is circling the drain doctors, I'm in Des Moines County are retiring and we're getting increased plus my patients don't have access because they have 5-10,000 other deductibles so it seems to me that we're putting the carpet for the horse, I think these are wonderful delivery system changes, they're absolutely needed but we need to look at systemic reform first and I would just ask that you consider addressing administrative costs and the idea of at least starting with primary care and expanding access to all Vermonters at least first dollar coverage thank you I think anybody can jump in here but one of the things I would like to say is that the all-care model doesn't have ship resources towards primary care the realization that primary care is incredibly important competitive health is incredibly important I think it's well recognized by all of us here on the board and I would also just like to point to a letter that we sent to the legislative committees what was that in December asking them to look carefully at the administrative burden that is imposed on providers and in particular to look into gold carding and finalization so that was a letter from the board to the legislative committees to address that very issue so we're very well aware of it trying to do some things that we can in our power to do that, we had a panel actually conversation back in several months before that about administrative burden and it's on our minds and we think about it okay not to jump in on that but if I could just take us far field for a second since we have Dr. Richter who's practicing in Memorial County and we have two doctors on the panel practicing in Memorial County do any of you have any ideas why Memorial is such an outlier on the uninsured rate I think there's probably what I'm seeing is that the cost of insurance is not worth it for most patients who are in a position to take a look at their finances and say look I can either pay for my deductible here and then really get nothing for my insurance I mean I'm seeing that first of all I think the insurance analysis wouldn't be any different if you're in a while or if you're involved and again I don't know if it's just sort of the number of people who are like independent I have a lot of patients working in construction who are uninsured it's very expensive for them and again it's not worth the cost there's not much value to the insurance they're buying so most of them decide to go uninsured and then pay directly for their care I don't know why that is any different really I think it might just be the jobs that are available what do you think so we're tackling up here and we think that one of the biggest problems is the lack of job opportunities there's just no opportunity for a lot of these younger families a lot of these red winners and the other problem is a lot of these people make just enough money to not be eligible for certain things like medicare, I mean medicare and that just throws them for loop somebody who makes a thousand dollars more is nowhere near has the ability to pay for healthcare sorry no no I think it was a great question because I had seen that data I just saw that data at Memorial County as an outlier Ken Ken Liverpool I want to express my disdain for raising my blood pressure under your birthday I'm sorry I have the nerve to raise the question of administrative costs so I do have a question but I just have to editorialize for a minute and say I appreciate the fact that the board has sent a letter to the legislature on this issue I can't tell you how dismayed I am about the board's lack of taking up this initiative a couple of months ago when I asked for a freeze on the highest salaries and a comparative study of three years of what the increase has been for administrators versus direct service providers and basically the board said we don't want to intervene and get involved in internal discussions this is an unacceptable position you are the regulators I urge you to partner with the legislature but they're not the regulators you are and it's a dangerous game to play to not take on the responsibility that you have so that's just a commentary I will add one more thing I hope the board will take up some time soon publicly the fact that administrators in Vermont hospitals who are making a million dollars or more have to pay a 21% tax and I presume that there's a plan for where that money is going to come from if tradition holds true we'll end up being the consumer who ends up paying the penalty in the end but it's just another example of the escalating costs that occur when rains are not placed on administrative burden which I wasn't going to raise necessarily but since somebody did I felt like I had to comment but I think the presentation is uplifting and it reminds me of a conversation that the Green Mountain Care Board must have had about 5 years ago where it had a whole host of practitioners come in to actually address issues to the Green Mountain Care Board it was some group, maybe Alan Ramsey was involved with putting it together and it was very uplifting one is because it's always great to hear from people who work very often at the Green Mountain Care Board we hear from CEOs or CFOs and I in no way want to disparage them or say that they're not riveting in their presentations but there's a different quality about hearing people who have left from treating patients and could explain their point of view so the question I have to those who presented and this is tricky in a way back then when the host of providers many of them were young providers in their careers they all kind of agreed that one goal that Vermont had to have was reduce the number of beds that are being utilized for a variety of reasons one arguing that a lot of work could be done outside the hospital in some ways it was kind of a radical presentation I kind of guess that's one of the reasons we're divided back because of the power structure that message just didn't go over real well but it was profound for somebody sitting there and so in some ways the presentation might argue today that there's less usage of beds or bed space and it's tricky in the sense that one theory might be that there's so much demand that's a false economy to think that there'll be any savings you know you throw out a figure that is a million dollars, $750,000 but is it really a savings will it ever show up in a budget that's presented to the Green Mountain Care Board now or five years from now because the hospitals are also money making endeavors and they have you know a business model that I don't think has come in here ever to say we've been able to reduce the expenditures in cardiology at the UVM Medical Network by 4% or 10% so we're asking for less but do you feel like in cardiology there's been a reduction in the overall cardiology budget yeah so my first comment is that every presentation you heard here today was about how to get more people cared for out of the hospital all our orthopedic presentations are about decreasing length of stay others are about saving bed nights for admissions and the trick is that if you look at demographics and you look at what's happening to our population there are not many people who are coming with acute issues right now they need to stay in the hospital very long in the old days they would stay for 4, 5, 6 days for total joint we've been in cardiology patient for 4 days that was very good in the fee-for-service model they were relatively easy to take care of our hospitals are filled now with people who are elderly with chronic health conditions who are hard to discharge back to home and so the people who can go home quickly and easily will work hard and the second part of that the much harder pieces to make sure we have good systems in our communities enough nursing home beds, enough step down beds enough other resources for people who have 3, 4, 5 co-morbidities who can't really go home and don't need inpatient care and any day at the medical center in Burlington we can have 15 to 30 patients who could be discharged if we had an appropriate place for them to go including maybe their home bed extra support but we don't have that so it's very complex to figure out how to help cut down even a single bed day for those people because it's not just healthcare they need other social supports it's a complex answer to your question but I mean I will tell you that if you look across any service that we provide for acute care most all in the length of stay is less overall length of stay goes up because the people who have to be in the hospital need to be in longer if we need to stay Steve gave a complicated answer I'd like to give a new answer outpatient joint replacement it's coming it's being done nationally it's going to start hopefully we're doing some patients outpatients are trying to say partially replacement go home that same day total joint replacement same day with the right services and we have somebody here who really wants to head in that direction and I'm going to let him speak about that one just to make a comment and it's taking me and I've been in practice for 10 years the concept is the total joint patient if we look at the program that's been in place to risk gratifying them and understand ahead of time what we might need in commentary I think it really helps and a patient who undergoes a joint replacement it's not sick I mean you go to the hospital it's not sick so these patients actually need a special type of care but they're not ill they're actually well and so we have concepts of they need to learn how to mobilize put their shoes and socks on get off the toilet take a shower they need to understand their medications and they need to be having how to put pain control they need to be eating and drinking these are all services through education and other resources that I think we can accomplish giving high quality care I think you're trying to look at some of you know what you're demonstrating the project is the way I look at it is you may not see a reduction or a change in the budget but what you're seeing is potentially greater access and that may be perceived as a smaller community if you're freeing up 270 bed nights then there may be a complex patient that's not appropriate for the community setting that has an easier chance of getting transferred in the day they present to our ER than actually staying potentially with some questionable clinical concerns for another day and so I actually see Steve's presentation as being very enlightened and hopefully helping us in a small community other communities get patients that need to be an attritionate person are there I was visiting out of a consumer and on Saturday I will be 82 years old that's my birthday and I've been following what Deb has said and what Ken has said I agree entirely with what they said I'm also a patient family advisor at Central Vermont Medical Center which is part of the UVM network however we do not have epic yet I have passwords to get into UVM MC that don't talk to Central Vermont Medical Center I'd like to know from you sir when are we going to get epic in Central Vermont in one year one year and then I can get the same messages and they won't be outdated by the time I get them and the other thing I wanted to say to the knee transplant the knee surgeons I was scheduled to have knee surgery here at Central Vermont Medical Center I have cancelled it I first I postponed it but I had said I want to have a bed waiting for me at Woodridge Nursing Home because I live alone I have no support network and I live in an apartment I can get nails on wheels but it's a little hard for me I have peripheral neuropathy I have a million other problems as well and I feel so much better because I cancelled my surgery and said I don't think my knees are the biggest problem in my life I can still walk I just wanted to make that comment and I agree with what everything they say but I also was concerned that this group the Gundersen group the patient family advisors on their committees it's all about the providers nothing and the staff the administrative and the providers and they have no feedback from the consumer I'd like some comment on that Rachel did you hear that my chance about whether it's the consumer I absolutely appreciate that yes and we do have many patient family advisory committees in our organization and we definitely take changes, process changes and ideas to them for feedback as we have worked hard on our patient education and caregiver education and classes we actually have worked with our patients and their caregivers to get feedback on those processes to make sure that we are taking into account what is working for them so I do appreciate that our patients and their families have to be partners with us in this so I do appreciate that feedback thank you thank you Rachel I think it was one more comment over there Louis Myers, a primary care physician for many years, hospice now but my heart's still in primary care and a fairly wise person wrote into the BT Digger which is our online newspaper here in the state recently said first we were patients then we were customers and now we are algorithms and I think that while the algorithms are very helpful in their place and particularly for the surgical specialties and because you get into more complex areas like primary care I think you overestimate or underestimate perhaps people's dismay of being treated as an algorithm and not as a person and I think there is going to be a blowback at some point I'm not sure where that's going to occur but I think you need to keep that in mind thank you I just want to, I've read that comment I forget who wrote it too but he's right on the money one of the things I had I listened to this presentation was when you go to a primary care physician and you're lucky if you get 10 minutes so how, you know, if they just ran through and ran you out and I've been through that you know, it's that algorithm mode again and Deb comment about access is the big one the moille, hardly any jobs up there, the salaries don't equal the costs it's the same all over the state not just the moille but I have, you know, that's a question I had you go into a physician's office whether it's this or that or that that's a comment thank you any other comments? yeah clarification how do I say how did I save anybody money as far as the affordability of that healthcare I can't find the measurement as I've been listening that actually shows that somebody saw that they didn't spend $100 they were going to have to spend or how do I prove the savings to the after all patient and all that we've heard I believe it's a clarification question anybody want to tackle that clarification question? well I can tackle it if you want to I mean so all of our medical expenditures over a year they build up and so this is spending that we're not seeing entering into the system so for example in our I'll give this an example in our insurance rate hearings the insurance rate premiums are set for next year based on the historical medical expenditure from the prior year this is an expenditure that does not happen therefore it's not being folded into future premium increases it's savings that you're not necessarily able to quantify all the time but we're bending the cost curve in ways that are going to reduce you know insurance premiums in future years reduce costs for consumers and free up resources so that patients can have better access to health insurance presumably if the costs of insurance are slowing down and to the extent that they're keeping people in the hospital that need to be they're freeing up beds it's going to increase access to those beds for the patients who really need it so that would be one answer can I just respond to that though because I think we're just neglecting the whole issue with fixed costs and the fact that if you look in the hospital system especially at a place like Gundersen where the majority of people are salary and again 65% of physicians that are moderate salary there's a study showing that 83% of hospital costs are fixed so what they don't spend their 750,000 ends up getting shifted that's pretty much for system costs so I think that really needs to be looked at I think Dale's question is well taken does that really happen? maybe it does in a variable cost you don't buy a drug then it doesn't enter the system but not so much in the issue of fixed costs what I saw in some of the examples at UM and Gundersen and in Cochle is if you were the individual that was going into the ER and you would have been admitted you would have had costs you would have been charged for that overnight stay for the testing and now you're not getting those costs so on an individual level if you're actually if you're not having those costs if you're no longer staying overnight in the hospital when you have your surgeries you're not incurring those costs if it was deductible so it does in those cases it wouldn't go back to the individual as well no I think that's a good example and it has an impact on staff overtime upscaling beds are open for tonight and there is a direct impact on patients who get to go home it's cheaper if you have a big deductible it's cheaper for the testing that you get as an outpatient than an inpatient so I agree with your assessment could I comment again on costs I'm a Medicare recipient quite obviously I don't get Medicaid I live in subsidized housing I get food stamps but I pay $225 a month for co-insurance for united health care that I've had forever and that was the reason I thought maybe I could go to a nursing home for two weeks and have some rest and use some of that co-insurance on and get some value from it I also pay $30 a month for my Humanity Part D I think you think that the only people that pay for their health care are young people older people do too I do want to extend the invitation that we can to spend from 5 to 7 at the Green Mountain Care Board office tonight with our monthly PCAC meeting since you are not sure that we're hearing from doctors on a regular basis other than that is there any old business to come to the board before you adjourn before Rachel you hang up sorry I meant to thank Rachel thank doctors here that took the time out of your very very busy day obviously to enlighten us all I found it very inspiring I really want to thank you Rachel thank you as well you're still on the phone absolutely thank you for the opportunity and thank you for learning back to my teacher well thank you everyone is there any new business to come to the board is there any new business to come to the board is there a motion to adjourn to move in second to adjourn all those in favor signify by saying aye thank you