How Better Care Drives Value

One of the most perplexing concerns with which every hospital executive must grapple is how to stop the loss of money wasted on surgery and other clinical procedures. A recent report published in the Journal of Neurosurgery conducted by the University of California in San Francisco suggested several areas where supplies, and therefore money, were wasted.

The report looked at 58 neurosurgeries performed by 14 different surgeons at UCSF Medical Center. Across the 36 cranial and 22 spinal procedures, the average cost of unused supplies was $653. This represented 13.1 percent of the total cost of surgical supplies. This results in $242,968 per month and $2.9 million per year of wasted resources.

Medical Supplies vs. Personnel Costs

While the amount of hospital resources wasted on medical supplies is relatively easy to calculate, the more insidious expenses – clinical personnel costs – are more difficult to quantify. However, when a Roanoke, Virginia hospital set out to improve patient outcomes by standardizing insulin dosing protocols, the facility discovered substantial savings by mechanizing this process.

Dr. Sandy Fogel first came to Carilion Clinic in 2008 as the Surgical Quality Officer and with a charge to improve the surgical processes at the hospital. He quickly became a self-described “data fiend.” As this data was analyzed, he and his team found that the facility could improve in a few areas, including mortality and surgical site infections.

After reviewing medical literature, they found that hyperglycemia and diabetes were the third highest risk factor in each category. This led them to review their data on glucose control and what they found surprised them.

For the most critically ill patients, there were seven different protocols approved for treatment. These protocols, which were all paper-based and required complex calculations, were lengthy with the shortest being seven pages and the longest being twelve pages.

Nurses were queried as to which protocol they used, given the relatively large number of choices. It was quickly determined that each attending physician could choose their favorite. Because of the complicated nature of the calculation, the nurses felt that there was no “standard” protocol. They felt that the policy allowed them to use their judgement and adjust the dose as they saw fit.

“It was the wild, wild West,” Dr. Fogel laughed.

Patient Outcomes Were Being Affected

It was obvious that this insulin dosing protocol guess-work was causing unacceptable patient outcomes. Data collection started two years before an arduous exercise of meetings with medical specialists in the hospital, educators, nurses and three outside vendors offering commercial products for dosing protocols. Dr. Fogel and the other doctors and nurses quickly realized that EndoTool was the right solution for them.

According to Dr. Fogel, “We realized after a short time of having EndoTool in our ICU’s and PCU’s that better care can be still be cheaper care. After the roll-out of EndoTool, we continued with a monthly analysis of patient results. What we found was enlightening. Not only did the patients have better glucose control, but they also had fewer complications and the nursing time was less than with the other protocols. The number of finger-sticks on patients went down by about 46 percent because the nurses were not ‘guessing’ when to do this. At about three years into this process, I was able to get the medical directors of each unit to mandate the use of EndoTool and almost immediately the use of the other protocols ceased. We even got the cardiac surgeons to switch.”

A Study of Nurse Efficiency

With his personal experience at Carilion Clinic, Dr. Fogel is convinced of the operational efficiency of this algorithmically based software. His proof also comes from data on nurse-time while using EndoTool.

“We did a study on this issue in our hospital,” he said. “We have a group called ‘performance institute’ and when we implemented EndoTool, this group came to our ICU to observe nurses, 24/7, for three days. They didn’t tell the nurses why they were there. They simply watched what the nurses did for a period of time and recorded what percentage of time the nurses spent on various activities. They found that after the first shift with a patient who is receiving dosing via this software, the number of minutes spent on glucose control on each shift thereafter goes down for the length of the stay in the ICU or PCU.”

What This Means for the Patient and the Hospital

“For the patient it’s clear — fewer complications and shorter hospital stay are advantageous,” Dr. Fogel noted. “As I have said, better care is cheaper care. For the hospital, there are three major sources of savings. First, if one day is cut on a patient’s hospital admission, there’s a small savings for the institution. Even though most hospital costs are fixed, there is a finite, albeit small, savings of getting the patient home sooner.”

According to Dr. Fogel, there is a bigger savings in the reduction of patient complications. If a patient has poor glucose control and gets a preventable hospital acquired condition or surgical site infection, CMS will not pay for it.

Dr. Fogel believes the biggest savings for the hospital comes in the form of greater capacity to admit more patients from referrals. “If we can get a patient home earlier, we have created more beds for others and the hospital has the potential of more CMS or insurance payments for a new patient,” Dr. Fogel said. “Our hospital cost accountants have analyzed the advantages of reducing the hospital stay of a patient by one day and found that there is a seven-to-one return on the investment that we employed to get them well quicker. Any CEO, in any industry would be happy with a seven-to-one ROI. Would I recommend EndoTool as a way for hospitals to save money and get better patient outcomes? Absolutely!”