Volume 8/Issue 2
Healthcare
Magazine
Leading Cost and Quality Strategies for the Healthcare Supply Chain
Featured Article:
Utilizing Guidewire Peripheral IV Technology to Improve Care for Patients with Difficult Venous Access at an Acute-Care Hospital
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The
RIGHT VA TOOLS make all the
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Contents
Healthcare Value Analysis & Utilization Management Magazine
4 FROM THE PUBLISHER’S DESK By Robert T. Yokl
Cost Optimization Is No Longer About Price Savings
Healthcare Value Analysis & Utilization Management Magazine is published Bi-monthly by SVAH Solutions®
6 FROM THE MANAGING EDITOR’S
DESK
P.O. Box 939, Skippack, Pa 19474
By Robert W. Yokl
Phone: 800-220-4274
Why Early Prevention is Better Than the Cure with Healthcare Supply Utilization Management
FAX: 610-489-1073 bobpres@ValueAnalysisMagazine.com
www.ValueAnalysisMagazine.com
8 GAINING BUY-IN
————————————
By Robert T. Yokl
5 Tips to Better Visualize Data You Want to Present to Get More Yeses on Your Proposals
Editorial Staff Publisher Robert T. Yokl
11 FEATURED ARTICLE By Cheryl Campos, Francie Moehring, and Halit Yapici
Utilizing Guidewire Peripheral IV Technology to Improve Care for Patients with Difficult Venous Access at an Acute-Care Hospital
bobpres@ValueAnalysisMagazine.com
————————————
Managing Editor Robert W. Yokl
24 VALUE ANALYSIS 101
ryokl@ValueAnalysisMagazine.com
By Robert T. Yokl
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How to Select VA Projects for a Value Analysis Study That Will Yield Big Savings and Quality Improvements
Senior Editor Patricia A. Yokl ————————————
26 UTILIZATION MANAGEMENT
Editor and Graphic Design
By Robert W. Yokl
Winning with the Successful Value Analysis and Supply Utilization Mindset
31 VALUE ANALYSIS ADVISOR By Robert T. Yokl
The Myth About Standardization
37 VA PERSPECTIVE By Robert T. Yokl
Virtual Value Analysis Team Meetings: 5 Best Practices
Volume 8/Issue 2
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Danielle K. Miller
Copyright 2020 SVAH Solutions. All rights reserved. Reproduction, translation, or usage of any part of this work beyond that permitted by Section 107 or 108 of the 1976 United States Copyright Act without permission of the copyright owner is unlawful. For permission, call, fax, or e-mail Robert W. Yokl, Managing Editor. Phone: 800-2204271 E-Mail: ryokl@valueanalysismagazine.com for approval to reprint, excerpt, or translate articles. 3
From the Publisher's Desk Cost Optimization Is No Longer About Price Savings Robert T. Yokl
I would assume that we would all like to be more cost efficient, functional, and effective with our value analysis programs. So, what’s holding us back? In my opinion, it’s our obsession with price savings! There isn’t anything wrong with price savings. However, we need to be mindful that price is only one aspect (and the smallest component) of the supply expense savings triangle optimization tactics. More importantly, we have been preaching for a number of years now that your price savings are slowly disappearing. If you can hold the line on inflation with better pricing each year, you are doing everything you can to optimize your pricing. As I see it, there are still savings opportunities with some physician preference items, like stents, cardiac rhythm devices, orthopedic implants, etc., but these commodities are much harder to gain consensus from your clinicians to standardize, thereby, harder to optimize their costs in the short term! The most logical candidate for cost optimization opportunities today is your supply utilization misalignments, or the wasteful and inefficient consumption, misuse, misapplication, and value mismatches in your supply streams. These supply utilization savings represent 7% to 15% of your total supply budget, or one million dollars per 100 beds. I don’t believe we can ignore these costs any longer. Due to the pandemic, the majority of hospitals, systems, and IDNs show losses in the first quarter of 2020. Consequently, these losses need to be made up in future quarters with supply savings and cuts in staffing. As I have outlined above, the best way to do so is to optimize your supply utilization savings…now! P.S. If you would like to know more about supply utilization cost optimization, just e-mail me at bobpres@svahsolutions.com and I will e-mail you, at no cost, our recently updated “Supply Utilization Management: The Future of Supply Chain Expense Management” e-book 2020 edition. Volume 8/Issue 2
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Sometimes It’s Hard to Ignore What An Automated System Can Do for Your Supply Chain Organization
Volume 8/Issue 2
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From the Managing Editor’s Desk Why Early Prevention is Better Than the Cure with Healthcare Supply Utilization Management By Robert W. Yokl, Sr. VP, Supply Chain & Value Analysis — SVAH Solutions
We all get excited when we identify a nice big utilization and/or value analysis savings opportunity. We get even more excited when we can make effective change with value analysis and utilization management tools to drive out these savings and show major results for our organizations. But there is a major point to these savings opportunities that may not be apparent to everyone. What should be apparent is the fact that this has been happening over a long period of time and thus has been damaging the organization’s bottom line. If these big savings opportunities had been found earlier by making a simple correction, wouldn’t that have been better?
How Long Has the Big Savings Opportunity Been There? Let’s say you find $255K (on a $1 million annual spend) in savings in endomechanical costs, $422K (on a $650K annual spend) in pulse Oxisensors, $700k (on a $1.6 million annual spend) in outside reference lab, or any other supply or purchased service utilization savings. Ask yourself, how long was this going on before we found out about it and then did something to correct it? We should be able to answer this question with any product category that we purchase with a simple utilization management system that should be in place now. In this case, the endomechanical dollars lost had gone on for two years at $510K in total, the Oxisensor dollars lost went on for three years at over $1 million, and $700K reference lab had gone on for just one year in overspend for a total of an aggregate missed savings opportunity of $2.21 million on a spend of $4.25 million. Wouldn’t it have been dramatically better for the organization if they were able to find the $2.21 million in savings when it was only a quarter ($553K) or an eighth ($276K) of the size that actually occurred? These were real savings examples at real hospitals just like yours. Consider that hospitals purchase over 500 major categories (plus 1,000 more minor categories) in supplies and at any given time there may be utilization misalignments (waste, inefficient use, value mismatches, over-consumption, etc.). In our studies that we have performed over the past 15 years at hospitals and health systems across the country, we have found utilization misalignments in up to 75% of organizations’ 500 major categories of purchase. That could be as many as 375 major product categories that have utilization misalignments! About 80% are smaller savings opportunities and about 20% are major savings opportunities. Each should still be managed and dealt with.
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From the Managing Editor’s Desk What is the Model for Successful Supply Utilization Management? One of my most successful hospital clients in supply chain utilization management over the past 10 years has adopted a simple strategy for handling supply utilization misalignments at their organization when we provide their reporting to them at their value analysis meetings. “Simple, we just work from the highest to the lowest savings opportunity,” says the Director of Clinical Operations. Keep in mind, they have bought into supply utilization management as a major savings engine for their organization and they are still on point with their GPO conversions and best contract pricing as well. Why is this hospital so successful? Because they have saved millions and millions of dollars year over year by attacking their supply utilization savings on an ongoing basis. They don’t doubt that their opportunities are real but instead investigate them for reasons as to why unfavorable trends are occurring. If they find the root causes, they make adjustments to correct the issues. A few months ago, they saw that their reference lab was increasing by over 7%, or $18K monthly, over the past few months. If this trend kept going it could end up costing them over $220K annually. Luckily, they attacked this savings opportunity within two months of this occurring. Not only did they eliminate the $18k per month overage but they are on track to save an additional $11K per month or $132K annually if sustained. Net results for the current year were $96K in the black on reference lab testing which included the loss and dollars gained from the positive utilization swing. The bottom line here is that if this hospital had not had any system in place to track after and attack their supply utilization costs, then that $220K may have gone on for the entire year, or even longer, and grown larger over time. Early prevention and intervention in supply utilization management over-spends has saved them millions over the years because they can act quickly and strategically on all savings opportunities they find. There would have been dramatic damage done to their bottom line if they had not attacked these savings.
Goal: Clear the Board on ALL Major Supply Utilization Savings There are always supply utilization misalignments popping up for this client and any other hospital or health system that I do business with. The difference with this hospital is that they have cleared the board of all major savings opportunities and are now working on knocking down savings that are popping up before they become major issues that can damage their bottom line if left untouched. Plus, they have become one of the best in cohort in over 40 major categories in our national benchmark database, which means that they are so good that they are the goal benchmark in their hospital cohort of like-sized hospitals. For you and your organization to have results like this, you must first start down the road of supply utilization management with systems, methods, and the right mindset to clear the board of all major supply utilization misalignments. Volume 8/Issue 2
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Gaining Buy-In
Robert T. Yokl
5 Tips to Better Visualize Data You Want to Present to Get More Yeses on Your Proposals Robert T. Yokl, President/CEO, SVAH Solutions
One little known secret of persuasion is to help your customers visualize, with charts, graphs or graphics, the data you want to present to them to get more yeses. For instance, we have discovered with our Clinical Supply Utilization Management1 clients that good graphs depicting their utilization misalignments (i.e. wasteful and inefficient consumption, misuse or misapplication of their products, services, or technologies) are usually enough to change their behavior. However, these five additional tips to better visualize the data you want to present to get more yeses on your proposals can be the difference between persuasion and indifference from your customers:
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Gaining Buy-In
Robert T. Yokl
Dramatic and effective data visualization is an art and science that has a set of rules like the five rules shown above. If you would like to learn more on these rules, I would suggest you read “Effective Data Visualization� by Stephanie Evergreen. If you do, it will make your savings job easier by visually displaying the right graphs and charts when you are making savings proposals to your department heads and managers. 1 See
video at www.SVAHSolutions.com explaining Clinical Supply Utilization Management in detail. 99designs.com Design Tips for Better Data Visualization.
2 Source:
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It’s a Fact…. The More Organized You Are with Your Value Analysis Program…
...the More You Save!
CliniTrack™ Value Analysis Manager gives you the automated tools, reporting, and knowledge library to help make the savings game much easier for you and your Value Analysis Teams See how CliniTrack™ Value Analysis Manager can help take your Value Analysis Program to a whole new level!
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Featured Article Utilizing Guidewire Peripheral IV Technology to Improve Care for Patients with Difficult Venous Access at an Acute-Care Hospital Cheryl Campos, DNP, RN-BC, CEN, CPHQ, Salinas Valley Memorial Hospital Francie Moehring, PhD, Boston Strategic Partners
Peripheral Intravenous Lines in Patients with Difficult Venous Access Nearly 90% of the patients who are admitted to hospitals receive a vascular access device. 1 The vast majority (95%) of them are peripheral intravenous (PIV) lines,2 which are simple, inexpensive catheters.3 PIVs are typically used to deliver non-irritating fluids, medications, and blood products as well as for blood draws after being inserted into the peripheral veins (i.e., vessels of the hand, forearm, or region of the antecubital fossa).4 Despite their prevalent use, there are several challenges associated with PIV catheters including low rates of successful first-time insertion attempts (~47%) and short dwell times (~1.5 days), which may lead to frequent IV restarts. 5 Ultimately, repeated attempts and frequent replacements may increase the risk of catheter-related complications and reduce patient satisfaction.5,6 PIV insertion presents additional challenges for patients with difficult venous access (DVA).6-8 Patients may present with DVA due to a variety of characteristics including age, vein size, preexisting conditions (i.e., obesity, diabetes, chronic kidney disease) or other medical factors (i.e.,
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Featured Article chemotherapy patients or patients who previously abused intravenous drugs). 5,7-10 Furthermore, the number of these patients is likely to increase due to an aging population as well as the rising prevalence of chronic conditions such as obesity and diabetes.11-14 When using conventional PIVs, DVA patients may require multiple cannulation attempts delaying treatment and increasing the risk of catheter-related complications, which are associated with increased costs and length of stay. 5,6,9 Additionally, repeated placement attempts and frequent catheter replacements may lead to a progressive depletion of peripheral veins.15 As a result of the exhaustion of peripheral vasculature, patients may be escalated to more invasive and higher cost forms of vascular access such as central catheters.6,16-18
Utilizing Advanced Peripheral Vascular Access Technologies Advances in peripheral vascular access technologies may provide more appropriate options compared to conventional PIV catheters. For example, AccuCath速 (Becton Dickinson [BD], Franklin Lakes, USA) is a guidewire assisted peripheral intravenous catheter (GAPIV), which supports ultrasound visualization thanks to its echogenic needle. This novel GAPIV includes an integrated guidewire allowing the clinician to guide the needle and confirm successful placement. 5 The unique coiled tip of the guidewire prevents vessel damage and posterior vessel wall perforation by entering the vein prior to catheter advancement.5 A randomized clinical trial comparing AccuCath速 to conventional PIV catheters demonstrated several clinical advantages including (I) reduced overall complication rates from 52% to 8% (i.e., infiltration, leaking, infection, phlebitis, occlusion, dislodgement, and patient-reported pain); (II) improved first-time insertion rate (89% vs. 47%, respectively); (III) extended dwell times (4.4 days compared to 1.5 days for conventional PIVs); and (IV) increased patient satisfaction. 5 The improvement in first-time insertion success rates is likely due to decreased vessel damage, which may lead to longer dwell times and reduce the need for multiple IV restarts.5 The utilization of advanced technologies may also provide economic benefits, which are illustrated by the same clinical study. Despite having a higher per-unit price, AccuCath速 led to lower overall costs by requiring approximately 50% fewer PIV components thanks to longer dwell times and higher success rates for the initial insertion attempt.5 Furthermore, AccuCath速 may achieve additional cost savings by decreasing the need for more expensive central lines.16,17
Salinas Valley Memorial Hospital Founded in 1953, Salinas Valley Memorial Hospital is the cornerstone of Salinas Valley Memorial Healthcare System, which serves communities throughout the Salinas Valley, Monterey Peninsula, and the surrounding region of California.19 Volume 8/Issue 2
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Featured Article The 263-bed acute care hospital employs more than 300 board-certified physicians across a broad spectrum of specialties19 and houses an emergency department (ED) providing care for roughly 44,000 patients annually.7 One of the main goals of Salinas Valley Memorial Hospital is to utilize the latest medical techniques with state-of-the-art technology to improve the health and well-being of their patients.19 Therefore, the hospital had already staffed nine diagnostic imaging (DI) nurses who were trained in using ultrasound for placing peripherally inserted central catheters (PICCs) as well as midlines.7 These nurses are considered experts in vascular access device placement and were typically called to assist when an inpatient nurse was unable to attain venous access.
A Path to Improve Care for DVA Patients A nurse with 20 years of Emergency Department experience, Dr. Cheryl L. Campos, always believed that patients should receive the most appropriate care and receive it with comfort. Therefore, she showed great interest when she learned about AccuCathÂŽ, which is a promising option to improve the quality of care.7 Being aware of the historical challenges that DVA patients face regarding catheter insertion, she immediately recognized the opportunity and pitched her idea to improve patient experience at Salinas Valley Memorial Hospital to her colleagues. Considering that roughly 17% of their patients faced difficulties regarding catheter insertion, 7 Cheryl received support from other clinicians who agreed with the potential value, and were motivated to evaluate the current situation and identify challenges and create solutions.7 The team identified three areas for improvement. First, even though the hospital had a specialty nurse team consisting of DI nurses, their use of ultrasound visualization was mostly limited to PICCs and midline placement. Second, there were no clear guidelines regarding when to call specialty nurses for assistance. The lack of a clear workflow led to variations/inconsistencies in practice (i.e., certain inpatient nurses immediately called for assistance after a single failed insertion attempt while others escalated the case only after numerous needle attempts).7 Third, there was a limited number of DI nurses who were primarily available during daytime on weekdays with limited availability on the weekends, which made it harder to utilize these resources after-hours.7 A larger vascular access specialty nurse Volume 8/Issue 2
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Featured Article team with increased availability was needed to avoid delays in patient care and patient discomfort due to multiple placement attempts.7 Considering the opportunities and challenges that were identified, the team drafted an initiative to improve vascular access practices, particularly for DVA patients. The initiative included: (I) receiving authorization from Salinas Valley Memorial Hospital to adopt the novel GAPIV, AccuCath ÂŽ; (II) establishing a step-by-step workflow to identify and treat DVA patients; and (III) increasing the number and availability of advanced-skilled nurses who are trained to perform GAPIV insertion using ultrasound guidance. Overall, the team wanted to create an efficient and evidence-based workflow to provide the most appropriate care for all patients while prioritizing patient comfort, regardless of the time of day or the day of the week.
Achieving the Stakeholder Buy-In The first task of the team was to obtain permission for the use of AccuCath ÂŽ at Salinas Valley Memorial Hospital. For this, it was essential for the team to receive support from multiple committees (i.e., value analysis committee) consisting of both clinical and non-clinical stakeholders, which required presenting the potential clinical benefits as well as economic evidence. Therefore, the team recruited allies such as a nurse manager and a physician in the ED, who advocated the clinical benefits of adopting a GAPIV along with a clear workflow to identify/treat DVA patients. Approval to go forward with product use and training was achieved in July 2016. The team also performed an in-depth cost analysis based on an economic model supplied by the vendor, which was especially useful in convincing hospital leadership.7 After numerous meetings with a wide range of stakeholders, the team was able to receive support to use AccuCath ÂŽ and finalize/implement the initiative in four units of Salinas Valley Memorial Hospital: (I) general medical/ surgical unit; (II) orthopedic, neurological and spine unit; (III) renal medical/surgical unit; and (IV) oncology unit.
From the Literature to Practice Identifying the Standards After receiving widespread support from the stakeholders, the project team proceeded to establish the standards which would feed into an evidence-based three-step workflow to identify and care for DVA patients. The team conducted a literature review using ProQuest Central, Ovid, CINAHL, and PubMed Central to research recent (2012-2017) developments and standards in vascular access. Overall, the search yielded 11,700 articles, 29 of which were found directly relevant after screening. 18
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Featured Article The findings from the literature provided recurring themes based on Infusion Nurses Society Standards of Practice, including limiting the number of PIV attempts (no more than 2 attempts/nurse or 4 attempts in total) and utilizing vascular visualization technology for the patients with DVA. 18,20 When implemented, these recommendations20 could lead to improved outcomes since limiting the number of placement attempts has been demonstrated to increase patient satisfaction and increase clinical efficiency.6,20,21 Creating an Evidence-Based Workflow
After establishing the standards, the team created a three-step workflow for inpatient nurses to identify the DVA patients and to utilize advanced technologies/advanced-skilled nurses effectively (see Figure: “Workflow to Identify/Treat DVA Patients”).18 The workflow was especially helpful in streamlining the process for identifying patients who could benefit from AccuCath ®. Furthermore, it prioritized the selection of the least invasive intravenous access device that supports the patient’s needs and avoided the over-utilization of more invasive catheters when not medically necessary, which was recommended by literature.6,22 Step 1- Identifying DVA Patients: The first step in the workflow included visually inspecting and/or palpating peripheral veins, followed by an assessment of the medical and vascular access history for certain chronic illnesses (i.e., diabetes, hypertension, or sickle cell disease) that can affect peripheral vasculature. 5,7-10,18 When a patient was classified as DVA based on either one of these assessments, the inpatient nurse was to proceed to the second step. The inpatient nurses also advanced to Step 2 when a patient was determined to be DVA based on the number of PIV insertion attempts (no more than 2 attempts/nurse or 4 attempts in total).18 Step 2- Utilizing GAPIVs and Advanced-Skilled Nurses: The case was elevated to the second step when a patient was identified as DVA in Step 1. Step 2 instructed the inpatient nurses to call an advanced-skilled nurse for assistance, who received specific training in ultrasound-guided AccuCath® insertion. The advanced-skilled nurse would then evaluate the case and, when necessary, place AccuCath® using ultrasound guidance. When an advanced-skilled nurse was not reachable (such as after-hours), the workflow instructed inpatient nurses to contact their administrative supervisors to determine whether any other advanced-skilled nurses were available to provide assistance.18 Step 3 – Escalating to a Physician: When the advanced-skilled nurse was unable to place a PIV, or the patient became unstable, the case was escalated to a physician who would consider other vascular access options including central venous catheters.18
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Featured Article Workflow to Identify/Treat DVA Patients
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Featured Article Building Capacity The standardized three-step workflow was expected to increase the demand for the advanced-skilled nurses with special training in GAPIV placement, which could not be met solely by the DI nurses. Therefore, Salinas Valley Memorial Hospital built capacity by providing specialized trainings for the DI nurses as well as additional advanced-skilled nurses in ultrasound-guided insertion of AccuCathÂŽ. The product education and training programs were provided by the vendor, which consisted of an online ultrasound course, 4-hour didactic course with practice using ultrasound and inserting the AccuCath ÂŽ on a gel block, followed by at least two educator supervised training sessions. To complete the training, nurses had to receive a minimum of two 4-hour supervised shifts during which three successful AccuCathÂŽ placements had to be completed.7 Initially, three DI nurses and three Emergency Department nurses interested in vascular access were enrolled in the training. This pilot group helped the team to identify characteristics of nurses (i.e., passion and skill for vascular access) who would make the best candidates to serve as advanced-skilled nurses. By August 2017, a total of 40 nurses received specialized training in GAPIV insertion, 34 of which completed all portions of the program. These 34 nurses were then certified as advanced-skilled nurses who could assist other nurses when a case was escalated to the second step of the workflow. 7
Implementing the Initiative It was essential for each stakeholder to fully understand their role in the three-step workflow for successful implementation. Therefore, the team employed a range of communication strategies to ensure a smooth transition for three major stakeholders: medical/surgical inpatient nurses, administrative supervisors, and DI/advanced-skilled nurses. First, the inpatient nurses were introduced to the three-step workflow with a demonstration of a step-by-step example. Eleven inpatient nurses who displayed an interest in taking more responsibility were then selected to become unit project champions. Their role was to encourage their colleagues to follow the guidelines and act as a resource to answer any questions that arose.7 Second, the team presented the three-step workflow at the DI staff meeting where they emphasized the importance of accurately documenting the number of PIV Volume 8/Issue 2
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Featured Article attempts for evaluation purposes. Finally, nursing administrative supervisors and DI nurses were notified regarding a potential increase in the requests for assistance in PIV placement. To initiate the project, a complete list of the advanced-skilled nurses was created, including the unit he/she worked on and shift information. The initiative was simultaneously rolled out in four units of the hospital: a general medical/surgical unit, a renal medical/surgical unit, an orthopedic, neurological and spine unit, and an oncology unit.
Clinical and Economic Outcomes: Initial Observations Following the implementation of the three-step workflow and adoption of GAPIV technology, clinicians observed several clinical and efficiency benefits. Nurses reported a decrease in the total number of PIV attempts, especially in DVA patients,7 since the first step of the protocol was to identify DVA patients early on, limit the number of catheter insertion attempts, and escalate the case to an advanced-skilled nurse. Furthermore, the clinical staff noted longer dwell-times for GAPIV catheters compared to traditional PIVs,7 which was expected based on the literature.5 The number of central line placements were also reduced due to utilization of GAPIV technology and advanced-skilled nurses.7 The decreased use of central catheters was expected, since the vascular visualization technology increases the success rates of peripheral cannulation, which may eliminate the need for a central device, when other indications are not present for a more invasive vascular access. 20 Overall, these improvements were welcomed by most patients. In fact, several nurses experienced patients specifically asking for GAPIV insertion after experiencing the advantages of utilizing newer technologies as well as a specialized workforce.7,18 Provider satisfaction and efficiency have also likely improved due to the initiative. 7 Nurses reported that having a clear protocol and the larger number of advanced-skilled nurses increased their productivity and decreased the wait-times.7 Moreover, the cases were less likely to be escalated to the MDs for central line placements, which freed up time for physicians to be spent on other patient care activities.7 These observations suggest a significant improvement in clinician satisfaction as well as a lower utilization of IV resources including central catheters.7,18
Quantifying the Outcomes and Limitations The team used a conservative evaluation method to quantify the potential benefits of the initiative, where nurses reported outcome measures such as dwell times, the number of insertion attempts, and the number of calls for assistance. Strict exclusion/inclusion criteria were applied, and the reports were only included in the analysis if all data points (i.e., catheter removal date, number of insertion attempts) were complete. Furthermore, the reported values had to match across multiple platforms (i.e., electronic medical records, paper audits for DVA), which resulted in a low sample size (N=24) since a large number of patients had to be excluded due to missing or non-matching values.18 Volume 8/Issue 2
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Featured Article Although this study had a low sample size and the effects did not achieve statistical significance, the evaluation provided important clinical insights. Hospital-wide data from the four-week project timeframe indicated that a total of 59 patients received the GAPIV out of 148 requests for assistance. 18 The average number of attempts required to place an AccuCathÂŽ device was less than conventional PIV catheters (1.50 versus 1.71, p=0.57) but did not achieve statistical significance. Additionally, AccuCathÂŽ consistently demonstrated longer dwell times, averaging nearly double the dwell times compared the standard PIV catheter.18 However, further studies with a larger sample size are needed to confirm these results.
The nurse-reported evaluation method introduced an important limitation regarding underreported failed insertion attempts, which may happen in multiple ways. First, nurses are likely to underreport the PIV insertion failures by other nurses who attempted insertion on the same patient before calling for assistance.7 Second, the inpatient nurses may underreport their total number insertion attempts in order to demonstrate better performance.7 Therefore, the true impact of utilizing GAPIVs is challenging to capture in a nurse-reported evaluation and other methods should be considered in future research. These limitations should be addressed in future research to determine the true clinical and economic outcomes.
Adhering to the Protocol and Sustaining the Improvements The continued use of the three-step workflow, as well as the effective utilization of new technologies and advanced-skilled workforce, was crucial for the sustainability of the initiative. Therefore, the hospital monitored medical units and addressed any issues that arose. For example, the team identified an issue where a nightshift administrative nursing supervisor misinterpreted the first step of the protocol and directed the nursing staff to escalate cases to Step 2 only after four failed insertion attempts. However, the workflow required immediate escalation to the second step when a patient was identified as DVA after visual inspection and/or the assessment of medical history. The situation was quickly resolved by the team, who stepped in, reinforced the correct workflow, and provided additional training to the staff.
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Featured Article Several inpatient nurses in the medical/surgical units were surveyed post-implementation to determine the long-term impact of the initiative. Responses showed that even several months after the initiative was complete, the units continued to utilize the three-step workflow to identify and treat DVA patients.7 Nearly four years later (as of April 2020) the hospital trained 32 additional nurses and now has 66 nurses trained to insert AccuCath with ultrasound guidance throughout the hospital, demonstrating Salinas Valley Memorial Hospital’s continued commitment to its patients. Furthermore, at the end of 2017, the IV Therapy Policy at the hospital was updated to include the recommendations from the workflow including (I) using vein visualization equipment when placing PIVs when necessary; and (II) limiting the number of insertion attempts to no more than two per nurse or four attempts in total.7,18
Final Thoughts This case study demonstrates that a handful of motivated clinicians can make a difference for the patients. Clinical practice was improved by developing an evidence-based three-step workflow to identify patients who would benefit from the GAPIV technology and a specially trained workforce. Overall, Salinas Valley Memorial Hospital recognized the importance of providing the most appropriate care to DVA patients while ensuring that they can receive this care with comfort. The needs of the patient subgroups may differ based on a variety of medical factors; therefore, hospitals should utilize evidence-based technologies and methods to provide the best care for all patient populations.
Correspondence: Halit Onur Yapici, Senior Consultant Boston Strategic Partners, Inc. 4 Wellington Street Suite 3 Boston, MA 02118 halit.yapici@bostonsp.com Disclosure: The development of this anecdotal hospital experience was sponsored by BD. Dr. Campos is an employee of Salinas Valley Memorial Hospital and is contracted as a speaker for BD. Dr. Moehring and Dr. Yapici are employees of Boston Strategic Partners Inc., contracted by BD to conduct the primary research and write the study.
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Featured Article References 1. 2. 3. 4. 5.
6. 7. 8. 9.
10.
11. 12. 13.
14. 15. 16. 17. 18. 19. 20. 21. 22.
Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing. 2015;38:189-203. Inc iR. European Market Report for Peripheral Intravenous Catheters2016, iData Research Intelligence Behind the Data. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: A practical review for 2009. Paper presented at: Canadian Family Physician • Le Médecin de famille canadien2009. Moureau NL, Alexandrou E. Device Selection. In: Springer International Publishing; 2019:23-41. Idemoto BK, Rowbottom JR, Reynolds JD, Hickman RL. The accucath intravenous catheter system with retractable coiled tip guidewire and conventional peripheral intravenous catheters: A prospective, randomized, controlled comparison. JAVA - Journal of the Association for Vascular Access. 2014;19:94-102. Chiricolo G, Balk A, Raio C, Wen W, Mihailos A, Ayala S. Higher success rates and satisfaction in difficult venous access patients with a guide wire-associated peripheral venous catheter. 2015. Campos CL. Enhancements in the identification of difficult venous access and the use of AccuCath. In: Yapici H, ed2020. Armenteros-Yeguas V, Garate-Echenique L, Tomas-Lopez MA, et al. Prevalence of difficult venous access and associated risk factors in highly complex hospitalised patients. J Clin Nurs. 2017;26(23-24):4267-4275. Sebbane M, Claret PG, Lefebvre S, et al. Predicting peripheral venous access difficulty in the Emergency Department using body mass index and a clinical evaluation of venous accessibility. Journal of Emergency Medicine. 2013;44:299-305. Lamperti M, Pittiruti M. II. Difficult peripheral veins: turn on the lights. British Journal of Anaesthesia. 2013;110 (6):888-891. He W, Goodkind D, Kowal P. An Aging World: 2015 International Population Reports2016, United Cencus Bureau. Hales CM, Carroll MD, Fryar CD, O’gden CLG, Naomi P. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–20182020, CDC website. Prevention. CfDCa. National diabetes statistics report 2020: Estimates of diabetes and its burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Published 2020. Accessed. Gregg EW, Li Y, Wang J, et al. Changes in Diabetes-Related Complications in the United States, 1990–2010. New England Journal of Medicine. 2014;370(16):1514-1523. Hadaway L, Dalton L, Mercanti-Erieg L. Infusion Teams in Acute Care Hospitals: Call for a Business Approach An Infusion Nurses Society White Paper. Journal of Infusion Nursing. 2013;36(5):356-360. Medical L. IV Dislodgement Data. Lineus Medical. https://lineusmed.com/dislodgement. Published 2020. Accessed March 10th, 2020. MacArthur R. The Difference Between Central Lines and PICC Lines: What All Patients Should Know. https:// www.myiv.com/difference-between-central-lines-picc-lines/. Published 2020. Accessed May 10th, 2020. Campos CL. Improving Patient Outcomes in Nurse-Placed Vascular Access Devices. https:// sigma.nursingrepository.org/handle/10755/17236. Published 2019. Accessed January 27th, 2020. Hospital SVM. Salinas Valley Memorial Hospital - About Us. https://www.svmh.com/about-us/. Published 2020. Accessed March 10th, 2020. Infusion Nurse Society I. Infusion Therapy Standards of Practice. In:2016. Harpel J. Best practices for vascular resource teams. In. Journal of Infusion Nursing. Vol 362013:46-50. Moureau N, Chopra V. Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations. British Journal of Nursing. 2016;25(8):S15-S24.
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The Ultimate Supply Chain Radar System Missing Utilization Savings Opportunities Can Do Damage to Your Bottom Line if Not Detected FINDING THE NEXT LEVEL OF BIG SAVINGS DOESN’T HAVE TO BE DIFFICULT WITH THE RIGHT SYSTEM TO DO THE HEAVY LIFTING FOR YOU!
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Volume 8/Issue 2
Value Analysis 101 How to Select VA Projects for a Value Analysis Study That Will Yield Big Savings and Quality Improvements Robert T. Yokl, President/CEO, SVAH Solutions
Value analysis is too often thought of by value analysis practitioners as a vetting tool for new product, service, or technology requests, or to evaluate new or renewal GPO contracts. While value analysis can be used for these purposes, it was originally designed to determine whether you are buying the right product, service, or technology for the right functionality. Consequently, VA isn’t being utilized to its fullest capabilities at most hospitals, systems, and IDNs. The purpose of value analysis is the study of function and the search for lower-cost alternatives with equal or better quality. Here are some ideas on how to get started on the path of doing so.
Three Most Productive Methods to Select Value Analysis Projects to Save Even More Money If you aren’t employing Value Analysis Analytics™(*) to select your projects for a value analysis study (i.e. in-depth functional analysis of one or more of the products, services, or technologies you are buying) here is a list of three alternative VA project selection methods to do so:
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Value Analysis 101
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1. Pareto’s Law of Distribution or ABC Analysis: By sorting (highest to lowest) annual dollar purchase spend by commodity, vendor, or product, service or technology, you can target the top 25 highest spend items in each category of purchase for a VA study. For instance, one food service client I work with had meat, eggs, and coffee as one of their top 25 highest spend categories. Naturally, these commodities were the first items that I selected for a value analysis study, which ultimately yielded thousands of dollars of savings. 2. Products, Services, and Technologies Over Budget: Any product, service, or technology that is over budget for any given year should be scheduled for a value analysis study. The reason for selecting these over budget items is that these commodities could easily be wasted, misused, misapplied, or a value mismatch vs. just an increase in volume in a department’s procedures, tests, cases, etc. 3. Complex Big-Ticket Products, Services, and Technologies: You should be conducting value analysis studies at least every three years on your complex big-ticket products, services, and technologies, like cardiac rhythm devices, spinal implants, orthopedic products, purchased service contracts, etc. The goal of these four VA study selection methods is to help you to apply the value analysis methodology to the products, services, and technologies you are buying on a scheduled rather than adhoc basis. This way, you can always be in control of your spending.
The Downside of Not Doing Value Analysis Studies To continue to purchase products, services, and technologies automatically without conducting value analysis studies on your best value analysis savings opportunities is akin to a baseball pitcher throwing a pitch to the batter without a baseball or a quarterback trying to throw a touchdown pass without a football. The result being that you will not uncover those big double-digit savings that your healthcare organization desperately needs to stay afloat in these difficult financial times. *If you would like a FREE copy of “Value Analysis Analytics: The New Science of Savings” ebook to understand this new and better way to identify the best value analysis savings opportunities, e-mail me at bobpres@svahsolutions.com. Volume 8/Issue 2
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Utilization Management Winning with the Successful Value Analysis and Supply Utilization Mindset By Robert W. Yokl, Sr. VP, Operations — SVAH Solutions
There are hundreds of supply chain articles that are written on various change models, strategies, and techniques to reduce costs while maintaining or improving quality at healthcare organizations. One area that gets little attention, though I think is one of the most important aspects of being a value analysis or supply utilization change agent, is that of mindset (attitude, approach, and outlook). It does not matter how good your contracts, methods, systems, or leverage is when working on a cost reduction or quality initiative; you must have the right mindset to make it work. Otherwise, you will get shut down often by your customers and stakeholders, and that does not do you or your organization’s bottom line any good. This article is a mindset guide for helping you save more in less time and with greater results for you and your internal customers. These are my own proven mindset approaches that I use and teach my team every day and which I have honed and continue to perfect over my 28+ years in Value Analysis and Supply Utilization Management.
You Have to Believe That the Savings Are There and Attainable It does not matter whether you have the best and most accurate proof of why a hospital product category has increased by 23% from last year to the current year to date, or whether you have a rock
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Utilization Management
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solid cohort benchmark within your own system that shows Hospital A is 67% better on their IV set costs as compared to Hospital B (similar operating characteristics). When this information is presented to a value analysis committee and/or the hospital directors who manage the nursing teams who are running over, you will find that they will give you many reasons why they are different and that these savings are not real. The bottom line is, everyone is okay with change until it’s at their own doorstep. You have to hold fast. If they give you a reason for why they are different or why their costs spiked, then you can just go back to their volumes or your cohort benchmarks to prove it one way or another. The moment you stop believing or give up on your savings opportunities, you and your organization lose!
Welcome Pushback and Excuses as the Front Door to Change Yes, our peers who sit on our own value analysis teams and understand our goals and objectives to save money can quickly start giving a litany of excuses for why savings opportunities identified are not real. Here are just a few example exchanges that occur on just about any product or service: Our costs are up because we had a patient volume blip that month. Our costs are up because we had several people on vacation and the contractors used more product because they did not follow our procedures. We are so different that I question your benchmark and where it came from. Because we are so unique that most benchmarks don’t match up to us. You’re not a nurse, doctor, cath lab manager, facilities manager, etc. How can a non-subject matter expert tell me that there is a 23% savings on this product?
You should expect that your peers will try to use every communication tactic they can to try to shew you away from pursuing this savings opportunity further. It is not that they are not interested in saving money, because they are very interested in saving. They wonder more about if the squeeze is worth the juice. They are not used to supply chain or value analysis teams calling them out on how much of a product they use or costs of utilization in their departments. They just don’t want to upset the balance of their department(s) with any type of change whether it be simple or not. This is natural, especially when an outsider is pushing for changes in the name of saving money.
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Utilization Management
Robert W. Yokl
Don’t Accept the Single Reason Brush Offs I wish there were only one reason per supply category as to why supply utilization costs increase and/or are out of alignment at hospitals and health systems. But the reality is that it is rarely just one reason why costs are out of line, and not just the initial one reason given by customers and stakeholders. I like to refer to this as the knee jerk reaction to the supply utilization opportunity by the department heads and managers and sometimes even C-Suite level stakeholders. The only way to find out for sure is to delve into each category by each department, by product, and by each modality of use. If you accept all the single reason brush offs, then your job will become very easy, but your organization’s supply utilization expenses will run rampant and damage your bottom line further.
Sometimes You Just Need to Weather the Storm for the Good I find that communication roadblocks and questions are just a call for more information for you to allow the department heads to buy into the change that you are prescribing. Sometimes, you just need to enlist them to assist you in helping them correct their own utilization misalignments. When they buy in, they are going to be big winners and so will the patients. For instance, if your nursing departments are using too many IV sets by as much as 67% over the comparable hospital in your health system, that is probably not a good thing (dollars and patient quality of care wise) and should be investigated. Many times, high supply utilization is indicative of issues with patient care.
Become the Iceman from Top Gun In the movie Top Gun, the main rival to Maverick was the Iceman. The Iceman’s flying style was described as one who stays on your tail just waiting for you to make a mistake for him to attack. In supply utilization management, you may get talked away from time to time, but you must have the Iceman mindset and just keep coming back to the savings opportunity if it persists. Eventually, they are going to have to give in and allow you to work through this savings opportunity for bottom line results. One Nursing Director said to me half-jokingly at the beginning of a meeting that if I bring up exam gloves or foley catheters again she is going to scream! Their hospital is currently sustaining at the best in national cohort level for both product categories for their size and unique characteristics. Why? Because the supply utilization by volume metrics kept pointing to opportunities that needed to be addressed. Volume 8/Issue 2
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Utilization Management
Robert W. Yokl
Become a Supply Utilization Expert and Stop Trying to Become a Subject Matter Expert for Every Product Category Most of the challenges that I see are clinical in nature, and key clinicians and stakeholders are quick to point out that I am not a clinician or a subject matter expert in the product or service categories in these situations. The good news is that you and I don’t have to be a subject matter expert to work on any supply, purchased service, or capital equipment project. The organization you are working for is chock full of highly skilled, highly trained, and highly educated subject matter experts. You need to enlist them to help find out the reasons why utilization is too high and/or what is happening that is affecting costs. You should become an expert in supply utilization management and value analysis inside and out in concept, methods, and application. Supply utilization management is new to most healthcare organizations and to department heads and managers. You can guide them and utilize their expertise accordingly. They are the true subject matter experts who will need to address supply utilization because they are the ones that consume the products, services, and technologies of a healthcare organization.
Victory Garden Analogy Applies to Supply Utilization Management Envision healthcare supply chain as a metaphor to the beautiful Victory Garden that we see on television, except healthcare’s Victory Garden has over 1,500 major and minor categories of purchase and anywhere from 5,000 to 30,000 line items of purchase. Even on TV, Victory Garden hosts must deal with weeds through proactive (preventive treatments and filters) and reactive methods (pulling weeds). Because of the sheer size and volume related to healthcare’s Victory Garden, there is no doubt that there are going to be weeds (utilization savings opportunities). Some will be simple weeds (minor changes) that we can just pluck out, and some require more effort to find and deal with. Supply utilization management is the system and methodology that gives you the edge with your Victory Garden! Volume 8/Issue 2
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FAST-TARGET SAVINGS ASSESSMENT Value Analysis 101
Robert T. Yokl
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Value Analysis Advisor The Myth About Standardization Standardization Vs. Customization Robert T. Yokl, President/CEO, SVAH Solutions
Conventional thinking would tell you that standardization is a good thing because it cuts down on variation and creates economy of scale, thereby enabling a buyer to obtain a better price. However, what we have found in our value analysis advisory practice is that standardization is a good thing up to a point, but it can also cost your customers money. For example, when a hospital is 100% standardized on an item, the result is excessive cost. Approximately ten percent of the product is purchased off contract, 5% is over-specified, and 5% is wasted because one size doesn’t fit all customers. Whereas, a hospital that has customized its products (Figure 1) has 80% standardization, 10% specified for higher use, and 10% specified for lower end use. The bottom line is that the customized hospital is saving hundreds of thousands of dollars a year because it is providing the right products to its customers, while not undershooting or overshooting its target.
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Value Analysis Advisor
Robert T. Yokl Figure 1
Value Analysis Case Study: Exam Glove Customization Let’s use exam gloves as another example of how this concept works in the real world of value analysis. We have seen hundreds of hospitals, systems, and IDNs standardize on hypoallergenic disposable exam gloves for each and every employee (e.g. nursing, dietary, housekeeping, etc.) that is required to wear disposable gloves in their department. However, we recommend that healthcare organizations standardize on 80% or more on a vinyl exam glove house wide. Then, provide departments or employees who have special requirements (e.g. pharmacy, OB, outpatient, etc.) with their own specialty gloves to meet their exact functional requirements. This scenario would save a 250-bed community hospital hundreds of thousands of dollars annually on their exam glove purchases.
What Does This Mean to a Sales Representative? When planning on quoting any of your products, services, or technologies, make sure you apply the 80/20 rule, which is that 80% of your hospital, system, and IDN customers will be able to standardize 80% or more on one product, service, or technology. However, about 10% of your customers can
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use a lower end product, service, or technology, and 10% will need a higher end product, service, or technology to meet their exact requirements. To determine what product, service, or technology will be acceptable to each customer segment you will need to conduct interviews, surveys, and focus groups. Here is a mathematical representation (figure 2) of this 80/20 rule (or customization concept) in action:
Figure 2
Under this scenario, your customer would have saved $32,021 on your proposal and you didn’t drop your price by one penny. We can almost guarantee that you would win the bidding war, too, with this positioning of your product, service, or technology. This is because you performed a value analysis study to determine your customers’ exact requirements. I can guarantee you that your competition won’t spend the time necessary to perform this study. You win, hands down!
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Why Do Clinical Departments Need More Proof Than Just Total Spend? Supply and Value Analysis Managers have been challenged with providing evidence to show where clinical departments’ supply utilization is running over. Normally, when the utilization overrun is brought to the clinical department managers’ attention in the form of spend totals, their first reaction is that patient volumes or acuity was high for the period. That is where the conversation usually ends and that is where huge dollars are tied up in your hospital’s supply chain. How do we provide the proof clinical departments need when it comes to supply utilization?
Clinical Departments Are Not Cost Management Adverse Clinical departments are not cost management adverse. On the contrary, they will help manage utilization costs but require solid evidence when it comes to their major and minor product category overspends. Supply and Value Analysis Managers have been able to keep costs low for many years with various value analysis and contracting strategies, but there comes a time when the clinical departments must learn where they need to do better.
Only Clinical Departments Can Control Their Clinical Departmental Supply Utilization Clinical departments have traditionally managed the supplies that are used for care on their patients but they have been doing this without a solid reporting system to tell them where they can do better based on patient volumes and acuity. With a system in place, clinical departments can now visualize all of their major supply categories and make the necessary adjustments which in turn will save big dollars (11% to 23% supply utilization savings per clinical department) for the hospital. Volume 8/Issue 2
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Finally… A Proven System that Engages Clinical Department Leaders to Save Money in Supply Utilization $3.8 Million for a 350-Bed Hospital Recently, a 350-bed hospital reported clinical departmental savings of over $3.8 million. Why so much savings? Because they had never taken the utilization reporting to the departmental level and thus the savings were low-hanging fruit when it was brought to the clinical department leaders’ attention. Clinical Department Utilization Manager Software made it easy to pinpoint the exact category in the exact nursing unit and the exact product(s) that were causing the overspend. Prior to this, they did not have any idea where to look or how to prove the savings to the clinical department leaders.
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VA Perspective
Virtual Value Analysis Team Meetings: 5 Best Practices Virtual Value Analysis Meetings are Here to Stay Robert T. Yokl, President/CEO, SVAH Solutions
It is often mentioned in the media that the Covid-19 pandemic will change many practices forever. I tend to agree with them, especially when it comes to virtual value analysis team meetings. This is because they take less time, reduce travel, and improve attendance. With this said, here are five best practices for engagement in virtual value analysis meetings. 1. Create with your VA team your rules of virtual meetings: We all realize that virtual meetings are different from physical meetings. That’s why for best results you need a set of rules to guide your meetings. For example, don’t multi-task (do other work) during the meeting, find a quiet space to participate, speak up to get attention if you have something to say, etc. These can easily be created in 20 minutes at your first virtual VA team meeting.
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The Last Word
Robert T. Yokl
2. If you want better engagement, identify different people to assume different management roles at your VA meetings: For instance, Facilitator, Notetaker, Technical Support, and Timekeeper. These individuals can be of great assistance regarding meeting management, discussion flow, and engagement. 3. Send meeting agenda with attachments prior to the virtual VA meeting: This step might seem obvious to you, but too often forgotten during a busy day or week. 4. Create a line for participants to follow: Establish a method for call-in participants to speak so they don’t talk over each other. This might include calling on individuals by alphabetical order or using the order of entrance to the meeting. 5. Evaluate and continuously improve your virtual VA meetings: Your virtual VA meetings will get better over time if you allocate 5 to 10 minutes at the end of your meeting to evaluate what went right, what went wrong, and how to improve. Virtual VA meetings are here to stay after the pandemic has dissipated. Take advantage of the lessons learned during this period to strengthen your value analysis program with virtual VA meetings. Believe it or not, they could be even more effective, efficient, and productive than your physical VA meetings are now. (Source: Beth Kanter, October 2017)
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Want to Learn More About How You Can Help Your Organization Achieve 7% to 17% in Additional Supply Utilization Savings Beyond Price? Read Our Special Reports to Find Out How. Volume 8/Issue 2
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It’s Not Too Late... To Rescue the Supply Utilization Dollars That Are Drifting Away From Your Bottom Line
Why Lose Any Dollars If You Don’t Have To? Learn Today How You Can Rescue All of Your Utilization Dollars and Never Let It Damage Your Bottom Line Again. Volume 8/Issue 2
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