PN

Delivering On The Vision:
Keys To Achieving Breakthrough

Operational Performance
2013 Children’s Hospital Association
Annual Leadership Conference
October 14, 2013
Mark Mullarkey, Senior Vice President, Texas Children’s Hospital

Dan May, Managing Director, Huron Healthcare
Agenda
I. Summary
II. Texas Children’s Hospital’s Opportunities & Challenges
III. Governance Approach
IV. Transforming the Organization: Key Initiatives
V. Tracking Progress & Measuring Benefit
VI. Physician Engagement Strategies
VII. Lessons Learned
VIII. Questions
© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 2
Summary
 In late 2012 Texas Children’s Hospital (TCH) identified the need to

improve financial performance of the health system by over $50M.
 TCH launched a health system wide performance improvement
initiative name “Delivering on the Vision.”
 Partnering with Huron Healthcare, TCH identified over $60M of
improvements in labor, non-labor, clinical operations, clinical
documentation, and physician services.
 Over the past year, the TCH team worked with Huron to successfully
implement the identified improvement.
Agenda
I. Summary
VIII. Questions
Background
Texas Children’s Hospital (TCH) identified the need to improve financial

performance of the health system by reducing costs, increasing revenue,
and improving quality.
• $50 million gap between projected 2013 profitability and target

operating margin
• Federal and state funding reductions driving most of this gap
• Higher margins crucial for replenishing capital and expanding TCH
facilities
• Competitive threats driving expected gap closer to $75M
Project Background & Scope
 The TCH leadership team initiated a health system wide performance

improvement project named “Delivering on the Vision” in reference to
the their “Vision 2010 Initiative”
 Project assessed and addressed performance in every key
operational area:
– Labor Expenses
– Non-Labor Expenses
– Clinical Operations
– Clinical Documentation Improvement
– Physician Services
Business Imperative of $50M identified
Today's Operating Margin Gap

$'s in 000
$120,000
$100,000
$80,000 Estimate higher margins will be

required to maintain an Aa2
rating, replenish capital and
$60,000
expand facilities
$40,000
2013 Estimate
$20,000 $50 MM
$- June 12 YTD
$75MM
$(20,000)
$(40,000)
$(60,000)
2011 June 2012 YTD 2013 2014 2015 2016 2017
Run Rate
Target Operating Margin Projected Operating Margin
7
Agenda
I. Summary
VIII. Questions
Executive Steering Committee
PROJECT GOVERNANCE – IMPLEMENTATION
TCH Executive Sponsors

Susan MacDonald, EVP, RN Project Management
Huron Client Services Executive Randy Wright, EVP & COO
TCH: Mark Mullarkey
Daniel May
Huron: Robert Donnert

Randy Wright, EVP & COO Susan MacDonald, EVP Ben Melson, EVP & CFO
Dr. Mark Kline, MD, Physician in-Chief Dr. Michael Belfort, MD, Ob/Gyn in-Chief Dr. Charles Fraser, MD Surgeon in-Chief
Dr. James Versalovic, MD Pathology Dr. George S Bisset, MD Radiology Dr. Dean Andropoulos, MD Anesthesia
Dr. Gordon Schutze, MD Peds Dr. Manju Monga, MD OB/Gyn Dr. David Wesson, MD Surgery
Lori Armstrong, SVP & CNO Linda Aldred, SVP HR Mallory Caldwell, SVP Strategy
Mary Jo Andre, VP Quality John Nickens, VP Supply & Hosp Based Tabitha Rice, VP
Michelle Riley-Brown, SVP West Cris Daskevich, SVP Women’s Pavilion Alec King, VP Finance
Sherry Fultz, AVP Mark Mullarkey, SVP Ambulatory & OR Matt Girotto, AVP Surgical Services
Chanda Cashen, AVP OB/Gyn Diane Scardino, AVP Medical Practice
Labor Non-Labor Physician Svc Clinical Ops CDI

Huron: Greg Bryan Huron: Dan May Huron: Chris Smedley Huron: Larry Burnett Huron: Gerri Berg
TCH: Lori Armstrong TCH: John Nickens TCH: Mallory Caldwell TCH: Tabitha Rice TCH: Dan DiPrisco
© 2013
© 2012Huron
HuronConsulting Group.Group.
Consulting All rightsAllreserved. Proprietary &Proprietary
rights reserved. Confidential.& Confidential. 9
PROJECT GOVERNANCE – WORK TEAMS
Labor Non-Labor Physician Svc Clinical Ops CDI

Solution Team Solution Team Solution Team Solution Team Solution Team
Huron: Greg Bryan Huron: Dan May Huron: C. Smedley Huron: Larry Burnett Huron: Gerri Berg
Huron: Irene Walsh Huron: P. Zimmerman TCH: Mallory Caldwell Huron: Brad Stater Huron: S Manierre
TCH: Lori Armstrong TCH: John Nickens TCH: T. Johnson TCH: Tabitha Rice TCH: Dan DiPrisco
TCH: M. Riley-Brown TCH: D. Scardino MD Leaders: TCH: G. Parazynski Coord: J. Austin
Coord: L. Toures TCH: Dr. D. Roth Dr. Shutze, Dr. Coord: G. Erwin
Coord: J. Estes Wesson, Dr. Monga Physician
Nursing Coord: M. Wilrich Case Education
Work Team Nursing Management Work Team
Work Team Work Team
Perioperative Pediatrics
Pharmacy Coding –
Work Team Work Team Patient
Work Team Reconciliation
Placement Work Team
Clinical Lab OB/Gyn Work Team
Ancillary Work Team Work Team
Work Team Care
Surgical Surgery Variation
Work Team Work Team
Work Team
Support
Services Cath Lab
Care
Work Team Work Team
Coordination
Non-Clinical Work Team
Corporate Work Team
Work Team
Food/EVS
Work Team
Surgical Work
Team
© 2013
© 2012Huron
Agenda
I. Summary
VIII. Questions
Assessment: Key Findings
 TCH’s growth in spending had been greater than its growth of revenue over the past
year, creating an imperative to reduce spending; early intervention is TCH’s motto.
 The following elements have prompted TCH to reduce spending:
 Staffing levels had risen faster than what has been budgeted
 Annual non-labor /supply chain spending had risen faster than what has been budgeted
 Funding of the Baylor College of Medicine had increased faster than what has been
budgeted
 TCH lacked standardization in key areas of operations, vendor contracting, and

clinical processes of care.
 TCH lacked a long term plan that integrated physician capacity and recruitment,
support staff needs, facility space needs, and required capital expenditures.
12
Assessment: Key Findings
 TCH lacked an integrated care management program, consistent coordinated
interdisciplinary meetings, and regular adherence to evidence based standards of
care for length of stay management.
 TCH lacked a productivity management tool to help department leaders and

providers to manage their labor costs and flex their staffing to changes in volume.
 TCH lacked an effective position control process to manage the hiring decisions
across the organization and an effective process for monitoring and managing
premium labor.
 TCH’s management to staff ratio was inconsistent across different areas.
 TCH lacked a clinical documentation management process for optimizing coding

and reimbursement of future Medicaid APR-DRG patients.
13
Total Opportunity Identified from Assessment
TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area Low Mid-Point High
Non-Labor $7,330,000 $8,847,500 $10,365,000
Labor $8,412,000 $12,297,000 $16,182000

Clinical Documentation $6,772,500 $9,030,000 $11,287,500
Clinical Operations $5,900,000 $9,350,000 $12,800,000
Physician Services $15,433,000 $20,651,150 $25,869,300
Annualized Total $43,847,500 $60,175,650 $76,038,800
Agenda
I. Summary
I. Non-Labor
II. Labor
III. Clinical Documentation
IV. Clinical Operations
V. Physician Services

Executive Summary: Non-Labor
Strengths
 GPO Compliance
 Clinical practice and product choices are strongly influenced by evidence based literature and
research
 Texas Children’s Hospital performs innovative, cutting-edge procedures. These procedures
often require extensive supply resources
Opportunities
 Majority of savings are related to standardization and utilization of supplies and services
 Some of the cost savings opportunities may require administrative support and leadership
Non-Labor Opportunity Identified
NON-LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Area Low Midpoint High

Medical/Surgical $660,000 $705,000 $950,000
Surgical Services $700,000 $850,000 $1,000,000
Cath Lab & Imaging $270,000 $330,000 $390,000
Laboratory $800,000 $1,000,000 $1,200,000
Pharmacy $2,000,000 $2,250,000 $2,500,000
Purchased Services $1,700,000 $2,100,000 $2,500,000
IT $550,000 $687,500 $825,000
Food Services/EVS $650,000 $825,000 $1,000,000
Agenda
I. Summary
I. Non-Labor
II. Labor

Labor Opportunity Identified
LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

AREA LOW MIDPOINT HIGH
Nursing $2,326,000 $3,757,500 $5,189,000
Clinical Ancillary $2,720,000 $4,025,500 $5,331,000
Non-Clinical Support $1,825,000 $2,727,000 $3,629,000
Administrative/Financial $1,541,000 $1,787,000 $2,033,000
Strengths
 Management is open and supportive of change and improvement
 Quality of talent is strong
 Passionate about Texas Children’s Hospital
Opportunities
 Implement discipline and tools for successful productivity management
 Design an organizational structure, span of control and accountability process to support strategic plans
 Review/revise/support system-wide position requisition and control process
Labor Opportunity by Facility
FTEs Total Main Campus Pavilion West Campus

Key Operational Areas Low High Low High Low High Low High
Nursing 24.0 53.5 16.0 45.5 4.0 4.0 4.0 4.0
Clinical Ancillary 33.8 66.1 28.2 57.7 0.6 0.8 5.1 7.6
Support Services 29.4 50.5 17.7 34.1 7.1 11.2 4.6 5.2
Financial/Administrative 21.5 28.8 21.5 28.8 0.0 0.0 0.0 0.0
TOTAL 108.7 199.0 83.4 166.1 11.7 16.0 13.7 16.9
Dollars Total Main Campus Pavilion West Campus
Key Operational Areas Low High Low High Low High Low High
Nursing $2,326,000 $5,189,000 $1,467,000 $4,330,000 $480,000 $480,000 $379,000 $379,000
Clinical Ancillary $2,720,000 $5,331,000 $2,276,000 $4,689,000 $26,000 $34,000 $418,000 $608,000
Support Services $1,825,000 $3,629,000 $1,200,000 $2,717,000 $348,000 $596,000 $277,000 $316,000
Financial/Administrative $1,541,000 $2,033,000 $1,541,000 $2,033,000 $0 $0 $0 $0
TOTAL $8,412,000 $16,182,000 $6,484,000 $13,769,000 $854,000 $1,110,000 $1,074,000 $1,303,000
Flexing Staffing to Demand
KEY IMPLEMENTATION APPROACH
Flexing Staffing to Volume

Volume to staffing regression correlations indicate 77% of patient care units are
not flexing efficiently to census
Note: R2 of 1.0 indicates the regression line perfectly fits the data
Agenda
I. Summary
I. Non-Labor
II. Labor

Clinical Documentation Improvement Opportunity
CLINICAL DOCUMENTATION IMPROVEMENT - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

Improved Reimbursement After CDI $6,772,500 $9,030,000 $11,287,500
Strengths
 The coding staff has an awareness that chart documentation needs improvement
 The coding staff desires to embrace change
Opportunities
 Coding opportunities were found that would significantly affect reimbursement with APR-
DRGs
 Coding opportunities were found that would affect severity of illness and risk of mortality
which would increase the case mix index (CMI)
© 2013
© 2012Huron
Case Review
CLINICAL DOCUMENTATION IMPROVEMENT
The following summary provides the results of an analysis conducted

on 75 cases reviewed during the assessment:
TCH’s TCH’s Improved

Incremental Change
Reimbursement Reimbursement at Reimbursement (APR-
Total Charges With Improved
at Current Rate of APR-DRG DRG) After
of the 75 Charts Documentation
36% of Charges Rate Implementation
$ 7,316,055 $2,633,781 $2,403,722 $3,191,981 $788,259
Agenda
I. Summary
I. Non-Labor
II. Labor

Clinical Operations Assessment Opportunity
CLINICAL OPERATIONS - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

Annual Length of Stay Benefit $5,900,000 $9,350,000 $12,800,000
Strengths
 Organization has been primed for change by the current leadership
 Leaders at all levels expressed interest in obtaining data to support decision making and increase
accountability
 Case Management leadership has outlined an appropriate vision for the future of their department
Opportunities
 Patients are staying longer than medically necessary and are not transitioning to a lower level of care
in a timely manner
 Without operational process improvement and a bed allocation analysis, TCH will not have the ability
to serve additional inpatients without operating above 85% utilization, which hinders patient
throughput
 No centralized tool is being used to track key throughput metrics. These metrics should be used
daily/weekly to support comprehensive patient flow improvement.
Length of Stay Opportunity
MAIN CAMPUS
Average Length of Stay for Top 10 APR-DRGs

50
Opportunity Days: 446
Volume: 14
45 Volume: 10
40
Average Length of Stay (Days)
35
30
25 Volume: 27
Benchmark
20
Volume: 27 TCH
15 Volume: 90 Opportunity Days: 415
Volume: 186
Opportunity Days: 728 Opportunity Days: 585

10 Volume: 200 Volume: 216
Opportunity Days:
920 Opportunity Days: 512
Volume: 891 Volume: 698
5
0
Appendectomy
Post-Op, Post-Traumatic,
Cardiac
Other
Valve
Device
Procedures
Malnutrition,
Infectionswithout
FailureCardiac
to ThriveCath
& other Nutiritional
Seizure
Cardiac
Disorders
Defibrillator & Heart
Craniotomy,
Assist Implant
except
Procedure
Cardiac
for Trauma
Cath
withwith
Diagnosis,
Circulatory
Rehab,
Disorder
Other
Aftercare
Hepatobiliary,
or Other Contact
Pancreaswith
& Abdominal
Heath Service
Procedures
Notes: except for Ischemic Heart Disease
Listed in order of descending opportunity days
TCH Date Timeframe: June 1, 2011 to May 31, 2012
Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry
Benchmark: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle)
© 2013
© 2012Huron
Length of Stay Opportunity
MAIN CAMPUS
35% of TCH patients have excess days. The delineation of those patients by number of excess
days is outlined below.
Excess Days Variance over Benchmark Length of Stay

60%
49%
50%
40% of cases have a variance of 2 to 11 days
40%
30%
20%
20%
10% 10%
10% 6% 5%
0%
> 0 to < 2 Days 2 to < 4 Days 4 to < 6 Days 6 to < 11 Days 11 to < 20 Days 20+ Days
Notes:
Timeframe: June 1. 2011 to May 31, 2012
Population: All Main Campus patients, all APR – DRGs except those related to newborn, rehabilitation and psychiatry
DRGs: APR – DRGs
Source: 2010 PHIS data (Atlanta, Boston, CHOP, Cincinnati, Dallas, LA, Seattle)
© 2013
© 2012Huron
Length of Stay Benefit Opportunity
MAIN CAMPUS
Clinical Operations Financial Benefit Low High

Length of Stay Benefit
• Reduction in 4,800 to 9,700 patient days results in the following benefit:
• Capacity created to serve an additional 450 to 930 patients annually (50% backfill)
$5.9 M $12.8M
• Cost savings associated with reducing 2,400 to 9,700 patient days (50% cost savings)
Demand Cost Backfill Patient Days Opportunity Opportunity

Backfill Savings (Number of Reduction Low High
Percentage Percentage Cases) (Associated with
Cost Savings)
50% 50% 700 3,600 $5.9 M $12.8 M
60% 40% 800 3,000 $8.3 M $17.7 M
70% 30% 1,000 2,200 $10.6 M $22.6 M
80% 20% 1,100 1,400 $13.0 M $27.6 M
90% 10% 1,200 700 $15.4 M $32.5 M
100% 0% 1,400 0 $17.7 M $37.4 M
Notes:
Benefit model incorporates lost revenue associated with reducing length of stay of patients with payers who reimburse based on percent of charges (except Medicaid given
the upcoming reimbursement change), which includes 70% of the total patient days
Alec King, Vice President of Finance, reviewed and approved the benefit model methodology
50% backfill estimate is based on conversations with several TCH senior executives
Includes Medical/Surgical patients (excludes NICU, newborns, chemical dependency, psychiatry, rehabilitation and ungroupable) who discharged 6/1/ 2011 – 5/31/2012
© 2013
© 2013Huron
Agenda
I. Summary
I. Non-Labor
II. Labor

Physician Services Opportunity
PHYSICIAN SERVICES - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY
Clinical Efficiency $15,000,000 $20,000,000 $25,000,000

Non-Provider Labor (1) $ 433,000 $ 651,150 $ 869,300
Opportunities
 Continue support of the TCH/Baylor mission through process improvements including, but not limited to:
 Increase provider throughput and revenue
 Improve patient flow and access in clinics by improving scheduling templates, utilization of support staff
and standardizing staffing models where appropriate
 Refine CART model to tie revenue to expenses
 Align labor costs, revenue and production to directly correlate with appropriate cost centers
(1) Non Provider Labor does not include Baylor staff as they were not accounted for in the Labor Analysis
Clinical Efficiency
wRVU Gap to
Potential Net wRVU Gap to
Number of New full time Sullivan Potential Net
Clinical Total wRVUs Collections to FPSC FTE
Department Physicians in Total FTEs FTES (hired Cotter FTE Collections to
FTEs Annualized Sullivan Cotter Adjusted
analysis After 7/1/2011) adjusted FPSCr Median
Median Median
Median
Pediatrics 617 489.89 290.14 63.00 1,066,278 329,140 $18,309,820 666,620 $36,840,622
Surgery 58 56.27 43.13 8.00 300,896 29,243 $2,005,042 80,772 $5,979,215
Obstetrics/
36 33.90 25.55 22.00 77,223 77,596 $4,943,768 103,576 $6,748,980
Gynecology – Baylor
Obstetrics/
13 13.00 13.00 **0 112,137 5,187 $523,101 9,476 $923,837
Gynecology - TCH
Anesthesiology 51 49.71 40.48 3.00 408,697 74,476 $2,276,571 * *
Pathology 21 21.00 9.20 6.00 42,108 8,859 $535,666 11,628 $706,526
Pediatric Radiology 26 23.90 20.00 0.60 109,555 15,963 $1,374,537 56,545 4,585,666
Total 822 687.67 441.50 102.60 2,116,894 540,464 $29,968,505 928,617 $55,784,846
* Providers were all acquired after 7/1/2011 but because the practice was already established all providers were included in analysis
** No benchmark for anesthesiology available in FPSC survey
Agenda
I. Summary
VIII. Questions
Timeline
Develop Initiatives Implement Initiatives Monitor Benefits

Months 1 - 3 Months 3 - 12 Months 9 – 12+
 Organize project teams  Compile improvement  Implement residual

 Establish baseline measurement documentation program
criteria  Train and educate staff  Ensure management
 Identify and quantify financial benefit  Implement improvement plans has accepted
initiatives and initiatives accountability
 Complete detailed operational  Implement management tools and  Monitor financial results
ACTIVITIES
analysis reporting  Transition project

 Build business case for specific  Empower management and drive management office
initiatives accountability
 Obtain approval to implement  Align organization structure to
initiatives support changes
 Implement detailed improvement  Begin measuring results
ideas and plans
Knowledge Transfer, Empower Management and Drive Accountability

DELIVERABLES
 Work steps completed for high  Work steps completed for  Residual work steps completed
priority initiatives additional initiatives for all initiatives
 Benefits tracking and  Benefits tracking and
monitoring tool monitoring tool
 Monitoring of savings
© 2013
© 2012Huron
Project Scorecard - Example
Delivering on the Vision Project Scorecard

Area Savings Timeline Issues
Non Labor
Labor
Clinical Documentation
Clinical Operations
Physician Services
Proceeding as planned At risk for trending off plan Require immediate attention
Non-Labor Project Scorecard (partial example)
Key Status Summary Issues Action/ Next Steps

Updates /Barriers
 Monitored initiatives at a confirmed value of $13M  None  None
Non-Labor  All teams working to complete implementation and
monitoring of remaining initiatives
 Identified to 179% of high goal  None  Monitor remaining
Purchased  Implemented to 166% of mid-point goal initiatives
Services  $1M in additional identified initiatives being completed
 Identified to 505% of high-goal  None  None

Information
 Implemented to 605% of mid-point goal
Technology
 All initiatives have been implemented
 Identified to 64% of high goal  Delays to a  Implement and monitor

 Implemented to 6% of mid-point goal number of remaining initiatives
Laboratory
 $700K in additional identified initiatives remaining to be initiatives being
implemented resolved
Proceeding as planned At risk for trending off plan Require immediate attention
Summary of Key Project Results
 Improved margin by $32M in FY 13 YTD

 Improved flexing of staff, reduced FTEs, and developed and implemented
a new labor productivity system; also developed worked hours per unit of
service (WHPUOS) standards for key departments
 Reduced non-labor supply and purchased services costs and improved
340B benefits
 Reduced length of stay, implemented interdisciplinary care rounds,
implemented Teletracking and other tools
Summary of Key Project Results
 Improved clinical documentation producing an increase in severity

adjusted case mix index
 Improved physician productivity
 Increased transparency with physicians and staff
 Improved quality by standardizing staffing levels and reducing care
variation
Benefit Scorecard – Overall Project (as of 09/ 2013)
Target Identified Implemented Realized Benefits

Solution Group
Benefits Benefits Benefits
FY 13 YTD
Non-Labor $8,847,500 $17,786,447 $14,011,071 $7,558,869

Labor $12,297,000 $13,725,177 $9,382,125 $5,276,000
Clinical Doc. $9,030,000 $9,030,000 $ TBD $ TBD
Physician Services $20,651,150 $14,263,000 $9,540,200 $8,089,000
Clinical Operations $9,350,000 $9,350,000 $11,874,500 $11,874,500
LOS Reduction (Days) 7250 7250 10,560 10,560
Total $60,175,650 $64,154,624 $44,807,896 $32,789,369
% of Target 107% 72% 52%
• Clinical Documentation tracking begins in 10/2013 following Medicaid APR-DRGs start in TX on 9/1/13
Labor – FTE’s
Labor – Salary & Benefit as % of NPSR
• Net Patient Service Revenue is up

11.9%
• Salary and Benefit Expense is up
just 5.9%
Labor – Control of Temp Expense
Estimated Financial Impact
ACTUAL PAYROLL DATA VS FY13 BUDGET
Average Paid FTE Variance from FY13 Budget= 386.7 paid FTE
Cumulative Paid Dollar Variance by Pay Period (FY13 to PPE 4/13/13) =
$16,013,200
Notes: In scope labor depts only; Dollars estimated based on avg wage rate per dept and include a 15% benefit factor
Project Results:
Clinical Operations Realization Schedule
Projected Annual
Benefit includes:
+ Demand Backfill
+ Cost Savings
– Revenue Loss
Confidential. 44
Physician Services
COUNTS %AGES COMPLETE
Overall Overall
Not In Not In Past
Specialty Started Process Past Due Complete Total Started Process Due Complete
OBG BCM 1 4 0 6 11 9% 36% 0% 55%
POGC/WSH 5 5 0 5 15 33% 33% 0% 33%
OBG MFM 0 5 0 8 13 0% 38% 0% 62%
A&I 0 1 0 7 8 0% 13% 0% 88%
ADO 2 1 2 10 15 13% 7% 13% 67%
AGP 0 0 0 0 0
CAR 0 4 0 9 13 0% 31% 0% 69%
DER 5 0 0 7 12 42% 0% 0% 58%
DEV 0 0 0 0 0
END 10 10 0 1 21 48% 48% 0% 5%
HEM/ONC 0 6 0 6 12 0% 50% 0% 50%
INF 0 0 0 0 0
NEP 0 0 2 14 16 0% 0% 13% 88%
NEU 0 1 1 12 14 0% 7% 7% 86%
NGI 0 0 2 12 14 0% 0% 14% 86%
PMR 0 0 0 0 0
PSY 0 0 0 0 0
PUL 0 5 0 6 11 0% 45% 0% 55%
RHE 0 4 0 3 7 0% 57% 0% 43%
CHS 0 5 0 0 5 0% 100% 0% 0%
NSU 0 0 0 6 6 0% 0% 0% 100%
OPH 10 0 0 0 10 100% 0% 0% 0%
ORT 0 3 3 10 16 0% 19% 19% 63%
OTO 1 4 0 9 14 7% 29% 0% 64%
PLA 3 0 1 4 8 38% 0% 13% 50%
PSU 0 3 0 11 14 0% 21% 0% 79%
SYSTEM WIDE 1 12 2 16 31 3% 39% 6% 52%
TOTALS 38 73 13 162 286 13% 26% 5% 57%
Updated as of 7.17.13
Access - 3rd Available
Specialties Tracked and Included:
Renal Neurology Genetics Development Pedi
Physical Medicine Clinic Psychology Service Plastic Surgery Dental
Rheumatology Orthopaedics Pediatric Surgery Congenital Heart Surgery
Allergy & Immunology Urology Retrovirology Dermatology
Endocrine Ophthalmology Orthodontics Cardiology
GI & Nutrition Pulmonary Medicine Res. Primary Care Hematology/Oncology
Otolaryngology Psychiatry - 17O Neurosurgery
Adol/Sports/Med/Yng Womens Gynecology Inf. Disease
Internal Texas Children’s Pediatrics Referral
Rate
TCH: Mid-Project Experience Survey Results
Clinical Operations Update - June 2013
Patient Day Results at a Glance …
Most Recent Three-Month Period (Mar-May ‟13) Key Accomplishments to Date
Accumulation
vs. Historic Period (June ‟11-May „12)
for Project Period Care Management
• Engaged over 20 care managers in weekly Clinical High Risk meetings to
(Nov-May FY13) Severity-adjusted average length of stay
collaboratively address and resolve barriers to efficient patient flow, efficient care,
transitions to the next level of care and hospital reimbursement
decreased by 15.9 hours per patient, an 11% • Implemented Morrisey, a Care Management software tool for discharge planning,
reduction compared to historic period! utilization review, and other work flow management
10,000 Care Progression
• Established 11 daily and multidisciplinary Care Progression Rounds (CPR) across over
9,000
8,000
• Patient flow efforts increased capacity to 35 services to proactively plan for patient's discharge with the care team and the
7,250
serve 5,531 more patient days, cumulatively patient/family
• Conducted over 1,200 CPRs (and counting) since project start, with participation by
5,531
7,000
6,000
• 51% decrease in Red Acute Care Census
over 500 physicians, nurses, and supporting care team members
5,000 Alert hours Room Management
4,000 (34 in Mar-May „13 vs. 69 in Mar-May „12) • Centralized Main campus bed assignment process which included the implementation
76%
of goal 3,000 • 9% decrease in EC boarding time average of TeleTracking (TT), an electronic bed board; Trained over 600 nurses, unit clerks,
2,000 EVS, and Patient Escort staff members on TT tool
(Mar-May „13 vs. Mar-May „12) • Redesigned the EVS & Patient Escort staffing model to support a dedicated discharge
1,000 • 14% decrease in readmissions within 48 cleaning team and discharge transportation process; automated discharge cleans and
hours transportation requests with use of the TT tool
(38 in Mar-May „13 vs. 44 in Mar-May „12)
Year End Net Days Delivering on the Vision: TM
Goal Saved TeleTrackingXT : An Update on the Centralized Bed
Care Process Updates
Assignment Process
7,250 5,531 The focus of the Care Process (CP) initiative is on creating a
foundation and work processes to support physician adoption of
• Room Management has placed approximately 1,500 patients in beds
“It's incredible when I think about the evidence-based standards of care. since go-live (5/29)
results we've had recently…it is making • Pneumonia Care Process team is developing a care pathway which • EVS has conducted over 1,200 discharge cleans since go live
a big difference.” supports earlier discharge preparation, cohorted beds, and respiratory
• Patient Escort has performed over 300 discharge trips since go live
-Executive Leadership
support
• DKA Care Process team is developing a business case for a Diabetes “[Requesting a bed] through TeleTracking makes my job so
“I’m on service this week and I have to tell much easier. I can trust that things will happen without me
you about how much the energy has Center for Excellence which includes pathway and education and
changed on the floors! Everyone’s talking translator availability; initiating hospital benchmarking for insulin pen vs. interfering and getting on the phone.”
about and planning for discharges.” insulin vial only on formulary -Charge Nurse
-Hospitalist
Clinical Documentation Initiative – Main Campus
BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION
Clinical Documentation Initiative - West Campus
BASELINE VERSUS IMPACT OF CDI PROGRAM IMPLEMENTATION
© 2013 Huron Consulting Group. All rights reserved. Proprietary & Confidential. ‹#›
Agenda
I. Summary
VIII. Questions
Physician Engagement Strategies
 Physician leaders should be involved from the beginning

 Transparency is important when working with the physicians
 Accurate data presentation and interpretation is key to get the physicians
engage
 Inclusion of medical staff at all levels and particularly in all work teams
 Communicate, communicate, communicate
Agenda
I. Summary
VIII. Questions
“Leadership always impacts and influences outcomes, not
some of the time, but all of the time.”
Labor Non-Labor
John Nickens
Michelle Riley-Brown VP
Lori Armstrong, MSN, RN Diane Scardino
SVP Hospital Based Services and
CNO, SVP TCH West Campus AVP
Supply Chain
Ambulatory Servcies
Clinical Operations Clinical Documentation
Tabitha Rice Jackie Ward, RN Joan Shook, MD Dan Diprisco

SVP Director Chief Safety Officer Director
Clinical Support Cancer Center Physician Revenue Cycle
Services
Physician Services
Mallory Caldwell Trent Johnson

SVP Strategy Director
Ambulatory Services
But it takes a team…..a very large team!
Jennifer Upshaw Sherry Fultz
Dr. Carol Altman Dr. Michael Braun
John Henderson
Sandra Tillis Dr. Charles Gay
Mike Towne
Dr. Scott Dorfman Sarah McMaster Dr. Doug Ris
Mari Trace Dr. Al Hergendroeder

Dr. Jed Nuchtern
Dr. Peter Hiatt Robert Turner
Kim Nguyen Kara Lenahan
Dr. Ryan Himes
Matt Timmons Cindy Miley
Ryan Breaux
Dr. Jake Kushner Dr. Angelo Giardino
Tuhin Pakaj
Diane Scardino
Binta Baudy Dr. Brigetta Meuller Travis Crum
Dr. Ellen Friedman Stephanie Ramirez
Dr. David Roth Dr. Theresa Wright
Dr. Gordon Schutze
Helen Currier
Dr. Robert Zeller
Daniel Fischer Barkha Chandwani Dr. David Coats
Tina Ninan Dr. Monju Monga
Dr. Thomas Shaw Mary Kana
Jeff Reinhart
Dr. Daniel Penny Lorraine Cogan Jackie Ward
Dr. Jordan Orange Dr. Jennifer Deitrich
Dr. William Phillips
Dr. Gary Clark Trent Johnson
Dr. Efrain Bleiberg Dr. Thomas Luerssen
Jennifer Evans Laura Hardy
Matt Girotto Chanda Cashen Dan Diprisco
56
Lessons Learned
 Successfully implementing enterprise-wide performance projects

requires:
• Executive engagement and support
• Physician engagement and support
• Transparency and accountability
• Setting realistic improvement goals for each solution
• Communicating savings targets per initiative to all affected parties
• Communication and early buy-in from all stakeholders to ensure timely
implementation
• Effective benefit realization monitoring and presentation – measure,
measure, measure. Data and trends as “pictures”
Lessons Learned
 Once redesign efforts are completed the organization must invest in

resources to continue monitoring to hold the gains
- Ongoing (although maybe modified) governance structures
- Hardwired reporting mechanisms
Agenda
I. Summary
VIII. Questions
Today’s Presenters
Mark Mullarkey
Senior Vice President
Texas Children’s Hospital
mwmullar@texaschildrens.org
1-832-824-1262
Dan May
Managing Director
Huron Healthcare
dmay@huronconsultinggroup.com
678-576-0408

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Delivering On The Vision:

Keys To Achieving Breakthrough

Mark Mullarkey, Senior Vice President, Texas Children’s Hospital

 In late 2012 Texas Children’s Hospital (TCH) identified the need to

Texas Children’s Hospital (TCH) identified the need to improve financial

• $50 million gap between projected 2013 profitability and target

 The TCH leadership team initiated a health system wide performance

Today's Operating Margin Gap

$80,000 Estimate higher margins will be

Target Operating Margin Projected Operating Margin

TCH Executive Sponsors

Executive Steering Committee

Labor Non-Labor Physician Svc Clinical Ops CDI

Labor Non-Labor Physician Svc Clinical Ops CDI

 TCH lacked standardization in key areas of operations, vendor contracting, and

 TCH lacked a productivity management tool to help department leaders and

 TCH’s management to staff ratio was inconsistent across different areas.

 TCH lacked a clinical documentation management process for optimizing coding

TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

Area Low Mid-Point High

Non-Labor $7,330,000 $8,847,500 $10,365,000

Labor $8,412,000 $12,297,000 $16,182000

Clinical Operations $5,900,000 $9,350,000 $12,800,000

Physician Services $15,433,000 $20,651,150 $25,869,300

Annualized Total $43,847,500 $60,175,650 $76,038,800

V. Tracking Progress & Measuring Benefit

NON-LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

Area Low Midpoint High

Surgical Services $700,000 $850,000 $1,000,000

Cath Lab & Imaging $270,000 $330,000 $390,000

Laboratory $800,000 $1,000,000 $1,200,000

Pharmacy $2,000,000 $2,250,000 $2,500,000

Purchased Services $1,700,000 $2,100,000 $2,500,000

IT $550,000 $687,500 $825,000

Food Services/EVS $650,000 $825,000 $1,000,000

Annualized Total $7,330,000 $8,847,500 $10,365,000

V. Tracking Progress & Measuring Benefit

LABOR - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

FTEs Total Main Campus Pavilion West Campus

Dollars Total Main Campus Pavilion West Campus

Nursing $2,326,000 $5,189,000 $1,467,000 $4,330,000 $480,000 $480,000 $379,000 $379,000

Financial/Administrative $1,541,000 $2,033,000 $1,541,000 $2,033,000 $0 $0 $0 $0

TOTAL $8,412,000 $16,182,000 $6,484,000 $13,769,000 $854,000 $1,110,000 $1,074,000 $1,303,000

Flexing Staffing to Volume

V. Tracking Progress & Measuring Benefit

CLINICAL DOCUMENTATION IMPROVEMENT - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

The following summary provides the results of an analysis conducted

TCH’s TCH’s Improved

$ 7,316,055 $2,633,781 $2,403,722 $3,191,981 $788,259

V. Tracking Progress & Measuring Benefit

CLINICAL OPERATIONS - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY

Annual Length of Stay Benefit $5,900,000 $9,350,000 $12,800,000

Average Length of Stay for Top 10 APR-DRGs

Opportunity Days: 728 Opportunity Days: 585

Excess Days Variance over Benchmark Length of Stay

Clinical Operations Financial Benefit Low High

Demand Cost Backfill Patient Days Opportunity Opportunity

60% 40% 800 3,000 $8.3 M $17.7 M

70% 30% 1,000 2,200 $10.6 M $22.6 M

80% 20% 1,100 1,400 $13.0 M $27.6 M

90% 10% 1,200 700 $15.4 M $32.5 M

100% 0% 1,400 0 $17.7 M $37.4 M

V. Tracking Progress & Measuring Benefit

PHYSICIAN SERVICES - TOTAL ANNUALIZED ASSESSMENT OPPORTUNITY