Welcome to the 2021 Quality Summit. Thank you for sharing your time with us today. I have the distinct honor to introduce our speaker for the presentation, Fine Tuning Process, Best Practice Sharing, Amber Lopez. Amber is a value-based healthcare specialist at Baylor Scott and White Heart Hospital. She serves as the Registry Site Manager for the LAO Registry and has made great contributions to helping improve processes for collection of follow-up data. Welcome Amber, and thank you for sharing your time with us today. Hello everyone and welcome. Are you tired of dealing with system change, short-timers disease, and undefined processes? Well, let me welcome you to the LAO Fine Tuning Process, Best Practice. I will be explaining how we experienced and overcame some of these obstacles at our facility. I am Amber Lopez, a value-based healthcare specialist with the Baylor Scott and White Heart Hospital. I am a first-time presenter. I hope this information will be helpful, and at the end of the presentation, I will have my contact information for any questions that you may have, so let's begin. A little bit of information about our facility, Baylor Scott and White The Heart Hospital is a freestanding, full-service, cardiovascular specialty hospital. We are located in Plano, Texas. Our first doors opened in January of 2007. We are ranked top 50 in the nation for cardiology and heart surgery six times by the U.S. News and World Report. Now, quality improvement is a team effort, so let me introduce you to our team. We are the Healthcare Improvement Department. Our department consists of quality improvement personnel, registry site managers, a data support team that advocate for registry productivity and accuracy. There is a total of 11 of us, including our quality director. Our team is a firm believer of engaging and expanding for process improvement. The LAAO program, the Left Atrial Appendage Occlusion Program. We began in August of 2016 with just three physicians. We are one of the top 20 facilities per volume. Our current yearly average is 159 Watchman devices with 12 physicians now implanting. We did reach a milestone this year and performed over 500 total cases, so that was a big thing for our facility. Today's learning objectives, we will cover our process improvement initiatives that we underwent to improve our outcomes, our workflow efficiencies, how we optimized patient care and engaged our physicians. Now what is the LAAO registry? In short, it's a registry designed to access the prevalence, the demographics, the management and the outcomes of patients undergoing percutaneous catheter-based left atrial appendage occlusion procedures to reduce the risk of stroke. Now follow-up and longitudinal patient outcome tracking is required. This is one of my favorite registries. It does require a base chart abstraction as well as several follow-ups. So hospitals are required to submit a 45-day, a six-month, a one-year and two-year follow-up. The third and fourth year follow-up data is gathered through Medicare claims. The NCDR registry collects all follow-ups performed in the required timeframes. So our 45-day, our six-month, our one-year and our two-year. Now the LAAO follow-up visits do not require labs or diagnostic studies to be performed at any given follow-up assessment. Now we'll be at the discretion of the provider and the facility. Now having said that, all elements are provided in the NCDR data collection tool so that the individual providers and facilities may have their own protocols of what is required at each follow-up interval based on device selection and directions for use. Now in the past year, our department underwent several transitions. We had a new EHR platform. We moved from Allscripts to Epic. We caught a bad case of the short-timers disease. We experienced downsizing due to the COVID pandemic. We had new hires. We were training employees without a defined process in place and then trying to train them virtually. We had inconsistent review and analysis of our chart abstractions. We experienced interdepartmental disconnect, just a lack of communication within our department and physicians. Again, COVID was new for everyone. So we had a lot of areas of opportunity to improve. So this last year left everyone a little strained. So all of these things provided an opportunity for our department to analyze our current state, identify our ideal future state, and then create and implement a plan. So we had to change our perspective. We were looking at the positive and thinking of the bigger picture. Yes, we had a new EHR platform. We moved to Epic. Epic has a new feature called Care Everywhere. So this assisted us in extracting our required follow-up cases for the LAAO registry. It's a feature that allows us to search and download follow-up documents from other healthcare facilities. Now, this feature has drastically cut down the time it would have taken to email or to call the cardiologist offices to request these records for these desired follow-ups. In regards to our short timers, we embraced the change and created a standardized process for our follow-ups. So it's no longer dependent upon one person's style for abstracting. For our new employees, they were given clearly defined roles and responsibilities, and our expectations were set at day one. We were able to speak the same language because acceptable follow-up documentation was clearly defined. For training, we created a written standardized LAAO registry follow-up guide. Now, this guide was given to all new employees, and it clearly defines all the follow-up timeframes, any available resources, and a hierarchy of visits we may use to abstract from, as well as frequently asked questions, case scenarios. Now, for inconsistent review, we implemented periodic auditing for our follow-up cases. So by ensuring that everyone is on the same page when it comes to abstracting our data. For interdepartmental disconnect, we had to slowly rebuild that relationship. So we attended all the LAAO case review meetings. We also sent out monthly compliance reports to our clinicians regarding their follow-up compliance. We were just present. We made sure that we were at every meeting, quality department was present, so we can just put our face back out into our hospital community. We created an access database that makes it easier for us to keep track of all of our cases and their follow-ups. We can also create and generate reports and analyze that data. So as we know, data tells a story. So as we begin to analyze our registry data during our transition periods, we determined our story was an inconsistent one. So as we created and implemented change, we decided the cleanup period was needed to review our data within the registry. So we had an opportunity. We went back and reviewed our cases with our new process in place. Now using our new process, we were able to increase our compliance across all follow-up timeframes, thus creating a more refined story. So this graph describes our improvement with the LAAO follow-up compliance in the recommended window. Now the recommended window is the preferred timeframe for follow-up visits preformed at 45-day, 6-month, 1-year, and 2-year. So if you'll take a moment to look at our graph, the black is the NCDR 50th percentile benchmark. This is where we strive to be. Our prior process is in yellow. Our new process is in green. And if you will look at the gray, it will demonstrate how much percentage-wise we've improved from our old process to the new. So if you can see in every timeframe, for example, our 45-day, we've increased 10%. Our 6-month, we've increased 23.5%. And that is for every timeframe that we went back and reviewed. So this provided us a more accurate story of our data and where we need to focus on our process improvements. All right, now this graph describes our improvement with the LAAO follow-up compliance performed in the allowable window. So on the left-hand side, we have the listed allowable timeframe window for follow-up visits performed for the 45-day, 6-month, 1-year, and 2-years. Again, the black is the NCDR 50th percentile benchmark where we strive to be. Our prior process is in yellow. Our new process is in green. And then the gray is demonstrating how much we've improved. So again, you can see our 45-day, we've improved 10%. Our 6-month, we've improved to 22.5%. Again, that's with every timeframe we were able to increase. So some of our techniques we implemented to increase our workflow efficiency for LAAO are we simply standardized the process. We created a written standardized process tool for our LAAO follow-ups. We run a daily report of all of our LAAO procedures preformed the previous day via our EHR, our EPIC system. We then enter those cases into an access database. This database allows us to automatically calculate our follow-up timeframes. Now our access database was created in-house by a member of our team, Catherine Aguas. This is an example of what our database looks like. So if you'll look at number one, you can see where you can enter in the patient's name, date of birth, account number, medical record number, procedure date, discharge date. You can have as many fields as you like because this is something that you created in-house. If you'll click on number two, it will automatically fill those follow-up tables and the timeframes were automatically calculated and they are put on an appropriate spreadsheet. So if you come in for the day and say, I want to work on 45-day follow-ups, you'll simply click on the left-hand side, 45-day follow-ups, and all your cases will be there for you to abstract from. So if you'll look at numbers three, four, and five, these are some examples of the reports that we are able to run at our facility. We can run number three is a follow-up report. Number four, we can do a mortality list. Number five, we can run a report to see if a physician has completed all of their follow-ups. Now this number five is a report that we send out every month to the physicians to let them know, hey, these patients have had their appointments or these patients need appointments. Can you investigate? So it's just an easy way for us to keep track of what needs to be follow-up. We have optimized our patient care by doing our best to make our data real-time. By improving the timeliness of our data, we are quickly able to make changes or to implement processes to improve patient care or their outcomes. So we try our best to abstract base procedures at less than or equal to seven days. So it's abstracting our LAAO follow-up cases for the current month and the following month, trying our best to stay ahead. So if we see that there is no follow-up performed or scheduled for the next month, we can actively be proactively emailing that office just to say, hey, heads up, this patient needs an appointment or did we see this patient? It just lets them know where we're at. We submit our LAAO data weekly. Doing this allows us to look for trends in our data. We also set out time to review the NCDR dashboard on every Monday and we look for any outliers. This gives us an opportunity, one, to know our data, two, to further research any outliers before final submission into the NCDR registry, and three, just take time to seek clarification from the provider if we need it. Now it is said engaged physicians are dedicated to their patients and committed to the improvement of their organizations. So it's a common practice at our facility to report out data on a regular basis. That way it keeps everyone on the same page. We have the ability to identify trends early and then assess any areas of opportunity. Our physicians are also engaged because it's their data. So in cases where the data might have fluctuated, they are interested in discovering the reason why and then taking action. It also tends to take out the surprise factor when the data is finally publicly reported and published, because they've seen the data and they know ahead of time what is coming. The most common elements that we report on are the LAAO volume, our mortality rate, the intra or post-procedural life-threatening bleeds, any major vascular complications, intra or post-op, the LAAO procedures that were successful excluding our cancel procedures, the LAAO procedures including cancel procedures, and our follow-up compliance rates. Now this is a sample of the LAAO follow-up guide that we use at our facility. Again, it's something that we've created in-house. It lists our resources, our follow-up time frame guide, the location of the NCDR Learning Center for the LAAO follow-up class, our general follow-up process, follow-up lessons that we feel are important, for example, coding a deceased patient and loss to follow-up patients, how to contact the NCDR registry for questions, performing an obituary search, frequently asked questions. Again, the primary intent of the document is to standardize our abstracting practices that impact our metrics in regards to follow-ups being performed. Now because these resources are not static, it is important to continue to revise and update this guide on an annual basis with multiple team members. Now my counterpart, Christy Verschilden, has shared several quality improvement tools and improvement processes on the NCDR participant resource sharing site available for you to review. Now we are currently working on the LAAO registry follow-up guide that we use and hope to get it submitted soon and uploaded to the resource sharing site. Currently, she has out there the LAAO follow-up tracker, she has a productivity workbook, a validation workbook, and how to reduce backlog cases. At this time, I will be taking any questions that you may have. Thank you so much, Amber, for sharing that valuable information. That was a wonderful presentation. We do have just a few questions about your processes that you've implemented. One of the first questions we have here, you mentioned that you started originally in your program with only three physicians and now you have 12. Do you have any one physician champion out of that group that kind of helps lead the monthly meetings or ensure compliance, if you will? Or is it a situation where, you know, everyone's participating agreeably and you don't have any of those individual physicians that need a little more nurturing or encouraging to comply? We do have a physician champion and then we do have a program manager. So our physician champion is very good at, you know, making sure everybody's on the same page, all the new information is disseminated to the physicians. Our program manager is there for compliance. So if we have those offices who just we can't get a hold of, she is who we would go to to seek assistance. So it's a team effort, a lot of team effort here. Right, yeah. It's always helpful to have that one physician champion that can rally around and you can know you can go to when you, you know, run into situations where you need help. You talked about how part of this process, right, was just simply improving communication overall, right? And once you did that and had your routine meetings, right, things start falling in place. So I guess along those lines, you know, you talked about your program manager for people who might not be compliant or, you know, when you need a little bit more help or your physician champion. And you talked about a lot of your information comes from care everywhere. Correct. Because you're able to pull a lot from that in the EPIC product. What about all those other pieces that you aren't able to get from care everywhere? There's individuals who are reaching out to particular physicians or offices or practices. Is that your process? Right. So if we can't find it in care everywhere, we do, we send out a monthly report to our offices to say, hey, you know, these patients have been seen and these patients have not been seen. Have they, have we just not getting, you know, gotten the follow-up report for these patients? We try to let them know as advanced as we can. So if we're abstracting the follow-up cases a month out, they're aware and they can research for us. Maybe they just haven't scanned it in the system and we can't find it. Or maybe the patient actually needs an appointment and that way they follow up that way and let us know. So by being proactive and just kind of, you know, working with the clinics, we kind of are able to catch like anything that, you know, we might not just, we might've just missed. Do you, do you know, is care everywhere only for EPIC users? Yes, it's a feature. It is only. Particularly just EPIC. Okay. So there are circumstances with some of your providers that might not have the EPIC system. Correct. We still rely on them scanning in records and letting us know that they're available. Right. And you find that these monthly compliance reports that you send out have created a much more engaged kind of network who are willing to submit their information so that their reports look good, if you will. Once we've went back and reviewed and where they've seen that we've increased our compliance rates, you know, we got things like, you know, we knew we were doing this right. It's our numbers never reflected it. Thank you for taking the time and going back to review it. It just kind of reinforced that we were there for them. We were trying to help them not hinder them. So, I mean, it just built a stronger relationship with those clinics. Very nice. Very nice. Throughout this whole process, were there any big unexpected barriers that surfaced that really surprised you? And our biggest barrier was, you know, everybody abstracts differently. So, before we had our process in place, we would abstract the same chart and we would get, you know, different things. It just depends upon the abstractor. So, by standardizing the process, we were able to all be on the same page and abstract the same data the same way. So, there's no question. So, that was very surprising, a surprising finding, if you will, that people were abstracting differently. Right. It's always, you know, objective to what they see in the chart, you know. You showed two different slides that contained your graphs and the performance and before and after you implemented process. I'm just curious, on those graphs, when you report compliance, does that include patients who are lost to follow-up in those numbers? It does not. It does not. I actually pulled our loss to follow-ups for the last public report from last month. We didn't have any. We didn't have any. So, I pulled, again, for April that just came out and we had three for those whole time frames. So, they've been very few. That's incredible. That's incredible. That says a lot about your process, for sure. So, curious, with that, that really is an incredible number. Is there a process that you have in place to communicate to the patient, do you know? So, I know on your end, you're discussing a lot of the back-end abstraction, but to help promote, like, patients coming or, you know, not dropping off, is there a process in place that you know about? Internally, you're having a discussion with the patients to say, this is the expectation, you know, you'll need to have follow-up here, here, and setting the expectation up front with the patient? We do the expectation up front. When we have our shared decision-making with the patient, we tell them, you know, what our procedure is and the required follow-ups. So, that way, they're allowed to ask questions then, if they need more understanding, you know, we're there to sit with them and talk to them. And then, we reinforce it every time they come in. If they're coming in for a 45-day, we'll remind them, hey, you still have all these other visits you need to come in for. So, it's just a process of constantly reminding them and then calling them, hey, this is a reminder, your appointment's coming up. We've had a lot of having to do reminders during COVID because a lot of patients weren't willing to come out, but we can either do a teleconference, I mean, whatever they were more comfortable with, to get them in. Wonderful. Yeah, so, it sounds like you certainly dedicate, put a lot of effort into ensuring that they have that follow-up. That's wonderful. Tell me, at your monthly meetings, are you sharing performance information or metric information at your hospital's performance level, or are you also displaying and breaking everything down at the physician level, their performance? It depends on the meeting. For, like, our MEC meetings, it's basic hospital-wide, this is how we're doing. For our, like, our individual meetings, for our LAAL physicians, we have a set meeting that we will discuss that data with. And then, if we see a trend, we let them know, hey, these are the physicians that, you know, we need to look into or maybe pump them up or get them more involved, you know, what are we lacking here? So, in that meeting, are the physicians all present, that they're seeing each other's performance, or are you handling that one-on-one with the physician? No. No, we present all data. Okay. We present all physicians and all their data. And then, sometimes, it's like a competition between them. Oh, this doctor is doing better than me. Oh, no, that can't be, you know. So, it engages them in a way. Right. And they're able to discuss, perhaps, the case or what happened and reasons why, and that's another part of the improvement. That's great. With their peers, they're able to kind of see, you know, what happened. Right. Right. That's wonderful. The other question we have here, you talked about your base abstraction time frame, and you try to do that in seven days or less. Can you elaborate why seven days again? Why that time was decided upon by your team? Sure. We try to stay as current as we can. So, we're thinking in our minds a week. If we can just go back a week, that's enough time for them to, hey, maybe, you know, we missed something, we're not going to miss it again. We can change it right away. Instead of waiting, you know, months out when we, you know, we were to extract, you know, months out, that would kind of hinder us. So, we try to be as time-sensitive as possible. That makes sense. And another piece you had on your slide, you talked about within your process, you implemented a periodic auditing process. Can you elaborate a little bit on that and what that entails or how often you perform? Sure. We have quality champions in the department whose focus is to abstract charts. So, once a month, they will pull charts from different registries we abstract from and they'll abstract it just to see if we are in compliant. And in compliant means we are at a 90% or above with our abstractions. So, every field has a number of value to it. So, if they match, we get the point. If they don't match, we don't get the point. So, we try to get at least a 90% match on all of our abstractions that we do. And so, we do it once a month. It's pulled at random. We don't know who's going to get pulled. And we just, you know, that way, we ensure our data is being abstracted correctly and then in the same manner. Very nice. And it's a subset of how many charts do they pull monthly or does it just one? If they can pull two, if you're fine at two, there's no issues. If not, they might pull three. Very nice. The other question that came up was about the access database you were talking about. So, you built that internally and the requirements or who determined what reports you wanted in there before it was built? Was that with physicians or was that just your internal quality team? It was just with our internal quality team. It's the reports that we would normally be reporting out anyway. So, it's just an easier way to access the data. You know, it's been revised several times. So, if we need something added, we can quickly add to it. I see. That's very nice. And the follow-up tracker that Christy, your facility, shared on the participant resource sharing page, that the follow-up tracker reminds me similar how you built it into your access database, right? Where you put in the day and it automatically will convert for you when that patient is due, what date they would be due for that follow-up. So, that's what you built into the access. It is. Very nice. Well, I think we are just about at the end of our time. I want to just first thank you so much, Amber, for sharing this valuable information with us today. Your process that you've implemented is incredible. And I know that many others in the audience have learned so much. And I'm sure there will be many people who want to reach out to you and learn more. But we do appreciate how much your facility has shared on the participant resource page as well. It's been a tremendous help. So, thank you again for sharing with us today and for all of your time dedicated to being here today. I also want to thank our audience. We appreciate your time today. We appreciate you being here and all that you do to support patient care. Have a great day, everyone. Thank you. Thank you very much.

Amber Lopez

value-based healthcare specialist

LAO Registry

EHR platform

compliance rates

patient care optimization

communication and engagement