UPMC is finding ways to squeeze savings, prevent waste
By Bill Toland, Pittsburgh Post-Gazette | |
McClatchy-Tribune Information Services |
"We were throwing away 3,000 units of blood" annually, said
When he came to UPMC by way of the
UPMC hospitals, like most health networks, are under relentless pressure to cut costs. Operating margins are thin, overnight inpatient traffic is declining, and health insurers --
Those are universal factors; UPMC also has created some its own, unique to the market, through its refusal to sign a full-access contract with
So UPMC must cinch its belt. Some of that, by necessity, will come out of labor costs -- in most health systems, staffing accounts for around 55 percent of total expenditures.
But the other 45 percent? That's facility operations, supplies and clinical management.
And that's where people such as Dr. Waters enter the frame.
'Waste all over the place'
Twenty years ago, when he was in
"There is waste all over the place in health care," Dr. Waters said last week. It's been "kind of a longstanding passion for me [to] reduce blood use."
Step 1 was arguably the easiest one: examining the entire blood supply line, figuring out where blood was being over-ordered and under-used, then calibrating contracts with blood suppliers accordingly.
In other words, buy and store only what you need.
Easier said than done. Platelets, for example, have not only the shortest shelf life, but they are particularly temperature sensitive: If refrigerated, or transported on ice, platelets leave the circulation system too rapidly. So storage can be tricky, requiring platelets to be delivered at room temperature, if they are to be optimally effective. Keeping the right amount of platelets on hand, at the right temperatures, required a redesign of the blood supply chain.
Step 2 was a more sweeping probe into UPMC's clinical guidelines, a process that was less about supply chain logistics and more about retraining doctors and nurses about when to use blood, and when not to.
In health care, clinicians have long believed that "blood is good, and more is better," Dr. Waters said. "Certainly, you need to be transfused at certain times. But there's a risk-benefit ratio. [And] the risks and benefits have evolved considerably since I went to medical school."
One thing that's changed is the old 10/?30 rule for patients needing an infusion of red blood cells because of anemia, hemorrhaging or to improve oxygen delivery. But the 10/?30 rule (transfusing when a patient's hemoglobin level is less than 10 grams per deciliter, and when his red-cell blood volume falls below 30 percent) has been abandoned over the last two decades as the baseline transfusion trigger.
Instead, the 10/?30 rule has become a 7/?21 rule, giving doctors more wiggle room to observe a patient's clinical symptoms before ordering a transfusion.
UPMC is trying to "reduce non-evidence-based transfusion," Dr. Waters said. Not only does it save blood, but may improve patient health. For certain surgeries, "reducing utilization of blood had better post-operative outcomes. ... A lot of literature [has associated] transfusion and increases in infection rates," particularly among critical injured patients.
But "getting doctors to change is really hard," Dr. Waters said.
Some clinicians learn quickly. Others benefit from UPMC's electronic decision-making system, which alerts doctors that a certain transfusion "is not consistent with UPMC institutional guidelines," automatically canceling the transfusion and the blood cell order. Savings add up fast: A single unit of red blood cells can cost
The most striking area of blood waste was self-inflicted, found in UPMC's system of collecting blood from patients prior to their elective surgeries. Called "pre-operative autologous donations," or PAD blood, it means that patients essentially are donating blood to themselves in case they need it later.
Problem is, they often don't need it later, or at least don't need all of it. In 2005, UPMC was throwing about half of that blood away -- 2,700 units in all,
But by 2013, UPMC was disposing of just 100 or so units of pre-collected blood, at a value of
It's a 94 percent reduction in blood waste, achieved, once again, through evolving clinical standards -- if the blood is never drawn, it can't be wasted later.
"So, we have been campaigning to eliminate the use of this as a therapy. We can give the patient their own blood via blood salvage, which works a lot better," Dr. Water said.
He has been tweaking UPMC's blood management system since he got here, and about two years ago, the health system made a bigger investment in blood supply management, fully implementing Dr. Waters' plan and hiring a full-time program manager.
Results:
Saving money, saving jobs
Dr. Waters' fiefdom is blood management, but at UPMC, the lord of the kingdom is
"If the product isn't there when it needs to be," he said, "you've done a bad job." Exhibit A is the ongoing national shortage of IV saline and dextrose supplies. UPMC has managed that shortage through sheer scale -- redistributing its stockpile from its in-house pharmacy to the non-acute sites running low on solution -- and through old-fashioned conservation, using less intravenous fluid when possible in favor of oral hydration (translation: drinking fluids instead of IV-ing them).
The pressure to cut costs without causing shortages is constant, he said, but can be heightened by external events. (The looming separation with Highmark qualifies as such an event.) That heightened cost-cutting pressure can mean simply moving faster, or it might mean tackling larger projects that had previously been ignored because of their complexity,
But mostly, it's an ongoing process. UPMC has 32 work teams from across the system, each meeting monthly or quarterly to discuss supply chain issues in their specific clinical areas.
Those teams then report to an umbrella committee, which decides which savings proposals ought to be implemented, and calculates how much can be saved.
"All of these are in the margins,"
Some recent examples:
--UPMC needs to dispose of reams of confidential documents every day. Those documents are dumped at one of 600 drop-off points, and later hauled away. But why pay someone to haul away the documents if the bins aren't full? By better monitoring the usage and capacity of individual drop-off points, UPMC was able to reduce the number of pick-ups from 14,000 annually to 6,300, resulting in a 55 percent reduction in cost, saving
--The hospital used to trade in outdated medical equipment, or send it to a landfill, any time it bought a new device. Now, that equipment is remarketed through a third party for use "in other parts of the world." UPMC now makes
Conversely, UPMC has saved
--The hospital system buys orthopedic fixation pins -- devices used to stabilize soft tissue during surgery, or bolt bones into place -- individually packaged and pre-sterilized. But now, UPMC plans to buy the pins in bulk, and sterilize them on-site. Savings:
--Hospital systems go through thousands of gowns a year, both the kind worn by patients and the isolation gowns worn by clinicians. UPMC is now using a new isolation gown, and is working with its supplier to ship them in bulk containers, a process that could save
The process of finding pockets of savings is exhaustive, said
"We look at the data. We look at the equipment ... we ask a lot of questions," searching for a penny in a haystack, he said.
And over time, those pennies add up.
If we can "save a few million, we [do] feel like we're saving jobs," he said.
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