Schön Klinik SE – Best Quality Data Model WINNER– 2017

Schoen Clinic is a family owned hospital group and one of the largest owner-managed clinic groups in Germany. The company runs 17 hospitals with nearly 10,000 employees and is among the leading private providers of inpatient care in Germany with more than 100,000 patients per year. It serves both statutory insured patients as well as privately insured patients and international patients. Its hospitals across Germany are specialised in orthopedics, neurology and psychosomatics (cognitive behavioral therapy)  with a revenue of € 743 m in 2015.

Schoen Clinic strongly believes that value and excellence in medicine is a result of specialisation and experience. That’s why we focus on acute inpatient services in three medical segments:

• In psychosomatics, Schoen Clinic is the market leader in Germany with 7 locations in total with specialised centres for eating disorder of adults and adolescents as well as anxiety, depression and compulsive disorders.
• In orthopaedics, Schoen Clinic is German market leader within all kinds of spinal treatments, top-player in hip and knee endoprosthesis and recognised as a FIFA medical centre of excellence.
• In neurology, we are focused on highly specialised therapeutic facilities including Robotic rehabilitation therapy for neurological rehabilitation . after stroke, trauma or severe epilepsy. We also run centres of excellence for neuropaediatric disorders and Parkinson´s disease.

This focus is completed with clearly defined integrated specialised practice units for bariatric and endocrine surgery.

Listed below are three examples of that make the delivery of medical services robust

Psychosomatic treatment for patients with eating disorders:

• 1.633 adults and adolescents with eating disorders per year
• Specialised care units with treatment pathways focused on medical conditions
• Effective treatment due to the focus on specific patient cohorts

 

Endo Active program for orthopaedic patients:

• 7.507 patients with hip or knee replacements per year
• Enhanced recovery concept with specific SOPs with focus on patient education, early mobilisation and fast track  recovery
• Specific education program for hip and knee patients before surgery, patient blood management, pain management etc.

Patients with neurological rehabilitation:

• 3.947 patients with neurological deficits after an acute severe event e.g. stroke, trauma etc.
• High-tech equipment like walking robots “EKSO Exoskeleton” that help patients retrain their motor function skills (Robotic rehabilitation therapy)
• Specific treatment pathways for tracheostomy management, to help patients wean from ventilation

 

This strategy with a clear attention on value-based healthcare is one of our core values and allows Schoen Clinic to provide excellent medicine with high end equipment in state of the art facilities. To ensure that these services will be offered efficiently and with high quality at the same time, we strive to enhance medical outcome via measurement along therapeutic pathways and integrated practice units which lead to value-based healthcare – from admission to follow-up. Schoen Clinic received international recognition for this approach to patient care – for example from Harvard Business School.

 

When Schoen Clinic started to measure outcomes, all hospitals had their own clinical information systems and forms which were usually documented at the end of the treatment process before discharge. This was a very time-consuming process, because not every detail was well documented in the system and in the end not every form was fully completed. Furthermore a valid benchmarking was not possible, because data collection was methodically different in all hospitals and outcomes such as infections were not clearly defined and not comparable.

That’s why we developed a concept called CompCard (=Composite Card) to measure medical outcome over the whole treatment process. Starting from initial conditions and indication criteria, to treatment processes and complications/mortality during the hospital stay and outcome from patient (Patient Reported Outcomes) and expert view. All these numbers and results are aggregated in the Quality Management Cockpit called MedQEX (Medical Quality and Excellence Index).

Firstly, the new quality data model ensures that all data is comparable (because of explicit definitions and defined data collection processes) and benchmarking between all Schoen hospitals is possible (which is one of the most important requirements to drive quality improvements).

Secondly, data collection is totally integrated into care and treatment processes. Relevant data will be collected in real time at the point of care. So initial demographics like age, gender etc. are collected only once during the first encounter while data like pain scoring or wound observations are collected every day on the wards by nurses. This process makes it possible to collect data in a very efficient way, reduce double documentation and improve data validity.

As Schoen Clinic has a standardized IT portfolio in all hospitals, data management can be automated so that all relevant data can be extracted, merged, transformed, analyzed and visualized automatically.

Usually Schoen Clinic tries to use existing quality data and scientific validated outcome criteria and scores to measure outcome. But sometimes the existing quality indicators do not fit to our patients portfolio or suitable quality indicators do not exist.  

 

Psychosomatic treatment for patients with eating disorders:

• Development of psychometric scores like ED-QUEST (=Eating Disorders Questionnaire) to assess the severity of eating disorders
• Development of psychometric scores like PHQ (=Patient Health Questionnaire) to assess the severity of depression

Endo Active program for orthopedic patients:

• Objective indication criteria for hip and knee surgery to eliminate unnecessary surgeries
• Process indicators like “ratio of patient with tranexamic acid to reduce blood loss”, “ratio of patient who completed the patient education program”
• Development of a functional scoring system called “Staffelstein Score” to assess the functional (motor) status of patients after surgery

Patients with neurological rehabilitation:

• Risk adjusted model based on regression to predict feasibility of weaning (endpoint the  successful removal of a tracheal cannula)

All quality data are regularly reported and visualized for specific target audiences. for example the report for complication and mortality are provided on a quarterly base directly to the heads of the medical departments. This report focuses on specific medical conditions, medical departments and includes patient details to check or analyze the medical details and learn from conspicuous cases. Other reports e.g. for the hospital board with aggregated KPIs on a hospital level to make sure, that there is a good overview on medical values and outcomes. This report is called MedQEX (=Medical Quality and Excellence Index) and contains all relevant key performance quality indicators and allows for governance and focused deep-dives.

 

All these hospital based results are also discussed yearly with the Schoen Clinic management board and the quality management department to find appropriate measures to improve quality and outcomes. Very complex issues or strategic questions can also be discussed in specific expert groups, who will meet twice a year. These groups enable Schoen Clinic to find sensible best practices or generate standards for the whole company which are evidence based on our own quality data and specific analyses

 

Three examples to show the effect of reporting, benchmarking and discussing quality data:

 

Psychosomatics: treatment for patients with eating disorders:

• Continuous measuring and monitoring of results with detailed discussion in our expert teams.
• Revision of existing therapy standards which included the expansion of supervising times during patients’ meals as best practice standard in all Schoen hospitals. This has led to an increase in effect size (indexed) from 0.6 (middle clinical effect) to 1,3 (strong clinical effect).
• Increase of average weight gained per week of 40% since 1996 during the inpatient stay, due to reevaluation of treatment protocols.

• Improved outcomes at discharge and better long term outcomes for our patients and higher efficiency of therapies with a reduction of length of stay for Schoen Clinic.

 

Orthopedics: Patients with hip replacement

• Introduction of patient blood management (several processes as part of the ENDO AKTIV© program to reduce the likelihood of blood transfusions e.g. preoperative iron supplementation intraoperative hemostasis and tranexamic acid etc.).
• Evidence based strict and clear transfusion criteria across all clinics.
• Reduction of blood transfusion rate from 16.7% to 1.3% in the last five years.

• Less complications due to lower blood transfusion rates and faster recovery for the patients and reduced complexity with less interventions at Schoen Clinic leads to a reduction in average length of stay as every patient who needs blood transfusion stays longer in hospital for an average of two days.

Patients with neurological rehabilitation:

• 2010 introduction of Schoen Clinic regression model to calculate feasibility of tracheal cannula removal.
• Implementation of new quality indicators to compare “expected values vs. calculated values”
• Regular review of cases, where expected outcome was not reached and additional training for employees on tracheal cannula management issues.
• Increase of ratio (expected vs. calculated) from 68% to 100% although patient portfolio has been expanded.

• Higher rates of tracheal cannula removal with a better long term outcome and better chance to avoid pneumonias after discharge for patients and less monitoring during inpatient stay which reduces costs for treatment and care at Schoen Clinic.

When we started to collect quality data it took us some time to get valid databases. But as there is a clear strategy for defining and collecting useful quality data (CompCard) and indicators, and these discussion and developments are done with our expert groups, the effects started from the first reporting within the hospitals and the expert groups.

A second aspect, which stimulates these focused discussions in our expert groups, was the voluntary publication of outcome measures for German patients on a yearly base.

The main key performance indicators are all included in the MedQEX framework with a focus on the following key topics:
patient outcome (e.g. indication criteria, mortality rates, PROMs etc.),
patient safety (CIRS, infection control, drug safety etc.)
patient experience (e.g. Net-Promoter-Score, complaint management etc.).

Several best practice projects (e.g. Eating Disorders, Depression, EndoActive for Hip- and knee replacements etc.) or significant changes in treatment pathways after analysing and discussion outcome items show the success of the project since several years at Schoen Clinic.