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Award Winning Patient Safety
Programs Start at the Top
1
Award Winning Patient Safety Programs Start at the Top
Goals of Session:
• Describe the patient safety imperative
• Learn from award winning systems
• Understand your leadership impact
Background:
• VHA Foundation Board commitment
• Health Care SafetyNetwork, a peer network of nearly 125 CEOs focused
on creating cultures of safety
Patient Safety Leadership Award:
• Introduced in 2008
• Co-sponsored with the National Business Group on Health
• Focused on leadership in patient safety
• Health care systems, as recognized in the 2009 AHA Guide, are eligible
• Invitations May 2009
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The Patient Safety Imperative:
An Employer Perspective
Helen Darling
President
National Business Group on Health
Annual VHA Leadership Conference -2009
NBGHExecutive Series
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Overview
• Patient Safety: A National Priority
• Why Employers Care
• How Employers Promote Safer
Care
• Recognition of Health System
Leaders by NBGH & VHAF
NBGHExecutive Series
4
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A National Priority
Consumers cite lack of progress: “10 years later, a million
lives lost, billions of dollars wasted”
---To Err is Human -- To Delay is Deadly, Consumers
Union, May 2009
Experts name safety a top priority: “Safety – to improve
reliability and eliminate errors wherever and whenever
possible”
---National Priorities Partnership Action Agenda, October
2008
Employers recognize importance: “We hope this award
encourages other health leaders to see the enormous
impact they can make if they take an active role in
patient safety.”
---Helen Darling, USA Today, December 2008
NBGHExecutive Series
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Why Do We Care?
• Between 5% and 10% of inpatients acquire one
or more HAIs
• CDC estimates 1.7 million HAIs occur each year in
U.S., resulting in an estimated 99,000 deaths
• This adds almost $20 billion in health care costs
1 Fortune 100 company estimated:
330 Deaths (1 per day), over 5,000
HAIs, $15 - $17 million excess cost
NBGHExecutive Series
Source: DHHS;NBGH
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Why Do Employers Care?
• Adverse events raise hospital costs significantly.
One study found that each patient, whether or
not having experienced an adverse error, cost
an additional $10,800 due to adverse events.
• The CDC estimates the annual cost of HAIs at
$5 billion. For each case of HAI prevented,
potential savings are about $15,000.
• Wrong site surgery occurs in 1 of 112,994
operations. The average indemnity payment for
each event is $54,790.
NBGHExecutive Series
Source: A Toolkit for Action: Ensuring Patient Safety Across Health Care, National Business Group on Health, 2008
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Why Do Employers Care?
• An employer with 25,000 covered lives can
anticipate between 1,200 and 1,500
hospitalizations in a year.
• Private sector reimburses at a rate 6 times higher
for cases with a hospital-acquired infection (HAI)
compared to cases without HAIs.
• Employers are further impacted by lost
productivity. An employer with 25,000 covered
lives will likely suffer about $9 million yearly in
lost wages due to adverse events.
NBGHExecutive Series
Source: A Toolkit for Action: Ensuring Patient Safety Across Health Care, National Business Group on Health, 2008
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How Employers Promote Safer Care
• Not paying for Never Events
• Supporting culture of safety at hospital
Trustee level (in roles as Board members)
• Requiring patient safety criteria for preferred
hospital and COE status (through health plans)
• Promoting public reporting of safety data
• Educating employees/consumers about
choosing safer care
NBGHExecutive Series
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Recognition of Health System Leadership
• First award addressing patient
safety leadership exclusively
• First award by a business/purchaser
organization
• Partnership with thought-leading
health organization adds credibility
& validity
NBGHExecutive Series
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5
Promoting Safer Care
“No organization can make the significant
changes that are necessary to develop a
culture of safety without vigorous leadership
at the top.”
“If boards have patient safety as a major
concern, then so will CEOs.”
Source: Is Hospital Patient Care Becoming Safer? A Conversation with Lucian Leape, Health Affairs Oct. 2007
NBGHExecutive Series
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Memorial Hermann
Healthcare System
Patient Safety
Cultural Transformation from
Board to Bedside
12
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Disclosure Information
• Nothing to Disclose
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Facts and Figures
• Total hospitals: 12 • Annual emergency visits: 377,256
• Acute care: 9 • Annual deliveries: 25,411
• Children’s: 1 • Annual Life Flight air ambulance
• Rehabilitation: 2 missions: 2,960
• Heart & Vascular Institutes: 3 • Employees: 19,500
• Managed acute care hospitals: 3 • Beds (licensed): 3,514
• Sports Medicine & Rehabilitation • Medical staff members: 4,178
Centers: 27 • Residency programs: 26
• Ambulatory surgery centers: 10 • Fellowship programs: 48
• Diagnostic laboratories: 12 • Physicians in training: 1,324
• Imaging Centers: 21 (physicians and fellows)
• Retirement/nursing center: 1 • Annual payroll: $1,091,207,000
• Annual community benefit:
• Home health agency: 1 $300,357,000
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Vision & Brand Promise
15
Path to High Reliability
Organization
August 14, 2006
A Call to Action
on Patient Safety
by Dan Wolterman
Transfusion Errors
Serious Safety Events
16
8
Path to Cultural Transformation
Design of Design of Design of
Policy & Culture Work
Design of
Protocol Processes of
Design
Structure Technology &
Environment
Why Do Events Happen?
Behaviors
of Individuals & Groups
Outcomes
17 Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
Path to Cultural Transformation
1. 2006, Leadership Commitment to “safety first”
2. Implement system changes with attention to human failure
prevention
• Maximize effective attention to detail and double checks
• Minimize barriers to compliance
3. 2006, Diagnostic assessment to determine readiness
• Safety Culture assessment
• Safety Governance assessment
• Event Cause Analysis – Common Human Failures
4. Performance gaps in communication, critical thinking,
knowledge, attention to task, and compliance
18
9
• Step 1: Set Behavior Expectations
Define Safety Behaviors & Error
Prevention Tools proven to help
reduce human error
• Step 2: Educate
Educate our staff and medical
staff about the Safety Behaviors
and Error Prevention Tools
• Step 3: Reinforce & Build
Accountability
Practice the Safety Behaviors and
make them our personal work
habits
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Red Rules
Absolute Compliance
1. Patient Identification
2. Time Out
3. Two Provider Check
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10
Self-Checking With STAR*
(Stop, Think, Act, & Review)
0.9
0.5
0.1
0.05
0.01
0.001
“It sort of makes you stop & think, doesn’t it?”
0.0001 Vigilance Tests
0.00001
0.000001
0.6 6 60 600 6,000
Seconds Paused in Thought
* Jefferson Center for Character Education
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MHHS Safety Culture Training
Hospital Training Complete
>14,000 Employees Trained
>1,000 Physicians Trained
>540 Safety Coaches Trained
>$18M Expense
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Set The Pace
Our current event rate, set at 100%
100%
Awareness
Skill Acquisition
80% Decrease
Event Rate
In Event Rate
Habit Formation Over 1-2 Years
20%
Performance
2 Years
Time
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Three Drivers of Accountability
Individual
• Integrate into hiring criteria
Optimal Accountability
Peers Leaders
• Safety Success Stories • Integrate into vision and mission
• Safety Coaches • Align goals, metrics, and incentives
• Peer checking & coaching • Rounding to observe and coach
• Integrate into preceptor and mentoring • Find and fix system problems
programs
25
Culture Change
• Quality & safety are important!
• There is no real quality without safety
at its core
• Quality & safety can be improved, but
only when we change culture
• That defines the strategy:
Change the Culture!
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Leadership Accountability
On-Line Flash Report
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Zero Hemolytic Transfusion Reactions
Transfusion Events
10
8
6
4
2
0
2006 2007 2008 2009
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14
Hospital Acquired Infections
Memorial Hermann - All Acute Care Facilities Adults
HAI Prevention
No Unexpected Complications
Campaign
50
40
30
20
10
0
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun-
07 07 07 07 07 07 07 07 07 07 07 07 08 08 08 08 08 08
Sys Adult VAP 19 13 13 6 10 3 9 6 3 5 4 9 4 5 10 4 6 3
“Hospital acquired infections should be
Sys Adult SSI 6 4 5 4 7 4 4 4 1 6 2 4 2 3 2 1 2 0
Sys Adult CR-BSI 19 20 19 29 24 21 16 18 9 12 11 9 9 14 6 10 11 6
considered to be industrial accidents.”
29
Luis Ostrosky, MD (2007)
Hospital Acquired Infections
Significant Reduction
in CR-BSI and VAP
May 2007 to December 2008
Potential Cost Avoidance
$7,639,052
Estimated Lives Saved
88 Lives
30
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What is Required for a Cultural
Transformation
Governance Commitment
Senior Leadership Mandate
Employee/Physician Engagement
31
Cultural Transformation Platform
Processes are Systematic
Processes are Aligned with MVV’s
Processes are Systematically Deployed
Ongoing Cycles of Improvement
32
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Essential Success Factors
• Precise Execution
• Organizational Hardwiring
• Sustainability of Results
• No Excuses Accountability
33
Mortality Reduction
A Case Study in
Leadership and Transparency
34
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Disclosure Information
• Nothing to Disclose
35
Henry Ford Health
System (HFHS)
• Southeast Michigan service
area, 4 million population
• Six acute med/surg and two
behavioral health hospitals
• HF Medical Group
– 22 Medical Centers
– 1,000 Physicians/Scientists
– 650 Residents
• Trauma and Transplant Centers
• Insurance Plan
• Home Care Services
36
18
Henry Ford Health System’s Quality
Transformation
• The Quality Journey
• HFHS Leadership System
• Mortality Case Study
37
HFHS Quality Journey
1989 Q101
(Use of industrial improvement tools)
1999 - 2001 IOM Reports
(Contemplation)
2002 IHI/RWJ Pursuing Perfection
(Execution – ambitious goals)
2003 CMS Surgical Infection Prevention
Collaborative
(Confidence – dramatic improvement)
2004 System-wide Mortality Reduction
(Mature Systems)
38
19
Leadership System
39
HFHS Strategic Framework
40
20
Quality and Safety Pillar
Aim and Objectives
We will be the organization that others emulate
for clinical innovations and best practices.
No Harm Campaign
Care Coordination Across the Continuum
Prevention and disease management bundles
E-Care Spread
Baldrige Journey
41
System Quality Forum
• Management committee comprised of System CEO, COO,
CQO, and CNO, plus all business unit CEOs, CMOs, CNOs, and
Quality managers/administrators
• Sets specific targets for quality and safety at every business
unit, prioritizes initiatives, and tracks progress against targets
for the Board of Trustees
• Agendas dedicated to evaluating performance, identifying
new teams/approaches, sharing better practices, and
addressing new local and national initiatives
42
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Culture Management
• Cultural Expectations /
• Reinforced through
Values
– High Performance – Selection
– Collaboration and – Expectations and
Teamwork leadership behaviors
– Innovation and – Structures
Continuous
Improvement – Recognition programs
43
Board of Trustees
• Approve and monitor quality goals
• Quality topic including harm stories on
every agenda
• Selected for expertise in quality
management
• Commissioned No Harm Campaign
44
22
Mortality Management
45
Henry Ford Hospital
Unadjusted Mortality Rate
3.25%
SIP
3.00%
2.75%
2.50%
Goal (25% Reduction)
2.25%
2.00%
1.75%
1.50%
3Q03
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
46
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Goal Setting
• Anticipate and Broadly Scan the
Environment and Customers
• Set Ambitious Aims
• In 3 year rolling process
• Disseminate Widely - Board to Bedside
47
Setting Ambitious Objectives
HFHS Guideline for Targets
• Process measures: 95-100% reliability
• Patient dependent measures: 75 Pct.
• No benchmarks: stretch improvement
over historical performance
48
24
Henry Ford Hospital
Unadjusted Mortality Rate
3.25%
SIP
3.00%
RRT
Glucose Palliative
2.75% ICU Care
Glucose
2.50% all HFH
2.25% Goa l (25% Reduction)
2.00%
1.75%
Aggressive Infection Control
1.50%
3Q03
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
1Q08
49
Performance Measurement
• Available on intranet
• Dashboards prepared and shared from
bedside to Board
• Include:
– Process and outcome measures
– Comparators - internal and external
• Most are posted on unit bulletin boards
50
25
Henry Ford Hospital Unadjusted Mortality Rate
3.25%
SIP
3.00% RRT
Glucose Palliative Sepsis
2.75% ICU Care Interrupted
Glucose
2.50% all HFH Sepsis
Goal (25% Reduction)
2.25%
2.00% Hand
Anticoag
Washing
1.75% Team
Aggressive Infection Control No Harm
1.50%
3Q03
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
51
System-wide Collaboration
• Chief Medical Officers
• Chief Nursing Officers
• Pharmacy Council
• Infection Control Committee
• System-wide Process Improvement Teams
– Sentinel Event Policy
– Discharge Process
– Medication Reconciliation
– Others
52
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Adjusted Mortality
3Q2007 - 2Q2008 Mortality for MI Hospitals (Normalized Data)
Goodod
Significantly Worse
than Expected
Significantly Better
than Expected
2007
-8.00 -6.00 -4.00 -2.00 0.00 2.00 4.00 6.00 8.00 10.00 12.00
Open icon change from 2004
Michigan Hospitals HFMH-W HFH
HFWH HFMH-W 2004 HFH 2004
HFWH 2004 HFMH
53
Key Drivers of
Performance Improvement
• Ambitious goals and confidence
• Engaged leadership System
• Performance data – timely and widely
available
• Performance monitoring process
54
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