2017 Nicolas E. Davies Enterprise Award of Excellence
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1 2017 Nicolas E. Davies Enterprise Award of Excellence
2 Agenda Memorial Hermann Health System Overview Journey to High Reliability Case study review CLABSI Prevention 2
3 Memorial Hermann Health System Woodlands Sugar Land TMC Katy Memorial City Southeast Total hospitals: 15 (11 acute, 2 rehab, 1 children s, 1 orthopedic) Inpatient admissions: 158,241 Annual emergency visits: 595,611 Annual deliveries: 25,146 Employees: 25,040 Beds (acute licensed): 4,016 Medical staff members: 5,708 Fellowship programs: 48 Greater Heights Northeast Cypress Pearland Children s Southwest TIRR Katy Rehab MHOSH
4 Our Network of Care 292 Care Delivery Sites 4
5 15 Certified Zero Awards 32
6 Memorial Hermann Recent Accolades Quality A competitive advantage for Memorial Hermann 15 Top Health Systems; Top 5 Large Health Systems (2012 & 2013) John M. Eisenberg National Patient Safety & Quality Award (2012) National Quality Forum National Quality Healthcare Award (2009) TIRR Memorial Hermann No. 2 in rehabilitation hospitals Texas Hospital Association Bill Aston Quality Award (2011) America s #1 Quality Hospital for Overall Care (2011 & 2012) Healthcare s 100 Most Wired 12 th consecutive year America s 50 Best Hospitals ( ) The Joint Commission Top Performer (2012), Heart Attack, Heart Failure, Pneumonia, Surgical Care 2011 Texas Healthcare Foundation Quality Improvement Awards (9 Memorial Hermann Campuses) 2015 Houston Business Journal (HBJ) No. 3 Best Places to Work
7 Memorial Hermann ACO ~4,000 MHMD Physicians, ~3,500 CIN Clinically Integrated Network Private, Employed & Faculty Integration 3 DISTINCT PRACTICE MODELS Employment Faculty Private Population Health Infrastructure 7
8 Memorial Hermann ACO High Moderate Degree of Risk Shifting to Providers TIER III Value Driven 501,447 Members TIER II Gain Sharing Community Health Choice 54,740 TIER I Partial -Full Risk CMS MSSP 47,400 Aetna Commercial 85,000 Humana Commercial 18,700 Aetna Medicare Advantage 5,800 Humana Medicare Advantage 5,000 United Healthcare Medicare Advantage 8,800 BCBS Commercial 75,000 United Healthcare Commercial 100,000 MH Health Plan Commercial MHHS 39,136 Other 28,881 MH Health Plan Medicare Advantage 6,790 Aetna Whole Health 26, ,700 Lives 101,007 Lives Low Fragmented Transitioning Integrated Increasing Degree of Integration Delivery System Readiness for Risk 8
9 Our Journey High Reliability Organization 9 Commercial Aviation Nuclear Aircraft Carriers Air Traffic Control
10 High Reliability Certified Zero Award 1. Zero Events Consecutive Months 3. Certified Zero Category
11
12 High Reliability Certified Zero Awards 12 ICU Central Line Associated Bloodstream Infections (18) ICU Catheter Associated Urinary Tract Infections (16) Hospital-Wide Central Line Associated Bloodstream Infections (7) Hospital-Wide Catheter Associated Urinary Tract Infections (5) Ventilator Associated Pneumonias (23) Retained Foreign Bodies (46) 263 Iatrogenic Pneumothorax (24) Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (37) Hospital Associated Injuries (7) Deep Vein Thrombosis and/or Pulmonary Embolism (2) Deaths Among Surgical Inpatients with Serious Treatable Complications (1) Birth Traumas (16) Obstetric Trauma in Natural Deliveries with Instrumentation (4) Serious Safety Events 1&2 (21) Serious Safety Events 1 & 2 for 1000 Days (2) All Serious Safety Events (1) Early Elective Deliveries (9) Manifestations of Poor Glycemic Control (21)
13 Wall of Pride! Memorial Hermann Facility
14 CLABSI Prevention: An Infectious Story - Siraj Anwar
15 Background Challenges Governance & Design Implementation & Monitoring Financial Impact Lessons Learned 15
16 Background Central Line Associated Blood Stream Infections 1,2,3,4 Common Costly (~$45,000) Lethal (~28,000 Deaths) 1. Association for Professionals in Infection Control and Epidemiology/ CDC 2. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132: [Erratum, Ann Intern Med 2000;133:5.] 3. Burke JP. Infection control a problem for patient safety. N Engl J Med 2003; 348: O Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections.
17 Challenges Complexity of Memorial Hermann 15 Hospitals 66 ICUs 965 ICU Beds ~ 8400 Central Line Days/Month
18 Adult ICU Central Line Associated Blood Stream Infections (CLABSI) 18
19 Is It Possible? 108 ICU s, 1981 ICU-months, 375,757 catheter days [T]he median rate per 1000 catheter days decreased to 0 at 3 months.
20 Design Implementation Governance
21 Burning Platform
22 Governance Stakeholder Meeting Clinical & Operational Leaders Physicians Nursing Infection Control Quality
23 Design and Implementation Joint Application Design (JAD) Sessions Clinical Stakeholders Application Analysts/ Experts Clinical Informaticists Key Design Decisions Functionality Data Elements Reporting
24 Operational Changes High Visibility Board & Senior Leaders Patient Safety Priority for everyone Empowering Staff to Say No Appropriate Supplies Available
25 Operational Changes Use of documentation bundles Infection Attribution Physician Nursing Unit Periodic Review of Data Daily Exception Report Monthly Report (Nursing Unit, Facility, System)
26 Central Line Insertion Bundle Elements MD Hand Hygiene Chlorahexadine Use MD gown, gloves, hat & mask Drape patient from head to toe Sterile field maintained during procedure Assistant gown, gloves, hat & mask
27 Central Line Maintenance Bundle Elements CVC dressing occlusive & intact Site healthy w/o redness or drainage Dressing change: < 7 days for transparent < 2 days for gauze CL Dressing Change Compliance CL Dressing Labeled with date/time All CVC tubing labeled with date/time All CVC tubing labeled with date/time of insertion
28 CLABSI Prevention Timeline of Events May 2007 Bundle Implementation on Paper Conversion to EHR Mar 2010 Electronic Abstraction 2013 Change to CLIP Electronic Documentation Continuous surveillance of: 1. Clinical Outcomes 2. CLABSI Bundle Compliance 2016 Change to CL Maintenance Documentation 2016 Physician Line Necessity Documentation 28
29 How Health IT was Utilized
30 Workflow With Health IT Interventions
31 Central Line Insertion Documentation Bundle Patient drape, head to toe? Sterile gown, gloves and mask? Skin prep dry before insertion? Ultrasound used? 31
32 Process Measures Central Line Insertion
33 Central Line Maintenance Documentation Bundle Dressing occlusive and Intact? Dressing Changed? Labeled with Insertion Date?
34 Process Measures Central Line Maintenance
35 Central Line Necessity Documentation Form
36 Process Measures Central Line Necessity
37 Central Line Necessity Next Steps Automation of necessity documentation Identify patients with central line Alert physician Patient chart open Add/ sign order Passive notification 37
38 Central Line Insertion Bundle Compliance 38
39 Central Line Maintenance Bundle Compliance 39
40 Our Journey.. CLABSI Rate 40
41 High Reliability! Certified Zero Awards 25 Certified Zero Awards for CLABSI Prevention 41
42 High Reliability! Certified Zero Awards 42 Zero CLABSIs Hospital-Wide x 17 Months
43 Financial Impact ICUs Only Central Line Days/ Month ( ) ~8472 Current Infection Rate ( ) 0.92 Previous Infection Rate (2007) ~5.79 Projected Difference in Infections (49)-(8)= 41 Infections Prevented/Month 41 x ~45,000 = ~$1.84 Million/Month Infections Avoided in CY : 984 Cost Avoidance for CY : ~44 Million
44 Lessons Learned Stakeholder buy-in Improvement driven through data Accountability is key Change to data elements? HOLD YOUR HORSES!!
45 Closing Thoughts. People Relationships Process (People) Technology (People)
46 THANK YOU! 46
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