Creating a Culture of Quality and Safety Gordon C. Hunt, MD, MBA Sr. Vice President & Chief Medical Officer, Sutter Health M2 This presenter has nothing to disclose December 2012 Blue Ribbon I & II In 2006 Sutter Health embarked on a mission to significantly enhance quality and safety. In 2006 and again in 2008, we sent multidisciplinary teams to multiple national top performing organizations seeking best practices to implement. This process lead to remarkable improvement in both quality and safety throughout Sutter Health. 1
Surprising Findings Achieving top decile quality performance isn t a matter of changing some of our patient care processes. It requires a fundamental change in how we do business. We must create a culture that is delivers continuous improvement in patient safety and quality as our core business. Leading Organizations Create a Patient Centered Culture of Quality & Safety ~ Leadership Commitment ~ Clarity of Focus ~ Empowerment ~ Consistent Framework ~ Physician Engagement ~ Constant Improvement Using Current Data & Continuous Feedback 2
Common Cultural Elements Patient Centeredness A Culture of Quality Clarity of Focus Physician Partnership Development Empowered Teams Continuous Improvement Sutter Health Initial Goals Six in 2006 Focus eliminate non-dashboard priorities Deploy physician portal to enhance data access Provide real time quality data for continuous feedback Implement a nursing model for concurrent care management VPMA at each facility Communicate patient-centered perfect care focus across all levels of the organization 3
2007 and Beyond Expansion of 6 in 2006 recommendations by senior management Establish measurement / definitions / tools / baseline data Identify & implement improvement strategies Addition of 7 th in 2007 ICU process & outcome measures Ventilator Associated Pneumonia (VAP) Stress Ulcer Prevention (SUP) Deep Vein Thrombosis Prophylaxis (VTE) Sepsis (Central Line Blood Stream Infection CLBSI) ICU Mortality 2008 Shift Focus to Ambulatory Settings Identify best practices at topperforming integrated systems with strong multispecialty physician groups to recommend for adoption within Sutter Health focusing on clinical quality, service quality, disease management and affordability. 4
First Surprising Finding While we originally focused on Ambulatory medical groups, we observed what turned out to be a significant success factor during our first two visits: Luther Midelfort and Park Nicollet had dissolved organizational boundaries between inpatient and outpatient services by putting focus where it belonged: on the patient. This led to improved overall performance. Our immediate action: change our focus to the patient and the patient s needs across the entire continuum of care. What does Patient-Centered look like? 5
Common Characteristics of BRT II Sites Recommendations for Sutter Health Develop patient centered Organizational Compact Coordinate & Integrate Patient Care Services for patients with complex illness Establish Paired Administrative/Physician Leadership teams Embracing lean principles & eliminate waste Integrating Financial reporting Focus on quality & efficiency while eliminating harm 6
Implementation 1. Initiate the process of creating an organizational compact to deliver patient-focused care. 2. Create disease management registries to identify patients with specific needs: ~ Congestive Heart Failure (CHF) ~ Diabetes ~ Those needing end-of-life palliative care 3. Create patient-centered Hospitalist programs in all affiliates that are integrated with ambulatory services. 4. Identify and proactively train appropriate physicians and administrators for management and leadership roles using the concepts of team accountability and paired leadership. 5. Modify and expand internal Lean training based on patient-centered principles. Prototype Programs Patient-Centered Care Ex: Hospitalist Single Condition Disease Management Program Ex: Heart Failure Multiple Conditions Disease Management Program Ex: End of Life Care (Inpatient Palliative Care, HH, AIM, Hospice) 7
BRT I BRT II Common Observations/Themes Patient-centeredness Combination of vision and catalyzing event led to culture change Focus and accountability Effort on breaking down and eliminating organizational silos Use of common language and approach to improvement Management & Clinical Excellence (MCE) Program 8
Sutter Health s Perinatal Patient Safety Program A Systematic Approach to Process Improvement in Maternal & Children s Services Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward Sutter Health Focus on Patient Safety 18 Implementation of Practice Guidelines Decreasing Practice Variation First Pregnancy and Delivery VBAC Policy Oxytocin Administration and Checklists Electronic Fetal Monitoring Terminology and Interpretation Maternal Hemorrhage Elective Deliveries < 39 Weeks Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward 9
First Pregnancy and Delivery 2001 clinical initiative focused on improving outcomes for women experiencing their first birth More than 11,000 births 21 birthing centers Identified a set of quality metrics Cesarean Section Cervical dilation > 3 cm on admission 3 rd and 4 th degree laceration Episiotomy 5 minute Apgar < 7 Developed a model for quality improvement that was replicated across the network 40.0% NTSV Episiotomy Target <= 19% 35.0% 30.0% Better 25.0% 20.0% 15.0% 10.0% Trend is significant, p <.0001 5.0% 0.0% 01Q1 01Q2 01Q3 01Q4 02Q1 02Q2 02Q3 02Q4 03Q1 03Q2 03Q3 03Q4 04Q1 04Q2 04Q3 04Q4 05Q1 05Q2 05Q3 05Q4 06Q1 06Q2 06Q3 06Q4 07Q1 07Q2 07Q3 07Q4 08Q1 08Q2 08Q3 08Q4 09Q1 09Q2 09Q3 09Q4 10Q1 10Q2 10Q3 10Q4 11Q1 11Q2 11Q3 11Q4 12Q1 12Q2 Episiotomy - System Episiotomy Target Linear (Episiotomy - System) 10
12% NTSV 3rd/4th Degree Laceration Target <= 6% 10% Better 8% 6% 4% 2% Trend is significant, p <.0001 0% 01Q1 01Q2 01Q3 01Q4 02Q1 02Q2 02Q3 02Q4 03Q1 03Q2 03Q3 03Q4 04Q1 04Q2 04Q3 04Q4 05Q1 05Q2 05Q3 05Q4 06Q1 06Q2 06Q3 06Q4 07Q1 07Q2 07Q3 07Q4 08Q1 08Q2 08Q3 08Q4 09Q1 09Q2 09Q3 09Q4 10Q1 10Q2 10Q3 10Q4 11Q1 11Q2 11Q3 11Q4 12Q1 12Q2 Laceration - System Laceration Target Linear (Laceration - System) Vaginal Birth After Cesarean Section In 1999 ACOG released updated recommendations on Vaginal Births After Cesarean Section In 2001 Sutter Health OB Quality Committee recommended that all hospitals providing VBACs need the surgical team immediately available, including anesthesia With the support of Risk Management a standard VBAC policy was adopted 11
0.090 0.080 2 Litigated VBAC Claims/1000 Births 0.070 0.060 2 0.050 0.040 1 1 Better 0.030 1 0.020 0.010 0.000 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 VBAC Claims/1000 - System Electronic Fetal Monitoring Electronic Fetal Monitoring Terminology and Interpretation is very important in preventing birth injury In 2008 the National Institute of Child Health and Human Development (NICHD) updated the Electronic Fetal Monitoring guidelines and recommended a Three-Tier FHR Interpretation System for categorizing fetal heart rate patterns. Sutter Health implemented a standard protocol on Electronic Fetal Monitoring Educational resources and tools were developed for interdisciplinary, scenario-based education 12
Oxytocin Administration ISMP designated oxytocin as a high-risk medication and IHI released the oxytocin Bundles In 2009 Sutter Health launched a comprehensive initiative to standardize oxytocin administration 40,000 births within Sutter Health (50-65% utilize oxytocin) Developed a standard protocol, order sets, informed consent, provider and patient education Integrated protocol-based checklists to: Ensure patients are appropriate candidates for oxytocin Determine titration frequency and dose based on uterine contractions and FHR assessment every 30 minutes 120% Checklist Every 30 Minutes During Oxytocin Administration All or None Bundle Target >= 90% 100% 80% 60% Trend is significant, p <.0001 40% 20% 0% 09_09 09_10 09_11 09_12 10_01 10_02 10_03 10_04 10_05 10_06 10_07 10_08 10_09 10_10 10_11 10_12 11_01 11_02 11_03 11_04 11_05 11_06 11_07 11_08 11_09 11_10 11_11 11_12 12_01 12_02 12_03 12_04 12_05 12_06 12_07 12_08 12_09 Better Oxy Checklist - System Checklist Target Linear (Oxy Checklist - System) 13
25% Oxytocin Cesarean Delivery Rate 20% 15% Trend is significant, p =.002 10% 5% Better 0% 09_09 09_10 09_11 09_12 10_01 10_02 10_03 10_04 10_05 10_06 10_07 10_08 10_09 10_10 10_11 10_12 11_01 11_02 11_03 11_04 11_05 11_06 11_07 11_08 11_09 11_10 11_11 11_12 12_01 12_02 12_03 12_04 12_05 12_06 12_07 12_08 12_09 Cesarean Rate - System Elective Delivery < 39 Weeks Elective delivery prior to 39 weeks leads to increased newborn complications NICU admissions, RDS, TTN, Ventilator support, sepsis Sutter Health developed a standard scheduling policy for cesarean sections and inductions. Requires provider to document medical indication for scheduled deliveries before 39 weeks Providers who request early deliveries without a medical indication need to consult with a physician champion Patient education continues to be an important component as patient preference drives elective deliveries The Elective Delivery < 39 week rate dropped from 18% to 2% over 5 quarters 14
35% Elective Delivery < 39 Weeks: Sutter Health System 30% 25% Better 20% 15% 10% 5% 0% -5% Elective Delivery - System Elective Delivery < 39 Weeks: Sutter Health System 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Sys P90 P50 Linear (Sys) *Benchmark is based on Leapfrog 2011 goal (P90) and 2010 50 th percentile (P50) 15
Elective Delivery < 39 Weeks: Sutter Health System 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Sys P90 P50 Linear (Sys) *Benchmark is based on Leapfrog 2011 goal (P90) and 2010 50 th percentile (P50) 10% NICU Admissions >= 37 Weeks 9% 8% 7% 6% 5% 4% Trend is significant, p <.0005 3% 2% 1% 0% Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Percent NICU Admits Linear (Percent NICU Admits) 16
Maternal Postpartum Hemorrhage Between 1996 and 2006, the rate of maternal deaths in California nearly tripled from 6-17/100,000 In 2011 a statewide collaborative released a Maternal Hemorrhage Toolkit All 18 birthing centers adopted standard clinical guidelines: Order set changes to allow early intervention in the event of postpartum hemorrhage Maternal Hemorrhage Protocol utilizing Quantitative Blood Loss (QBL) Adoption of a hemorrhage cart and medication kit to ensure supplies are readily available Implementation of in-situ hemorrhage drills and simulation Perinatal Patient Safety Program Implement high reliability perinatal teams to improve recognition and response to emergencies Enhance the culture of safety through communication, training and team based simulation Utililze TeamSTEPPS training and in-situ simulation Engage interdisciplinary teams including obstetricians, anesthesiologists, midwives, and nurses Evaluate impact on maternal and neonatal Adverse Events and Culture of Safety survey 17
Perinatal Patient Safety Program In 2012 after extensive evaluation the Board approved $3.5 million over 3 years to implement at all 18 birthing centers The Perinatal Patient Safety Program (PPSP) has four components Perinatal Risk Assessment: onsite 2-3 days Team and Communication Training Simulation Metrics Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward Team and Communication Training Dept. of Defense and AHRQ s TeamSTEPPS An evidence-based teamwork system to improve communication and teamwork skills among health care professionals Increases team awareness and clarifies team roles and responsibilities Resolves conflicts Four hour interdisciplinary team training for all physicians, midwives, and nurses Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward 18
Simulation Implement local, in-situ simulation at 18 birthing centers Samuel Merritt University Simulation Center to serve as content experts and program instructors Train a core group of champions who will conduct local simulation Evaluate simulation equipment such as Pelvis, Noelle mannequin, Baby Hal Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward 37 Provider Engagement 38 Physician and nurse champions are critical Identify 2-3 physician champions per hospital Strategies to engage providers Opportunities with insurers (NorCal, etc.) Embed in Credentialing process Link with medical foundation QI programs Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward 19
Metrics 39 Enterprise-wide OB Quality Council will evaluate potential outcome and process metrics. Potential metrics include: The Adverse Outcome Index, Weighted Adverse Outcome score and the Severity Index Outcome improvement by implementation of Practice Guidelines Perinatal Claims Culture of Safety Survey Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward Benefits 40 Reduces harm improving mother and infant outcomes Clinical decisions filtered through Patient Safety perspective Reduces Perinatal liability claims Meets Leapfrog National Quality Forum Safe Practices Improves Culture of Safety Survey results Creates a model for other high-risk areas, such as ED, critical care Attorney Client Privilege - Confidential and Propriety Do Not Print, Do Not Forward 20