Building a Culture That Lasts

Building a Culture That Lasts Establishing a Leadership Legacy Quality Texas Foundation June 28, 2016 M. Michael Shabot, MD, FACS, FCCM, FACMI Executive Vice President System Chief Clinical Officer V2 1

Leadership Legacies Mahatma Gandhi (1869-1948) Jack Welch (GE) 1935 - Franklin D. Roosevelt (1882-1944) Steve Jobs (1955-2011) Martin Luther King, Jr. (1929-1968) 2

Leadership Legacies Beyond Personal Greatness...... What can you leave behind that lasts? Mahatma Gandhi (1869-1948) Jack Welch (GE) 1935 - How can you ensure that Franklin D. Roosevelt (1882-1944) organizational achievements continue beyond your time at the helm? Steve Jobs (1955-2011) Martin Luther King, Jr. (1929-1968) 3

Building a Culture Mahatma Gandhi (1869-1948) Jack Welch (GE) 1935 - Franklin D. Roosevelt (1882-1944) Steve Jobs (1955-2011) Martin Luther King, Jr. (1929-1968) 4

Building a Culture Mahatma Gandhi (1869-1948) Jack Welch (GE) 1935 - Franklin D. Roosevelt (1882-1944) Why is this so important? Steve Jobs (1955-2011) Martin Luther King, Jr. (1929-1968) 5

Example: Eliminating Patient Harm Question: How many avoidable deaths occur in U.S. hospitals each year? 25,000 50,000 100,000 200,000 Equivalent to a fully-loaded Boeing 737 crashing every 7 hours Source: James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Jol Patient Safety 2013;9:122-128. 6

Example: Eliminating Patient Harm Question: How many avoidable deaths occur in U.S. hospitals each year? Memorial Hermann s Goal 25,000 50,000 100,000 200,000 Equivalent to a fully-loaded Boeing 737 crashing every 7 hours Source: James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Jol Patient Safety 2013;9:122-128. 7

High Reliability Organizations Commercial Aviation Nuclear Aircraft Carriers Air Traffic Control 8

Transformation to a High Reliability Organization August 14, 2006 A Call to Action on Patient Safety Transfusion Errors Serious Safety Events 9

Burning Platform 10 10

Board Commitment Moving the Memorial Hermann Healthcare System from Safety as a Priority to Safety is our Core Value. Behavioral expectations change when safety is the core value 11

MHHS Safety Culture Training Completed in 2007 Hospital Training Complete >20,000 Employees Trained >4,000 Physicians Trained >540 Safety Coaches Trained >$18M Expense 12 12

Breakthroughs in Patient Safety Training 13

Safety Culture Training 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 14

Robust Process Improvement: Path to Quality Outcomes 15

Robust Process Improvement: Path to Quality Outcomes Lean Six Sigma Change Management 16

Robust Process Improvement: Changing Standard Work Standard Work = What we do every day What we do every day = CULTURE! 17

Robust Process Improvement: High Reliability Standard Work Central Line Sterile Insertion Bundle OR Surgical Safety Checklist Ultrasound Guidance for Central Line Punctures High Reliability Hand Hygiene 18

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Hospital Acquired Conditions Never Events Acute Hemolytic Transfusion Reactions Transfusion Events Jan 2007- December 2015 2,214,000 Adjusted Admissions 12,020,000 Adjusted Pt Days 1,115,000 Transfusions This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee Privilege contained in the Texas Health and Safety Code 161.031 & 161.032, or Medical Peer Review under the Medical Practice Act, Texas Occupations Code, 151.001 et. seq.; and the Medical Peer Review immunity provided by federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq. 20

Hospital Acquired Conditions Never Events Acute Hemolytic Transfusion Reactions Transfusion Events Jan 2007- December 2015 2,214,000 Adjusted Admissions 12,020,000 Adjusted Pt Days 1,115,000 Transfusions This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee Privilege contained in the Texas Health and Safety Code 161.031 & 161.032, or Medical Peer Review under the Medical Practice Act, Texas Occupations Code, 151.001 et. seq.; and the Medical Peer Review immunity provided by federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq. 21

Joint Commission Hand Hygiene Center for Transforming Healthcare Baseline Compliance 44% >90% compliance since Nov 2012 Compliance Rate Secret Shopper measurements per month 22

Adult ICU Central Line Associated Blood Stream Infections (CLABSI) 12.00 System Adult ICU CLABSI Central Line Associated Blood Stream Infections 10.00 UCL = 9.42 CLABSI Rate per 1K Line Days 8.00 6.00 4.00 2.00 Mean = 5.53 Mean = 3.04 LCL = 1.64 UCL = 5.79 UCL = 5.13 UCL = 3.86 UCL = 2.97 UCL = 2.55 Mean = 2.52 Mean = 2.12 Mean = 1.46 Mean = 1.17 0.00 2006 2007 LCL = 0.29 2008 2009 LCL = 0.38 2010 2011 2012 2013 2014 2015 Generated: 4/24/2015 10:43:32 AM Source file date: 4/23/2015 Reporting Months produced by System Quality and Patient Safety 23

Ventilator Associated Pneumonias: All Adult ICUs 24

MH Sugar Land: Hospital Acquired Infection Scorecard Number of HAIs in one month 25

MH Sugar Land: Hospital Acquired Infection Scorecard Number of HAIs in one month 26

MH Sugar Land: Zero ICU Cental Line Infections Zero ICU Central Line Infections x 36 Months 27

High Reliability Certified Zero Award 1. Zero Events 2. 12 Consecutive Months 3. Certified Zero Category 28

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MH Greater Heights: Zero Retained Foreign Bodies MD/Nursing OR Count Policy Mandatory RFID Scanning Zero Retained Foreign Bodies x 72 Months 30

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September 6, 2015 MH Greater Heights Hospital 1000 Days Since Last Serious Safety Event 1-2 32

High Reliability 2011-16 Certified Zero Awards ICU Central Line Associated Bloodstream Infections (16) ICU Catheter Associated Urinary Tract Infections (8) Hospital-Wide Central Line Associated Bloodstream Infections (6) Hospital-Wide Catheter Associated Urinary Tract Infections (3) Ventilator Associated Pneumonias (23) 217 Surgical Site Infections Retained Foreign Bodies (41) Iatrogenic Pneumothorax (22) Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (32) Hospital Associated Injuries (6) Deep Vein Thrombosis and/or Pulmonary Embolism (1) Deaths Among Surgical Inpatients with Serious Treatable Complications (1) Birth Traumas (14) Obstetric Trauma in Vaginal Deliveries with Instrumentation (2) Serious Safety Events 1&2 (14) Serious Safety Events 1 & 2 for 1000 Days (2) All Serious Safety Events (1) Early Elective Deliveries (4) Manifestations of Poor Glycemic Control (18) 33

High Reliability Organizations Commercial Aviation Air Traffic Control Nuclear Aircraft Carriers 34

High Reliability Organizations Memorial Hermann Health System Air Traffic Control Nuclear Aircraft Carriers Commercial Aviation 35

Thank you! You must be the change you want to see in the world Mahatma Gandhi (1869-1948) 36