High Reliability and Robust Process Improvement

Session Code B15 The presenters have nothing to disclose High Reliability and Robust Process Improvement M. Michael Shabot, MD, FACS, FCCM, FACMI Memorial Hermann Health System Mark Chassin, MD, FACP, MPP, MPH The Joint Commission December 6, 2016 11:15 a.m. 12:30 p.m.

High Reliability Healthcare M. Michael Shabot, MD, FACS, FCCM, FACMI Executive Vice President Chief Clinical Officer Memorial Hermann Health System V11 2

Hospital Patient Harm Question: How many avoidable deaths occur in U.S. hospitals each year? 25,000 50,000 100,000 200,000 251,454 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. Crash every 5.5 hours 3

Hospital Patient Harm Question: How many avoidable deaths occur in U.S. hospitals each year? Memorial Hermann s Goal 25,000 0 (Zero) 50,000 100,000 200,000 Source: James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Jol Patient Safety 2013;9:122-128. 251,454 Equivalent to a fully-loaded Boeing 737 crashing every 7 hours Crash every 5.5 hours 4

Becoming a High Reliability Healthcare System 5 It s the right thing to do First Do No Harm Our current healthcare system is harming and killing patients at an unacceptable rate Accountability for transparent quality data

Transformation to a High Reliability Organization 6 August 14, 2006 A Call to Action on Patient Safety Transfusion Errors Serious Safety Events

Burning Platform 7 7 7

Board Commitment 8

9 Safety as the Core Value Moving the Memorial Hermann Healthcare System from Safety as a Priority to Safety is our Core Value. Leadership behavioral expectations change when safety is the core value

IHI From the Top The Role of the Board in Quality & Safety 10

2015 MH From the Top The Role of the Board and Medical Staff in Quality & Safety February 20, 2015-7:30am-5:00pm, Houston, Texas 55 Memorial Hermann Board members and 100 MEC members & hospital execs trained 11

Total Transparency with the Board 12

Memorial Hermann s Journey to High Reliability 13

14 MHHS Safety Culture Training Completed in 2007 Hospital Training Complete >20,000 Employees Trained >4,000 Physicians Trained >540 Safety Coaches Trained >$18M Expense 14

15 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

Self-Checking With STAR* (Stop, Think, Act, & Review) 16 0.9 0.5 0.1 0.05 0.01 0.001 0.0001 0.00001 0.000001 Vigilance Tests It sort of makes you stop & think, doesn t it? It sort of makes you stop & think, doesn t it? 0.6 6 60 600 6,000 Seconds Paused in Thought * Jefferson Center for Character Education

Safety Success Stories Edna Coutts, RN Sugar Land Hospital Safety Champion of the Month 2007 17 Self-Check with STAR (Stop, Think, Act, & Review)

Support Each Other: CUSS Words 18 I am Concerned I am Uncomfortable This is for Safety MH Southwest Hospital Central Line Standoff Stand up and Stand Together

19 Red Rules Absolute Compliance 1. Patient Identification 2. Time Out 3. Two Provider Check

Robust Process Improvement: Path to Quality Outcomes 20

Robust Process Improvement: Path to Quality Outcomes 21 Lean Six Sigma Change Management

Robust Process Improvement: Changing Standard Work 22 Standard Work = What we do every day What we do every day = CULTURE!

Robust Process Improvement: High Reliability Standard Work Central Line Sterile Insertion Bundle Ultrasound Guidance for Central Line Punctures OR Surgical Safety Checklist High Reliability Hand Hygiene 23

4 th Annual Robust Process Improvement Expo 4/14/16 24

High Reliability Transformation 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 25

Clinical Programs Committee, Board Quality Committee and MEC Approvals for Quality & Safety Guidelines 26

MHMD Clinical Programs Committee & Subcommittees MHMD Board of Directors Clinical Programs Committee H&V Neuro Woman/ Child Surgery Medicine Oncology Contract Primary Care Cardiology Neurology Neonatal Anesthesia Critical Care Oncology Imaging Adult PCP CV Surgery Neurosurgery Order Set Editorial Board OB/Gyn Bariatrics Emergency Orthopedics 457 Evidence-Based Practice ENT Hospital Informatics Recommendations made by CPCs in 2015 Medicine Acute Surgery 2015 SUMMARY OF ACTIONS Ad hoc Allergy Post Acute Pathology Peds Clinical Ethics & Palliative Care Peer Review 27

Selected MEC-Approved CPC & SQC Safety & Quality Guidelines Real-Time Ultrasound for Central Line Insertion Real-Time Ultrasound for Cath Lab Central Punctures OB Safety Training Prevention of Retained Foreign Bodies Policy DVT/PE Prophylaxis Bariatrics Privileging and Leveling Moderate and Deep Sedation Privileging Peer Review for Physician-Related SSEs Clinical Escalation Policy Postoperative Pulse Oximetry Monitoring 29

2 Obtaining MEC Approvals Across the System Up and Over

3 Safety & Quality Guidelines MEC Approval Up and Over BOARD SYSTEM QUALITY COMMITTEE MHMD Board of Directors Clinical Programs Committee Hospital MECs (11) CPC Subcommittee(s): Critical Care Surgery Medicine

MEC Up or Down Vote 31

Hospital Acquired Conditions Never Events Acute Hemolytic Transfusion Reactions Transfusion Events Jan 2007- June 2016 2,450,000 Adjusted Admissions 13,331,000 Adjusted Pt Days 1,185,000 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. 33

Hospital Acquired Conditions Never Events Acute Hemolytic Transfusion Reactions Transfusion Events Jan 2007- June 2016 2,450,000 Adjusted Admissions Zero 13,331,000 Adjusted Pt Days 1,185,000 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. 34

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

System 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 Mean = 2.52 UCL = 3.86 Mean = 2.12 TJC Center for Transforming Healthcare Hand Hygiene UCL = 2.97 UCL = 2.55 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 produce d by Syste m Qua lity a nd Patie nt Safe ty 36

37 Hospital HAI Scorecards Number of HAIs in one month

38 Hospital HAI Scorecards Number of HAIs in one month

Hospital Acquired Infections, Conditions and Patient Safety Indicators Central Line Associated Bloodstream Infections Ventilator Associated Pneumonias Surgical Site Infections Retained Foreign Bodies Iatrogenic Pneumothorax Accidental Punctures and Lacerations Pressure Ulcers Stages III & IV Hospital Associated Injuries Deep Vein Thrombosis and/or Pulmonary Embolism Deaths Among Surgical Inpatients with Serious Treatable Complications Birth Traumas Serious Safety Events 39

MH Southeast Hospital Iatrogenic Pneumothorax 42 MH Southeast Hospital MH Southeast Hospital 22 Months Zero Iatrogenic Pneumothorax

MH Southeast Hospital Real Time Ultrasound Guidance 43 1 st Memorial Hermann Hospital >90% Ultrasound Compliance Use ICU Safe Practice Guideline: Real-time ultrasound guidance will be used for placement of all central venous catheters, whenever possible.

High Reliability Certified Zero Award 45 1. Zero Events 2. 12 Consecutive Months 3. Certified Zero Category

MH Northwest: Zero Retained Foreign Bodies 46 MD/Nursing OR Count Policy Mandatory RFID Scanning Zero Retained Foreign Bodies x 60 Months

MH Katy: Zero Central Line Blood Stream Infections Hospital-Wide 47 Central Line Bundle Compliance Zero CLABSIs Hospital-Wide x 17 Months

MH Sugar Land: Zero ICU Catheter Associated UTIs 48 CAUTI Bundle Compliance Zero ICU CAUTIs x 36 Months

MH Woodlands: Zero Hospital Acquired Injuries 49 Zero Hospital Injuries x 21 Months

High Reliability 2011-16 Certified Zero Awards ICU Central Line Associated Bloodstream Infections (17) ICU Catheter Associated Urinary Tract Infections (9) Hospital-Wide Central Line Associated Bloodstream Infections (7) Hospital-Wide Catheter Associated Urinary Tract Infections (4) Ventilator Associated Pneumonias (23) Surgical Site Infections 231 Retained Foreign Bodies (43) Iatrogenic Pneumothorax (23) Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (33) Hospital Associated Injuries (6) Deep Vein Thrombosis and/or Pulmonary Embolism (2) Deaths Among Surgical Inpatients with Serious Treatable Complications (1) Birth Traumas (14) Obstetric Trauma in Vaginal Deliveries with Instrumentation (3) Serious Safety Events 1&2 (16) Serious Safety Events 1 & 2 for 1000 Days (2) All Serious Safety Events (1) Early Elective Deliveries (6) Manifestations of Poor Glycemic Control (18) 50

51 In 2013 the South Carolina Hospital Association established the Certified Zero Harm Award www.sczeroharm.com

Zero Harm Awards were first presented in 2014 Results to date: Two-thirds of South Carolina s acute care hospitals have received at least one Zero Harm Award All together, South Carolina hospitals have earned 258 Zero Harm Awards This year s award winners amassed 55,291 central line days without an infection They also performed 9,700 harm-free surgical procedures And twelve of this year s winners were recognized for 42 consecutive months without harm 52

MH Serious Safety Events 53

September 6, 2015 MH Greater Heights Hospital 1000 Days Since Last SSE1-2 55

FINAL 56 Next Generation Healthcare Quality Assurance

Healthcare as a High Reliability Organization 57

High Reliability Organizations 58 Commercial Aviation Air Traffic Control Nuclear Aircraft Carriers

High Reliability Organizations Memorial Hermann Health System Air Traffic Control Nuclear Aircraft Carriers Commercial Aviation 59

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

A Better Way to Improve Mark R. Chassin, MD, FACP, MPP, MPH President, The Joint Commission Institute for Healthcare Improvement 28th Annual Forum Orlando, FL December 6, 2016

Current State of Quality Routine safety processes fail routinely Hand hygiene Medication administration Patient identification Communication in transitions of care Uncommon, preventable adverse events Surgery on wrong patient or body part Fires in ORs, retained foreign objects Infant abductions, inpatient suicides

Current State of Improvement We have made some progress Project by project: leads to project fatigue Satisfied with modest improvement Current approach is not good enough Improvement difficult to sustain/spread Getting to zero, staying there is very rare High reliability offers a different approach The goal is much more ambitious High reliability is not a project

High Reliability Healthcare Our team has worked for >7 years with academics and experts from HROs (nuclear, aviation, military, amusement parks) We have created a model for healthcare: Leadership commitment to zero harm goal Safety culture embedded throughout RPI (lean, six sigma, change management) New resources, tools, and strategies Get started with Oro TM 2.0 self-assessment

Robust Process Improvement Systematic approach to problem solving Joint Commission has adopted RPI Improve processes and transform culture Focus on our customers, increase value The Joint Commission is adopting all components of safety culture We measure RPI and safety culture and report on strategic metrics to Board

Quality Progress Cover Story June 2016

What is Lean? Philosophy: continuous improvement of processes through employee empowerment Teaches us to view our processes from the customer s perspective in value streams Tools: to increase value by eliminating steps in processes that represent pure waste Waste increases cost, produces no value All unexamined processes have waste; often as much as 50% of time and effort is waste

Before After Lean Fundamentals Process Improvement Using Lean Same value, Less time, lower cost Work Time: value added Waiting, rework: non-value added time Business Improvement = Eliminate Waste + Improve Outcomes Lean Six Sigma

Six Sigma Uses DMAIC To Improve the Outcomes of Processes Define Measure Analyze Improve Control

Six Sigma Uses DMAIC To Improve the Outcomes of Processes Define Measure Analyze Improve Control Who are the customers? What is critical to the quality of the process? How do we measure how well the process is performing? What are the most important causes of the defects?

Six Sigma Philosophy Six sigma philosophy puts quality in a different light We think in percentages Six sigma measures bad outcomes as defects per million opportunities 1% rate of bad outcomes = 10,000 defects per million Six sigma gives us tools and a way to think about getting to zero harm: the high reliability goal

How Safe are US Airlines? 1990-2001----safest commercial aviation in the world 129 deaths per year 9.3 million flights per year Rate = 13.9 deaths per million flights 2002-2013 14.6 deaths per year = 90% 10.2 million flights per year Rate = 1.4 deaths per million flights

The Technical Solution is Not Enough Lean and six sigma provide technical solutions Why does improvement fail so often? Change management Not for lack of a good technical solution Failures is the occur rocket when organization science fails of to accept and implement a good solution it had improvement RPI addresses this challenge directly Change management = a systematic way to implement and sustain good solutions

Facilitating Change Key components of managing change effectively 1. Plan: engage all stakeholders, identify sponsor, champion and process owner 2. Inspire: paint a convincing picture of how the change will be beneficial 3. Launch: initiate the change, intensify communication to stakeholders 4. Support: sustain gains; empower process owner Change management is not linear

Getting Started Identify all the relevant stakeholders ARMI analysis Approvers Resources Members Interested parties Different roles at different phases of change Revisit periodically during change process

Resistance to Change Managing resistance is critical to success Resistance Analysis is a vital tool Who is likely to resist and why? Sources of resistance Technical Political Cultural Each requires a different strategy to overcome

Engaging Stakeholders Attitude/Influence Matrix Assess attitudes of key stakeholders (support or oppose) Who can influence the attitude of those who are opposed? Works to build support, overcome resistance Requires continuous attention during project as attitudes typically change over time Opponents, if converted, are best advocates

RPI in Health Care Today An increasing number of hospitals and systems use one or more RPI tools RPI is used differently by different hospitals Most use only some of the parts; change management is most often left out Most limit training to small group Most do not use it to transform Compelling business case for RPI

The Business Case Administrative processes in health care are often just as broken as clinical processes Billing, supply chain, throughput RPI can directly improve margins Learning RPI allows organizations to solve their own problems, eliminate consultants Quality improvements often don t save $$ Generate positive ROI now while learning how to redesign clinical care processes Mayo program ROI = 5:1 J Patient Safety 2013;9(1):44-52

Training and Deployment We have a large group of experts in lean, six sigma, and change management (RPI) Studied experience of major corporations (for example, GE, Lilly, BD, Cardinal) Extensive experience with 27 hospitals and systems applying RPI tools We are training hospitals and systems to: Get the most out of RPI tools and methods Embed RPI throughout their organizations

Create an RPI Program to Last Don t confine training to group of experts Aim to spread RPI throughout system Establish different levels of training Use RPI training to identify best and brightest for staff development, promotion RPI becomes transformative when: It becomes the way we work every day Front-line employees see opportunities and have the tools to initiate improvement

Center for Transforming Healthcare www.centerfortransforminghealthcare.org

Center for Transforming Healthcare Using RPI together with leading US hospitals and systems to solve most difficult quality problems Project topics: 2009-10: hand hygiene, wrong site surgery, hand-off communications, SSIs 2011: safety culture, preventable HF hospitalizations, and falls with injury 2012: sepsis mortality, insulin safety 2013-4: C. difficile prevention, VTE

Participating Hospitals and Systems Atlantic Health Memorial Hermann Barnes-Jewish New York-Presbyterian Baylor North Shore-LIJ Cedars-Sinai Northwestern Cleveland Clinic OSF Exempla Partners HealthCare Fairview Sharp Healthcare Floyd Medical Center Stanford Hospital Froedtert Texas Health Resources Intermountain Trinity Health Johns Hopkins VA Healthcare System-CT Kaiser-Permanente Virtua Mayo Clinic Wake Forest Baptist Wentworth-Douglass

Health Facilities Management Magazine

RPI Improves Housekeeping New wing added in 2012: 130,000 SF Challenge to ES staff: Add this building to existing 364,000 SF No new staff, same high quality cleaning Used RPI to redesign workflow Met the challenge Saved the hospital about $440,000 Wentworth-Douglass RPI program = 3:1 ROI (only 60% of projects aim at financial goals)

RPI Delivers Results One-size-fits-all best practice is inadequate Complex processes require more sophisticated problem-solving methods (RPI) Three crucial and consistent findings: Many causes of the same problem Each cause requires a different strategy Key causes differ from place to place RPI: producing next generation best practices; solutions customized to your causes

Some Important Causes of Hand Hygiene Failures 1. Faulty data on performance 2. Inconvenient location of sinks or hand gel dispensers 3. Hands full 4. Ineffective education of caregivers 5. Lack of accountability Each requires a very different strategy to eliminate

Causes Differ by Hospital Each letter = one hospital

RPI Drives Major Improvements Center Projects Hand hygiene Hand-off communication failures Wrong site surgery risks Scheduling Pre-op Operating Room Colorectal SSIs Falls with injury Results(%) 71 56 46 63 51 32 62

Targeted Solutions Tool (TST) Web-based tools: secure extranet channel Available to all accredited customers now No added cost, voluntary, confidential Educational, no jargon, no special training Coaches available to guide users to solutions Targeting only your causes means you don t use resources where they aren t needed 2010: hand hygiene; 2012: safe surgery, hand-off communication; 2015: falls

January 2015 Jt Comm Journal on Qual Pat Safety 2015;41(1):4-12 and 13-25

Impact of Hand Hygiene TST TST improves HH: 55% to 85%, Reduces HAIs by 35% 200 Beds Expect 370 HAIs/yr Annual impact: 129 fewer HAIs 8 lives saved $2.5M cost avoided 400 Beds Expect 730 HAIs/yr Annual impact: 260 fewer HAIs 16 lives saved $5M cost avoided

Used TST to achieve >95% hand hygiene compliance Bloodstream infections fell by 2/3

Hand Hygiene Compliance (%) MRSA Rate Decreases as Hand Hygiene Improves 100 90 80 70 60 50 40 30 HH MRSA 2.5 2.0 1.5 1.0 0.5 0.0 2008 2009 2 MRSA Cases (per 1000 patient days)

System - Ventilator Associated Pneumonias: All Adult ICUs

Joint Commission, RPI and High Reliability We must have much more ambitious goals for healthcare improvement: zero harm Current methods will not get us there Lean, six sigma, and change management (RPI) have far greater promise Some hospitals and systems making real progress; showing that zero is achievable Joint Commission has tools to help