Commitment to Zero Harm - Home | Michigan Health ... to Zero Harm.pdfCommitment to Zero Harm:...

Commitment to Zero Harm:

Memorial Hermann Health System’s

Journey to High Reliability

MHA Patient Safety & Quality

SymposiumMarch 8, 2017

M. Michael Shabot, MD, FACS, FCCM, FACMI

Executive Vice President

System Chief Clinical Officer

Memorial Hermann Health System

Memorial Hermann Health System (02/17)

Grand Pkwy

Beltway 8

IS-610

Memorial Hermann Health System (02/17)

MH The Woodlands

MH NortheastMH Cypress

MH Pearland

MH SoutheastMH Sugar Land

MH KatyMH Memorial City

MH Northwest

MH TMC

Children’s

MHHMH Southwest

MH Katy Rehab

Hospitals: 15Rehab Hospitals/Units: 2/5Conv Care Centrs: 5+3 constr Amb Surgery Centers: 22Imaging Centers: 37Sports Med & Rehab: 44Diagnostic Labs: 37Adv Prim Care Practice: 497

Clinical Integ Specialists: 2,620

TIRR MH

IS-610

Grand Pkwy

Beltway 8

Hospital 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.

251,454737 crash every 5.5 hours

Hospital 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.

251,454737 crash every 5.5 hours

Memorial Hermann’s Goal

0 (Zero)5

How Can Memorial Hermann Get to Zero?

New Nursing Staff?

New Doctors?

All New Execs?

How Can Memorial Hermann Get to Zero?

New Nursing Staff?

New Doctors?

All New Execs?

Robust Process Improvement: Path to Quality Outcomes

The Role of Culture

March 22, 1966

Hospital Safety 1966

“If healthcare was an airline…”

“If healthcare was an airline, only dedicated risk takers, thrill seekers and those tired of living would fly on it.”

Patient Safety (2005)

by Charles Vincent

What if These Kinds of

Risks Weren’t an Option?

High Reliability Organizations

Commercial

Aviation

Nuclear AircraftCarriers

Air Traffic Control

United Airlines

Customer Service: Worst US Airline x5+ yr

Bankruptcies: Too Many to Count (TMTC)

CEOs: TMTC, Smisek Possible Indictment

Last Fatal Crash? 1992

Employee Unions: In Disarray x5+ Years

Memorial Hermann’s Journey to High Reliability

Transfusion Errors

Serious Safety Events

Transformation to a High Reliability Organization

August 14, 2006

A Call to Action

on Patient Safety

Burning Platform

Board Commitment

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

Safety as the Core Value

Role of the Board

• Leadership for high reliability, safety &

quality initiatives

• Ensuring the Board receives quality &

safety results information it needs

• Providing guidance for the System

Quality Committee

• Providing support for safety & quality

initiatives, including financial support

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

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

Total Transparency with the Board

MHHS Safety Culture TrainingCompleted in 2007

Hospital Training Complete

>4,000 Physicians Trained

>20,000 Employees Trained

>540 Safety Coaches Trained

>$18M Expense

Breakthroughs in Patient Safety 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

Safety Culture Training

* Jefferson Center for Character Education

Vigilance

0.6 6 6,00060060

Seconds Paused in Thought

0.000001

0.0001

0.00001

“It sort of makes you stop & think, doesn’t it?”

Self-Checking With STAR*(Stop, Think, Act, & Review)

“It sort of makes you stop & think, doesn’t it?”

Edna Coutts, RNSugar Land Hospital Safety Champion of the Month

Safety Success Stories

Self-Check with STAR

(Stop, Think, Act, & Review)

Support Each Other:CUSS Words

• I am Concerned

• I am Uncomfortable

• This is for Safety

• Stand up and Stand Together

MH Southwest Hospital

Central Line Standoff

Red Rules Absolute Compliance

1. Patient Identification

2. Time Out

3. Two Provider Check

Robust Process Improvement:Path to Quality Outcomes

Change Management

Six Sigma

Effectiveness of solutions

Effectiveness = Q x A1 x A2

Quality of solution (Q) x

Acceptance (A1) x

Accountability (A2)

Robust Process Improvement:Changing Standard Work

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

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

High Reliability Transformation

5th Annual Robust Process Improvement Expo Feb 17, 2017

Over 150 Attendees - 63 RPI Projects

2nd Annual High Reliability Sharing Days Feb 15-17, 2017

• Mem City Hospital Tours

• End to End Care Vision

• High Reliability Journey

Milestones

• CEO/CMO Collaboration

• Individuals and Teams

• CMO Perspective

• Physician Engagement in

• Structure of Safety

• Robust Process Improvement: Role in High Reliability

• Ambulatory Quality: Early Work

• Panel Discussion: Quality and Performance Improvement

Governance Structure

• Ben Taub/BCM

• Dignity Health

• Flagler Hospital

• Harris Health

• Henry Ford

• Hoag Hospital

• IHI

• Intermountain

• MedStar

• Michigan Hospital

Association

• Mount Sinai

• Navigant

• Orlando Health

• Sentara

• St. Joseph Mercy

• Swedish Health System

• Tampa General

• University Health

Network, Toronto

• UT Southwestern

• VCU Medical Center

2nd Annual High Reliability Sharing Days Attendees (41)

MEC Approvals for

Quality & Safety Guidelines

Across a Health Care System

Issue:

Achieving uniform

physician governance

in multiple hospitals

MHMD Board of Directors

Clinical Programs Committee

Cardiology

CV Surgery

Neurology

Neurosurgery

Woman/Child

Neonatal

OB/Gyn

Surgery

Anesthesia

Bariatrics

Orthopedics

Allergy

Medicine

Critical Care

Emergency

Ad hoc

Hospital Medicine

Post Acute

Oncology

Contract

Imaging

Pathology

Primary Care

Adult PCP

Peer Review

Clinical Ethics &

Palliative Care

Order Set

Editorial Board

Informatics

Acute Surgery

MHMD Clinical Programs Committee & Subcommittees

519 Evidence-Based Practice

Recommendations made by CPCs in 2016

2015 SUMMARY OF ACTIONS

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

“Up and Over”

Obtaining MEC Approvals Across the System

Safety & Quality Guideline MEC Approval

Clinical Programs Committee

Critical Care Surgery Medicine

MHMD Board of Directors

Hospital MECs (12)

BOARD SYSTEM

QUALITY COMMITTEE

“Up and Over”

CPC Subcommittee(s):

MEC Up or Down Vote

Acute Hemolytic Transfusion Reactions

Hospital Acquired Conditions“Never Events”

Transfusion Events Jan 2007- Dec 2016

2,617,000 Adjusted Admissions

14,234,000 Adjusted Pt Days

1,240,000 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.

Acute Hemolytic Transfusion Reactions

Hospital Acquired Conditions“Never Events”

Transfusion Events Jan 2007 - Dec 2016

2,617,000 Adjusted Admissions

14,234,000 Adjusted Pt Days

1,240,000 Transfusions

Joint Commission Hand HygieneCenter for Transforming Healthcare

BaselineCompliance

>90% compliance since Nov 2012

“Secret Shopper”

measurements per month

Compliance Rate

System Adult ICU CLABSICentral Line Associated Blood Stream Infections

Source fi le date: 4/23/2015

Generated: 4/24/2015 10:43:32 AM Reporting Monthsproduce d by Syste m Qua l i ty a nd Pa tie nt Sa fe ty

UCL = 9.42

Mean = 5.53

LCL = 1.64

UCL = 5.79

Mean = 3.04

LCL = 0.29

UCL = 5.13

Mean = 2.52

UCL = 3.86

Mean = 2.12

LCL = 0.38

UCL = 2.55

Mean = 1.17

UCL = 2.97

Mean = 1.46

Adult ICU Central Line Associated Blood Stream Infections (CLABSI)

TJC Center for

Transforming Healthcare

Hand Hygiene

Ventilator Associated Pneumonias: All Adult ICUs

TJC Center for

Transforming Healthcare

Hand Hygiene

Catheter Associated Urinary Tract Infections (CAUTIs)

Catheter-Associated UTIs Floor & ICU House-Wide

Do No HarmFloor CAUTI NHSN SIR

HAI Hospital Scorecards

Number of HAIs in one month

HAI Hospital Scorecards

Number of HAIs in one month

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

Hospital Acquired Infections, Conditions and Patient Safety Indicators

Birth Traumas

Hospital Acquired Infections, Conditions and Patient Safety Indicators

Birth Traumas

High ReliabilityCertified Zero Award

1. Zero Events

2. 12 Consecutive Months

3. Certified Zero Category

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 & 160.007.; and the Medical Peer Review immunity provided by federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq. 61

MH Greater Heights: Zero Retained Foreign Bodies

Zero Retained Foreign Bodies x 72 Months

MD/Nursing OR

Count PolicyMandatory RFID

Scanning

MH Children’s: Zero Ventilator Associated Pneumonias

Zero Ventilator Associated Pneumonias x 48 Months

Ventilator Bundle

Compliance

MH Katy: Zero Central Line Blood Stream Infections Hospital-Wide

Zero CLABSIs Hospital-Wide x 17 Months

Central Line Bundle

Compliance

MH Sugar Land: Zero ICU Catheter Associated UTIs

Zero ICU CAUTIs x 24 Months

CAUTI Bundle

Compliance

MH Woodlands: Zero Hospital Acquired Injuries

Zero Hospital Injuries x 21 Months

High Reliability 2011-16Certified Zero Awards

ICU Central Line Associated Bloodstream Infections (18)

ICU Catheter Associated Urinary Tract Infections (13)

Hospital-Wide Central Line Associated Bloodstream Infections (7)

Hospital-Wide Catheter Associated Urinary Tract Infections (4)

Ventilator Associated Pneumonias (23)

Surgical Site Infections (0)

Retained Foreign Bodies (44)

Iatrogenic Pneumothorax (23)

Accidental Punctures and Lacerations (3)

Pressure Ulcers Stages III & IV (34)

Hospital Associated Injuries (6)

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 (17)

Serious Safety Events 1 & 2 for 1000 Days (2)

All Serious Safety Events (1)

Early Elective Deliveries (7)

Manifestations of Poor Glycemic Control (18)67

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

September 6, 2015MH Greater Heights Hospital1000 Days Since Last SSE1-2

John M. Eisenberg Patient Safety and Quality Award

March 8, 2013 | Washington, DC

Memorial Hermann Sugar Land Hospital

Next Generation Healthcare Quality

Assurance

Healthcare as a High Reliability Organization

Air Traffic Control

Commercial Aviation

Air Traffic Control

Commercial Aviation

Memorial Hermann Health System

“You must be the change

you want to see in the world”

Mahatma Gandhi (1869-1948)

Thank you!

Commitment to Zero Harm - Home | Michigan Health ... to Zero Harm.pdfCommitment to Zero Harm:...

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