1

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

V9

Memorial Hermann Health System (02/17)

Grand Pkwy

Beltway 8

IS-610

22

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

MH

OSH

33

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.

4

251,454737 crash every 5.5 hours

2016

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

2016

Memorial Hermann’s Goal

0 (Zero)5

6

How Can Memorial Hermann Get to Zero?

New Nursing Staff?

New Doctors?

All New Execs?

7

How Can Memorial Hermann Get to Zero?

New Nursing Staff?

New Doctors?

All New Execs?

8

Robust Process Improvement: Path to Quality Outcomes

The Role of Culture

9

March 22, 1966

Hospital Safety 1966

5

“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

11

What if These Kinds of

Risks Weren’t an Option?

12

High Reliability Organizations

13

Commercial

Aviation

Nuclear AircraftCarriers

Air Traffic Control

United Airlines

14

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

15

Transfusion Errors

Serious Safety Events

Transformation to a High Reliability Organization

August 14, 2006

A Call to Action

on Patient Safety

16

Burning Platform

1717

Board Commitment

18

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

19

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

20

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

21

2015 MH “From the Top”The Role of the Board and Medical Staff in Quality & Safety

22

February 20, 2015 - 7:30am-5:00pm

Houston, Texas

55 Memorial Hermann Board members and

100 MEC members & hospital execs trained

23

Total Transparency with the Board

24

MHHS Safety Culture TrainingCompleted in 2007

Hospital Training Complete

>4,000 Physicians Trained

>20,000 Employees Trained

>540 Safety Coaches Trained

>$18M Expense

24

Breakthroughs in Patient Safety Training

25

• 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

26

* Jefferson Center for Character Education

Vigilance

Tests

0.6 6 6,00060060

Seconds Paused in Thought

0.000001

0.9

0.1

0.5

0.01

0.05

0.0001

0.001

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?”

27

Edna Coutts, RNSugar Land Hospital Safety Champion of the Month

2007

Safety Success Stories

Self-Check with STAR

(Stop, Think, Act, & Review)

28

Support Each Other:CUSS Words

• I am Concerned

• I am Uncomfortable

• This is for Safety

• Stand up and Stand Together

29

MH Southwest Hospital

Central Line Standoff

Red Rules Absolute Compliance

1. Patient Identification

2. Time Out

3. Two Provider Check

30

31

Robust Process Improvement:Path to Quality Outcomes

Change Management

Lean

Six Sigma

32

Robust Process Improvement:Path to Quality Outcomes

33

Effectiveness of solutions

Effectiveness = Q x A1 x A2

Quality of solution (Q) x

Acceptance (A1) x

Accountability (A2)

Robust Process Improvement:Path to Quality Outcomes

34

Robust Process Improvement:Changing Standard Work

Standard Work =

What we do every day

What we do every day =

CULTURE!

35

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

36

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

High Reliability Transformation

37

5th Annual Robust Process Improvement Expo Feb 17, 2017

Over 150 Attendees - 63 RPI Projects

38

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

RPI

• Structure of Safety

• Robust Process Improvement: Role in High Reliability

• Ambulatory Quality: Early Work

• Panel Discussion: Quality and Performance Improvement

Governance Structure

39

• 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

40

Issue:

Achieving uniform

physician governance

in multiple hospitals

41

MHMD Board of Directors

Clinical Programs Committee

H&V

Cardiology

CV Surgery

Neuro

Neurology

Neurosurgery

Woman/Child

Neonatal

OB/Gyn

Surgery

Anesthesia

Bariatrics

Orthopedics

ENT

Allergy

Medicine

Critical Care

Emergency

Ad hoc

Hospital Medicine

Post Acute

Oncology

Oncology

Contract

Imaging

Pathology

Primary Care

Adult PCP

Peds

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

13

43

“Up and Over”

Obtaining MEC Approvals Across the System

44

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):

45

MEC Up or Down Vote

46

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

47

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

48

Zero

49

Joint Commission Hand HygieneCenter for Transforming Healthcare

BaselineCompliance

44%

>90% compliance since Nov 2012

“Secret Shopper”

measurements per month

Compliance Rate

CL

AB

SI

Ra

te p

er

1K

Lin

e D

ay

s

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

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Adult ICU Central Line Associated Blood Stream Infections (CLABSI)

50

TJC Center for

Transforming Healthcare

Hand Hygiene

Ventilator Associated Pneumonias: All Adult ICUs

TJC Center for

Transforming Healthcare

Hand Hygiene

51

Catheter Associated Urinary Tract Infections (CAUTIs)

52

Catheter-Associated UTIs Floor & ICU House-Wide

53

Do No HarmFloor CAUTI NHSN SIR

54

55

HAI Hospital Scorecards

Number of HAIs in one month

56

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

Serious Safety Events

Hospital Acquired Infections, Conditions and Patient Safety Indicators

57

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

Hospital Acquired Infections, Conditions and Patient Safety Indicators

58

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

High ReliabilityCertified Zero Award

1. Zero Events

2. 12 Consecutive Months

3. Certified Zero Category

59

60

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

62

MD/Nursing OR

Count PolicyMandatory RFID

Scanning

MH Children’s: Zero Ventilator Associated Pneumonias

63

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

64

Central Line Bundle

Compliance

MH Sugar Land: Zero ICU Catheter Associated UTIs

Zero ICU CAUTIs x 24 Months

65

CAUTI Bundle

Compliance

MH Woodlands: Zero Hospital Acquired Injuries

Zero Hospital Injuries x 21 Months

66

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

243

In 2013 the South Carolina Hospital Association

established the Certified Zero Harm Award

www.SCZeroHarm.com

68

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

69

70

Serious Safety Events

71

72

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

John M. Eisenberg Patient Safety and Quality Award

March 8, 2013 | Washington, DC

73

Memorial Hermann Sugar Land Hospital

74

FINAL

Next Generation Healthcare Quality

Assurance

75

Healthcare as a High Reliability Organization

76

2011

High Reliability Organizations

Nuclear AircraftCarriers

Air Traffic Control

77

Commercial Aviation

High Reliability Organizations

Nuclear AircraftCarriers

Air Traffic Control

78

Commercial Aviation

Memorial Hermann Health System

“You must be the change

you want to see in the world”

Mahatma Gandhi (1869-1948)

79

Thank you!