Eliminating Harm: The Foundation of High Performance

in Healthcare

Richard P. ShannonFrank Wister Thomas Professor of

MedicineChairman, Department of Medicine

University of PennsylvaniaSchool of Medicine

• Canadians: Please divert your course 15 degrees to the South to avoid collision.

• United States: Recommend you divert your course 15 degrees to the North to avoid a collision.

This is a transcript of an actual radio conversation between a US Naval ship and Canadian authorities off the coast of

Newfoundland in October, 1995. Radio conversation released by the Chief of Naval Operations 10/10/95

A Metaphor for the US Healthcare System

• Canadians: Negative. We insist that you divert your course 15 degrees to the South to avoid a collision.

• United States: This is the Captain of a US Navy Ship. I say again, divert YOUR course.

• Canadians: No. I say again, you divert YOUR course.

• United States: This is the aircraft carrier USS Lincoln, the second largest ship in the United States’ Atlantic Fleet. We are accompanied by three destroyers, three cruisers, and numerous support vessels. I demand that you change your course 15 degrees North! I say again, that’s one five degrees North or counter-measures will be undertaken to ensure the safety of this ship.

• Canadians: This is a lighthouse. Your call.

Photo by Lynn Botterman

Our Contract With Society• Commitment to professional competence• Commitment to honesty with patients• Commitment to patient confidentiality• Maintenance of appropriate relationships with patients• Commitment to improving quality of care• Commitment to improving access to care• Commitment to scientific knowledge• Commitment to trust by managing conflict of interest• Commitment to professional responsibilities• Commitment to the just distribution of finite resources

ABIM Physician Charter

Primum Non Nocere

Oath of Hippocrates

Will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone

I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

The Question

• Can the elimination of harm (hospital acquired infections, medication errors, readmissions) serve as a starting point for reducing unnecessary costs (waste) in healthcare?

• Does it fulfill our professional duty to “do no harm” and to be good stewards of finite resources?

Healthcare Spending and Social Good

• US spends 18% of the GDP in healthcare• CMS accounts for 20% of the total government

spending-8x more than on education-12x more than food aid-30x more than on law enforcement-78x more than conservation-87x times more than water supply-830x more than on energy conservation

Problems with the US Healthcare System

• Costs are too high and value is too low

• Cut your way or improve your way to greater value

• If one can identify and eliminate waste, we can spare cuts to important services

• Waste

overtreatment

failures in care delivery

failures in care transitions

excess administrative costs

fraud and abuse

High Performing Organizations

• High performing organizations are the best in class

• They achieve high performance not necessarily through technological advances but through complete engagement of all the wisdom and skill embedded in each worker

• These organizations and their leaders never stop learning

Spear Chasing the RabbitSpear S Chasing the Rabbit

Dynamics of HPO

• Cope with complexity by continuous focus on learning more about how to improve the work they do.

• Nothing is ever good enough

Spear S Chasing the Rabbit

The Four Capabilities of HPO

• Specifying work to capture existing knowledge

• Swarm and solve problems to build new knowledge (avoid “information perishability”)

• Share that knowledge throughout the organization

• Lead by developing these capabilities in all workers

Spear Chasing the RabbitSpear S Chasing the Rabbit

Leaders in HPOs• Set clear and unambiguous expectations

• Practice not espouse values

• Amazing problem solving capabilities

• Empower and create systems that “discover” the right answers

• They do away with excuses as to “why not” or “if only, then”

Spear S Chasing the Rabbit

US Navy’s Nuclear Submarine Program

• 200 nuclear powered ships launched • 5,700 reactor years of operation• 154 million miles underway• Not a single reactor related casualty or escape

of radiation

Spear S Chasing the Rabbit

Current US Estimates

• 5-10% of inpatients acquire an HAI• 1.7 million HAIs annually• 99,000 deaths• Estimated costs:$28.4-33.8 billion• It is 27X safer to work at Alcoa than it is to

walk into a US hospital

Safer?

HAI in Pennsylvania 2009

23,287 HAI (1.2%)

Patient Outcomes

Seven Leverage Points:If you want to achieve system-level results…

1. Set specific system-level aims and oversee their achievement at the highest levels of governance

2. Build an executable strategy to achieve the aims, and oversee the execution at the highest levels of administration

3. Channel attention to system-level aims and measures

4. Get patients and families on your team!5. Engage the CFO in achieving the aims6. Engage doctors in achieving the aims7. Build the improvement capability necessary to

achieve the aims Reinertsen IHI

A “Project”

System Level Aim

Setting the Course

Current Conditions

Decode: 37 CLABS(July 2002-June 2003)

PRHI Central Line Data

Observations of Dressing Changes

Root Cause Analysis

Solve to root cause in real timethe origins of CLABS in

MICU / CCU

Counter Measures GeneratedBy the People That Do The Work

Eliminate CLABSIn MICU/CCUIn 90 days

Reassess ResultsGenerate AdditionalCounter Measures

Problems With Bench MarkingThe Difference Between Reporting and Actionable Data

01 Q3 01 Q4 02 Q1 02 Q2 02 Q3 02 Q4 03 Q1 03 Q20

1

2

3

4

5

6

7

8

9

10

CCU/MICU

CDC

PRHI

Decoding the Data:What Does 5.1 infections/ 1000 line days

Really Mean??

• 37 patients / total of 49 infections• 193 lines were employed (5.2 lines / patient)• 1753 admissions• 1063 patients had central access for more than 12 hours• 1 out of 22 patients with a central line became infected.• We were reporting only half the actual infections (not including

femoral line infections!!)• Two-thirds of the infections involved virulent organisms. Twenty

percent were MRSA• 19 patients died (51%)

Journal of Quality and Patient Safety 2006;32:479

Personal Stories Send the Message

• 22 yo. woman, a single mother of a 2 year old child, presented with relapsing acute myeloid leukemia.

• Following re-induction with a highly toxic chemotherapy regimen, she is found to be in complete remission.

• Day 18, she develops fever, chills and hypotension. BC grow staph aureus from her Hickman catheter.

• In retrospect, the unused lumen of her triple lumen catheter had cracked and been repaired.

• The cracked lumen-repair process was common place despite evidence that it was associated with a27% risk of infection

• RCA revealed unspecified understanding about flushing unused catheters and that there was a small area on the lumen where a clamp should be re-enforced.

• The patient spend an additional 17 days in the hospital, away from her child.

• She died 27 days after discharge.

Penn Medicine/ DOM Approach to Patient Safety

• Trained 220 nurses in the Lean methodology• Exposed all senior leadership to observation

exercises at the point of care• Completely redesigned standard methods for

placing and maintaining all catheters.• Incorporated training modules for house staff

and fellows.• Create UBCL teams with Problem Solving

Skills

Disciplined Problem Solving

Current ConditionHow work is currently done and what problems

are encountered

Root cause analysisFactors revealed by investigation to cause or

contribute to the problem

Actual Outcomehow the system performs with changes made

Target Conditionprediction of the expected effects of

countermeasures

Countermeasures

Changes in how the work is done to offset causal effects

Expected Outcome

How did you expect the system to perform

28

Background: What’s the problem or concern?

Gap Analysisdifference between what was

predicted and what actually happened

Rounding on Sick Systems

• Chief complaint• Present illness• Physical exam/diagnostic

test

• Therapeutic intervention• Clinical course• Natural history

• Assessment of outcome

• What’s the problem ?• How is work currently

done?• What defects are

encountered in the work?• Intervene to eliminate

defects• Create a target condition• Measure what actually

happens• Gap analysis

29

Rounding on Sick patients Rounding on Sick Systems

Variation in the Course of Work (Line Placement)

• No standard pre-procedure checklist

• Informed consent in 25% of procedures

• Eight different ways to “gown and glove”

• Six different ways to “prep and drape”

• Four different approaches to central veins

• Five different insertion kits

• 55% of procedures were documented

The Current Condition of VariationSteps 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

Enter Glove Visual Set up Wipe Flush Draw Wipe Vac Draw Draw Prob. Vac Wipe Flush Prob. Wipe Cap DiscardGlove Flush Wipe Vac Draw Wipe Draw Draw Vac Wipe Flush Wipe Cap DiscardLabel Docum.Seal Wash

Glove Gow n Enter Alarm Set up Cap Wipe Vac Draw Draw Draw Alarm Vac Wipe Flush Wipe Alarm Glove Label Docum.send

Enter Set up Wipe Flush Waste Draw Wipe Draw Trans. Draw Draw Draw label Seal Docum.Seal Glove Exit

Labels Supplies Enter Set up Purell Alarm Disc. Tubalcohol Un- Cap BD Wipe Vac Draw Draw Draw Draw Vac Wipe Flush Discardlabel Seal Prob. SuppliesAlarm alcohol Disc. TubUn- Cap Wipe Vac Draw Draw Draw Vac Flush DiscardDisc f lushWipe Rec. Tublabel Seal DiscardExit Wash send

Supplies Labels Glove Enter Med Set up Wipe Flush Alarm Vac Draw Draw Draw Vac Wipe Flush Prob. (untag- line)DiscardGlove Alarm Label Docum.Seal send

Supplies Enter Glove Unw rapAlarm Flush Vac Draw Draw Draw Vac Wipe Flush Rec. TubDiscardlabel Wash send

Enter Glove Visual Set up Wipe Flush Wipe Vac Draw Draw Draw Wipe Vac Wipe Flush Cap DiscardGlove Label Seal Wash send

Enter Glove Visual Alarm Wipe Flush Prob.( no blood)Flush Vac Draw Draw Draw Vac Wipe label Discard

Supplies Enter Glove Visual Set up(bed) Alarm Flush Vac Draw Draw Draw Draw Vac Wipe Flush Wipe Flush Glove Docum.Label Seal

Labels Supplies Purell Glove Enter Alarm Set up(bed) Disc. TubUnw rapWipe Flush Draw Wipe DiscardDraw Trans. Fill Fill DiscardWipe Flush Rec. TubDiscardlabel Glove Seal send Wash

Labels Supplies Glove Enter Alarm Set up clamp Disc. TubWipe Flush Draw Wipe Vac Fill Fill Fill Fill clamp Vac Wipe Flush clamp Rec. Tubclamp DiscardAlarm label Exit send Glove

Labels Supplies Label Docum.Gow n Glove Enter Set up (TOWEL ON BED)Alarm Wipe Flush Draw Wipe Draw Needle Wipe Draw Needle Wipe Flush DiscardSyr Fill Fill Syr Fill Fill Fill DiscardGlove Exit Wash Seal send

Labels Supplies Unw rapDocum.Wash Enter Set up(bed) Glove Wipe Flush Vac Fill Fill Fill Fill Fill Fill Vac Wipe Flush Discardlabel BD label BD Wash Exit Docum.Seal send

Labels Supplies Enter Unw rapSet up(bed) Wipe Flush DiscardWipe Draw Trans. Fill Fill DiscardWipe Draw Trans. Fill Fill Fill DiscardWipe clamp Flush DiscardPurell Exit Docum.Label Seal send

Labels Supplies Wash Unw rapGow n Glove Enter Alarm Wipe Flush Draw Draw Wipe Alarm DiscardSyr Fill Fill Fill Syr Fill Fill label BD DiscardGow n Glove Exit Seal send

Enter Gow n Purell Glove SuppliesProb. Glove (off)Gow n (off)Wash Exit SuppliesEnter Set up(podium) Purell Gow n Glove Stock Explain Alarm Un- Cap StopcockVac Fill Fill Flush Cap StopcockAlarm Gow n Glove Wash Exit Glove Label Seal send

Gow n Enter Glove SuppliesAlarm Set up(bed) StopcockUn- Cap Vac Fill Fill Fill Fill Fill Syr Flush w ith green tube)Vac Cap Discardlabel Gow n Glove Purell Exit Seal send

Supplies Un- Cap Wipe Syr Fill Fill Wipe pump DiscardSyr recap

Order LabelPurell Glove SuppliesExplain Alarm Line Set up(bed) (ABG &4x4)Un- Cap Draw w asteDraw ABGWaste (gauze)Flush Cap Flush DiscardPurell Spec/gloveLabels Label Seal send

Purell Labels SuppliesGlove Alarm Line Set up(bed) 4x4)AssembleVacUn- Cap Cap/gauzeVac Draw w asteFill (purple)Flush w ith green tube)Discardlabel DiscardWash Spec/gloveProb. Tries to sendSeal send

Glove Supplies Set up(bed) 4x4)Un- Cap Vac Draw w asteFill red tubeAlarm ABG syrCap ABGFlush DiscardVac Glove Spec/glovePurell Labels Label Seal send Seal send

Comp. Purell SuppliesAssembl VacAlarm Glove StopcockUn- Cap Cap/ infusion pumpVac Draw w asteFill (tiger top)Vac Flush Discard stop in vacCap stopcockAlarm Discard Glove Purell Labels Label Seal send

Set up Flush Vac Fill Fill Flush Un-Gow nSuppliesWipe Draw Fill Flush Wipe Syr Fill Discard

Enter Wash SuppliesWipe Unw rapDraw Trans. Wipe bottleFill Wipe bottle 2Fill Wipe Vac Fill Wipe Unw rap flushWipe Flush Wipe Syr Wipe Rec. TubAlarm Discard Labels Label Seal send

Supplies Gow n Glove Wipe Flush Wipe SuppliesGow n Glove Wipe Vac Fill Syr Wipe Flush Discard bed TPA

Labels Supplies Gow n Glove Set up Explain SuppliesAlarm Line StopcockUn- Cap Assemble vacVac Fill Fill Fill Stopcockvac Gauze on portSqueezeCap StopcockFlush Discard waste gauzeAlarm Discard label Discard other workUN-GloveWash Glove Seal send

Glove Gow n Enter

Prob.(look for Alarm Glove

Supplies

Set up (bed)

Unw rap Visual Vac

Waste (tube) Fill Fill Fill

Discard (vacut Syr Flush Cap

Discard (sharp

Discard (red)

Discard (w hite UN-Glove

De-Gow n Wash Label Seal send

Glove Gow n Enter

Prob.(look for Flush Visual Alarm Flush

Waste (10 cc.) Draw StopcockCap Flush

Alarm (restart)

Discard (sharp

Discard (red)

Discard (w hite UN-Glove

De-Gow n Wash Label Seal send

Order Gow n Glove EnterSupplies

Set up (bed) Visual

Stopcock Syr Waste

Cap (hold)

Syr (remove)

Prob. (cap on

Syr. (in stopc Draw

Prob. (dirty cap Unw rap 4x4Flush

Cap (back on) Flush

Discard (sharp

Discard (red)

De-Gow n Purell Label Seal send

Wash Supplies GloveSet up (bed)

Unw rap

Remove air Wipe Vac Fill Fill

Vac (remove) Wipe Flush Clamp Alarm

Discard (sharp

Discard (red)

Discard (w hite

Label (pink, supply

Label (pt., at desk) Docum.Label

Prob. (no tube)

call blood bank wait

call CDR wait

1st tube arrive Seal send

2nd tube arriveProb.

(look for labels) Glove

Supplies

Stopcock

Set up room (Move

assemble vac

Stopcock

Cap (remove) Vac Fill Fill

Stopcock Flush Cap Flush

Stopcock

Purell GloveSupplies

Prob. (look for UN-Glove

Supplies (Omni Purell Glove Alarm

Set up (bed) Cap

Syr (3 cc)

Prob. (diff. draw

Prob. (manipulate

Syr (ABG) Draw

Unw rap 4x4 Flush Waste Cap

Clear air from

Discard (w hite

Discard (sharp Label

UN-Glove Purell

Order LabelPurell

Prob. (w ait for Purell Glove Alarm BD

Set up (bed) Cap

Unw rap 4x4

Syr (3 cc) Waste

Syr (ABG)

Cap (hold)

4x4 (hold) Waste Cap

Clear air from

Discard (sharp

Discard (red)

UN-Glove Purell Label Seal send

Purell GloveSupplies

Unw rap 4x4

Unw rap 4x4 Cap Waste Fill Fill Fill

Prob. (manipulate

Cleared line at

Cleared line at

Discard (sharp

Discard (red)

UN-Glove Purell Label Seal send

SuppliesSet up (table) Wipe Vac Waste Fill Fill Fill

Vac (remove) Wipe Flush Clamp label BD Seal send Docum.

Enter Explain Alarm Wash Glove Set up room (Move iv pole - move chair)Supplies (w ipes in room)Unw rap

Remove air Wipe UN-Cap Flush

UN-Clamp Vac

Fill (w aste)

Supplies (stude

Set up (bed) Fill Fill Vac Flush ClampWipe

Discard (sharp

Discard (red)

Discard (w hite UN-GloveWash other workLabel Seal send

Purell Wipe Clamp Attach Flush unclampFlush

Fill (w aste)

Discard (sharp Explain

Assemble Vac Fill Fill Fill BD Wipe Flush Clamp Docum.Wipe Disconnect tubingExplain Label Seal Prob- no tubes told sec.send

Supplies Wash Glove Set up room (Move iv pole - move chair)Wipe Flush

Fill (w aste)

Discard (sharp clamp Fill

Discard (sharp Flush Reconnect tubingDocum.Cap Explain label Seal Prob- no tubes sec calling for tubes

Supplies Purell Enter Glove (Purple)Alarm Flush Wipe vac Waste Fill Alarm Fill Flush Alarm

Discard (sharp UnGlovePurell labels Label ice Seal send

Wash Enter Set up bedGlove prob SuppliesWipe vac Flush Waste Fill Fill BD Fill label Wipe Flush clamp Wipe Flush label

Discard (sharp Exit Wash

Labels Supplies Glove Gow n Set up room tableAsemble vacUnw rapWipe Flush Waste Wipe vac Fill Fill Fill Unw rapWipe Flush clamp

Discard (sharp

Discard (red)

Discard (w hite BD label

1) Set up work Hand Hygiene Open Drape Open Dressing Kit Drop Biopatch

work Wash or Purell Space

2) Prepare Adjust Bed Don Masks Clean Gloves People (nurse) (patient)

3) Remove Remove with alcohol Discard Trash Wash Hands Dressing

DRESSING CHANGE STANDARD WORK

5. Apply New Apply Outline Apply Seal Apply Strips in Biopatch Dressing Dressing Dressing X and label

4. Clean site Apply Chloraprep Allow to dry Sterile 30 seconds 30 seconds gloves

Central Line AssociatedBlood Stream Infections

0

5

10

15

20

Months

Nu

mb

er o

f In

fecti

on

s

BSI

2007 2008 2009 20100

100

200

300

400

Infe

cti

on

s

Approaching the Theoretical Limit?The Journey of 1,000 Days

Problem Solving: The 5 Whys

• What did the patients get infected?Defective sterilizing process

• Why was the process defective?It was a rapid process that avoided ETOH

rinsing and medical air drying• Why were we using the device?

It had the fastest turn around time• Why did we need a fast turn around?

We were doing a lot of bronchoscopies• Why were we doing a lot of bronchoscopies?

We had many ventilator associated pneumonia

Eliminating VAP:How Did We Do It?

• Step 1: Elevate the head of the Bed 30• Step 2: Chlorhexidine mouthwash BID• Step 3: Change vent tubing weekly• Step 4: Change suction catheter daily• Step 5: provide a hook for hanging resuscitation

bag• Step 6: Check endotracheal cuff pressure

Total Added Cost: $17/ ventilated patient

Applying a Construct:Placing, Maintaining, and Manipulating

0

10

20

30

40

50

FY 04 FY 05 FY 06 FY07 FY08 FY09 FY10

FY 04FY 05FY 06FY07FY08FY09FY10

E-VAP

2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

BSI

VAPS

MRSA

Fiscal Year

Reductions in HAIs

Journal of Quality and Patient Safety 2006;32:479

Improvement is Based on Values

• Improvement is about Values not about tools and technology

• Three Core Values of Effective Improvement Teams

1. I am treated with dignity and respect by all regardless of my education or rank

2. I am given the tools to make a contribution that adds meaning to my life

3. I am recognized for what I do.

• Practice not espouse Values

Values Trumps Process

The Conspiracy of Error and Waste

• What is the cost of a CA-BSI in human and financial terms?

• What does society pay for healthcare associated infections (HAI)?

• Do hospitals and physicians make money on HAIs ?

Case 1:

• 37 year old video game programmer, father of 4, admitted with acute pancreatitis secondary to hypertriglyceridemia.

• Day 3: developed hypotension, and respiratory failure• Day 6 : fever and blood cultures positive for MRSA

secondary to a femoral vein catheter in place for 4 days.

• Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy

• Day 86: Discharged to nursing home

The Losses Attributable to CA-BSI are Staggering

• Average Payments: $64,894• Average Expense: $91,733• Average Loss from Operations: -$26,839• Total Loss from Operations:-$1,449,306 • In only 4 cases did the hospital make money!• The cost of the additional care averaged 43% of the

total costs of care• Average LOS: 28 days (7-137)• Only three patients were discharged to home.

The Losses Attributable to Ventilator associated Pneumonia are Equally

Staggering

• Average Payments: $62,883

• Average Expense: $87,318

• Average Loss from Operations: -$24,435

• Total Loss from Operations:-$2,419,065

• The average payments were twice that for a similar care without VAP ($33,569)

• Average LOS: 34 days versus 17 days

• 32% of patients died and 43% underwent tracheotomy.

CCU/MICU and HAIA Big Return on Investment

• Total Operating Improvements CLAB= $1,235,765 (2 years)VAP= $1,003,162 (1 year)MRSA= $ 295,342 (1 year)

• Highmark PFP = $3,100,000 (2 years)• HAI elimination Initiatives = +$5,634,269• Investment = $85,607 • 388 additional ICU admissions • 57 lives saved

Strategies for Reducing Per Unit Cost (Pugh)

ClinicalProcesses

Direct Inputs•Supplies

•Labor

Big Dots•Financial•Clinical

•Patient Experience

Indirect Inputs•Structure

•Technology

TraditionalStrategy:

Control Inputs

SupportProcesses

*waste = unintended variation, rework, error, valueless care,

needless complexity, etc.

QualityStrategy:

Remove Waste* from Production

Build a Parking Garage or Fix the Care Process?

Not more…better Not volume….value

Modifying the Patient Experience

14 days 57 min22

min31

min23

min

Call Wait for App Travel Park Reg Wait VS Wait MD CO Tests Exit

18min

17min

14min 97 min

18min

4:05

77 min

$32 parking

7 days 57 min 15min

7min

20min

11min

45 min14

min

2:02 $8 parking

37 min

Patient visits from 7-9/session On –Time Performance Patient satisfaction (waiting) Lag days

Summary

• Data must not only be reportable but actionable• Lessons borrowed from HPO are widely applicable in

health and medical care• HAI are not inevitable, but rather fully preventable• The elimination of unsafe conditions such as HAI will

free up extensive financial resources currently consumed in their care.

• In eliminating harm we do what is right and we also reduce waste thereby discharging our professional duty to “do no harm” and to be “good stewards of finite resources.

Primum non nocere Cura te ipsa