Creating an Effective Partnership for HealthCare

Quality and Safety

Quality and Safety Partnership“The American health care delivery system is in

need of fundamental change. Patients, doctors, nurses, and health care leaders are concerned that the care delivered is not the care we should receive. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits.”

Industry Change

• Evidence based guidelines for common diseases and procedures

• Maturation of quality improvement models– New developments and adaptation of techniques from other

industries (ISO9000, Six Sigma, TQM, etc.) – Hospitals around the country have demonstrated these techniques

work

• Improved information technology makes data collection and sharing possible

• Increasing # of states w/ public reporting systems– Multi stakeholder interest in change

Forces of Change- Employer• Escalating health care costs with double digit

insurance premium increases– Employers concerned about their ability to provide

health care benefits with the economic slowdown– Employers looking at benefit plan designs to

encourage consumerism. This requires reliable quality and cost information.

– Employer/Payer demand for access to quality data• Healthgrades• Leapfrog• SC Business Coalition

Forces of Change-Providers

• Reports of less than optimal safety and quality practices – 98,000 people die each year and many more are injured from

preventable mistakes made in hospitals (To Err is Human, IOM, 2000)

• Huge variation in clinical practice and outcomes– 50-60% of patients received recommended evidence based

care– It is estimated that it takes approximately 17 years for relatively

definitive research on clinical practice (evidence based health care) to become standard practice (Agency for Health Care Research and Quality, 2002)

• Lack of comparative and best practice information to guide internal improvement

SC Quality and Safety Partnership- Historical

Perspective• IOM Reports- Magnitude of Patient Harm and

Aims for Improvement• TJC- Pt. Safety Goals/Core Measures• CMS P4R- HQA/Hospital Compare• CMS- 8th Scope of Work/ Surgical Care Improvement

Project (SCIP)• NQF- List of “Never Events”• Leapfrog Group- Link to NQF Safe Practice Standards• IHI- Pursuing Perfection/100K Lives/5M Lives Campaigns• CMS- Evolution through P4P to P4V

SC Quality and Safety Partnership- Historical

Perspective• SC Node- Link to IHI Campaigns/Initiatives• BCBS Hospital Recognition Program• Lewis Blackman Act• HIDA Act- HAI Public Reporting• PHTS ISO 9000 Project• American Heart Assoc.- Get w/ the Guidelines• SC Diabetes Initiative• Health Sciences SC- TDE Grant• SCHA- TDE Grant/QPS Advisory Council

Patient Safety- HIDA• Tremendous public discussion over

hospital-acquired infections—IOM Report• New SC law requires hospitals to report

infection rates semi-annually beginning in 2008; DHEC to issue annual public reports beginning 2009.

• Two types of infections must be reported: central line-related bloodstream infections and surgical site infections.

“Every system is perfectly designed to achieve the results it gets”

- Dr. Don Berwick

Compliance-Driven Quality Management

• Reactive in nature

• Designed to meet standards

• Clinicians often not engaged in process

• Clinician leadership not essential

• Indicators become the goal

• Difficult to sustain clinical improvement over time & across organization

Patient-Centered Clinical Effectiveness

• Proactive in nature• Evidence-based foundation• Clinicians actively engaged in process• Clinician leadership critical to success• Best and safest care as the goal,

indicators as markers of success• Sustainable improvement over time and

across organization

Where Do We Go From Here?

“We can’t solve problems by using the same kind of thinking we used when we created them”

- Albert Einstein

Changing Course- A Confluence of Important

Events• SMLC/Patient Safety Committee joint session• CEO/COO Leadership Retreat• SCHA Board Retreat• Quality Reporting/Transparency task force• TDE grant submission and approval• Quality Advisory Council formed by SCHA Board• Quality Council establishes framework and guiding

principles for quality and safety partnership• Partnership vision/mission/goals approved by

SCHA Board

SC Quality and Safety Partnership- Guiding Principles

• IOM Six AimsIOM Six Aims for Improvement-for Improvement- Patient care that is:

• Safe- avoidance of unintended pt. harm• Effective- evidence-based• Patient-centered- focused on needs and

rights of the individual patient• Timely- avoidance of delays & barriers

to patient care flow• Efficient- elimination of waste• Equitable- fair access to comparable

health care services for all

The Power of Engaged Leadership

and Governance• Establish the missionmission, visionvision, and strategystrategy• Build an effective leadershipleadership system foundationfoundation• Build willwill to make measurable systemic

improvement• Ensure access to ideasideas and innovationsinnovations• Attend relentlessly to executionexecution so that

improvements can be sustainedsustained and spreadspread• Establish and monitor system-level measuressystem-level measures• Aggressively embrace collaborationcollaboration and

transparencytransparency

Visionary Leadership

“Far better it is to dare mighty things, to win glorious triumphs, even though checkered by failure, than to take rank with those who neither enjoy much or suffer much, because they live in the gray twilight that knows not

victory or defeat”

-Teddy Roosevelt

The South Carolina Partnershipfor

HealthCare Quality and Safety

SC Partnership for HealthCare

Quality and Safety SC Hospitals have an unprecedented opportunity to:

Take the lead in shaping the scope and direction of the quality and safety agenda in SC

Shift from a competitive to a collaborative approach as it relates to quality and safety

Re-establish the public trust in hospitals as the community center for quality health care

Offer a viable alternative to legislative and regulatory quality and safety mandates

Bring other health system stakeholders to the table to define the future of health care in SC

SC Partnership for HealthCare

Quality and Safety• Vision: That all South Carolina hospitals deliver

safe, high quality health care to each patient, every time

• Mission: To establish a culture of continuous improvement in quality and

safety across all hospitals statewide

SC Quality and Safety Partnership- Key Goals

• Promote a collaborative organizational culture focused on quality improvement and safety in all hospitals statewide

• Provide dynamic leadership and guidance to the public and private sector in the areas of safety and quality improvement

SC Quality and Safety Partnership- Key Goals

• Encourage hospitals and medical staffs to adopt a systemic approach to patient safety and quality improvement that is board-directed, clinician-led, evidence-based, and data driven.

• Create an organizational framework that supports active learning, knowledge sharing, open communication & teamwork

SC Quality and Safety Partnership- Key Goals

• Institute a reliable data reporting system for transparent dissemination of standardized, understandable information on key quality and safety indicators

• Promote strategic partnering with other key SC health system stakeholders to maximize the timeliness, efficiency & effectiveness of safety & quality improvement efforts statewide

SC Quality and Safety Partnership

“ Unity is strength….when there is teamwork and collaboration,

wonderful things can be achieved”-Mattie Stepanek

SC Quality and Safety Partnership-

Key Components• Explicit alignment of member hospitals statewide to• Actively pursue continuous improvement in quality

and safety together based on• Clearly defined and shared vision, mission, and aims • Voluntary organizational commitment to participate in

the Partnership with• Specific performance goals and measurements• Inclusive of commitment to transparency and public

reporting of quality/safety data

Cultural Capability

• Organizational culture readiness assessment• Vision/mission/strategic plan alignment• Board engagement• Physician/clinician engagement• Commitment to internal & external transparency• Active leadership support for teamwork & open

communication• Zero tolerance for disruptive professional behavior

Technical Capability

• Rapid Response Teams

• SBAR communication process

• Clinical protocols, checklists & order sets

• Clinical care bundles- VAP; Sepsis

• CPOE/EMAR/Bar Coding systems

• Reliable data mgt. and reporting systems

Organizational Platform/Bridge

• ISO 9000

• Six Sigma

• Toyota Lean

• TeamSTEPPS program

“Alone we can do so little, together we can do so much”

─ Helen Keller

South Carolina Partnershipfor

HealthCare Quality and Safety

SC Node- 5M Lives Campaign

Integration of 12 Initiatives• Leadership Foundation- Board Engagement• Cardiac Care- Evidence-based AMI and CHF Care• Infection Control- Prevent MRSA, CLABSI, VAP• Surgical Care- SCIP, SSI Prevention• Medical Care- Prevent Pressure Ulcers• Critical/Emergency Care- Rapid Response Teams• Medication Safety- Medication Reconciliation

- High Alert Medications

SCHA Quality and Safety Partnership Related Programs/Initiatives

• HIDA training sessions and NHSN reporting system registration

• Expansion of ISO 9000 project• TeamSTEPPS teamwork training project• Lean Six Sigma Black Belt training program• IHI Rural Hospital Alliance project• Promoting Professional Behavior Collaborative• Integration of AHA GWTG programs• D2B Program/Database- ACC

Engage Leadership and Governance

The Goal:

Boards in all hospitals will spend at least 25% of their meeting time on quality and safety issues.

Boards will have a conversation with at least one patient (or family member of a patient) who sustained serious harm at their institution within the last year.

What Does the Evidence Tell Us?

• Outcomes are better in hospitals where:– The board spends >25% of its time on quality and

safety.– The board receives a formal quality measurement

report.– There is a high level of interaction between the board

and medical staff on quality strategy.– Senior executive compensation is based in part on

quality and safety performance.– The CEO is identified as the person with the greatest

impact on QI, especially when so identified by the QI executive.

Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.

Six Things That Boards Can Do

Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement (e.g., reduction in unnecessary mortality or harm).

Select and review progress towards safer care as the first agenda item at every board meeting.• Get data on harms and hear stories; put a “human

face” on data. Establish and monitor a small number of

organization-wide “roll-up” measures that are updated continually and are transparent to the entire organization and its customers.

Six Things That Boards Can Do

Commit to establish and maintain an environment that is respectful, fair, and just for all who experience pain and loss from avoidable harm.• Patients, their families, and staff at the sharp end of

error Develop the capability of the board.

• Learn how the “best in the world” boards work with executive and MD leaders to reduce harm.

• Set an expectation for similar levels of education/training for all staff.

Oversee the effective execution of a plan to achieve the board’s aims to reduce harm, including executive team accountability for clear quality improvement targets.

Tapping the Boards Full Potential

• Choose board members w/ the “right stuff”

• Educate the board

• Use measures to focus board work on quality

• Pursue perfection, not improvement

• Pay more attention to culture

• Exercise leaders powerful influence

• Recognize and reward excellence

SC Quality and Safety Partnership- “Existing

Partners”• PHTS- SC Node; ISO 9000 Project• CCME- SC Node; CMS 8th Scope of Work• DHEC- HIDA Program• BCBS- Hospital Recognition Program• American Heart Assoc.- Get with the Guidelines• SCMA/JUA/PCF- SC Node; PPB Project• SBME- PPB Project• AHEC- SC Node

SC Quality and Safety Partnership-

Key Phase I Actions• Establish formal Quality/ Safety Partnership with

individual hospital pledge to participate• 5 Million Lives Campaign roll out via SC Node• HIDA training and reporting system implementation• Expansion of ISO 9000 Project• Implementation of quality public reporting system• Focus on “Board Engagement” initiative and “Moving

the Big Dots” template dashboard

ISO:9001-2000 Quality Management System- Pharmacy

Initiative

• Joint PHTS/SCHA Quality & Safety Project• Extension of Consortium Project- 6 SC Hosp.• Self Regional will serve as mentor hospital• Framework for linking cultural commitment to

quality/safety with targeted interventions• Elimination of variability/reduction in errors• Replication of desired patient outcomes when

combined w/ evidence-based practice

ISO:9001-2000 Quality Management System- Pharmacy

Initiative

• Statewide ISO:9000 educational program• On-site visits w/ each interested hospital• Development of a process plan for ISO-

based QM system in Pharmacy dept.• Active Senior leadership support at cultural

and technical levels• Quality and Pharmacy directors as co-

champions of the project

“We can drive the train, or we can wait until it runs over us.” - Wisconsin CEO when asked, Why Public Report? Jan, 2000

Public Quality Reporting System- Guiding Principles

• The system should be:– Cost effective– Voluntary and non-punitive– Non-competitive in nature 

• The information should be: – Comparable across similar hospitals for benchmarking– Readily accessible, user friendly and available in a timely manner– Capable of instilling confidence in consumers through the ethical

distribution of reliable and valid data• The measures should be:

– Evidence based– Coordinated with national initiatives – Relevant to hospital quality improvement efforts– Interesting/of value to various stakeholders– Supportive of other SC initiatives

Moving the Big Dots

“Not everything that can be counted counts, and not

everything that counts can be counted.”

-Albert Einstein

But what is reported, is changed!

Potential “Big Dot” Indicators

• Leadership -Rate/incidence of Avoidable Harm -Occurrence of “Never Events”

-Inpatient Mortality Rate• Cardiac Care – AMI/CHF Optimal Care Measures and Mortality Rates• Infection Control –Hosp. Acquired Infection Rates• Critical Care – Inpatient Codes; VAP Rates• Medication Safety – Medication Error Rate• Surgical Care – Surgical Complications Rate

Moving the Big Dots- Real World

2005 134 CLABSI 2.0 codes/1000 d 78 VAPs 52 SSIs AMI mortality rate

of 12%

2006 10 CLABSI 0.9 codes/1000 days 9 VAPs 22 SSIs AMI mortality rate of

<5%

15 fewer deaths per month than in 2005

Will these lines ever converge?

Will these lines ever converge?

It is possible . . . .

Quality&

Safety

Covering the

Uninsured

Health Status

of South

Carolina

“Alone we can do so little, together we can do so much”

─ Helen Keller

South Carolina Partnershipfor

HealthCare Quality and Safety