Harvard Medical School Quality and Safety In Action At Beth Israel Deaconess Medical Center Presentation to Region Sjaelland Leadership March 8, 2011
Harvard Medical School
Quality and Safety In Action At
Beth Israel Deaconess Medical Center
Presentation to Region Sjaelland Leadership
March 8, 2011
Harvard Medical School
Beth Israel Deaconess Medical Center Statistical Profile (FY09)
Annual Inpatient Discharges:
Medicine 14,600
Surgery 9,800
Cardiovascular 5,400
Obstetrics/Newborn 10,800
Psychiatry 800
41,400
Average Daily Inpatient Census: 523 Patients
Observation Patients 8,200
Outpatient Clinic Visits 532,000
Emergency Department Visits 53,000
Full-Time Equivalent Employees
(Excluding Research)
6,100
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Boston: A Highly Competitive Market for Patient Care
% Patients Giving Top Rating
Aong: all respondents
57
6262
45
60
5961
47
57
2007 2009
% In
To
p B
ox
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BIDMC: A Turnaround Story:
Consolidated Operating Margin FY99- FY10
($70)($60)($50)($40)($30)($20)($10)
$0$10$20$30$40$50$60
Mil
lio
ns
FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY08 FY10Proj
FY07 FY09
Harvard Medical School
Boston Academic Medical CentersMedical/Surgical Discharges
Percentage Growth, FY06 – FY09
%
7.77.0
4.0
2.5
1.1
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
BIDMC BMC BWH TOTAL MGH
Harvard Medical School
Boston Academic Medical CentersEmergency Department Visits
Percentage Growth, FY06 – FY09
%
13.7
5.6
2.1
(0.9)
(3.5)(6.0)
(4.0)
(2.0)
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
MGH BIDMC TOTAL BWH BMC
Harvard Medical School
Recent Awards
• Thompson Top 100 Hospitals (several years running – only hospital in Massachusetts)
• Premier Award for Quality(Awarded to 23 hospitals out of ~3800 eligible)
• AHA-Mckesson Quest for Quality Award(3 hospitals received this National recognition)
• Leapfrog Top Hospital (Awarded to 45 hospitals nationally)
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We adopt the IOM Framework for Care
• Safe: no injuries from the care
• Timely: reduce waits and delays
• Effective: services based on scientific knowledge
• Patient Centered: care that is responsive to the individual
• Efficient: avoiding waste
• Equitable: quality does not vary because of personal characteristics
-Institute of Medicine, 2001
CROSSING THE QUALITY CHASMCROSSING THE
QUALITY CHASM
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We Pay Attention to External Masters:
• Joint Commission: 501c3 with delegated authority from CMS:– Mission predominantly around quality of care and the
environment of care for patients
– Unannounced survey at least every 3 years.
• CMS/Other Payers:– Interested in clinical performance Standards
– Has developed required metrics, “pay for performance.”
• Department of Public Health: Regulator
• Board of Registration in Medicine: Regulator of Clinical Practice. Massachusetts code requires the PCAC
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• National Quality Measures Clearinghouse™ (NQMC) - specific measurement initiatives:
• Ambulatory Care Quality Alliance
• Home Health Compare
• Hospital Compare
• Hospital Quality Alliance
• National Healthcare Disparities Report (NHDR)
• National Healthcare Quality Report (NHQR)
• Nursing Home Compare
• Physician Quality Reporting Initiative
–Health Care Quality and Cost Information
–www.mass.gov/healthcareqc
External Measure SourcesSome Examples:
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Trends Among Regulators in the United States
• Increasing “Pay for Performance:” Incentives linked to quality metrics
• Increased public reporting– Adverse Events– Trended performance.
• Unlawful to seek reimbursement for costs associated with an adverse event
• Mandated disclosure and apology• Mandated patient involvement
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Harvard Medical School
Board Participates Directly in Quality and Safety
Board of Directors
FinancePatient Care Assessment
and Quality (PCAC)Audit
Chiefs/ Medical ExecutiveCommittee
Board hears clinical performance as well as
adverse events, analysis, andCorrective actions
Medical StaffGovernance Reports
to the Board
Board Chair, CEO, several chiefs, several
Board Members participate
QI Directors
Dept Dept
Dept
Harvard Medical School
Annual Cycle for Quality and Safety, Coordinated with Budget Cycle
February: Full assessment of Quality and Safety.
April: Present follow-up detail on requested areas of potential focus for Quality and Safety.
June: Approve statement of priorities for quality and safety.
October: Review and Comment on quality/safety aspects of BIDMC Annual Operating Plan.
December: Present other items PCAC elects to review annually
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Quality Goals Manifest in Annual Operating Plan
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Quality and SafetyPriority Determination
Priority Analysis:Performance onTrended Data
Priority Analysis:Internal Analysis of
Adverse Events
Priority Analysis:Regulatory Mandate or
Recommended Best Practice
Readmission Rate
SSI Reduction
Handoff ProcessesPatient/Family
Triggers
H1N1
Ambulatory RiskManagement
Physician PerformanceEvaluation
Internal Auditing ofRegulatory Readiness
Cognitive Error Prevention
Criteria-Based Goal-Setting
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Attention to Data, Publicly Share
– Try to measure the truth (documentation ≠ practice!)
– Collect data in a way that is believable to your ICU staff.
– Understand the story it’s trying to tell you, and help others see it too
• Data information knowledge ??wisdom
– Get data to the people who do the work. They NEED it.
• At the point of care
• Very rapidly (quarterly feedback is nearly irrelevant to sustainable change)
• Transparency of performance with patients and families (?)
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Transparency
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20
Q1 Q2 Q3 Q4
Favorable Comparison
Unfavorable Comparison
AIMFY10
TargetCHANGE Q3 09 Q4 09 Q1 10 Q2 10 Q3 10
MEDICAL MANAGEMENT RELATED
Death Related to Medical Management ▼ 0 0 0 0 0 0
Disease Progression or End Organ Injury (reversible or
permanent) Related to Medical Management▼ 0 0 1 0 0 1
Cardiac and/or Respiratory Failure or Arrest Related to
Medical Management▼ 0 2 2 0 0 1
INFECTION RELATED
Nosocomial Catheter Associated Bloodstream Infections ▼ 0 2 2 2 2 3
Nosocomial Surgical Site Infections (SSIs) ▼ 0 17 17 18 19 16
Nosocomial C. Difficile Infections ▼ 0 0 0 0 0 0
Ventilator Associated Pneumonia ▼ 0 4 2 2 2 2
Other Nosocomial Infection ▼ 0 2 1 0 6 0
CARE RELATED
Falls Resulting in Injury ▼ 0 3 2 2 1 0
Soft Tissue Injuries (Includes Pressure Sores) ▼ 0 0 1 1 2 0
Medication Related Adverse Events ▼ 0 1 0 0 0 1
Procedure Related Harm/Complication (Non Infectious)-
Surgical Services▼ 0 1 2 1 2 1
Procedure Related Harm/Complication (Non Infectious)-
Non-Surgical Services▼ 0 1 0 0 0 1
Obstetrical Harm/Complication (Non Infectious) ▼ 0 1 0 0 0 0
Neonatal Harm/Complication (Non Infectious) ▼ 0 0 0 0 0 0
Other ▼ 0 0 0 1 0 0
TOTAL ▼ 0 34 30 27 34 26
PREVENTABLE HARM
PCAC S C O R E C A R D
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21
Using the Metrics to Facilitate Change
• Most ‘Vulnerable’ Metrics have real time feedback processes supported by HCQ
– Real Time Feedback or Prompting Examples:
• AMI (Emergency Department/Cath Lab) – Door to Balloon
• PN (Emergency Department) – Blood Culture /Antibiotic Timing
• HF (Medicine/Cardiology -- ACE-I/ARB Use in LVSD)
• Noted improvement in performance and constructive feedback/input re: process
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22
Using the Metrics to Facilitate Change
• HCQ Meets Monthly with Program/Metric Clinical Leaders
• Review the performance data
• Provide Feedback in a meaningful way
• Acknowledge outliers and comments from clinicians
• Establish plans for improvement in • Process/Workflow
• Infrastructure/Technology
• Behavior/Education
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23
Example of Applying Multiple PI Models/Principles
• Combined principles of TeamSTEPPS, Evidence Based strategies of care, PDSA and available technologies – Strengthen an interdepartmental alliance, coordination of care and
communication between • Emergency Department, • Interventional Cardiology and • Health Care Quality
• Designed – standard protocols to support expected time frames for assessment; – efficient and safe “One Call Activation of CathLab” and – effective real time feedback loop processes– Monthly Team Meeting reviews process segments and outliers. Focus on
process/system analysis ‘to root’
• Achieved 100% STEMI D2B times <90 minutes
for the past 100+ cases (2 ½ years) – Standard Work– Predictable/Consistent Processes
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24
FY07
Door To Balloon
FY10 To Date
Door To Balloon
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25
Harvard Medical School
Celebrate “Call Outs” Publicly and With Leadership
We Continue to Recognize and Reward
Harvard Medical School
Annual Symposium
March 23, 2010
8:00 – 9:30 am
The Climate and Expectations of Health ReformSherman Auditorium – East Campus
A panel discussion featuring:
• Glenn Steele, MD, President and CEO of Geisinger Health System
• Paul Guzzi, President and Chief Executive Officer, Greater Boston Chamber of Commerce
• H Gene Lindsey, MD, President and CEO, Atrius Health
• Roberta Herman, MD, Chief Operating Officer and Chief Medical Officer, Harvard Pilgrim Health Care
Moderated by Paul Levy, President and CEO Beth Israel Deaconess Medical Center
10:00 am – 12:30pm
2010 Poster Session – Celebrating Improvement at BIDMC
Carl J. Shapiro Clinical Center Atrium Lobby – East CampusThis poster session features the work of nearly 100 Process Improvement Teams from across the medical center, and offers
everyone the opportunity to share experiences and learn about efforts to improve Quality and Safety at BIDMC.
Sustaining Process Improvements Measuring SuccessCelebrating/Sharing Stories
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28
Progress toward eliminating preventable harm -Hand hygiene trends
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Consistent Progress: Bloodstream InfectionRate per 1000 patient days
4.14 4.05
2.91
1.551.30
0.700.52
0.0
1.0
2.0
3.0
4.0
5.0
FY03 FY04 FY05 FY06 FY07 FY08 FY09
Rate
per
1000 P
ati
en
t D
ays
F Y M ean
87% reduction
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50%
60%
70%
80%
90%
100%
Ventilator Bundle Performance
Initial unit champion-based work
VAP-focused clinical nurse specialist begins
New Critical Care Electronic Medical Record implented (changing documentation practice)
Goal (initial)
Goal (current)
Goal (2nd)
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0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
1.1
2004 2005 2006 2007 2008 2009 2010
No
n-D
NR
, N
on-I
CU D
eath
s p
er
1,0
00 D
isch
arge
sNon-DNR, Non-ICU Deaths per 1,000 Discharges
Triggers period
Benchmark = 1.06 (intervention arm of largest RCT – Lancet 2005)Benchmark = 1.06 (intervention arm of largest RCT – Lancet 2005)
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Consistent Progress: Ventilator Pneumonia
0
10
20
30
40
50
60
FY06 Q2*
FY06 Q3
FY07 Q2*
FY07 Q3
FY08 Q2*
FY08 Q3
FY08 Q4*
FY09 Q2*
FY09 Q3
FY09 Q4*
VA
P C
ase
s P
er
1,0
00 V
en
tila
tor
Da
ys
* only two months of quarter assessed
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Percent of Admitted Patients Experiencing an Adverse Event
22.5
16.9
14.2
11.5
0
5
10
15
20
25
2006 baseline 2008 2009 2010 Jan-early
June
Note: Lower value is better
Pe
rce
nt
of
Ad
mit
ted
Pa
tie
nts
Ex
pe
rie
nc
ing
an
Ad
ve
rse
Ev
en
t
Harvard Medical School
Ventilator Bundle Compliance
50%
60%
70%
80%
90%
100%
Fe
b-0
6
Ma
r-0
6
Ap
r-0
6
Ma
y-0
6
Ju
n-0
6
Ju
l-0
6
Au
g-0
6
Se
p-0
6
Oct-
06
No
v-0
6
De
c-0
6
Ja
n-0
7
Fe
b-0
7
Ma
r-0
7
Ap
r-0
7
Ma
y-0
7
Ju
n-0
7Ven
t B
un
dle
Co
mp
lian
ce
Be
tte
r
VAP Cases(Three-ICU Sample)
0
5
10
15
20
25
30
Fe
b-0
6
Ma
r-0
6
Ap
r-0
6
Ma
y-0
6
Jun
-06
Ju
l-0
6
Au
g-0
6
Se
p-0
6
Oct-
06
No
v-0
6
De
c-0
6
Jan
-07
Fe
b-0
7
Ma
r-0
7
Ap
r-0
7
Ma
y-0
7
Jun
-07
Be
tter
No
data
Ventilator Days(Three-ICU Sample)
200
250
300
350
400
450
500
Fe
b-0
6
Ma
r-0
6
Ap
r-0
6
May-0
6
Jun-0
6
Jul-
06
Au
g-0
6
Se
p-0
6
Oct-
06
Nov-0
6
De
c-06
Jan-0
7
Fe
b-0
7
Ma
r-0
7
Ap
r-0
7
May-0
7
Jun-0
7
Be
tter
Number of ICU Patients(ICU Throughput)
300
350
400
450
500
Fe
b-0
6
Ma
r-0
6
Ap
r-0
6
Ma
y-0
6
Jun
-06
Ju
l-0
6
Au
g-0
6
Se
p-0
6
Oct-
06
No
v-0
6
De
c-0
6
Jan
-07
Fe
b-0
7
Ma
r-0
7
Ap
r-0
7
Ma
y-0
7
Jun
-07
Be
tte
r
Long-Stay ICU Patients(% of patients with ICU LOS > 10 days)
0%
2%
4%
6%
8%
10%
12%
Feb-0
6
Mar-
06
Apr-
06
May-0
6
Jun-0
6
Jul-06
Aug-0
6
Sep-0
6
Oct-
06
Nov-0
6
Dec-0
6
Jan-0
7
Feb-0
7
Mar-
07
Apr-
07
May-0
7
Jun-0
7
Be
tter
Harvard Medical School
1
2
3
4
5
2005 2006 2007 2008 2009
Fiscal Year
-
1,000
2,000
3,000
4,000
5,000
6,000
2005 2006 2007 2008 2009
Fiscal Year
5%
7%
9%
11%
13%
15%
2005 2006 2007 2008 2009
Fiscal Year
ICU Length of Stay
(Days)
ICU Throughput(Patients)
In-Hospital Mortality
(%)
1,429 discharges per year (33%)
ICU LOS by 1.0 days (22%)
Mortality by 2.5% (21%)
For every 40 ICU patients, one fewer death.
Harvard Medical School
Accountability/Visible Goal Setting:2007 Board Retreat, Devoted to Quality
and Safety• Activities:
– Board members shadowed HCWs
– Panel discussion involving patients with a range of experiences.
– Didactic session on role of governance in quality
– Breakout sessions on institutional goal setting
• Results: Confirmation of a deep commitment to quality, safety, aggressive goal setting, and transparency of approach
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1. Intellectual honesty
– No cherry-picking of measures
– No negotiating: Show the good and the bad
2. Salience to patients/employees
– Clinical areas where patients make or influence the choice of provider
– Topics that align to internal priorities for employees
– Measures that can be understandable, relevant, and useful to patients and employees
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3. Strategic value to BIDMC
– Clinical areas identified as important to BIDMC’s future, aligned with values and goals
– Areas that draw attention to competitive strengths, new capabilities
4. Timeliness
– Data that are as up-to-date as feasible.
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5. Credibility with medical staff– Endorsed by National Quality Forum; recommended by
national organizations (e.g., JCAHO, CMS, AHRQ)
– Statistically valid and reliable
– Substantive (i.e., linked to patient’s outcome or safety)
– Inclusive (i.e., affects large proportion of patients)
6. Interpretable information – Data and benchmarks available (whether national, regional,
or local)
– Whenever possible, provide a visual way to easily evaluate performance as good or bad
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Engagement Continues
• Leaders Huddle in Real Time
• Governance, Leaders participate in “Go and See”