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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
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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
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Transfusion Errors
Serious Safety Events
Transformation to a High Reliability Organization
August 14, 2006
A Call to Action
on Patient Safety
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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
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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
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2015 MH “From the Top”The Role of the Board and Medical Staff in Quality & Safety
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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
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• 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
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* 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?”
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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
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Robust Process Improvement:Path to Quality Outcomes
Change Management
Lean
Six Sigma
32
Robust Process Improvement:Path to Quality Outcomes
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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
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Robust Process Improvement:Changing Standard Work
Standard Work =
What we do every day
What we do every day =
CULTURE!
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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
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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
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• 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
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Zero
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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
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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!