1 Alice Bell - Transformational Quality Deck For Webconference

1
Transformational Quality
Leading the Organisation to Clinical Excellence
2012 THE ADVISORY BOARD COMPANY
Road Map
The New Quality Mandate
Creating Collective Commitment to Quality Improvement
2012 THE ADVISORY BOARD COMPANY 25038
Coda: Future Prospects: Expanding the Ambition

Imperative to Improve
Quality in the Spotlight
Increasing Understanding of Quality Performance

Hospital Adverse Events Even More Frequent Than Previously Reported
Prevalence of Adverse Events1 354
Global Trigger Tool detected significantly higher incidence of adverse events than commonly used systems
35 4
IHI Global Trigger Tool
AHRQ Patient Hospital Voluntary Safety Indicators Reporting System
Quality Worse Than Expected

Our study detected far more adverse events in hospitalised patients than have been found in prior studiesOur detection levels were also higher than those of comparative studies of adverse events with other methods in hospitalised patients from England, Australia, and Canada.
Classen et al. Health Affairs
1) Researchers reviewed 795 patient records across 3 hospitals using 3 different event detection methodologies.
Source: Classen D, Resar R, et al., Global Trigger Tool Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured, Health Affairs, 2011 30(4): 581-589; Special Eurobarometer 327, Patient safety and quality of healthcare, 2010; Advisory Board interviews and analysis.
Transparency Increasing
Incessant Negative Publicity Around Quality

Media Relentlessly Covers High Profile Incidents
Hospital left patient sobbing and humiliated
Hospital mistakes killed 28 people in Victoria this year

The Telegraph
BBC
Technician charged in fatal injection with cleaning solution

Seattle Times
Nearly 2,000 Carrying H.I.V. in Chile Were Not Notified

New York Times
Man has unnecessary cancer surgery after misdiagnosis

New Zealand Herald
Hospital boss tried to cover up details of patients death

The Daily Mail
Boston hospital admits drug overdose caused death of Globe columnist, damage to second woman
Boston Globe
Bacteria kills newborns in German hospital

Euronews
Routine operation ends with death of mother of four

ABC News
Mother left paralysed from waist down after injection with powerful skin antiseptic instead of saline solution during epidural
Sydney Morning Herald
NHS patients discharged from hospital alone in the middle of night

Huffington Post UK
Source: Advisory Board interviews and analysis.
Hospitals Losing Public Trust

Disturbing Changes in Public Perception
Percentage of People Responding to Likelihood of Adverse Events in Hospital
n=26,663
Percentage of People Who Have Suffered or Had a Family Member Suffer an Adverse Event When Receiving Health Care
n=26,663
Dont Know Hospital Infections Incorrect, Mixed or Delayed Diagnosis Medication Errors
59
38
3%
58
39
3 No 72% 25% Yes
49
48
Surgical Errors Likely
46
Not Likely
50
Don't Know
Source: European Commission, Special Eurobarometer: Patient Safety and Quality of Healthcare, April 2010; Advisory Board interviews and analysis.
What is Quality?
The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Institute of Medicine
That "which consistently contributes to improvement or maintenance of the quality and/or duration of life.
American Medical Association
Quality of care is the level of attainment of health systems' intrinsic goals for health improvement and responsiveness to legitimate expectations of the population.
World Health Organisation
Health care should be safe, effective, patient -centered, timely, efficient and equitable.
Quality Chasm Report, Institute of Medicine
At a broad level, quality reflects the extent to which a health care service or product produces a desired outcome. At a more detailed levelquality [is] a guiding principle in assessing how well the health system is performing in its mission to improve the health of Australians.
Australian Institute of Health and Welfare
That kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.
When there is an almost perfect overlap between expectations and resultsthe three dimensions of quality are structure, process and outcomes.
German Federal Joint Committee
Clinically effective, personal and safe.

High Quality Care for All: NHS Next Stage Review Final Report
Avedis Donabedien
Source: Institute of Medicine of the National Academies, Crossing the Quality Chasm: The IOM Health Care Quality Initiative, 2011; American Medical Association, 1986; World Health Organisation, 2000; Donabedien, A, 1980; American College of Medical Quality, 2011; NHS, High Quality Care for All: NHS Next Stage Review Final Report, 2011; Australian Institute of Health and Welfare, "Definitions of safety and quality of health care,"; Gemeinsamer Bundesausschuss, Was ist Qualitt und wie wird sie gemessen?"; Advisory Board interviews and analysis.
Result: Quality Rising Up National Agendas
Worldwide Attempts to Measure, Manage Quality

Selected Quality Metrics Measured by National and International Bodies
Germany: 34
Cross-Sector Quality in Health Care
Sweden: 134
National Healthcare Quality Registries
UK: 150 Canada: 16

Institute of Health Performance National Institute for Health and Clinical Excellence (NICE) Standards
Denmark: 40
National Indicator Project
US: 44
Centers for Medicaid and Medicare Services
Netherlands: 26
Performance Indicators on Patient Safety and Effectiveness
Switzerland: 30
Federal Office of Public Health
Australia: 17
National Health Performance Authority Hospital Indicators
Safety Improvement for Patients in Europe: 26
EUPHORIC Project: 54
EUNetpas: 343
World Health Organisation: 25

Performance Assessment Tool for QI in Hospitals
For common quality indicators and examples by country see appendix p 2-3
Source: Copnell B, et al., Measuring the quality of hospital care: an inventory of indicators, Centre of Research Excellence in Patient Safety, Department of Epidemiology and Preventive Medicine, Monash University; EUNetpas, Patient Safety Culture Report focusing on indicators, 2010; EUPHORIC Project, Disease Areas and Indicators, 2010; Sektorenbergreifende Qualitt im Gesundheitswesen, Dokumentationsbgen und Ausfllhinweise 2011,; Schweizerische Eidgenossenschaft Bundesamt fr Gesundheit, Qualittsindikatoren in Schweizer Akutspitlern wurden erneut erhoben, 20 Aug 2010; Swedish National Healthcare Quality Registries, ppna jmfrelserav hlsooch sjukvrdenskvalitet och effektivitet, 2010; Advisory Board interviews and analysis.
Transparency New Way of Life

League Table Prevalence Increasing
Sample League Table
Average A&E Wait Time Emergency Readmission Rate C.difficile Rate
Hospital Name
Mortality Rate
Boshier Hospital Drexler Health Care Lindner Clinic Strider Hospital

Thiebaud Medical Centre Exceptional Performance Satisfactory Performance Below Average Performance Unacceptable Performance
10
Already Struggling to Make the Grade

Hospital Performance Trails Best Demonstrated Practice
Selected Recent Studies of Guideline Compliance at Hospitals

New Zealand 61% France 50% Norway Switzerland 65% 61% Spain 60% Canada 59% England 59%
Hand Hygiene
COPD 1
Cancer Pain
VTE2 Prophylaxis
Sepsis
Pneumonia Correct Site Surgical Marking
1) Chronic obstructive pulmonary disease. 2) Venous Thromboembolism
Masud D., et al., Current practice on preoperative correct site surgical marking, Journal of Perioperative Practice, June 2010; Jebrak G, COPD routine management in France: are guidelines used in clinical practice? Revue des Maladies Respiratoires, 2010; Hakonsen GD, et al., Adherence to medication guideline criteria in cancer pain management, Journal of Pain Symptom Management, June 2009; Pestana D., et al., Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients, Journal of Trauma, Nov 2010; Alak A., et al., Variations in the management of pneumonia in pediatric emergency departments: compliance with the guidelines, Canadian Journal of Emergency Medicine, Nov 2010; Chopard, Pierre, et al., Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study, Swiss Medical Weekly, 2009; The Patient Safety Company, One in twenty deaths in Dutch hospitals could be prevented,; Surveillance of Healthcare Associated Infections, Australian Commission on Safety and Quali ty in Healthcare; Sally Roberts, Implementing and Sustaining a Hand Hygiene Culture Change Programme at Auckland District Health Board, NZMJ May 2012; Advisory Board interviews and analysis.
Future Threat: Demand
11
Patients Older, Sicker

More Complex Patient Population Increasing Risk
Global Population Aged 60 Years or Over

Millions 2,000 M
Heart Failure Prevalence in Europe

Millions 30 M
14 M
200 M
1950
2011
2050 (e)
2011
2020 (e)
Source: UN Department of Economic and Social Affairs, World Population Ageing 2009; Ekinci O, Getting to the Heart of things, 20 August 2010, European Hospital; Advisory Board interviews and analysis.
Not All Bad News
12
Quality a Means of Competitive Differentiation

Proportion of Members Regarding Publication of Quality Metrics as Key Marketing/Public Relations Strategy1
n=210 hospital clinicians and managers
74%
1) Survey question: Is publicising the quality of care of your organisation among your top three marketing/public relations strategies?
Recognising the Competitive Landscape

Its no longer sufficient in hospital management just to get the financials right, its just as important to take care of the quality and safety issues. In terms of customer satisfaction, we have an increasingly discerning patient group, who dont just see it as a privilege for them to be allowed to come to us. We also have competitors, and our commitment is thus very much to put that patient experience into the foreground and into the front of mindThe whole world is moving towards more discerning and higher expectations from patients and their relatives .
Chief Medical Officer Australian Private Hospital
Source: 2012 Clinical Operations Board Survey on Quality in United Kingdom, Australia, and New Zealand; Advisory Board interviews and analysis.
13
Pursuit of Quality Engages Medical Staff

Doctor Engagement Essential for Multiple Hospital Initiatives
Top Five Drivers of Doctor Engagement
n= 3610, r2=0.699
Driver
I would recommend this organisation to a friend or relative to receive care
Beta
0.209
Three of top five engagement drivers have quality component

The actions of this organisations executive team reflect the goals and priorities of participating clinicians I am interested in doctor leadership opportunities at this organisation The organisation supports the economic growth and success of my individual practice
0.192
0.174
0.147
The organisation provides excellent clinical care to patients
0.110
Source: Advisory Board Survey Solutions, Physician Engagement Initiative, 2011; Advisory Board interviews and analysis
14

Confronting the Quality Challenge
Improvement Challenges Story #1: The Human Factor
15
No Magic Bullet
Hospitals Cant Buy Quality Care
Limited Efforts to Engage Doctors Erosion of Medical Staff Trust Doctors Revolt
CEO and board rely exclusively on CMO to choosing CPOE1 system Medical staff already alienated over cost control targets
CPOE1 rollout with two-month implementation time frame, limited support System requires additional doctor time, does not allow for deviation from protocols
Hospital leaders slow to respond to complaints about system Doctors revolt and take opposition to the press
Case in Brief: Cedars Sinai Hospital

746-bed tertiary hospital in Los Angeles, California Launched $34 million2 CPOE system in autumn 2002 Doctor opposition prompted return to paper system 3 months later
1) Computerised Physician Order Entry. 2) USD. Source; Connolly C, "Cedars-Sinai Doctors Cling to Pen and Paper," Washington Post, 21 March 2005; Smelcer J, Miller-Jacobs H, Kantrovich L, "Usability of Electronic Medical Records," Journal of Usability Studies, February 2009 vol. 4 (2): 70-84; Advisory Board interviews and analysis.
Improvement Challenges Story #2: Campaign Mentality
16
Individual Interventions Successful

Heroic Efforts on Hand Hygiene Compliance
Hand Hygiene Australia: Five Moments Campaign Hand Hygiene Compliance
New South Wales, Australia 75% 69% 58% 61%
Elements
Sustained leadership attention Repeated education initiatives Compliance monitoring and enforcement 2008 2009 2010 Q1 2011
Source: McLaws M, et al., Improvements in hand hygiene across New South Wales public hospitals: Clean hands save lives, Part III, Medical Journal of Australia, 2009, Hand Hygiene Australia, 5 moments for hand hygiene; NSW Health, Media Release: Clean Hands Saves Lives, 28 April 2011; Advisory Board interviews and analysis.
17
Not Enough to Achieve High Quality

Hand Hygiene Critical But Not Alone Sufficient to Avoid Infections
Selected Infection Rates
New South Wales, Australia 4 3.5 3.77
MRSA1 infections per 1000 ICU bed days

ICU associated CLABSI2 per 1000 central line days
3
2.5 2 1.5 1
2.1
2.29
1.62 Gap to best practice for CLABSIs 2008 2009 2010 Q1 2011
0.5 0
1) Methicillin-resistant Staphylococcus aureus. 2) Central Line Associated Blood Stream Infection.
Source: NSW Health, NSW Healthcare Associated Infections Data Collection, 2011; 191(8 Suppl): S18-S25; Clinical Excellence Commission, Safety and Quality of Healthcare in NSW: Chartbook 2009, December 2010; Australian Commission on Safety and Quality in Healthcare, Windows into Safety and Quality in Health Care 2010,; Advisory Board interviews and analysis.
Improvement Challenges Story #3: The Checklist Conundrum
18
Difficult to Change Long-Held Mindsets

Failing to Execute on Knowledge
Percentage of Clinicians Agreeing
94% 79% 80%
Checklist Prevents Checklist is Easy to Would Want Errors in Surgery Use Checklist Used If I Were A Patient
Study in Brief
Survey of 281 surgeons, nurses, anaesthesia personnel, and technicians at seven hospitals worldwide Organisations had implemented the World Health Organisation Surgical Safety Checklist Personnel responded to survey anonymously following two weeks of using checklist
Source: Staines, R, WHO Safe Surgery Checklists Are Not Being Followed by NHS Trusts, Nursing Times, 17 February 2009; Haynes, Alex B., et al, Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention, British Medical Journal, 2009, 20: 102-107; Fitzpatrick, Laura, Atul Gawande: How to Make Doctors Better, Time, 4 January 2010; Advisory Board interviews and analysis.
A Waste of TimeUntil You Are the Patient

A lot of the reaction is, 'My God, another piece of paperwork? It's just a waste of time.' 20% [of doctors] in our surveys still felt it was a pain, a waste of time; they didn't want to use it. Of course, we asked them a follow-up question: If they were having an operation, would they want the checklist? And 94% of them did.
Atul Gawande, Surgeon Brigham and Women's Hospital
19
The Core Problem: Complexity

Quality Impossible to Manage through Central Control
Clostridium Difficile Volume: 907 cases Cost variance/case: $6,5581 LOS2 opportunity for reduction: 8 days
Environment
Equipment and Supplies
Technique
Past Antibiotic Treatments
Influenza and Pneumococcal Vaccinations
Stool Culture
Isolation
Personal Protection Equipment and Supplies
Isolation Precautions
Potential for Drug-Resistant Organism
Vaccinated
Not Vaccinated
C. Difficile Screen (False negation)
Appropriate Cleaning
Cost
Hand Hygiene
Potential for DrugResistant Organism
Clostridium Difficile Assay
Cleaning Products
1) USD. 2) Length of Stay.
Infection Treated with Antibiotic
Inappropriate Antibiotic Treatment
Inappropriate Treatment
The Way Forward
20
Tactical Approach Insufficient

Successful Organisations Not Relying on Discrete Initiatives
Protocols and processes for AMI1 care did not differ between high-mortality and low-mortality hospitalsin the absence of a supportive organizational culture, specific interventions may not be sufficient for achieving the highest performance in care for patients with AMI.2
Study in Brief: What Distinguishes Top Performing Hospitals in Acute Myocardial Infarction Mortality Rates
Qualitative study published in the Annals of Internal Medicine March 2011 Assessed high- and low-performing hospitals to identify factors related to better AMI care outcomes Identified that having clear values and goals, strong engagement from staff members of diverse disciplines and senior management, strong communication among groups, and solving problems in a way that seeks and addresses root causes were main predictors of high-quality patient outcomes
1) Acute myocardial infarction. 2) Our emphasis.
Source: Curry L, et. al., What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? Annals of Internal Medicine, March 15, 2011; Chen, Pauline W. "What Makes a Hospital Great," New York Times, March 17 2011; Advisory Board interviews and analysis.
Culture Matters
We have to focus on the relationships inside the hospital and be committed to making the organisation work. It isnt expensive and it isnt rocket science, but it requires a real commitment from everyone.
Elizabeth H. Bradley Yale Global Health Leadership Institute
Our Approach
21
Viewing Quality Through a Different Lens

Looking for a Common Thread Among Exemplars
Select ing Best Practice Case Study Inst it utions 1 1 2 3

Consistent national or international recognition for quality performance Achieved quality improvement across the organisation; not confined to single departments or initiatives; improveme Continuous, consistent quality improvement journey
1) Selected organisations included both academic and general hospitals, from various financial contexts, and where doctors were employed, not employed, unionised and not unionised.
22
All
Hands On Deck Required to Overcome Complexity
Ascension Health Johns Hopkins Medicine Sentara Healthcare Mayo Clinic Health System Eau Claire Baylor The Common Factor Health System Cedars Sinai Medical Organisation-wide commitment to collective quality improvement MCenter Center Beth Israel Deaconess Rotterdam Eye Hospital Rankin Medical Center St. Mary's Health Care System Intermountain Healthcare Jnkping County Council
23
Diverse Case Study Organisations

Sustained Success Built on Three Pillars of Improvement
Eight hospital not-forprofit system based in Virginia with 20,000 employees and 3,400 medical staff members Set ambitious executive vision for quality improvement; established performance standards, reinforced behaviours, and trained staff to overcome patient safety risks
23-hospital system headquartered in Salt Lake City, Utah, with over 32,000 employees System-wide focus on leveraging data systems, metrics to reduce clinical variation and improve outcomes
Independent specialty eye hospital located in Rotterdam, Netherlands, with 30 independent ophthalmologists, 21 residents, 400 staff members Focus on improving care delivery through innovation resulted in dramatic decrease in wrong-site surgeries and steady rise in patient satisfaction scores
24
Lessons for Leading the Organisation to Clinical Excellence
I
Commit to Quality Transformation
1. 2. 3. Articulate specific, aspirational vision Demonstrate informed dedication to front line Enforce and reinforce new norms 4.
II
Support Front Line Leadership
Empower front line to improve quality systems 6. 7.
III
Embed Culture of Measurement
Set data expectations Establish comprehensive clinical data infrastructure Enable principled clinician autonomy Educate clinicians in quality improvement
5.
Explicitly define doctor champion role

8. 9.
Case Study Sentara Healthcare
Case Studies The Johns Hopkins Hospital Baylor Healthcare
Case Study Intermountain Healthcare
25
Road Map
Creating Collective Commitment to Quality Improvement
Coda: Future Prospects: Expanding the Ambition
26
Column I
Commit to Quality Transformation: Standard Approach
27
Always Part of the Mission

Who is Not Aiming for High Quality?
Gibson Hospital1 Mission Statement

The multi-disciplinary team at Gibson Hospital will provide efficient and effective treatment options in a caring and professional environment. Our highly experienced staff will deliver care in comfortable surroundings with fully resourced facilities. We continually aim to improve our performance by implementing quality management principles.
1) Pseudonym.
Quality Case Study
28
Overview: Sentara Healthcare
Case in Brief: Sentara Healthcare

10-hospital not-for-profit system based in Virginia 20,000 employees and 3,400 medical staff members Frustrated with lack of safety improvements, set goal of being in the top 10% of hospitals for all nationally reported safety metrics and attaining zero defect rate for preventable harm Drew on high reliability learning from nuclear and aviation industries to improve safety Broad involvement of executive team in setting performance standards, reinforcing behaviours, and training staff to overcome patient safety risks Achieved 80% reduction in serious safety event rate over 7 years
Source: Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.
Catalyst for Change
29
A Wake-Up Call
National Focus on Quality Improvement Galvanises Sentara
To Err is Human: Building a Safer Healthcare System Health Care is Not as Safe as It Should Be
Preventable adverse events are a leading cause of death in the United States. Sizable numbers of Americans are harmed as a result of medical errors. Total national costs (lost income, lost household production, disability, health care costs) are estimated to be between $37.6 billion and $50 billion1 for adverse events and between $17 billion and $29 billion1 for preventable adverse events.
Medication-related errors occur frequently in hospitals; not all result in actual harm, but those that do are costly. To Err Is Human (1999)
1) USD
Source: Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors, To Err Is Human, Committee on Quality of Health Care in America, Institute of Medicine (1999): 17-19; Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.
30
Initial Efforts Fall Short

Unfocused Message and Isolated Interventions Slow Early Quality Efforts
Selected Quality Improvement Interventions 1999-2001
Medication Safety We will focus, plan and act on our commitments to our community mission, to our customers and to the highest quality standards of healthcare to achieve our vision for the future. August 2000 IT system to streamline and reduce errors in medication dispensing Ventilator Associated Pneumonia Education program to reduce VAP in all system sites
The Big Picture

We were frustrated. The sense at the time was that if we continued to work on discrete things without a larger framework, wed make progress, but we really wouldnt make the impact that we thought we needed.
Dr Gary Yates, CMO Sentara Healthcare
Source: Sentara.com, August 2000, accessed through web.archive.org 10 April 2012; Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.
31
Executive Leadership Required to Move Forward

External Expertise Pushes Senior Team to Reprioritise
Genesis of Quality Improvement Program at Sentara Healthcare
Out-of-Industry Assessment Focus on Culture Leadership Prioritisation
External safety experts with experience in risk reduction in nuclear power and airline industries conduct baseline assessment of safety processes
Assessment results and executive discussions turn focus from individual quality improvement processes to inculcating a system-wide culture of safety
Leadership team recognises senior executive prioritisation of quality improvement will be critical to sustained culture change
Four Principles of Quality Improvement at Sentara Elevate safety to core organisational value Communicate behaviours for error prevention Create systems that reduce the chance of human error Use root cause analysis to understand safety events
Lesson #1: Articulate Specific, Aspirational Vision
32
Setting a New Standard

Quality Mission Statement Signals Clear Change to Staff
Providing the highest quality of care and exceptional patient safety standards are imperative strategies throughout Sentara Healthcare. Our goal is to lead the industry to achieve top 10 percent performance wherever national benchmarks exist.
Characteristics of Quality Definition at Top-Performing Hospitals

Aspirational goal set Success clearly defined Vision specific and tailored to the organisation
33
Vision Alone Not Enough

Executive Commitment Often Not Translating
Executives Reporting High Quality Care as Top Priority1
n=111 senior hospital executives
Doctors Reporting High Quality Care as Top Priority for Executive Team2
n=30 doctors
Yes
85%
15%
No
Yes
30%
70%
No
1) Survey question: How important is ensuring high quality care for patients to you personally? No displayed in chart as survey answers of high, medium or low priority. 2) Survey question: How important do you feel ensuring high quality care for patients is to the executive leadership of your organisation as a whole? No displayed in chart as survey answers of high, medium or low priority.
Source: 2012 Clinical Operations Board Survey on Quality in United Kingdom, Australia, and New Zealand; Advisory Board interviews and analysis.
34
Active Management Methods Falling Short

Sentara Finds Typical Approaches Inadequate for Culture Change
Common Active Management Concepts
Open Door Policy Theory Signal that leaders are always available and receptive to staff challenges and concerns Walkrounds at Random Theory Anticipate staff needs and ensure compliance with quality goals through unplanned drop-ins Scheduled Senior Walkrounds Theory Demonstrate executive commitment to quality through scheduled ward visits by most senior leadership
Practice Staff unwilling to admit inability to perform tasks Staff fear not meeting manager expectations Staff want to avoid appearing weak or needy
Practice Non-clinical executives intimidated by front line atmosphere Executives fail to ask pertinent questions Staff feel check-in indicates lack of trust, not convinced of executive quality interest
Practice Predictable nature of visits results in extensive staff preparation for interaction Walkrounds too infrequent to create ongoing dialogue between management and staff
Lesson #2: Demonstrate Informed Dedication to Front Line
35
Making Executive Rounds Work

Consistency, Constant Visibility, Preparation and Purpose Key
Asking Staff to Think Ahead 1. What in the last 24 hours has threatened our ability to provide safe care?
2. What might we expect to arise in the next 24 hours that would threaten the safety of our care?
3. How would we respond to what we think might happen?
Keeping Everyone Focused
Sentara Rounding With Intention Process

Executives round with relevant questions Note any issues raised by staff Create action plans with staff to address issues
A Constant and Consistent Message

The idea that were going to be out there each day and teaching and actively engaging folkshas been important in sending a constant message about safety to our staff.
Dr Gary Yates, CMO Sentara Healthcare
Crib Sheet for Clinical Rounds Can you demonstrate how to use the care bundle to prevent urinary catheter infections?
36
Constantly Reinforcing Executive Commitment

Sentara Daily Check-ins Anticipate Potential Problems, Prove Priority
Daily Check-In Procedure Sample Agenda Items
1. Update on progress against hospital and ward goals 2. Share positive or negative patient feedback 3. Address safety issues within last 24 hours Hospital executives, medical staff leaders and nurse managers meet every morning to review safety or quality concerns Meeting conducted while standing, lasts 20 minutes or less
4. Discuss potential safety issues within next 24 hours and mitigating strategies
Sentara Leadership Method for Performance Excellence
Sentara Leadership Method for Performance Excellence

1. Safety Walkrounds: to identify problems and reinforce safety as a priority 2. Daily Safety Check-in: to share and maintain situational awareness 3. Action Plans: to manage and ensure accountability for improvement work
Lesson #3: Enforce and Reinforce New Norms
37
Creating a Sense of Quality Ownership

Positive Reinforcement and Just Culture Foster Accountability
Example of Positive Reinforcement at Sentara
Environmental Services worker in Critical Care Unit corridor hears beeping from patient room Collaborative Improvement Enters room to find patient struggling to breathe; runs to find nearest nurse who resuscitates patient No punishment for honest mistakes; all system and human factors taken into account Substitution test decreases likelihood of attribution problem Enables unbiased analysis, individual and system improvement following safety mistakes
Just Culture
Sentara leadership team gives environmental services worker special recognition public recognition
Hospital system blog regularly profiles Patient Safety Success Stories: http://sentarainfo.com/today
For a complete version of Sentaras Performance Management Decision Guide, please see appendix p 4
38
Walking the Talk

Standing Up for A Strong Institutional Vision
Quality Takes Precedence Over Clinical Autonomy

The expectation on the part of the [doctors] is that autonomy will not trump quality. Thats a real big issue and it is one that the organisation is currently working ontheres no room for cowboys. Quality comes first.
Senior Executive Mayo Clinic Health System in Eau Claire
Case in Brief: Mayo Clinic Health System in Eau Claire

305-bed hospital located in Eau Claire, Wisconsin; part of the Mayo Clinic Health System Following merger in 1992 between Luther Hospital, Midelfort Clinic and affiliation with Mayo Clinic Health System, embarked on institution-wide transformation based around vision of multidisciplinary, integrated care Strong leadership and continued commitment to quality improvement resulted in sustained quality improvement over nearly two decades Organisation scores in top 1% of US hospitals on composite measure of 22 publicly reported metrics of standards in heart attack, heart failure, pneumonia and surgical care
Source: Paul Bate and Peter Mendel and Glenn Robert, Organizing for Quality: The improvement journeys of leading hospitals in Europe and the United States, Radcliffe Publishing: Oxford, 2008; Advisory Board interviews and analysis.
Enforce and Reinforce New Norms: Summary
39
No Single Method Sufficient

Array of Enforcement, Reinforcement Mechanisms Required
Leadership Response Techniques
Positive Reinforcement
Celebration of notable successes spreads enthusiasm and knowledge of expected behaviours
Just Culture
Principled system required to manage quality errors, focusing on root causes and learning from mistakes For persistent resisters, firmer action required; coaching out of the organisation as needed in extreme cases
Disciplinary Action Frequency of Use
40
Critical Leadership Actions

Executives Must Take First Steps on Quality Improvement Journey
Elements of Transformational Commitment
Articulate specific, aspirational vision Demonstrate informed dedication to the front lines Enforce and reinforce new norms
Vision includes specific, measurable definition of success; goal is aspirational but achievable and tailored to organisations culture
Executives visibly dedicate substantial time and attention to quality improvement goals at every level of the organisation
Leadership publicly celebrates staff achievements related to quality vision and responds to noncompliance in a fair and consistent manner
Selected Results
41
Attaining Consistent Improvement

In-Hospital Mortality Ratio: Sentara Hospitals, 2003 2008
Mortality Ratio (Actual Deaths/Expected Deaths) 0.73 0.66 0.64 0.6 0.60 0.58 0.56 0.5 0.5 0.4 0.3 0.2 0.1 2003
Serious Safety Event Rate per 10,000 Adjusted Patient Days1

Sentara Hospitals, 2003-2010
0.2
2004
2005
2006
2007
2008
0.0
2003 2004 2005 2006 2007 2008 2009 2010
Sentara Quality Awards 2012 Top 10 Integrated US Hospital System2 2010 Leapfrog Group of Top Hospitals
1) Deviation from standard of care resulting in moderate to severe harm to the patient. 2) Modern Healthcare Magazine. 3) Awarded by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality Forum. Sentara received the award for "Innovation in Patient Safety and Quality at a Local or Organizational Level." 4) Awarded by the American Hospital Association.
2005 John M. Eisenberg Award for Patient Safety3 2004 Quest for Quality Prize4
Source: Sentara Healthcare, Norfolk, Virginia; Douglas McCarthy and Sarah Klein, Sentara Healthcare: Making Patient Safety an Enduring Organizational Value, The Commonwealth Fund, March 2011; Advisory Board interviews and analysis.
42
Action Items to Commit to Quality Transformation

Self-Test Questions
Review organisations mission statement Is it clear that quality of care is central to the mission? Are quality goals specific to the organisation, measurable, and ambitious? Evaluate executive communication around quality Are front line staff convinced of senior clinical and non-clinical executives quality commitment? Is executive time spent on quality visible to staff? Do executives have a mechanism to surface honest commentary on potential problem areas from staff?
Evaluate quality enforcement and reinforcement practices Are quality successes celebrated organisation-wide, in a way that is meaningful to staff? Are adverse events consistently and fairly evaluated? Do medical staff governance procedures allow for quality compliance enforcement if necessary?
43
Column II
44
Column III
45
Lessons for Leading the Organisation to Clinical Excellence
I
1. 2. 3. Articulate specific, aspirational vision Demonstrate informed dedication to front line Enforce and reinforce new norms 4.
II
Empower front line to improve quality systems 6. 7.
III
Set data expectations Establish comprehensive clinical data infrastructure Enable principled clinician autonomy Educate clinicians in quality improvement
5.
Explicitly define doctor champion role

8. 9.
Case Study Sentara Healthcare
Case Studies The Johns Hopkins Hospital Baylor Healthcare
Case Study Intermountain Healthcare
Leading the Organisation to Clinical Excellence
2012 THE ADVISORY BOARD COMPANY

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2012 THE ADVISORY BOARD COMPANY

The New Quality Mandate

Creating Collective Commitment to Quality Improvement

2012 THE ADVISORY BOARD COMPANY 25038

Coda: Future Prospects: Expanding the Ambition

The New Quality Mandate

2012 THE ADVISORY BOARD COMPANY 25038

Quality in the Spotlight

Increasing Understanding of Quality Performance

AHRQ Patient Hospital Voluntary Safety Indicators Reporting System

Quality Worse Than Expected

Classen et al. Health Affairs

Incessant Negative Publicity Around Quality

Hospital mistakes killed 28 people in Victoria this year

Technician charged in fatal injection with cleaning solution

Nearly 2,000 Carrying H.I.V. in Chile Were Not Notified

Man has unnecessary cancer surgery after misdiagnosis

Hospital boss tried to cover up details of patients death

Bacteria kills newborns in German hospital

Routine operation ends with death of mother of four

NHS patients discharged from hospital alone in the middle of night

Source: Advisory Board interviews and analysis.

Hospitals Losing Public Trust

3 No 72% 25% Yes

Surgical Errors Likely

2012 THE ADVISORY BOARD COMPANY 25038

Clinically effective, personal and safe.

Result: Quality Rising Up National Agendas

Worldwide Attempts to Measure, Manage Quality

UK: 150 Canada: 16

Safety Improvement for Patients in Europe: 26

World Health Organisation: 25

Transparency New Way of Life

Boshier Hospital Drexler Health Care Lindner Clinic Strider Hospital

Source: Advisory Board interviews and analysis.

Already Struggling to Make the Grade

Selected Recent Studies of Guideline Compliance at Hospitals

Pneumonia Correct Site Surgical Marking

1) Chronic obstructive pulmonary disease. 2) Venous Thromboembolism

Future Threat: Demand

Patients Older, Sicker

Global Population Aged 60 Years or Over

Heart Failure Prevalence in Europe

2012 THE ADVISORY BOARD COMPANY 25038

Not All Bad News

Quality a Means of Competitive Differentiation

2012 THE ADVISORY BOARD COMPANY 25038

Recognising the Competitive Landscape

Pursuit of Quality Engages Medical Staff

Three of top five engagement drivers have quality component

The organisation provides excellent clinical care to patients

The New Quality Mandate

2012 THE ADVISORY BOARD COMPANY 25038

Improvement Challenges Story #1: The Human Factor

2012 THE ADVISORY BOARD COMPANY 25038

Case in Brief: Cedars Sinai Hospital

Improvement Challenges Story #2: Campaign Mentality

Individual Interventions Successful

2012 THE ADVISORY BOARD COMPANY 25038

Not Enough to Achieve High Quality

MRSA1 infections per 1000 ICU bed days

1) Methicillin-resistant Staphylococcus aureus. 2) Central Line Associated Blood Stream Infection.