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Pursuing ExcellenceQuality and Safety as the New Currency
Richard P Shannon, MDFrank Wister Thomas Professor of Medicine
Chairman, Department of MedicineUniversity of Pennsylvania
Perelman School of Medicine
Session Objectives
• Explore the importance of organizational values as the foundation for high performance
• Understand the characteristics of high performing organizations
• Examine the application of such principals to the elimination of harm as represented by hospital acquired infections and unexpected deaths.
• Determine the business case for quality
Where is Academic Medicine in the Journey toward Quality and Safety?
• Lack of clearly specified and audacious goals• Infatuation with reportable not actionable
data• Awash in meaningless measures• Lack a common, disciplined problem solving
system (Hawthorne effect)• No room for learning• Confuse effort with success
AMCs and US Healthcare System
Why do we need “Leadership Leverage” ?
• Quality improvement has been about “projects.” We have become good at making improvement happen for one condition, on one unit, for a while
• We haven’t learned how to get measured results, quickly, across many conditions for the whole organization
• Quality is never an accident; it is always the result of high intention, intelligent direction and skillful execution; it requires a commonly shared, disciplined problem solving approach embraced not in the conference room but at the point of care.
A “Project”
System Level Aim
• “If we solve our health care spending, practically all of our fiscal problems go away,” said Victor Fuchs, emeritus professor of economics and health research and policy at Stanford. And if we don’t? “Then almost anything else we do will not solve our fiscal problems.”
The Sense of UrgencyHealth Care and the Nation’s Economy
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
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 Rabbit
Dynamics of HPOs
• Cope with complexity by continuous focus on learning more about how to improve the work they do.
• Its is not about knowing the right answer, its about discovering the right answer.
• Nothing is ever good enough
Spear Chasing the Rabbit
The Four Capabilities of HRO
• 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 Rabbit
Leaders in HPOs
• Set clear and unambiguous expectations• Amazing problem solving capabilities• Empower and create systems that provide
answers….• How they spend their time reflects their
values• Take away all the excuses as to “Why not?”
Spear Chasing the Rabbit
Levers of Waste
Don Berwick
•Harm•Overtreatment•Defects in care delivery•Defects in care transitions•Excess administrative costs•Fraud and abuse
Why Safety?
• It is unassailable• Harm violates our professional duty• Harm is the elementary form of waste• It is valueless• It can be eliminated
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 work
into a US hospital
Safer?
HAI in Pennsylvania 2012
23,287 HAI (1.2%)
Patient Outcomes
An Audacious and Unassailable Goal
• 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?
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
NNIS
PRHI
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
• 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.
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
The Work of Physician LeadersRounding 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
Rounding on Sick patients Rounding on Sick Systems
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 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
Value Stream MappingA Way to Identify and Correct Defect
• Types of catheters associated with HAIsintravenous cathetersendotracheal tubesbladder catheterssurgical sites
• Steps in Standard workPlacing Maintaining Manipulating
28
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
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
Penn MedicineThe Journey of 1,000 Days
• Reduction in Variable Costs attributed to CA BSI elimination:$10,923/case
• Total: $3,823,050• Reduction in LOS: 10.7 days• Additional admissions: 623• Additional revenue: $3,613,400• IBC P4P: $3,200,000
• Total Financial Improvement: $10,636,450• Lives saved 65
Human Costs of CA-BSI• 37 year old video game programmer, father of 4,
admitted with acute pancreatitis secondary to hypertriglyceridemia.
• Day 3: developed hypotension, and respiratory failure• Day 6 : fever and blood cultures positive for MRSA
secondary to a femoral vein catheter in place for 4 days.
• Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy
• Day 86: Discharged to nursing home
Shannon RP: AJMQ
6 86
CLAB
Day 1
2/07/02Transfer 5/04/022/12/02M. S.
T o ta l C o s t o fP a tien t S tay2 4 1 ,8 4 3 .8 2
T o ta l C o s t a f te rC L AB
2 2 9 ,3 8 1 .0 8
T o ta l C o s t b ef o r eC L AB
1 2 ,4 6 2 .7 4
T o ta l Attr ib u tab leC o s t
1 7 0 ,5 6 5 .1 2
N o t R ela ted toC L AB
5 8 ,8 1 5 .9 6
M I C U S er v ic e1 0 6 ,7 3 7 .5 6
P r im ar y to C L AB5 2 ,9 1 4 .0 9
S ec o n d ar y to C L AB1 0 ,9 1 3 .4 7
T o ta l Attr ib u tab leC o s t0 .0 0
N o t R ela ted toC L AB
1 2 ,4 6 2 .7 4
T o tal C o s t A ttrib u tab le toIn fe c tio n
1 7 0 ,5 6 5 .1 27 0 .5 3 % o f T o tal
T o ta l Attr ib u tab le C o s tBef o r e C L AB
0 .0 0
T o ta l Attr ib u tab le C o s tAf ter C L AB1 7 0 ,5 6 5 .1 2
P r im ar y to C L AB0 .0 0
S ec o n d ar y to C L AB0 .0 0
The Impact of CA-BSI on Gross Margin
DRG 204/2721(n=3)
DRG 191(n=3)
DRG 483(n=2)
Case 1
Acute pancreatitis
Pancreatitis w cc
Pancreatitis w trach
Revenue ($) 5,907 99,214 125,576 200,031
Expense 5,788 58,905 98,094 241,844
Gross Margin
119 40,309 27,482 -41,813
Costs attributable to CA-BSI
170,565
LOS 4 38 41 86
UHC Mortality Rank 2012: 26th
• There were 804 deaths at HUP• There were 462 deaths attributed to Medicine• There were 49 deaths among electively
admitted patients• There were 89 deaths among patients with
low/moderate severity of illness index• 59% of deaths had an in-hospital complication
A Matter of Life and Death
• Who died last night?• Was it expected or unexpected?• If unexpected, what happened?• Create clinical vignettes on all deaths• Were there any “bumps in the night?”
MICU transfers
Unexpected Deaths15-20%
• Aspiration Pneumonia SIT UPPatients at RiskInterventions
• Delays in Diagnosis and TreatmentHeart failureLiver Failure
UHC Mortality
2009 2010 2011 2012 20130
100
200
300
400
500
600
700
800
900
1000
O/EDeaths
0.89 0.86 0.81 0.79 0.62
468 453 464 453 372
Summary• High performing organizations are best in class based upon values
based leaders, disciplined problem solving systems and a commitment to habitual excellence.
• Habitual excellence requires continuous improvement and continuous improvement requires continuous learning as to how to execute our work better.
• The elimination of harm and unexpected deaths is an unassailable goal and illustrates the importance of values as a the starting point on a journey toward excellence in Medicine.
• Coupling the business case for quality with performance improvement can accelerate the progress.
• Resources liberated from the elimination of waste as fuel the virtuous cycle of our academic missions.
If Not us, Who?
Somebody has got to do something…
…its just incredibly pathetic that it has to be us !!!
Jerry Garcia The Grateful Dead
The Barriers to Change
There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.
Niccolo Machiavelli 1513
78%
19%
0%
20%
40%
60%
80%
100%
2001 2002 2003 2004 2005 2006 2007
Health Insurance Premiums Workers' Earnings
Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, 2001-2007
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April).
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 min
14min
2:02 $8 parking
37 min
Patient visits from 7-9/session On –Time Performance Patient satisfaction (waiting) Lag days
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• The leader: Admiral Hyman Rickover and the
discipline of specifying expectations and the developer of incident reports
• Leaders and learning are indispensable
What Leaders think matters…What leaders do matters more
• Your personal leadershipSetting audacious goalsPractice don’t espouse Values
• Your leadership systemLessons from highly performing organizationsThe importance of a common disciplined problem
solving
• TransparencyPersonal stories
The business case for quality51
Begin with a Value PropositionOur 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
Primum non nocere
will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to them anyone
will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
Values Trumps Process
Improvement vs. Habitual Excellence
2007 2008 2009 2010 2011 2012 20130
50
100
150
200
250
300
350
400
Infections
1,000 days