Russ Ricci, MD - Moderator, President Emeritus, eHealth Initiative; Chairman, MEDITECH Advisory Board

Jane Englebright, PhD, RN, Vice President, Quality Hospital Corporation of America (HCA), Nashville, TN

Denni McColm, CIOCitizens Memorial Hospital, Bolivar, MO2005 HIMSS Davies Award Recipient

Robert Dart, MD, Chief of Emergency Medicine and Director of Medical Informatics Quincy Medical Center, Quincy, MA

Introductions

Do You Remember the Year?

Why Quality Reliability Must Also be Improved,

Even Though it May Cost Somewhat More

Challenges

• Competition exceeds cooperation and trust

• Lack of – standards – interoperability – personal identifiers – funding – physician support

• Rising health care costs

Mission: To drive improvement in the quality, safety, and efficiency of health

care through information and information technology.

Vision: Consumers, health care providers, and those responsible for population health will have ready

access to timely, relevant, reliable, and secure information and services through an interconnected,

electronic health information infrastructure to support better health and health care.

Does this sound like your mission?

Middle Class Voters Become Uninsured

1987 2003

Wealthy Uninsured 2% 5%

Middle Class Uninsured – 1st Tier 6% 11%

Middle Class Uninsured – 2nd Tier 15% 25%

Middle Class Uninsured – 3rd Tier 33% 44%

Lower Class Uninsured 48% 52%

Source: Analysis of the March 1988-2004 Current Population Surveys by Danielle Ferry, Columbia University for the Commonwealth Fund.Adapted from “A Need to Transform the US Health Care System: Improving Access, Quality and Efficiency.”Compiled by A. Gauthler and M. Serber: The Commonwealth Fund, October 2005.2005 A. Milstein, MD

Percent of working adults uninsured, by household income quintile 1987-2003

Crossing the Quality Chasm

* Source: Preventing Medication Errors: Quality Chasm Series, Institute of Medicine, July 2006

Errors cost $3.5 billion per year in

medical expenses

1.5 million people harmed by medication errors

•e-Prescribing by year 2010•Enhanced communication between patients and care providers•Interoperable medication data

Necessary Actions:

Current Status

• Expectation for quality initiatives and outcomes reporting

• Communication • Nursing Documentation • Medication Bar Coding • Computerized Physician Order Entry • Informed Decision Support • EMR/EHR/PHR • Comparative Performance Reporting

Your Status on Quality Improvement Initiatives

• Interoperability?

• Bar Coding?

• CPOE?

• Physician Documentation?

• Decision Support?

• Links to Ambulatory Physicians?

• Performance Reporting?

The Challenge Today is the Sociology not the Technology

Change the Process, Don't Pave the Cowpath

Panelists: How Have You Succeeded in Your Quality

Initiatives?

• Governance– What has changed in your culture?

• Critical success factors

• Challenges to success

Jane Englebright, PhD, RN

Vice President, Quality

HCA

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U.K.

Switzerland

USUS176 Hospitals176 Hospitals

92 ASC’s in92 ASC’s in22 States22 States

INTERNATIONAINTERNATIONALL

8 Hospitals8 Hospitals

Who is HCA?

HCA Mission and Values Statement• Above all else, we are committed to the care and improvement of human life.

In recognition of this commitment, we will strive to deliver high quality, cost-effective healthcare in the communities we serve.

• In pursuit of our mission, we believe the following value statements are essential and timeless:– We recognize and affirm the unique and intrinsic worth of each individual.– We treat all those we serve with compassion and kindness.– We act with absolute honesty, integrity and fairness in the way we

conduct our business and the way we live our lives.– We trust our colleagues as valuable members of our healthcare team

and pledge to treat one another with loyalty, respect, and dignity.

Through the Patient Safety Initiatives, HCA strives to . . . .

Create a Culture of Patient Safety

• Establish patient safety as a visible commitment to putting patients first philosophy

• Move from blaming people to improving processes• Improve use of technology to prevent and detect

error• Use data to identify and measure improvements

Areas of Concern for HCA Arise from Four Main Avenues

Areas of Concern are defined by HCA Senior Management. Once identified, the Patient Safety Department conducts the literature review, best practice survey of HCA hospitals, and organizes a Design Team. Design Team recommendations create the core elements and approaches for the resulting Patient Safety Initiative.

Areas of Areas of Concern for Concern for

HCAHCA

Operational Operational ConcernsConcerns

• Emergency• Surgical• Critical Care

Public Policy ConcernsPublic Policy Concerns• Medication Safety• Hospital Associated Infections

Regulatory ConcernsRegulatory Concerns• Medication Safety• Hospital Associated Infections• Perinatal• Surgical Care

HCI Claims DataHCI Claims Data• Perinatal• Emergency• Surgical

HCA Definition of Quality is Derived from IOM Report:“Crossing the Quality Chasm”

• Safe: Avoiding injuries to patients from the care that is intended to help.

• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services not likely to benefit

• Patient Centered: Providing care that is respectful and responsive to individual patient preferences, needs and values and assuring that patient values guide all clinical decisions

• Timely: Reducing waits and sometimes harmful delays for both those who receive care and those who give care.

• Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

• Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status.

HCA Patient Safety Implementation Model

Process Change

Culture Change

Technology Change

Patient Safety is Organizational Change for the hospital and the physician. A key component of each Patient Safety Initiative is to move the hospital organization and medical staff toward a common goal

of saving lives. Cultural transformation and process re-engineering are the key work efforts. Technology tools are used to embed the changes into the daily work of clinicians.

PhysiciansHos

pita

l

HCA Patient Safety Emphasis on Technology

Forcing Functions & Constraints

Automation & Computerization

Standardization & Protocols

Checklists & Double-Checks

Policies & Procedures

Education & Information

eMARePOM

EDM / TSystemEvOR Module

Clin DocumentationResults Review

PACS

ICU Clin DashboardED Dashboard

Rank Order of Error Reduction Strategies HCA Technologies

Meditech modules support clinical operations and provide a mechanism for delivering protocols, checklists, procedures, and information to the point of care. Dashboards provide information about the care of groups of

patients that is necessary for process improvement.

HCA Patient Safety Initiatives

Medication SafetyStarted 2000

Emergency ServicesStarted 2002

Perinatal SafetyStarted 2003 (1997)

Surgical ServicesStarted 2005

Hospital Associated Infections / Critical Care

Started 2005

Areas of Concern

• IOM Report• JCAHO NPSG• Leapfrog/NQF

• HCI Claims Data• Operational concern with

ED Building Boom• Regulatory concern:

EMTALA• Public Policy concern

with ED Overcrowding

• HCI Claims Data• JCAHO Core Measure

• Operational Concern with underutilization of ORs & need for growth

• HCI Claims Data• JCAHO NPSG• CMS HQA & JCAHO

Core Measure starting 2006

• Public Policy• Operational Concern• Leapfrog/NQF

Key Elements

• eMAR & Bar Coding• Practice Guidelines

Tool Box• ePOM• VTE Prevention• Med Reconciliation

Best Practice

• ED Dashboard• Triage competency &

staffing• Misdiagnosis & Never

Events• Documentation

standards

• Fetal Monitoring Competency

• Kernicterus Screening• High Risk Algorithms• High Risk Medications• Team Communication

• “Never Events” education

• Technology optimization• Leadership development• Best practice for pre-

operative processing

• IHI 100K Lives Campaign

• Safer Critical Care Project with VUMC (AHRQ Grant)

Results

• eMAR deployed 2002-2005

• eMAR averting 2.1 Million errors/year

• HCI Med Admin claims decreased 16%

• HCI ED Claims decreased 28% since 2002

• HCI Perinatal Claims decreased 38% since 2002m, saving $70 million / year

• “Never Event” campaign participation =

• Technology training participation = 86

• WFD results = pending

• Lives saved = 5588• Grant participants = 63

Denni McColm, CIOCitizens Memorial Healthcare

CMH Fast Facts• 74 acute beds• Level III trauma

center• 5 LTC facilities • Residential care &

independent living• Home care/hospice• 16 physician offices• 1,550 employees• 98 physicians

Project Infocare Vision• Enable a patient to enter

anywhere into the continuum of care and have a personal identity that is maintained across that continuum

• Physicians and other caregivers will have access to all of that patient’s medical information within the health care continuum

Project Infocare

• EMR that crosses continuum

• 100% use of CPOE

• No paper charts

Governance-What Changed?

• Desire to provide seamless care across the continuum

• Frustration with inability to do so with a paper-based system

• Acceptance of the fact that we could not efficiently or effectively manage care information across the continuum without information technology tools

• Commitment of resources

Critical Success Factors

• Talk, Talk, Talk• Listen, Listen, Listen

Challenges to Success

RESOURCES

PROCESS CHANGE

Robert Dart, MD Chief of Emergency Medicine and Director of Medical Informatics Quincy Medical Center

Quality in the Emergency Department

• 91 patients per day

• 20 inpatient admissions per day– 60% of hospital admissions

• Fully automated Emergency Department including a patient tracker and electronic physician and nursing note

• Patient chart easily accessible electronically

Quality Improvement Drivers

• JCAHO

• Payers

• Internal QA

• Patient Flow

• Best Practices/Practice Guidelines

Key Success Factors

• Goals clearly communicated to entire organization

• Support from all levels of the organization, beginning with the CEO

• Constantly encouraged physicians to embrace technology

• Instant workflow improvement with introduction of ED tracker

Challenges to Success

• Project Funding

• Overcoming “paper dependency”

• Pay for Performance - the wave of the future

• Performance improvement - dependent on collecting and tabulating process and outcome data

• An ED tracking system and Electronic Medical Record simplifies data collection thereby facilitating process improvement

Emergency Department Quality Summary

"It Takes a Culture to Raise a Technology"

Carolyn Clancy, MD, Director, Agency for Healthcare Research and Quality