2017 Nicolas E. Davies Enterprise Award of

Excellence

Agenda

• Memorial Hermann Health System Overview

• Case study review– VAP Prevention

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Memorial HermannHealth System

Woodlands Sugar Land TMC Katy Memorial City Southeast

Greater Heights

Northeast

TIRR Katy RehabKaty Rehab

Children’s Southwest

• Total hospitals: 15 (11 acute, 2 rehab, 1 children’s, 1 orthopedic)

• Inpatient admissions: 158,241• Annual emergency visits: 595,611• Annual deliveries: 25,146

• Employees: 25,040• Beds (acute licensed): 4,016• Medical staff members: 5,708• Fellowship programs: 48

PearlandCypress

MHOSH3

Our Network of Care

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292 Care Delivery Sites

Certified Zero Awards32

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Memorial HermannRecent Accolades

15 Top Health Systems; Top 5 Large Health Systems

(2012 & 2013)

National Quality Forum National Quality

Healthcare Award (2009)

TIRR Memorial Hermann No. 2 in rehabilitation

hospitals

2011 Texas Healthcare Foundation Quality

Improvement Awards (9 Memorial Hermann

Campuses)

Healthcare’s “100 Most Wired” 12th

consecutive year America’s 50 Best Hospitals (2010-2014)

Texas Hospital Association

Bill Aston Quality Award (2011)

America‘s #1 Quality Hospital for Overall

Care (2011 & 2012)

John M. Eisenberg National Patient Safety &

Quality Award (2012)

2015 Houston Business Journal (HBJ) No. 3 Best Places to Work

The Joint Commission

Top Performer (2012), Heart Attack, Heart

Failure, Pneumonia,

Surgical Care

Quality – A competitive advantage for Memorial Hermann

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Population Health Infrastructure

~4,000 MHMD Physicians, ~3,500 ‘CIN’ Clinically Integrated NetworkPrivate, Employed & Faculty Integration

PrivateEmployment Faculty

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The MH ACO allows for integration of a pluralistic physician model (UT, MHMG & MHMD) to drive quality outcomes

3 DISTINCT PRACTICE MODELS

428 2961 1170

High

Moderate

Low Fragmented Transitioning Integrated

Increasing Degree of Integration

Degree of Risk Shifting to Provide

rs

Delivery System Readiness for Risk

BCBS Commercial75,000

United Healthcare

100,000

United Healthcare Commercial

100,000Community Health Choice

54,740

Aetna Medicare Advantage5,800

Humana Medicare

5,000

Humana Medicare Advantage

5,000United Healthcare Medicare

Advantage 8,800

CMS MSSP47,400

Aetna Commercial85,000

Humana Commercial18,700

MH Health Plan CommercialMHHS 39,136 | Other

28,881MH Health Plan

Medicare Advantage 6,790Aetna Whole Health

26,200

TIER

 IIGain Sharing

TIER

 III

Value Driven

TIER

 IPartial ‐Full Risk

501,447Members

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101,007Lives

345,700 Lives

MH assumes varying degrees of risk for their ACO members

Our JourneyHigh Reliability Organization

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Commercial Aviation

Nuclear AircraftCarriers

Air Traffic Control

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High ReliabilityCertified Zero Award

1. Zero Events

2. 12 Consecutive Months

3. Certified Zero Category10

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High Reliability 2011-2017Certified Zero Awards

ICU Central Line Associated Bloodstream Infections (18)ICU Catheter Associated Urinary Tract Infections (16)

Hospital-Wide Central Line Associated Bloodstream Infections (7)Hospital-Wide Catheter Associated Urinary Tract Infections (5)

Ventilator Associated Pneumonias (23)Retained Foreign Bodies (46) Iatrogenic Pneumothorax (24)

Accidental Punctures and Lacerations (3)Pressure Ulcers Stages III & IV (37)

Hospital Associated Injuries (7)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 (21)

Serious Safety Events 1 & 2 for 1000 Days (2)All Serious Safety Events (1)Early Elective Deliveries (9)

Manifestations of Poor Glycemic Control (21)

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263

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Wall of Pride!Memorial Hermann Facility

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THE VAP BUNDLE A Story of Data Driven Process

Improvement

- Jennifer Westmorland- Tawanna McInnis-Cole- Jocelyn Thomas

BundlesWhy are they important?

• Evidence based, interdisciplinary plans for patient care

• Focus on 3-6 interventions that significantly improve patient outcomes for a specific population

• Foundation in research and peer reviewed literature

• Regulatory and in house surveillance

• Drive process improvement and standardization

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Complication of Mechanical Ventilation- Ventilator Acquired Pneumonia (VAP) - Ventilator Associated Events (VAE)

• Up to 20% of vented patients develop VAP 1

• > 39% of pneumonia cases in acute care setting 1

• Increase in ventilator days, length of stay and antibiotic use 1

• Mortality may exceed 10% 1

1. Coffin, Susan E., et al. “Strategies to Prevent Ventilator‐Associated Pneumonia in Acute Care Hospitals.” Infection Control and Hospital Epidemiology, vol. 29, no. S1, 2008, pp. S31–S40. JSTOR, JSTOR, www.jstor.org/stable/10.1086/591062.

VAPWhy Does it Matter?

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VAPFinancial Impact

• At least 20% may be preventable 2

• 52,543 cases per year 3

• VAPs make up 31.6% of the cost of the top 5 HAIs 4

• Estimated cost of $40,144 per case in 2013 4

2. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-266

3. R. Douglas Scott II. The DirecT MeDical cosTs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009

4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039–2046. doi:10.1001/jamainternmed.2013.9763

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VAP Bundle (Adults Only)

Nursing Bundle• Suction – 4 Hrs.• Oral Care – 4 Hrs.

MD Bundle• Head of Bed – 4 Hrs.• SUD Prophylaxis – 24 Hrs.• VTE Prophylaxis (Mechanical 4 Hrs./ Pharmaceutical 24 Hrs.)• Sedation Holiday – 24 Hrs.

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Houston…..We Have a Problem

It was the year 2006…

Data analysis showed the VAP rate was too high!!!

VAP rates to become focus for CMS

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System VAP Rate

VAP rate = count of VAPs per 1,000 vent days20

What Did We Do?

We implemented our VAP Bundle because:

• Infection Control leadership believed we could reduce the VAP rate

• IHI and evidence based literature

• Standardize and monitor care across the system

Do No Harm 21

VAP Bundle TimelineMajor Events

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Continuous surveillance of 1. Clinical Outcomes2. VAP Bundle Compliance

July 2017 VAP Upgrade Implemented

2016 Start VAP Bundle Upgrade

2013 CDC Changes VAP to VAE

Mar 2010 Electronic Abstraction

2008-2009 Conversion to EHR

May 2007 Implementation on Paper

2013 VAE Report Developed

Jan 2017 TheraDoc Infection Control

People• Multi-disciplinary HAI Taskforce created• All hospitals represented

Process• Clinical Stakeholders identified for design sessions• Design sessions used process improvement tools• Workflows defined• Operational definitions standardized• All lCUs required to maintain policies and procedures• Communication and education• Performance Incentives

May 2007 Implementation on Paper

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Technology• Paper forms

Weekly manual auditsExcelMIDAS database – focus studies

• Reporting at System & Nursing Unit Level:- Bundle Compliance (documentation audits)- Clinical Outcomes (VAP Rate)

May 2007 Implementation on Paper

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Data Analysis

Data AnalysisVAP Rates

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Technology Advances -Electronic Documentation and Abstraction

• Facilities converted to EHR

• Daily reports manually processed and emailed to nursing

• Monthly Facility Compliance metrics published

• Monthly metrics reported to System Executives

2008-2009 Conversion to EHR

EHR

The Attack of the EHR

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VAP Bundle Nursing Documentation in the EHR

VAP Bundle Automation in the EHR

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VAP Monthly ReportFinancial Number Attending Type of

Unit Facility Nursing Unit Midas ICU Code for CLIP & VAP

55555555 Dr House Adult MEMORIAL CITY - ACUTE MC - NEUROSCIENCE A (J4EC) MC - Neuroscience Unit55555555 Dr Jekyl Adult HERMANN HOSPITAL - ACUTE HH - ICU MICU MEDICAL ICU (MICU) HH - ICU MEDICAL ICU55555555 Dr Who Adult HERMANN HOSPITAL - ACUTE HH - ICU CCU CARDIAC CARE UNIT HH - CCU

Bundle elements = Yes or No EXCEPTSedation Holiday = Yes, No or N/A

Audit Date HOB up 30 deg Oral hygiene q4 Hrs. Suction q4 Hrs. DVT Prophylaxis SUD Prophylaxis Sedation weaning

trial q24 hours3/1/2014 Yes Yes Yes Yes Yes Yes3/2/2014 No No No No No No3/1/2014 Yes Yes Yes No Yes N/A

Mar 2010 Electronic Abstraction Begins

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In 2013, the CDC proposed a new algorithm for preventable events related to mechanical ventilation.

VAP was replaced by four broader surveillance tiers:1. Ventilator-Associated Conditions (VAC)2. Infection-related ventilator-associated complications

(IVAC)3. Possible VAP*4. Probable VAP*

#3 and #4 later combined to become pVAP

2013 CDC Changes VAP to VAE

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Impact of VAE Report 2013Technology Improvement Story

• Newly introduced surveillance for VAE required the assistance of technology– Report was created and enabled the new

surveillance • Report simplified surveillance in a manner

that allowed IPs to be objective.• All pertinent factors were summarized in

report which lead to an overall efficient process for conducting surveillance.

• Initial surveillance showed unexpected FiO2 and PEEP fluctuations

• The technology prompted the analyses that improved patient care– Allow for process improvement

Multiple people were changing the vent settings

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Clinical Event

Performed Date

APRV Vent Mode

Peep Min

FiO2 Min

Temp Min

Temp Max

WBC Min

WBC Max

ABX-Vancomycin

ABX -All

Others

ABX-Cefepime

09/23/2013 5 0 98 102.3 77.7 77.7 vancomycin Mero-penem

ABX-All Other Cephalosporins Anti-fungal Anti-

influenza

Culture Order

Description

Micro Source

Organism Identified (Drawn Date)

Invasive Airway Type

Infection Control

Alert

Infection Control

Alert Response

Culture: Respiratory

w/Gram StainSputum MRSA Endotracheal

(Intubated)

2013 VAE Report Developed

• Not at zero VAPS / VAEs• Compliance rates high• Review new evidence in the literature• Documentation drift• Data drift in compliance report• New medications• Use of single ventilation orders was leading to fallouts • Ventilator order set use was low• Order sets (MPPs) not aligned with VAP Bundle• Each MPP had different content

2016 Start VAP Bundle Upgrade

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How Did We Implement?

People• VAP Bundle Workgroup created• Sponsored by HAI Steering Committee• Multi-disciplinary

Process• Weekly meetings• Clinical stakeholders consulted• Design sessions• Complex approval process• Testing and validation 36

How Did we Implement?

Process (continued)• Clinical Stakeholders testing sessions• Communication and education• Pilot at one ICU• System Go Live July 2017

Technology• Online research, meetings, training & education • Extensive data analysis

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VAP Bundle UpgradeUse of Data to Drive Decisions

• Identified all documentation elements and compared with evidence based research

• Wrote custom reports to pull documentation data

• Analyzed each response in terms of volume, clinical content and alignment with Bundle elements

• Presented data to clinical stakeholders

• Used data to drive decision making for future state

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Vent Check by Nurse PowerForm Usage Dec 2015

FacilityNumber of times the PowerForm was Signed

GH Greater Heights 1584HC Childrens 1594HH HERMANN 9044KM Katy 775MC Mem City 1180NE Northeast 845SE Southeast 1399SG Sugar Land 71SW Southwest 2304TR TIRR 30TW The Woodland 1283Grand Total 20,109

841 visits

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Data AnalysisPUD Prophylaxis Documentation

Meds for prevention of PUD being administered 18,266Meds for prevention of PUD not being administered due to contraindications 288Physician order 287Exclusion exists 575Patient on enteral feeding 577Grand Total 19,993

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Data AnalysisFree text responses

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Reason not Using Int. Compression Device # of times documented

Other: lymphedema 72Other: heparin gtt 65Other: pt receiving anti‐coagulant therapy 33Other: bath 25Other: pt oob 25Other: in chair 23Other: On heparin gtt 23Other: On Heparin 22Other: patient on heparin drip 22Other: up to chair 18Other: PVD 17Other: Heparin drip 16Other: on heparin drip 16Other: pt up in chair 16Other: angiomax gtt 15Other: DVT 15Other: pt recieving anti‐coagulant therapy 15Other: Up in chair 15Other: HEPARIN 14Other: chair 13Other: IVC filter 13Other: pt up to chair 13Other: Comfort measures 11Other: disease process 11Other: pt recieivng anti‐coagulant therapy 10Other: Betty said not to 1

Other: Betty said not to

When Different Technologies Collide…

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VAP Bundle

VTE AdvisorWhat is it?

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VTE Advisor• Cerner Clinical Decision Support tool• Used only by providers• Not viewed by nursing or RT• Helps assess individual risk of adult VTE• Includes orders for VTE prophylaxis

VAP Bundle vs the VTE Advisor• Memorial Hermann designed tool• Includes orders for DVT prophylaxis• Different terminology• Some overlapping content• Some different indications and contraindications

VTE Advisor

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Pharmacologic ProphylaxisDifferent Exception Reasons

• Active Bleeding• Coagulopathy (non-therapeutic)• History of HIT• Spinal tap within next 24 hours• Epidural catheter in next 24 hours• Active hepatitis or hepatic

insufficiency• Infective endocarditis• Thrombocytopenia• Uncontrolled Hypertension

• Abnormal Clotting Times• Bleeding Disorder• Epidural catheter in place• HIT• Hypersensitivity to UHG or LMWH• INR > 2• IVC Filter• Major Surgery past 3 months • PTT > 60• Pt currently on thrombolytic meds• Pt on SCDS only per MD Order• Pregnancy• Severe Renal Failure• Reason for Non-Compliance: 45

VTE Advisor VAP Nursing Documentation

Jan 2017 TheraDoc Infection Control

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Highlights from the Upgrade

• Increased accuracy of compliance data

• Order sets updated and integrated with VAP Bundle

• Increased order set use

• Automated communication from provider to nurse

• VAP Bundle integrated with VTE Advisor

July 2017 Upgrade Implemented

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• Increased documentation efficiency- 69% reduction in clicks for prophylaxis nursing form- Reduced from 1,327,194 clicks/month to 422, 289

• Automated display of medication orders

• Automated display of medication administration

• Zero reported fallouts in CHG mouthwash orders

July 2017 Upgrade Implemented

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VAP Bundle UpgradeSmarter Documentation

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Data FlowFrom Physician to Nurse

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Ventilation Order SetsIncreased Utilization

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0

100

200

300

400

500

600

700

800

900

May-17 Jun-17 Jul-17 Aug-17 Sep-17

Number of Times Adult Ventilation Order Sets Used

Ventilator Add On MPP

Ventilator High Frequency MPP

Ventilator Initiation/Bundle OrdersMPP

Ventilator Non Invasive MPP

VAP Bundle Upgrade

VAP Bundle Compliance

Accurate data reveals opportunity to improve compliance

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VAP Bundle Phase 2

Optimization continues:

• Use data to determine whether to keep SUD prophylaxis

• Add Tidal Volume data to daily report

• Create interactive compliance dashboard using Tableau

• Implement TheraDoc VAE Surveillance 53

Our JourneyResults from a Decade of VAP Bundle Partnership

Maintaining Our VAP Rate

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High Reliability!

5623 Certified Zero Awards for VAP

Financial ImpactVAP Bundle

If we had done nothing

Hospital expansion = more vent days1,200 extra VAP infections @ $40,144 per infection

Estimated lives saved = 100+VAP Bundle projected cost avoidance =

$48,172, 800

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Lessons Learned

• Governance structure• Multidisciplinary, multi-level groups• Scheduled reviews• Clinical champions• Data Validation

- always examine and understand your data

• Automation can decrease infections• Partnership is the building block of change

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VAP Bundle

Infection Control

Quality

Respiratory Therapy

Nursing

Physicians

Medical Informatics

Key Partnerships

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v

PharmNet(Meds)

Campus Support

System Pharmacy

Support Center

Application Teams

System Leaders

ISD Technical

Teams

HPUX (ops jobs)

Cerner Technical

Teams

Clinical Informatics

(NYCU)

CCL ReportTeam

PathNetTeam

RadNetTeamHealthQuest

(ADT)

Net AdminDesktop

Moral of our VAP Story…

…the price of excellence

is eternal vigilance

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THANK YOU!