increasing verified hand hygiene compliance to 92% system ......•all 12 mhhs hospitals:...

Hospital Association of

San Diego and Imperial

Counties

Anne-Claire France, PhD

August 15, 2013

Increasing Verified Hand Hygiene

Compliance to 92% System-Wide:

The Memorial Hermann Health

System Experience

Memorial Hermann Health System

Woodlands Sugar Land TMC Katy Memorial City Southeast

Northwest Northeast TIRR PaRC Children’s Southwest 2

• Total Hospitals: 12 (9 Acute, 2 Rehab, 1 Children’s) • Ambulatory Surgery Centers: 18 • Heart & Vascular Institutes: 3 • Imaging Centers: 21 • Breast Care Centers: 9 • Sports Medicine & Rehab Centers: 32 • Diagnostic Laboratories: 21 • Retirement/Nursing Center: 1 • Home Health Branches: 3 • Cancer Centers: 7

• Adjusted Admissions: 256,175

• Annual Emergency Visits: 450,010

• Annual Deliveries: 23,111

• Employees: 20,241

• Beds (acute licensed): 3,147

• Medical Staff Members: 5,790

• Physicians in Training: 1,694

• Annual Labor Cost: $1.191 billion

Transfusion Errors

Serious Safety Events

August 14, 2006

A Call to Action

on Patient Safety

Journey to Cultural Transformation

• 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

MHHS Safety Culture Training 2007-2008

Hospital Training Complete

>1,000 Physicians Trained

>15,000 Employees Trained

>540 Safety Coaches Trained

>$18M Expense

Leaders: Reinforce Awareness

• Build Accountability

• Find and fix problems

• Convert statistics to

“real people”

• Publicly recognize

physicians/employees

for excellence

• 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

Camp Rules

1. Lights out at 10 PM

2. No food in the cabins

3. Safety first

4. No cohabitation

System-Wide Strategies

Quality

& Safety

Lead healthcare to superior patient outcomes through

creation of a high reliability culture with evidence-

based quality and patient safety as our core value.

Patients Create strong customer loyalty by providing

exceptional experiences for all patients.

Physicians Build sustainable, trusting & collaborative relationships to

advance our respective quality and economic objectives.

People Recruit, develop, & retain top performing employees.

Operational

Excellence

Achieve targeted financial operating performance. Optimize the

efficiency and value of services provided and focus on

operational improvement opportunities in preparation for a new

business model.

Growth

Strategically grow services to capture current revenue

opportunities. Simultaneously, begin implementation of an

accountable and integrated care delivery system in partnership

with our physicians.

Hemolytic Transfusion Reactions

Hospital Acquired Conditions “Never Events”

Transfusion Events Jan 2007 – Dec 2012

1,425,000 Adjusted Admissions

7,762,000 Adjusted Pt Days

763,000 Transfusions

Hemolytic Transfusion Reactions

Hospital Acquired Conditions “Never Events”

Transfusion Events Jan 2007 – Dec 2012

1,425,000 Adjusted Admissions

7,762,000 Adjusted Pt Days

763,000 Transfusions

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

Hospital Acquired Infections, Conditions and Patient Safety Indicators

Birth Traumas

Serious Safety Events 15

Hospital Acquired Infection Journey to Zero

• 2007: Implemented Manually Documented

HAI Bundles

• 2008: Rolled Out Electronically

Documented HAI Bundles

• 2009: Automated HAI Bundles Data

• 2007-2009: Ventilator Associated

Pneumonia UCL 6.86 to 3.12

16 Still NOT Zero!

opyright, T

Expectations Vs. Reality

Methodology Development 2008-10: Four Sites

• MH The Woodlands: Methodology

Development

• MH Northeast: Methodology Pilot

• MH TMC Heart and Vascular Institute:

Methodology Pilot

• MH Northwest: Targeted Solutions Tool

Goals for FY2011

July 2010 – June 2011

• All 12 MHHS hospitals:

– Implement the hand hygiene methodology via

the Targeted Solutions Tool

– Implement in “rounds” so that all clinical care

areas are live with the TST and

• Accomplish reliable baseline compliance rates

• Obtain contributing factors for non-compliance

• Continue collecting compliance data and provide

feedback to staff

Goals for FY2012

July 2011 – June 2012

• Utilize contributing factors data to

implement targeted solutions for

improvement

• Increase compliance by at least 30

additional percentage points from house

wide baseline or reach 90%

Hand Hygiene Methodology Process

• Identify units

• Train secret observers

• Collect baseline data

• Identify contributing factors via JIT

coaching/continue to collect data

---------------------------------------------------------

• Implement solutions

• Sustain the gains 23

FY2011

FY2012

FY11 Do No Harm Performance Goals

• Identify units to participate

• Identify Process Owners for units

• Identify Secret Observers

• Train/test Secret Observers

• Gather Baseline Data

• Lock-in Baseline Compliance Rate

• Identify Just in Time Coaches

• Train Just in Time Coaches

• Collect data indicating contributing factors

• Continue to collect compliance data

• Lock in contributing factors

• Continue to collect compliance data

Sites rolled out in

up to three

“rounds” of units.

Monthly Goal Examples

• Nov 2010: Round one secret observers accomplish

baseline data collection

• After baseline data collection completed, secret

observers begin collecting on-going compliance data

(reduce by 50%)

• Jan 2011: For units with “locked in” baseline

compliance, continue to collect on-going compliance

• Train Round TWO secret observers

• Identify Round THREE units

• Feb 2011: Round TWO secret observers collect baseline

• Round ONE JIT coaches COMPLETE data collection on

contributing factors for non-compliance

FY12 Do No Harm Performance Goals

• Identify contributing factors for non-

compliance by unit via Pareto on TST

• Identify solutions from menu on TST per

• Submit solutions to System QPS

• Implement solutions by unit

• Submit monthly house-wide compliance

• Increase compliance by 30 percentage

points above baseline or reach 90% 26

Keys to Success

• Awareness Before Go-Live

• TST Steps Converted to Gantt Chart

• Facility and Unit Process Owners

• Bi-weekly Teleconferences

• Frequent Site Visiting

• Monthly “Nag-omatic” Assessments to

Meet Performance Standards

Hand Hygiene Myth Busters

• Myth 1: During baseline data collection each secret

observer collects at least 20 observations per day.

– Truth: 20 observations is a total for all observers per

unit. Baseline collection can occur during any

fourteen 24 hour periods.

• Myth 2: Access to web portal is limited.

– Truth: Based on the needs identified by the Process

Owner, designees can be given access to hand

hygiene (TST) only.

• Myth 3 – Must divy up hospital into 3 equal rounds.

– Truth: Sites free to customize to achieve house wide

reliable data by July 1, 2011. 29

Targeted Solutions Tool

Count: Diet-41, HSK-30, Lab-39, MD-130, NA-107, Other-94, PT-11,

RN-391, RT-123

Oct 2010 N = 966 20 Projects/Units 52%

FY2011 Journey

Count: Case Mgmt-17, Diet-148, HSK-137, Lab-103, MD-876, NA-779,

Other-483, Pharm-5, PT-170, RN-3258, RT-356

June 2011 N = 6332 150 Projects/Units 75%

FY2011 Journey

House wide Baselines: 150 Units

• Katy 36%

• Katy-R 61%

• MC 50%

• NE 65%

• NW 40%

• SE 23%

• SGL 53%

• SW/HVI 51%

• TIRR 32%

• TMC/CMHH 51%

• WDL 27%

• System 44%

Contributing Factors

• 14,543 data points

• Top Contributing Factors to

non-compliance (81%)

– Inappropriate use of gloves

– Frequent entry and exit

– Hands full of supplies

– Distracted

– Following a person entry and exit

– Dispenser location

Count: Case Mgmt-64, Diet-367, HSK-302, Lab-247, MD-1495,NA-

1490, Other-865, Pharm-26, PT-282, RN-5769, RT-579

June 2012 N = 11486 150 Projects/Units 89%

FY2012 Journey

Count: Case Mgmt-70, Diet 442 HSK-234, Lab-163, MD-1353,NA-

1612, Other-688, Pharm-28, PT-299, RAD – 194 RN-5321, RT-558

Dec 2012 N = 10962 150 Projects/Units 92%

FY2013 Journey

Expanding to Outpatient

July 2011 TST Go Live

• Ambulatory Sports Medicine and Rehab (30)

• Outpatient Imaging (21)

• Diagnostics Labs (50) grouped by hospital

• Baseline 65.2% (July 2011 – April 2012)

– Rolled out by region

– Goal is 30 observations per month for each site

• Challenge to define “entry” vs “exit”

• Learned where sanitizers needed and the need

for cleaning patient equipment

• Data Collected > 30,000 observations

Count: MD-34, Other-1 Pharm 1, PT-779, RAD-434, RN-33

Dec 2012 N = 1282 58 Projects/Units 92%

January – July 2013 90+%

FY2013 Journey

The Power of Robust Process Improvement

• Method and measurement leads to

performance

– Reliable baseline data collection

– Targeted solutions implemented

– Spread to outpatient

– 330,000+ observations assessing

compliance

– December 2012 compliance = 92%

– January 2013 – July 2013 = 90+%

Stories Reflect Culture Change

• A secret observer was a patient for an outpatient

procedure. She collected data during her stay.

Of 18 opportunities, the staff posted 95%

compliance.

• A family member commented to a nurse how

impressed she was with the level of hand

washing.

• A dietary staff member was heard reminding a

clinical staff member to wash.

• A family member washed his hands as a

reminder to the physician to do so. 41

TJC Hand Hygiene Compliance Center for Transforming Healthcare

Baseline

Compliance

Secret Observations Compliance Rate

Adult ICU Central Line Associated Blood Stream Infections (CLABSI)

System Adult ICU CLABSIDo No Harm

Central Line Associated Blood Stream Infections

Source file date: 3/23/2012Generated: 4/2/2012 7:45:37 AM Reporting Months

produced by System Quality and Patient Safety

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

February CLABSI rates not available due to ISD technical difficulties

2006 2007 2008 2009 2010 2011 2012

NICU Central Line Associated Blood Stream Infections (CLABSI)

Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

UCL = 19.19

Mean = 11.96

LCL = 4.74

UCL = 8.62

Mean = 3.45

UCL = 4.44

Mean = 1.62

2006 2007 2008 2009 2010 2011 2012

Adult & Pedi ICU Ventilator Associated Pneumonias (VAP)

System Adult VAPDo No Harm

Ventilator Associated Pneumonia

UCL = 4.30

Mean = 2.19

LCL = 0.07

UCL = 3.12

Mean = 1.37

UCL = 2.47

Mean = 0.72

2006 2007 2008 2009 2010 2011 2012

Advantages/Limitation

• Participation in methodology development

• Participation in pilot of methodology and

• Leadership Commitment for 2 year

timeline

• Dedicated MBB

• Clear association with HAI improvement

• Measures Moments 1 and 5 Only

High Reliability Certified Zero Award

1. Zero Events

2. 12 Consecutive Months

3. Certified Zero Category

ICU Central Line Associated Bloodstream Infections (10)

Hospital-Wide Central Line Associated Bloodstream Infections (2)

Ventilator Associated Pneumonias (22)

Retained Foreign Bodies (19)

Iatrogenic Pneumothorax (12)

Accidental Punctures and Lacerations (2)

Pressure Ulcers Stages III & IV (16)

Hospital Associated Injuries (5)

Birth Traumas (8)

Serious Safety Events (1)

High Reliability 2011-13 Certified Zero Awards

“You must be the change

you want to see in the world”

Mahatma Gandhi (1869-1948)

Thank you!

increasing verified hand hygiene compliance to 92% system ......•all 12 mhhs hospitals:...

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