High Reliability as a Foundation for Leading

Through Disasters

South Carolina Hospital Association

Transforming Health Symposium

Columbia, SC

April 10, 2018

Angela A. Shippy, MD

SVP & Chief Quality Officer

This presenter has

nothing to disclose.

2

Who Are We?!

Memorial Hermann Health System

3

MH Health System

$6.6B Total Assets

25,000 Employees

16 Hospitals

227 Locations

24.5% Inpatient Market Share

MHMD Physician Network

2,000 ACO Physicians

400 Patient-Centered Medical Home Physicians

>650 total PCPs

Additional 800 Specialty Physicians from University of Texas Medical School (UT Health)

Memorial Hermann Health System

3300+

4

FINAL

Evolution of Quality and Patient

Safety at MHHS

5

The Beginning

6

Burning Platform

7 7

Board Commitment

8

9

A Culture of Safety

10

=

What we do every day

What we do every day =

CULTURE!

Robust Process Improvement

Journey to High Reliability

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Exceptional Outcomes Healthcare That Is Safe – Zero Events of Harm

Timely, Effective, Efficient, Equitable & Patient Centered

Reliability Science Knowledge and understanding of human error and

human performance in complex systems

Healing Without Harm Don’t Hurt Me, Heal Me, & Respect Me Will

Reliability Culture

© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Behaviors of Individuals & Groups

Design of

Culture Behaviors for

Error Prevention, Red Rules, CRM

Design of

Structure

Design of

Technology & Environment

Electronic medical record, barcode technology,

smart pumps

Design of

Policies & Protocols

Focus & Simplify

Design of

Work Processes Lean, Six Sigma

Means

Execution

Leadership Reinforce & Build Accountability

for performance expectations and Find & Fix system problems

12

Three Principles of Anticipation: Stay Out of Trouble Preoccupation with Failure Operating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion

Sensitivity to Operations Paying attention to what’s happening on the front-line

Reluctance to Simplify Interpretations Taking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations

Two Principles of Containment: Get Out of Trouble Commitment to Resilience Developing capabilities to detect, contain, and bounce-back from events that do occur

Deference to Expertise Pushing decision making down and around to the person with the most related knowledge and expertise

High Reliability Five Principles

to Achieve Mindfulness

13

High Reliability 2011-2017 Certified Zero Awards

ICU Central Line Associated Bloodstream Infections (19)

ICU Catheter Associated Urinary Tract Infections (19)

Hospital-Wide Central Line Associated Bloodstream Infections (7)

Hospital-Wide Catheter Associated Urinary Tract Infections (5)

Ventilator Associated Pneumonias (23)

NHSN Hip Arthroplasty Surgical Site Infections (1)

NHSN All Surgical Site Infections

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 (12)

Manifestations of Poor Glycemic Control (21) 14

271

Implemented Certified Zero Awards for those hospitals that went 12 consecutive months without an adverse event.

Underlying Process

15

Performance Improvement, Quality & Safety Communication & Reporting Structure

Memorial Hermann Health System

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MHMD CPC Structure

Green Boxes: Program

Directors

Dark Blue Boxes: CPC Chairs

Light Blue Boxes: Taskforce

Chairs

Revised 5/10/2017

MHMD Clinical Programs

Governance Council Alexander/Gogola

Primary Care

Giglio Primary

Care CPC - Prihoda

Pediatrics CPC - Regan Allergy &

Immunology CPC - Peters

Ob/Gyn CPC - Heaps

Neonatology CPC –

Khan / Weisoly Behaviora

l Medicine CPC - Bauer

Diabetes JOC –

Orlander

Supportive Medicine CPC –

Gomez/Peyachu

Inpatient Hospital-Based Khan

Radiology CPC - Khan

Perioperative CPC - Zaafran

Pain Taskforce Taskforce-

Zaafran

Pathology CPC - Brown Pharmacy

&Therapeutics CPC -

Johnson/Baleva Blood

Management JOC – Brown/Felix

Hospital Medicine

Harbison

Hospitalist CPC - Harbison

Nephrology CPC -

Finkel Neurolog

y CPC - Majmundar

Stroke Taskforce

Taskforce- Kim

Neuro IP Taskforce

McCullough & Monday

Neuro OP Taskforce

Taskforce- Blum

Infectious Disease CPC - Johnson

GI CPC -

Flax Anesthesia/GI

Taskforce Taskforce-Khan

Heme/Onc CPC - Karni

PM&R/Transitions of Care

CPC – Francisco/Lock

hart

Fragility Fracture Pathway

TF Taskforce- Harvin & Munz

CV/CVS R.

Alexander

Cardiology CPC –

Arain/Rahman CV

Surgery CPC - Alexander

ECMO Taskforce

Taskforce- Eisenberg

Surgery Salcedo

Bariatrics CPC -

Wilson Food &

Nutrition Taskforce

Taskforce - Davis

Orthopedics CPC - Sabonghy Biologics

Taskforce Taskforce -

Sabonghy

ORL CPC - Citardi

Tracheostomy TF Taskforce-

Alava

Thyroid Nodule Taskforce-

Karni

Surgery/ Robotics CPC -

Cali ERAS

Taskforce Taskforce- Cali

Neurosurgery CPC -

Kim

Supply Chain

CPC - Wilson

Robotics CPC - Wilson

Critical Services

Patel

Critical Care CPC –

Doshi/Kelly

Sepsis Taskforce

Taskforce- Patel/Doshi

VTE Reduction

JOC - Coogan

Trauma CPC –

McNutt/Peterkin Emergen

cy Medicine CPC –

McCarthy/Svoboda

Clinical Complianc

e C.

Alexander

SMIC CPC –

Okafor/Weiss

AMIC CPC - Weiss

Acute Care Med

Informatics CPC - Okafor

Ethics/P.P.I. CPC -

Monday Value

Assess. & Clinical Effec.

TBD

MHPP McDonald

17

Performance Improvement, Quality & Safety Communication & Reporting Structure

Memorial Hermann Health System

18

19

8/19/2014 3/9/2015

Understand

Current State

& Define

Scope

Define CTQs

& CHG

Products

Draft

Instructions

& System

Procedure

Gain Pre-

Approval of

Draft

Procedure

Finalize

Link &

Script for

Video

Draft Children’s

Procedure &

Instructions

Finalize

Instructions,Video,

& Reminder

Process

Timeline for Standardizing CHG Process System-wide

Milestones:

1/14/2015

Film CHG Video

9/29/2014

Process Owner

Meeting 12/29/2014

Finalize Script

12/2/2014

Policy & Procedure

Council

1/8/2015

Care

Fusion

Reminder

System

10/21/2014

Work-Out #1

1/5/2015

Instructions

Submitted

for Proof

11/10/2014

Work-Out #2

1/13/2015

Children’s

Procedure

First System Steering

Committee Meeting

System CHG Procedure

Implemented

Monitor

Compliance

Facility Implementation & Education

Plans

2/2/2015

Inventory Obtained

Obtain

Inventory

Major SPD Project

Surgical Site Infection Update

Performance Improvement, Quality & Safety Communication & Reporting Structure

Memorial Hermann Health System

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VBP Safety Measures - System With Additional HAI SIRs

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Division Quality Committee We saved a tree!

27

Performance Improvement, Quality & Safety Communication & Reporting Structure

Memorial Hermann Health System

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Event Classification

Performance Improvement, Quality & Safety Communication & Reporting Structure

Memorial Hermann Health System

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Goals of Quality Care

Doing the right thing

At the right time

In the right way

To achieve the best possible results

Avoiding underuse

Avoiding overuse

Eliminating misuse

Saving

Lives

Do No Harm Clinical

Excellence

Execution in the above metrics equals evidence-based care

26

Be Prepared!

27

Always Ready: Highly Infectious Patient

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MHHS Readiness Timeline August 2014

August 1 Engaged in TDH and CDC calls

August 8-14 Communication of algorithm, guidelines, posts to Physician Link

August 13 Clinical leadership meeting with key tasks identified and assigned

August 13 First rule out patient at MHSL

August 14 MHHS Guideline Document (version 1) distributed across the organization

August 22 MHHS Ebola Conference Call

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September 19 Debrief of first Ebola rule out

October 7 Ambulatory Process Meeting

October 9 Mock drill at MHNE and MHSW

October 14 Finalization of High Level PPE selection

October 15 High Level PPE training began

October 16 High Level PPE Video filmed

October 17 Daily training calls began

October 15-30 High Level PPE training for high priority staff and physicians

MHHS Readiness Timeline September & October 2014

3

0

36

October 22 Communication of updated CDC guidance

October 23 Required 1MD:2RN ratio of high level PPE trained personnel for all ED shifts

October 24 Policy and Procedure - Management of Suspect/Confirmed Ebola Cases

Oct. 31 - Dec. 3 Full Scale Ebola Mock Drills – Operation Clean Room

Nov. 24 - Present Continuous Readiness Training Planning

Dec. 3 - Present Mock Drill After Action Reviews

MHHS Readiness Timeline October - December 2014 and beyond

31

Signage and Point of Entry Screening • Hospital Entry Signage • Screening Algorithm

Acute Care Setting

Have you recently traveled from West Africa -

either Guinea, Liberia, Sierra Leone, or Mali

within the past 21 days?

Have you been in close contact with a sick person

who traveled from West Africa within the past 21

days?

Please do the following:

1. Provide surgical mask to patient and have

them place over mouth and nose.

2. Call charge nurse to move patient to a private

room/negative pressure room as soon as

possible.

3. Call/Page Infection Control

Patient does not meet case definition for

Ebola. Proceed with routine triage questions.

NO

What brings you

to Memorial

Hermann today?

YES

NO

YES

RN/MD start triage process for Ebola symptoms -

Fever, headache, joint and muscle pain,

weakness, fatigue, lack of appetite, vomiting,

diarrhea, abdominal pain, or unexplained

bleeding

AND

32

Electronic Medical Record Screening and Alerts

• Triage Screening

• Interruptive Order Alert

• Email Alert Notification

33

High Level Personal Protective Equipment (PPE) Selection

Multiple configurations tested to ensure doffing capability without contamination (chocolate syrup and Glo Germ)

– Tyvek Suit (hooded and footed)

– Goggles vs. face shield

– Long rubber gloves vs. surgical gloves

– Multiple impervious gowns

– Shoe covers vs. boots

– Surgical mask with attached face shield vs. N95 mask

34

Functional Testing (Performed by MD and RNs)

– IV Insertion and Intubation

– Patient Care

MHHS Recommendations Patients and Contacts • Hospital Presentation

– Private room

– Contact & Airborne precautions

– High Level PPE providing full coverage and no exposed areas

– Commence per MHHS Guideline Document

• Ambulatory Presentation – Private room

– Contact & Droplet precautions

– High Level PPE

– Surgical mask for patients with pulmonary symptoms

– Promptly transport to hospital for further evaluation

35

PPE and Room Staging Procedure and Tools • Donning and Doffing

Procedure Checklists • Room Staging Diagram

36

High Level PPE Training

A team of 13 Infection Preventionists trained approximately 200 MH employees in 4 days including physicians, nurses, and staff from various

departments such as ED, L&D, Education, Operations Administration, Lab Services, and Environmental Services.

37

High Level PPE Training

• Covered Guidelines for Caring for Highly

Infectious Patients

• 2 Employees : 1 Infection Prevention Trainer

• Completed Full Donning and Doffing Process

• Focus on High Risk Doffing Steps

38 44

Teamwork

45

Operation Clean Room

40

Operation Clean Room Exercise Drill • Full-scale exercise developed to test MH processes and

procedures for caring for a highly infectious or “high risk” viral hemorrhagic fever (Ebola) patient.

• Exercise planning team was composed of numerous groups: – Quality, Patient Safety, and Infection Prevention

– Emergency Preparedness

– Emergency Department

– Risk Management

– Occupational Health and Safety

– Case Management

– External Communications & Media Relations

41

Operation Clean Room Objectives and Follow Up • Exercise planning team developed objectives and

expected outcomes for the exercises that are linked to the core capabilities necessary to ensure safe management of the highly infectious patient.

• Operation Clean Room objectives – Objective 1: Identify suspect patient and initiate response plan

– Objective 2: Demonstrate proper isolation practices

– Objective 3: Audit, validate, and/or correct Employee Safety hazard controls and preparedness measures

• After Action Reviews to determine areas for improvement and hospital’s created specific improvement plans

42

Continual Readiness Training Plan

• Infection Prevention and Emergency Preparedness are creating a framework and guidance for continuous readiness training to ensure safe management of highly infectious patients across the continuum of care and ensure staff safety for those caring for a highly infectious patient.

• Draft Plan currently includes the following areas: – Process Owners, Liaisons, and Stakeholder Responsibilities

– Facility Notification and Communication

– Core Team Assignments and Staff Planning

– High Level PPE Training and Competency

– Recordkeeping

– Patient Room Configuration and Risk Assessment

– Assessments, Exercises, and Drills

– Education and Training 43

I left you a message earlier this afternoon. My name is Deborah Cosimo and I am a program analyst with the Department of Health and Human

Services (HHS) in the Office of Inspector General (OIG). Our particular office is the Office of Evaluation and Inspections, which conducts national

evaluations, to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues.

My team is developing a study focusing on hospitals, and we are looking for hospitals that are willing to assist us in gaining a deeper knowledge of hospital processes and to inform the development of our hospital questionnaire and interview protocols for our actual study. I am contacting you to ask if Memorial Hermann Northeast would be willing to assist us. Hospitals that assist us in developing our protocols are not included in our final sample; information learned about hospitals assisting us is not included in our final report. We direct the knowledge gained

towards informing our data collection methods.

Our study is examining the extent to which hospitals have prepared to respond to emerging infectious disease threats and to describe the lessons

learned and challenges faced by hospitals as they prepare to respond to these threats. An example of our work regarding hospital preparedness can be found here: http://oig.hhs.gov/oei/reports/oei-06-13-00260.pdf.

To accomplish these goals, we are requesting that assisting hospitals conduct an emergency preparedness drill using an emerging infectious disease

scenario while we observe both the drill and subsequent debriefing. Each hospital will determine the kind and extent of its exercise, with the focus on

emerging infectious diseases. We will not be assessing, approving or disapproving the hospitals’ emergency preparedness plans or drills. We would like to attend and observe the exercise, learn from your expertise, and ask questions at the end of the debriefing. Additionally, your proximity to the airport

Would your hospital be willing to assist us in this way? If so, please contact me so that we can arrange a date and time for our visit and answer any questions or concerns that you may have. We also welcome any suggestions you may have about the study! Thank you. Regards, Deborah Cosimo S. Deborah Cosimo, PhD Senior Program Analyst Department of Health and Human Services Office of Inspector General 1100 Commerce Street, Room 437 Dallas, TX 75242-0493 (214) 767-6316 Deborah.Cosimo@oig.hhs.gov

Always Ready: Mass Casualty Event

45

Mass Casualty Event

52

Always Ready: The Eye of the Storm

47

Tropical Storm Allison June 2001

48 Steve Ueckert, Houston Chronicle, 6/9/2001

• Over 25” inches of rain in the Texas Medical Center

• Memorial Hermann-TMC flooded with 31 feet of water

• Over 500 patients evacuated in 36 hours

Lessons Learned •Get the generators up •Coordination of flood protection •Need a plan

54

Hurricane Rita September 2005

• 3rd Category 5 storm of the season

• 3 weeks after Hurricane Katrina

• 2nd largest evacuation in US history

• 107 deaths associated with the evacuation of Houston

Lessons Learned

• “Run from the water – hide from the wind”

• Evacuation by zip code

• Healthcare infrastructure is like dominoes

49

James Nielsen, Houston Chronicle, 2005

55

Hurricane Ike September 2008

• Category 2 winds, Category 4 surge

• Coordinated transfer of 110 patients from Memorial Hermann Southeast, located in an evacuation zone

Lessons Learned • “Hunker down, then evacuate”

• Hurricane teams worked

• Hurricane Preparedness Guide

50

Steve Ueckert, Houston Chronicle, 9/13/2008

56

57

Everything is Bigger in Texas!

52

Hurricane Harvey Aug/Sept 2017

53

Melissa Phillip, Houston Chronicle 8/28/2017

• Over 50 inches of rain over

the region

• Torrential downpours quickly

changed landscape

• Unlikely flooded areas

• Hospitals were islands for days

Lessons Learned • Tracking visitors

• Going virtual

59

Local Hospital Team - Evaluate Schedule

- Identify A/B Teams

- Address local Provider Needs

Deploy communication tools

(Slack, Text, Email, etc.)

- Start Personal planning

- Identify Cross Credentialed Providers

- Moonlighter/PRN contingencies

- Special Ops Contingency

- Teams Notified

- Disaster Schedule Built (NO FMDs as primary staff)

- Teams arrive in-house (hospital, Hotel)

- Schedule locked

- FMD on-site

- Plan for low census

- Down staff to allow rest

- Plan for ~72 hour schedule

- Plan for higher volume

- Schedule to increase staffing

- Identify/ Address local provider needs

- Back to normal Schedule

- Assess long term staffing changes

- Perform local Postmortem

Identification of Potential Disaster

1 Week

Imminent Threat

48 – 72 Hours

Active Threat

24 hours

Event

0-X hours

Immediate Post-Threat

+24 -72 hours

Return to Steady State Operations

TeamHealth National Service Center

- Secure Hotels

- Standby national relief resources (preference to EMR training)

- Scribe strategy?

- Project Staffing need during disaster and immediately post

- Finalize the “ask” from local teams

- Scribe use decision

- Have evacuation decisions made

- BID situation calls

- Commit to projected staffing needs

- Deploy high water transportation/Vehicle rental

- Continue BID calls

- Continuous assessment of local needs

- HR to plan provider rounds

- Deploy relief providers

- HR provider rounds

- Assess long term staffing changes

- Perform national postmortem

Hospital Based Physicians

Special Considerations

• Hemodialysis Patients

• Timing of A/B teams in protracted disaster

• Staff stressors

• Transport of Relief Teams

• Take support services outside of market

• State Government Support

60

“Strangers helping strangers and neighbors helping neighbors”

55

62

Be Prepared Emergency preparedness infrastructure and drill, drill, drill

Team up Include local, state and federal government in drills and plans

Contracted services EVS, FANS and hospital based MD groups can provide knowledge and resources

Awareness as mergers and acquisitions increase to consider impact on current resources

Lessons Learned

64

Resilience!

59