quality and safety in action at beth israel deaconess

Harvard Medical School

Quality and Safety In Action At

Beth Israel Deaconess Medical Center

Presentation to Region Sjaelland Leadership

March 8, 2011


Beth Israel Deaconess Medical Center Statistical Profile (FY09)

Annual Inpatient Discharges:

Medicine 14,600

Surgery 9,800

Cardiovascular 5,400

Obstetrics/Newborn 10,800

Psychiatry 800

41,400

Average Daily Inpatient Census: 523 Patients

Observation Patients 8,200

Outpatient Clinic Visits 532,000

Emergency Department Visits 53,000

Full-Time Equivalent Employees

(Excluding Research)

6,100


Boston: A Highly Competitive Market for Patient Care

% Patients Giving Top Rating

Aong: all respondents

57

6262

45

60

5961

47

57

2007 2009

% In

To

p B

ox


BIDMC: A Turnaround Story:

Consolidated Operating Margin FY99- FY10

($70)($60)($50)($40)($30)($20)($10)

$0$10$20$30$40$50$60

Mil

lio

ns

FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY08 FY10Proj

FY07 FY09


Boston Academic Medical CentersMedical/Surgical Discharges

Percentage Growth, FY06 – FY09

%

7.77.0

4.0

2.5

1.1

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

BIDMC BMC BWH TOTAL MGH


Boston Academic Medical CentersEmergency Department Visits

Percentage Growth, FY06 – FY09

%

13.7

5.6

2.1

(0.9)

(3.5)(6.0)

(4.0)

(2.0)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

MGH BIDMC TOTAL BWH BMC


Recent Awards

• Thompson Top 100 Hospitals (several years running – only hospital in Massachusetts)

• Premier Award for Quality(Awarded to 23 hospitals out of ~3800 eligible)

• AHA-Mckesson Quest for Quality Award(3 hospitals received this National recognition)

• Leapfrog Top Hospital (Awarded to 45 hospitals nationally)


We adopt the IOM Framework for Care

• Safe: no injuries from the care

• Timely: reduce waits and delays

• Effective: services based on scientific knowledge

• Patient Centered: care that is responsive to the individual

• Efficient: avoiding waste

• Equitable: quality does not vary because of personal characteristics

-Institute of Medicine, 2001

CROSSING THE QUALITY CHASMCROSSING THE

QUALITY CHASM


We Pay Attention to External Masters:

• Joint Commission: 501c3 with delegated authority from CMS:– Mission predominantly around quality of care and the

environment of care for patients

– Unannounced survey at least every 3 years.

• CMS/Other Payers:– Interested in clinical performance Standards

– Has developed required metrics, “pay for performance.”

• Department of Public Health: Regulator

• Board of Registration in Medicine: Regulator of Clinical Practice. Massachusetts code requires the PCAC


• National Quality Measures Clearinghouse™ (NQMC) - specific measurement initiatives:

• Ambulatory Care Quality Alliance

• Home Health Compare

• Hospital Compare

• Hospital Quality Alliance

• National Healthcare Disparities Report (NHDR)

• National Healthcare Quality Report (NHQR)

• Nursing Home Compare

• Physician Quality Reporting Initiative

–Health Care Quality and Cost Information

–www.mass.gov/healthcareqc

External Measure SourcesSome Examples:

http://www.ahrq.gov/

http://www.qualitymeasures.ahrq.gov/

http://www.jointcommission.org/

http://www.cms.hhs.gov/


Trends Among Regulators in the United States

• Increasing “Pay for Performance:” Incentives linked to quality metrics

• Increased public reporting– Adverse Events– Trended performance.

• Unlawful to seek reimbursement for costs associated with an adverse event

• Mandated disclosure and apology• Mandated patient involvement


Board Participates Directly in Quality and Safety

Board of Directors

FinancePatient Care Assessment

and Quality (PCAC)Audit

Chiefs/ Medical ExecutiveCommittee

Board hears clinical performance as well as

adverse events, analysis, andCorrective actions

Medical StaffGovernance Reports

to the Board

Board Chair, CEO, several chiefs, several

Board Members participate

QI Directors

Dept Dept

Dept


Annual Cycle for Quality and Safety, Coordinated with Budget Cycle

February: Full assessment of Quality and Safety.

April: Present follow-up detail on requested areas of potential focus for Quality and Safety.

June: Approve statement of priorities for quality and safety.

October: Review and Comment on quality/safety aspects of BIDMC Annual Operating Plan.

December: Present other items PCAC elects to review annually


Quality Goals Manifest in Annual Operating Plan


Quality and SafetyPriority Determination

Priority Analysis:Performance onTrended Data

Priority Analysis:Internal Analysis of

Adverse Events

Priority Analysis:Regulatory Mandate or

Recommended Best Practice

Readmission Rate

SSI Reduction

Handoff ProcessesPatient/Family

Triggers

H1N1

Ambulatory RiskManagement

Physician PerformanceEvaluation

Internal Auditing ofRegulatory Readiness

Cognitive Error Prevention

Criteria-Based Goal-Setting


Attention to Data, Publicly Share

– Try to measure the truth (documentation ≠ practice!)

– Collect data in a way that is believable to your ICU staff.

– Understand the story it’s trying to tell you, and help others see it too

• Data information knowledge ??wisdom

– Get data to the people who do the work. They NEED it.

• At the point of care

• Very rapidly (quarterly feedback is nearly irrelevant to sustainable change)

• Transparency of performance with patients and families (?)


Transparency


20

Q1 Q2 Q3 Q4

Favorable Comparison

Unfavorable Comparison

AIMFY10

TargetCHANGE Q3 09 Q4 09 Q1 10 Q2 10 Q3 10

MEDICAL MANAGEMENT RELATED

Death Related to Medical Management ▼ 0 0 0 0 0 0

Disease Progression or End Organ Injury (reversible or

permanent) Related to Medical Management▼ 0 0 1 0 0 1

Cardiac and/or Respiratory Failure or Arrest Related to

Medical Management▼ 0 2 2 0 0 1

INFECTION RELATED

Nosocomial Catheter Associated Bloodstream Infections ▼ 0 2 2 2 2 3

Nosocomial Surgical Site Infections (SSIs) ▼ 0 17 17 18 19 16

Nosocomial C. Difficile Infections ▼ 0 0 0 0 0 0

Ventilator Associated Pneumonia ▼ 0 4 2 2 2 2

Other Nosocomial Infection ▼ 0 2 1 0 6 0

CARE RELATED

Falls Resulting in Injury ▼ 0 3 2 2 1 0

Soft Tissue Injuries (Includes Pressure Sores) ▼ 0 0 1 1 2 0

Medication Related Adverse Events ▼ 0 1 0 0 0 1

Procedure Related Harm/Complication (Non Infectious)-

Surgical Services▼ 0 1 2 1 2 1

Procedure Related Harm/Complication (Non Infectious)-

Non-Surgical Services▼ 0 1 0 0 0 1

Obstetrical Harm/Complication (Non Infectious) ▼ 0 1 0 0 0 0

Neonatal Harm/Complication (Non Infectious) ▼ 0 0 0 0 0 0

Other ▼ 0 0 0 1 0 0

TOTAL ▼ 0 34 30 27 34 26

PREVENTABLE HARM

PCAC S C O R E C A R D


21

Using the Metrics to Facilitate Change

• Most ‘Vulnerable’ Metrics have real time feedback processes supported by HCQ

– Real Time Feedback or Prompting Examples:

• AMI (Emergency Department/Cath Lab) – Door to Balloon

• PN (Emergency Department) – Blood Culture /Antibiotic Timing

• HF (Medicine/Cardiology -- ACE-I/ARB Use in LVSD)

• Noted improvement in performance and constructive feedback/input re: process


22

Using the Metrics to Facilitate Change

• HCQ Meets Monthly with Program/Metric Clinical Leaders

• Review the performance data

• Provide Feedback in a meaningful way

• Acknowledge outliers and comments from clinicians

• Establish plans for improvement in • Process/Workflow

• Infrastructure/Technology

• Behavior/Education


23

Example of Applying Multiple PI Models/Principles

• Combined principles of TeamSTEPPS, Evidence Based strategies of care, PDSA and available technologies – Strengthen an interdepartmental alliance, coordination of care and

communication between • Emergency Department, • Interventional Cardiology and • Health Care Quality

• Designed – standard protocols to support expected time frames for assessment; – efficient and safe “One Call Activation of CathLab” and – effective real time feedback loop processes– Monthly Team Meeting reviews process segments and outliers. Focus on

process/system analysis ‘to root’

• Achieved 100% STEMI D2B times <90 minutes

for the past 100+ cases (2 ½ years) – Standard Work– Predictable/Consistent Processes


24

FY07

Door To Balloon

FY10 To Date

Door To Balloon


25


Celebrate “Call Outs” Publicly and With Leadership

We Continue to Recognize and Reward


Annual Symposium

March 23, 2010

8:00 – 9:30 am

The Climate and Expectations of Health ReformSherman Auditorium – East Campus

A panel discussion featuring:

• Glenn Steele, MD, President and CEO of Geisinger Health System

• Paul Guzzi, President and Chief Executive Officer, Greater Boston Chamber of Commerce

• H Gene Lindsey, MD, President and CEO, Atrius Health

• Roberta Herman, MD, Chief Operating Officer and Chief Medical Officer, Harvard Pilgrim Health Care

Moderated by Paul Levy, President and CEO Beth Israel Deaconess Medical Center

10:00 am – 12:30pm

2010 Poster Session – Celebrating Improvement at BIDMC

Carl J. Shapiro Clinical Center Atrium Lobby – East CampusThis poster session features the work of nearly 100 Process Improvement Teams from across the medical center, and offers

everyone the opportunity to share experiences and learn about efforts to improve Quality and Safety at BIDMC.

Sustaining Process Improvements Measuring SuccessCelebrating/Sharing Stories


28

Progress toward eliminating preventable harm -Hand hygiene trends


Consistent Progress: Bloodstream InfectionRate per 1000 patient days

4.14 4.05

2.91

1.551.30

0.700.52

0.0

1.0

2.0

3.0

4.0

5.0

FY03 FY04 FY05 FY06 FY07 FY08 FY09

Rate

per

1000 P

ati

en

t D

ays

F Y M ean

87% reduction


50%

60%

70%

80%

90%

100%

Ventilator Bundle Performance

Initial unit champion-based work

VAP-focused clinical nurse specialist begins

New Critical Care Electronic Medical Record implented (changing documentation practice)

Goal (initial)

Goal (current)

Goal (2nd)


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

2004 2005 2006 2007 2008 2009 2010

No

n-D

NR

, N

on-I

CU D

eath

s p

er

1,0

00 D

isch

arge

sNon-DNR, Non-ICU Deaths per 1,000 Discharges

Triggers period

Benchmark = 1.06 (intervention arm of largest RCT – Lancet 2005)Benchmark = 1.06 (intervention arm of largest RCT – Lancet 2005)


Consistent Progress: Ventilator Pneumonia

0

10

20

30

40

50

60

FY06 Q2*

FY06 Q3

FY07 Q2*

FY07 Q3

FY08 Q2*

FY08 Q3

FY08 Q4*

FY09 Q2*

FY09 Q3

FY09 Q4*

VA

P C

ase

s P

er

1,0

00 V

en

tila

tor

Da

ys

* only two months of quarter assessed


Percent of Admitted Patients Experiencing an Adverse Event

22.5

16.9

14.2

11.5

0

5

10

15

20

25

2006 baseline 2008 2009 2010 Jan-early

June

Note: Lower value is better

Pe

rce

nt

of

Ad

mit

ted

Pa

tie

nts

Ex

pe

rie

nc

ing

an

Ad

ve

rse

Ev

en

t


Ventilator Bundle Compliance

50%

60%

70%

80%

90%

100%

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ma

y-0

6

Ju

n-0

6

Ju

l-0

6

Au

g-0

6

Se

p-0

6

Oct-

06

No

v-0

6

De

c-0

6

Ja

n-0

7

Fe

b-0

7

Ma

r-0

7

Ap

r-0

7

Ma

y-0

7

Ju

n-0

7Ven

t B

un

dle

Co

mp

lian

ce

Be

tte

r

VAP Cases(Three-ICU Sample)

0

5

10

15

20

25

30

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ma

y-0

6

Jun

-06

Ju

l-0

6

Au

g-0

6

Se

p-0

6

Oct-

06

No

v-0

6

De

c-0

6

Jan

-07

Fe

b-0

7

Ma

r-0

7

Ap

r-0

7

Ma

y-0

7

Jun

-07

Be

tter

No

data

Ventilator Days(Three-ICU Sample)

200

250

300

350

400

450

500

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

May-0

6

Jun-0

6

Jul-

06

Au

g-0

6

Se

p-0

6

Oct-

06

Nov-0

6

De

c-06

Jan-0

7

Fe

b-0

7

Ma

r-0

7

Ap

r-0

7

May-0

7

Jun-0

7

Be

tter

Number of ICU Patients(ICU Throughput)

300

350

400

450

500

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ma

y-0

6

Jun

-06

Ju

l-0

6

Au

g-0

6

Se

p-0

6

Oct-

06

No

v-0

6

De

c-0

6

Jan

-07

Fe

b-0

7

Ma

r-0

7

Ap

r-0

7

Ma

y-0

7

Jun

-07

Be

tte

r

Long-Stay ICU Patients(% of patients with ICU LOS > 10 days)

0%

2%

4%

6%

8%

10%

12%

Feb-0

6

Mar-

06

Apr-

06

May-0

6

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct-

06

Nov-0

6

Dec-0

6

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-0

7

Jun-0

7

Be

tter


1

2

3

4

5

2005 2006 2007 2008 2009

Fiscal Year

-

1,000

2,000

3,000

4,000

5,000

6,000

2005 2006 2007 2008 2009

Fiscal Year

5%

7%

9%

11%

13%

15%

2005 2006 2007 2008 2009

Fiscal Year

ICU Length of Stay

(Days)

ICU Throughput(Patients)

In-Hospital Mortality

(%)

1,429 discharges per year (33%)

ICU LOS by 1.0 days (22%)

Mortality by 2.5% (21%)

For every 40 ICU patients, one fewer death.


Accountability/Visible Goal Setting:2007 Board Retreat, Devoted to Quality

and Safety• Activities:

– Board members shadowed HCWs

– Panel discussion involving patients with a range of experiences.

– Didactic session on role of governance in quality

– Breakout sessions on institutional goal setting

• Results: Confirmation of a deep commitment to quality, safety, aggressive goal setting, and transparency of approach


1. Intellectual honesty

– No cherry-picking of measures

– No negotiating: Show the good and the bad

2. Salience to patients/employees

– Clinical areas where patients make or influence the choice of provider

– Topics that align to internal priorities for employees

– Measures that can be understandable, relevant, and useful to patients and employees


3. Strategic value to BIDMC

– Clinical areas identified as important to BIDMC’s future, aligned with values and goals

– Areas that draw attention to competitive strengths, new capabilities

4. Timeliness

– Data that are as up-to-date as feasible.


5. Credibility with medical staff– Endorsed by National Quality Forum; recommended by

national organizations (e.g., JCAHO, CMS, AHRQ)

– Statistically valid and reliable

– Substantive (i.e., linked to patient’s outcome or safety)

– Inclusive (i.e., affects large proportion of patients)

6. Interpretable information – Data and benchmarks available (whether national, regional,

or local)

– Whenever possible, provide a visual way to easily evaluate performance as good or bad


Engagement Continues

• Leaders Huddle in Real Time

• Governance, Leaders participate in “Go and See”

quality and safety in action at beth israel deaconess

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