russ ricci, md - moderator, president emeritus, ehealth initiative; chairman, meditech advisory...
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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