the development, implementation, and results

The Development, Implementation, and Results

of Tenet Healthcare’s

Commitment to Quality Initiative

The Development, Implementation, and Results

of Tenet Healthcare’s

Commitment to Quality Initiative

Jennifer Daley, MDSenior Vice President—Clinical Quality

Chief Medical OfficerTenet Healthcare Corporation

Dallas, TX469-893-2988

CONFIDENTIAL – DO NOT DISTRIBUTE BEYOND ORIGINAL ADDRESSESCONFIDENTIAL – DO NOT DISTRIBUTE BEYOND ORIGINAL ADDRESSES

Tenet HealthCareTenet HealthCare

Created in 1996 as the merger of two for-profit hospital chains with subsequent acquisitions of over 40 hospitals

Currently 97 hospitals primarily across the southern tier states; within the year will be 70 hospitals

Typical Tenet hospital is a 150-200 bed community hospital offering secondary and tertiary services

Four academic health centers (USC, Creighton, Hahnemann, St. Louis University)

About 30% of the hospitals have some affiliated teaching programs

Created in 1996 as the merger of two for-profit hospital chains with subsequent acquisitions of over 40 hospitals

Currently 97 hospitals primarily across the southern tier states; within the year will be 70 hospitals

Typical Tenet hospital is a 150-200 bed community hospital offering secondary and tertiary services

Four academic health centers (USC, Creighton, Hahnemann, St. Louis University)

About 30% of the hospitals have some affiliated teaching programs


Among Tenet’s Challenges in Early 2003Among Tenet’s Challenges in Early 2003

What is the state of quality in Tenet Healthcare?

How can we improve it?

How can we improve it rapidly?

How can we incorporate quality, safety, and service into the culture of Tenet hospitals quickly?

How can we sustain improvements for the foreseeable future?

Can we afford to do it?

Can we afford not to do it?

What is the state of quality in Tenet Healthcare?

How can we improve it?

How can we improve it rapidly?

How can we incorporate quality, safety, and service into the culture of Tenet hospitals quickly?

How can we sustain improvements for the foreseeable future?

Can we afford to do it?

Can we afford not to do it?


What are the most critical areas to improve rapidly?

What are the most critical areas to improve rapidly?

Evidence based medicine

Patient safety

Physician excellence

Nursing excellence

Patient flow and capacity management

Clinical leadership

Clinical resource management and utilization review

Equity in access and pricing for the uninsured

Service excellence

Evidence based medicine

Patient safety

Physician excellence

Nursing excellence

Patient flow and capacity management

Clinical leadership

Clinical resource management and utilization review

Equity in access and pricing for the uninsured

Service excellence

The birth of the Commitment to Quality » “C2Q”


To Tenet Hospitals: CTQ can help you improve…To Tenet Hospitals: CTQ can help you improve…

“Convince me that this is really important…..”

― Subtext: “Show me that improving quality and safety brings me more revenue…”

• “Don’t impose this on us from the top down….”

― Subtext: “Corporate initiatives are DOA…”

– Subtext: “Give us some choice in what we do….”

• “How can we do this with all the other things you expect us to do?”

― Subtext: “We don’t really know how to do this. Send help!”

“Convince me that this is really important…..”

― Subtext: “Show me that improving quality and safety brings me more revenue…”

• “Don’t impose this on us from the top down….”

― Subtext: “Corporate initiatives are DOA…”

– Subtext: “Give us some choice in what we do….”

• “How can we do this with all the other things you expect us to do?”

― Subtext: “We don’t really know how to do this. Send help!”


C2Q Implementation Vehicle: Transformation TeamsC2Q Implementation Vehicle: Transformation Teams

In-depth (300 page) self assessment of over 200 metrics associated with each major transformation initiative (1 month)

On-site (five days a week/12 hours a day for eight weeks;) team of content experts in areas identified for improvement alongside hospital leadership and staff

10,000 mile checks to achieve ongoing improvement and sustainability

Thirty two hospitals will have completed TT (Phase I) by end of 2004; all 70 retained hospitals by the end of 2005

In-depth (300 page) self assessment of over 200 metrics associated with each major transformation initiative (1 month)

On-site (five days a week/12 hours a day for eight weeks;) team of content experts in areas identified for improvement alongside hospital leadership and staff

10,000 mile checks to achieve ongoing improvement and sustainability

Thirty two hospitals will have completed TT (Phase I) by end of 2004; all 70 retained hospitals by the end of 2005


C2Q Transformation Teams: EBM (2004)C2Q Transformation Teams: EBM (2004)

Goal 1: “Hardwire” 95% adherence to evidence-based guidelines in AMI, Pneumonia, CHF, Surgical Infection Prophylaxis, and isolated CABG by the end of 2004

Goal 2: Have hospitals with CABG, valve, and PCI programs to require cardiac surgeons and invasive cardiologists to assess and record the AHA/ACC appropriateness classification (I, IIa, IIb, or III) for every CABG, valve replacement, and PCI

Goal 1: “Hardwire” 95% adherence to evidence-based guidelines in AMI, Pneumonia, CHF, Surgical Infection Prophylaxis, and isolated CABG by the end of 2004

Goal 2: Have hospitals with CABG, valve, and PCI programs to require cardiac surgeons and invasive cardiologists to assess and record the AHA/ACC appropriateness classification (I, IIa, IIb, or III) for every CABG, valve replacement, and PCI


AMI: Beta Blocker Prescribed At DischargeAMI: Beta Blocker Prescribed At Discharge

Mean Rate: Tenet vs. JCAHO National Benchmark

85% 86%91%89% 90% 91% 92%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO

85% 86%91%89% 90% 91% 92%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO



AMI: ACEI for LVSDAMI: ACEI for LVSD

71%73%

78%77% 78% 78% 80%

65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO

71%73%

78%77% 78% 78% 80%

65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO



Pneumonia: Pneumococcal Screening and/or Vaccination

Pneumonia: Pneumococcal Screening and/or Vaccination

22%25% 27%

34%36% 37%

42%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO

22%25% 27%

34%36% 37%

42%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Tenet

JCAHO


Mean Minutes: Tenet vs. JCAHO National Benchmark

Pneumonia: Time To First Dose of AntibioticsPneumonia: Time To First Dose of Antibiotics

254 254 251

228

256 251 253245

0

50

100

150

200

250

300

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Av

era

ge

Min

ute

s

Tenet

JCAHO

254 254 251

228

256 251 253245

0

50

100

150

200

250

300

2003 Q1 2003 Q2 2003 Q3 2003 Q4

Av

era

ge

Min

ute

s

Tenet

JCAHO


Utilization Management and ReviewUtilization Management and Review

Interqual assessment for 100% of all adult medical/surgical admissions for appropriateness of inpatient admission, continuation of stay, and discharge

In invasive cardiology, use American Heart Association/American College of Cardiology appropriateness guidelines for CABG, valve replacement, and percutaneous coronary intervention

Use NIH guidelines for appropriateness of bariatric surgery

In the 6 months, implement the Interqual SIMS criteria for all major discretionary procedures

Interqual assessment for 100% of all adult medical/surgical admissions for appropriateness of inpatient admission, continuation of stay, and discharge

In invasive cardiology, use American Heart Association/American College of Cardiology appropriateness guidelines for CABG, valve replacement, and percutaneous coronary intervention

Use NIH guidelines for appropriateness of bariatric surgery

In the 6 months, implement the Interqual SIMS criteria for all major discretionary procedures


C2Q: Improvement in CABG Processand Outcome

C2Q: Improvement in CABG Processand Outcome

Comprehensive assessment of all aspects of isolated CABG surgery

Appropriateness of surgery (AHA/ACC criteria)

Processes of care demonstrated to improve mortality and morbidity

Outcomes: risk-adjusted mortality and morbidity

Comprehensive assessment of all aspects of isolated CABG surgery

Appropriateness of surgery (AHA/ACC criteria)

Processes of care demonstrated to improve mortality and morbidity

Outcomes: risk-adjusted mortality and morbidity


CABG Appropriateness at Tenet Hospital JCABG Appropriateness at Tenet Hospital J

Target Jan

04

Feb

04

Mar

04

Apr

04

May

04

Jun

04

July

04

Aug

04

Isolated CABG

(n)

44 39 29 48 43 32 37 25

CABG + CABG-valve

(n)

51 50 37 58 56 36 44 34

AHA/ACC Level

IIb/III

0% 0% 0% 0% 0% 0% 0% 0% 0%

AHA/ACC Guideline Adherence for Appropriateness of CABG


CABG Mortality in Tenet Hospitals:Observed vs. Expected Mortality

CABG Mortality in Tenet Hospitals:Observed vs. Expected Mortality

3.6%

3% 3%

3.9%4.1%

3.5%

0%

1%

2%

3%

4%

5%

CY 2001 CY 2002 CY 2003

Mo

rta

lity

Ra

te

Observed Mt% Expected Mt%

3.6%

3% 3%

3.9%4.1%

3.5%

0%

1%

2%

3%

4%

5%

CY 2001 CY 2002 CY 2003

Mo

rta

lity

Ra

te

Observed Mt% Expected Mt%


C2Q: Patient SafetyC2Q: Patient Safety

Implement web-based occurrence reporting system

Reduce hospital acquired infections by 50% (VAP, central line BSI, UTIs associated with catheters, surgical site infections)

Reduce high severity adverse drug events by 50%

Promote a culture of safety in each hospital

Build team training in high risk areas of hospital (ICU, ER, L&D, OR, invasive radiology)

Provide hospitals with educational material for governing boards, administrators, clinical staff, physicians, patients, and families

All Tenet hospitals are members of the National Patient Safety Foundation Stand Up program

Corporate level Patient Safety Committee monitors trends, develops patient safety policies, identifies new trends in patient safety

Implement web-based occurrence reporting system

Reduce hospital acquired infections by 50% (VAP, central line BSI, UTIs associated with catheters, surgical site infections)

Reduce high severity adverse drug events by 50%

Promote a culture of safety in each hospital

Build team training in high risk areas of hospital (ICU, ER, L&D, OR, invasive radiology)

Provide hospitals with educational material for governing boards, administrators, clinical staff, physicians, patients, and families

All Tenet hospitals are members of the National Patient Safety Foundation Stand Up program

Corporate level Patient Safety Committee monitors trends, develops patient safety policies, identifies new trends in patient safety


Informatics-enabled Infection Control Monitoring

Informatics-enabled Infection Control Monitoring

Sample screen shots from the CCM and IC story boards due 9/12 will go here


C2Q: Physician ExcellenceC2Q: Physician Excellence

Half day educational session annually for all Tenet hospital governing board members regarding their fiduciary responsibility for quality, safety, and physician credentialing

Standardization of the business processes of physician credentialing and privileging through web-based tool

Identification and remediation of physicians whose utilization/quality is substandard through peer review and established medical staff and governing boards processes

Consistent physician performance assessments using objective data and peer review

Half day educational session annually for all Tenet hospital governing board members regarding their fiduciary responsibility for quality, safety, and physician credentialing

Standardization of the business processes of physician credentialing and privileging through web-based tool

Identification and remediation of physicians whose utilization/quality is substandard through peer review and established medical staff and governing boards processes

Consistent physician performance assessments using objective data and peer review


CredentialingCredentialing

Echo and Echoapps screen shots


Completing the Circle of Supporting Physician Excellence

Completing the Circle of Supporting Physician Excellence

Individual informatics-enabled projects dependent upon one another

IT integration strategy to support hospital management processes

Individual informatics-enabled projects dependent upon one another

IT integration strategy to support hospital management processes

Incident Reporting

Physician ClinicalPerformance Assessmentfor Quality

andUtilization

Peer Review

Re-Appointment

Physician Excellence


C2Q nursing program has improved nursing retention, quality, and patient satisfaction

C2Q nursing program has improved nursing retention, quality, and patient satisfaction

Example nursing improvements from last round of C2Q

Hospital 3 significantly decreased voluntary turnover and accelerated involuntary turnover– June RN voluntary turnover improved to 13.8% vs. 20% for the

previous year– June RN percent involuntary terms less than 90 days dropped to zero,

while voluntary terms less than 90 days rose to 22.2%

Nursing retention

Pressure ulcers/falls

Hospital 84 implemented corporate policies to reduce the incidence of pressure ulcers and patient falls

Hospital 11 developed a shared governance/nursing peer review model aimed at improving the quality of nursing care

Nursing peer review

Hospital 53 dramatically improved inpatient satisfaction with pain management scores from 61% before C2Q to 96%

Pain management

Hospital 19 demonstrated significant improvement in inpatient satisfaction scores (hospital never achieved 4 star status before but was 4 star 2 of the past 3 months) by implementing a new nurse staffing model

Inpatient satisfaction


C2Q: Patient Flow and Capacity Management

C2Q: Patient Flow and Capacity Management

Hypothesis 1: delays and “blocks” in high flow areas of the hospital are not the result of lack of space or staff

Hypothesis 2: delays and “blocks” in high flow areas of the hospital are the result of a failure to “connect the dots” in tightly coupled systems and a failure of synchronization

Key Areas: Emergency Room, Operating Rooms, ICUs, discharge processes (bed turnover)

Hypothesis 1: delays and “blocks” in high flow areas of the hospital are not the result of lack of space or staff

Hypothesis 2: delays and “blocks” in high flow areas of the hospital are the result of a failure to “connect the dots” in tightly coupled systems and a failure of synchronization

Key Areas: Emergency Room, Operating Rooms, ICUs, discharge processes (bed turnover)


24

8

0

13

43

45

48

9

100

92

C2Q operations impact has been strong

and sustained

C2Q operations impact has been strong

and sustained

Average discharge time

Average minutes DOW to DC

Average minutes exit to room clean

Asset utilization in hours

First case delay in minutes

Cancellation percentage

LOS minutes – discharged

LOS minutes – admitted

LWBS percentage

Diversion hours*

Continuum of care

Operating room

Emergency Department

Metrics

Gap closed at C2Q team departurePercent

Gap closed by September, 2004Percent

30

4

-5

23

48

57

42

45

100

75


Daily Tool SnapshotDaily Tool Snapshot


Examples of C2Q Quality Improvements From Most Recent Round

Examples of C2Q Quality Improvements From Most Recent Round

– Improved medication safetyPatient

Safety

Compliance

with EBM

–Lowered the incidence of ventilator associated pneumonia

Medical Staff Support

Hosp 1

Hosp 17

– Increased CHF patients receiving discharge education from 8% to 79%

Hosp 4

–CAP patients receiving IDSA approved antibiotics improved from 33% to 80%

–CAP pneumovax immunization rate improved from 59% to 90%

Hosp 64

–Strengthened its credentialing process by infusing better data into re-appointment processes

Hosp 35

–Reviewed criteria for sub specialist performance on medical staff

Hosp 51

–Considerable body of evidence that level of quality is improving significantly due to C2Q

–Hospitals building necessary skills and tools through C2Q to tackle next-wave quality issues in their hospitals


C2Q cultural impact is acceleratingC2Q cultural impact is acceleratingWays the culture is changing

New skills are being learned

Physicians are embracing the program

“I wasn't before, but now I'm a believer in C2Q. An initiative I thought would take 8 months got done in 8 weeks.”

– MD

“The training opened my eyes to new ways of approaching the same issue.”

– Director

“For the first time, I believe we can make change happen; the outside help has really opened our eyes.”

– MD

“The training gave me some really good ideas for how I’m going to tackle the one physician issue I’m struggling with.”

– Director

“For the first time in my 20 years, I finally feel that we have a mechanism to drive positive change.”

– MD

“C2Q gives us the capability to be able to tackle new issues as they arise. In the future we are going to “C2Q” new problems.”

– CEO


Enabling mechanisms in place to sustain impactEnabling mechanisms in place to sustain impact

Current tools

Bi-weekly performance reporting from hospitals to Program Management Office

Process to feed back action items to regional and hospital teams

Near-term (monthly) and long-term (12-24 month) targets Clinical Quality measurement index Performance evaluation and development tool for

regional team

Performance management

Best practice sharing

User-friendly best practice database in Tenet intranet Process for ongoing best practice development, codification,

and dissemination Key operations and quality expert resource contact list


New strategic direction to achieve service excellenceNew strategic direction to achieve service excellence

Transform Tenet’s service strategy through new value propositions for patients and physicians

Build upon the best elements of Target 100 and fill gaps to strengthen Tenet’s service culture

Integrate T100 and C2Q teams to align service, quality, and operations initiatives Build distinctive service levels in selected local markets

Strategic direction

Patient service commitment

Physician service commitment

Description

“Tenet will offer physicians operationally effective, collegial professional communities where they can be significantly more productive and have their patients treated safely and with dignity.”

“Tenet will create a physical and emotional environment that delivers positive patient-centered experiences, not just health service transactions.”

Safe, comfortable and prompt

Respectful, empathetic, and coordinated

Consistent with other ‘service- excellent’ environments

Doing the right thing, the first time, on time

Equitable governance to give physicians a sense of ‘ownership’

Economics, technological support, and improved lifestyle need to make a 15-20% difference


Positive Forces At WorkPositive Forces At Work

Leadership

Resources

Standardized Approach with “Local Customization”

Communication, communication, communication

Accountability

Public influence in dialogue about performance

“Quality” or “safety” or “safeguarding”?

Leadership

Resources

Standardized Approach with “Local Customization”

Communication, communication, communication

Accountability

Public influence in dialogue about performance

“Quality” or “safety” or “safeguarding”?

the development, implementation, and results

Documents