Transcript The Transformation Journey - Massachusetts Coalition for the

The Transformation Journey
Jeanette G. Clough
CEO, Mount Auburn Hospital
Presentation to the
Massachusetts
Coalition to Prevent Medical
Errors
June 23, 2009
Overview of the LEAD Program



A Blue Cross Blue Shield program aimed at
supporting transformational change in health
care.
Health care institutions were chosen for their
leadership and organizational commitment to
quality and safety.
Participants were required to set “audacious”
safety goals and provide monthly measures
of progress toward these goals.
Overview of the LEAD Program

LEAD encourages learning from experts in
quality and safety. Monthly meetings with
experts from around the world are held for the
CEOs and the leadership teams.

LEAD provides a $1.5 million dollar stipend to
support the transformational work.

LEAD is a 24 month program ending in March
2009.
The Challenge

Mount Auburn was ready
-to commit to more rigorous and accelerated
action on quality and safety
-to commit further resources of time and
dollars
-to set audacious goals and establish a
timeline for goal achievement
The Challenge
The LEAD program was consistent with our
belief that quality is a strategic imperative
and with our organizational goals and
guiding principles for quality and safety:
Organizational Principles

Measurement and benchmarking
Collection, interpretation and measurement
of clinical, operational and financial metrics
measured against the Hospital’s past
performance and against national and “best
performer” benchmarks.
Organizational Principles

Transparency
Sharing performance data against best
practice benchmarks within the Hospital, the
healthcare community and with the public to
foster discussion, debate, competition and
improvement.
Organizational Principles

Uniting process with technology
Using technology in the design and function
of systems and processes in the delivery of
care to improve efficiency, enhance
communication, enable data collection and
limit the potential for human error.
Organizational Principles

Learning from error
Examining and exhuming the causes of near
or actual error followed by education,
training, communication and change to
prevent further errors from occurring.
Organizational Principles

Linking employee and physician
satisfaction with achievement of all
organizational goals including quality and
safety
Carefully listening and responding to
employees and physicians through a variety
of methods as the foundation for meeting
organizational goals and objectives.
Setting the goals
What would it take to become the safest
hospital for the delivery of medications and
eliminate any harm to patients from
medications?
Don’t all patients deserve to enter the
Hospital and not be subject to a medication
error? And don’t all employees deserve a
safe system to deliver medications?
LEAD Goal: Medication Safety

Use state-of-the-art technology to automate
the process for medication delivery…from
ordering to administering… in order to
achieve “six sigma” reliability (less than 1
event per million doses administered) and to
eliminate medication errors.
Key Steps to Achieve the Goal

Automating the medication process
-CPOE: ordering and decision support
-PYXIS: dispensing
-Talyst: bar coding of drugs and inventory
management
-”Smart pump” implementation: IV drug delivery
-BMV: bedside med verification
-EMAR: electronic med administration record
Results: Medication Safety
Mount Auburn has now achieved five sigma
reliability and has had no Level 2-3-4
(events that reached a patient) events
since Sept. 17, 2008.
Mount Auburn has had a 67% reduction in
medication events since LEAD began.
Minor Patient Harm from Medication Events
Sixty Seven Percent (67%) Reduction During LEAD
Error Rate/ Medications Administered
0.000030
0.000025
0.000024
0.000020
0.000015
0.000013
0.000010
0.000009
0.000005
0.000000
0.000000
MAH Baseline 2006
Lead Year 1: CY2007
Lead Year 2: CY2008
Time Period
Current YTD: CY2009
(Jan- Mar 09)
7/1/06
7/15/06
7/29/06
8/12/06
8/26/06
9/9/06
9/23/06
10/7/06
10/21/06
11/4/06
11/18/06
12/2/06
12/16/06
12/30/06
1/13/07
1/27/07
2/10/07
2/24/07
3/10/07
3/24/07
4/7/07
4/21/07
5/5/07
5/19/07
6/2/07
6/16/07
6/30/07
7/14/07
7/28/07
8/11/07
8/25/07
9/8/07
9/22/07
10/6/07
10/20/07
11/3/07
11/17/07
12/1/07
12/15/07
12/29/07
1/12/08
1/26/08
2/9/08
2/23/08
3/8/08
3/22/08
4/5/08
4/19/08
5/3/08
5/17/08
5/31/08
6/14/08
6/28/08
7/12/08
7/26/08
8/9/08
8/23/08
9/6/08
9/20/08
10/4/08
10/18/08
11/1/08
11/15/08
11/29/08
12/13/08
12/27/08
1/10/2009
1/24/2009
2/7/2009
2/21/2009
3/7/2009
3/21/2009
Days Between Events
Days Between Level 2- 4 Medication Events
180
LEAD Begins: 1/1/2007
150
120
90
UCL
60
30
0
Year and Week
Infection Prevention Goals



To achieve six sigma level of central blood
stream infections: less than 1 CBI in 10/6th
central line days in both ICUs
To achieve six sigma level of ventilator
assisted pneumonias (VAPs): less than 1
VAP in 10/6th ventilator days in both ICUs
Identify, cohort and decontaminate to reduce
hospital acquired MRSA infection by 50%
Setting the goal
What would it take to eliminate MRSA in the
ICUs? What would it take to also eliminate all
VAPs and CBIs? Can it be done?
Results: Infection Prevention
Mount Auburn has achieved a 68%
reduction in central bloodstream infections
over the two years of the LEAD program.
Mount Auburn now has less than 1 CBI per
1000 central line days.
Hospital Acquired Central Bloodstream Infections
Sixty Eight Percent (68%) Reduction During LEAD
2.50
2.22
CBI Rate/ 1000 Line Days
2.00
1.50
1.14
1.00
0.70
0.50
0.00
MAH Baseline 2006
Lead Year 1: CY2007
Time Period
Lead Year 2: CY2008
Results: VAPs
Mount Auburn has had a 50% decrease in
VAPs during the two years of the LEAD
program.
Mount Auburn now has a rate of 1.25 VAP
per 1000 ventilator days. (The rate is lower
than 1.25 in the MICU and is approaching six
sigma).
Hospital Acquired Ventilator Associated Pneumonia
Fifty Percent (50%) Reduction During LEAD
3.00
2.51
VAP Rate/ 1000 Vent Days
2.50
2.00
1.50
1.25
1.00
0.54
0.50
0.00
MAH Baseline 2006
Lead Year 1: CY2007
Time Period
Lead Year 2: CY2008
Results: MRSA in the ICUs
Mount Auburn has reduced MRSA CBI
and VAP to six sigma levels with zero HAI
MRSA infections in the ICU and CCU
since October 06.
Results :Cost Savings
Mount Auburn has calculated total savings of the
following from January 2006 thru April 2009:
$813,629.65 for CBI reduction
$1,132,593.00 for VAPs reduction
$148,907.62 for med safety improvement
Looking Back….
In 2006 Mount Auburn ..
 had many strengths to build upon for LEAD
 took the LEAD challenge seriously
 set audacious and meaningful goals
 Applied strategy, planning, teamwork and
perseverance to achieve gains in both sets of
goals
Looking Back….
Despite the strengths we still had…
 Early and late adopters
 Some resisters and many doubters
 Lots of infrastructure to put together
 IS challenges
 A huge $90M construction project going on
 Lots of opportunity to be distracted
Looking Back….
It would have been easy to get distracted….
 The economy started to crumble and
collapsed
 Investments and value of real estate
plummeted
 The competition got even hotter and nastier
 The physician shortage grew larger
Key Elements for Success

Strong organizational structure
Committed and stable senior management
and physician leadership
Deep physician – hospital alignment
Size of the organization
Looking Back….
Critical Elements to Success





Culture is absolutely key
Understanding the dynamics of change
Constancy of purpose –unwavering commitment
One step at a time –a strategic plan and timetable
Applying the four key principals:
measurement and benchmarking, transparency,
learning from error, uniting processes with
technology
Moving forward…





New norms have been established
Error or infection is a rare, if ever, event
Culture and roles are strengthened
Cost of care is reduced and efficiencies
gained
Payment reform in the AQC allows us to
focus even more on quality and safety