1 alice bell - transformational quality deck for webconference

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y

Transformational QualityLeading the Organisation to Clinical Excellence

1

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

382

Road Map

2

3

1

Creating Collective Commitment to Quality Improvement

Coda: Future Prospects: Expanding the Ambition

The New Quality Mandate

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

383

The New Quality MandateImperative to Improve

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

384

Quality Worse Than Expected

“Our study detected far more adverse events in hospitalised patients than have been found in prior studies…Our detection levels were also higher than those of comparative studies of adverse events with other methods in hospitalised patients from England, Australia, and Canada.”

Classen et al.Health Affairs

354

35 4

Increasing Understanding of Quality Performance

Hospital Adverse Events Even More Frequent Than Previously Reported

Source: Classen D, Resar R, et al., “’Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured,” Health Affairs, 2011 30(4): 581-589; Special Eurobarometer 327, “Patient safety and quality of healthcare,” 2010; Advisory Board interviews and analysis.

Quality in the Spotlight

1) Researchers reviewed 795 patient records across 3 hospitals using 3 different event detection methodologies.

Prevalence of Adverse Events1

Global Trigger Tool detected significantly higher incidence of adverse events than commonly used systems

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

385

Incessant Negative Publicity Around Quality

“Technician charged in fatal injection with cleaning solution”

Seattle Times

“Routine operation ends with death of

mother of four”ABC News

“Nearly 2,000 Carrying H.I.V. in Chile Were Not

Notified”New York Times

“Hospital mistakes killed 28 people in Victoria this

year”The Telegraph

“Mother left paralysed from waist down after injection with powerful skin antiseptic instead

of saline solution during epidural”

Sydney Morning Herald

Media Relentlessly Covers High Profile Incidents

“Man has unnecessary cancer surgery after

misdiagnosis”New Zealand Herald

Source: Advisory Board interviews and analysis.

Transparency Increasing

“Hospital left patient sobbing and humiliated”

BBC

“Hospital boss tried to cover up details of patient’s death”

The Daily Mail

“NHS patients discharged from hospital alone in the

middle of night”

Huffington Post UK

“Bacteria kills newborns in German

hospital”Euronews

“Boston hospital admits drug overdose caused death of

Globe columnist, damage to second woman”

Boston Globe

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

386

25%72%

3%

Series1 46

49

58

59

50

48

39

38

4

3

3

3

Likely Not Likely Don't Know

Hospitals Losing Public Trust

Source: European Commission, “Special Eurobarometer: Patient Safety and Quality of Healthcare,” April 2010; Advisory Board interviews and analysis.

Percentage of People Who Have Suffered or Had a Family Member Suffer

an Adverse Event When Receiving Health Care

No Yes

Don’t Know

n=26,663

Percentage of People Responding to Likelihood of Adverse Events

in Hospital

Medication Errors

Surgical Errors

Hospital Infections

n=26,663

Incorrect, Mixed or Delayed Diagnosis

Disturbing Changes in Public Perception

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

387

What is “Quality”?

Source: Institute of Medicine of the National Academies, “Crossing the Quality Chasm: The IOM Health Care Quality Initiative, 2011; American Medical Association, 1986; World Health Organisation, 2000; Donabedien, A, 1980; American College of Medical Quality, 2011; NHS, “High Quality Care for All: NHS Next Stage Review Final Report,” 2011; Australian Institute of Health and Welfare, "Definitions of safety and quality of health care,"; Gemeinsamer Bundesausschuss, “Was ist Qualität und wie wird sie gemessen?"; Advisory Board interviews and analysis.

“The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Institute of Medicine

“At a broad level, quality reflects the extent to which a health care service or product produces a desired outcome. At a more detailed level…quality [is] a guiding principle in assessing how well the health system is performing in its mission to improve the health of Australians.”

Australian Institute of Health and Welfare

That "which consistently contributes to improvement or maintenance of the quality and/or duration of life.“

American Medical Association

“That kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.“

Avedis Donabedien

“Clinically effective, personal and safe.”

High Quality Care for All: NHS Next Stage Review

Final Report

“Quality of care is the level of attainment of health systems' intrinsic goals for health improvement and responsiveness to legitimate expectations of the population.”

World Health Organisation

“Health care should be safe, effective, patient-centered, timely, efficient and equitable.”

Quality Chasm Report, Institute of Medicine

“When there is an almost perfect overlap between expectations and results…the three dimensions of quality are structure, process and outcomes.”

German Federal Joint Committee

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

388

Worldwide Attempts to Measure, Manage Quality

Source: Copnell B, et al., “Measuring the quality of hospital care: an inventory of indicators,” Centre of Research Excellence in Patient Safety, Department of Epidemiology and Preventive Medicine, Monash University ; EUNetpas, “Patient Safety Culture Report focusing on indicators,” 2010; EUPHORIC Project, “Disease Areas and Indicators,” 2010; Sektorenübergreifende Qualität im Gesundheitswesen, “Dokumentationsbögen und Ausfüllhinweise 2011,”; Schweizerische Eidgenossenschaft Bundesamt für Gesundheit, “Qualitätsindikatoren in Schweizer Akutspitälern wurden erneut erhoben,“ 20 Aug 2010; Swedish National Healthcare Quality Registries, “Öppna jämförelserav hälso- och sjukvårdenskvalitet och effektivitet,” 2010; Advisory Board interviews and analysis.

Result: Quality Rising Up National Agendas

Sweden: 134 National Healthcare Quality Registries

Denmark: 40National Indicator

Project

Switzerland: 30 Federal Office of

Public Health

Australia: 17 National Health

Performance Authority Hospital

Indicators

EUNetpas: 343

Germany: 34Cross-Sector Quality

in Health Care

UK: 150National Institute for Health and Clinical Excellence (NICE)

Standards

Netherlands: 26Performance

Indicators on Patient Safety and

Effectiveness

Safety Improvement for

Patients in Europe: 26

World Health Organisation: 25

Performance Assessment Tool for

QI in Hospitals

US: 44 Centers for Medicaid

and Medicare Services

Canada: 16Institute of Health

Performance

EUPHORIC Project: 54

For common quality indicators and examples by country see appendix p 2-3

Selected Quality Metrics Measured by National and International Bodies

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

389

Below Average Performance

Transparency New Way of Life

League Table Prevalence Increasing


Hospital Name Mortality RateAverage A&E

Wait Time

Emergency Readmission

Rate

C.difficile Rate

Boshier Hospital

Drexler Health Care

Lindner Clinic

Strider Hospital

Thiebaud Medical Centre

Exceptional Performance

Satisfactory Performance

Unacceptable Performance

Sample League Table

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3810

Switzerland61%France

50%

England59%

Norway65%

Spain60%

Canada59%

New Zealand61%

Already Struggling to Make the Grade

Hospital Performance Trails Best Demonstrated Practice

Masud D., et al., “Current practice on preoperative correct site surgical marking,” Journal of Perioperative Practice, June 2010; Jebrak G, “COPD routine management in France: are guidelines used in clinical practice?” Revue des Maladies Respiratoires, 2010; Hakonsen GD, et al., “Adherence to medication guideline criteria in cancer pain management,” Journal of Pain Symptom Management, June 2009; Pestana D., et al., “Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients,” Journal of Trauma, Nov 2010; Alak A., et al., “Variations in the management of pneumonia in pediatric emergency departments: compliance with the guidelines,” Canadian Journal of Emergency Medicine, Nov 2010; Chopard, Pierre, et al., “Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study,” Swiss Medical Weekly, 2009; The Patient Safety Company, “One in twenty deaths in Dutch hospitals could be prevented,”; “Surveillance of Healthcare Associated Infections,” Australian Commission on Safety and Quality in Healthcare; Sally Roberts, “Implementing and Sustaining a Hand Hygiene Culture Change Programme at Auckland District Health Board,” NZMJ May 2012; Advisory Board interviews and analysis.

1) Chronic obstructive pulmonary disease.2) Venous Thromboembolism

1

Selected Recent Studies of Guideline Compliance at Hospitals

2

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3811

Patients Older, Sicker

More Complex Patient Population Increasing Risk

Source: UN Department of Economic and Social Affairs, “World Population Ageing 2009”; Ekinci O, “Getting to the Heart of things,” 20 August 2010, European Hospital; Advisory Board interviews and analysis.

Future Threat: Demand

Global Population Aged 60 Years or Over

Millions

1950 2011 2050

200 M

2,000 M

Heart Failure Prevalence in Europe

2011 2020 (e)

14 M

30 M

Millions

(e)

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3812

74%

Quality a Means of Competitive Differentiation

Not All Bad News

1) Survey question: “Is publicising the quality of care of your organisation among your top three marketing/public relations strategies?”

Proportion of Members Regarding Publication of Quality Metrics as Key Marketing/Public Relations Strategy1

n=210 hospital clinicians and managers

Recognising the Competitive Landscape

Chief Medical Officer Australian Private Hospital

”

“It’s no longer sufficient in hospital management just to get the financials right, it’s just as important to take care of the quality and safety issues. In terms of customer satisfaction, we have an increasingly discerning patient group, who don’t just see it as a privilege for them to be allowed to come to us. We also have competitors, and our commitment is thus very much to put that patient experience into the foreground and into the front of mind…The whole world is moving towards more discerning and higher expectations from patients and their relatives.”

Source: 2012 Clinical Operations Board Survey on Quality in United Kingdom, Australia, and New Zealand; Advisory Board interviews and analysis.

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3813

Pursuit of Quality Engages Medical Staff

Doctor Engagement Essential for Multiple Hospital Initiatives

Source: Advisory Board Survey Solutions, Physician Engagement Initiative, 2011; Advisory Board interviews and analysis

Top Five Drivers of Doctor Engagementn= 3610, r2=0.699

Driver Beta

I would recommend this organisation to a friend or relative to receive care 0.209

The actions of this organisation’s executive team reflect the goals and priorities of participating clinicians 0.192

I am interested in doctor leadership opportunities at this organisation 0.174

The organisation supports the economic growth and success of my individual practice 0.147

The organisation provides excellent clinical care to patients 0.110

Three of top five

engagement drivers have

quality component

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3814

The New Quality MandateConfronting the Quality Challenge

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3815

No Magic Bullet

Source; Connolly C, "Cedars-Sinai Doctors Cling to Pen and Paper," Washington Post, 21 March 2005; Smelcer J, Miller-Jacobs H, Kantrovich L, "Usability of Electronic Medical Records," Journal of Usability Studies, February 2009 vol. 4 (2): 70-84; Advisory Board interviews and analysis.

Improvement Challenges – Story #1: The Human Factor

1) Computerised Physician Order Entry.2) USD.

Limited Efforts to Engage Doctors

Erosion of Medical Staff Trust

Doctors Revolt

• CEO and board rely exclusively on CMO to choosing CPOE1 system

• Medical staff already alienated over cost control targets

• Hospital leaders slow to respond to complaints about system

• Doctors revolt and take opposition to the press

Case in Brief: Cedars Sinai Hospital

• 746-bed tertiary hospital in Los Angeles, California

• Launched $34 million2 CPOE system in autumn 2002

• Doctor opposition prompted return to paper system 3 months later

• CPOE1 rollout with two-month implementation time frame, limited support

• System requires additional doctor time, does not allow for deviation from protocols

Hospitals Can’t Buy Quality Care

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3816

2008 2009 2010 Q1 2011

58%61%

69%

75%

Individual Interventions Successful…

Heroic Efforts on Hand Hygiene Compliance

Source: McLaws M, et al., “Improvements in hand hygiene across New South Wales public hospitals: Clean hands save lives, Part III,” Medical Journal of Australia, 2009, Hand Hygiene Australia, “5 moments for hand hygiene”; NSW Health, “Media Release: Clean Hands Saves Lives,” 28 April 2011; Advisory Board interviews and analysis.

Improvement Challenges – Story #2: Campaign Mentality

Hand Hygiene Compliance New South Wales, Australia

Hand Hygiene Australia: Five Moments Campaign

Elements• Sustained leadership attention• Repeated education initiatives• Compliance monitoring and

enforcement

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3817

2008 2009 2010 Q1 20110

0.5

1

1.5

2

2.5

3

3.5

4

2.29

1.62

3.77

2.1

…Not Enough to Achieve High Quality

Hand Hygiene Critical But Not Alone Sufficient to Avoid Infections

Source: NSW Health, “NSW Healthcare Associated Infections Data Collection,” 2011; 191(8 Suppl): S18-S25; Clinical Excellence Commission, “Safety and Quality of Healthcare in NSW: Chartbook 2009,” December 2010; Australian Commission on Safety and Quality in Healthcare, “Windows into Safety and Quality in Health Care 2010,”; Advisory Board interviews and analysis.

1) Methicillin-resistant Staphylococcus aureus.2) Central Line Associated Blood Stream Infection.

Selected Infection RatesNew South Wales, Australia

ICU associated CLABSI2 per 1000 central line days

MRSA1 infections per 1000 ICU bed days

Gap to best practice for CLABSIs

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3818

Difficult to Change Long-Held Mindsets

Failing to Execute on Knowledge

Source: Staines, R, “WHO Safe Surgery Checklists Are Not Being Followed by NHS Trusts,” Nursing Times, 17 February 2009; Haynes, Alex B., et al, “Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention,” British Medical Journal, 2009, 20: 102-107; Fitzpatrick, Laura, “Atul Gawande: How to Make Doctors Better,” Time, 4 January 2010; Advisory Board interviews and analysis.

Improvement Challenges – Story #3: The Checklist Conundrum

79% 80%94% A Waste of Time…Until You Are

the Patient

”

“A lot of the reaction is, 'My God, another piece of paperwork? It's just a waste of time.' 20% [of doctors] in our surveys still felt it was a pain, a waste of time; they didn't want to use it. Of course, we asked them a follow-up question: If they were having an operation, would they want the checklist? And 94% of them did.”

Atul Gawande, SurgeonBrigham and Women's Hospital

Study in Brief• Survey of 281 surgeons, nurses, anaesthesia personnel, and technicians at seven hospitals worldwide

• Organisations had implemented the World Health Organisation Surgical Safety Checklist

• Personnel responded to survey anonymously following two weeks of using checklist

Percentage of Clinicians Agreeing

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3819

The Core Problem: Complexity

Quality Impossible to Manage through Central Control

Source: Advisory Board interviews and analysis.1) USD.2) Length of Stay.

Influenza and Pneumococcal Vaccinations

TechniquePast Antibiotic

TreatmentsStool Culture

Equipment and Supplies

Environment

IsolationIsolation

Precautions

Personal Protection

Equipment and Supplies

Potential for Drug-Resistant

Organism

Not Vaccin-

ated

Vaccin-ated

C. Difficile Screen (False

negation)

Clostridium Difficile Assay

Hand HygieneCostAppropriate

Cleaning

Cleaning Products

Inappropriate Treatment

Inappropriate Antibiotic Treatment

Infection Treated with

Antibiotic

Clostridium DifficileVolume: 907 cases

Cost variance/case: $6,5581

LOS2 opportunity for reduction: 8 days

Potential for Drug-

Resistant Organism

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3820

Culture Matters

”

Tactical Approach Insufficient

Successful Organisations Not Relying on Discrete Initiatives

Source: Curry L, et. al., “What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?” Annals of Internal Medicine, March 15, 2011; Chen, Pauline W. "What Makes a Hospital Great," New York Times, March 17 2011; Advisory Board interviews and analysis.

The Way Forward

1) Acute myocardial infarction.2) Our emphasis.

“We have to focus on the relationships inside the hospital and be committed to making the organisation work. It isn’t expensive and it isn’t rocket science, but it requires a real commitment from everyone.”

Elizabeth H. BradleyYale Global Health Leadership Institute

“Protocols and processes for AMI1 care did not differ between high-mortality and low-mortality hospitals…in the absence of a supportive organizational culture, specific interventions may not be sufficient for achieving the highest performance in care for patients with AMI.”2

Study in Brief: What Distinguishes Top Performing Hospitals in Acute Myocardial Infarction Mortality Rates• Qualitative study published in the Annals of Internal Medicine March 2011• Assessed high- and low-performing hospitals to identify factors related to better AMI care outcomes• Identified that having clear values and goals, strong engagement from staff members of diverse

disciplines and senior management, strong communication among groups, and solving problems in a way that seeks and addresses root causes were main predictors of high-quality patient outcomes

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3821

Viewing Quality Through a Different Lens

Looking for a Common Thread Among Exemplars


Our Approach

1) Selected organisations included both academic and general hospitals, from various financial contexts, and where doctors were employed, not employed, unionised and not unionised.

Selecting Best Practice Case Study Institut ions 1

Consistent national or international recognition for quality performance

Achieved quality improvement across the organisation; not confined to single departments or initiatives; improveme

Continuous, consistent quality improvement journey

1

2

3

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3822

Ascension Health Johns Hopkins Medicine Sentara Healthcare Mayo Clinic Health System Eau Claire Baylor Health System Cedars Sinai Medical Center Beth Israel Deaconess MCenter Rotterdam Eye Hospital Rankin Medical Center St. Mary's Health Care System Intermountain Healthcare Jönköping County Council

The Common FactorOrganisation-wide commitment

to collective quality improvement

“All Hands On Deck” Required to Overcome Complexity


©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3823

Diverse Case Study Organisations

Sustained Success Built on Three Pillars of Improvement

• Eight hospital not-for-profit system based in Virginia with 20,000 employees and 3,400 medical staff members

• Set ambitious executive vision for quality improvement; established performance standards, reinforced behaviours, and trained staff to overcome patient safety risks

• 23-hospital system headquartered in Salt Lake City, Utah, with over 32,000 employees

• System-wide focus on leveraging data systems, metrics to reduce clinical variation and improve outcomes


• Independent specialty eye hospital located in Rotterdam, Netherlands, with 30 independent ophthalmologists, 21 residents, 400 staff members

• Focus on improving care delivery through innovation resulted in dramatic decrease in wrong-site surgeries and steady rise in patient satisfaction scores

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3824

Transformational Quality

Lessons for Leading the Organisation to Clinical Excellence

IIIEmbed Culture of

Measurement

6. Set data expectations

7. Establish comprehensive clinical data infrastructure

8. Enable principled clinician autonomy

9. Educate clinicians in quality improvement

Case StudyIntermountain Healthcare

IISupport Front Line

Leadership

4. Empower front line to improve quality systems

5. Explicitly define doctor champion role

Case StudiesThe Johns Hopkins

HospitalBaylor Healthcare

ICommit to Quality

Transformation

1. Articulate specific, aspirational vision

2. Demonstrate informed dedication to front line

3. Enforce and reinforce new norms

Case StudySentara

Healthcare

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3825

Road Map

2

3

1

Creating Collective Commitment to Quality Improvement

Coda: Future Prospects: Expanding the Ambition

The New Quality Mandate

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3826

Column ICommit to Quality Transformation

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3827

Always Part of the Mission

Who is Not Aiming for High Quality?

Source: Advisory Board interviews and analysis.1) Pseudonym.

Commit to Quality Transformation: Standard Approach

Gibson Hospital1

Mission Statement

The multi-disciplinary team at Gibson Hospital will provideefficient and effective treatment options in a caring and professional environment. Our highly experienced staff will deliver care in comfortable surroundings with fully resourced facilities. We continually aim to improve our performance by implementing quality management principles.

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3828

Overview: Sentara Healthcare

Case in Brief: Sentara Healthcare• 10-hospital not-for-profit system based in Virginia

• 20,000 employees and 3,400 medical staff members

• Frustrated with lack of safety improvements, set goal of being in the top 10% of hospitals for all nationally reported safety metrics and attaining zero defect rate for preventable harm

• Drew on “high reliability” learning from nuclear and aviation industries to improve safety

• Broad involvement of executive team in setting performance standards, reinforcing behaviours, and training staff to overcome patient safety risks

• Achieved 80% reduction in serious safety event rate over 7 years

Quality Case Study

Source: Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3829

A Wake-Up Call

National Focus on Quality Improvement Galvanises Sentara

Source: Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors, To Err Is Human, Committee on Quality of Health Care in America, Institute of Medicine (1999): 17-19; Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.

Catalyst for Change

1) USD

“Health Care is Not as Safe as It Should Be”

• “Preventable adverse events are a leading cause of death in the United States.”

• “Sizable numbers of Americans are harmed as a result of medical errors.”

• “Total national costs (lost income, lost household production, disability, health care costs) are estimated to be between $37.6 billion and $50 billion1 for adverse events and between $17 billion and $29 billion1 for preventable adverse events.”

• “Medication-related errors occur frequently in hospitals; not all result in actual harm, but those that do are costly.”

To Err Is Human (1999)

To Err is Human:Building a Safer

Healthcare System

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3830

Initial Efforts Fall Short

Source: Sentara.com, August 2000, accessed through web.archive.org 10 April 2012; Sentara Healthcare, Norfolk, Virginia; Advisory Board interviews and analysis.

We will focus, plan and act on our commitments to our community mission, to our customers and to the highest quality standards of healthcare to achieve our vision for the future.

August 2000

Selected Quality Improvement Interventions 1999-2001

Medication Safety

IT system to streamline and reduce errors in medication dispensing

Ventilator Associated Pneumonia

Education program to reduce VAP in all system sites

The Big Picture

“We were frustrated. The sense at the time was that if we continued to work on discrete things without a larger framework, we’d make progress, but we really wouldn’t make the impact that we thought we needed.”

Dr Gary Yates, CMOSentara Healthcare

”

Unfocused Message and Isolated Interventions Slow Early Quality Efforts

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3831

Executive Leadership Required to Move Forward

External Expertise Pushes Senior Team to Reprioritise

Genesis of Quality Improvement Program at Sentara Healthcare

External safety experts with experience in risk reduction in nuclear power and airline industries conduct baseline assessment of safety processes

Assessment results and executive discussions turn focus from individual quality improvement processes to inculcating a system-wide culture of safety

Leadership team recognises senior executive prioritisation of quality improvement will be critical to sustained culture change

Focus on Culture Leadership PrioritisationOut-of-Industry Assessment

Four Principles of Quality Improvement at Sentara

Elevate safety to core organisational value

Communicate behaviours for error prevention

Create systems that reduce the chance of human error

Use root cause analysis to understand safety events


©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3832

Providing the highest quality of care and exceptional patient safety standards are imperative strategies throughout Sentara Healthcare. Our goal is to lead the industry to achieve top 10 percent performance wherever national benchmarks exist.

Setting a New Standard

Quality Mission Statement Signals Clear Change to Staff

Lesson #1: Articulate Specific, Aspirational Vision

Characteristics of Quality Definition at Top-Performing Hospitals

Aspirational goal set

Success clearly defined

Vision specific and tailored to the organisation


©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3833

Vision Alone Not Enough

Source: 2012 Clinical Operations Board Survey on Quality in United Kingdom, Australia, and New Zealand; Advisory Board interviews and analysis.

1) Survey question: “How important is ensuring high quality care for patients to you personally?” “No” displayed in chart as survey answers of high, medium or low priority.

2) Survey question: “How important do you feel ensuring high quality care for patients is to the executive leadership of your organisation as a whole?” “No” displayed in chart as survey answers of high, medium or low priority.

Executives Reporting High Quality Care as Top Priority1

15%85%Yes No

Doctors Reporting High Quality Care as Top Priority for Executive Team2

30% 70%

n=111 senior hospital executives n=30 doctors

Yes No

Executive Commitment Often Not Translating

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3834

Active Management Methods Falling Short

Sentara Finds Typical Approaches Inadequate for Culture Change


Walkrounds at RandomOpen Door Policy

Practice• Non-clinical executives

intimidated by front line atmosphere

• Executives fail to ask pertinent questions

• Staff feel check-in indicates lack of trust, not convinced of executive quality interest

Practice• Staff unwilling to admit

inability to perform tasks• Staff fear not meeting

manager expectations• Staff want to avoid appearing

weak or needy

Scheduled Senior Walkrounds

TheoryAnticipate staff needs and ensure compliance with quality goals through unplanned drop-ins

TheorySignal that leaders are always available and receptive to staff challenges and concerns

TheoryDemonstrate executive commitment to quality through scheduled ward visits by most senior leadership

Practice• Predictable nature of visits

results in extensive staff preparation for interaction

• Walkrounds too infrequent to create ongoing dialogue between management and staff

Common Active Management Concepts

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3835

Making Executive Rounds Work

Consistency, Constant Visibility, Preparation and Purpose Key

Lesson #2: Demonstrate Informed Dedication to Front Line

Keeping Everyone Focused

A Constant and Consistent Message

“The idea that we’re going to be out there each day and teaching and actively engaging folks…has been important in sending a constant message about safety to our staff.”

Dr Gary Yates, CMOSentara Healthcare

”Note any issues raised by staff

Create action plans with staff to address issues

Executives round with relevant questions

Sentara “Rounding With Intention” Process

Asking Staff to Think Ahead

1. “What in the last 24 hours has threatened our ability to provide safe care?”

2. “What might we expect to arise in the next 24 hours that would threaten the safety of our care?”

3. “How would we respond to what we think might happen?”

Crib Sheet for Clinical Rounds“Can you demonstrate how to use the care bundle to prevent urinary catheter infections?”


©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3836

Constantly Reinforcing Executive Commitment

Sentara Daily Check-ins Anticipate Potential Problems, Prove Priority

• Hospital executives, medical staff leaders and nurse managers meet every morning to review safety or quality concerns

• Meeting conducted while standing, lasts 20 minutes or less

Daily Check-In Procedure

Sentara Leadership Method for Performance Excellence

Sample Agenda Items

1. Update on progress against hospital and ward goals

2. Share positive or negative patient feedback

3. Address safety issues within last 24 hours

4. Discuss potential safety issues within next 24 hours and mitigating strategies

Sentara Leadership Method for Performance Excellence

1. Safety Walkrounds: to identify problems and reinforce safety as a priority2. Daily Safety Check-in: to share and maintain situational awareness3. Action Plans: to manage and ensure accountability for improvement work


©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3837

Creating a Sense of Quality Ownership

Positive Reinforcement and “Just Culture” Foster Accountability


Collaborative Improvement

• No punishment for honest mistakes; all system and human factors taken into account

• “Substitution test” decreases likelihood of attribution problem

• Enables unbiased analysis, individual and system improvement following safety mistakes

Lesson #3: Enforce and Reinforce New Norms

“Just Culture”

For a complete version of Sentara’s Performance Management Decision Guide, please see appendix p 4

Hospital system blog regularly profiles “Patient Safety Success Stories”: http://sentarainfo.com/today

Enters room to find patient struggling to breathe; runs to find nearest nurse who resuscitates patient

Sentara leadership team gives environmental services worker special recognition public recognition

Environmental Services worker in Critical Care Unit corridor hears beeping from patient room

Example of Positive Reinforcement at Sentara

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3838

Quality Takes Precedence Over Clinical Autonomy

Case in Brief: Mayo Clinic Health System in Eau Claire• 305-bed hospital located in Eau Claire, Wisconsin;

part of the Mayo Clinic Health System • Following merger in 1992 between Luther Hospital,

Midelfort Clinic and affiliation with Mayo Clinic Health System, embarked on institution-wide transformation based around vision of multidisciplinary, integrated care

• Strong leadership and continued commitment to quality improvement resulted in sustained quality improvement over nearly two decades

• Organisation scores in top 1% of US hospitals on composite measure of 22 publicly reported metrics of standards in heart attack, heart failure, pneumonia and surgical care

Walking the Talk

Standing Up for A Strong Institutional Vision

Source: Paul Bate and Peter Mendel and Glenn Robert, “Organizing for Quality: The improvement journeys of leading hospitals in Europe and the United States,” Radcliffe Publishing: Oxford, 2008; Advisory Board interviews and analysis.

“The expectation on the part of the [doctors] is that autonomy will not trump quality. That’s a real big issue and it is one that the organisation is currently working on…there’s no room for cowboys. Quality comes first.”

Senior ExecutiveMayo Clinic Health System in

Eau Claire

”

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3839

No Single Method Sufficient

Array of Enforcement, Reinforcement Mechanisms Required


Frequency of Use

Celebration of notable successes spreads enthusiasm and knowledge of expected behaviours

Principled system required to manage quality errors, focusing on root causes and learning from mistakes

For persistent resisters, firmer action required; coaching out of the organisation as needed in extreme cases

Leadership Response Techniques

Positive Reinforcement

“Just Culture”

Disciplinary Action

Enforce and Reinforce New Norms: Summary

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3840

Critical Leadership Actions

Executives Must Take First Steps on Quality Improvement Journey

Commit to Quality Transformation


Elements of Transformational Commitment

Demonstrate informed dedication to the front lines

Articulate specific, aspirational vision

Vision includes specific, measurable definition of

success; goal is aspirational but achievable and tailored to

organisation’s culture

Enforce and reinforce new norms

Leadership publicly celebrates staff achievements related to quality vision and responds to noncompliance in a fair and

consistent manner

Executives visibly dedicate substantial time and attention to

quality improvement goals at every level of the organisation

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3841

2003 2004 2005 2006 2007 2008

0.730.66 0.64

0.60 0.58 0.56

Attaining Consistent Improvement

Source: Sentara Healthcare, Norfolk, Virginia; Douglas McCarthy and Sarah Klein, “Sentara Healthcare: Making Patient Safety an Enduring Organizational Value,” The Commonwealth Fund, March 2011; Advisory Board interviews and analysis.

Selected Results

1) Deviation from standard of care resulting in moderate to severe harm to the patient.2) Modern Healthcare Magazine.3) Awarded by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality

Forum. Sentara received the award for "Innovation in Patient Safety and Quality at a Local or Organizational Level." 4) Awarded by the American Hospital Association.

In-Hospital Mortality Ratio: Sentara Hospitals, 2003 – 2008

Mortality Ratio (Actual Deaths/Expected Deaths)

Serious Safety Event Rate per 10,000 Adjusted Patient Days1

Sentara Hospitals, 2003-2010

2003 2004 2005 2006 2007 2008 2009 20100.0

0.1

0.2

0.3

0.4

0.5

0.60.5

0.2

Sentara Quality Awards

2012 Top 10 Integrated US Hospital System2

2010 Leapfrog Group of Top Hospitals

2005 John M. Eisenberg Award for Patient Safety3

2004 Quest for Quality Prize4

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3842

Action Items to Commit to Quality Transformation


Self-Test Questions

Review organisation’s mission statement• Is it clear that quality of care is central to the mission?• Are quality goals specific to the organisation, measurable, and

ambitious?

Evaluate executive communication around quality• Are front line staff convinced of senior clinical and non-clinical

executives quality commitment?• Is executive time spent on quality visible to staff?• Do executives have a mechanism to surface honest commentary on

potential problem areas from staff?

Evaluate quality enforcement and reinforcement practices• Are quality successes celebrated organisation-wide, in a way that is

meaningful to staff?• Are adverse events consistently and fairly evaluated? • Do medical staff governance procedures allow for quality compliance

enforcement if necessary?

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y •

250

3845

Transformational Quality

Lessons for Leading the Organisation to Clinical Excellence

IIIEmbed Culture of

Measurement

6. Set data expectations

7. Establish comprehensive clinical data infrastructure

8. Enable principled clinician autonomy

9. Educate clinicians in quality improvement

Case StudyIntermountain Healthcare

IISupport Front Line

Leadership

4. Empower front line to improve quality systems

5. Explicitly define doctor champion role

Case StudiesThe Johns Hopkins

HospitalBaylor Healthcare

ICommit to Quality

Transformation

1. Articulate specific, aspirational vision

2. Demonstrate informed dedication to front line

3. Enforce and reinforce new norms

Case StudySentara

Healthcare

©20

12 T

HE

AD

VIS

OR

Y B

OA

RD

CO

MP

AN

Y

Transformational QualityLeading the Organisation to Clinical Excellence

1 alice bell - transformational quality deck for webconference

Documents