Pursuing Excellence
Quality and Safety as the New Currency
Richard P Shannon, MD
Frank Wister Thomas Professor of Medicine
Chairman, Department of Medicine
University of Pennsylvania
Perelman School of Medicine
Session Objectives
• Explore the importance of organizational values
as the foundation for high performance
• Understand the characteristics of high
performing organizations
• Examine the application of such principals to the
elimination of harm as represented by hospital
acquired infections and unexpected deaths.
• Determine the business case for quality
Where is Academic Medicine in the
Journey toward Quality and Safety?
• Lack of clearly specified and audacious goals
• Infatuation with reportable not actionable
data
• Awash in meaningless measures
• Lack a common, disciplined problem solving
system (Hawthorne effect)
• No room for learning
• Confuse effort with success
AMCs and US Healthcare System
Why do we need “Leadership Leverage” ?
• Quality improvement has been about “projects.” We have
become good at making improvement happen for one
condition, on one unit, for a while
• We haven’t learned how to get measured results, quickly,
across many conditions for the whole organization
• Quality is never an accident; it is always the result of high
intention, intelligent direction and skillful execution; it
requires a commonly shared, disciplined problem solving
approach embraced not in the conference room but at the
point of care.
A “Project”
System Level Aim
The Sense of Urgency
Health Care and the Nation’s Economy
• “If we solve our health care
spending, practically all of
our fiscal problems go away,”
said Victor Fuchs, emeritus
professor of economics and
health research and policy at
Stanford. And if we don’t?
“Then almost anything else
we do will not solve our fiscal
problems.”
Healthcare Spending and Social Good
• US spends 18% of the GDP in healthcare
• CMS accounts for 20% of the total
government spending
-8x more than on education
-12x more than food aid
-30x more than on law enforcement
-78x more than conservation
-87x times more than water supply
-830x more than on energy conservation
High Performing Organizations
• High performing organizations are the best in
class
• They achieve high performance not
necessarily through technological advances
but through complete engagement of all the
wisdom and skill embedded in each worker
• These organizations and their leaders never
stop learning
Spear Chasing the Rabbit
Dynamics of HPOs
• Cope with complexity by continuous focus on
learning more about how to improve the work
they do.
• Its is not about knowing the right answer, its
about discovering the right answer.
• Nothing is ever good enough
Spear Chasing the Rabbit
The Four Capabilities of HRO
• Specifying work to capture existing knowledge
• Swarm and solve problems to build new
knowledge (avoid “information perishability”)
• Share that knowledge throughout the
organization
• Lead by developing these capabilities in all
workers
Spear Chasing the Rabbit
Leaders in HPOs
• Set clear and unambiguous expectations
• Amazing problem solving capabilities
• Empower and create systems that provide
answers….
• How they spend their time reflects their
values
• Take away all the excuses as to “Why not?”
Spear Chasing the Rabbit
Levers of Waste
•Harm
•Overtreatment
•Defects in care delivery
•Defects in care transitions
•Excess administrative costs
•Fraud and abuse
Don Berwick
Why Safety?
•
•
•
•
•
It is unassailable
Harm violates our professional duty
Harm is the elementary form of waste
It is valueless
It can be eliminated
Current US Estimates
•
•
•
•
•
5-10% of inpatients acquire an HAI
1.7 million HAIs annually
99,000 deaths
Estimated costs:$28.4-33.8 billion
It is 27X safer to work at Alcoa than it is to work
into a US hospital
Safer?
HAI in Pennsylvania 2012
23,287 HAI (1.2%)
Patient Outcomes
An Audacious and Unassailable Goal
• Can the elimination of harm (hospital
acquired infections, medication errors,
readmissions) serve as a starting point for
reducing unnecessary costs (waste) in
healthcare?
• Does it fulfill our professional duty to do no
harm and to be good stewards of finite
resources?
Problems With Bench Marking
The Difference Between Reporting and Actionable Data
10
9
8
7
6
NNIS
5
CCU/MICU
4
PRHI
3
2
1
0
01 Q3
01 Q4
02 Q1
02 Q2
02 Q3
02 Q4
03 Q1
03 Q2
What Does 5.1 infections/ 1000 line days
Really Mean??
•
•
•
•
•
•
37 patients / total of 49 infections
193 lines were employed (5.2 lines / patient)
1753 admissions
1063 patients had central access for more than 12 hours
1 out of 22 patients with a central line became infected.
We were reporting only half the actual infections (not including femoral
line infections!!)
• Two-thirds of the infections involved virulent organisms. Twenty percent
were MRSA
• 19 patients died (51%)
Journal of Quality and Patient Safety 2006;32:479
Personal Stories
• 22 yo. woman, a single mother of a 2 year old child, presented with
relapsing acute myeloid leukemia.
• Following re-induction with a highly toxic chemotherapy regimen, she is
found to be in complete remission.
• Day 18, she develops fever, chills and hypotension. BC grow staph aureus
from her Hickman catheter.
• In retrospect, the unused lumen of her triple lumen catheter had cracked
and been repaired.
• The cracked lumen-repair process was common place despite evidence
that it was associated with a27% risk of infection
• RCA revealed unspecified understanding about flushing unused
catheters and that there was a small area on the lumen where a clamp
should be re-enforced.
• The patient spend an additional 17 days in the hospital, away from her
child.
• She died 27 days after discharge.
Current Conditions
Root Cause Analysis
Decode: 37 CLABS
(July 2002-June 2003)
PRHI Central Line Data
Solve to root cause in real time
the origins of CLABS in
MICU / CCU
Observations of Dressing
Changes
Eliminate
CLABS
In MICU/CCU
In 90 days
Counter Measures Generated
By the People That Do The Work
Reassess Results
Generate Additional
Counter Measures
The Work of Physician Leaders
Rounding on Sick Systems
Rounding on Sick patients
• Chief complaint
• Present illness
• Physical exam/diagnostic
test
• Therapeutic intervention
• Clinical course
• Natural history
• Assessment of outcome
Rounding on Sick Systems
• What’s the problem ?
• How is work currently
done?
• What defects are
encountered in the work?
• Intervene to eliminate
defects
• Create a target condition
• Measure what actually
happens
• Gap analysis
The Current Condition of Variation
1
Steps
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DRESSING CHANGE STANDARD WORK
1) Set up work
Hand Hygiene
Wash or Purell
Open Drape
Open Dressing Kit
Drop Biopatch
Space
2) Prepare
People
3) Remove
Dressing
Adjust Bed
Remove with alcohol
4.) Clean site
Apply
Sterile
gloves
5.) Apply New
Apply
Biopatch
Don Masks
(nurse)
(patient)
Clean Gloves
Discard Trash
Chloraprep
30 seconds
Outline
Dressing
Apply
Dressing
Wash Hands
Allow to dry
30 seconds
Seal
Dressing
Apply Strips in
X and label
Central Line Associated
Blood Stream Infections
15
10
5
Months
ep
t
S
Ju
ly
pr
il
A
Ja
n
ep
t
0
S
Number of Infections
20
Value Stream Mapping
A Way to Identify and Correct Defect
• Types of catheters associated with HAIs
intravenous catheters
endotracheal tubes
bladder catheters
surgical sites
• Steps in Standard work
Placing
Maintaining
Manipulating
28
Reductions in HAIs
60
BSI
50
VAPS
40
MRSA
30
20
10
0
2001
2002
2003
2004
Fiscal Year
Journal of Quality and Patient Safety 2006;32:479
2005
2006
2007
2008
CCU/MICU and HAI
A Big Return on Investment
• Total Operating Improvements
CLAB= $1,235,765 (2 years)
VAP= $1,003,162 (1 year)
MRSA= $ 295,342 (1 year)
• Highmark PFP = $3,100,000 (2 years)
• HAI elimination Initiatives = +$5,634,269
• Investment = $85,607
• 388 additional ICU admissions
• 57 lives saved
Penn Medicine
The Journey of 1,000 Days
• Reduction in Variable Costs attributed to CA BSI elimination:
$10,923/case
• Total:
$3,823,050
• Reduction in LOS:
10.7 days
• Additional admissions:
623
• Additional revenue:
$3,613,400
• IBC P4P:
$3,200,000
• Total Financial Improvement:
• Lives saved
$10,636,450
65
Mortality
0.6%
12.3%
20X
Human Costs of CA-BSI
• 37 year old video game programmer, father of 4,
admitted with acute pancreatitis secondary to
hypertriglyceridemia.
• Day 3: developed hypotension, and respiratory
failure
• Day 6 : fever and blood cultures positive for MRSA
secondary to a femoral vein catheter in place for 4
days.
• Multiple infectious complications requiring
exploratory laparotomy and eventually
tracheostomy
• Day 86: Discharged to nursing home
Shannon RP: AJMQ
M. S.
CLAB
2/12/02
2/07/02
Day 1
Transfer
5/04/02
6
86
Total Cost of
Patient Stay
241,843.82
Total Cost before
CLAB
12,462.74
Not Related to
CLAB
12,462.74
Total Cost after
CLAB
229,381.08
Total Attributable
Cost
0.00
Primary to CLAB
0.00
Not Related to
CLAB
58,815.96
Secondary to CLAB
0.00
Total Attributable Cost
Before CLAB
0.00
Primary to CLAB
52,914.09
Total Attributable Cost
After CLAB
170,565.12
Total Cost Attributable to
Infection
170,565.12
70.53% of Total
Total Attributable
Cost
170,565.12
Secondary to CLAB
10,913.47
MICU Service
106,737.56
The Impact of CA-BSI on Gross Margin
DRG
204/2721
(n=3)
DRG 191
(n=3)
DRG 483
(n=2)
Case 1
Acute
Pancreatitis Pancreatitis
pancreatitis w cc
w trach
Revenue ($) 5,907
99,214
125,576
200,031
Expense
5,788
58,905
98,094
241,844
Gross
Margin
119
40,309
27,482
-41,813
Costs
attributable
to CA-BSI
LOS
170,565
4
38
41
86
UHC Mortality Rank
2012: 26th
• There were 804 deaths at HUP
• There were 462 deaths attributed to Medicine
• There were 49 deaths among electively
admitted patients
• There were 89 deaths among patients with
low/moderate severity of illness index
• 59% of deaths had an in-hospital complication
A Matter of Life and Death
•
•
•
•
•
Who died last night?
Was it expected or unexpected?
If unexpected, what happened?
Create clinical vignettes on all deaths
Were there any “bumps in the night?”
MICU transfers
Unexpected Deaths
15-20%
• Aspiration Pneumonia SIT UP
Patients at Risk
Interventions
• Delays in Diagnosis and Treatment
Heart failure
Liver Failure
UHC Mortality
1000
900
0.89
0.86
0.81
0.79
0.62
800
700
600
500
O/E
400
Deaths
300
200
468
453
464
453
372
2010
2011
2012
2013
100
0
2009
Summary
• High performing organizations are best in class based upon
values based leaders, disciplined problem solving systems
and a commitment to habitual excellence.
• Habitual excellence requires continuous improvement and
continuous improvement requires continuous learning as to
how to execute our work better.
• The elimination of harm and unexpected deaths is an
unassailable goal and illustrates the importance of values as
a the starting point on a journey toward excellence in
Medicine.
• Coupling the business case for quality with performance
improvement can accelerate the progress.
• Resources liberated from the elimination of waste as fuel
the virtuous cycle of our academic missions.
If Not us, Who?
Somebody has got to do something…
…its just incredibly pathetic that it has to be us !!!
Jerry Garcia The Grateful Dead
The Barriers to Change
There is nothing more difficult to take in hand, more perilous
to conduct, or more uncertain in its success, than to take the
lead in the introduction of a new order of things. For the
reformer has enemies in all those who profit by the old
order, and only lukewarm defenders in all those who would
profit by the new order, this lukewarmness arising partly
from fear of their adversaries … and partly from the
incredulity of mankind, who do not truly believe in anything
new until they have had actual experience of it.
Niccolo Machiavelli 1513
Primum Non Nocere
Cumulative Changes in Health Insurance Premiums and
Workers’ Earnings, 2001-2007
Health Insurance Premiums
Workers' Earnings
100%
80%
78%
60%
40%
19%
20%
0%
2001
2002
2003
2004
2005
2006
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the
Current Employment Statistics Survey, 1988-2007 (April to April).
2007
A new revolution….
Build a Parking Garage or Fix the Care Process?
Not more…better
Not volume….value
Modifying the Patient Experience
4:05
$32 parking
77 min
14 days
Call Wait for App
7 days
57 min
22
31
min min
Travel
Park Reg
57 min
15
min
23
min
Wait
VS
18
min
17 14
min min
Wait
MD
20
min
7
min
CO
11
min
97 min
Tests
45 min
18
min
Exit
14
min
37 min
Patient visits from 7-9/session
 On –Time Performance
 Patient satisfaction (waiting)
 Lag days
2:02
$8 parking
US Navy’s Nuclear Submarine Program
•
•
•
•
200 nuclear powered ships launched
5,700 reactor years of operation
154 million miles underway
Not a single reactor related casualty or escape of
radiation
• The leader: Admiral Hyman Rickover and the
discipline of specifying expectations and the
developer of incident reports
• Leaders and learning are indispensable
What Leaders think matters…
What leaders do matters more
• Your personal leadership
Setting audacious goals
Practice don’t espouse Values
• Your leadership system
Lessons from highly performing organizations
The importance of a common disciplined problem solving
• Transparency
Personal stories
The business case for quality
51
Begin with a Value Proposition
Our Contract With Society
•
•
•
•
•
•
•
•
•
•
Commitment to professional competence
Commitment to honesty with patients
Commitment to patient confidentiality
Maintenance of appropriate relationships with patients
Commitment to improving quality of care
Commitment to improving access to care
Commitment to scientific knowledge
Commitment to trust by managing conflict of interest
Commitment to professional responsibilities
Commitment to the just distribution of finite resources
Primum non nocere
will prescribe regimens for the good of my
patients according to my ability and my
judgment and never do harm to them anyone
will apply dietic measures for the
benefit of the sick according to my ability
and judgment; I will keep them from harm
and injustice.
Values Trumps Process
Improvement vs. Habitual Excellence
400
I
n
f
e
c
t
i
o
n
s
350
300
250
1,000 days
200
150
100
50
0
2007
2008
2009
2010
2011
2012
2013
Leadership Mentor
Leaders are responsible
for everything in an
organization, especially
what goes wrong.
Paul O’Neill