University of Texas Clinical
Safety and Effectiveness
Program
Third Year Evaluation
October 27,2011
Sherry Martin, Chancellor’s Health Fellow in
Clinical Effectiveness Programs
University of Texas Clinical Safety
and Effectiveness Program
Goal:
• To integrate quality and safety concepts into the
way we do our work everyday and enhance
organizational knowledge through disseminated
successful practices across the UT System
– The Clinical Safety and Effectiveness (CS&E)
quality improvement course
– Annual conference and recognition event
– University of Texas CS&E Fellowship Core
CS&E Quality Improvement
Course
The purpose of the CS&E course is to
establish a critical mass of clinicians able
to lead improvement efforts and serve as
faculty for the course to make
improvement practices part of daily
operations
UT CS&E Course Objectives
and Related Measures
• Establish the course at each of the UT healthcare
organizations
– # of organizations achieving full
implementation
• Reach a critical mass of graduates, completing
successful projects and leading improvement
efforts
– # of graduates
– # of successful projects
– % of graduates leading improvement initiatives
– # of publications and presentations by
graduates
CS&E Course Implementation
Third Year Results
• Fully implemented at MDACC, UTHSC –
Houston, UTSW, and UTHSCSA
– 936 Graduates + 35 enrolled
– 328 Completed projects + 18 underway
• UTMB – preparing for first class
graduation in 2012
• UTHSC-Tyler faculty graduates provide
organizational project mentorship and
oversight
• All campuses have course graduates
CS&E Course Implementation
Third Year Results
CS&E Annual Survey of Graduates
• Purpose:
– Determine extent to which course goals are
achieved
– Identify opportunities for improvement
– Identify individuals demonstrating exceptional
quality improvement expertise
• Electronic survey
• 2011 response – 18%
University of Texas CS&E
Annual Conference and Recognition
Event
• Goals:
– Transfer learning and applicable best
practices across the UT health care
organizations
– Recognize exceptional individual and
team improvement efforts
– Develop ideas and concepts to drive
system-wide improvement initiatives
UT CS&E Conference
Organizational Learning Goal
Measures
• # of conference participants/ % satisfaction
• # of abstracts accepted for presentation
• # of participants adopting CS&E project
practices
• # of projects achieving sustained results
• $ achieved through cost avoidance or
revenue enhancement
Second Year CS&E Conference
Results
• 80 abstracts accepted
• 233 participants
• “Overall satisfaction”- 74%
“excellent”; 98% “excellent/good”
“Identify strategies to adopt new
‘best practices’ 52% “excellent”; 92%
“excellent/good
Third Year CS&E Conference
Results
• 83 abstracts accepted for presentation
• Score to be considered for awards =
greater than 825
• Registration = 250
• One project submitted under “Adopted ”
• Five demonstrated sustained results over
2 years or more
• 18 publications by CS&E graduates in
peer-reviewed journals; numerous
graduates presented at national and state
meetings
Course/Conference Results
Quality Pays!
The “return-on-investment” for the
projects presented at the 2011
conference:
• $2.2M in project revenue, realized
• $0.9M in project cost avoidance, realized (
assuming 50% reimbursement)
• $3.7M projected savings/revenue if even
50% of the projections are realized
• $6.8M = Total gain
UT System Fellowship Program
• Goal: Establish a body of healthcare
providers who demonstrate
exceptional improvement expertise
and commitment to apply these skills
to make regular improvements and to
educate others
• Inducted 16 Fellows from all six UT
health care organizations
New Curriculum Concepts
• Lean Thinking and/or Six Sigma – all
campuses
• Team STEPPS – UTHSCSA
• Crew Resource Management –
UTSW, UTHSCSA
• Disclosure Training – UTHSCH,
UTHSCSA
Graduate and Undergraduate
Training Programs
• Integrated quality and patient safety interprofessional education into medical and
nursing students curriculum
• Established internal medicine and family
medicine residency rotations focused on
CS&E principles
• Provide quality principles at ground rounds
Web –Based Training
• IHI Open School courses suitable for
all health professions - five sites
• Quality College, courses at all levels,
resulting in certification – MDACC
• Office Time – courses in Microsoft
Office graphing principles - UTSW