The Baylor Health Care System STEEEP Journey
ISQua Webinar
March 13, 2014
David J. Ballard, MD, MSPH, PhD, FACP
Chief Quality Officer, Baylor Scott & White Health
President, STEEEP Global Institute
President, ISQua, 2001 – 2003
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
1
Overview of Baylor Health Care System
 More than 300 access points of care including:
 30 hospitals owned, operated, joint-ventured or affiliated with
BHCS
 28 ambulatory surgery/endoscopy centers
 209 locations for the HealthTexas Provider Network (the BHCSaffiliated ambulatory care physician network)
 91 satellite outpatient facilities for imaging, rehabilitation, and
pain
 3 senior health centers
 6 retail pharmacies
 3 Baylor Research Institute locations
 1 accountable care organization (Baylor Quality Alliance)
 Merged with Scott & White Healthcare on September 30, 2013 to
form the largest not-for-profit health care system in Texas . . .
2
The New Baylor Scott & White Health
 More than 500 patient care sites including 43 hospitals
 5.3 million patient encounters annually
 More than 34,000 employees
 More than 6,000 affiliated physicians
 Scott & White health plan
 $8.3 billion in total assets
 $5.8 billion in total net operating revenue
3
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
5
Crossing the Quality Chasm
(Institute of Medicine, United States, 2001)
 The nation’s health care delivery system has fallen far short in
its ability to translate knowledge into practice and to apply
new technology safely and appropriately
 Overly devoted to dealing with acute, episodic care needs
and lacking the multidisciplinary infrastructure required to
provide the full complement of services needed by people
with common chronic conditions
 Delivery of care often is overly complex and uncoordinated,
requiring steps and patient “handoffs” that slow down care
and decrease rather than improve safety
 Bringing state-of-the-art care to all Americans in every community
will require a fundamental, sweeping redesign of the entire health
system…
5
U.S. Institute Of Medicine
Six Aims for Improvement, 2001
Safe
Avoids injuries to patients from care that is intended to help them
Timely
Reduces waits and harmful delays impacting smooth delivery of care
Effective
Provides services based on scientific knowledge to all who could benefit & refrains
from providing services to those not likely to benefit (avoids overuse & underuse)
Efficient
Uses resources to achieve best value by reducing waste, production, and
administration costs
Equitable
Does not vary in quality according to personal characteristics such as gender,
income, ethnicity & location
Patient Centered
Respectful of and responsive to individual patient preferences, needs, and values
6
Baylor Health Care System’s STEEEP Journey
 The STEEEP acronym was trademarked by BHCS
to communicate the challenge of achieving its objective to
provide ideal care in terms of the IOM’s call for care that is
safe, timely, effective, efficient, equitable, and patientcentered.
 STEEEP also communicates the “steep” challenge of
ascending from current levels of care to achieving the
national Triple Aim (articulated by Don Berwick in 2008) of
better care for individuals, better health for populations, and
reduction in per-capita health care costs.
7
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
9
International Quality Frameworks:
United States
National Quality Strategy (2011)
Three aims
Six priorities
Better care
Healthy
people/healthy
communities
Affordable care
 Making care safer by reducing harm caused in the
delivery of care.
 Ensuring that each person and family are engaged as
partners in their care
 Promoting effective communication and coordination
of care.
 Promoting the most effective prevention and
treatment practices for the leading causes of
mortality, starting with cardiovascular disease.
 Working with communities to promote wide use of
best practices to enable healthy living
 Making quality care more affordable for individuals,
families, employers, and governments by developing
and spreading new health care delivery models.
9
International Quality Frameworks:
Australia
Australian Safety and Quality Framework for Health Care (2010)
Safe, high quality health is always:
Consumer
centered
• Providing care that is easy for patients to get when they need it.
• Making sure that healthcare staff respect and respond to patient
choices, needs and values.
• Forming partnerships between patients, their family, carers and
healthcare providers.
Driven by
information
• Using up-to-date knowledge and evidence to guide decisions
about care.
• Safety and quality data are collected, analysed and fed back for
improvement.
• Taking action to improve patients’ experiences.
Organised for
safety
• Making safety a central feature of how healthcare facilities are
run, how staff work and how funding is organised
10
International Quality Frameworks:
Norway
National Strategy for Quality Improvement for the Health and Care
Services, 2005-2015
Effective
Safe and secure
Six aims/elements
of high-quality
health services
Involve users and allow them to have influence
Coordinated and integrated
Utilize resources appropriately
Available and equally distributed
11
International Quality Frameworks:
United Kingdom
2008: Quality should include patient safety, patient experience, &
effectiveness of care. (Source: Lord Darzi, National Health Service Next Stage Review)
2013-2014: Five domains for quality improvement derived from the quality
definition outlined by Lord Darzi (Source: NHS Outcomes Framework 2013/14)
12
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
15
System Alignment for STEEEP Care:
Governance
 Board of Trustees Quality Resolution (2000, reaffirmed in 2010)
“Therefore, be it resolved, that the Board of Trustees of Baylor
Health Care System hereby challenges itself and everyone
involved in providing health care throughout the system to give
patient safety and continuous improvement in the quality of
patient care the highest priority in the planning, budgeting and
execution of all activities in order to achieve significant,
demonstrable and measurable positive improvement in the
quality of patient care and safety.”
14
System Alignment for STEEEP Care:
Governance
Board of Trustees Mortality Resolution (2005)

Baylor Healthcare System management, medical staffs and
hospitals will commit their attention and necessary resources to
rapidly implement the six programs that are part of the Institute
for Healthcare Improvement 100,000 Lives Campaign, and

The Baylor Health Care System will, during fiscal year 2006,
attempt to reduce the inpatient mortality rate experienced during
fiscal year 2005 by four percent, in each acute care hospital and
in the aggregate across the system.
15
System Alignment for STEEEP Care:
Organization
STEEEP Governance Council
Consolidates efforts of clinical, operational, & financial leadership and ensures that all improvement efforts
encompass all domains of STEEEP care
BHCS President
STEEEP Governance Council
Clinical Service
Lines:
- Cardiovascular
- Critical Care
- Emergency
Services
- Gastrointestinal
- Neuroscience
- Oncology
- Orthopedics
- Transplant
- Women’s Health
- Path & Lab Med
- Radiology
STEEEP Subcommittees
Patient Safety
Clinical Excellence:
(Timeliness & Effectiveness)
Efficiency & Fiscal Impact
Equity / Population Health
Patient Centeredness/Patient Experience
Business Support
Services:
-Information
Services/ IT
-Compliance
-Finance
-Human Resources
New Business Development
(e.g., STEEEP framework applied to new
model urgent care centers)
- Supply Chain
16
STEEEP Governance Council,
Subcommittees & Aligned Entities
STEEEP Governance Council
Voting members: Chief Quality Officer (Chair), Chief Medical Officer, Senior Vice President of
Financial Operations, Chief Nursing Officer, Senior Vice President BHCS Hospitals, Chair of
the BHCS Physician Group, President of the BHCS Accountable Care Organization
STEEEP Governance Council Subcommittees
Patient
Safety
Clinical
Excellence
(Timeliness and
Effectiveness)
Efficiency and
Fiscal Impact
(Led by Finance, with
clinical and operational cochairs)
Equity /
Population
Health
Patient
Centeredness/
Patient
Experience
Aligned Entities
STEEEP Measurement, Analytics, and Reporting
STEEEP Care Improvement Training
Clinical Service Lines
17
System Alignment for STEEEP Care:
Leadership

Chief Quality Officer: 1999
o
Center for Health Care Research & Improvement: 1999

Physician Champions: 2000

Chief Patient Safety Officer: 2004

Chief Medical Officer: 2006

Chief Health Equity Officer: 2006

Chief Nursing Officer: 2007

Chief Patient Centeredness Officer: 2007
18
System Alignment for STEEEP Care:
Accountability: Goal Setting & Incentives
 System-wide care goals aligned with BHCS ‘Circle of Care’
People: Employee retention
Quality: Core Measures, inpatient mortality reduction,
30-day readmission for AMI, HF, & PN
Service: Patient satisfaction survey scores (HCAHPS)
Finance: Net operating margin
 Director-level and above have compensation at risk, linked to
performance relative to goals
 All employees have annual merit compensation linked to performance
relative to goals
19
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
22
Infrastructure and Tools for STEEEP Care:
STEEEP Academy
Teaches the theory and techniques of process improvement and empowers
physicians, nurses, administrators, and other stakeholders with the skills and
strategies needed to improve health care quality, patient safety, and operational
outcomes.
Leadership, Creativity, Innovation
Knowledge
of Tools
Kaizen
Gradual, unending
improvement by
doing things better
and setting and
achieving
increasingly higher
standards
Lean
Improving process
flow and minimizing
waste with the same
or fewer resources to
enhance efficiency,
reduce time, and
create more value.
Six Sigma
A statistical
approach to improve
quality outcomes by
identifying and
eliminating defects
(errors) and
minimizing process
variation
Focus on
Improvement
• Standardize processes
• Simple, tactical focus
• Obvious quick fixes
• Inventory performance
• Improve speed, cycle
time
• Complex problems
• Increase process
stability, predictability
• Prevent errors
Staff Involvement and Engagement
21
Infrastructure and Tools for STEEEP Care:
STEEEP Academy
Project alignment with BHCS’s four areas of focus and annual goals
Area
Issues/Goals/Initiatives
Service
Patient satisfaction (e.g., indicators HCAHPS, Press Ganey, and Point-of-Care patient
satisfaction surveys); departmental service scores—how well the department/service line serves
its customers
Quality
Projects that affect the outcomes of care given to the end-user (patient or population) (e.g.,
indicators including National Patient Safety Goal compliance, Quality Measures, Leapfrog, and
National Quality Forum standards); in-service activities; efforts to eliminate unnecessary variance
in processes that affect clinical outcomes
People
Mobilization of human resources (e.g., float pools, PRN programs, cross-training); recruitment,
retention, training, and development; environmental work culture (e.g., Magnet designation)
Finance
Reducing waste/nonvalue-added activities; decreasing average length of stay; increasing
revenue; increasing volume; improving coding.
> More than 3200 employees and 250 external customers have been trained to date
22
Infrastructure and Tools for STEEEP Care:
Electronic Health Records
The EHR is an essential tool for supporting STEEEP care:
 Patient safety – the EHR performs automatic checks for known allergies,
correct dosing and other medication safety issues.
 Elimination of repetition – patients don’t need to provide information over
and over.
 Timely test reports – lab reports and test results are available as soon as
they’re entered in the EHR.
 Accuracy and legibility – eliminates handwriting errors and legibility
problems.
 Quick data retrieval – easy access to patient records.
 Enhanced communication – authorized users have immediate
access to the same patient information from anywhere in the
hospital.
 Clinical decision support – enables access to clinical
information and evidence-based guidelines from
respected resources.
23
Infrastructure and Tools for STEEEP Care:
STEEEP Measurement, Analytics and Reporting





Data management, data mining, analysis and reporting to support
data-driven decision making
Implementation and reporting of performance measurement indicators
Integration of data from multiple sources within BHCS, as well as
state, regional, and national databases for benchmarking purposes
Biomedical data management from EHRs and other clinical systems
System-wide support for standardized reporting and ad-hoc data
requests
Major areas of performance measurement and reporting at BHCS include:




Value-based purchasing
CMS Core Measures
Clinical preventive service delivery
Measurement of hospital-standardized mortality rates
24
STEEEP Analytics Examples:
Evaluation of Clinical & Financial Outcomes
Standardizing Care
With a Pneumonia
Order Set
Standardizing Care
With a Heart Failure
Order Set
Pneumonia order set use
resulted in:
Heart Failure order set
use resulted in:
 Reduction in inhospital mortality
 Increase in heart
failure Core Measures
compliance
 Reduction in 30-day
post-admission
mortality
 Reduction in inpatient
mortality
 Increase in core
measures compliance
 Reduction in 30-day
mortality
 Potential life years
saved of 12 years per
patient
 Reduction in 30-day
readmission
 Reduction in direct
cost
Measuring the Financial
and Non-Financial
Costs of Implementing
EHRs
EHR implementation for
an average 5-physician
practice resulted in:
Effectiveness and Cost
of a Transitional Care
Program for Heart
Failure
An advanced practice
nurse-led transitional
care program resulted in:
 Implementation cost of  Reduction in 30-day
$162,000
readmission rates
 $85,500 in
maintenance
expenses during the
first year
 611 hours to prepare
for and implement the
electronic health
record system
 Little effect on length
of stay or total 60-day
direct costs
 Reduction in hospital
financial contribution
margin of $227 per
patient
25
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
28
Achieving STEEEP Health Care:
Efficient Care
Creating a highly efficient cost structure requires:
Operational Excellence
Business Restructuring
Clinical Restructuring
Budgets and Controls
Mergers and Acquisitions
Care Processes
Revenue Cycle
Enhanced Capital Allocation
Physician Integration
Supply Chain
Operating Model Redesign
Narrow Networks
Measurement, Data Mining
and Reporting
Portfolio Optimization
Service Distribution
Optimization
Productivity
Payment Transition (fee-forservice to fee-for-value)
Care Continuum
Coordination
Expense Management
IT Operable Information
Optimization
Progress Toward Comprehensive Cost Reduction
Effective Transition/Change Management and Execution
Hard
Engage Many Providers
Harder
Hardest
Engage Selected Leading Providers
27
Example: Efficient Care
OPPORTUNITY FOR IMPROVEMENT
An inventory of heart failure initiatives across BHCS revealed
more than 60 order sets in use across the health care system,
many of which duplicated efforts and were implemented by
different teams with different processes at individual facilities.
28
Example: Efficient Care
INTERVENTION
Development and implementation of a standardized heart
failure order set:
• Order set was developed internally, with content driven by
the prevailing ACC/AHA clinical practice guidelines, and
deployed system-wide via an intranet physician portal
• More than 2000 staff members trained in rapid-cycle
quality improvement over a 15-month period, creating a
critical mass of physicians, nurses, and hospital
administrators to drive change initiatives including
standardized order set adoption.
• Rapid dissemination of unblinded hospital-level and
physician-level performance data (order set use)
29
Example: Efficient Care
RESULTS
 95% use of the standardized order set at 9 months
 51% decrease in risk of in-hospital mortality
 $1909 decrease in total direct cost (initial hospitalization + 1-yr
all-cause readmissions costs
Annually, this translates into savings of >15,000 inhospital deaths and $2 billion in hospital costs
nationally
Ballard, D. J., G. Ogola, N. S. Fleming, B. D. Stauffer, B. M. Leonard, R. Khetan, and C. W. Yancy. 2010.
Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care.
International Journal for Quality in Health Care 22 (6): 437–444.
30
Topics to be Covered
1.
2.
3.
4.
Overview of Baylor Scott & White Health
Defining STEEEP Care and the STEEEP Journey
International Quality Frameworks
System Alignment for STEEEP Care
 Governance
 Organization
 Leadership
 Accountability: Goal Setting & Incentives
5. Infrastructure and Tools for STEEEP Care
 STEEEP Academy
 Electronic Health Records
 STEEEP Measurement, Analytics, and Reporting
6. Achieving STEEEP Health Care: An Example
7. Concluding Remarks
38
Concluding Remarks
BHCS has gained valuable experience along its STEEEP quality journey.
Critical success factors include:
1. Commitment to quality improvement from the highest levels of leadership
2. Investments in training leaders in quality improvement techniques and clinicians
in leadership skills, and supporting their application of those skills
3. Creation and maintenance of the infrastructure needed to support large-scale, indepth data collection, analysis, and reporting of performance data
4. Application of the STEEEP framework both to clearly communicate goals and
priorities throughout the organization and to guide the organizational
management framework
5. Close alignment with BHCS employed physicians as well as other physician
members of our Accountable Care Organization
6. Remaining vigilant of changing conditions in the health care environment through
participation in national learning organizations & implementing new strategies,
tactics, and tools when these indicate a new need to be met
32
Questions?
33
Additional Resources on
BHCS’s STEEEP Journey
 Ballard DJ, ed. Achieving STEEEP Health Care. Boca Raton: CRC Press, 2013.
 Kennerly DA, Kudyakov R, da Graca B, Saldana M, Compton J, Nicewander D, Gilder R.
Characterization of adverse events detected in a large health care delivery system using
an enhanced Global Trigger Tool over a 5-year interval. Health Services Research (in
press).
 Kennerly DA, Saldaña M, Kudyakov R, da Graca B, Nicewander D, Compton J.
Description and evaluation of adaptations to the global trigger tool to enhance value to
adverse event reduction efforts. J Patient Saf. 2013 Jun;9(2):87-95.
 Compton J, Copeland K, Flanders S, Cassity C, Spetman M, Xiao Y, Kennerly D.
Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient
Saf. 2012 Jun;38(6):261-8.
 Kennerly D, Richter KM, Good V, Compton J, Ballard DJ. Journey to no preventable risk:
the Baylor Health Care System patient safety experience. Am J Med Qual. 2011 JanFeb;26(1):43-52.
 Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. Large-scale deployment of
the Global Trigger Tool across a large hospital system: refinements for the
characterisation of adverse events to support patient safety learning opportunities. BMJ
Qual Saf. 2011 Jan;20(1):25-30.
34
Additional Examples of
STEEEP Care Initiatives
35
Achieving STEEEP Health Care:
Safe Care
The BHCS patient safety vision:

Achieving no preventable deaths (hospital-standardized mortality ratio)

Ensuring no preventable injuries (hospital-acquired adverse events)

Seeking no preventable risk
Strategies and Tactics:



Culture: Employee patient safety culture survey, hospital and clinic biennial
patient safety survey, data review, site visits, formal report to leaders and
shared goal setting
Processes: e.g., increased evidence-based order set use, reduce adverse
drug events, National Patient Safety Goals, NQF Safe Practices… …
Technology: EMRs and clinical decision support, computerized physician
order entry, bar code medication administration
36
BHCS Biennial Patient Safety Culture Survey
 Electronic survey designed to facilitate data-driven conversations about
patient safety issues
 Assesses the culture of safety as measured by both attitudes and practices
pertinent to patient safety
 Specific reports to target groups
• System leaders; hospital level; service line/care areas
Domain
Leadership
Resources
Teamwork
Reporting &
Feedback
Domain Definition
The degree to which hospital leadership promotes patient safety through
their direct involvement and their ability to deal with staff issues that impact
patient safety.
The degree to which the resources provided to staff are adequate to
support a safe environment to give and receive care.
The degree in which there is teamwork among individual staff, departments
and different professional groups.
The degree in which there is a safe environment that encourages speaking
up to protect patient safety and to learn from near misses.
37
BHCS Biennial Patient Safety Culture Survey
OPPORTUNITY FOR IMPROVEMENT
Sup-optimal response to the
survey item:
“The Safe Surgery Saves
Lives (SSSL) process took
place as well as you would
like if you or a family member
were the patient”
38
BHCS Biennial Patient Safety Culture Survey
INTERVENTIONS
 Rounded with OR staff to determine barriers in compliance with the SSSL
checklist
 Passed resolution to fully implement and monitor the SSSL process
(Operating Policy and Procedure Board, September 2009)
 Monitored checklist compliance every 6-8 months by e-Survey
 Increased OR staff competence and confidence in “stopping the line” if
processes were not followed in the OR
 Shared survey data with surgeons/OR team and recognized those surgeons,
anesthesiologists, and team members that consistently complied with checklist
 Continuing e-Survey questions and rounding with OR staff as part of the
Patient Safety Program every two years
39
BHCS Biennial Patient Safety Culture Survey
RESULTS
The SSSL processes took place as well as you would
like if you or a family member were the patient
96%
94%
95%
94%
2012
2013
92%
88%
2009
2010
2011
2014
Overall results for all BHCS hospitals
40
Baylor Adverse Event Measurement Tool
 Identifies rates and types of adverse patient events (AEs) associated
with measurable patient harm through randomly chosen chart
reviews (~2%)
 Goal is to reduce patient harm through the prioritization of patient
safety concerns and implementation of process improvements
 The electronic application allows for data analysis / trending to target
when and where intervention may be needed to address AEs
41
Baylor Adverse Event Measurement Tool
OPPORTUNITY FOR IMPROVEMENT
46% of all AEs identified during FY08-FY10 were related to
surgical or other procedures
Type of Adverse Event
% of all AEs
Procedures/Surgery
46%
Adverse Drug Events
24%
Hospital-Acquired Infection
11%
VTE
2%
All Other
17%
(for patients with LOS >3 days)
42
Baylor Adverse Event Measurement Tool
INTERVENTION
Office of Patient Safety Human Factors Engineer and
front-line OR staff developed a process and form to
overcome barriers when identifying patients in the OR
setting and labeling specimens, transfusing blood and
other high risk interventions
43
Baylor Adverse Event Measurement Tool
RESULTS
OR Passport in use
1
2
Pre Op Interview
Pre Op Checklist
RN attaches the patient
label to the OR passport at
the time of Pre OP
Interview
RN utilizes the Passport
Checklist to complete Pre
Op Interview
3
Passport Completion
When Patient arrives in OR
suite RN will initial and date
Passport as a second
confirmation of Patient ID at
sign in
Reported usage after 3 months: highly preferred and used
- Most (81%) respondents use OR Passport 100%
- “It really is a safety net”
- “Easy to use. Central location for needed information.”
44
Example: Safe Care
OPPORTUNITY FOR IMPROVEMENT
In 2006, BHCS hospitals performed worse than the Society of
Thoracic Surgeons (STS) national averages for:
 Risk-adjusted mortality for isolated coronary bypass surgery and
aortic valve surgery
 Use of internal mammary artery
 Pre-operative beta blockade (for coronary bypass surgery)
45
Example: Safe Care
INTERVENTIONS
 Education and monthly feedback on performance on key STS quality
metrics
 ALL CV surgeons expected to attend semi-annual meetings during
which facility-level metrics are reported & individual surgeon data are
presented (originally blinded; now unblinded). No elective cardiac
surgeries scheduled before meetings
 Physician, nurse, and non-clinical administrator training in rapid-cycle
quality improvement (STEEEP Academy)
 Implementation of standardized care paths, order sets, and nurse
checklists
 Mandatory 2nd opinion for pre-op risk assessment >8% for in-hospital or
30-day mortality
46
Example: Safe Care
RESULTS
2 BHCS hospitals are among only 24 hospitals nationwide to have a 3star rating from STS for both isolated coronary artery bypass graft
surgery and aortic valve surgery.
BHCS ISOAVR Risk Adjusted Mortality
By Year
BHCS ISOCAB Risk Adjusted
Mortality By Year
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
6.0%
3.8%
3.2%
2.5%
2.7%
1.9%
2012
STS =
1.9%
1.7%
5.0%
5.0%
4.7%
4.1%
4.0%
2012
STS =
2.6%
3.0%
2.1%
2.0%
1.1%
0.9%
2011
2012
1.0%
0.0%
2007
2008
2009
2010
2011
2012
2007
2008
2009
2010
53
Achieving STEEEP Health Care:
Timely Care
Delivery of the “right care at the right time”

Lack of timeliness signals a lack of attention to flow and
a lack or respect for the patient, which can result in:
o Physical harm due to delay in diagnosis or treatment
o Emotional distress

Waiting times should be continually reduced for both patients and those who
give care

Requires multiple ways of responding to patient needs beyond patient visits,
including use of the internet
Example Initiatives:

Sepsis QI program to improve triage to antibiotic delivery time

Collaborative STEMI teams to improve door-to-balloon times
48
Example A: Timely Care
OPPORTUNITY FOR IMPROVEMENT:
STEMI care processes at The Heart Hospital Baylor Plano were
deemed inefficient and inconsistent with average door-toballoon time below the target of 90th percentile for STEMIreceiving hospitals nationwide
 The size of a heart attack and the risk of death are directly related
to the amount of time the heart is ischemic, or starved for blood
and oxygen.
 Opening the blocked artery within 90 minutes of hospital, as
recommended by national guidelines (American College of
Cardiology/American Heart Association) has repeatedly been
associated with better outcomes.
49
Example A: Timely Care
INTERVENTION:
 Creation of structured and collaborative STEMI teams
 Increased education and support for local EMS and referring
hospitals
 Standardized tools and care
processes including a “STEMI
bucket” containing essential
medical supplies
50
Example A: Timely Care
RESULTS
 10% reduction in median door-to-balloon time between 2012 and 2013
Median Door-to-Balloon Time
65
60
60
Minutes
56
55
55
54
2013Q1
2013Q2
50
45
40
2012Q3
2012Q4
D2B Median Time
2013Q2 90th Pctl (47.3)
51
Example B: Timely Care
OPPORTUNITY FOR IMPROVEMENT:
Prior to launch of a specific sepsis QI program, BSWH facilities
were meeting the NQF endorsed 3-hour time goal (triage to
antibiotic delivery) in only 60% of cases and median time to
antibiotic delivery was over 2 hours
 Severe sepsis and septic shock are associated with mortality as
high as 30-40%
 Prompt recognition and resuscitation have been shown to
improve patient outcomes in severe sepsis and septic shock;
every hour that antibiotics are delivered earlier reduces mortality
by 7%
52
Example B: Timely Care
INTERVENTION:
 Establish interdisciplinary teams and joint ownership of sepsis care (ED,
hospitalist, critical care)
 Appointment of system level task force to align QI activities at individual
hospitals
 Cultural shift to place sepsis as an emergent, time-sensitive condition similar to
acute MI and stroke
Specific QI Tactics (under a LEAN framework)
 Development of a standardized performance report and feedback loops with
well defined accountability (service line and clinician level)
 Protocol driven diagnostic work-up in ED
 Implementation of 3 and 6-hour bundle order sets to facilitate antibiotic admin.
 Institution of daily huddles with case reviews in ED
 Streamlined nursing workflow (minimize delays waiting for 2nd blood cultures;
reinforcement that administration of 2 antibiotics concurrently was an
acceptable practice).
53
Example B: Timely Care
RESULTS
Improvement in antibiotic administration time (3-hour time goal)
Launch of QI Initiative
54
Example B: Timely Care
RESULTS
 Pushing Achievement Level:
(2-hour adherence & reduced average
antibiotic delivery time)
Median time triage to abx.
% pts. triage to abx. <120 mins.
Launch of QI initiative
Launch of QI initiative
55
Achieving STEEEP Health Care:
Effective Care
 Clinical care processes centered on patient welfare
 Evidence-based practice is supported by integrating
evidence with clinical expertise and patient values
 Underuse of effective care and overuse of ineffective care
should be avoided (e.g., imaging for lower back pain)
 Newest STEEEP subcommittee – at an early stage of
implementation for these types of initiatives in alignment with
Clinical Service Lines and the BHCS ACO (Baylor Quality Alliance)
56
Example: Effective Care
OPPORTUNITY FOR IMPROVEMENT:
Baseline data collected for the Medicare Image Demonstration
project from December 2011 through March 2012 revealed that
43% of lumbar spine MRIs ordered by HealthTexas physicians
were inappropriate compared with 7% for the national
comparison group.
 Frequent and unnecessary lumbar spine imaging is a major
contributor to unnecessary surgical procedures and the inherent
risks therein
57
Example: Effective Care
INTERVENTIONS
 Major education initiative to raise awareness about imaging
overuse among HTPN physicians and to educate them, and
their patients, about appropriate use.
 Development of a Low Back Pain Protocol, approved by the HTPN
Best Care Committee and Board, to assist physicians in providing
evidence-based treatment, while reducing costly and unnecessary
imaging and/or diagnostic studies.
 Regular reporting and dissemination of performance measures
commensurate with participation in the Medicare Imaging
Demonstration project
58
Example: Effective Care
RESULTS
Appropriateness data collected through the Medicare Imaging
Demonstration (MID) project between April 1, 2012 and August 31,
2012 show that the percentage of inappropriate lumbar spine MRIs
decreased from 43% during the baseline period to 8%
Baseline Period
Intervention Period
(Oct. 1, 2011–March 31, 2012*)
(April 1, 2012–August 31, 2012)
HTPN (n = 40)
Demonstration
HTPN (n = 109)
Demonstration
% inappropriate
43%
7%
8%
5%
% uncertain
3%
9%
2%
12%
% appropriate
54%
84%
90%
84%
59
Achieving STEEEP Health Care:
Equitable Care
BHCS structures to support health equity:



STEEEP Governance Council
Institute of Chronic Disease and Care Redesign
HTPN Best Care Committee (subcommittee on equity)
Major Initiatives:






HTPN Volunteers-in-Medicine (for community health improvement)
Community-based partnership to reduce ED utilization among the uninsured
Diabetes Equity Program
Baylor Community Care Clinics (full functioning clinics with EHR and NCQA
PCMH recognition for un- and under-insured)
Vulnerable Patient Network (house calls w/ Advanced Practice RN)
Diabetes Health & Wellness Institute
60
Example: Equitable Care
OPPORTUNITY FOR IMPROVEMENT
In June 2010, only 12% of participants at the BHCS Diabetes Health
and Wellness Institute in South Dallas met the recommended
diabetes care guidelines for hemoglobin A1c control
 Prevalence of diabetes in Dallas County exceeds both state and
national rates (11.4%, compared with 9.6% in Texas, and 8.3%
nationwide).
 The burden is disproportionately borne by communities in southern
Dallas County (which lack adequate access to health services, safe
environments, and healthy foods)
61
Example: Equitable Care
INTERVENTION
DHWI holistic care model coordinated by a diabetes care team that
includes a primary care physician, nurses, diabetes educators,
community health workers, pastors, social workers, and exercise
specialists
62
Example: Equitable Care
RESULTS
A 16% increase in participants who achieved the recommended
guideline for hemoglobin A1c control between June 2010 and
December 2013
Hemoglobin A1c (<8.0%) n = 326
Meets
Does Not Meet
Baseline
50%
50%
Follow-Up
66%
34%
Participants shown were diagnosed with type 2 diabetes and enrolled in DHWI treatment
programs for ≥ 1 year. Mean length of time between baseline and follow-up
measurements was 11.3 months.
63
Achieving STEEEP Health Care:
Patient-Centered Care
Patients need to be actively invited at every encounter, by
every caregiver, to:
 Participate in their own care
 Offer their needs, values, and preferences
 Understand all of their options and the related consequences and
commitments before making informed decisions
Example Initiatives:
 AIDET (acknowledge, introduce, duration, explanation, thank you)
 Rounding for outcomes
 Care calls
 Open access
 Shared decision making
64
Example: Patient-Centered Care
OPPORTUNITY FOR IMPROVEMENT
According to system-wide HCAHPS scores in 2009, only 72% of
patients rated BHCS hospitals a 9 or 10 on a scale of 0-10; and
72% thought that nurses explained things in a way they
understood.
65
Example: Patient-Centered Care
INTERVENTIONS
Open access to loved ones to meet the preferences or patients in their
care including:
 Signage & Access: Restrictive signage removed; additional signage in
2nd language where appropriate
 Policy: New policy adopted as a system; changes made to the
Patients’ Rights guide
 Primary Support: Systematic process to identify the PSP, including
adding field to EHR
 Open Access 24/7: Accommodations to support presence of PSP;
reasons for restrictions explained and documented
 Guidelines: Written for facility or unit level
66
Example: Patient-Centered Care
% Top Box
% Top Box
RESULTS
Improved system-wide HCAHPS scores in the areas of nurse and overall
hospital rating.
Open access begins
Question:
Nurses explain things in a
way you understand
Top box includes rating of
“Always”
Question:
How would you rate this
hospital during your stay?
0 (worst) – 10 (best)
Top box includes ratings
“9” and “10”
67