2017 nicolas e. davies enterprise award of excellence
TRANSCRIPT
2017 Nicolas E. Davies Enterprise Award of
Excellence
Agenda
• Memorial Hermann Health System Overview
• Case study review– VAP Prevention
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Memorial HermannHealth System
Woodlands Sugar Land TMC Katy Memorial City Southeast
Greater Heights
Northeast
TIRR Katy RehabKaty Rehab
Children’s Southwest
• Total hospitals: 15 (11 acute, 2 rehab, 1 children’s, 1 orthopedic)
• Inpatient admissions: 158,241• Annual emergency visits: 595,611• Annual deliveries: 25,146
• Employees: 25,040• Beds (acute licensed): 4,016• Medical staff members: 5,708• Fellowship programs: 48
PearlandCypress
MHOSH3
Our Network of Care
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292 Care Delivery Sites
Certified Zero Awards32
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Memorial HermannRecent Accolades
15 Top Health Systems; Top 5 Large Health Systems
(2012 & 2013)
National Quality Forum National Quality
Healthcare Award (2009)
TIRR Memorial Hermann No. 2 in rehabilitation
hospitals
2011 Texas Healthcare Foundation Quality
Improvement Awards (9 Memorial Hermann
Campuses)
Healthcare’s “100 Most Wired” 12th
consecutive year America’s 50 Best Hospitals (2010-2014)
Texas Hospital Association
Bill Aston Quality Award (2011)
America‘s #1 Quality Hospital for Overall
Care (2011 & 2012)
John M. Eisenberg National Patient Safety &
Quality Award (2012)
2015 Houston Business Journal (HBJ) No. 3 Best Places to Work
The Joint Commission
Top Performer (2012), Heart Attack, Heart
Failure, Pneumonia,
Surgical Care
Quality – A competitive advantage for Memorial Hermann
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Population Health Infrastructure
~4,000 MHMD Physicians, ~3,500 ‘CIN’ Clinically Integrated NetworkPrivate, Employed & Faculty Integration
PrivateEmployment Faculty
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The MH ACO allows for integration of a pluralistic physician model (UT, MHMG & MHMD) to drive quality outcomes
3 DISTINCT PRACTICE MODELS
428 2961 1170
High
Moderate
Low Fragmented Transitioning Integrated
Increasing Degree of Integration
Degree of Risk Shifting to Provide
rs
Delivery System Readiness for Risk
BCBS Commercial75,000
United Healthcare
100,000
United Healthcare Commercial
100,000Community Health Choice
54,740
Aetna Medicare Advantage5,800
Humana Medicare
5,000
Humana Medicare Advantage
5,000United Healthcare Medicare
Advantage 8,800
CMS MSSP47,400
Aetna Commercial85,000
Humana Commercial18,700
MH Health Plan CommercialMHHS 39,136 | Other
28,881MH Health Plan
Medicare Advantage 6,790Aetna Whole Health
26,200
TIER
IIGain Sharing
TIER
III
Value Driven
TIER
IPartial ‐Full Risk
501,447Members
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101,007Lives
345,700 Lives
MH assumes varying degrees of risk for their ACO members
Our JourneyHigh Reliability Organization
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Commercial Aviation
Nuclear AircraftCarriers
Air Traffic Control
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High ReliabilityCertified Zero Award
1. Zero Events
2. 12 Consecutive Months
3. Certified Zero Category10
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High Reliability 2011-2017Certified Zero Awards
ICU Central Line Associated Bloodstream Infections (18)ICU Catheter Associated Urinary Tract Infections (16)
Hospital-Wide Central Line Associated Bloodstream Infections (7)Hospital-Wide Catheter Associated Urinary Tract Infections (5)
Ventilator Associated Pneumonias (23)Retained Foreign Bodies (46) Iatrogenic Pneumothorax (24)
Accidental Punctures and Lacerations (3)Pressure Ulcers Stages III & IV (37)
Hospital Associated Injuries (7)Deep Vein Thrombosis and/or Pulmonary Embolism (2)
Deaths Among Surgical Inpatients with Serious Treatable Complications (1)Birth Traumas (16)
Obstetric Trauma in Natural Deliveries with Instrumentation (4)Serious Safety Events 1&2 (21)
Serious Safety Events 1 & 2 for 1000 Days (2)All Serious Safety Events (1)Early Elective Deliveries (9)
Manifestations of Poor Glycemic Control (21)
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263
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Wall of Pride!Memorial Hermann Facility
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THE VAP BUNDLE A Story of Data Driven Process
Improvement
- Jennifer Westmorland- Tawanna McInnis-Cole- Jocelyn Thomas
BundlesWhy are they important?
• Evidence based, interdisciplinary plans for patient care
• Focus on 3-6 interventions that significantly improve patient outcomes for a specific population
• Foundation in research and peer reviewed literature
• Regulatory and in house surveillance
• Drive process improvement and standardization
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Complication of Mechanical Ventilation- Ventilator Acquired Pneumonia (VAP) - Ventilator Associated Events (VAE)
• Up to 20% of vented patients develop VAP 1
• > 39% of pneumonia cases in acute care setting 1
• Increase in ventilator days, length of stay and antibiotic use 1
• Mortality may exceed 10% 1
1. Coffin, Susan E., et al. “Strategies to Prevent Ventilator‐Associated Pneumonia in Acute Care Hospitals.” Infection Control and Hospital Epidemiology, vol. 29, no. S1, 2008, pp. S31–S40. JSTOR, JSTOR, www.jstor.org/stable/10.1086/591062.
VAPWhy Does it Matter?
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VAPFinancial Impact
• At least 20% may be preventable 2
• 52,543 cases per year 3
• VAPs make up 31.6% of the cost of the top 5 HAIs 4
• Estimated cost of $40,144 per case in 2013 4
2. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-266
3. R. Douglas Scott II. The DirecT MeDical cosTs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009
4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039–2046. doi:10.1001/jamainternmed.2013.9763
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VAP Bundle (Adults Only)
Nursing Bundle• Suction – 4 Hrs.• Oral Care – 4 Hrs.
MD Bundle• Head of Bed – 4 Hrs.• SUD Prophylaxis – 24 Hrs.• VTE Prophylaxis (Mechanical 4 Hrs./ Pharmaceutical 24 Hrs.)• Sedation Holiday – 24 Hrs.
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Houston…..We Have a Problem
It was the year 2006…
Data analysis showed the VAP rate was too high!!!
VAP rates to become focus for CMS
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System VAP Rate
VAP rate = count of VAPs per 1,000 vent days20
What Did We Do?
We implemented our VAP Bundle because:
• Infection Control leadership believed we could reduce the VAP rate
• IHI and evidence based literature
• Standardize and monitor care across the system
Do No Harm 21
VAP Bundle TimelineMajor Events
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Continuous surveillance of 1. Clinical Outcomes2. VAP Bundle Compliance
July 2017 VAP Upgrade Implemented
2016 Start VAP Bundle Upgrade
2013 CDC Changes VAP to VAE
Mar 2010 Electronic Abstraction
2008-2009 Conversion to EHR
May 2007 Implementation on Paper
2013 VAE Report Developed
Jan 2017 TheraDoc Infection Control
People• Multi-disciplinary HAI Taskforce created• All hospitals represented
Process• Clinical Stakeholders identified for design sessions• Design sessions used process improvement tools• Workflows defined• Operational definitions standardized• All lCUs required to maintain policies and procedures• Communication and education• Performance Incentives
May 2007 Implementation on Paper
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Technology• Paper forms
Weekly manual auditsExcelMIDAS database – focus studies
• Reporting at System & Nursing Unit Level:- Bundle Compliance (documentation audits)- Clinical Outcomes (VAP Rate)
May 2007 Implementation on Paper
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Data Analysis
Data AnalysisVAP Rates
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Technology Advances -Electronic Documentation and Abstraction
• Facilities converted to EHR
• Daily reports manually processed and emailed to nursing
• Monthly Facility Compliance metrics published
• Monthly metrics reported to System Executives
2008-2009 Conversion to EHR
EHR
The Attack of the EHR
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VAP Bundle Nursing Documentation in the EHR
VAP Bundle Automation in the EHR
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VAP Monthly ReportFinancial Number Attending Type of
Unit Facility Nursing Unit Midas ICU Code for CLIP & VAP
55555555 Dr House Adult MEMORIAL CITY - ACUTE MC - NEUROSCIENCE A (J4EC) MC - Neuroscience Unit55555555 Dr Jekyl Adult HERMANN HOSPITAL - ACUTE HH - ICU MICU MEDICAL ICU (MICU) HH - ICU MEDICAL ICU55555555 Dr Who Adult HERMANN HOSPITAL - ACUTE HH - ICU CCU CARDIAC CARE UNIT HH - CCU
Bundle elements = Yes or No EXCEPTSedation Holiday = Yes, No or N/A
Audit Date HOB up 30 deg Oral hygiene q4 Hrs. Suction q4 Hrs. DVT Prophylaxis SUD Prophylaxis Sedation weaning
trial q24 hours3/1/2014 Yes Yes Yes Yes Yes Yes3/2/2014 No No No No No No3/1/2014 Yes Yes Yes No Yes N/A
Mar 2010 Electronic Abstraction Begins
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In 2013, the CDC proposed a new algorithm for preventable events related to mechanical ventilation.
VAP was replaced by four broader surveillance tiers:1. Ventilator-Associated Conditions (VAC)2. Infection-related ventilator-associated complications
(IVAC)3. Possible VAP*4. Probable VAP*
#3 and #4 later combined to become pVAP
2013 CDC Changes VAP to VAE
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Impact of VAE Report 2013Technology Improvement Story
• Newly introduced surveillance for VAE required the assistance of technology– Report was created and enabled the new
surveillance • Report simplified surveillance in a manner
that allowed IPs to be objective.• All pertinent factors were summarized in
report which lead to an overall efficient process for conducting surveillance.
• Initial surveillance showed unexpected FiO2 and PEEP fluctuations
• The technology prompted the analyses that improved patient care– Allow for process improvement
Multiple people were changing the vent settings
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Clinical Event
Performed Date
APRV Vent Mode
Peep Min
FiO2 Min
Temp Min
Temp Max
WBC Min
WBC Max
ABX-Vancomycin
ABX -All
Others
ABX-Cefepime
09/23/2013 5 0 98 102.3 77.7 77.7 vancomycin Mero-penem
ABX-All Other Cephalosporins Anti-fungal Anti-
influenza
Culture Order
Description
Micro Source
Organism Identified (Drawn Date)
Invasive Airway Type
Infection Control
Alert
Infection Control
Alert Response
Culture: Respiratory
w/Gram StainSputum MRSA Endotracheal
(Intubated)
2013 VAE Report Developed
• Not at zero VAPS / VAEs• Compliance rates high• Review new evidence in the literature• Documentation drift• Data drift in compliance report• New medications• Use of single ventilation orders was leading to fallouts • Ventilator order set use was low• Order sets (MPPs) not aligned with VAP Bundle• Each MPP had different content
2016 Start VAP Bundle Upgrade
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How Did We Implement?
People• VAP Bundle Workgroup created• Sponsored by HAI Steering Committee• Multi-disciplinary
Process• Weekly meetings• Clinical stakeholders consulted• Design sessions• Complex approval process• Testing and validation 36
How Did we Implement?
Process (continued)• Clinical Stakeholders testing sessions• Communication and education• Pilot at one ICU• System Go Live July 2017
Technology• Online research, meetings, training & education • Extensive data analysis
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VAP Bundle UpgradeUse of Data to Drive Decisions
• Identified all documentation elements and compared with evidence based research
• Wrote custom reports to pull documentation data
• Analyzed each response in terms of volume, clinical content and alignment with Bundle elements
• Presented data to clinical stakeholders
• Used data to drive decision making for future state
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Vent Check by Nurse PowerForm Usage Dec 2015
FacilityNumber of times the PowerForm was Signed
GH Greater Heights 1584HC Childrens 1594HH HERMANN 9044KM Katy 775MC Mem City 1180NE Northeast 845SE Southeast 1399SG Sugar Land 71SW Southwest 2304TR TIRR 30TW The Woodland 1283Grand Total 20,109
841 visits
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Data AnalysisPUD Prophylaxis Documentation
Meds for prevention of PUD being administered 18,266Meds for prevention of PUD not being administered due to contraindications 288Physician order 287Exclusion exists 575Patient on enteral feeding 577Grand Total 19,993
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Data AnalysisFree text responses
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Reason not Using Int. Compression Device # of times documented
Other: lymphedema 72Other: heparin gtt 65Other: pt receiving anti‐coagulant therapy 33Other: bath 25Other: pt oob 25Other: in chair 23Other: On heparin gtt 23Other: On Heparin 22Other: patient on heparin drip 22Other: up to chair 18Other: PVD 17Other: Heparin drip 16Other: on heparin drip 16Other: pt up in chair 16Other: angiomax gtt 15Other: DVT 15Other: pt recieving anti‐coagulant therapy 15Other: Up in chair 15Other: HEPARIN 14Other: chair 13Other: IVC filter 13Other: pt up to chair 13Other: Comfort measures 11Other: disease process 11Other: pt recieivng anti‐coagulant therapy 10Other: Betty said not to 1
Other: Betty said not to
When Different Technologies Collide…
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VAP Bundle
VTE AdvisorWhat is it?
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VTE Advisor• Cerner Clinical Decision Support tool• Used only by providers• Not viewed by nursing or RT• Helps assess individual risk of adult VTE• Includes orders for VTE prophylaxis
VAP Bundle vs the VTE Advisor• Memorial Hermann designed tool• Includes orders for DVT prophylaxis• Different terminology• Some overlapping content• Some different indications and contraindications
VTE Advisor
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Pharmacologic ProphylaxisDifferent Exception Reasons
• Active Bleeding• Coagulopathy (non-therapeutic)• History of HIT• Spinal tap within next 24 hours• Epidural catheter in next 24 hours• Active hepatitis or hepatic
insufficiency• Infective endocarditis• Thrombocytopenia• Uncontrolled Hypertension
• Abnormal Clotting Times• Bleeding Disorder• Epidural catheter in place• HIT• Hypersensitivity to UHG or LMWH• INR > 2• IVC Filter• Major Surgery past 3 months • PTT > 60• Pt currently on thrombolytic meds• Pt on SCDS only per MD Order• Pregnancy• Severe Renal Failure• Reason for Non-Compliance: 45
VTE Advisor VAP Nursing Documentation
Jan 2017 TheraDoc Infection Control
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Highlights from the Upgrade
• Increased accuracy of compliance data
• Order sets updated and integrated with VAP Bundle
• Increased order set use
• Automated communication from provider to nurse
• VAP Bundle integrated with VTE Advisor
July 2017 Upgrade Implemented
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• Increased documentation efficiency- 69% reduction in clicks for prophylaxis nursing form- Reduced from 1,327,194 clicks/month to 422, 289
• Automated display of medication orders
• Automated display of medication administration
• Zero reported fallouts in CHG mouthwash orders
July 2017 Upgrade Implemented
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VAP Bundle UpgradeSmarter Documentation
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Data FlowFrom Physician to Nurse
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Ventilation Order SetsIncreased Utilization
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0
100
200
300
400
500
600
700
800
900
May-17 Jun-17 Jul-17 Aug-17 Sep-17
Number of Times Adult Ventilation Order Sets Used
Ventilator Add On MPP
Ventilator High Frequency MPP
Ventilator Initiation/Bundle OrdersMPP
Ventilator Non Invasive MPP
VAP Bundle Upgrade
VAP Bundle Compliance
Accurate data reveals opportunity to improve compliance
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VAP Bundle Phase 2
Optimization continues:
• Use data to determine whether to keep SUD prophylaxis
• Add Tidal Volume data to daily report
• Create interactive compliance dashboard using Tableau
• Implement TheraDoc VAE Surveillance 53
Our JourneyResults from a Decade of VAP Bundle Partnership
Maintaining Our VAP Rate
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High Reliability!
5623 Certified Zero Awards for VAP
Financial ImpactVAP Bundle
If we had done nothing
Hospital expansion = more vent days1,200 extra VAP infections @ $40,144 per infection
Estimated lives saved = 100+VAP Bundle projected cost avoidance =
$48,172, 800
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Lessons Learned
• Governance structure• Multidisciplinary, multi-level groups• Scheduled reviews• Clinical champions• Data Validation
- always examine and understand your data
• Automation can decrease infections• Partnership is the building block of change
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VAP Bundle
Infection Control
Quality
Respiratory Therapy
Nursing
Physicians
Medical Informatics
Key Partnerships
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v
PharmNet(Meds)
Campus Support
System Pharmacy
Support Center
Application Teams
System Leaders
ISD Technical
Teams
HPUX (ops jobs)
Cerner Technical
Teams
Clinical Informatics
(NYCU)
CCL ReportTeam
PathNetTeam
RadNetTeamHealthQuest
(ADT)
Net AdminDesktop
Moral of our VAP Story…
…the price of excellence
is eternal vigilance
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THANK YOU!