you can’t fix it if you don’t know about it! · you can’t fix it if you don’t know about...

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Donna Saxton, MHA, MPH, FACHE

VP Quality and Safety Ochsner Health System

Cyntrell

Janeau, RNPerformance Improvement

Coordinator Ochsner Medical Center New Orleans

You Can’t Fix It If You Don’t Know About It!

Sandy Kemmerly, MD

Donna Saxton, MHA, MPH

Ochsner Health System and General ElectricConfidential & Proprietary Information

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Part one


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Ochsner Health System

Ochsner Health System»

Large academic, tertiary medical center ~ 70 medical specialties

»

Seven hospital locations, 1557 licensed beds»

Over $1 billion in annual revenue

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600+ employed MDs, »

Approximately 12,000 employees

Largest multi-specialty group practice in Gulf South»

40 + neighborhood clinic sites

Member of “Six Clinics”

peer group:»

Cleveland Clinic Foundation, Mayo Clinic, Henry Ford Health System, Lahey Clinic, and Lovelace Health System


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Rwerwewrwer

DestrehanElmwood

OCHC - Slidell

Slidell

Hamm Heart-Vasc

HammondCovington

Uptown

Baptist

Lapalco

Metairie

OHC - KennerOCHC - Metairie

Ochsner Medical Center

OMC - Kenner Lake Vista

OHC - Algiers OBAlgiers

OMC - West Bank

OMC - Baton Rouge

Abita Springs

MidCity

Bluebonnet

Prairieville

Mandeville

Denham Springs

St. Anne


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Leadership


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The dashboard

Category Goal Metric Period Actual Mortality NA Number of Inpatient DeathsMortality Rate <2% All Inpatient Deaths/Inpatient Discharges

Core Measures >90% Patient Appropriate Score (PACS) AMI >90% PACS

Heart Failure >90% PACS PN >90% PACS

SCIP >90% PACSOccurrence Reporting

Number of Falls Na Number of FallsFalls Rate <3 Inhospital falls: Per 1000 patient days

Discharges with Pressure Ulcers 0 Number of Patients with Pressure UlcersPressure Ulcers Rate 0% Patients with Pressure Ulcers/Discharges (%)

Medication Error (harm) Zero (0) NQF "with harm" status errors reportingInfection Control

Class 1 infections Zero (0)Post Op Surgical Site Infection - CDC definition

Class 1 infection rate Zero (0) Total Infections / Total Procedures (%)Catheter Associated UTI Zero (0) Number of Infections

Ventilator Associated Pneumonia (VAP) Zero (0) Number of InfectionsCentral Line Infections (CLI) Zero (0) Number of Infections

30 day re-admit rate <10% Acute Inpatient, All Payor 30 day re-admits

Risk Adjusted Mortality Index <.75 ***** Actual to Expected <.75 (All Payor Adult)Risk Adjusted Complication Index <.75 ***** Actual to Expected <.75 (All Payor Adult)


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Questions from Leadership

Despite standardized definitions of quality indicators….Why the lag in the data?Why is data reporting not consistent?Why do we have facilities who report zero hospital acquired pressure ulcers, falls, and medication errors with harm?


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Every now and then…


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part two


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Our Communication mission


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In the beginning…

System-wide teaser campaign―

Naming contest for systemAnnouncements at meetings (all levels in organization)Daily newsletters“Everyone”

emailsMail box in-servicesWebsite announcements (multiple pages)Computer learning modules –

not for training but to provide overview of systemIn-depth webinar with quality departments to introduce them to system capabilities


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Implementation –

Part 1

Began at Main Campus (largest facility)― Strict deadline due to previous contract agreements― One database for entire system

Initial "To Do”

list from vendor carried out by a representative from the PI Department and representative from the IT DepartmentSketched out phased implementation for other system hospitals


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Implementation –

Part 1

Held rapid cycle meetings with key departments to complete “pre-work”

in anticipation of customization

Designed constraints in the system to support― Definitions of occurrences― Standardized reporting


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Implementation –

Part 1

Team + Computer Screen = Event Specific Customizations― Analysts― Data entry

Focused on Dashboard Metrics― Medication/Fluid Errors― Pressure Ulcers― Falls


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Training Approach –

Part 1

Just in timeOne week prior to go liveFocused on Super Admins


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Resource Development


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System Implementation (Part 2)

Rapid cycled each implementation at system facilitiesOne month cycle consisted of:―

Initial planning meeting with quality dept to establish go live date―

Facility “go live”

date determined training dates(JIT)Training schedule established and communicated to system facility“Go live”

date to coincide with search and destroy mission for paper occurrence forms

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JIT training for quality departments one week prior to facility training―

Overlapped implementation cycles at system facilities


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System Training

Tiered training (super admin, admin, general)Super Admins

attended live training

― They became the admin trainers –

team approach/divide and conquer

Feedback from attendees and observers revealed inconsistencies in training

― Standardized training agendas― Embedded standardized definitions of occurrences in

training


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Part three


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Reporting

Jan-Jun 2008 vs

Jan-Jun 2009

50% percent increase in reported occurrences across the system


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Run Chart

400500600700800900

10001100

Jan-08

Feb-0

8Mar-

08Apr-

08May-

08Jun

-08Jul

-08Aug-

08Sep-

08Oct-

08Nov-

08Dec-

08Jan

-09Fe

b-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Num

ber

of O

ccur

ence

s

Number of Occurrences Average for Time Period

Implementation Phases


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SPC

0.00

200.00

400.00

600.00

800.00

1,000.00

1,200.00

1,400.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

xx-barLCLUCL


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The dashboard

Category Goal Metric Period Actual Mortality NA Number of Inpatient DeathsMortality Rate <2% All Inpatient Deaths/Inpatient Discharges

Core Measures >90% Patient Appropriate Score (PACS) AMI >90% PACS

Heart Failure >90% PACS PN >90% PACS

SCIP >90% PACSOccurrence Reporting

Number of Falls Na Number of FallsFalls Rate <3 Inhospital falls: Per 1000 patient days

Discharges with Pressure Ulcers 0 Number of Patients with Pressure UlcersPressure Ulcers Rate 0% Patients with Pressure Ulcers/Discharges (%)

Medication Error (harm) Zero (0) NQF "with harm" status errors reportingInfection Control

Class 1 infections Zero (0)Post Op Surgical Site Infection - CDC definition

Class 1 infection rate Zero (0) Total Infections / Total Procedures (%)Catheter Associated UTI Zero (0) Number of Infections

Ventilator Associated Pneumonia (VAP) Zero (0) Number of InfectionsCentral Line Infections (CLI) Zero (0) Number of Infections

30 day re-admit rate <10% Acute Inpatient, All Payor 30 day re-admits

Risk Adjusted Mortality Index <.75 ***** Actual to Expected <.75 (All Payor Adult)Risk Adjusted Complication Index <.75 ***** Actual to Expected <.75 (All Payor Adult)


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PACs

Percent of Discharges

Without Harm

AMI

PN

SCIP

CHF

Med Errors

Pressure Ulcers

Patient Safety

Indicators

Falls


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Dashboard Reporting

Leadership has moved past initial “data”

barriers and on to improvement―

Supports further accountability up and down leadership structure

Improvement doesn’t rest on the quality departments shoulder anymore

Data on dashboards reporting real time―

Raw data is reported as leading indicators

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Data is now dynamicData integrity ensured―

Third party (informatics) pulls data for dashboard


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Alleviated Fears!

Severity Scoring― E vs

F

― Analysis results:No notable difference!Staff picked a higher level of incident severity


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Transparency

Quality leadership has access to all events across the system― Big Culture Change!― Reports developed to support ongoing surveillance― Events are discussed at monthly operating meetings,

focus is improvement, not blame― Organization leadership engaged in outcomes and

action plans


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Impact on Quality Departments

Organizational culture change = change in work process in the department ―

Quality departments are facilitating change and getting out of analysis paralysis!

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Not just reporting the data and arguing validity―

Movement away from “recreational data collection”

Daily operations have shifted from extremely delayed retrospective manual chart audits real time investigations ―

Weekly Falls and Pressure Ulcer calls

Added capacity into quality departments


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System Falls

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12

Week

Num

ber

of F

alls

Number of Falls Number of Falls With InjuryAve of Time Period Ave of Time PeriodLinear Trend

First month of w eekly calls

Second month of w eekly calls


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Response

Serious Event Group― Fired alerts improve notification of serious events― Ease or running surveillance reports further supports

notification and response to events― Increased awareness of reporting occurrences has led

to increased verbal reporting of occurrences


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Patient Safety Initiatives

Leadership support system wide patient culture assessment― Base line assessment― Highly utilized occurrence reporting system is

foundation for: Highly Reliable OrganizationImproved surveillance has identified underlying root causes of incidents across the system


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Success factors

Don’t get bogged down in consensus –

especially when under time constraintsCommunication between implementation team is crucialClear understanding of operational issues are necessary when customizing they systemUnderstand how your organizations learnAlways look aheadContinue to spread ongoing learningsDon’t stop promoting the system


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Lessons learned

When customizing, you aren’t always going to get it right on the first, second, third try…Flex to every situation―

Nothing is ever set in stone

―

Cannot put everything in a bucket―

Cannot please everyone!

You will always overlook something, that’s ok! Just don’t stop improving!Learn something from every implementation


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Next Steps

Communication –

8 times 8 ways!Continuous renewal of the message!― Relentless pursuit of problem identification is the key

to faster improvement

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Questions?

you can’t fix it if you don’t know about it! · you can’t fix it if you don’t know about...

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