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Pursuing Excellence Quality and Safety as the New Currency Richard P Shannon, MD Frank Wister Thomas Professor of Medicine Chairman, Department of Medicine.

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Presentation on theme: "Pursuing Excellence Quality and Safety as the New Currency Richard P Shannon, MD Frank Wister Thomas Professor of Medicine Chairman, Department of Medicine."— Presentation transcript:

1 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

2 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

3 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

4 AMCs and US Healthcare System

5 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.

6 A “Project”

7 System Level Aim

8 “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.” The Sense of Urgency Health Care and the Nation’s Economy

9 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

10 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

11 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

12 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

13 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

14 Levers of Waste Don Berwick Harm Overtreatment Defects in care delivery Defects in care transitions Excess administrative costs Fraud and abuse

15 Why Safety? It is unassailable Harm violates our professional duty Harm is the elementary form of waste It is valueless It can be eliminated

16 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?

17 HAI in Pennsylvania 2012 23,287 HAI (1.2%)

18 Patient Outcomes

19 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?

20 Problems With Bench Marking The Difference Between Reporting and Actionable Data CCU/MICU NNIS PRHI

21 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

22 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.


24 The Work of Physician Leaders Rounding on Sick Systems Chief complaint Present illness Physical exam/diagnostic test Therapeutic intervention Clinical course Natural history Assessment of outcome 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 Rounding on Sick patients Rounding on Sick Systems

25 The Current Condition of Variation

26 1)Set up work Hand HygieneOpen Drape Open Dressing Kit Drop Biopatch Wash or Purell Space 2) Prepare Adjust Bed Don Masks Clean Gloves People (nurse) (patient) 3) Remove Remove with alcohol Discard Trash Wash Hands Dressing DRESSING CHANGE STANDARD WORK 5.) Apply New Apply Outline Apply Seal Apply Strips in Biopatch Dressing Dressing Dressing X and label 4.) Clean site Apply Chloraprep Allow to dry Sterile 30 seconds 30 seconds gloves


28 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

29 Reductions in HAIs Journal of Quality and Patient Safety 2006;32:479

30 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

31 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:$10,636,450 Lives saved65

32 Mortality 0.6% 12.3% 20X

33 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

34 686 CLAB Day 1 2/07/02 Transfer 5/04/02 2/12/02 M. S.

35 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 w cc Pancreatitis w trach Revenue ($)5,90799,214125,576200,031 Expense5,78858,90598,094241,844 Gross Margin 11940,30927,482-41,813 Costs attributable to CA-BSI 170,565 LOS4384186


37 UHC Mortality Rank 2012: 26 th 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

38 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

39 Unexpected Deaths 15-20% Aspiration Pneumonia SIT UP Patients at Risk Interventions Delays in Diagnosis and Treatment Heart failure Liver Failure

40 UHC Mortality 0.89 0.86 0.81 0.79 0.62 468 453 464 453 372

41 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.

42 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

43 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


45 Primum Non Nocere

46 Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, 2001-2007 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).

47 A new revolution….

48 Build a Parking Garage or Fix the Care Process? Not more…better Not volume….value

49 Modifying the Patient Experience 14 days57 min 22 min 31 min 23 min Call Wait for App Travel Park Reg Wait VS Wait MD CO Tests Exit 18 min 17 min 14 min 97 min 18 min 4:05 77 min $32 parking 7 days57 min 15 min 7 min 20 min 11 min 45 min 14 min 2:02$8 parking 37 min  Patient visits from 7-9/session  On –Time Performance  Patient satisfaction (waiting)  Lag days

50 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

51 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

52 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

53 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 anyoneprescribenever do harm will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

54 Values Trumps Process

55 Improvement vs. Habitual Excellence 1,000 days

56 Leaders are responsible for everything in an organization, especially what goes wrong. Paul O’Neill Leadership Mentor

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