1. At The Crossroads * Designing A System for Ideal Patient Safety and Outcomes
Frederick C. Ryckman, M.D.
Senior Vice President – Medical Operations
Professor of Surgery
Cincinnati Children’s Hospital and Medical Center
University of Cincinnati, Cincinnati, Ohio USA

2. Institute of Medicine Report
Timely Care
Efficient Care
Family-Centered care
Effective Care
Equitable Care
Safe Care - Priority #1 !
Crossing the Quality Chasm: A New Health System for the 21st Century, IOM’s Committee on the Quality of Health Care in America, 2001.

3. Roadmap for Today Where have we come from
Why have we not gotten further
Hypothesis – Taking Healthcare from Good to Great
Preconditions for Safety
Role of Leadership
Operational Excellence
Summary

4. Where We Are Today

5. Where We Are Today
80% Reduction in SSE’s
No Reduction in SSE’s

7. The Blueprint for Success “2002 - 2012”
Leadership Focus on “Safety”
Built Institutional Infrastructure to improve on Major Focus Areas - Initiatives
Built Capability and Capacity through Improvement Training
Improvement Focus on Single Processes – “Bundles” for Care Delivery, Checklists OR
Transparency of Data to Providers
Shine Light on Performance

8. Why Haven’t We Gone Further
Leadership Focus - Safety / Flow
Not Team Culture
Focus on “Bundles”
Not Integrated Strategy
Focus was on “Improvement”
Not Flawless Execution of Care
Recurrent “Initiatives” and “Improvements”
Fatigue by the Caregivers
Unclear “Focus”

9. Hypothesis Getting from Good to Great
We Know – What and How
Bundles, Improvement Work, Evidence Based Care, etc
It is not about “Safety”
Integration for Ideal Outcomes
Safety as a Pre-Condition

10. Hypothesis Getting from Good to Great
We Know – What to Do
Bundles, Improvement Work, Evidence Based Care, etc
It is not about “Safety”
Integration for Ideal Outcomes
Safety as a Pre-Condition
Integration of Daily Work –
Patient Experience, Staff Experience
Mutual Respect at all levels
Awareness / Prediction
Proactive Planning
Operational
Excellence
And
Efficiency

11. Respect is a Pre-condition for Safety
Treat all employees with respect and dignity, provide them with the needed resources to do their work, and show your appreciation for their contribution. *
Mutual
Respect
Collaborative
Teamwork
Effective Work
Safe Care +
Common Purpose and
Vision
* Paul O’Neill, Former Alcoa CEO
L. Leape et al, Acad Med. 2012; 87:

12. Respect is a Pre-condition for Safety
Treat all employees with respect and dignity, provide them with the needed resources to do their work, and show your appreciation for their contribution. *
Mutual
Respect
Collaborative
Teamwork
Effective Work
Safe Care +
Common Purpose and
Vision
* Paul O’Neill, Former Alcoa CEO
L. Leape et al, Acad Med. 2012; 87:

13. Disrespectful Behavior and Safety
Humiliation / Demeaning Treatment
Passive Aggressive Behavior
Passive Disrespect
Un-cooperation, “difficult people”
Don’t complete safety behaviors, checklists, time-outs, hand washing
Dismissive Treatment of Patients
Failure to partner
Failure to Listen / respect
L. Leape et al, Acad Med. 2012; 87:

14. Disrespectful Behavior and Safety Lack of Mutual Respect
Humiliation / Demeaning Treatment
Passive Aggressive Behavior
Passive Disrespect
Un-cooperation, “difficult people”
Don’t complete safety behaviors, checklists, time-outs, hand washing
Dismissive Treatment of Patients
Failure to partner
Failure to Listen / respect
Ask the right Questions
Uncommon
Common
L. Leape et al, Acad Med. 2012; 87:

15. Effects of Lack of Mutual Respect
Short Term
Humiliation and anger / self doubt
Inhibit ability to think clearly, increase errors in decision making
Most intense – create an unsafe act
Long Term
Avoid the person that is disrespectful
Don’t call to clarify orders, concerns
Only make absolutely needed contact
patient suffers the consequences
error in diagnosis or treatment
“Burn Out”
L. Leape et al, Acad Med. 2012; 87:

16. Effects of Lack of Mutual Respect
Major Barrier to Current Safety
Teamwork suffers - cornerstone for safety behaviors, complex patient treatment
Physician leadership – Essential Role
Major safety initiatives, checklists / bundles
Major Barrier to Future Safety
Lack of physician collaboration and participation make progress in new initiatives impossible
Behavior is an “infectious disease” – next generation of improvement suffers
L. Leape et al, Acad Med. 2012; 87:

17. Leadership in Improvement
Them – M.D’s, R.N.’s, OR Techs, Residents
Summary Knowledge – Experience, pitfalls
Know where improvement work most improvement!
Positional Power – As health care team leaders, we affect other’s mood and attitude toward improvement efforts. Possess a “Red Card”
Future Leaders – Need to constructively re-define the obligations of leadership
Team building - Partnerships
Role modeling – define and support change
Integrated and Coordinated Care Delivery
Innovative Thinking – Every Day Safer

18. Role of Leadership 100 people 1 meter, not 1 person 100 meters
Set a Mission, Define Purpose, Convey a Vision
Persuade others to Join the Vision
100 people 1 meter, not 1 person 100 meters
Set and Be the Example – Visible Leadership
“How difficult it is to avoid having a special standard for oneself” C.S Lewis
Make Space for Operational Excellence
Re-Evaluate past initiatives, Only important work remains
Engage All Professional Staff
Team Based Care at the bedside / office / community
Respect Professionals Time
Exchange rate for Physicians / Nurses
Example – bad ideas and good ideas are alike – like barnicles on a boat, have to remove them or they build up
Get space by getting rid of poor processes and waste – open opportunity space
Operational leaders must set these priorities and sequence the work
Design to do work differently so can unburden overworked healthcare team - work where people are having difficulty

19. Guardrails and Flexibility
Define what is “Core” and what is “Flexible”
Responsibility of Leadership – Set “Guardrails”
Balance in Tight vs Loose Management
Key Processes – Narrow Guardrails
Define Pace - Balance Patience and Speed of Change
Profound Simplicity – know the few things that really matter and execute on them.
Empower Resource Accountable

20. Engage Physicians to Lead
A prerequisite for changing behavior is perceiving the need to change
Pick the “Right Work”, Pick the “Right People”
Build the Case – Sell the Vision
Drive Change with Data
Make it “Personal”

21. Fiscal Year SSI Patients - CCHMC
Aim – To Decrease the Surgical Site Infection
Rate from 2.0 infections per 100 cases of Class I and II Surgical Cases to < 1.0 infections per 100 Surgical Cases within 2 years.
How do we “Connect the Dots” for Caregivers 95
9 Special
Cause SSI 52 43 44 29 12

22. Make it Personal Don’t let the Data Drown out the Dream
Head vs Heart Discussion
Stories not Statistics
Names and Faces

23. Fiscal Year SSI Patients - CCHMC95
It is Patients not Numbers
9 Special
Cause SSI 52 43 44 29 12

24. Fiscal Year SSI Patients - CCHMC95
570
SSI’s
It is Outcomes
6 Years
233
SSI’s
Prevented 52 43 44
337
SSI’s 29 12

25. Build the Business Case for Quality SSI Aggregate Cumulative Costs
It is “Value”
Cost Difference = $436,607
Per Pt = $27,287
LOS – Additional 10.4 days
Sparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health Care 2007;16:

26. Fiscal Year SSI Patients - CCHMC
Case Average
10 days LOS
$27,000.00
Business Case
2330 days LOS
$6.3 million 95
570
SSI’s
6 Years
233
SSI’s
Prevented 52 43 44
337
SSI’s 29 12

27. Patient Satisfaction
Only 3-4% of 1 Million outpatient visitors rank our care in the lower half (0-6 of 10 pts)
35,000 patient per year
(Parken Stadium – 38,009 seats)

28. Partnership with Families / Patients
Olivia
Olivia is an amazing person. I first met Olivia in my clinic. She has a diagnosis of arthrogryposis. She is unable to walk due to extreme contractures in her lower extremities. When I met her, she seen numerous surgeons throughout the country. She had thought and read much about her treatment plan. Often the treatment plan is to due extensive surgery to replace the knees and better positions than treat the contractures. After a great deal of thought and prior to seeing me, she had wished to have amputations at her knees. As a surgeon, this was difficult and my first instinct was to encourage her not to have this done, despite the fact this is something that she and her family had wanted; also despite the fact that she had seen numerous other surgeons all whom refused to do this. I worked with her or in fact, in reality she worked with me to convince me that this was a reasonable thing to do. Our therapist and prosthesist tried provisional prosthesis to see if she would be able to walk after the amputations. Ultimately they developed ways at home and worked on ways to assure themselves and probably more correctly to ensure me that this is the right decisions. Ultimately, we did perform bilateral through knee amputations. Today as you can see in the picture, she is standing and extremely happy and remarkably tall. She emphasizes the point that despite what we think and feel as providers, the patient perspective truly is a perspective that we need.

29. Operational Excellence
The difference between a dreamer and a pioneer is discipline and process
Eric Weihenmayer Blind Climber / Adventurist

30. Jan 2012

31. Operational Excellence
Optimizing Outcomes, Experience & Value
Patient Experience
Employee Experience
Empowered & Accountable Leadership
Maintain Resilient Staffing
Build Engaged & Committed Teams
Reliably Execute Key Processes
Reliably Implement Situation Awareness
GARDIANS Daily Risk Prediction
Partnering with Patients & Families
Scott
Integrated Care Delivery
Every Patient
Every Time

32. Operational Excellence
Optimizing Outcomes, Experience & Value
Patient Experience
Employee Experience
Empowered & Accountable Leadership
Maintain Resilient Staffing
Build Engaged & Committed Teams
Reliably Execute Key Processes
Reliably Implement Situation Awareness
GARDIANS Daily Risk Prediction
Partnering with Patients & Families
Scott
Integrated Care Delivery
Every Patient
Every Time

33. Operational Excellence
Co-Leaders (MD-RN) for all Care Delivery Teams
Present focus is on Inpatient Units
Integrated leader evaluations of performance
Mutual accountability for Unit performance
Partner with Patients and Families
Clear Job Description and Responsibilities

34. Operational Excellence
Co-Leaders (MD-RN) for all Care Delivery Teams
Staff Inpatient Units with the correct physician / nursing complement to meet the needs of the population
Number and Competency
Flexible with Changing Environment

35. Operational Excellence
Nurse Staffing and Hospital Mortality
Relationship between nurse staffing and patient turnover
Risk of Death 2% for each below target shift
Risk of Death 4% for every high turnover shift
Admissions, discharges, and transfers
Meta-Analysis – Dose response relationship of nurse staffing and death
Increase 1 FTE per patient day – 9% mortality in ICU, % in a surgical setting, 6% in medical setting
State of California – mandated nurse staffing
Increase of 1 RN FTE / 1000 inpatient days – mortality 4.3%
Needleman J. et al. N Engl J Med 2011;364:
Shekelle P. Ann Intern Med. 2013;158:
Harless DW. Et al. Med Care.2010:48:

36. Operational Excellence
Nurse Staffing and Hospital Mortality / Failure to Rescue
Effect of Nurse / Staffing Ratio on Mortality and Failure to Rescue is directly related to team work environment
Lowering the patient-to-nurse ratio –
Marked improvement – good environment
Modest improvement – fair environment
No effect – poor environment
Better environments lower mortality at all hospitals…but
Poorly staffed hospitals % improvement
Best staffed hospitals % – 14%
Education Effect – 10% BSN educated RN’s 4% mortality
Aiken L. et al. Med Care 2011;49:

37. Operational Excellence
Co-Leaders (MD-RN) for all Care Delivery Teams
Correct Staffing at all times
Clear Focus - Critical Processes for Success
Identification of “Standard Work”
Flawless Execution
Build in High Reliability Principles

38. High Reliability at the Unit Level
Daily Rounding with a Purpose
Situational Awareness
Identification of “Watchers” on the Unit
Specific Plans for “Watchers”
Unit Awareness of Plan
Roll-Up throughout the Medical Center

39. Serious Harm Slide

40. SSI Accomplishments 60% reduction Estimated 60 fewer children harmed
Since October $1.9 million in health care costs saved
Slide Owner: Anne 40

41. SSE Accomplishments
50% reduction

42. Serious Harm Accomplishments
42% reduction

43. Summary Ideal Outcomes Safety, Quality of Care, Patient Experience
Staff Experience
Identification of
Correct Patient Care
Clear Focus on Operational
Excellence
Know what to Do Do what you Know Measurably Great Outcomes
Evidence Based Care
“Bundles”
Admission / Discharge Plan
Care Coordination
Leadership
Staffing
Rounding
Situational Awareness with Mitigation
Institutional Plan
Execution
Outcome
Measurement
Skilled Dedicated Teams
Mutual Respect
Leadership Focus

44. Questions ?