Make sure you’ve got the right bus driver and the “right people on the bus”.

-Jim Collins

Good to Great

Dr. Robert Laskowski, President & CEO sends his greetings to the attendees, and he wants everyone to know that he strongly believes that effective leadership & teamwork matters “a whole bunch”.

Quality leadership always leads to better quality outcomes.

What we have in common with other healthcare systems & hospitals

Physician practices & Private physician issues Increasing organizational complexity Credential vertically & practice horizontally Limited sources of profitability Increasing costs, competition, quality & pt. safety stds Ongoing capacity challenges Residency review committee rules & regs Sustaining viable research funding & structure

What is quality health care & safety?

Care that maximizes the probability of desired outcomes– Effective, efficient, timely, patient-centered,

equitable, and safe

Absence of complicationsRef: Alex Hover, MD, FACP (CareScience)

DOING THE RIGHT THING RIGHT! Patient Safety – 1st Do No Harm!

“Hospitals & Physicians more aware of “Public Reporting” on Quality & Safety

Government & other– CMS, AHRQ, NQF, State…

Regulatory Agencies– JCAHO, CMS…

Purchasing Consortia– Leapfrog, NBCH…

HIT Companies– CareScience, HealthGrades..

Lay Press– US News & World Report…

Objectives & targets differ ● Some agreement on best & worst ● Poor overall agreement ● Aren’t changing patients’ behavior-yet

List of National Report Card Agencies

• JCAHO – EB meds/procedures & safety

• CMS – EB meds/procedures & safety

• Leapfrog – EB systems/practices, M & M

• US News & World Report – Reputation, AHA survey data, M & M

• Solucient – M & M and Operating Margin

• Healthgrades – M & M for specific surgical procedures and diseases

US News and World Report: Annual Best Hospitals CCHS Results

CCHS 2005 Results: Top 100 Hormonal Disorders– Top 200 Eligible Hospitals

• Cancer 783 • Digestive Disorders 1265 • Ear, Nose & Throat 1099• Geriatrics 1253• Heart & Vascular Surgery 853• Kidney Disease 1326• Orthopedics 1318

HealthGrades – 2006 Results

Total Knee Replacement

Joint Replacement

Partial Hip Replacement

Hip Fracture Repair

Back & Neck Procedures

SurgeryOverall Orthopedic Rating

Resection AAA

Carotid Endarterectomy

Peripheral Vascular Bypass

Overall Vascular Star Rating

Overall Stroke Rating – Top 10% Nation

CABG

Valves

PCI

AMICHF

A-Fib

2005 Annualized ReportCONFIDENTIAL AND PRIVILEGED INFORMATION-DO NOT SHARE WITHOUT PERMISSION

BOARD PI FY05 GOALS MEASUREMENT REPORT: JUNE 2005

Goal2

Clinical Outcomes and Service Delivery

Patient Safety

1 Number of measures under-performing in comparison to benchmark/goal, based on total data available to PI/CM as of May 2004 2Number of under-performing measures that we need decrease to by end of FY 2005.3Number of under-performing measures as of report date.

Annualized Status of Indicator Sets

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Meet or exceed benchmark/goal criteria for 50% of CMS Inpatient Quality Improvement Project and JCAHO ORYX Measures which are currently under-performing.

Meet or exceed benchmark/goal criteria for 50% of patient safety indicators which are currently under-performing.

60% 80%

13

24

Baseline DataTotal # Under-

performing1

Progress Toward Goal

612

20% 40% 100%

57

Current # Under-

Performing3

US News/Solucient/Healthgrades/LeapfrogJCAHO/CMS Measures

Performance Improvement: Major Areas of Activities – Proactive & Reactive

Patient Safety– Sentinel Events, FMEA– JCAHO Patient Safety Goals– AHRQ Safety Plan– Leapfrog compliance (ICU, eICU)– IHI’s Rapid Response Teams

Accreditation Compliance– JCAHO, NCQA, CMS– ACS – Trauma – Cancer

Improving Care Delivery– Guideline & PI Teams– Staff Competency & JCAHO Standards

Quality/Performance Measures– CMS/JCAHO, Patient Safety, Clinical Registries

Example – Sentinel Event - Leadership at all levels involved

Fire in the EP Cath Lab – patient with significant burns on chest, face, airway was transferred to Crozer’s Burn Unit

Family support by Patient Relations Dept. Staff support by Psych Crisis Team Duraprep immediately suspended from use Root Cause Team convened Tool to identify fire risk and other risk reduction strategies

developed & implemented Outside consultant trained over 400 staff members

Patient Safety – Failure Mode & Effects Analysis

Proactive analysis and improvement of high risk procedures and processes, examples include:

Response to ventilator alarms Telephone system failure Prevention of patient elopement in LTC Patients at risk for suicide or harm in non-psychiatric

settings

Improving Care Delivery – Standards of Care

Continuous review of clinical, performance improvement and patient safety literature to identify what improves care and outcomes

Feedback from Medical Staff and other clinical staff leaders in all areas on new and tested ways to improve care delivery and outcomes

Leapfrog/CMS/JCAHO and others driving to standardize care delivery nationally

Improving Care Delivery – Example Development of Sepsis Protocol

USA sepsis mortality = 30 -50%; CCHS = 26% International Sepsis Forum published treatment

guidelines a few months ago – reduces mortality rates by 25-50%

Interdisciplinary Team formed at CCHS to develop implementation plan

Protocol focuses on antibiotics/fluids within 1 hour of presenting in the ED or diagnosis on a Nursing Unit

CCHS implemented “Sepsis Alert Protocol” Compliance with protocol & M & M rates—tracked

Performance Measurements in as close to real time as possible

Twenty databases utilized for benchmarking Clinical areas – detailed benchmark data Results publicly available

– CMS– JCAHO– Leapfrog– Healthgrades– US News & World Report

KEEP IT SIMPLE…MAKE SURE IT’S USEFUL INFORMATION

Chief Medical Officer: Primary Function at CCHS

The CMO as the leader of the Medical Affairs functions, will have responsibility for strategic planning, clinical services, quality, professional performance, business performance, medical education, clinical research and physician practice and network development. As part of the Sr. Exec. Team, the CMO participates in the development of system-wide medical & administrative policies and procedures, acts as liaison between the medical staff, Sr. Mgmt, Board of Directors, and reports directly to the President & CEO.

2006 Current ResultsCONFIDENTIAL AND PRIVILEGED INFORMATION-DO NOT SHARE WITHOUT PERMISSION

BOARD PI FY06 GOALS MEASUREMENT REPORT: August 2005

Focus on Excellence1

FY06

Goal3

Clinical and Service Excellence

Safety First

Current Status of Indicator Sets

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2 Number of measures under-performing in comparison to benchmark/goal, based on total data available to PI/CM as of May 2005 3 Number of under-performing measures that we need decrease to by end of FY 2006.4 Number of under-performing measures as of report date.

1 First pie shows percent of the 24 CMS/JCAHO indicators that are at/better than target. Second shows percent of 18 indicators for which 90th percentile rate data are available that are at/better than 90th percentile.

Meet or exceed benchmark/goal criteria for 50% of CMS Inpatient Quality Improvement Project and JCAHO ORYX Measures which are currently under-performing.

Meet or exceed benchmark/goal criteria for 50% of patient safety indicators which are currently under-performing.

60% 80%

5

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Goal2

Progress Toward Goal

105

20% 40% 100%

43

Current # Under-

Performing4

CMS/JCAHO Indicators below 90th %ile (18)

CMS/JCAHO Indicators at 90th %ile (4)

Goal - 33%(n=7)

CMS/JCAHO Indicators below

target/ benchmark (6)

CMS/JCAHO Indicators at

target/ benchmark (18)

JCAHO/CMS Measures US News/Solucient/Healthgrades/Leapfrog

Christiana CareCorporation Board

System HealthImprovement Council

Christiana CareBoard PI Committee

CancerCommunity Physicians PracticesCritical CareEthicsHeart & VascularMedicalNutritionPain and PalliativePharmacy and TherapeuticsTransfusion PracticeTraumaWomen's & Children Health

Christiana Care - PI Structure

OperationalDepartments/PI Committees

Medical Quality/PI Forum

Central CredentialsCommittee

DepartmentalCredentialsCommittee

Staff CouncilSubsidiary PICommittees

Health ServicesBoard PI Committee

ClinicalDepartment PI

DepartmentalPeer Review

Population & PI

Committees

Unit BasedMedical Directors

Group

Patient SafetyCommittee

Clinical Materials ManagementEmergency ManagementFacilities and ServicesLaboratoryNursing - PI Council - Unit Based PI CommitteesPatient RelationsPatient SatisfactionPMRIRadiologyRisk ManagementRiversideStaff EducationSystem Service ImprovementWellness Centers

Environment of CareInfection ControlMedication Safety

IRB

Revised: April 13, 2005

PURPOSE: Staff Council will designate a Medical Quality/PI Forum to monitor the quality, safety, access, and efficiency of the care and services provided by the Medical Dental staff. This is accomplished through the review of care delivery processes, assessment of clinical outcomes, and individual case discussion and peer review.

COMPOSITION: Membership shall reflect the Committee’s responsibilities as outlined in this description and will include the following representation:

– Chief Medical Officer– Associate Chief Medical Officer– President, Medical-Dental Staff – President-Elect Medical-Dental Staff– Past President, Medical-Dental Staff– Sr VP, Care Management/ Performance Improvement– Clinical Department Chair, of Anesthesiology, Dentistry, Emergency Medicine, Family and

Community Medicine, Medicine, OB/GYN, Pathology, Pediatrics, Psychiatry, Radiation Oncology, Radiology and Surgery

– Physician Members of Staff Council– Other Physician peers as deemed necessary.

MEETINGS: The Committee shall meet at least quarterly or more frequently as deemed necessary by the Chairperson.

REPORTING: The Committee will report to Staff Council as well as to System Health Improvement Council on an ongoing basis. The Medical Quality/PI Forum minutes are maintained by a member of the Department of Performance Improvement and shared with Staff Council for approval. Outcomes of peer review activity are also submitted to Staff Council for approval. The committee may request other reports

Medical Quality Forum Description

Give Information—not just data, and make it personal

ACUTE MI: By Dept, Section, & Group D/Cs LOS $Tot Chgs Severity AMI

CompCCHSFMMedSurgCardIMGrp 1Grp 2

Christiana CareCorporation Board

System HealthImprovement Council

Christiana CareBoard PI Committee

CancerCommunity Physicians PracticesCritical CareEthicsHeart & VascularMedicalNutritionPain and PalliativePharmacy and TherapeuticsTransfusion PracticeTraumaWomen's & Children Health

Christiana Care - PI Structure

OperationalDepartments/PI Committees

Medical Quality/PI Forum

Central CredentialsCommittee

DepartmentalCredentialsCommittee

Staff CouncilSubsidiary PICommittees

Health ServicesBoard PI Committee

ClinicalDepartment PI

DepartmentalPeer Review

Population & PI

Committees

Unit BasedMedical Directors

Group

Patient SafetyCommittee

Clinical Materials ManagementEmergency ManagementFacilities and ServicesLaboratoryNursing - PI Council - Unit Based PI CommitteesPatient RelationsPatient SatisfactionPMRIRadiologyRisk ManagementRiversideStaff EducationSystem Service ImprovementWellness Centers

Environment of CareInfection ControlMedication Safety

IRB

Revised: April 13, 2005

Unit Based Medical DirectorsPhysicians & Nurses Working as a Team

Communication & Engagement

– Vital to success of the program

100% participation is necessary– Monthly Meeting– Monthly Summary Report

UNIT BASED MEDICAL DIRECTOR MONTHLY REPORT(TO BE COMPLETED IF YOU ARE UNABLE TO ATTEND THE MONTHLY MEETING)

1) Nursing Unit rounding and support.Unit-based operational issues and clinical issues addressed this month:

2) Involvement in PI/Patient Safety initiatives on the unit.

PI/Patient Safety activities addressed this month:

3) Educational sessions for the nursing/ancillary staff.

Monthly didactic program provided:

Unit Based Medical Director Evaluation Summary

• Rounds/Operational Issues – Average score – 2.4 (out of 3.0)

• PI/Patient Safety Activities– Average score – 2.2 (out of 3.0)

• Monthly Didactic Education– Average score – 1.8 (out of 1.8)

Monthly didactic education – lowest score

Scores < 2 are unacceptable

- Safety First

- Great Place to Work

- Clinical Service Excellence

-Think of Yourself as the Patient

Dr. Robert Laskowski, President & CEO trusts that everyone is a believer that leadership, quality, safety, and teamwork matter “a whole bunch”!

Focus on Excellence is the CCHS way.

Abbreviations by Staff Title

 

Compliance(May 2005)

Compliance(June 2005)

Compliance(July 2005)

Compliance(August

2005)

Overall 90% 94% 95% 96%

Physicians 79% 87% 89% 93%

Nurses 87% 93% 96% 96%

Clerk 87% 100% 94% 99%

Unknown/illegible

88% 93%89% 95%

Other96% 96% 99% 99%

Safety FirstUnacceptable Abbreviations

DO NOT USE U for UnitsA “U” can be misrepresented as a 0 as shown in

this example.This patient received 80 units instead of 8.

Do not use U for UnitsA “U” can be misrepresented as 0,4, or cc

USE “units”

71%

94%

65%

90%94% 95% 96%

73%

65%70%

35%

49%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall Compliance Results: Unacceptable Abbreviations

Summary

Effective Leadership Skills Can Be Learned Invest in Leadership and Choose Your Medical Staff

Leaders Carefully Manage Relationships Keep Things as Simple and as Focused as Possible

– Results Orientated, Peered & Personal in real time National Report Cards (e.g., JCAHO) are useful

measures of what should already be being done Stay Positive and Have Fun!!

Questions & Comments