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Physician Led Changes in Patient Safety

Marilouise Venditti MDChief Medical Officer

Anthony Macchiavelli MDAdult Hospitalist Program Director

AtlantiCareRegional Medical

Center

AtlantiCare Health

Services

AtlantiCare Health

Engagement

AtlantiCare Foundation

AtlantiCare Behavioral

Health

AtlantiCare

The AtlantiCare Family

5100 Member WorkforceMedical Staff

700 Physicians (150 Employed)5 Operating Boards65 Sites80 Volunteer Board Members

Validation of Quality Work

Patient Safety Committee

• Platform which integrates all departments and services into the safety program

• Mission: Enhance and provide the highest principles, practice, and culture of safety for the benefit of all who are served by AtlantiCare

Quality Management Steering Committee of the Board

Patient Safety Committee

Medical Executive Committee

Physicians’ Role in Patient Safety

Reporting Structure - Patient Safety Activities

PSC Members• William Aarons MD, CIMO• Howard Axelrod MD, Chair Dept. Surgery,

CSO• Robyn Begley DNP, VP of Nursing• Margaret Belfield, COO• Joan Brennan DNP, VP of Performance

Excellence• Rene Bunting VP Marketing and PR• Ana Cilursu MD, Medical Residency Dir• Haitham Dib MD, Attending Cardiologist and

Division Director• Julia Drew MSW MPH, System Executive

Dir Behavioral Health• Kathy Dudick MD, Chair Critical Care• Sandra Garrett-Baggs, Corporate Dir

Pharmacy• Walter Greiner, VP of Finance• Lori Herndon, President and CEO

• Cathy Iocona, Asst CIO• Kathi Johnson, Risk Director• Dr Joby Kolsun MD, Director Medical Staff

Quality• Anthony Macchiavelli MD, Director Adult

Hospitalist Program• Kevin McDonnell, COO Health Services• Romeo Pericic MD, Chair Dept of

Anesthesia• Liz Readeau MSN, Asst VP of Nursing• Gary Rosman MD, Medical Staff• John Saia DO, Medical Staff• Katherine Schneider MD, VP of Health

Engagement• Alexander Sharnoff Esq. Assoc. Corporate

Counsel• Marilouise Venditti MD, CMO• Mary Beth Kelly, Director Patient Safety

Serious Occurrence Process

Type of Event– Undesirable, Unexpected

– Serious Occurrence (may include near miss)

– Sentinel Event

Response– Investigate, counsel,

peer review, briefing– Action plan, case conf,

PI team + above– RCA, manage public

perception, consider command center + above

RCA Team

• Lead by an administrator and a medical staff officer

• Key stakeholders invited to participate

• Tools: brainstorming, VA cause analysis tool

• Results report to Patient Safety Committee

Priority Themes to Date

• Clear communication and accessible information

• On-site supervision of residents

• Critical care model

Hospitalist Service: Our Solution to the Remote Care Challenge

• The Hospitalist Service provides 24 hour physician coverage of acute care campuses

Days:• City: 6 Hospitalists and 2 APN / Day• Mainland: 5 Hospitalists and 2.5 APN / Day

Nights:• City: 1 Hospitalist / Night• Mainland: 1 Hospitalist and .5 APN / Night

• 12 Hospitalists operational / 24hours = 26 FTEs

Hospitalist Service Mission

1. Provide the highest quality patient service in a caring and efficient manner

2. Educate and train medical professionals in Hospital Medicine.

3. Advance medical knowledge through clinical researchand process improvement.”

Supervision of Residents

Hospitalist Teaching Service

Teaching attending and resident round together-City July 1-Mainland October 1

Critical Care Model

• Intensivists • Closed Units• Redundancy • Transitions of care

Memorial Regional Hospital

The American Hospital AssociationMcKesson Quest for Quality

Prize Award

Our MissionMemorial Healthcare System provides safe, quality,

cost-effective, patient- and family-centered care, regardless of one’s ability to pay, with the goal of improving the health of the community it serves.

Our VisionMemorial Healthcare System will improve the health of the community by becoming a world-class model

of safety, quality, service and efficiency.

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The Memorial Experience Pillars of Excellence

Safety Quality Service People Finance Growth Community

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THE MEMORIAL EXPERIENCEA Culture of Safety, Quality and Service

Safety• Crew Resource Management• Patient First Awards (Safety Alerts)• Elopement Alerts• OB Critical Assessment Team• Safety and Quality Steering Committee• PI Initiatives Stemming from Multiple Sources• Just Culture (Accountability)

Patient Centered Care• Patient- and Family-Centered Care• Patient Friendly MAR (Daily Medication Schedule)• Help Alerts • Palliative Care• Healing Environment• Transparency through Storytelling, Memorial Experience and Disclosure

• Patient and Family Initiated Support Network / Groups

Effectiveness• Evidence-Based Practices• Bedside Change of Shift Report• Outcome Reporting

Efficiency• Unit-Based Clinical Pharmacists• Employed Intensivists and Hospitalists• EPIC Electronic Medical Record

Timeliness• Dedicated Rapid Response Teams• Hourly and Multidisciplinary Rounding• PCI Task Force

Equity• Community Programs and Partnerships• Special Needs Coordinator • MOD Squad (Memorial Outfitted for Diversity)• Charity Policy for the District • Cultural Competency Training

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MRH Cultural DriversOngoing Monitoring and Reporting through:90-Day Action PlansMonthly Operations Review Monthly Balanced Scorecards for LeadershipBoard Quality and Peer ReviewCommitment to Culture

Committed to Leadership DevelopmentBoard Retreats and Educational PresentationsOngoing Leadership Development Sessions Personalized Coaching and Employee Mentorship ProgramsContinuing Education ProgramsAHA National Safety Foundation

“Patient Safety Leadership Fellowship”5

Community DiversityDiversity in our Board Diversity in our Leadership TeamDiversity in our Medical StaffDiversity in our Employment PracticesDiversity in our Patient and Family Advisory

Council Supplier Diversity ProgramsDiversity in our approach to the Community

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Quality and Safety Reporting Flows Through the System

Board Peer Review

Hospital Medical Executive Committee

Quality Care & Patient Safety Council

Medical Staff Departments

Multidisciplinary Peer Review Committee Performance Improvement/Risk

Management Committee

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Board Peer Review Credentialing Activities

• Appointments, Reappointments and Peer Review Actions Quality of Care and Service Reviews

• Physician Satisfaction• Quality Indicators

Core Measures Mortality & Morbidity Readmissions Surgical Case Review Hospital-Acquired Conditions (HAC)

• Safety Indicators Mislabeled/Unlabeled Specimens Medication Errors Pressure Ulcers Code 15, Sentinel Events and Sentinel Event Alerts

Risk Management and Safety Function• Sentinel Events• Root Cause Analyses• Closed Claim Reporting 8

Performance Improvement Initiatives Crew Resource Management Chemotherapy Administration Remifentanil Ordering and Administration Interventional Radiology and Sedation Obstetrical Critical Assessment Team (OB “CAT”) Rapid Transfusion Protocol Elopement Alert Difficult Airway Magnetic Resonance Imaging (MRI) Safety Pressure Ulcers Board Mandated Reduction in Mortality Central Line Associated Blood Stream Infection (CLABSI) Ventilator Associated Pneumonia (VAP)

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MRH Annual Mortality Rate (includes in-patient)

0

0.5

1

1.5

2

2.5

3

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Rat

eMRH Mortality

Excludes ED, Hospice, Psych, Rehab, and stillborn 10

34.6% reduction

Central Line Associated Blood Stream Infection (CLABSI)Memorial Regional Hospital

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6.4 3.8 2 1.3 1.3

4165

236

132

0

50

100

150

200

250

2006 2007 2008 2009 2010

#CLABSI RATE Linear (#CLABSI)

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83.9% reduction

Ventilator Associated Pneumonia Memorial Regional Hospital

60

21

81.9 0.7 0.33

40.4

5.6

0

10

20

30

40

50

60

70

2006 2007 2008 2009 2010

#VAP RATE Linear (#VAP)

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95.0% reduction

Patient- and Family-Centered Care Initiatives

Patient- and Family-Centered Care Department Patient and Family Resource Centers Bedside Change of Shift Report Daily Medication Schedule (Patient-Friendly MAR) Family Faculty Presentation at New Employee Orientation Patient and Families are Involved in Multidisciplinary Rounds Patient and Family Advisors Participate in the following:

• PI and Risk Management• Quality Care Councils• District Quality and Safety• Satisfaction Teams• Architectural Designs• Product Line Focus Groups• Palliative Care Team• Ethics Committee

• Dietary Meetings• Fall Prevention Team• Way Finding• Website Design• Strategic Planning Sessions• e-Health• End of Life Team• Bereavement Team 13

Improving Patient Satisfaction

Flow Variability

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MRH HCAHPS Hospital Overall Percentile Rank by Received Date

15

0

10

20

30

40

50

60

70

80

90

100

Nov '10 Dec '10 Jan '11 Feb '11 Mar '11 Apr '11 May '11 Jun '11 Jul '11 Aug '11 Sept '11

Rate Recommend Goal Linear (Rate)

Evidence Based Order Sets

Goals and Objectives

Optimize Quality and

Patient Safety

Achieve Meaningful Use

Improve Resource Utilization

Develop ~250 Order Sets

Utilizing Zynx® Content

Develop seamless transition to CPOE

Deliverables

Reduce medication errors and adverse events

Specialty based Order Set workgroups drive content, filtering up to Med Exec governance structure

Reduce variations in practice between physicians and facilities

Improve operational efficiencies: reduce turnaround times for meds, labs, diagnostic tests

Reduce length of stayand readmission rates

Ensure compliance with evidencebased guidelines (CMS, TJC)

Derive provider specific quality and utilization metrics via electronic data mining

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COMMUNITY-BASEDHEALTHCARE

PRIMARY CARE SERVICES

• HITS Initiative • JDCH Children’s Mobile Health Center • MHS Adult Mobile Health Center • Back-to-School Health Fairs•Homeless Clinics

• Adult, Pediatric & OB/GYN services• Four convenient clinic locations• Pharmacy • Specialists• Disease Management• Behavioral Health • Social Services

• Quality of Life Studies• Neighborhood Targeted Programs• State of Florida DOH Charts Database• State of Florida DOH Charts Database• Vital Statistics• Healthy People 20xx• Selected Benchmark Report• Other Community Information Services (United Way, 211, etc.)

COMMUNITY NEEDSASSESSMENT

INPATIENT

HOSPITAL-BASED HEALTHCARE

ED• Hospitalists• Specialists• Intensivists

• Laboratory• Radiology• PT-OT• Pain Center• Etc.

OUTPATIENTSERVICES

• Hospice Care• Palliative Care• Home Health

POSTDISCHARGE

Commitment to Community Health

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Overall Community Health ApproachMajor Initiatives

Primary Care Initiative – Since 1992• Pediatric / Obstetrical and Adult Services• Prevention / Wellness• Disease Management• ED Diversion (2011)

Community Services Initiative• Leading Causes of Death by Age• Unintentional Injury by Age• Collaboration / Partnerships

Community Benefits Initiative• Trust / Quality of Life / Health

Community Youth Services• Adolescent Behavioral Health and Childhood Obesity

Health Intervention with Targeted Services (HITS) Program Initiative• Phase I – Overall Health and Eligibility - Targeted Neighborhoods• Phase II – Preventable Admissions

Health Employees Reaching Out (H.E.R.O.) Initiative –Employee Volunteer Program

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Questions?