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The Transformation Journey
Jeanette G. CloughCEO, Mount Auburn HospitalPresentation to the MassachusettsCoalition to Prevent Medical ErrorsJune 23, 2009
Overview of the LEAD Program
A Blue Cross Blue Shield program aimed at supporting transformational change in health care.
Health care institutions were chosen for their leadership and organizational commitment to quality and safety.
Participants were required to set “audacious” safety goals and provide monthly measures of progress toward these goals.
Overview of the LEAD Program
LEAD encourages learning from experts in quality and safety. Monthly meetings with experts from around the world are held for the CEOs and the leadership teams.
LEAD provides a $1.5 million dollar stipend to support the transformational work.
LEAD is a 24 month program ending in March 2009.
The Challenge
Mount Auburn was ready
-to commit to more rigorous and accelerated action on quality and safety
-to commit further resources of time and dollars
-to set audacious goals and establish a timeline for goal achievement
The Challenge
The LEAD program was consistent with our belief that quality is a strategic imperative and with our organizational goals and guiding principles for quality and safety:
Measurement and benchmarking
Collection, interpretation and measurement of clinical, operational and financial metrics measured against the Hospital’s past performance and against national and “best performer” benchmarks.
Organizational Principles
Transparency
Sharing performance data against best practice benchmarks within the Hospital, the healthcare community and with the public to foster discussion, debate, competition and improvement.
Organizational Principles
Uniting process with technology
Using technology in the design and function of systems and processes in the delivery of care to improve efficiency, enhance communication, enable data collection and limit the potential for human error.
Organizational Principles
Learning from error
Examining and exhuming the causes of near or actual error followed by education, training, communication and change to prevent further errors from occurring.
Organizational Principles
Linking employee and physician satisfaction with achievement of all organizational goals including quality and safety
Carefully listening and responding to employees and physicians through a variety of methods as the foundation for meeting organizational goals and objectives.
Organizational Principles
Setting the goals
What would it take to become the safest hospital for the delivery of medications and eliminate any harm to patients from medications?
Don’t all patients deserve to enter the Hospital and not be subject to a medication error? And don’t all employees deserve a safe system to deliver medications?
LEAD Goal: Medication Safety
Use state-of-the-art technology to automate the process for medication delivery…from ordering to administering… in order to achieve “six sigma” reliability (less than 1 event per million doses administered) and to eliminate medication errors.
Key Steps to Achieve the Goal
Automating the medication process
-CPOE: ordering and decision support
-PYXIS: dispensing
-Talyst: bar coding of drugs and inventory management
-”Smart pump” implementation: IV drug delivery
-BMV: bedside med verification
-EMAR: electronic med administration record
Results: Medication Safety
Mount Auburn has now achieved five sigma
reliability and has had no Level 2-3-4 (events that reached a patient) events since Sept. 17, 2008.
Mount Auburn has had a 67% reduction in medication events since LEAD began.
Minor Patient Harm from Medication EventsSixty Seven Percent (67%) Reduction During LEAD
0.000024
0.000013
0.000009
0.0000000.000000
0.000005
0.000010
0.000015
0.000020
0.000025
0.000030
MAH Baseline 2006 Lead Year 1: CY2007 Lead Year 2: CY2008 Current YTD: CY2009(Jan- Mar 09)
Time Period
Err
or
Rate
/ M
edic
ati
ons
Adm
inis
tere
d
Days Between Level 2- 4 Medication Events
0
30
60
90
120
150
180
7/1
/06
7/1
5/0
67
/29
/06
8/1
2/0
68
/26
/06
9/9
/06
9/2
3/0
61
0/7
/06
10
/21
/06
11
/4/0
61
1/1
8/0
61
2/2
/06
12
/16
/06
12
/30
/06
1/1
3/0
71
/27
/07
2/1
0/0
72
/24
/07
3/1
0/0
73
/24
/07
4/7
/07
4/2
1/0
75
/5/0
75
/19
/07
6/2
/07
6/1
6/0
76
/30
/07
7/1
4/0
77
/28
/07
8/1
1/0
78
/25
/07
9/8
/07
9/2
2/0
71
0/6
/07
10
/20
/07
11
/3/0
71
1/1
7/0
71
2/1
/07
12
/15
/07
12
/29
/07
1/1
2/0
81
/26
/08
2/9
/08
2/2
3/0
83
/8/0
83
/22
/08
4/5
/08
4/1
9/0
85
/3/0
85
/17
/08
5/3
1/0
86
/14
/08
6/2
8/0
87
/12
/08
7/2
6/0
88
/9/0
88
/23
/08
9/6
/08
9/2
0/0
81
0/4
/08
10
/18
/08
11
/1/0
81
1/1
5/0
81
1/2
9/0
81
2/1
3/0
81
2/2
7/0
81
/10
/20
09
1/2
4/2
00
92
/7/2
00
92
/21
/20
09
3/7
/20
09
3/2
1/2
00
9
Year and Week
Day
s Bet
wee
n E
vents
LEAD Begins: 1/1/2007
UCL
Infection Prevention Goals
To achieve six sigma level of central blood stream infections: less than 1 CBI in 10/6th central line days in both ICUs
To achieve six sigma level of ventilator assisted pneumonias (VAPs): less than 1 VAP in 10/6th ventilator days in both ICUs
Identify, cohort and decontaminate to reduce hospital acquired MRSA infection by 50%
Setting the goal
What would it take to eliminate MRSA in the ICUs? What would it take to also eliminate all VAPs and CBIs? Can it be done?
Results: Infection Prevention
Mount Auburn has achieved a 68% reduction in central bloodstream infections over the two years of the LEAD program.
Mount Auburn now has less than 1 CBI per 1000 central line days.
Hospital Acquired Central Bloodstream InfectionsSixty Eight Percent (68%) Reduction During LEAD
2.22
1.14
0.70
0.00
0.50
1.00
1.50
2.00
2.50
MAH Baseline 2006 Lead Year 1: CY2007 Lead Year 2: CY2008
Time Period
CBI Rate
/ 1000 L
ine D
ays
Results: VAPs
Mount Auburn has had a 50% decrease in VAPs during the two years of the LEAD program.
Mount Auburn now has a rate of 1.25 VAP per 1000 ventilator days. (The rate is lower than 1.25 in the MICU and is approaching six sigma).
Hospital Acquired Ventilator Associated PneumoniaFifty Percent (50%) Reduction During LEAD
2.51
0.54
1.25
0.00
0.50
1.00
1.50
2.00
2.50
3.00
MAH Baseline 2006 Lead Year 1: CY2007 Lead Year 2: CY2008
Time Period
VA
P R
ate
/ 1000 V
ent
Days
Results: MRSA in the ICUs
Mount Auburn has reduced MRSA CBI and VAP to six sigma levels with zero HAI MRSA infections in the ICU and CCU since October 06.
Results :Cost Savings
Mount Auburn has calculated total savings of the following from January 2006 thru April 2009:
$813,629.65 for CBI reduction
$1,132,593.00 for VAPs reduction
$148,907.62 for med safety improvement
Looking Back….
In 2006 Mount Auburn .. had many strengths to build upon for LEAD took the LEAD challenge seriously set audacious and meaningful goals Applied strategy, planning, teamwork and
perseverance to achieve gains in both sets of goals
Looking Back….
Despite the strengths we still had… Early and late adopters Some resisters and many doubters Lots of infrastructure to put together IS challenges A huge $90M construction project going on Lots of opportunity to be distracted
Looking Back….
It would have been easy to get distracted…. The economy started to crumble and
collapsed Investments and value of real estate
plummeted The competition got even hotter and nastier The physician shortage grew larger
Key Elements for Success
Strong organizational structure
Committed and stable senior management and physician leadership
Deep physician – hospital alignment
Size of the organization
Looking Back….Critical Elements to Success
Culture is absolutely key Understanding the dynamics of change Constancy of purpose –unwavering commitment One step at a time –a strategic plan and timetable Applying the four key principals:
measurement and benchmarking, transparency, learning from error, uniting processes with technology
Moving forward…
New norms have been established Error or infection is a rare, if ever, event Culture and roles are strengthened Cost of care is reduced and efficiencies
gained Payment reform in the AQC allows us to
focus even more on quality and safety
