Leading Transformational Change

Leading Transformational Change:
The Big Picture

South Carolina Hospital Association
2010 Patient Safety Symposium
Columbia, SC

Maureen Bisognano
Executive Vice President and COO
Institute for Healthcare Improvement

Objectives

After this session, participants will be able
to:

─Identify key drivers for leaders seeking to
thrive in a new environment
─Define a portfolio of new designs that will
improve patient health and experience and
drive down costs

Health Care Expenditure Out of GDP

Difficulty Getting Care on Nights, Weekends, Holidays Without
Going to the Emergency Room, Among Sicker Adults

Percent of adults who sought care reporting ―very‖ or ―somewhat‖ difficult

2005 2007

United States

International Comparison

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

HEALTHY LIVES

Mortality Amenable to Health Care

Deaths per 100,000 population*

150 1997/98 2002/03
134
130 128
116 115 113 115
109 106
99 97 97
100 88 89 89 88
81 84
76

103 103 104 110
50 90 93 96 101
77 80 82 82 84 84
71 71 74 74
65

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* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial
infections.
See report Appendix B for list of all conditions considered amenable to health care in the analysis.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization
mortality files (Nolte and McKee 2008).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5

http://www.commonwealthfund.org/Maps-and-Data/State-Scorecard-2009/DataByState/State.aspx?state=SC

South Carolina HSMRs
Regression-Adjusted Hospital Standardized Mortality Ratios (HSMRs) for South Carolina
Hospital Referral Regions (HRRs)

120

110
Regression Adjusted HSMR

100
Charleston HRR
Columbia HRR
90
Florence HRR
80 Greenville HRR
Spartanburg HRR
70 USA Medicare

60

50
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year

So What If . . .

• Together, in this room, we set out to be as
safe as Ascension, or safer?
• Together, we design care across the
boundaries of our buildings?
• Together, we engage all to make our
families, friends, and staff healthier?
• Together, we show Washington that better
care can cost less?

So What If . . .

• Together, in this room, we set out to
be as safe as Ascension, or safer?

• Together, we design care across the boundaries of our buildings?
• Together, we engage all to make our families, friends, and staff
healthier?
• Together, we show Washington that better care can cost less?

Ascension Health’s Strategy
• Health care that works
• Health care that is safe
• Health care that leaves no one behind
─No preventable deaths by July 2008 across
the entire Ascension system
─No preventable harm by July 2008 across the
entire system
Pressure ulcers
Falls with harm
Medical errors
Birth trauma

Mortality Reduction Driver Diagram
Primary Drivers Secondary Drivers

Analysis of mortality causes
2x2 review of last 50 patient deaths
Leadership Global Trigger Tool review of patient deaths in boxes 3
and 4
Board review on mortality

Standardization of patient handoffs
Communication SBAR training for clinical staff & physicians
Multi-disciplinary rounds
between caregivers Identification of attending physician for all patients
Reduce
mortality Implement birth bundles
Identification of high risk patients on admission and
by 12% during assessments
this year High risk patient care Rapid Response Team
Increased nursing and physician care
Hospitalists

Multi-disciplinary rounds
Daily goal sheets
Ventilator bundle
Intensive/Critical care Glycemic control
Remote monitoring of patients
Intensivists

Influenza vaccine status of pneumonia patients
Community partnerships to promote care that prevents
Prevention critical illness
Eliminate falls with harm
Eliminate pressure ulcers

Perinatal Safety (Birth Trauma)
Seton Medical Center – Austin, TX
St. Mary’s Medical Center – Evansville, IN

Alpha Spread Ascension Health System
Birth Traum a Rate
Unfavorable
S t. M ary's B irth T rau m as - C Y2005 4.5

20% Birth Traum a Rate Goal for
As cesnion Health = 0 /1000 Births
18.87% 4.0
D e liv e rie s

17.36%
16.00%
3.5
15% N = 32
N = 33
13.95% 3.03
IHI Target Birth Trauma Rate = 3 /1000 Births
2.97
12.69%

Birth Trauma Rate per 1000 Live Births
12.06% 12.50% 3.0
N = 36

2.68 N = 35
10.30% 10.58%
10% 2.52
9.15% 8.63% 2.5
P e rc e n t

7.26%
2.0
5% 1.84
1.97

N = 36

1.26% 2.99% 1.5
1.82% 0.61% 1.39% 0.71% 1.32% 1.61% 1.92% N = 35
0.72% 0.00% 0.00%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1.0

Jan Feb Mar A pr May Jun Jul A ug Sep Oc t Nov Dec National Birth Trauma Rate = 6.59 /1000
Births
0.5

-5%
0.0

2005 Jan-06 Feb-06 Mar-06
Month
Apr-06 May-06 Jun-06

Favorable Birth Trauma Rate per 1000 Live Births Linear (Birth Trauma Rate per 1000 Live Births)
Ins trum ent-A s s is ted Deliveries S houlder Dy s toc ia B irth Traum a N = Number of Reporting Hospitals

Zero!

Reducing Harm in the ICU
Ventilator Acquired Pneumonia
St. Vincent’s Hospital, Birmingham
System Trend VAP Rate
ICU/CVICU Combined VAP Rate Unfavorable
Ascension Health Goal is 0 VAP per 1000 Ventilator Days
4.5

16
4.0
14 N = 43 NNIS Average = 4.15 VAP per 1000 Ventilator Days
3.55

12 3.5
VAP rate Per 100 Vent days

NNIS Average = 4.15 VAP per 1000 Ventilator Days N =43

VAP rate Per 100 Vent days
3.03
10
3.0
N = 43 N = 42
8 2.63
2.50
2.53
2.5

6 N = 44
2.25
2.0
4 N = 43

2 1.5 1.68
N =39

0
1.0
11/1/2004
5/1/2004

7/1/2005
7/1/2004

9/1/2004

1/1/2005

3/1/2005

5/1/2005

9/1/2005

1/1/2006

3/1/2006

5/1/2006

7/1/2006
11/1/2005

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
Month
Favorable
Vap Rate per 1000 ICU Vent days Linear (Vap Rate per 1000 ICU Vent days)

N = Number of Reporting Hospitals

Zero!

Blood Stream Infections
St. John’s Hospital, Detroit
BSI Rate System Trend BSI Rate
Unfavorable
Ascension Health Goal is 0 BSI per 1000 Central Line Days
4.5

10
4.0
9 NNIS Average = 4.22 BSI per 1000 Central Line Days

NNIS Average = 4.22 BSI per 1000 Central Line Days 3.5
8
BSI per 1000 Central Line days

BSI Rate Per 1000 Central Line days
3.0
7
N = 39
2.33
6 2.5

N =39
5 2.0
1.74
N =35
4 1.37
1.5
1.69
3 N = 39 1.38 1.38 1.35
1.0
N = 38 N =38 N =38
2
0.5
1
0.0
0 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
Mar-04

May-04

Mar-05

May-05

Mar-06

May-06
Nov-04

Nov-05
Feb-04

Aug-04
Sep-04

Feb-05

Aug-05
Sep-05

Feb-06
Jan-04

Apr-04

Jun-04

Jan-05

Apr-05

Jun-05

Jan-06

Apr-06

Jun-06
Dec-03

Dec-04

Dec-05
Jul-04

Jul-05

Jul-06
Oct-04

Oct-05

Month
Favorable
BSI Rate Per 1000 CL Days Linear (BSI Rate Per 1000 CL Days)
N = Number of Reporting Hospitals

Zero!

POAE Rate per Patient

M

0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
ar
-0
Ap 4
r- 0
M 4
ay
-0
Ju 4
n-
04
Ju
l-0
Au 4
g-
0
Se 4
p-
0
O 4
ct
-0
No 4
v-
0
De 4
c-
04
Ja

POAE Rate
n-
0
Fe 5
b-
0
M 5
ar
-0
Ap 5

CL
r- 0
M 5
ay
-0
Ju 5
n-
05
Ju
l-0

UCL
Columbia St. Mary's, Milwaukee WI

Au 5
g-
0
Perioperative Adverse Event (POAE) Rate

Se 5
p-
0
O 5
ct
-0

LCL
No 5
v-
0
De 5
c-
Columbia St. Mary’s - Milwaukee

05
Ja
n-
0
Fe 6
b-
0
M 6
ar POAE Rate per Patient
-0
Ap 6
r- 0

0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4

0
M 6
ay
-0
Jan-04 6
Feb-04
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
POAE Rate
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Columbia St. Mary’s – Milwaukee, WI

CL

Mar-05
Sacred Heart Hospital – Pensacola, FL

Apr-05
Surgical Complications

May-05
Jun-05
Jul-05
Sacred Heart Hospital, Pensacola FL

Aug-05
Perioperative Adverse Event (POAE) Rate

UCL

Sep-05
Oct-05
Nov-05
Sacred Heart Hospital

Dec-05
Jan-06
LCL

Feb-06
Mar-06
Apr-06
Zero!

May-06
Jun-06
Jul-06

Pressure Ulcer Prevention
Facility Acquired Pressure Ulcer Rate
St. Vincent Hospital, Jacksonville
50 hospitals reporting: Overall Rate 1.38
National Rate:
Overall PU ratio by week U n f a v o r a b le

7.00
2 .0 0

P re s u re U lc e r R a t e p e r 1 0 0 0 P a t ie n t D a y s
N = 50
6.00
N = 51
N =50 1 .6 6
1 .6 3
1 .5 7
5.00
N = 50
1 .5 0
1 .3 8
1 .4 8
4.00
1 .4 1 N = 51

N = 50
3.31
1 .2 7
3.00
N = 50
2.78
2.53 2.46
1 .0 0
2.11
2.00 1.93 2.00
1.90
1.68 1.65
1.46
1.47 1.41
1.38 1.39
1.171.17 1.07
1.04 1.001.03 1.03 1.01 1.05 1.05 1.07
1.00 0.94 0.990.99
0.75 0.74 0.69 0.69 0.71 0.71 0.75 0.69

0.67
0.38 0.390.37 0.36 0.32 0.340.33 0.39 0.35 0.39
0.32 0.32 0.37
0.35
0 .5 0
0.00 0.00
Ja n -0 6 Feb-06 Mar-06 A pr-06 May -06 Ju n -0 6 J u l- 0 6
WE 8/29/05

WE 9/12/05

WE 9/26/05

WE 10/10/05

WE 10/24/05

WE 11/7/05

WE 11/21/05

WE 12/5/05

WE 12/19/05

WE 1/2/06

WE 1/16/06

WE 1/30/06

WE 2/13/06

WE 2/27/06

WE 3/13/06

WE 3/27/06

WE 4/10/06

WE 4/24/06

WE 5/8/06

WE 5/22/06

WE 6/5/06

WE 6/19/06

WE 7/3/06

WE 7/17/06

WE 7/31/06

WE 8/14/06

WE 8/28/06

F a v o r a b le
M o n th
P r e s s u r e u lc e r r a t e p e r 1 0 0 0 In p a t ie n t D a y s L in e a r ( P r e s s u r e u lc e r r a t e p e r 1 0 0 0 In p a tie n t D a y s )
N = N u m b e r o f R e p o r tin g H o s p it a ls

Zero!

Rapid Response Teams – Non-Critical Care Codes and RRT Calls
Borgess Hospital, Kalamazoo

33 hospitals reporting: Overall Rate 2.71
Borgess Medical Center
Non-Critical Care Code Rate by Month for Reporting Hospitals
Non-Critical Care Codes
per 1,000 discharges unfavorable
10 3.6
3.56 Non-CC Code Rate Goal for
3.50
3.47 Ascension Health: 0 / 1000
3.4

Rate per 1000 Discharges
3.38 Discharges
8
3.29
3.23 3.25
3.2 3.19

6 3.07
3.0
2.96

2.84 2.85
4 2.8
2.71
2.6
2
n=25 n=27 n=24 n=24 n=22 n=22 n=36 n=34 n=35 n=35 n=35 n=37 n=33
2.4
0
Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06
favorable Non-Critical Care Code Rate per 1000 Discharges
NON-CC CODES (per 1000 disch)
N= Number of Reporting Hospitals Linear (Non-Critical Care Code Rate per 1000 Discharges)

Error Reduction at Ascension
Preventable Error Reduction in rate
Pressure Ulcer 95%

Neonatal mortality 79%

Birth Trauma 74%

Ventilator-acquired pneumonia 56%

Falls with serious injury 54%

Blood-stream infections 32%

July, 2008 Update: ―A Partial Success‖

• Ascension set a goal of preventing 900
unnecessary deaths by Summer 2008.

• In July, they announced they had, in their
estimation, prevented 2,700 deaths –
three times their stated goal.

Ascension Health: New Aim

Healing Without Harm
by 2014

Palmetto Hospital Mortality Rates

So What If . . .
• Together, in this room, we set out to be as safe as Ascension, or
safer?

• Together, we design care across the
boundaries of our buildings?
• Together, we engage all to make our families, friends, and staff
healthier?

A Case Study From University of
Pittsburgh Medical Center (UPMC)
• Aims in redesigning care for patients
undergoing total joint replacement
1. Patient and family education
2. Less invasive techniques
3. Multimodal anesthesia and pain management techniques
4. Rapid rehabilitation protocols
5. Rapid outcomes feedback (from the patients’ and the
providers’ perspectives
6. Creating a learning environment and culture
7. Developing a sense of community, competition and teamwork
among patients and between patients, caregivers and staff
8. Promoting a wellness (rather than sickness) approach to
recovery DiGioia A, Greenhouse P, Levison T. ―Patient and Family-
centered Collaborative Care: An Orthopaedic Model‖.
Clinical Orthopaedics and Related Research. 2007: 463;
pp: 13-19.

Tony DiGioia

Dr. Anthony M. DiGioia III, orthopedic surgeon
and developer of the patient- and family-centered
care program for UPMC, in his office at Magee-
Womens Hospital in Oakland.

A Case Study From UPMC

• New Designs:

─Pre-op testing, teaching
─Coaching meetings with other patients
─Pre-surgery discharge planning
─Strong focus on complete pain management
─―Wellness‖ design in orthopedics unit

DiGioia A, Greenhouse P, Levison T. “Patient and Family-
centered Collaborative Care: An Orthopaedic Model”. Clinical
Orthopaedics and Related Research. 2007: 463; pp: 13-19.

Results

• Safe:
─Mortality rate: 0%
─Infection rates: 0.3% (0.2% for TKA and 0.7%
for THA)
─Zero dislocations
─SCIP compliance: 98% for antibiotics within one
hour of surgery


Results

• Effective:
─95% of patients discharged without handheld
assistance directly to home (national rates:
23-29%)

─99% of patients reported that pain was not an
impediment to physical therapy, including
same-day-of-surgery physical therapy


Results

• Patient-centered:
─ Press-Ganey mean satisfaction score is 91.4% (99th
national percentile ranking) with 99.7% positive
responses to ―Would you refer family and/or friends?‖
• Efficient:
─ Average length of stay:
 2.8 days for TKA (national average is 3.9 days)
 2.7 days for THA (national average is 5.0 days)
─ One MD able to perform 8 joint replacements before
2:00pm


Other PFCC Projects at UPMC
• Day of Surgery (UPMC Presbyterian)
• Human Resources – The New Hire Experience (UPMC
Corporate)
• Trauma (UPMC Presbyterian)
• Wayfinding / Lobby (Magee-Women’s Hospital)
• Rheumatology (Children’s Hospital of Pittsburgh)
• Minimally Invasive Bariatric and General Surgery
(Magee-Women’s Hospital)
• Home Health Rehabilitation (Jefferson Regional)

So What If . . .
• Together, in this room, we set out to be as safe as Ascension, or
safer?
• Together, we design care across the boundaries of our buildings?

• Together, we engage all to make our
families, friends, and staff healthier?


Health Outcomes
• 1 in 10 adults in SC has diabetes
• 22% of adults in SC smoke (compared with 18.3% nationally)
• 65.8% of adults in SC are either obese or overweight (compared
with 63% nationally)
• 15.1% of adults in SC report having a disability (compared with
12.8% nationally)
• Mortality rates amenable to health care are 115.5 per 100,000
compared with 89.9 per 100,000 nationally.
• Commonwealth Fund ranks SC 33th in US for Prevention and
Treatment in 2009 (in 2007 was ranked 35th)
 What if we started with all health care workers in
out hospitals like Bellin, and then spread to our
families and friends?

Health Navigation: Bellin Health
The new gateway to
Bellin Health.
Personal, tailored
treatment to
individuals’ needs,
learning styles and
lifestyles.

Bellin Health
Cost of Employee Plan vs. Averages
Bellin Health
Solutions
Program
Introduced Funded Personal
Benefit Accounts began
($500/$1000)

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Leading Transformational Change

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