Achieving Excellence in Achieving Excellence in Patient Care: Empowering Patient Care: Empowering

the Front Linethe Front Line

Maureen Broms, MS, RNMaureen Broms, MS, RNVice President Vice President

Health Care Quality and Health Care Quality and Patient SafetyPatient Safety

New England Baptist New England Baptist HospitalHospital

June 23, 2009June 23, 2009

Our Journey Toward Our Journey Toward ExcellenceExcellence Our VisionOur Vision Where We WereWhere We Were The Zero ChallengeThe Zero Challenge Empowering the Front LineEmpowering the Front Line ResultsResults

What Drives Us?What Drives Us?

Our Vision Our Vision

New England Baptist Hospital New England Baptist Hospital will be known as a premier will be known as a premier Orthopedic Center of Excellence, Orthopedic Center of Excellence, providing the highest quality providing the highest quality medical and surgical care. medical and surgical care.

How were we doing?How were we doing?

Superior performance in surgical Superior performance in surgical site infection eliminationsite infection elimination

Nationally 94Nationally 94 – 98% compliance with SCIP– 98% compliance with SCIP SSI rate – 0.51* vs NNIS database rate 1.5SSI rate – 0.51* vs NNIS database rate 1.5

Patient Fall Rate and Hospital Patient Fall Rate and Hospital Acquired Skin Breakdown less than Acquired Skin Breakdown less than the national averagethe national average

Superior patient satisfaction resultsSuperior patient satisfaction results* All SSIs* All SSIs

The “Zero” ChallengeThe “Zero” Challenge

The Board of Trustees challenged us to do The Board of Trustees challenged us to do betterbetter

Our staff felt agreed improvement was Our staff felt agreed improvement was possiblepossible

Ultimate goal – avoid preventable harmUltimate goal – avoid preventable harm Areas to explore, assess, and monitor Areas to explore, assess, and monitor

included:included:– Reducing HAIsReducing HAIs– Reducing medication eventsReducing medication events– Eliminating post-operative DVT and PEsEliminating post-operative DVT and PEs

What Would It Take?What Would It Take?

Required out-of-the-box thinking Required out-of-the-box thinking and a new philosophical approach and a new philosophical approach

Front-line empowermentFront-line empowerment Eliminate:Eliminate:

– lack true ownership by front-line stafflack true ownership by front-line staff– natural tendency to slide back to old natural tendency to slide back to old

habitshabits– Hawthorne effectHawthorne effect

Great CompaniesGreat Companies

For great companies – For great companies –

“There was no miracle moment. “There was no miracle moment. Instead, a down-to-earth, pragmatic, Instead, a down-to-earth, pragmatic, committed-to-excellence process -- a committed-to-excellence process -- a framework -- kept each company, its framework -- kept each company, its leaders, and its people on track for the leaders, and its people on track for the long haul.” long haul.” Jim CollinsJim Collins

Our ApproachOur Approach

Develop a new framework and stick to Develop a new framework and stick to itit– TPS LEANTPS LEAN– Focused approach – med eventsFocused approach – med events

Develop a mechanism for staff and Develop a mechanism for staff and physicians to call out problems as they physicians to call out problems as they occurred occurred

Implement real-time problem-solvingImplement real-time problem-solving Ensure improvements happen at the Ensure improvements happen at the

level closest to the patient, i.e. Out of level closest to the patient, i.e. Out of the conference roomthe conference room

FrameworkFramework

Agreed upon principles applied Agreed upon principles applied carefully and consistently:carefully and consistently:– To each and every phase of To each and every phase of

medication pathway redesignmedication pathway redesign– To real-time problem-solvingTo real-time problem-solving

Real-time Problem-Real-time Problem-solvingsolving Implemented mechanisms to call out Implemented mechanisms to call out

problems as the occurred problems as the occurred – Help ChainHelp Chain– Problem logProblem log

Improvements occur at the level Improvements occur at the level closest to the patient and toward the closest to the patient and toward the characteristics of an ideal processcharacteristics of an ideal process– With front-line staff leading the With front-line staff leading the

improvement (those who do the work)improvement (those who do the work)– In the work area (allows for observations)In the work area (allows for observations)

Help ChainHelp Chain

Mechanism by which problems Mechanism by which problems are addressedare addressed

Begins at level closest to patient Begins at level closest to patient and moves toward CEOand moves toward CEO

Creates safety by requiring cross Creates safety by requiring cross level communication, i.e. level communication, i.e. manager to manager or director manager to manager or director to directorto director

Patient

Staff(Ordering Practitioner, RN, RPH Secretary)

Clinical Resource Nurse

Problem

New England Baptist Real-Time Root Cause Problem Solving Help Chain

Clinical Manager

Director of Patient Care Services

SVP of Patient Care

Services

CEO Dept. Chief

Problem LogProblem Log

BenefitsBenefits Makes problems visibleMakes problems visible Creates “pull” from leadership Creates “pull” from leadership

vs. “push”vs. “push” Allows others to learn from Allows others to learn from

solutions and key pointssolutions and key points

Surgical Site Infection Surgical Site Infection Prevention FY06-FY09Prevention FY06-FY09

Results:Results: FY06 46 orthopedic SSI in 9027 cases FY06 46 orthopedic SSI in 9027 cases

(0.51%)(0.51%) FY07 39 orthopedic SSI in 9027 cases FY07 39 orthopedic SSI in 9027 cases

(0.43%)(0.43%) FY08 37 orthopedic SSI in 8884 cases FY08 37 orthopedic SSI in 8884 cases

(0.42%)(0.42%) FY09* 9 orthopedic SSI in 3620 cases FY09* 9 orthopedic SSI in 3620 cases

(0.21%)(0.21%) (*Oct-Feb 2009)(*Oct-Feb 2009)

ResultsResults

  

NationalNationalBenchmarksBenchmarks NEBH FY07NEBH FY07 NEBH FY08NEBH FY08

NEBHNEBHFY09 YTDFY09 YTD

PulmonaryPulmonaryEmboliEmboli 3.7%3.7% 2.3 % (9)2.3 % (9) 0.8% (3)0.8% (3) 00

Deep VeinDeep VeinThrombosisThrombosis 12%12% 4% (16)4% (16) 00 00

NEB Medication Pathway NEB Medication Pathway RedesignRedesign

CHART

NURSE

PATIENTORDERING PRACTITIONER

PHARMACISTUNIT SECRETARY

PACU ResultsPACU Results

Time Spent on Addressing Problems

33.71%

10.13%

0%

10%

20%

30%

40%

PRE POST

Per

cent

age

of T

ime

PACU ResultsPACU Results

Problems

56

22

0

10

20

30

40

50

60

PRE POST

Tota

l Num

ber

of P

robl

ems

PACU ResultsPACU Results

Calls to Clarify

26

4

44

14

0

10

20

30

40

50

PRE POST

Tota

l Num

ber

of C

all O

uts

PACU Results PACU Results

Medication Orders That Could Not Be Processed

28.7

16.67

9.3

1.1

0

5

10

15

20

25

30

35

PRE POST

Rat

e P

er D

ay

Hold Acknowledgement

"Pending Clarification"

Hospital-wide Outcomes – Hospital-wide Outcomes – Patient SatisfactionPatient Satisfaction

Improvement in Patient Satisfaction

88

88.5

89

89.5

90

90.5

91

4/07 - 6/07 7/07 - 9/07 10/07 - 12/07 1/08-3/08 4/08-6/08 7/08-9/08 10/08-12/08 1/09 - 3/09

Quarter

Mea

n S

core

Overall Hospital Mean Score

Audacious Goal

Kick-off

One of our Proud One of our Proud Moments!Moments! 2008 recipient of the Press Ganey 2008 recipient of the Press Ganey

Summit AwardSummit Award– Three consecutive years above the Three consecutive years above the

9595thth percentile or greater (nationally) percentile or greater (nationally) – First Hospital in Massachusetts First Hospital in Massachusetts

to receive the award to receive the award for inpatient satisfactionfor inpatient satisfaction

Questions?Questions?