an excursion into deep engagement - ihi home...

An Excursion into Deep Engagement The Orlando Health Journey

December 8, 2014

Session Code FE3

These presenters have nothing to disclose

Carol Haraden Jamal Hakim, MD Thomas Kelley, MD Anne Peach, RN, MSN

Agenda

1. Welcome 2. The Orlando Health Safety Journey 3. IHI Patient Safety Framework 4. Site Visits 5. Lunch 6. Organize Your Experience 7. Debrief 8. Wrap Up

Objectives

Describe the structures that build the deep engagement of clinicians and staff. Discuss the leadership behaviors that can be used to deepen the engagement of staff and patients and lead to great results in care. Develop two strategies that you will use to improve engagement at your institution.

Why Orlando Health?

Orlando Health Board of Directors commitment to quality and safety Engagement and commitment of physicians, nurses, allied health and administrative leaders on the quality journey Statistics: – 41 leaders have completed the Patient Safety Executive

Development Program – 300 leaders have attended IHI National Forum in the past 4

years – Board members and executive leadership completed IHI training – Resident requirement for Open School education

Orlando Health – Our Mission Improving the health and quality of life of the

individuals and communities we serve

Orlando Health Highlights One of Florida’s most comprehensive private, not-for-profit healthcare networks. Nine facilities: Five leading community hospitals, three nationally-recognized specialty hospitals, and one world-class cancer center. Central Florida’s only statutory teaching hospital offering graduate medical education. A healthcare leader for nearly two million residents and thousands of international visitors annually. Home to the only Level One Trauma Center for Adults and Pediatrics.

Orlando Health Highlights More than 2,000 inpatient beds

– Orlando Regional Medical Center (ORMC) – Arnold Palmer Hospital for Children – Winnie Palmer Hospital for Women & Babies – Dr. P. Phillips Hospital – Health Central Hospital – South Seminole Hospital – South Lake Hospital (50% ownership)

Two large physician practices – Physician Associates & Orlando Health Physician Group

Orlando Health providers are active participants in Accountable Care Organizations

*20% ownership

Arnold Palmer Medical Center – 473 beds Arnold Palmer Hospital for Children (APH) – 158 beds Winnie Palmer Hospital for Women & Babies (WPH) – 315 beds

– Comprehensive range of pediatric and OB/GYN sub-specialties

– WPH recognized as an Academic Center of Excellence for Minimally Invasive Surgery – 85% rate

– Received Magnet designation – Received USNews Top 100 Hospitals in 8

pediatric subspecialties – Beacon Award recipient – Tertiary Referral Center – 20 counties – WPH largest Neonatal ICU and 2nd

largest delivery hospital in the U.S. – over 14,000 babies delivered each year

– OB/GYN and Pediatric Residency’s

8

The Orlando Health Safety Journey

Session Code FE3


Journey of Engagement

Board Retreat Chief of Staff

Watershed moment Board Goals

IHI PSO The First Triad

Transparency about harm Quality retreat

Respect Pledge

10 HEN groups CQO/ CNO/ Leader Triad

CQAC Safety Alerts Scorecards

Quality Rounds Patient Advisory Councils

Shift Safety Briefing

AHRQ Survey Open School Challenge

Patient Safety Curriculum

2009-2010 2010-2011 2011-2012

2012-2013 2013-2014

Quality Timeline 2010

Watershed moment for our organization… We hurt an Orlando Health family member and left them permanently disabled

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Hospital Standardized Reimbursement Ratio (HSRR 2007)

Hospital Standardized Mortality Ratio versus Hospital Standardized Reimbursement Ratio (2007 Medicare data)

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OrlandoHealth

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Hospital Standardized Reimbursement Ratio (HSRR 2007)

Hospital Standardized Mortality Ratio versus Hospital Standardized Reimbursement Ratio (2007 Medicare data)

All US

US Mean

OrlandoHealth

2007

2008

Reduce overall mortality (excluding inevitable mortality) by 50% by 2015. Reduce all cases of patient harm by 80% by 2015. Provide ‘right care’ to 100% of patients by 2015. Reduce unplanned readmissions by 80% by 2015. Achieve top 10% patient satisfaction scores by 2016.

Board Goals




IHI PSO The First Triad formed Transparency – Harm

Quality Retreat Respect Pledge

10 HEN groups CQO/ CNO/ Leader Triad

CQAC Safety Alerts Scorecards

Quality Rounds Patient Advisory

Councils Shift Safety Briefing

AHRQ Survey Open School Challenge


2009-2010 2010-2011 2011-2012

2012-2013 2013-2014

The building was on fire

IHI changed us because we realized …..

…and our results proved it !

Quality Timeline 2010-2011

V.P. Patient Care

Chief of Staff

Chief Quality Officer

V.P.PatientCare

ef ofChief of Staff

ef ofChie


ChieChie

First Triad

Dr Hakim Promise …. “ I am here to tell you, on behalf of all the physicians of Orlando Health,

that we seek your voices and your minds in this journey of ours to improve quality and service.

We, the physicians, pledge that going forward, you are as much a part

of the team AND the solution, as we are. We cannot do this without you. And, that we want you to know that we

never again want you to feel marginalized, intimidated, or threatened in the care of our patients.

We seek to partner with you in a collaborative process, where

communication between us opens doors to improving the culture. The search for improving our Quality and Service starts here.”

-Joint Board-Medical Staff-Leadership Quality Retreat January 2011






10 Hospital Engagement Network Groups

CQO/ CNO/ Leader Triad CQAC

Safety Alerts Scorecards

Physician Leadership Academy

Quality Rounds Patient Advisory Councils

Shift Safety Briefings

AHRQ Survey Awards

Open School Challenge YouTube challenge


2009-2010 2010-2011 2011-2012

2012-2013 2013-2014

Quality Timeline 2011-2012

V.P. Patient Care

Chief of Staff


V.P.Patient Care

ef ofChief of Staff

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ChieChieChief

Nursing Officer

Medical Staff Leadership

Chair

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Chief NursingOfficer

al Staff Leadership

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Leade

Nurse or

Ancillary Manager

Unit Practice Chair

Unit Director Medical Quality

Nurse or

AncillaryManagerMManager

PracticeUnit PracticeChair

PracticeUnit P

Unit DirectorMedicalQuality

Unit PUnit P

System Level

Department Level

Hospital Level

Quality Timeline









Executive Quality Rounds Patient Advisory Councils


SAFE teams AHRQ Survey

Open School Challenge Patient Safety Curriculum

2009-2010 2010-2011 2011-2012

2012-2013 2013-2014









Executive Quality Rounds Patient Advisory Councils


SAFE Teams AHRQ Survey

Open School Challenge Patient Safety Curriculum

2009-2010 2010-2011 2011-2012

2012-2013 2013-2014

Successes

APH recognized by US News and World Report in 8 areas Success with Leapfrog Five years no CLABSI in the Neuro ICU Two hospitals have had no CAUTI for over a year Many departments have received Certified Zero Awards – No harm in three areas for over a year

Health Central recognized for success in core measures Engaged Patient and Family Advisory Councils

10 Years of Data: Then and Now

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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Orlando Regional Medical Center Neuro ICU

Central Line Associated Bloodstream Infections(CLABSI) 2013 & 2014

Jan-0/224 Feb-0/195 Mar- 0/197

Apr- 0/147 May-0/198 Jun- 0/116

Jul-0/189 Aug- 0/140 Sep-

Oct- Nov- Dec-

Jan-0/209 Feb- 0/167 Mar- 0/204

April-0/154 May- 0/149 June- 0/150

July- 0/211 Aug- 0/294 Sep- 0/182

Oct- 0/232 Nov- 0/217 Dec- 1/197

Failures

Still struggling in some of our quality measures Have not met all the board goals Leapfrog grade dropped in three hospitals Inadequate trending of harm and communication of care review action plans between facilities Need for increased patient and family representation at all levels of the organization

What we have learned….

There are no miracle pills that will suddenly improve quality and safety. It is a journey and takes vigilant effort and hard work.

…. It also requires a preoccupation with FAILURE and celebrating success.

Sole Survivors "The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been."

Donald M. Berwick, MD, MPP Former President and CEO Institute for Healthcare Improvement

A Comprehensive Framework for Patient Safety

Session Code FE3


Accountability Teamwork

Leadership

Continuous Learning

Improvement and Measurement

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Another Framework

A safety framework – 9 components Leadership – facilitate and mentor teamwork, improvement, respect and psychological safety Teams – agree upon specific behaviors Communication – transmission and reception of information is one and the same Accountability – supports psychological safety because employees believe that they’ll be treated fairly Psychological Safety – speaking up is safe to do Continuous learning – generate reliable care by applying best evidence and minimizing variation Reliable care – continuous and owned by the frontline Improvement and measurement – generate quality, mitigates and eliminates defects Transparency

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Site Visits

Session Code FE3


Site Visits

WPH – Neonatal Intensive Care Unit – Labor and Delivery – Women’s Intensive Care Unit (WICU) – Mother Baby Unit (Tower 8)

APH – Pediatric Emergency Department – Pediatric Intensive Care Unit – Pediatric Special Care – Pediatric Cath Lab

Neonatal ICU Description: The Neonatal ICU consists of two units. Care is provided to critically ill newborn infants with a wide variety of services available including ECMO, dialysis, hypothermia treatment and post-op recovery. Comprehensive discharge planning and teaching is provided to the families prior to the infant’s discharge Number of beds: 142 Triad: Dr. Doug Hardy, Ann Diaz NOM, Sarah Molzan RN UNPC, Robin Modesto NOM, & Tracey Waddell RN UNPC Patient Safety Initiatives: Optimal Surgical Management, Tiny Baby Protocol, Car Seat Safety, First Feeding at Breast Challenges: coordination of care, communication, bar coding

Labor and Delivery Description: As a Level III Perinatal Center, comprehensive patient centered obstetrical nursing care is provided for both low and high-risk families during the antenatal, labor and delivery and immediate postpartum periods Number of Beds: 30 Triad: Dr. Bill Scott, Deb Davis NOM, Amy Lee Slicko UNPC Patient Safety Initiatives: Labor options, hemorrhage response process, OB coordinator, Skin to skin Challenges: volume, communication, electronic fetal monitoring

Women Intensive Care Unit (WICU) Description: Provides highly skilled care to the critically ill female through a multi-disciplinary team including the medical and/or surgical critical care intensivist and the maternal-fetal medical team and critical care trained nurses Number of beds: 5 Triad: Dr. Cole Greves, Jennifer Montemayor NOM, Sharon Sabella UNPC Patient Safety Initiatives: multidisciplinary rounding tool, early removal of urinary catheters Challenges: communication among all care givers, team work

Mother – Baby Unit (Tower 8) Description: Mother Baby care is provided on three floors where mother, father or significant other can comfortably care for their newborn infants and bond as a family. In addition each floor has a holding nursery Number of beds: 34 Triad: Dr. Mike Bartfield, Dr. Sara Hmielowski, Virginia Wright NOM & Julie Bacon UNPC Patient Safety Initiatives: stratification of patients by delivery type, cardiac screening, plan of care handoff tool Challenges: volume, parent education, team work, accountability, continuous learning, reliable care

Pediatric Emergency Department Description: Provides comprehensive emergency care to an age population of birth to 18 years; and trauma care to trauma victims, age birth to 15 years Number of beds: 29 private, acute beds and 4 trauma beds Triad: Drs. Brandon Carr & Kelly Cramm, Andrea Schuermann NOM, Maureen Laffick, RN UNPC Patient Safety Initiatives: patient hand off, disaster preparedness Challenges: minimizing parent child separation during disasters, communication, team

Peds Special Care Description: Monitored unit providing comprehensive care to the medical/surgical population, ages birth to 21 years of age. Services include dialysis, post-op recovery, moderate sedation, special infusions and the care of trauma patients Number of beds: 26 with sleeping rooms Triad: Dr. Shoba Srikantan, Lourdes Rosario NOM & Gabi Zafrani UNPC Patient Safety Initiatives: Ultrasound guided IV insertion, Transfer to higher level of care debriefings Challenges: Communication, continuous learning, reliable care, asthma core measures

Pediatric Intensive Care Unit (PICU) Description: Multidisciplinary unit with family-centered rounds providing care to critically ill children. Serving a busy level-one trauma center, an active Pediatric Emergency Department, active general surgical, neurosurgical and orthopedic services, as well as providing all the advanced techniques necessary in support of the critically ill patient including CRRT, ECMO, and HFOV. Number of beds: 17 private rooms with family sleep space Triad: Dr. Spack, Jodi McDuffie NOM, Sarah Walter UNPC Patient Safety Initiatives: care bundles, CHG bathing compliance, interruptions during medication administration, IDV at handoff, sedation and mechanical ventilation weaning tools Challenges: Communication, Collaboration

Pediatric Cath Lab Description: Pediatric Hybrid Cath Lab Rooms: 1 Triad: Kathy Jackson, NOM; Surgical issues brought to OR Triad; patient care issues brought to PCICU Triad Patient Safety Initiatives: Reducing radiation exposure, antibiotics prior to intervention, reduction of re-bleeds post cath Challenges: Complexity and length of cases increases exposure to radiation, which increases risk of radiation burns

Quality Information

Session Code FE3


System Quality Structure

Interim Chief of Quality& TransformationDr. Thomas Kelley

CQO/CNO/APMC Phy Ldrshp Chair

Drs. Plumley & Spack/Louise Kaigle/Dr. Auerbach

OR /EndoscopyCath Lab

Anesthesia/PACU

EmergencyServices

Radiology Hematology-OncologyCardiology

(PCICU)

Dr. Larry Spack

Jodi McDuffieNOM

Dr. RamonRuiz

Anita LogginsKathy Jackson

NOMs

Dana WaresUPC Chair

Dr. SusanHussein

Marlo JustesenNOM

MeaganWouda

UPC Chair

Sharon MawaNOM

StephanieNeubert &

KristinO’Donnell UPC Chair

Dr. KellyCramm

AndreaSchuermann

NOM

MaureenLaffick

UPC Chair

Dr.SusanSmith

Larry SimmonsManager

NoUPC

Maria ClarkNOM

APH CQO Quality Structure

August 2014

President APHKathy Swanson

Medical ExecutiveCommittee

Critical Care QA

APH Quality Council

Critical Care

Liz EischerUPC Chair

RESOURCES

Acute Peds

Hem/Onc QA

Surgery QA

Peds QA

Lori CulbrethNOM

Cherie Campbell& Karen Peters

UPC Chair

PSCU

Dr. ShobaSrikantan

Lourdes RosarioNOM

Gabi ZafraniUPC Chair

Ortho Neuro

Lori CulbrethNOM

KristinaWattersonUPC Chair

CV QA

ER QA

Sarah WalterUPC Chairs

AdministratorsMary Rogers

Meena MorganSuzanne Worthington

Dr. Alex LevyDr. Don Felix Dr David SkeyDr. Hmielowski

Risk Posie KenneyCPI Jill Dykstra-Nykanen

Infection Control Scott BrownCNS for Nsg Quality Cindy Kling

Social Work Mary NorrisNurse Prac Council Chair Kelli Wilde

System Structure Triad Model – Chief Quality and Transformation Officer, VP of

Patient Care, Chief of Staff System positions: – Chief Quality Officer’s for each hospital – Director of Patient Safety – Director of Operational Performance Improvement – Director of Clinical Effectiveness – Director of Infection Prevention

System Structure System teams: – Collaborative Quality Advisory Council – Corporate Quality Committee – Collaborative Practice Teams – Strategic Action for Excellence Teams – Patient Family Advisory Councils – Nursing Executive Cabinet – Ancillary Executive Cabinet – Medical Executive Committee – Corporate Nursing Practice Council

Board Quality Committee Medical Staff Corporate and Department Leadership

System Approach Board Quality Committee with review of status on goals, initiatives and barriers Expectation that the system and hospital triad leaders complete IHI Patient Safety Executive Officer Course Engagement of Corporate Nursing Executive, Ancillary Executive and Corporate and Ancillary Practice Council Engagement Patients and Families in advisory councils, quality committees, quality rounds Expectation of transparency of quality and patient safety results and information for all team members, clinicians and the public in each facility and service line Defined strong physician leadership as a core value Administrative commitment to collaborative relationship with physician and nursing leadership Recognition that the patients voice is integral to our success

System Approach Ten SAFE teams drive quality improvements in specific areas of harm, for example falls, CLABSI, CAUTI, SSI, pneumonia, readmissions Weekly review of harm events by key leadership teams:

– Nurse executive leaders – Allied health leaders – President and senior executive leaders

Continuous learning opportunities including: – IHI open school and PSO course – Physician Leadership Academy – Patient Safety curriculum – Annual Quality Retreat – National Quality Forum

Recognition for excellence in quality and safety: – Certified Zero Awards – Great Catch Awards – Physician Exemplar, Nursing and Allied Health Awards

Hospital Approach Hospital quality triads meetings on a regular basis reviewing data, identifying trends and sharing best practices Expectation that the hospital triad leaders complete IHI Patient Safety Executive Officer Course Engagement of Hospital Nursing Practice Council Patients and Families in advisory councils engaged in quality, safety and the patient experience Expectation of transparency of quality and patient safety results and information for all team members, clinicians and the public Public display of quality measures Identification and cultivation of influential thought leaders Weekly quality rounds Review of all harm events and deaths through care review

Department Approach Unit Quality Triad meets and collaborates regularly to drive quality improvements Engagement of the unit nurse practice council Team quality/safety huddles Digital communication frames for quality and safety messages/ alerts Quality boards displayed and reviewed during safety huddles Weekly quality rounds Daily rounds by manager; hourly rounds by staff Review of all harm events and deaths through care review Create improvement through transparency and a data driven approach Increase awareness and facilitate buy in through positive reinforcement

– Great Catch Award, Certified Zero Award, Recognition Center

Orlando Health Demographic Information

Session Code FE3


Orlando Health – Our Mission Improving the health and quality of life of the

individuals and communities we serve

Orlando Health Highlights One of Florida’s most comprehensive private, not-for-profit healthcare networks. Nine facilities: Five leading community hospitals, three nationally-recognized specialty hospitals, and one world-class cancer center. Central Florida’s only statutory teaching hospital offering graduate medical education. A healthcare leader for nearly two million residents and thousands of international visitors annually. Home to the only Level One Trauma Center for Adults and Pediatrics.

Orlando Health Highlights More than 2,000 inpatient beds

– Orlando Regional Medical Center (ORMC) – Arnold Palmer Hospital for Children – Winnie Palmer Hospital for Women & Babies – Dr. P. Phillips Hospital – Health Central Hospital – South Seminole Hospital – South Lake Hospital (50% ownership)

Two large physician practices – Physician Associates & Orlando Health Physician Group

Orlando Health providers are active participants in Accountable Care Organizations

*20% ownership

Arnold Palmer Medical Center – 473 beds Arnold Palmer Hospital for Children (APH) – 158 beds Winnie Palmer Hospital for Women & Babies (WPH) – 315 beds

– Comprehensive range of pediatric and OB/GYN sub-specialties

– WPH recognized as an Academic Center of Excellence for Minimally Invasive Surgery – 85% rate

– Received Magnet designation – Received USNews Top 100 Hospitals in 8

pediatric subspecialties – Beacon Award recipient – Tertiary Referral Center – 20 counties – WPH largest Neonatal ICU and 2nd

largest delivery hospital in the U.S. – over 14,000 babies delivered each year

– OB/GYN and Pediatric Residency’s

56

Orlando Health Highlights

One of Central Florida’s largest employers – 16,000 team members – 2,000 medical staff members

Key Economic Driver: – Total financial impact on Central Florida Region is $3.8 billion – Total purchasing power of $1.4 billion – Nearly $92 million of charity care provided last year – More than $225 million in Committee Benefit last year

Orlando Health Hospitals

Hospital Map Code

Orlando Regional Medical Center 1UF Health Cancer Center at Orlando Health 2Arnold Palmer Hospital for Children 3Winnie Palmer Hospital for Women & Babies 4Dr. P. Phillips Hospital 5South Seminole Hospital 6Orlando Health Central Hospital 7South Lake Hospital 8St. Cloud Regional Medical Center 9Source: System Management

Total Service Area

Primary service area population has grown ~33% since 2000 and expected to grow an additional ~6% through 2018

Statutory Teaching Hospital – Orlando Regional Medical Center is one of twelve hospitals in Florida recognized as a statutory teaching hospital. Orlando Health has a total of 17 accredited training programs. – 7 residency and 10 fellowship programs with the

Accreditation Council for Graduate Medical Education (“ACGME”), the national accrediting body for all training programs, and 7 non-ACGME accredited programs.

Graduate Medical Education

Teaching Affiliations We maintain master affiliation agreements with the following institutions:

University of Central Florida College of Medicine Florida State University College of Medicine University of Florida College of Medicine College of Medicine at the University of South Florida

808 acute care bed tertiary care center Central Florida’s only Level One Trauma Center 38,000 square foot Ambulatory Care Center Provides services in the following key areas: ̶ Heart and Vascular ̶ Cancer ̶ Neurosciences ̶ Orthopedics ̶ Surgical Specialties Including Robotics ̶ Emergency Services ̶ Outpatient Services

Orlando Regional Medical Center

UF Health Cancer Center Orlando

More than 200 cancer specialists treating each unique type of cancer.

Leading-edge treatments, drugs, clinical trials and advanced technologies.

Treatment is tailored to each patient’s specific genetic profile.

Orlando Regional Medical Center – Orlando Regional Medical Center (“ORMC”) – UF Health Cancer Center at Orlando Health – Orlando Health Heart Institute

Dr. P. Phillips Hospital 237 bed full-service medical and surgical facility ̶ 16 ICU beds

24 hour emergency services with 42 patient bays; most active ED in the system Provides services in the following key areas: ̶ Cardiovascular care ̶ Oncology services ̶ Neurosciences ̶ Orthopedics ̶ Surgical specialties including

robotics Home to a fully accredited chest pain program and a designated primary stroke center

South Seminole Hospital 206 bed full-service medical/surgical acute care facility Home of Orlando Health Behavioral Healthcare, an 80 bed psychiatric hospital Provides a full range of outpatient services including: ̶ Hyperbaric oxygen therapy

for wound care ̶ Diagnostic and interventional

radiology ̶ Nuclear Medicine ̶ Laboratory ̶ Surgical services ̶ Sleep disorder services ̶ Outpatient psychotherapy

Orlando Health Central 171 bed acute care hospital 87,000 square feet of medical office space connected to the hospital 228 bed skilled nursing facility known as Health Central Park Recently approved a $25 million grant funded renovation and expansion of the emergency department Provides services in the following key areas: ̶ Cardiac, Stroke, Orthopedics, Women’s

Health ̶ Emergency Services ̶ Express Care ̶ Orthopedics ̶ Wound Healing

South Lake Hospital 104 bed acute care hospital Owns and operates: ̶ Surgical center ̶ Endoscopy center ̶ Medical office building ̶ Hospital-based home health agency ̶ Wound care center ̶ Outpatient lab and x-ray facility ̶ Medical practices including: OB/GYN,

Neurology, Endocrinology, Urology and the Center for Women’s Health

Home to the LiveWell Fitness Center and National Training Center Recently broke ground on a Skilled Nursing Facility

St. Cloud Regional Medical Center 84 bed facility Comprehensive inpatient and outpatient care to Osceola County residents Provides medical services in the following key areas: ̶ Emergency medicine ̶ Cardiology ̶ Imaging and Radiology ̶ Orthopedics ̶ Rehabilitation ̶ Surgery/Robotic surgery ̶ Sleep care ̶ Wound care

an excursion into deep engagement - ihi home...

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