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Memorial Hermann wins national quality award
Dashboard one winning element of system
Houston-based Memorial Hermann Healthcare System will be honored this month at a gala event in Washington, DC, as the winner of the National Quality Forum's (NQF) 2009 National Quality Healthcare Award. Michael Shabot, MD, system chief medical officer, explains why the health system was chosen and how it met the five criteria NQF established for the award:
• Effective prioritization of performance improvement goals.
Shabot says Memorial Hermann has a "very small goal-setting mentality." Detailed annual goals are created for quality and safety, operational efficiency, and financial goals. Criteria include employee satisfaction and physician involvement. Metrics are approved yearly by the health system's board.
• Well designed and deployed "dashboard" to measure and manage whole system performance.
"The operation of the Memorial Hermann health system is very strongly metrics-based. By that I mean we have our dashboards actually embedded into our computerized operating environment," Shabot says. A daily "flash report" resides on each desktop as an icon at the bottom right part of the screen and blinks to notify when new data are added. All data included are current. When an employee clicks on the icon, he or she can see the hospital's censuses and financial standing, which Shabot says is up to date through midnight of the previous day.
All publicly reported core measures and multiple quality measures are available in the flash report in real time. Each operating unit has its own drop-down menu. The dashboard includes a year's worth of data, which are color coded. "If a hospital is high performing, then that cell is colored blue for blue ribbon. If they're just in the good stage, they might get a green. Yellow is warning, and red is below our standards," Shabot says.
For core measures, only 100% performance gets coded as blue. And since the system "is very strict on core measures," Shabot says he sees a lot of blue.
All inpatient and outpatient quality measures play a role in the dashboard. Shabot says the system's focus on health care-associated infections is robust and doesn't focus only on infections but the bundles proved to help prevent them from occurring.
"Our dashboards include 11 items for central line insertion. Everything from the caregiver washing their hands before the procedure to the use of chlorhexidine to directing the patient. All of those are individually scored criteria for replacing the central line. And we score compliance on those," he says.
Every central line is audited each day and recorded, and actual nosocomial infection rates are shown. Catheter-related blood stream infection, ventilator-associated pneumonia, surgical site infections —"those are all shown, along with their bundle prevention scores... We're really performing very well and have eliminated those from some of our hospitals for a long time."
The health system just added a new page to the report for ambulatory core measures and is adding patient safety indicators from the Agency for Healthcare Research and Quality. Reports are prepared from the dashboard results, which also are reviewed by the C suite. "We're very heavily dashboard oriented," says Shabot.
• Commitment to transparency. Data-driven improvement of chronic care, with an emphasis on care coordination and disparities reduction.
"We've got both internal and external commitments," Shabot says. Internal is the flash reports, which "literally thousands" have access to. Shabot says the system focuses on data-driven improvement in chronic care and care coordination. "Our physician groups that have set down their quality measures document their performance through their [electronic medical records]. The quality scores actually come directly out of their EMR, which is the way EMRs are supposed to be used." Monthly performance data are shown in real time.
Regarding transparency outside the system, Shabot says, "I think we were one of the first hospitals in the country to put our current core measures scores on our public web site. If you go to memorialhermann.org, you can click on the front page. There's a quality and safety icon on the home page, and it'll take you right into more current scores. The data on the Hospital Compare site are usually almost a year old. We update our site every quarter."
• Demonstrated results on publicly reported performance measures.
"Our publicly reported core measures are high," Shabot says, adding that the system has won numerous awards from VHA for going 12 consecutive months without any cases of catheter-related blood stream infections or ventilator-associated pneumonia.
The system also implemented an initiative it calls "Breakthroughs in Patient Safety." In mid-2006 it decided to "implement a cultural change across the entire health system changing the way everybody does their work." Consultants from the nuclear power safety industry were brought in to help carve out this foundation and "build in safety precautions that weren't there before. Building in the kind of culture change that has made air travel, federal aviation, nuclear power so safe. These are all high-risk industries that have been made low risk by cultural change."
Employees were pulled out of work for cultural training and one-on-one classroom training for three to four years. "This is being applied to our 20,000 employees and as many physicians as we can rope into training. We have currently completed our hospital training, that is all 14,000 employees. When I say 'all,' I don't just mean the nurses and pharmacists; we include everyone — housekeepers, our maintenance people, our construction people, because they all work in hospitals and they all have an opportunity to prevent an accident or to prevent a mistake."
Shabot says the system goes beyond Joint Commission or Medicare requirements to monitoring "what we call a serious safety event rate. And every event is classified with a classification system that came in with our Breakthroughs in Patient Safety campaigning."
Successful HAI initiative
Shabot points to one successful initiative to show how the system approaches challenges — eliminating hospital-acquired infections (HAIs). When he joined Memorial Hermann in January 2007, he began to evaluate the rates that were a part of the monthly dashboards. Individual units may have had successes, but those had come and gone. "Preventing HAIs, you never really solve that problem," he says. "Because the organisms are always present in the environment, you actually have to run the initiative continually and permanently." So he employed the Six Sigma process to approach HAI rates. All the process owners were involved in workout sessions to put a plan into place by May 1, 2007, which "began the bundle auditing in a uniform way across all of our hospitals." The system saw dramatic results.
"The No. 1 factor [to success of preventing HAIs] is continuous auditing of infection prevention bundles — every line insertion, every ventilator, every ventilator day, every line day, close attention to antibiotics and SCIP [Surgical Care Improvement Project], getting those rates to 100%," he says.