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Rapid Response Teams	Pressure Ulcers
Acute Myocardial Infarction	High-Alert Medications
Medication Reconciliation (ADE)	Congestive Heart Failure
Central Line Infections	MRSA
Surgical Site Infections	Surgical Complications
Ventilator-Associated Pneumonia	Boards on Board

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Banner Health – Phoenix, AZ
Availability Status: Available to answer requests
Licensed Beds: 20 acute care hospitals in the system; 3,010 total licensed acute care beds
Teaching / Non-Teaching Status: 2 teaching; 18 non-teaching
Setting: 9 urban; 11 rural
Start Date of Intervention Work: 2000
Mentor Contact Name: John Hensing, MD
Mentor Contact Email: John.Hensing@bannerhealth.com
Mentor Contact Phone: 602-747-4477

Additional Information:

Set aims:  Banner Health’s aim is to be the national leader in clinical performance by the Year 2020.

Banner Health, is on a journey to excellence. To achieve this aim, annual goals for improvement are articulated. Patient safety and reduction of harm is considered a dimension of our clinical performance along with delivering evidence based care, achieving superior clinical outcomes, using our resources efficiently, and meeting the expectations of patients. Recognizing that this is a journey, our targets for 2008 are set at “industry upper quartile” or beyond, and expected to continue to increase as we progress towards our aim.

For 2008, our specific areas of focus, referred to as strategic initiatives,  are to provide appropriate care for our AMI, HF, PN, and Surgical patients and to provide safe care, avoiding accidental injury to patients.   Our success is measured as follows:
• Appropriate Care is based on a composite score for publicly reported measure.
• Patient Safety uses the AHRQ Patient Safety Indicators, compliance with effective skin care processes, completion of thorough and credible root cause analyses, and the AHRQ Culture of Safety Survey. The framework for these measures is based on a model developed by Peter Pronovost that refers to Outcomes, Processes, Structure, and Context as areas of measurement for patient safety.

Progress is reviewed monthly by management and quarterly by the board, a single board of directors for the entire health system that is comprised of 20 hospitals in seven states. As an operating company, Banner Health’s system-wide board governs the company and all of its hospitals. The board is ultimately accountable for quality and safety.

Get data and hear stories:  At the request of the Committee Chair, the Patient Safety report is presented of the Board Care Management and Quality Committee early on the agenda of each Committee meeting.  Along with the summary information, case information is presented as stories to bring the human dimension to the numbers. Information about steps that have been taken to avoid such harm in the future is also provided to demonstrate improvement in avoiding future harm. Patients and family members are not currently part of the Board meetings though information about their interests and concerns is conveyed on their behalf through the various safety and risk reports provided to the Board.

Establish and monitor system-level measures:  Banner’s system-level performance includes data about our progress in making improvement, our strategic initiatives, as well as the monitoring of the quality of the services and products provided.   Measurement is done in five dimensions, clinical outcomes, patient safety, evidence based care, utilization management, and patient satisfaction.  Our indicators for these different dimensions are selected to help answer the following questions:

How well are we achieving superior clinical outcomes?

• ICU Mortality (actual)
• CABG Mortality O/E Ratio(STS Risk Adjusted)
• Overall Mortality(Care Science Risk Adjusted)
• AMI Mortality(actual)
• HF Mortality (actual

How well are we avoiding causing harm to the patient?

• Morbid Complications (Care Science)
• Skin Care Overall (processes of care)
• ICU-Central Line Infections per 1,000 (Infection Control CDC defined)
• CABG - Re-operative Bleeds (STS)

How well are we able to comply with evidence-based care practices?

• AMI Composite (CMS defined)
• PN Composite(CMS defined)
• HF Composite(CMS defined)
• SCIP Composite (CMS defined)
• Overall VTED (CVA, ICU, HF)(internally defined)

How well are we providing efficient care?

• Medicare LOS Risk Adjusted (Care Science)
• Medicare LOS Raw Data
• How well are we meeting the expectations of patients?
• HCAHPS-Overall Rating of Hospital
• HCAHPS-Likelihood to Recommend Hospital

Change the Environment, Policies, and Culture: Banner Health is committed to maintaining a safe environment for staff, patients, and families.  When there is avoidable harm and adverse outcomes, Banner’s approach is to provide full disclosure to patients and families.   The organization has adopted a systemwide policy for this purpose that emphasizes a timely response to patient incidents, communication with patients, families, staff and physicians, and support for staff involved in medical incidents.

Banner Health has also adopted “Service Standards” which have been highly publicized throughout the organization and are also tied into performance reviews (they account for 50% of an individual’s performance rating each year).  Safety is the first standard, and its overarching philosophy is that “We protect the safety of our patients and colleagues in an environment focused on prevention of injury or harm.  Our commitment is reflected by our actions, attitudes and attention to detail.” 

Learn:  The composition of the board brings in expertise from a variety of disciplines including MDs, industry leaders from finance, laboratory, IT and a host of other backgrounds that lends broad expertise and multiple perspectives to governance.  Each board member is oriented to their new role, including an in-depth discussion of the role of clinical quality and patient safety.

Additional education is incorporated into the Board agendas, with presentations from internal Banner leadership (e.g., CMO presentation on IHI 5 Million Live, Leapfrog, our e-ICU and clinical systems investments and outcomes) and external experts.
In between board meetings, a packet of reading materials is sent to each board member.  A recent packet, for example, included articles from the Wall St. Journal, New York Times, Modern Healthcare, among others on issues such as transparency, improving clinical outcomes, etc. 

Establish executive accountability:  Both clinical improvement measures and patient safety initiatives are considered ‘strategic initiatives’ and as such are included in the management incentive plan. The board holds senior management, leaders and managers accountable for these strategic initiatives.  A heavy emphasis is placed on clinical initiatives; six of the 15 system initiatives for 2008, in fact, are clinical.

[1/31/08]

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Children's Hospitals and Clinics of Minnesota – Minneapolis, MN
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 319
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2000
Mentor Contact Name: Leslie Loeding, Performance Effectiveness Consultant
Mentor Contact Email: leslie.loeding@childrensmn.org
Mentor Contact Phone: 612-813-5803

Additional Information:

Set aims:  Patient safety goals with specific aims are part of Children’s Operating Plan and Key Performance Indicator (KPI) Report every year. Children’s Operating Plan acronym is SAFEST (Safety, Access, Finance, Experience, and Strategic Thinking), which emphasizes Safety as a key principle of Operations.   This plan is reviewed and approved by the Board on an annual basis.

Get data and hear stories:  Reports to the Board begin with Children’s Operating Plan, which begins with patient safety.  Any sentinel event is reviewed through the Focused Event Review (FER) process and all reviews are presented to the Board Quality Committee, which oversees quality and improvement on behalf of the Board. Children’s Chief Medical Officer discusses in detail the story behind each FER at monthly Board Quality meetings. 

Establish and monitor system-level measures:  Children’s distributes a monthly Quality Report that includes measures reviewing all aspects of patient safety, and creates a quarterly patient safety report.   Indicators include infection rates, medication errors, mortality rates, readmission rates, and measures documenting progress towards patient safety goals.   Both reports are reviewed by the Board Quality Committee, and distributed throughout the organization.  Efforts are currently underway to have these metrics reported and readily accessible on the organization’s internal and external websites using a dashboard display. 

Change the Environment, Policies, and Culture: Maintaining a patient safety culture is a core value at Children’s. Since 1999, Children’s has maintained a full disclosure policy with families regarding errors and harm. Staff are supported in these events with the Employee Assistance program which is available 24/7. The patient safety culture has been hard-wired through such efforts as the Safety Learning Reports (SLR) system, unit-level Safety Action Teams, and focused updates at managers and directors meetings regarding progress towards patient safety goals.  An approach of active inquiry and learning is key to Children’ safety culture as evidenced by the SLR system.  Safety Learning Reports are not incident reports, but rather use a story telling methodology, allowing each person to tell their story of the event, expressing the experienced system gap in their own words. Most SLR are now filed online and are analyzed for common themes.
 
Learn: The Board Quality Committee is a key vehicle for board member education regarding patient safety.  The committee is led by the Board Chairman, and all new board members serve a one-year term.  Prior to assuming their role on the Board Quality Committee, board members are oriented to patient safety principles and practice, quality oversight, and measurement. Children’s progress toward patient safety goals is reviewed and discussed within this committee monthly.  In addition, patient safety education is integrated into new employee orientation, sharp end staff education, and family welcome packets. Completing a patient safety education course is a requirement of the physician/professional staff credentialing process.

Establish executive accountability: Clear executive accountability for patient safety is established and documented in Children’s annual Operating Plan.  Progress towards these goals is described to the Board in quarterly Operations Reports, Safety Reports, and Key Performance Indicator Reports.  Management and Executive incentives are linked to performance on the SAFEST initiatives.

[5/31/07]

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Cincinnati Children's Hospital Medical Center – Cincinnati, OH
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 451
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Mary Beth Thomas, Assistant Vice President of Clinical Effectiveness
Mentor Contact Email: Marybeth.thomas@cchmc.org
Mentor Contact Phone: 513-803-0129

Additional Information:

Set aims:  Patient Safety is the primary strategic improvement initiative for FY 2007 and FY2008 at Cincinnati Children’s Hospital Medical Center (CCHMC).  The Board set aims for each of the two years (FY2007 to reduce serious safety events by 25% from baseline, and FY2008 to reach an overall reduction in serious safety events of 80% from baseline).  Significant resources are committed to reaching this very ambitious goal, including dedicated patient safety staff, a Patient Safety Officer, resources from the CCHMC Education and Training Department, continuous quality improvement consulting staff, patient service and treatment area staff who coach peers on safety behaviors, adoption of serious safety event metrics by the medical staff through performance-based privileging and more.

Get data and hear stories:  Every Board meeting begins with a story from a family who received care at CCHMC.  The Board reviews all Root Cause and Common Cause analyses, and receives regular updates about progress toward the overall goal of 80% reduction in serious safety events, as well as toward intermediate process goals which include safety training and follow-up for all CCHMC staff, providers and non-providers alike, and progress on actions plans following root cause analyses.  In addition, three Board members sit on the CCHMC Family Advisory Council and are active participants in discussions about family experiences and needs, as well as planning for improvement.

Establish and monitor system-level measures:  CCHMC has identified a group of system-level measures that are continually updated and made transparent to the entire organization.  The measures include Codes outside the ICU, rates for ventilator-associated pneumonia and central-vein catheter blood-stream infections, surgical site infections, adverse drug events, percent of patients receiving evidence based care, patient satisfaction data on key questions and others.  Selected information is provided on our external website, and includes patient satisfaction with several components of the overall care experience, ratings for selected outpatient clinics, outcomes for certain high risk procedures such as liver transplants, and others.

Change the Environment, Policies, and Culture: The Board has allocated significant resources and attention to the creation of an environment that is respectful, fair and just for all.  CCHMC’s Service Standards require that all employees be Courteous, Attentive, Respectful, Enthusiastic and Safe as we care for our patients, families and colleagues.  Through the execution of employee safety surveys (AHRQ), safety training for all employees, the institution of a safety coach program and a culture that promotes 200% accountability for safety (for self and others), CCHMC is highly engaged in changing the environment and the culture with particular emphasis on those at the sharp end of error.  Policies and job descriptions have been rewritten to place a greater emphasis on patient safety awareness and safe behaviors.  In addition, compensation incentives for clinical managers focus on patient safety.

Learn: The Board at CCHMC is engaged in continuous learning about the reduction of harm.  Board members attend IHI meetings, have frequent retreats dedicated to improving knowledge about healthcare, safety and the execution of their responsibilities, and work closely with the Vice President of Education and Training to update their understanding of how the organization is using education to further its aims.  Board members attend and speak to participants during our internal improvement science series aimed at CCHMC leaders, attend the organization’s required 3-hour safety training course, and avail themselves of other internal and external opportunities to become safety-savvy.

Establish executive accountability: In addition to providing regular Board updates regarding the organization’s progress on all improvement aims, and particularly those related to patient safety, CCHMC senior leaders have 20% of their incentive compensation tied to meeting goals on system-level safety measures.  Each senior leader is a champion for one or more improvement initiatives, including specific safety initiatives and is actively involved with team leaders and members in identifying and meeting goals.

[6/26/07]

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Dana-Farber Cancer Institute – Boston, MA
Availability Status: Available to answer requests
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Saul Weingart, MD, PhD
Mentor Contact Email: saul_weingart@dfci.harvard.edu
Mentor Contact Phone: 617-632-4935

Additional Information:

Set aims:  Each year, the board-level quality committee establishes patient safety, quality improvement, and risk management goals with specific timelines.  Since serious adverse events are rare, goals often address process measures such rollout of a critical intervention across the ambulatory adult program or a specified percent increase in patient or provider participation.

Get data and hear stories:  The full board includes over 100 members, and plays a significant role in high-level priority-setting.  The responsibility for detailed oversight of quality and safety is delegated to the board-level quality committee, chaired for the past decade by a former chair of the full board.  This committee spends each meeting reviewing aggregate data, sentinel events, and reports from clinical and administrative data.  Patient representatives from our adult and pediatric patient and family advisory councils are members of the committee, and put a “human face” on the data.  The committee chair reports to the full board quarterly. 

Establish and monitor system-level measures:  The organization monitors and reports several key indicators regularly, including hand hygiene compliance and medication reconciliation results.  A patient safety dashboard that includes information about medication events, chemotherapy-related symptoms, and falls was developed in the past year and we plan to (but have not yet) disseminated this information publicly.

Change the Environment, Policies, and Culture: The organization adopted and promulgated a set of fair and just culture principles in 2003.  Demonstrating the organization’s core value of Respect, these principles guide the conduct of root cause analyses and the organization’s response to adverse events and medical errors.   A Respect Retreat helped to disseminate the principles throughout the organization.  A presentation of the fair and just culture principles is included in the orientation of all new employees. 

Learn: The ongoing activities of the board-level quality committee -- including comments and presentations by board members, clinicians, and executives -- serve as a mechanism for board members to become educated about patient safety and quality of care.  The committee chair is also well informed about board capabilities as he teaches a course on governance and board leadership in his faculty role at a school of business administration.  Staff members are educated about safety in a variety of ways including conferences, online courses, lectures and presentations, newsletters, email broadcasts, and intranet offerings.

Establish executive accountability: The organization’s annual safety, quality, and risk goals are reviewed regularly, with mid-term progress reports and end-of-year results.  Key quality goals are included in incentive compensation for senior executives.  Other leaders’ performance on safety goals for which they have responsibility are reviewed in their annual reviews.

[5/31/07]

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Delnor-Community Hospital – Geneva, IL
Availability Status: Available to answer requests
Licensed Beds: 118
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2007
Mentor Contact Name: John Hubbe, Vice President Medical & Legal Services
Mentor Contact Email: hubbe@delnor.com
Mentor Contact Phone: (630) 208-4195

Additional Information:

Set aims:  The Board Quality Committee has set aims over the past several years to reduce targeted harm events (e.g., Surgical Site Infections, Hospital-Acquired Pressure Ulcers, Inpatient Falls) and has now developed a global Harm-Safety Index measurement indicator for their Clinical Dashboard. This serves as a “surrogate” index for harm events and a specific aim is being developed based upon internal historical performance.

Get data and hear stories:  A “patient experience” story has been presented at meetings since January 2006. Each story is specifically selected and connected to highlight a “Big Dot” or “Driver” measure on the Clinical Dashboard (i.e., “connecting the dots”). The story is told by either the patient themselves, a medical staff member, and/or Senior Management. It is at the beginning of the agenda and usually lasts about 25-30 minutes. It has also provided opportunities to educate and discuss Root Cause Analysis Processes, disclosure to patient and family policies, and other related performance improvement and risk management systems. Recent stories are used whenever possible (i.e., 1-2 months old). This process has been particularly valuable to make the data become real and demonstrate the need for continuous improvement.

Establish and monitor system-level measures:  A Clinical Dashboard has been used for more than six years. Indicators are either “Big Dots,” “Drivers” or “Project Level” indicators and selected based upon the board’s quality commitment aim to deliver Safe, Effective, Patient-Centered, Efficient, Timely, and Equitable care to patients, and directly connected to the strategic plan of the organization. Eight to ten indicators are used and are viewed as a continuously evolving (i.e., reviewed annually with some indicators that may added or subtracted). The Clinical Dashboard provides a description of each measure including why it is measured and recent activities. Gauges are used to determine performance levels, along with control charts. Education sessions have been conducted on the use and interpretation of control charts. Transparency is encouraged and the last two annual reports to the community have focused on quality and include objective outcome measures.   

Change the Environment, Policies, and Culture:  In the event of serious error or harm, the Delnor-Community Hospital Board supports open, honest, early, and full disclosure to patients and families. This approach is consistent with existing risk management and performance improvement policies. A non-punitive, supportive, and communicative environment is fostered for staff who may be involved in an event. Management works to ensure systems are in place with improved educational and safety environments. The overall perception of safety and quality are measured by survey tools involving patients, physicians, nurses, and other staff members. Feedback is provided and the IHI “Model for Improvement” method is used to further develop and reinforce a positive culture. 

Learn: The full Delnor-Community Hospital Board conducts an annual retreat for educational and developmental purposes. For the last three years, the entire retreat has been focused on quality. Speakers who are national experts have been invited to present and have incorporated hospital specific information and data. This has “raised the bar” in the board’s involvement, expectation, and understanding of their critical leadership role in quality. These educational sessions include active participation from medical staff leaders, senior management, and board members. Specific case scenarios have been utilized to dialog on quality topics and deepen communications.

Establish executive accountability: Clear, objective performance measures are set annually by the Compensation Committee of the board (including quality measures with recommendations from the Quality Committee). Organizational goals are aligned from the CEO level down through management and team level performance. Progress and results are shared throughout the organization on a monthly basis.

[6/8/07]

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Henry Ford Health System – Detroit, MI
Availability Status: Available to answer requests
Licensed Beds: 904
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2007
Mentor Contact Name: Edie Eisenmann, Vice President of Governance
Mentor Contact Email: eeisenma@hfhs.org
Mentor Contact Phone: 313-876-8400

Additional Information:

Set aims:  HFHS is in the process of setting a “big aim” around harm with input from our Trustees at the local and System level.  For now, we are measuring multiple dimensions of harm for each hospital in the System and reviewing these at each Board Quality Committee meeting.  Measures include raw and adjusted mortality, infection rates (bloodstream, dialysis, surgical infections, MRSA, etc.), patient falls, surgical complications, readmission rates, medication errors, sentinel and risk events and near-misses, etc.

Get data and hear stories:  Detailed data on a variety of quality and satisfaction measures are provided to and reviewed by the Quality Committee at each meeting.  A larger set of measures, including system-level measures of quality, safety, and service, are provided to the System Board quarterly.  A “deep dive” on a specific aspect of quality and/or a specific project is provided at each Quality Committee meeting on a schedule determined at the beginning of the year.  For example, the July meeting each year includes a broad overview of risk events, sentinel events, malpractice cases, and near misses, highlighting trends, lessons learned, and progress against action plans that have been developed through the year in response to these issues.  Specific stories are shared as appropriate to the topic. 

Establish and monitor system-level measures:  We have quality and safety outcome and process measures in each IOM Aim category.  The harm measures tracked both locally and System-wide include risk events/sentinel events, infection rates, readmissions, and normalized hospital mortality compared to all other state hospitals. Results of both detailed and System-level measures are shared with all boards and with the senior leadership team of the System (approximately 100 administrators and physician leaders) in the Quarterly Quality Performance Report and summarized in the Monthly System Dashboard.

Change the Environment, Policies, and Culture: HFHS has committed to disclosing harm to our patients and to NQF’s policy of not billing for “never events.”  We have a System-wide committee focusing on patient- and caregiver-level supports when harm occurs, with a corresponding policy to guide disclosure management and procedures.  Our Culture of Safety work plan is System-wide and includes several tactics on team communications, routine measurement of our employees and physicians to assess their belief in our culture of safety, implementation of “Just Culture” policies and training, Speak Up and Speak Out approaches, and several other initiatives.

Learn: We held a ½ day retreat in March to educate our System Quality Committee and every Quality Committee and Board Chair System-wide on the research about “best” boards, the 5M Lives Campaign, and other work by the IOM, IHI, and improvement/measurement organizations like Leapfrog and NQF.  We discussed and committed to additional orientation on quality and safety for our board members, increased use of “lay” terms when presenting and discussing our progress and results, and additional time spent in interactive discussions of quality and safety at each board meeting.

Establish executive accountability: Our quality and safety initiatives and goals are directly incorporated into our 3-year strategic plan as one of seven performance pillars.  All of our executives, including physician executives, are held accountable for specific, business-unit level quality and safety goals as part of their annual incentive bonus (15% of bonus eligibility, balancing other performance areas such as financial performance, service excellence, employee satisfaction, and individual goals).  Our employees’ opinions of the culture of safety is one component on each plan; where appropriate, leaders are also held accountable for business area-specific goals in quality/safety.  For example, each hospital’s leadership team is held accountable for Core Measures reliability.

[5/31/07]

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Hot Springs County Memorial Hospital – Thermopolis, WY
Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: May 2005
Mentor Contact Name: Belenda Willson
Mentor Contact Email: Belenda.Willson@mail.hscmh.org
Mentor Contact Phone: 307-864-3121

Additional Information:

Set aims:  Set a specific aim to reduce harm every year.  March 2006

Get data and hear stories:  January 2006 - Quality reports prepared monthly by all departments.  All departments report twice a year to the Quality Committee.  Quality is reported directly to the board by administration.  Formal quality report is presented at every board meeting with the goal of 30% of board time spent on quality.  Hot Springs County Memorial Hospital brings patients and families who have suffered medical errors to our board meetings to tell their story.  We also asked our senior staff to apologize to these patients and relay how their experience is going to change hospital operations.

Establish and monitor system-level measures:  May 2005 - Supported the reporting of all CMS measures through the Mountain Pacific Quality Health Foundation.  Publicly reporting on Hospital Compare.  We voluntarily report all of the CMS Quality Measures, mortality and the HCAPS Survey. (As a Critical Access Hospital, we are not required to do this reporting.) The board focuses on system-level advances on moving the organization's big dots and not on the individual department level projects or the small dots:  safe medication delivery, workplace safety, reducing the mortality rate, improving quality of life and function.

Change the Environment, Policies, and Culture:  March 2006 - Primary focus of the board is not only on the bottom line.  Chief of Medical Staff reports directly to the board.  Zero tolerance where patient safety is concerned, but uses non-adversarial, non-punitive methods to mitigate problems.  Participated in two Patient Safety Culture surveys with great success.  Implemented a Service Excellence Program for the whole staff.  Celebrated achieving 100% compliance for two quarters with SCIP appropriate care measures by having the board and administration cook breakfast for the staff.     

Learn:  December 2006 - Board members have attended quality conferences and national meeting on trusteeship.  Articles and educational materials are distributed at board meetings.  Quality leaders are invited to brief the board on quality issues.  Hospital leaders are encouraged to attend educational programs and outside conferences to learn cutting edge methods to bring back great ideas to the hospital.

Establish executive accountability:  March 2006 - The Hot Springs board commits financial resources to provide a quality medical staff.  Hires the CEO and holds the CEO accountable for assuring high-quality medical care.  Our board recognizes and rewards excellence.  They exercise this when they evaluate and reward the CEO by considering quality in their evaluation as well as financial incentives for a strong balance sheet and market share growth.  The board sends a strong message when rewards are based on improving quality, patient safety, and customer service and employee satisfaction.  We have launched a customer service process that involves every staff member in quarterly employee satisfaction surveys and monthly leadership rounding, employee forums.    

[3/27/08]

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Mary Imogene Bassett Hospital – Cooperstown, NY
Availability Status: Available to answer requests
Staffed Beds: 152
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Bertine C McKenna, PhD, Chief Operating Officer, Executive Vice President
Mentor Contact Email: Bertine.McKenna@Bassett.org
Mentor Contact Phone: (607) 547-3100

Additional Information:

Set aims:   Bassett Healthcare sets specific aims to reduce harm as well as conditions/events that increase the potential for harm. For example, during the past year, the organization specifically focused on reducing mislabeled laboratory specimens by 50%, as well as reducing the rate of hospital-acquired pressure ulcers in the Critical Care Unit below the American Nurse’s Credentialing Center’s Magnet hospital benchmark.

Get data and hear stories:  Bassett Healthcare’s Board of Trustees Performance Improvement Committee focuses  quality improvement, risk management, and patient safety at every meeting. The “human face” of harm is quite visible. For example, members receive in-depth summaries of each adverse patient event that is reported to the New York State Department of Health, including findings of root cause analyses and plans of correction. Cases that result in litigation are reviewed in depth, and the focus is never on dollars, but on the impact on the plaintiff, and what, if anything, could have been done differently.  

Additionally, the Board of Trustees Performance Improvement Committee developed a clinical quality scorecard to ensure their ongoing oversight of significant quality/safety-related processes such as medication events,  adverse  drug reactions, patient falls, ventilator-associated pneumonia, compliance with hand hygiene, and MRSA transmission rate, to name a few.

Finally, if there is a significant patient event that occurs between meetings, the CEO personally sends each member of the board of trustees information on the event, the consequences to the patient, the review findings, and plan of correction.  At the next meeting of the board, the CEO will provide updated information on the case and engage in dialogue with the board about the event.

Establish and monitor system-level measures:  This is one area that Bassett is working towards augmenting over the next year. In late 2007, the Quality Management Council developed a Corporate Balanced Scorecard in conjunction with the board of trustees. One of the measures under development is “rate of medical harm per 1000 patient days.” The organization has collected more specific measures for a number of years, such as patient falls with harm and hospital-acquired pressure ulcers per 1000 patient days.

Change the Environment, Policies, and Culture: For a number of years, Bassett has had a very active policy/process governing “Evaluation of Accountability Surrounding Errors and Events,” which has facilitated Bassett being recognized as having a “just culture.” On the AHRQ Patient Safety Culture survey, staff responses were above comparison groups in terms of affirming a “non-punitive” culture surrounding errors and events.  Further, when staff is involved in an avoidable harm or adverse outcome incident, support and counseling are made available to them via the organization’s Employee Assistance Program. If the event involves multiple staff, it is not uncommon to have group de-briefings and support groups convened.

Additionally, the organization’s policy/process surrounding “Guidelines for Disclosure of Anticipated Outcomes” has standardized the process for disclosure. Hospital Risk Management and the Office of the Medical Director oversee all disclosures, and work closely with the staff, patients and families to ensure communication is open, ongoing, and resolution is equitable and timely.

Learn: Members of the board of trustees could well be characterized as life-long learners from a variety of professional backgrounds. Both the Board of Trustees Chair and Board of Trustees Performance Committee Chair are well-respected physicians. Further, a number of other members are medical experts. However, despite this innate understanding in the “way” of health care, all board members are given initial and ongoing education about a variety of health care topics, medical errors, quality improvement, and so on.

Further, speakers are often called upon to present to the board on various pertinent topics, such as improving flow in the Emergency Department, leveraging technology to reduce medication errors, and recruitment and retention of employees as a quality/safety strategy.

Establish executive accountability: Bassett has linked a director-level and above annual financial incentive with the achievement of a number of quality and safety goals. Furthermore, all employees are rated in a number of safety/quality-related areas on their annual performance evaluation.  Increases in salary are linked to the overall evaluation score achieved.

Additionally, the Board of Trustees Performance Improvement Committee is engaged in giving feedback and making recommendations for improvement based upon information they receive. For example, the committee requested an in-depth analysis over the past year about patient falls, and strategies to reduce the likelihood of patients falling. They request a follow-up report at each meeting regarding this topic from the Vice President of Patient Care Services.

[3/6/08]

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New London Hospital Association, Inc. – New London, NH
Availability Status: Available to answer requests
Total Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: October 2005
Mentor Contact Name: Leigh Roche, RN, Director of Quality Improvement
Mentor Contact Email: leigh.roche@newlondonhospital.org
Mentor Contact Phone: 603-526-5513

Additional Information:

New London Hospital is a critical access hospital in the Lake Sunapee region of New Hampshire. 

Set aims:  Board-set quality goals are developed annually for each facility.  Annual quality goals are reported to the Quality Steering Committee of the board on a quarterly basis.  These goals cover all aspects of quality and patient safety.

Get data and hear stories:  The Chief Clinical Officer presents a quality story at each board of trustees meeting.  Stories illustrate where errors occurred and what has happened to improve the processes and systems associated with those errors to prevent them in the future.

The Quality Steering Committee of the board and medical staff meets monthly to provide leadership and monitor performance of quality improvement.  A trustee-physician (independent) chairs the committee.
This committee’s minutes are included in board packets and the board of trustees receives quarterly updates.

Establish and monitor system-level measures:  We have a balanced score card of higher level composite measures that include not only quality, but also development, strategic planning, HR and financial measures.  Reports on the balanced scorecard are given to the board of trustees quarterly.

Change the Environment, Policies, and Culture:  With increased transparency, through our Patient Care Council and the Medication Safety Steering Committee, we are making interventions to move toward a more just culture.  The Quality Steering Committee leads the organization in this regard.

Learn:

Our board learns in several ways:
• New Board member orientation
• Clinical quality stories at board meetings
• Dartmouth-Hitchcock Alliance activities
• New Hampshire Hospital Association activities
• New England Healthcare Assembly Annual Trustee Conference
• Education sessions at the Board of Trustee meetings and at the Quality Steering Committee of the Board meetings

Establish executive accountability:  Meeting quality goals is a full 30% (the largest percentage) of the incentive compensation package for executives.

[1/31/08]

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University Health Systems – Greenville, NC
Availability Status: Available to answer requests
Total Licensed Beds: 1,116
Teaching / Non-Teaching Status: 3 Critical Access Hospitals, 3 community hospitals, and 1 tertiary academic medical center
Setting: Urban/Rural
Start Date of Intervention Work: 2007
Mentor Contact Name: Joan D. Wynn
Mentor Contact Email: jwynn@pcmh.com
Mentor Contact Phone: 252-847-1946

Additional Information:

We are a 7 hospital health system in eastern North Carolina, about 90 miles east of Raleigh.  We have 3 Critical Access Hospitals, 3 community hospitals, and 1 tertiary academic medical center. Pitt County Memorial Hospital, the tertiary flagship of our health system is an academic medical center affiliated with the Brody School of Medicine at East Carolina University.

Set aims:  Aims include - Reduce sentinel events by 30 percent in first year of patient safety culture work 2007. An additional 50 percent in year 2 (2008).  Reduce VAP and CLAB by 50 percent in two years. 

Get data and hear stories:  Each month, a Patient Safety Report is given to the board quality committee during their monthly 1.5-hour meeting.  A review of every sentinel event is provided to tell the story of what happened to the patient, and the apparent cause of the event.  A more detailed report on each event is given in subsequent quality committee meetings as the root cause analyses are completed.  Follow up reports also contain actions taken by operations to prevent recurrence.

Establish and monitor system-level measures:  Monitor sentinel event numbers, observed mortality rate, optimal care (perfect care) for publicly reported patient populations, infection rates, bundle compliance, and satisfaction.

Change the Environment, Policies, and Culture: Comprehensive system-wide patient safety culture work ongoing since 2006.  This involves establishment of behavior-based expectations for safety for our employees, leaders, and medical staff.  Specific policies are in place to support disclosure of medical errors, web based event reporting, and a non-punitive approach to human errors.  Safety coaches assist in unit level education and coaching of peers in expected safety behaviors.

Learn: Annual board orientation contains a 3-hour quality and safety session for new members.  Quarterly 3-hour education sessions are provided to board members to develop their knowledge and expertise in various aspects of quality and safety. Board members seek out state and national quality meetings to attend as part of their development.  The institution provides financial support for Board members to attend state and national meetings regarding quality.

Establish executive accountability: There is an annual set of quality and safety goals for the organization along with targets.  There are specific quality and safety metrics on the CEO and Vice President scorecards and compensation is tied to attainment of established goals.

[1/18/08]

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Virginia Mason Medical Center – Seattle, WA
Availability Status: Available to answer requests
Licensed Beds: 270
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: 2002
Mentor Contact Name: Celeste Derheimer, RN, MBA, CPHQ, Administrative Director Corporate Quality & Safety
Mentor Contact Email: celeste.derheimer@vmmc.org
Mentor Contact Phone: 206-223-6792

Additional Information:

Set aims:  VMMC has one organizational goal – To ensure the safety of our patients through the elimination of avoidable death and injury.  This has been the only goal since 2005.  Prior to then, a corporate goal focused on improving patient safety was one of several organizational goals.

Get data and hear stories:  Each month – all patient safety alert [PSA] data is reviewed by the board. Specific cases are looked at in detail and all “red” PSAs must come to the board for approval prior to closure. The accountable executive comes to the committee to review case narrative, timeline, value stream map and mistake-proofing of process.

Establish and monitor system-level measures:  Currently on the board dashboard is risk-adjusted mortality rate, days since a sentinel event, compliance with AMI bundle, culture of safety survey results and patient satisfaction as well as 4 financial indicators and 2 staff satisfaction indicators.

Change the Environment, Policies, and Culture: VMMC has had an organizational strategy focused on improving safety and reporting since 2002.  We have measured a culture of safety/reporting since then.  There is an annual work plan focused on engaging patients and their families to improve patient safety since 2005.

Learn: VMMC’s board has an annual retreat focused on some area of learning for several years.  The board made a decision to adopt the business case for quality as a key strategy and we are fortunate to have representatives such as Jamie Orlikoff helping us guide this work.

Establish executive accountability: The entire executive leadership group is held accountable to achieving the patient safety goals.  A part of each of the executive’s compensation is dependent on meeting the patient safety initiative goals.  The Senior Vice President, Quality and Compliance and the Medical Director of Quality provide oversight to ensure success.

[5/31/07]