Primum non nocere – First Do No Harm

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It’s no secret that hospitals can be unsafe places. It is reported that every year in the U.S. 200,000 people die from hospital acquired medical errors or infections. That means that a patient is 33,000 times more likely to die from hospital acquired harm than in a plane crash.  This is unacceptable and Saint Francis is doing something about it.

At the core of our calling is to ‘First do no Harm.’ Every physician I’ve met over the past 20 years adheres to this professional mantra. We want to help, not harm, our patients. We carefully consider our treatment decisions. Sometimes ruminating about our choices, especially if the outcome for our patient was not what we had intended. We do inform our patients of the potential for harm as a result of our interventions, but all of us hope for and fully intend to avoid them.

We own these individual patient risks as physicians. But we are embedded in a system, and the system imposes its own challenges and risks upon us and our patients. Astute clinicians and administrative leaders recognize that system errors and inefficiencies lead to harm, not necessarily the decisions or actions of any one individual. Other industries have acknowledged this reality and have been working to find and fix these errors for decades. These include the aviation and nuclear energy industries as well as the U.S. military. The result has been a remarkable reduction in deathly errors and the emergence of high reliability science. What has been learned in these other industries can be translated into health care. The results will be safer care.

With the help of CHI, Saint Francis Medical Center is one year into a cultural transformation that is being fueled by high reliability science branded as “SafetyFirst.” All Saint Francis employees have undergone initial training and have begun to use numerous safety techniques to help create a culture of safety. We have already seen a reduction in common errors as a result. For example, the near elimination of mislabeled specimens and the elimination of orphan EKG’s. The newly created SafetyFirst infrastructure, data collection, and analysis has provided insights to our global care that we did not have access to before. After reviewing three years of incidences, a top ten list of common process challenges has been identified. Teams are actively working to fix these process weaknesses. We are learning and patient care is improving.

Physician awareness and participation is critical to the ultimate success of this cultural change. Without us, the transformation will be incomplete, and patients will suffer harm. With us, the organization will continue on its journey to truly exceptional care, and our patients will reap the reward.

This month there will be two opportunities for physicians and providers to obtain CME credit for learning more about high reliability science – SafetyFirst. Additionally, if unable to attend in person, a video recording is available for viewing.

In my opinion SafetyFirst is an excellent example of where the three major ‘tribes’ of health care – nursing, administration, and physicians – are drawn together by our passionately shared and common goal of taking exceptionally good care of patients. While we each come to the table from different and valuable perspectives, we unite together to first, do no harm.

Leapfrog Rating of SFMC – A response

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Printed last year – but still appropriate:

Recently, The LeapFrog Group, a respected commercial nonprofit organization that promotes transparency and patient safety, released what it called “Hospital Safety Scores for America’s Hospitals.” The Independent accurately reported that Saint Francis Medical Center received a “C” grade.

Patients are increasingly making healthcare decisions based upon widely available quality and patient experience scores. We welcome this. Scores for quality at Saint Francis Medical Center are available at Hospital Compare (www.hospitalcompare.hhs.gov). Although the information published there is about two years old, we believe that Hospital Compare is superior to commercial sources like LeapFrog because it provides free, non-commercial, unbiased and accurate information.

LeapFrog bases its scores on two data sources: data that all hospitals are required to report to the Center for Medicare and Medicaid services (Hospital Compare) and data provided by some hospitals through a lengthy voluntary survey. Saint Francis Medical Center — and many other hospitals — elected not to complete the Leapfrog survey as we deemed it an unnecessary use of time and resources.

The American Hospital Association correctly identifies problems with commercial scoring agencies like LeapFrog. If some hospitals are providing data through the survey while others are not, and that information isn’t available anywhere else, it’s difficult to make fair and accurate comparisons between facilities. This is what has happened with the release of the Leapfrog data.

The larger hospitals in the tri-cities area, in Lincoln, and even the Nebraska Medical Center and the Cleveland Clinic received “C” grades. Kaiser Health reported LeapFrog gave 729 hospitals an “A” grade, 679 hospitals a “B” and 1,111 hospitals a “C.” LeapFrog didn’t release the names of hospitals who rated a “D” or an “F.” Unlike Hospital Compare, children’s hospitals and critical access hospitals were not rated at all. Furthermore, it appears that facilities that elected not to complete the survey could not score higher than a “C” grade. Therefore, labeling Saint Francis a “lower-rated facility,” as the Independent did may have been considered headline-worthy, but was ultimately misleading.

It’s also important to know that LeapFrog offers high-price consulting services to hospitals who wish to improve their scores. They charge hospitals licensing fees reported to be from $5,000-$12,000 for the rights to promote their high rankings if they achieve them. This means that if a hospital completed the survey and scored high, they would have to pay LeapFrog for the right to publicize their high score. The nationwide release of these new rating scores was a way to build business for their company. At Saint Francis Medical Center, we find this kind of commercialization of quality and safety data distasteful and misleading.

 We understand that these types of programs will become more and more common. Our strategy is, and always has been, to focus on what is most important: working with physicians to provide every patient with the safest and highest quality care possible and continually improving the care we provide.

In 2005, Saint Francis was singled out for performance excellence by being the first and only hospital to receive the Edgerton Award of Excellence. This recognizes an organization’s ongoing commitment to improving systems and processes that lead to better outcomes. We understand that we are on a journey of continuous improvement and success requires us to be tirelessly vigilant. Here are some of our milestones so far:

  •  Saint Francis successfully meets the rigorous standards for accreditation by the Joint Commission. Several services — like Cancer Treatment Center, Cardiac Rehab, Laboratory and all radiology modalities are accredited by national organizations. We have also been named a Blue Cross Blue Shield Distinction Center for Hip and Knee Replacement. 
  • We were recently recognized by Women’s Certified as the Region’s Best Hospital for Patient Experience. 
  • Our patient experience scores currently rank us one of the best in nation (the 93rd percentile) when compared with Healthstream’s extensive list of clients. Patient satisfaction surveys look at key activities that relate to safety and quality, such as physician and nurse communication, quick response from staff, pain control, explaining medications and discharge instructions. 
  • As leaders in patient safety, we were one of the first hospitals in the state to implement bedside medication verification, using technology to prevent medication errors. And we continue to upgrade technology with Smart IV Pumps. We were one of the first Catholic Health Initiatives hospitals to introduce Rapid Response Teams. We use evidence-based practices that have proven to be the best for preventing several common safety risks.

And there are other exciting things we’re working on that will continue to raise the bar: 

  • SafetyFirst is a comprehensive program designed to eliminate serious safety events at Saint Francis Medical Center. Every employee and members of our medical staff are currently attending powerful safety and error prevention training. Recently, hospital leaders began brief daily huddles where we identify and work through potential safety concerns 
  • We are currently developing computerized physician order entry systems (CPOE) within an electronic health record.  The order sets are in the development stage and include the use of evidence-based practice and current best practices, while also allowing physicians to individualize care. This is slated to be operational in 2014. 
  • We have begun the process to achieve Magnet status from the American Nurses Credentialing Center. Magnet hospitals must satisfy a set of criteria designed to measure the strength and quality of nursing care.  

For 125 years, the people of Grand Island and Central Nebraska have trusted Saint Francis Medical Center for their healthcare needs. You can be confident that we are tirelessly pursuing the highest quality and safest care available. And there are 1,110 employees and 100 physicians passionately committed to continually improving the care we provide to our friends and neighbors in the place we call home.

 

Michael S. Hein, MD, MS, FACP

Chief Medical Officer/Vice-President of Medical Affairs

Saint Francis Medical Center

People not Process: The Missing Focus of Patient-Centered Medical Homes

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I’ve learned an important lesson about changing health care delivery systems – in the end it’s about people and not just the process. No doubt the process matters. That’s because we often we create crazy wasteful ones. Unlike manufacturing, in healthcare a human being is the one doing the process, not a machine. Therein lay the opportunities and the challenges.

If it were just one person that touched the patient it would be easier to impact the outcomes of the processes, but healthcare is a team sport. We know that when the team plays well together, patients have better outcomes, are more satisfied, and are less likely to suffer harm.

Recognizing the importance of team function, inpatient healthcare has seen much work in the area of team development. So there are examples of high performing teams in the operating rooms, neonatal units and many other areas. Where they have been developed, these teams have contributed to significant improvements in care.

The outpatient world – and by that I specifically mean outpatient primary care clinics – working as a high performing team is not the norm. We structure our primary care delivery systems the same way we have for 6o years or more. It is a physician-centric delivery model. This delivery model is perfectly designed to deliver the outcomes that we see – fragmentation of care, limited access, unknown or questionable quality, and it is expensive.

Many are discussing how we change this reality. Some have pointed to new models of healthcare delivery, specifically team-based, data-driven, continuously improving, patient-centered teams of individuals working as a high performing team. The model that embodies these ideals most often mentioned is the patient-centered medical home.

Transforming primary care clinics into team-based care is exceedingly difficult work. It is not because the processes are inordinately difficult to implement, or that the technology is hard to acquire or use, or that the model can’t reap financial rewards for success. It’s because it requires human beings to rethink their professional identities, to redefine their roles and responsibilities, and be able to embrace the redefined roles and responsibilities of others on the team. Since professional identities for adults are intertwined with personal identities, changing from a physician-centric practice model to a team-based practice model is both professionally and personally threatening. Not only do physicians not know how to function on a team, in order to do so is threatening to them. Making the transition from physician-centric care to patient-centric care; from individual autonomous care to team-based care, requires coaching, facilitation, and patience.

Most healthcare leaders moving towards Accountable Care Organizations, which are by definition built upon the foundation of primary care redesigned into the medical home model, are much more attuned to process and technology, not psychology and social development. Therein lays the greatest risk for failure of ACO’s and PCMH’s.

If you’d like to read more I suggest this article: Medical Homes Require More Than and EMR and Aligned Incentives.

 

So Much Good

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There’s so much good going on at Saint Francis Medical Center. 

Core Measures

December marked 100% achievement of all our monthly Core Measures for SFMC. This is more than a number. We have rarely achieved this in the past. It reflects actual clinical care that is evidence-based. It takes a team of hard-working individuals diligently learning about and approving our care and processes of care in order to achieve these targets.

Patient Satisfaction

Patients continue to rank SFMC as one of the highest in overall inpatient satisfaction in the nation. In December, 85% of our patients scored the overall care they received at the highest level possible – the “Top Box.” This was the highest score for December amongst all CHI-NE facilities. Our fiscal year to date score, after 6 months, is 4% points higher than last year, and keeps our facility in the 95th percentile or higher in the country. It takes a team of hard-working individuals who are constantly reviewing, listening, learning, and improving upon our processes of care in order to achieve scores like this.

Ventilator Associated Pneumonia

We had a problem with Ventilator Associated Pneumonia (VAP). After careful review of our past data, deep analysis of our existing processes, and significant multi-disciplinary team discussion and work, we have implemented several specific interventions, including education, re-training, and new monitoring processes which are designed to reduce our rate of VAP’s. This team, led by Jeri Erickson, was a model of how we need to approach our clinical challenges: team-based, data-driven, and continuously improving. We have not had a VAP at SFMC since November 6th. The day’s between VAP’s appears to have been lengthened significantly.

Physician Leadership

While it ‘takes a village’ of individuals to improve care and the processes of care, it is difficult to advance an organization towards higher quality and safety without active physician leadership and participation. Over the course of the past 18 months, I’ve noted a marked change in the involvement and leadership from physicians at SFMC. This can be measured by the participation in quarterly medical staff meetings, the attendance and contribution at ad-hoc decision making points (i.e Palliative Care Forum), the re-establishment of Medicine and Surgery Division meetings and the leadership by those Division Chairs at those meetings, the ongoing efforts to increase the amount of MD-to-MD communication, the participation by physicians on the IV Access Team, the CHF Team, the Sepsis Team, the VAP team, and numerous other formal and informal gatherings where discussion about quality of care is had. It takes a team of physicians, partnering with other clinicians, working together,  to create the highest quality, safety and experience for our patients.

Collegiality between Nursing Leadership and Physician Leadership

Maybe you’ve noticed, and maybe not, but there is a shift occurring in our organization. It’s intentional. In the past, some saw a distinct line drawn between nursing and physicians.  Now we see increasing collaboration and shared decision-making between the two disciplines. This is most notable within the Division Meetings where we have physician chairs partnered with nursing directors, but it is also seen in work around performance improvement, at MEC, and at PCEC. Other notable areas are in the Surgery and the OR under Rebecca Shuman and Dr. Steve Schneider’s leadership. Our future success and our path towards truly exceptional care must be a road traveled by nursing and physicians together. We are dependent upon each for our mutual successes, and more importantly, patient outcomes are directly correlated to the strength and vitality of this relationship between disciplines. There are few things that encourage me more about our future than what I see happening between nursing and physicians at SFMC.

Environmental Services takes on Infection Rates

In order for patients to experience the best care possible, it takes a team. One critical member of our clinical team is our environmental services (EVS) staff. These unsung heroes’s are on the front line of preventing the spread of infections that kill. This past month, I had the true pleasure and distinct honor of sharing my “heart” with them. I expressed my appreciation and acknowledgement of their hard work and its critical nature directly related to patient outcomes. Without their diligent attention to kill-times, their labor-intensive efforts to clean every surface, and their ownership of this essential piece of safe clinical care, our patients will suffer harm. They were gracious and received my message to them with appreciation and renewed enthusiasm for the important work they do. My hope is that you, the reader, also will stop them in the hall, or in the room, and thank them for what they do for our patients.

Safety First

Dr. Steve Moore, Chief Medical Officer for CHI visited us this week. He was here to get a sense of where we were at in regards to our Safety First journey. He shared with us that over the past year, CHI-NE has seen a remarkable decrease in Serious Safety Events and that in those facilities across CHI that haven’t instituted Safety First, there has been no reduction. We have ten teams at SFMC working on reducing harm to patients caused by some of our challenged processes. Physicians and nurses are teamed-up reviewing our cases and identifying issues to work on. In a measurable way, as a result of the work around Safety First, we have reduced harm and potential harm to our patients at SFMC. We are early in our journey, but we are seeing benefits already.

Closing Comments

There is so much more goodness going on that there’s no way to acknowledge it all. These items are just on my mind as I write this. We are all working on continuously improving our quality, but also striving to reduce our costs, and improve the experience that our patients have when the encounter us.

Megatrends in Healthcare

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This is an interesting presentation I thought that I would share: Click Here

Profound changes in healthcare will come about from strong forces outside of healthcare. Often we who live and work in this ‘space’ are so focused on the day-to-day work, that we can easily miss what is happening all around us. This video provides a brief and important view of the horizon.

The Centrality of the Patient

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I had the opportunity to interview a young man from India today. He has been at St. Francis Medical Center for many months, serving as an intern for our performance improvement team. As the interview came to a close, we began to talk about his experience here. He had many nice things to say about how welcoming our organization was to him, how impressed he was about our desire to do better, and he was thankful for the opportunity to be with us.

This is a bright young man. He is working on his Master’s degree in engineering. He plans to go on to get an MBA. He would like to move into healthcare administration.

As we finished off the interview, he reflected on what was the most important lesson he learned while he was here. Without hesitation he stated, “The passion for the best patient care is inspiring.” When I came here, he said, he was interested in experiencing health care. As a result of his exposure to our work, our passion for the best patient care, he now wants to invest his life and career in health care. We converted him.

The interview reminded me of a central truth; a truth that unites us – nursing, physicians, administrators, clinicians, technologists, ancillary staff – all of us. This truth is our passion to provide the best care to patients. Each of our professions and disciplines brings a valuable and necessary skill set that is leveraged for the benefit of the patient. Everyone has value, everyone has a different role, and all of us have the same goal.

If we remember this, much misunderstanding, cynicism, and conflict will fall to the wayside, and we don’t need spend a great deal of time or energy questioning other people’s motives. When we face problems, trying to improve our care, we don’t need to make our analysis about people, we can focus on processes.

As we move into new models of healthcare delivery, the role and responsibility of the physician will expand. We’ve always needed to be clinically astute, but the future will demand clinical acumen and systems thinking. We need to work with our patients to prevent and help them recover from illness and be able to diagnose and treat sick systems of care which may harm or deter recovery from our clinical interventions. The exceptional physician of the future will fully recognize the value of all those involved in the care delivered to patients and contribute towards developing, sustaining, and fixing processes that support their clinical actions.

Our common passion for the best patient care serves to bridge disciplines and silos. This passion for patient care is where we find our motivation, our shared vision, and our hope for continuous improvement.

Sometimes reminders about this central truth come at us from interesting directions. In this case, a twenty-something, non-clinician.

Day 1 – Schneider, Novinski and Boon

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In medical school, some of my classmates and I, those who sat in the back row, designed a professorial rating system. The metric we created was the “Snooze Factor.”

This is how it worked. Midway through the lecture, we would count the number of students (numerator) who were snoozing and divide that number (denominator) by the total number of students in class. Our premise was that the best professors kept us engaged in the lecture, and the least proficient did not. As a surrogate marker of the overall quality of the course, we would rate professors on their average snooze factor.

I have to admit that these many years after I sat in a medical school lecture hall, I still find myself surveying audiences during presentations at conferences, just to see how everyone is doing. And in my head, I start calculating the snooze factor. I did that today.

The snooze factor was very low. The presentations were exceptional and the content thought-provoking and challenging. No one (well, almost no one) was sleeping.

I was quite surprised to find that Dr. Schneider also used the snooze factor. He commented, “Wonderful meeting. Dr. Schneider stayed awake the whole time.” That’s high praise from any physician, in my estimation.

Dr. Boon likewise was taken with the first two presentations: Generative Governance, and The New Realities of Care Delivery and Accountability. The latter stimulated a robust conversation amongst the physicians about what the potential impact of social media, telemedicine, technology, and self-generating – organizing without organization – and what it might mean for healthcare delivery in the future. In the end we all agreed, we couldn’t predict the future, but that the future was very interesting.

Dr. Novinski also thought that the New Realities presentation was eye-opening. In fact, moved by the presentation to step into new communication tools, he attempted to Tweet me his thoughts about the day. But it failed, for some reason – either end-user failure on my part or misfiring on his part. This is what happens when the Baby Boomers stumble into the territory of the Millennials. Since we fumbled on our foray into the new reality, we reverted to a tried and true method of communication – we talked face-to-face.

Next I’ll give a brief synopsis on the presentations from the first day

Opening Comments – CHI National Leadership Conference – 2012

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Travel was a bugger. Due to the vagaries of airline schedules and bad weather, less than half of the expected cadre from Saint Francis were able to attend. This was unfortunate, as Dr. Traci Rauch and Dr. Michael McGahan were in the group that didn’t make it. Drs Schneider, Boon, and Novinski joined me (Dr. Hein) prior to the opening session for breakfast where we reviewed the agenda and speakers. We decided to text or tweet at the end of the day a brief summary of our thoughts regarding the content and what it may mean for us. I will share some of those thoughts in later blogs.

 

The session line up for the first day was:

 

  1. “Generative Governance,” by William P. Ryan.
  2. “The New Realities of Care Delivery and Accountability,” by Kaveh Safavi
  3. “Abolishing Health Inequities,” by Joseph R. Betancourt

 

However, I thought that the key message was delivered early in the day: Our mission creates our focus, sharpening our vision, as leaders. During a period of unprecedented change in healthcare, we can find unprecedented opportunity by adhering to the mission of the organization. In some sense, our mission is prescient of the work we must now accomplish.

 

Let me share our mission statement with you:   

 

“The mission of Catholic Health Initiatives is to nurture the healing ministry of the Church by bringing it new life, energy and viability in the 21st century.  Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities.”

 

The last part about creating healthier communities takes on new meaning in an era of integrated care delivery, shared risk, and payment reform. I do agree that while we reside in the midst of a tempest, we can find the eye of the storm by focusing on the mission of the organization and our goal to create health within the communities we serve.

 

By beginning with our mission, the entire conference was than centered squarely upon what matters – our communities.

Motrin

Catholic Health Initiatives National Leadership Conference

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Saint Francis Medical Center is owned and operated by Catholic Health Initiatives. Several physician leaders from the community and myself are attending the national conference in San Antonio, Texas this week (October 26-27th, 2012).

In an attempt to continue building communication, especially with my colleagues in the community, I will be posting some thoughts and responses to the content of the conference on this blog during the conference.

I can also be followed on twitter: @heindoc

Stay tuned.

On Being a Physician

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Much of my day to day routine is translating the mindset of the physician into the administrative side of medicine.

In that regard, some are surprised to hear my perspective on what physicians are feeling and experiencing. This article sums up the general perspective of physicians, even in Grand Island.

These are particularly challenging times in healthcare, and especially challenging for physicians. This breeds uncertainty.

Personally, I see opportunity and hope for physicians, especially as leaders. While I agree that medicine as we know it is coming to the end of an era, the future for physicians who are both system-minded and clinically astute is bright.