Welcome

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Welcome Congratulations!Colorado 5
Million Lives Campaign Hospitals Campaign
Launch 2007
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• Irene M. Ibarra
• President and CEO
• The Colorado Trust

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• Colorado Hospitals

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Advancing the Health and Well-being of the People
of Colorado
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• Kimberly Linn McDonald
• ONE in 5 Million
• Gayle Grider
• Mother and Patient Safety Advocate

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Getting Boards on Board
Michael D. Pugh
Colorado Launch November 15, 2007
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Four Challenges faced by Hospital Governing Boards

• Getting comfortable with their responsibility for
  the care and safety of patients
• Setting the right expectations
• Monitoring Performance
• Getting useful information out of mounds of data
  and reports
• Creating accountability

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Colorado Hospital Report CardHB 06-1278

• Initial Report scheduled for public release on
  November 30, 2007 and includes measures for
  2004-2006
• AHRQ Risk Adjusted Mortality for selected
  conditions and procedures
• AHRQ Volume Measures for selected procedures
• AHRQ Prevention Measures
• Other Measures
• AHRQ Safety Measures
• Hospital Acquired infection rates
• Pediatric Volume Measures

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Getting Comfortable

• Barriers to good governance
• Myth of the Three-legged Stool
• Good doctors good quality
• Deferring to experts
• Complexity and language

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How Does Your Board Answer these Questions

• How good is our hospital?
• How do we know?

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Another Way to Think About How Good

• What are you willing to promise patients about
  medication safety at your hospital?
• What are you willing to promise patients about
  the use of evidence-based medicine in your
  hospital and clinics?
• What are you willing to promise patients about
  the level of care and service that will be
  provided?
• What are you willing to promise the community
  about access and cost?

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How Good?

• What level of medication error is acceptable if
  you are the patient?
• How do you pick the patient that is not to
  receive evidence-based treatment?
• How do you decide which patient should have a
  surgical site infection?
• How do you explain to your mother that it is
  perfectly acceptable to wait in the ER for 8
  hours and receive a bill for 3500.00?

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What are you willing to Promise?

• Every system is perfectly designed to produce
  the results it gets.Donald Berwick, M.D

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Six Changes Which Decrease Hospital Mortality

• Deploy Rapid Response Teams
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarction (Heart Attacks)
• Prevent Adverse Drug Events (ADEs)
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator-Associated Pneumonia

Is your hospital pursuing all six initiatives?
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Ventilator Acquired Pneumonia (VAP) Cases in MICU
Number of Cases
Trendline
.
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Reducing Harm to Patients

• Unintended physical injury resulting from or
  contributed to by medical care (including the
  absence of indicated medical treatment), that
  requires additional monitoring, treatment or
  hospitalization, or that results in death.
• Such injury is considered harm whether or not it
  is considered preventable, resulted from a
  medical error, or occurred within a hospital.

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• Prevent Harm from High-Alert Medications...
• starting with a focus on anticoagulants,
  sedatives, narcotics, and insulin
• Reduce Surgical Complications
• by reliably implementing all of the changes in
  care recommended by SCIP, the Surgical Care
  Improvement Project (www.medqic.org/scip)
• Prevent Pressure Ulcers...
• by reliably using science-based guidelines for
  their prevention

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• Reduce Methicillin-Resistant Staphylococcus
  Aureus (MRSA) infection
• by reliably implementing scientifically proven
  infection control practices
• Deliver Reliable, Evidence-Based Care for
  Congestive Heart Failure
• to avoid readmissions
• Get Boards on Board
• by defining and spreading the best-known
  leveraged processes for hospital Boards of
  Directors, so that they can become far more
  effective in accelerating organizational progress
  toward safe care

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Business Case for Quality

• There is always a business case that can be made
  for improving clinical and service quality in
  hospitalswhether or not there is a financial
  case for a specific proposed strategy is a
  different issue.

MDP 2006
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Finding 1Reliable care costs less
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Cost and Quality relationships appear to be
less Random for certain conditions
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The Cost of Patient Safety Events
Data from two mid-sized hospitals
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And the Stakes have Been Raised

• Payment based on Conditions present on Admission
• No increased payment for eight conditions
• Object left in after surgery
• Air embolism
• Blood incompatibility (Wrong blood type given to
  a patient)
• Catheter-associated urinary tract infections
• Pressure ulcers
• Vascular catheter associated infections
• Surgical site infectionMediastinitis after CABG
• Hospital acquired injuries
• Expect all other Payers to follow

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Setting the Right Expectations

• Focus on the Big Dots
• Mortality
• Infections
• Patient Safety
• Evidence-based Care
• Create transparency
• Colorado Hospital Report Card Launch

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Setting the Right Expectations and Monitoring
Performance

• Set system-level aims and measures
• What by When
• Oversee their achievement at the Board level
• Owned by the governing board
• Collectively, the measures answer the question
  How good are we?
• Transparenteveryone in the organization should
  know the Key Measures

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Why Boards Should Use Performance Scorecards

• Create a focus on what is important
• Help to make sense out of the mounds of data and
  reports
• You would not expect to be able to govern without
  meaningful financial data
• In God we Trust, all else bring data.

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What Should Be On the Hospital Boards
Performance Scorecard?
Board performance measures should at minimum
include expected aims and results for

• Employee Satisfaction or Engagement
• Operating Margin
• Cost per Discharge
• Days Cash on Hand
• Waiting Time/Access Measure

• Mortality Rate
• Re-admission Rate
• Patient Experience
• of Patients Receiving Care According to the
  Evidence
• Number of Patient Adverse Events

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Simple Rules for Board Level Scorecards and
Dashboards

• Measure what is important
• Review every meeting
• Use topic specific scorecards to drill down at
  committee level (Colorado Report Card, finance,
  strategy planning, quality, safety, etc.)
• Use Simple Formats

• Set all-or-none target levels for clinical care
  and safety measures (100 or 0)
• Avoid using averages use percentiles measured
  against standards
• Avoid color coding to low expectations
• Data graphed over time is the most powerful
  format

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The Case For All-or-None Measurement

• Report to the Board Quality Committee
• Our MI Core Indicators were greatly improved
  last quarter. Only one measure requires
  corrective action.

Governance Question What of Patients Got the
Right Care?
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The Case For All-or-None MeasuresOnly 30 of
Patients Received the Right Care
Right Care defined as receiving all of the
required EBC elements that the patient was
eligible for
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The Case for Measuring Against Standards/Expectati
ons

• Door to Intervention time proven to be critical
  to Heart Attack outcomes
• Standard30 minutes from presentation to
  (Thrombolytics or 90 minutes to Angioplasty)

• Quality Committee Report
• Our data indicates that we are exceeding the
  national standard. Our average time for
  thrombolytics is 29.5 minutes.

Great Report or Not?
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Not. What about the 25 of patients with delayed
care?
Average 29.5 Minutes
30 Minute Standard
25 of All Patients Beyond the Standard
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Anywhere HospitalHeart Surgery Program Board
Report
Compared to January of last year, our heart
surgery mortality has decreased from 5.9 to 1.1
Monthly Mortality
5.9
Jan 05
Should this be a cause for celebration?
1.1
Jan 06
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When do you want to have your Heart Surgery?
St. Elsewhere Monthly Heart Surgery Mortality
5.9
AVG 3.5
1.1
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Color Coded DashboardsOnly As Good As Your
Targets

• Simple, and sometimes too simple
• Color coding without numbers can mislead
• Tendency is to assume that only the red blocks
  need attention
• If used, boards need to frequently ask how the
  targets are set

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Scorecard Summary

• Every hospital board should adopt a set of high
  level performance measures and targets used to
  define expectations and track performance
• Content and systematic review is more important
  than format
• Use All-or-None Targets for Key Clinical Measures
• Asking good questions the key to successful
  governance
• Create multiple scorecards by topic rather than a
  single monster scorecard

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Board Strategies for Creating Accountability

• Asking the right questions
• Linking CEO performance evaluation to scorecard
  metrics
• Alignment of strategy with performance objectives
• Transparency of performance measures and targets
• Concept of equal time
• Engage with your physicians

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Asking The Right Questions

• What are the important dimensions of performance
  for our community?
• Where is our performance now?
• Where should our performance be?
  (benchmarking/best in class)
• How does our strategy move this dot?
• What resources are we committing to this effort?

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Critical Questions For Creating Alignment Between
Desired Results and Quality Projects
IHI 2007
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Aligned Operating Strategies and Quality Projects
Drive Desired Results
IHI 2007
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Engaging Physicians Some Good Ideas

• Adopt a new stance Consider MDs partners, not
  customers
• Ask them to lead, and to do real work share
  power and information
• Equip MDs to lead and improve
• Uncover common purpose The MD quality agenda
• Patient outcomes and wasted time
• Expand the scope Encourage a system view of
  responsibility
• Report system measures at every level

• Use data sensibly Generate light, not heat
• Dont report system attributes as if they were
  individual MD results
• Reduce variation Standardize what is
  standardizable, no more
• Bundles and key processes, not complex care
  pathways
• Demonstrate backbone Show courage

Jim Reinertsen, MD
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How to Help Your Boards and Senior Leaders

• Create sense out of the mounds of data
• Use topic specific scorecards (safety, mortality,
  infection control, etc.)
• Separate out indicators that are simply being
  monitored from those that you want to improve
• Each scorecard/report should tell a story
• Focus discussion at the board level on
  improvement efforts, not just a report of the
  data
• Encourage board members to ask questions
• Seek to cut the gap in half from current
  performance to all or none targets
• Avoid target setting based on incremental
  improvement

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For More Information

• Michael Pugh
• Pugh Ettinger McCarthy Associates, LLC
• P.O. Box 8298
• Pueblo, Colorado 81008
• 719 542-2433 Direct
• 719 542-2564 Fax
• mpugh_at_verismasystems.com

• Institute for Healthcare Improvement www.ihi.org
• Center for Healthcare Governance
• www.americangovernance.com

These slides may be used by others only in their
existing format with proper attribution/service
marks of Pugh Ettinger McCarthy Associates, IHI
and the Center for Healthcare Governance
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Advancing the Health and Well-being of the People
of Colorado