RACE for Results: Accelerating Knowledge Adoption to Improve Quality

1. RACE for Results: Accelerating Knowledge Adoptionto Improve Quality Lessons Learned from a Children’s Hospital Alliance Donna Payne, Sr. Vice President, CHCA Janet Guptill, President, KM At Work, Inc. ACHE 2007 Congress on Healthcare Leadership March 21, 2007, New Orleans

2. Knowledge Transfer Improves Hospital Performance Strategy Drives Approach • Informal peer networking builds a culture of sharing and collaboration • Formal collaboratives are needed to create immediate results • Systematic rewards and support are needed to spread initial results Knowledge Transfer involves Technology, People/Process, and Strategy • Technology enables information sharing and people directories • People processes ensure productive interaction and knowledge exchange • Strategy determines impact measures and ensures organizational momentum CHCA Case Study Results: • 42 children’s hospitals participate in 30 peer networking forums, regularly sharing improvement tools and resources, exchanging best practices and learning from industry experts • 18 children’s hospitals averted 13,478 adverse drug events (ADEs), representing $2.7 million in net savings, and reduced PICU blood stream infections (BSIs) by 57% • More than 60 intensive care units are working to sustain and spread improvements in ADEs and BSIs based on the initial collaboratives’ work

3. Knowledge Transfer Building Blocks at CHCA

4. Knowledge Transfer to Improve Performance: A Case Study • 42 non-competing hospitals US, Canada • $14 billion combined revenue (1) • Average per member revenue of $330 million • If Fortune 500 would be ranked 142 • IDN influence: • 500,000 inpatients; 10 million outpatients (2) • 102,000 employees (2) • >20,000 pediatric physicians (5,162 medical specialists;1,985 surgical specialists(2)) • Top 5 among U.S. health systems/IDNs Sources: (1) Estimated from Goldman Sachs report to CHCA, July 2004; (2) Estimated from personnel report in AHA Guide 2003/ 2004

5. RACE for Results: Accelerating Knowledge Adoptionto Improve Quality Peer Networking Performance Improvement Spread

6. Peer Networking:Creating a Connected Culture How CHCA Forums Accelerate Knowledge Exchange and Build Connections

7. Peer Networking Builds Loyalty The Opportunity: • The combined knowledge and expertise of all the member hospitals is tapped when a new manager comes on board • Centralized knowledge space limits brain drain due to turnover and retirements • CEO turnover is 30% annually industry wide; higher among departmental managers • Average hospital staff age is 50; getting new employees trained quickly is critical • Online communities among peers limits “re-inventing the wheel” each time an issue is faced The Relevance: • Employee satisfaction drives customer satisfaction and market share • Employee productivity drives operating cost and margin Results: • 42 children’s hospitals participate in 30 forums representing over 2600 executives/managers.

8. Peer Networking Forums are Highly Active 2006 Hospital Participation in Forums Overall 2006 satisfaction: 5.24 of 6.0 (87%)

9. Peer Networking Forums webpage

10. How does it work? • Internet site for Forum members only • Exclusivity, confidentiality, knowledge of colleagues • Dedicated staff facilitator – Supports 3-5 Forums depending on content knowledge and required expertise • Share documents, post weblinks, initiate discussions, find resources • Technology combined with meetings keeps the group connected • Teleconferences, webcasts, bi-annual meetings • Ad hoc conversations, focused research, group problem-solving • Rapid response to posted questions • Benchmarking and identifying variation

11. How can you learn from this? • Upgrade intranet to include 2-way communication capabilities • Incorporate suggestion box for online idea submissions • Utilize team e-rooms for special projects or cross-facility peer group networking • Institute employee email system and instant intranet access to facilitate organization-wide communication • Reinforce a culture of connectivity • Post meeting materials and minutes online before and after • Incorporate online learning tools where appropriate • Exclusively utilize email and intranet site to keep employees current on organization-wide strategies, department-specific issues, or for shift scheduling • Potential reward • Reduces error, reduces time spent searching for solutions to common issues, improves employee satisfaction, facilitates employee professional development • Reinforces organizational strategy and performance goals

12. Performance Improvement:The Power of Collaboratives How CHCA Collaboratives Accelerate Adoption

13. Collaborative Reduces Adverse Drug Events The Opportunity: • ADEs occur in 6 to 10 percent of hospitalized patients • Narcotics among highest risk for errors for children • 50 percent of ADEs related to narcotics • 5.2 narcotic-related ADEs for every 100 patients The AIM Statement: • Reduce the occurrence of ADEs related to opioid and non-opioid narcotics by 50 percent Results: • 18 children’s hospitals averted 13,478 ADEs, representing $2.7 million in net savings (CHCA-approved methodology)

14. Goal Avg. CHCA Hospitals with reduction in ADE rate Collaborative Reduces Adverse Drug Events Hospital Teams: • Atlanta • Birmingham • Buffalo • Cincinnati • Columbus • Corpus Christi • Dayton • Fort Worth • Kansas City • Miami • Nashville • New Orleans • New York/Morgan-Stanley • New York/Komansky Center • Orange • Palo Alto • Pittsburgh • St. Petersburg • 16 teams (89%) had a reduction in ADE rate • Average among teams with a reduction: 64% reduction • Average for all teams: 49% reduction • 11 teams (61%) had at least a 50% reduction in ADE rate BETTER

15. Collaborative Reduces Adverse Drug Events Developed new tools and knowledge to detect adverse events • 3 new trigger tools have effectively prevented adverse events • 15 pediatric triggers improved detection of ADEs by 22x • 8 triggers increased narcotic ADE detection • 16 neonatal triggers improved detection of ADEs by 12x

16. Adverse Drug Event Collaborative webpage • Add ADE Collaborative screenshot

17. Collaborative Reduces Blood Stream Infections The Opportunity: • Catheter-associated blood stream infections (BSIs) are a serious threat to patients’ safety • Areas of highest risk for BSIs include PICU, NICU, CICU, and Hematology/Oncology The AIM Statement: • Reach zero tolerance for BSIs among targeted patient populations Results: • 18 children’s hospitals reduced BSIs in the PICU by 57% • Hospitals prevented 112 BSIs resulting in nearly $1 million in estimated net cost savings • Accelerating a goal: One PICU has been BSI free for 563 days as of 9/20/06

18. Collaborative Reduces Blood Stream Infections Includes only hospitals with a reduction in Catheter-related BSI rate • 18 teams (62%) achieved a reduction in BSI rate • Average among teams with a reduction: 57% reduction • Average for all teams: 31% reduction • 11 teams (38%) achieved a 50% reduction in BSI rate Better * * GOAL: 50% reduction * *Statistically significant improvement p<0.05

19. Blood Stream Infection Collaborative webpage

20. Surgical Infection Prevention Collaborative The Opportunity: • Surgical Site Infections (SSIs) are third most frequently reported hospital acquired infection • 16 percent of all nosocomial infections • Among surgical patients, 38 percent of all infections, 77 percent of deaths for patients with SSI • SSIs increases LOS 7 to 10 days • In children: • One of the most common indications for operative intervention • 40 to 60 percent of SSIs are preventable • >200,000 surgical procedures (n=34 hospitals) • Inappropriate use of prophylactic antibiotic = 25 to 50 percent of operations Source: CDC’s National Nosocomial Infections Surveillance (NNIS)

21. Surgical Infection Prevention Collaborative The AIM Statement: • Appropriate use of prophylactic antibiotics as follows: • Selection: 95 percent of procedures will be accompanied by prophylactic antibiotics consistent with hospital guidelines • Start time: 95 percent of procedures will have antibiotic prophylaxis initiated 30-60 minutes before the incision • Re-dosing: 95 percent of procedures for which re-dosing is indicated will receive a 2nd dose of intraoperative antibiotics consistent with hospital guidelines • Post-operative discontinuation: 95 percent of procedures will have prophylactic antibiotics discontinued within 24 hours after surgery • Skin preparation performed as follows: • Hair removal: 95 percent compliance with appropriate hair removal (for those patients undergoing hair removal) • Skin antisepsis: 95 percent compliance with appropriate skin antisepsis • SIP bundle compliance:95 percent of procedures will be accompanied by appropriate prophylactic antibiotic use ( selection, timing, intraoperative re-dosing if necessary and post-operative discontinuation) and appropriate hair removal • Reduce Surgical Site Infection (SSI) by 50 percent

22. Surgical Infection Prevention Collaborative

23. Surgical Infection Prevention Collaborative The Power of Collaboration: • 28 Hospitals set Goal to reduce Surgical Site Infections by 50% • 11 outcome, process and balancing measures • On-line tracking and reporting(July 2006-2007) • Final Report: September 2007 Hospital Teams: • Akron • Atlanta • Birmingham • Boston • Chicago • Columbus • Corpus Christi • Dallas • Detroit • Fort Worth • Hartford • Houston • Kansas City • Los Angeles • Memphis- Le Bonheur • Memphis - St Jude • Miami • Milwaukee • Nashville • New Orleans • New York • Palo Alto • Philadelphia • Phoenix • Pittsburgh • Seattle • St. Petersburg • Washington, DC

24. How does it work? • Dedicated Performance Improvement staff and resources • Trained in IHI improvement methodology • Hospitals agree to share results, post data and publish results • Use industry and hospital expert panels to validate clinical direction • Combine research and rapid cycle - essential for academic engagement • Technology tools and partners integral to success • Knowledge repository available real time • improvements, tool kits, lessons learned, comparative data, audios of webcasts and lessons learned • Strategic partners essential to spreading results and gaining credibility • AHRQ Partnership for Quality Grant helped fund participation and training for all 42 hospitals • Data-sharing agreements developed to expand comparative data sets (Vermont Oxford Neonatal Network and others)

25. How can you learn from this? • Post performance targets and results on intranet • Develop online performance reporting capabilities • Customize for different audiences: employees, physicians, consumers, board • Include resources and educational materials for ease of access • Reinforce a culture of transparency • Engage physicians in research design and collaborative process • Build in research rigor and evidence-based medicine findings • Utilize dedicated PI staff to ensure that project leadership is experienced, professional, and credible • Potential reward • Improves patient safety, reduces operating costs, reduces patient errors • Focuses on organizational performance and peer accountability

26. Spread:RACE for Results Rewards Initiative How Awards Program Achieves Spread and Sustainability

27. Quality Awards Program Accelerates Spread The Opportunity: • Provide an incentive for hospitals to document their success in improvement • Create a competitive and rigorous selection process for formal recognition • Recognize team efforts within organizations and accelerate knowledge adoption RACE for Results: Recognize and Celebrate Excellence • Initiated in 2004 – idea of CHCA Vice President, David Bertoch • Judged by recognized national experts • Awarded to hospital demonstrating sustained performance improvement • Ambassador status includes obligation to teach others • Relay RACE rewards adoption of others’ successes • Relay Report sustains focus on spread and sustainability

28. RACE for Results Award

29. “Asthma Attack” Critical Care Units Quality Improvement Collaborative: Reducing Ventilator Associated Pneumonia Rates in Three Pediatric Care Units Duplicate Medical Record Number Clean-Up Improvements in Beta-Agonist Therapy Practices Improving Patient Safety by Decreasing Mislabeled Specimens Improving Patient Safety by Standardizing the Patient Identification Process Improving Patient Safety through Reduction of Medication Errors Increasing ED Patient Care Revenue Measuring the Impact of a Short Stay Unit with Bronchiolitis/ Viral Pneumonia Patients Meeting the Standard of Evidence-Based Asthma Care Pain Control in Children with Sickle Cell Vaso-Occlusive Crisis Patient Safety Indicator Validations for Application to Unique Pediatric Population Preventing Cardiopulmonary Arrest outside the ICU – Implementation of a Medical Response Team RACE for the Gold: A Swift Reduction of Catheter-Related Blood Stream Infections in the PICU Reducing Adverse Drug Events related to Opioid and Non-Opioid Narcotics in Children Reducing Catheter-Related Bloodstream Infections in Children Reducing Central Line Associated Bloodstream Infections in the NICU Reducing TPN-Associated Medication Errors Using a Multi-Process Approach Reduction in Manual Differential Turnaround Time for Emergency Room Patients Stat Medication Administration: Improving Timeliness and Patient Safety RACE for Results 2006 Entries

30. Judged by Nationally Recognized Experts • David Classen, M.D., M.S.,Vice PresidentFirst Consulting Group Lloyd Provost, M.S., PartnerAssociates in Process Improvement • Teri C. Simmonds, RN, Partner • Safe and Reliable Healthcare, LLP

31. 2006 RACE for Results Winners The Children’s Medical Center, Dayton winner of the RELAY Award reduced central venous catheter-associated bloodstream infections by 100%. Children’s Hospital of Omaha’s “Asthma Attack” led to reduced LOS and readmission rates, and improved medication management.

32. RACE for Results Winners

33. Press Releases FOR IMMEDIATE RELEASE The Children’s Medical Center of Dayton Reduces Infections and Wins National Award for Excellence DAYTON, OH (March 30, 2006) The Children’s Medical Center of Dayton (Dayton Children’s) has received a national quality and safety award from Child Health Corporation of America (CHCA), a business alliance of 42 of North America’s leading children’s hospitals. The distinguished “RACE for Results” award recognizes and celebrates excellence in performance improvement within children’s hospitals. Dayton Children’s earned a 2006 “RACE for Results” award for its success in reducing bloodstream infections in the Pediatric Intensive Care Unit (PICU). The hospital collaborated with 28 other children’s hospitals to pursue an improved care system for children requiring treatment involving central venous catheters, a serious threat to patients’ safety. The result was a 100 percent reduction in infections; the hospital has gone a full year without a single central venous catheter-associated bloodstream infection in their PICU! “We are honored that our efforts to improve safety have been recognized by our peers, the leading children’s hospitals in North America,” said David Kinsaul, President and CEO of Dayton Children’s. “And we’re very motivated by the improved quality of care we’ve been able to offer our patients. We’ve already started spreading this improvement to other areas of our hospital.” Dayton Children’s was selected for the prestigious “RACE for Results” award by a panel of independent national quality and safety experts. Children's Hospital of Omaha was also a recipient of a 2006 CHCA “RACE for Results” award. FOR IMMEDIATE RELEASE Asthma Best Practices Wins Children’s Hospital Omaha National Award for Excellence OMAHA, NE (March 29, 2006) Children’s Hospital in Omaha, announced today that it is a recipient of a national quality and safety award sponsored by Child Health Corporation of America (CHCA). The distinguished “RACE for Results” award recognizes and celebrates excellence in performance improvement within children’s hospitals. The award is given by CHCA, a business alliance of 42 of North America’s leading children’s hospitals, to children’s hospitals that demonstrate significant and sustained improvements in care through the use of CHCA data and improvement resources. Children’s Hospital earned a 2006 “RACE for Results” award for its work in improving care for children with asthma. By using national asthma and steroid data, Omaha began a series of projects to help implement new treatment guidelines and restructure their Respiratory Care Department. These projects helped to reduce unnecessary time spent in the hospital and return visits after being discharged from the hospital. “We are honored to be recognized among our peers, the leading children’s hospitals in North America, for our efforts in making asthma care more safe, effective and efficient,” said Gary Perkins, CEO of Children’s Hospital Omaha. “This particular improvement is just one in a series of improvements to change the way we care for children.” Children’s Hospital was selected for the prestigious “RACE for Results” award by a panel of independent national quality and safety experts. The Children’s Medical Center of Dayton was also a recipient of a 2006 CHCA “RACE for Results” Relay award.

34. RACE Results in Performance Improvement

35. How does it work? • Formal RACE for Results awards program • Formal application process with strict submission requirements • External judges panel representing industry experts in quality and patient safety • Results announced at award ceremony during annual Quality & Safety Meeting • Winners required to serve as Ambassadors during subsequent year to teach techniques and encourage adoption of proven practices • Formal marketing campaign to publicize event • Emails, posters, web notices to promote the competition and publicize winners • Email-based Relay Report to report progress as proven practices are replicated across the alliance • Resources and contacts posted on the intranet to facilitate connections and encourage adoption • Benchmarking reports regularly published to document improvements

36. How can you learn from this? • Walk the Talk • If you are serious about knowledge transfer and adoption of proven practices, develop programs and tools to facility this activity • Start with the strategy and invest in the technology • Redefine job roles and incentive structures to reward collaboration and knowledge adoption • Create a culture of connectivity • Online spaces for collaboration and informal conversation - Get ready for the MySpace generation • Incorporate web thinking into every communication intention • Build web-based tools into every job in the hospital, make it part of the way work gets done • Measure the results • Tie collaboration activity to attainment of strategic goals • Publicly celebrate successes • Learn from failures – focus on continual improvement

37. Knowledge Transfer Building Blocks

38. Questions?

39. Contact us for further discussion • Donna Payne, Sr. Vice President, CHCA Donna.Payne@chca.com 913-262-1436 • Janet Guptill, President, KM At Work, Inc. Janet.Guptill@kmatwork.com 314-963-7710