The Development, Implementation, and Results of Tenet Healthcare’s Commitment to Quality Initiative

1. The Development, Implementation, and Resultsof Tenet Healthcare’s Commitment to Quality Initiative Jennifer Daley, MD Senior Vice President—Clinical Quality Chief Medical Officer Tenet Healthcare Corporation Dallas, TX 469-893-2988

2. Tenet HealthCare • Created in 1996 as the merger of two for-profit hospital chains with subsequent acquisitions of over 40 hospitals • Currently 97 hospitals primarily across the southern tier states; within the year will be 70 hospitals • Typical Tenet hospital is a 150-200 bed community hospital offering secondary and tertiary services • Four academic health centers (USC, Creighton, Hahnemann, St. Louis University) • About 30% of the hospitals have some affiliated teaching programs

4. Among Tenet’s Challenges in Early 2003 • What is the state of quality in Tenet Healthcare? • How can we improve it? • How can we improve it rapidly? • How can we incorporate quality, safety, and service into the culture of Tenet hospitals quickly? • How can we sustain improvements for the foreseeable future? • Can we afford to do it? • Can we afford not to do it?

5. What are the most critical areas to improve rapidly? • Evidence based medicine • Patient safety • Physician excellence • Nursing excellence • Patient flow and capacity management • Clinical leadership • Clinical resource management and utilization review • Equity in access and pricing for the uninsured • Service excellence The birth of the Commitment to Quality » “C2Q”

6. To Tenet Hospitals: CTQ can help you improve… • “Convince me that this is really important…..” • Subtext: “Show me that improving quality and safety brings me more revenue…” • “Don’t impose this on us from the top down….” • Subtext: “Corporate initiatives are DOA…” • Subtext: “Give us some choice in what we do….” • “How can we do this with all the other things you expect us to do?” • Subtext: “We don’t really know how to do this. Send help!”

7. C2Q Implementation Vehicle: Transformation Teams • In-depth (300 page) self assessment of over 200 metrics associated with each major transformation initiative (1 month) • On-site (five days a week/12 hours a day for eight weeks;) team of content experts in areas identified for improvement alongside hospital leadership and staff • 10,000 mile checks to achieve ongoing improvement and sustainability • Thirty two hospitals will have completed TT (Phase I) by end of 2004; all 70 retained hospitals by the end of 2005

8. C2Q Transformation Teams: EBM (2004) • Goal 1: “Hardwire” 95% adherence to evidence-based guidelines in AMI, Pneumonia, CHF, Surgical Infection Prophylaxis, and isolated CABG by the end of 2004 • Goal 2: Have hospitals with CABG, valve, and PCI programs to require cardiac surgeons and invasive cardiologists to assess and record the AHA/ACC appropriateness classification (I, IIa, IIb, or III) for every CABG, valve replacement, and PCI

9. AMI: Beta Blocker Prescribed At Discharge Mean Rate: Tenet vs. JCAHO National Benchmark

10. AMI: ACEI for LVSD Mean Rate: Tenet vs. JCAHO National Benchmark

11. Pneumonia: Pneumococcal Screening and/or Vaccination Mean Rate: Tenet vs. JCAHO National Benchmark

12. Pneumonia: Time To First Dose of Antibiotics Mean Minutes: Tenet vs. JCAHO National Benchmark

13. Utilization Management and Review • Interqual assessment for 100% of all adult medical/surgical admissions for appropriateness of inpatient admission, continuation of stay, and discharge • In invasive cardiology, use American Heart Association/American College of Cardiology appropriateness guidelines for CABG, valve replacement, and percutaneous coronary intervention • Use NIH guidelines for appropriateness of bariatric surgery • In the 6 months, implement the Interqual SIMS criteria for all major discretionary procedures

14. C2Q: Improvement in CABG Processand Outcome • Comprehensive assessment of all aspects of isolated CABG surgery • Appropriateness of surgery (AHA/ACC criteria) • Processes of care demonstrated to improve mortality and morbidity • Outcomes: risk-adjusted mortality and morbidity

15. CABG Appropriateness at Tenet Hospital J AHA/ACC Guideline Adherence for Appropriateness of CABG

16. CABG Mortality in Tenet Hospitals:Observed vs. Expected Mortality

17. C2Q: Patient Safety • Implement web-based occurrence reporting system • Reduce hospital acquired infections by 50% (VAP, central line BSI, UTIs associated with catheters, surgical site infections) • Reduce high severity adverse drug events by 50% • Promote a culture of safety in each hospital • Build team training in high risk areas of hospital (ICU, ER, L&D, OR, invasive radiology) • Provide hospitals with educational material for governing boards, administrators, clinical staff, physicians, patients, and families • All Tenet hospitals are members of the National Patient Safety Foundation Stand Up program • Corporate level Patient Safety Committee monitors trends, develops patient safety policies, identifies new trends in patient safety

18. Informatics-enabled Infection Control Monitoring Sample screen shots from the CCM and IC story boards due 9/12 will go here

19. C2Q: Physician Excellence • Half day educational session annually for all Tenet hospital governing board members regarding their fiduciary responsibility for quality, safety, and physician credentialing • Standardization of the business processes of physician credentialing and privileging through web-based tool • Identification and remediation of physicians whose utilization/quality is substandard through peer review and established medical staff and governing boards processes • Consistent physician performance assessments using objective data and peer review

20. Credentialing Echo and Echoapps screen shots

21. Credentialing Echo and Echoapps screen shots

22. Completing the Circle of Supporting Physician Excellence • Individual informatics-enabled projects dependent upon one another • IT integration strategy to support hospital management processes Physician Excellence

23. C2Q nursing program has improved nursing retention, quality, and patient satisfaction Example nursing improvements from last round of C2Q Nursing retention • Hospital 3 significantly decreased voluntary turnover and accelerated involuntary turnover • June RN voluntary turnover improved to 13.8% vs. 20% for the previous year • June RN percent involuntary terms less than 90 days dropped to zero, while voluntary terms less than 90 days rose to 22.2% Pressure ulcers/falls • Hospital 84 implemented corporate policies to reduce the incidence of pressure ulcers and patient falls Pain management • Hospital 53 dramatically improved inpatient satisfaction with pain management scores from 61% before C2Q to 96% Nursing peer review • Hospital 11 developed a shared governance/nursing peer review model aimed at improving the quality of nursing care Inpatient satisfaction • Hospital 19 demonstrated significant improvement in inpatient satisfaction scores (hospital never achieved 4 star status before but was 4 star 2 of the past 3 months) by implementing a new nurse staffing model

24. C2Q: Patient Flow and Capacity Management • Hypothesis 1: delays and “blocks” in high flow areas of the hospital are not the result of lack of space or staff • Hypothesis 2: delays and “blocks” in high flow areas of the hospital are the result of a failure to “connect the dots” in tightly coupled systems and a failure of synchronization • Key Areas: Emergency Room, Operating Rooms, ICUs, discharge processes (bed turnover)

25. C2Q operations impact has been strong and sustained Gap closed at C2Q team departure Percent Gap closed by September, 2004 Percent Metrics Average discharge time Continuum of care Average minutes DOW to DC Average minutes exit to room clean Asset utilization in hours Operating room First case delay in minutes Cancellation percentage LOS minutes – discharged LOS minutes – admitted Emergency Department LWBS percentage Diversion hours*

26. Daily Tool Snapshot

27. Examples of C2Q Quality Improvements From Most Recent Round • Improved medication safety Hosp 1 Patient Safety • Lowered the incidence of ventilator associated pneumonia • Considerable body of evidence that level of quality is improving significantly due to C2Q • Hospitals building necessary skills and tools through C2Q to tackle next-wave quality issues in their hospitals Hosp 17 Hosp 4 • Increased CHF patients receiving discharge education from 8% to 79% Compliance with EBM • CAP patients receiving IDSA approved antibiotics improved from 33% to 80% • CAP pneumovax immunization rate improved from 59% to 90% Hosp 64 Medical Staff Support • Strengthened its credentialing process by infusing better data into re-appointment processes Hosp 35 • Reviewed criteria for sub specialist performance on medical staff Hosp 51

28. C2Q cultural impact is accelerating Ways the culture is changing Physicians are embracing the program “I wasn't before, but now I'm a believer in C2Q. An initiative I thought would take 8 months got done in 8 weeks.”  – MD “For the first time in my 20 years, I finally feel that we have a mechanism to drive positive change.” – MD “For the first time, I believe we can make change happen; the outside help has really opened our eyes.”  – MD New skills are being learned “The training gave me some really good ideas for how I’m going to tackle the one physician issue I’m struggling with.”  – Director “The training opened my eyes to new ways of approaching the same issue.” – Director “C2Q gives us the capability to be able to tackle new issues as they arise. In the future we are going to “C2Q” new problems.” – CEO

29. Enabling mechanisms in place to sustain impact Current tools • Bi-weekly performance reporting from hospitals to Program Management Office • Process to feed back action items to regional and hospital teams • Near-term (monthly) and long-term (12-24 month) targets • Clinical Quality measurement index • Performance evaluation and development tool for regional team Performance management • User-friendly best practice database in Tenet intranet • Process for ongoing best practice development, codification, and dissemination • Key operations and quality expert resource contact list Best practice sharing

30. New strategic direction to achieve service excellence Description Strategic direction • Transform Tenet’s service strategy through new value propositions for patients and physicians • Build upon the best elements of Target 100 and fill gaps to strengthen Tenet’s service culture • Integrate T100 and C2Q teams to align service, quality, and operations initiatives • Build distinctive service levels in selected local markets Safe, comfortable and prompt Respectful, empathetic, and coordinated • “Tenet will create a physical and emotional environment that delivers positive patient-centered experiences, not just health service transactions.” Patient service commitment Consistent with other ‘service- excellent’ environments Doing the right thing, the first time, on time Equitable governance to give physicians a sense of ‘ownership’ Physician service commitment • “Tenet will offer physicians operationally effective, collegial professional communities where they can be significantly more productive and have their patients treated safely and with dignity.” Economics, technological support, and improved lifestyle need to make a 15-20% difference

31. Positive Forces At Work • Leadership • Resources • Standardized Approach with “Local Customization” • Communication, communication, communication • Accountability • Public influence in dialogue about performance • “Quality” or “safety” or “safeguarding”?