Bundle Compliance for Blood ProductHigh Reliability Care to Every Patient, Every Time
William Holland, MD, VP of Care Management and Chief Medical Informatics Officer
Jill Howard, Associate VP for Quality, Design and Reliability
Banner at a Glance
Our Mission:Making healthcare easier, so life can be better.
Our Strategy:
• Integrated governing process– Single Board of Directors– Centralized management structure– Centralized corporate functions
• Designed to achieve results– Enhance clinical quality– Affordable cost model– Patient/member experience
• Alignment from strategy through initiatives– Drives common strategy from senior leaders down through entire organization– Allows IT leaders to tightly align technology strategies with Banner strategy– Aligns IT sub-strategies and tactics across IT operations
Banner’s Operating
Model
The Banner Operating Model
Banner Health’s Approach to Care Management & Clinical Reliability
Physician Involvement with Design and Implementation
6
Designing Reliable CarePrevent Failure (10-1)
―Standardization―Checklists, feedback mechanisms
Identify and Mitigate Failure (10-2)―Eliminate ambiguities, work arounds―Reminders, differentiation, constraints
Redesign (10-3)―Identify the failure mode―Improve processes and structures
“Reliability” - Isn’t 99% accuracy pretty good?
“If we had to live with 99.9% (10-3), we would have: ―2 unsafe plane landings per
day at Chicago O’Hare Airport―16,000 pieces of mail lost
every hour―32,000 bank checks deducted
from the wrong account every hour”
W.E. DemingJAMA Vol 272 (23), 21 Dec. 1994, 1851-57
Clinical Reliability at Banner•Banner’s approach to quality and safety is based on ensuring
reliability* of its clinical systems and processes including:
*The capability of a process, procedure or health service to perform its intended function in the required time under existing conditions. (IHI, 2004)
Defining clinical standards, designing delivery processes, and implementing across the organization
Identifying and addressing opportunities for further improvement
Monitoring and assessingperformance to those
standards and addressing periodic issues
• Honor the contributions of clinician experts• Leverage the “Operating Company Model”• Recruit deep physician talent for leadership• Train clinicians in leading change• Encourage the multi-disciplinary approach• Engage engineering expertise• Deploy technology to simplify care• Consistent methodology to improvement
Banner Health Approach
Clinical Consensus Groups (CCG)
ED
Pulmonary
Palliative Care
NICU/Newborn
Neurosciences
Critical Care
Behavioral Health
Anesthesia
Pediatrics
Women’s Health
Post Acute Care
Medical Imaging
Primary Care
Hospital Medicine
Cardiology
Urgent Care
Surgery
Pharmacy & Therapeutics
Infectious Disease
CV Surgery
Oncology
Ortho
Clinical Leadership
Team
Program management
CCGs and Clinical Practice
Development
InformaticsClinical & Medical
Professionals assist with
design & build
Quality
CPAClinical
Performance Analytics
Clinical Education
Process EngineeringClinicians and
Engineers assist with Design
Purpose: Define expected clinical practices for Banner Health based on best available evidence, including practice- based evidence.
“Engineering” New ModelsDDI Process for Implementing Evidence Based Clinical Practices
• Research Practices
• Reach Consensus on requirements
Define
• Describe reliable workflow and roles
• Develop tools
Design• Communicate
and train• Address issues• Monitor
Implement
Evidence Based Practices
Local ProblemHow does Banner Health drive increased bundle compliance to improve outcomes by providing
high reliability care to every patient, every time?
Example: Blood product utilization
2011 National Blood Collection Survey and Report
51,000 transfusion-related adverse events occurred
• Death• Renal injury• Lung injury• Allergic reactions• Iron overload• Immune suppression• Fever
Unnecessary Transfusions
The American Association of Blood Banks recommends
transfusing only when Hgb <7g/dL unless the patient is symptomatic or meets exclusion
criteria
Research indicates that approximately
30% RBC, 25% platelet & 60% FFP
transfusions are unnecessary
Healthcare providers have
historically used the 10/30 rule,
ordering transfusions when Hgb <10g/dL and
Hct <30g/dL
Use of Blood and Blood Products
Reduce Variation in Blood UtilizationIn 2012, Banner Health created a strategic initiative aimed to reduce unnecessary transfusions. These unnecessary transfusions contribute to patient harm and waste. The purpose of this initiative has been to improve patient safety and clinical outcomes while reducing cost. Over the course of several years, processes involved in ordering blood have resulted in fewer transfusions administered.
What is Blood Management?• A subsection of the national patient
safety movement• The appropriate provision and use of all
blood-derived therapeutics and the strategies to avoid unnecessary transfusions1
– Address preoperative anemia and optimize erythropoiesis
– Prevent, minimize or control blood loss– Employ blood conservation methods– Focus on evidence-based use of banked
blood and minimize inappropriate use
1 Adapted from SABM
Facility Denominator Numerator RateEMCH 6 3 50.00%WMC 6 2 33.33%BTMC 135 44 32.59%SRM 44 13 29.55%FMH 75 21 28.00%BCCH 23 6 26.09%BDMC 242 61 25.21%BGMC 225 56 24.89%
BDWMC 717 172 23.99%BIMC 17 4 23.53%MMC 265 59 22.26%BBMC 769 162 21.07%
BGSMC 247 42 17.00%BBWMC 798 134 16.79%
BEMC 96 16 16.67%NCMC 268 39 14.55%OCH 3 0 0.00%
• Premier average • (7/1/2011 – 6/30/2012): 21.3%
• Banner average • 7/1/2011 – 7/1/2012): 20.4%
• Process for Target Setting: • Improvement • 2009: 26.1%• 2010: 23.4%• 2011: 21.5%• 2012 YTD (thru Aug): 21.2%• 2013 Target: 20.2%• Stretch target: 19.8%
Elective Joint Replacement: Historical Blood Transfusion Performance
2011-2012
Design and Implementation
Governance: Ortho CCG
ED
Pulmonary
Palliative Care
NICU/Newborn
Neurosciences
Critical Care
Behavioral Health
Anesthesia
Pediatrics
Women’s Health
Post Acute Care
Medical Imaging
Primary Care
Hospital Medicine
Cardiology
Surgery
Pharmacy & Therapeutics
Infectious Disease
CV Surgery
Oncology
Ortho
Clinical Leadership
Team
Program management
CCGs and Clinical Practice
Development
InformaticsClinical & Medical
Professionals assist with
design & build
Quality
CPAClinical
Performance Analytics
Clinical Education
Process EngineeringClinicians and
Engineers assist with Design
Purpose: Define expected clinical practices for Banner Health based on best available evidence, including practice-based evidence.
Urgent Care
Blood Management for Elective Joint ReplacementStrategies for Success
Expected Practice RationaleAutologous donation: Discontinuation • Worsens anemia pre-op
• Increases the risk for transfusion of multiple units (homologous)
• Risk of infection/reaction from transfusion of units near-expiration date
“Restrictive” transfusion strategy • Literature supports better outcomes than for “liberal” transfusion strategy
• Transfusion threshold < 7 gms Hgb**(for hemodynamically stable patients)
• Reduced immunosuppressive effects of Transfusion
Anemia Screening & RX* increase Hgb pre-op
*Epo + Fe for appropriate patients
Elective, scheduled surgeryDramatic reduction in transfusionsBetter outcomes
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Barriers to Success Implementation Plan to OvercomeSurgeon habit/practice routinere-transfusion threshold
EducationPeer comparisonConcurrent monitoring
Lack of surgeon accountability Quality indicatorsOPPEPeer Review
Autologous transfusion users Education re obsolete practiceDiscontinue autologous BB programs
PRBCs ordered by non-surgeons (e.g. hospitalists)
Clinical practice PRBCs only by surgeons
Addressing Anticipated Barriers
Process Design
Concurrent Monitoring AlertRule Logic• Trigger = Nursing to administer blood product• age >17• hgb >=7 within the last 24 hours; OR No hgb within the last 24 hoursOptional Logic Items• SBP >= 90• Heart Rate <= 100• Hgb ordered but no results Alert Options• Cancel incoming order; OR• Override Reasons• Acute unmeasureable bleeding, ie GIbleed; • Acute >15% blood volume loss; • Hypovolemia with CVP, 4 cm H2O; diaphoretic; EBL > 1000 ml; • HD patient (hgb <9); • Oncology Patient (hgb <9); • CAD (new MI hgb<10 or pre-op hgb<9); • 3rd trimester (hgb < 10)
Transfusion alert: if hemoglobin is on file and it is greater than 7.0 at the time the transfusion is requested and the patient is hemodynamically stable
Triggering the Alert: Hgb >7
Millennium transfusion alert if no hemoglobin is on file at the time the transfusion is requested
Triggering the Alert: No Hgb on File
Concurrent Monitoring Report
Value derived
Percent Blood TransfusionsElective Joint Replacements
15.2%
0.2%0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Q12013
Q22013
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Q42013
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Q22014
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Q12015
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Q22016
Q32016
Q42016
$3M annual cost savings
0
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Q12013
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Coun
t
Alert Events Patient Encounters
New Facilities
Alert Created
Transfusion Alert Trend
• Stakeholder engagement• Discontinuation of autologous donation• Restrictive transfusions <7gm Hgb• Patient’s underlying conditions and risk for pre-surgery anemia• Order sets geared to safely reduce PRBCs• Patient education in setting family / patient expectations
Blood Utilization Keys to success
Thank You