Security Policy Development

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Leading Executing Change
William W. Stead, M.D. McKesson Foundation
Professor of Biomedical Informatics
Medicine Associate Vice Chancellor for
Strategy/Transformation CIO Vanderbilt
University Medical Center September 25, 2008
Disclosures McKessons Horizon Expert Orders is
licensed from Vanderbilt. Vanderbilt is a
founder of Informatics Corporation of America. I
am a Director of Healthstream.
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A leader is a person who takes a group of people
to peaks they did not believe possible.
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Goal
Gap
Trajectory
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Vanderbilts Stretch Visions

• Help people make better decisions
• Reduce variability in practice
• Personalize medicine
• 2007 Improve health status

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Testing the Vision

• Does it inspire?
• Does it force people to challenge their beliefs
  about their work?
• Does it result in gt 40 improvement?

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Challenge 1
Imagining what work would be like in an ecology
that does not exist
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Individual Expert
Clinician
Patient Record
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Clinician and Patient are Partners
Personalized Knowledge Base
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Vignette from a System of Care

• The clinician and patient are on the same page,
  the approach is standardized yet individualized
• Complementary and alternative approaches to
  health improvement work in combination with
  scientific medicine
• The patient is a full partner in tracking their
  progress and adapting course
• The patients plan is updated proactively as
  standard of practice evolves

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Challenge 2

• Finding a starting point to
• minimize dependencies
• maximize short term benefit
• test long term direction

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Dependencies
of Uses
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Key Practice
Deliver then Improve
Get it Right

V0 Initial Concept V1 Based on Evidence V?
Latest Iteration
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Challenge 3
Overcoming resistance to change
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of People
Low
Resistance to Change
High
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Phases of Change
Phase Idea Prototype Pilot Implementation Adoption
Purpose Direction Discussions Demonstration Scale-
up Adoption
of People 1 10 100 1,000 10,000
1 2 3 4 5
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Vision without execution is hallucination
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If a unit performs each of 7 practices 90 of the
time, what is the probability that they will
perform all 7 for a patient?

• 90
• 75
• 50
• 25

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Shift from expert-based practice to expert
managed, system supported practice VUMC
ventilator management improvement
IDEA
CASE
Challenge 1 Translating evidence into standard
practice
Challenge 2 Closing the control loop while
keeping people in the loop

Results
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The Healthcare Non-system
Experts Practice by Working around Systems
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Systems Approach to Care

• Individualize Act
• Assess
• Plan
• Order

System-supported Practice

• Pick Population
• Risk
• Cost
• Variability

• Evidence
• Research
• Guidelines
• Practice database

• Monitor Correct
• Process Patient
• Sentinel Events Status
• Process Outcomes Results
• Clinical Outcomes Trends

• Workflow
• Peoples roles
• Process
• Technology Tools

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Ventilator Management - The Evidence

• Guidelines.gov. (2003)
• Systematic Review (Ann Intern Med, 2003)
• Ventilator Bundle (Am J Crit Care, 2007)
• CDC, UHC, IHI, others

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Stress Ulcer Prophylaxis
Guidelines
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Mechanically ventilated patients are at high risk
of developing gastrointestinal bleeding and
should receive stress ulcer prophylaxis unless
medically contraindicated.
UHC
?
Stress ulcerations are the most common cause of
GI bleed in ICU patients, and the presence of GI
bleed is associated with a 5- fold increase in
mortality compared with ICU patients without
bleeding therefore prophylaxis is recommended.
IHI
VUMC Practice Standard
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VUMCs Bundle of Standard Practices

• HOB Elevation
• Oral swabs
• Tooth brushing
• Hypopharyngeal Suctioning
• Goal directed Sedation (Individual Target RASS)
• Rapid Weaning gt daily assessment of readiness to
  extubate _at_ 24 hours
• DVT Prophylaxis
• Stress Ulcer Prophylaxis

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Supporting Practice (Process)
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Supporting Practice (Order Sets)
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Supporting Practice (Real-time Feedback)
Process Control Dashboard
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Closed Loop Control
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Closed Loop Control

• Environment
• Outside Temperature

Room Temperature
Sensor

• Target Temperature
• High
• Low

• House
• Ventilation
• Insulation
• Ducts

Signal to firebox

• Record
• Temperature On
• Last Low
• Temperature Off
• Last High

• Furnace
• Fan
• Firebox

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Adapting Practice for Closed Loop Control
Status

• Plan
• Objectives
• Process Steps
• Measures

• Performance
• Actions
• Results

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Ventilator Management Highest Level Plans
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Ventilator Management Tier 2 Plans
Measures
Process Steps
Objectives

• Ordered value, date time
• Charted value, date time

• Physician order for individual target RASS q12Hr
• Nurse assessment of actual RASS q 4hr

Goal directed sedation

• Screen pass/fail, date time
• Trial pass/fail, date
• time

• Rapid weaning protocol
• If gt 24hr daily screen for trial readiness by RT
• If Pass, spontaneous breathing trial within 6
  hours

Rapid Weaning
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Ventilator Management Tier 3 Plans
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Timeline

• February 2007 Bundle DesignShop
• March 2007 Order set revisions nursing
  education implemented
• May 2007 Dashboard as Screensaver
• June/July 2007 Dashboard Refinements (Resp
  Therapy, Oral Care)
• August 2007 Reports Available
• October 2007 Improvement Opportunity Reports
  Available
• Nov-December 2007 Emphasis on consistent
  execution of complete bundle for each patient
• Jan-March 2008 Nurse Charting Improvements
• March 2008 Renewed Nursing Education
  Education Materials

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2007 to Present
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Tangible Results (last 6 months)

• 71 VAPs prevented
• 1.6 Million Saved
• SHEA Guideline 22,875 per VAP
  (9,986-54,503), IHI 40,000 per VAP
• 680 Hospital Days Saved
• SHEA Guideline 9.8 day additional LOS per VAP
  (7.4-11.5)
• 280 ICU Days Saved
• Assumes 4 days additional ICU LOS per VAP
• 11 Deaths Prevented
• Assumes 15 increased mortality rate over
  Ventilated Patient without VAP

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The science of biomedical informatics holds the
key to an agile information infrastructure
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Techniques to Structure, Discover, Visualize
Reason with Information Content

Data sources created by people
Information useable by people computers

• Text literature
• Bibliographic
• evidence databases
• Patient records
• Environmental
• databases

• Drug x potentiates drug y
• Pt x is on the following drugs

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Approaches to Link People, Process Technology
together as a System
People

• Compassion
• Pattern Recognition
• Judgment

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StarChart
?
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Patient Safety
Cost Management
Service
Benefits
Quality

• Communication Documentation
• StarPanel Quill
• VPIMS
• Horizon Expert Documentation Med Administration

• Quality Management
• Indicator Dashboard
• Process Control Whiteboard
• StarTracker

• Provider Order Entry
• Horizon Expert Orders
• Advanced WizOrder Functions

Clinical Tools
Business Process
Information
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Biomedical informatics is NOT a spectator sport