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%

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Q32016

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$3M annual cost savings

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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