CS&E News - Winter 2011

Winter 2011

Joseph L. Nates, M.D. holds the Bill Aston Award for Quality from the Texas Hospital Association he received in Austin.  MD Anderson colleagues shown in photo, from left, are Victoria Jordan, Ph.D. director for quality measurement and engineering; Nates; John Bingham, vice president for performance improvement; and Thomas Feeley, M.D., vice president for medical operations

MD Anderson, Nates Win Texas Hospital Award

The inaugural Texas Hospital Association Bill Aston Award for Quality goes to the University of Texas MD Anderson Cancer Center and Joseph L. Nates, M.D., for reducing the incidence of ventilator-associated pneumonia (VAP) in the ICU to zero since September 2009.  

Dr. Nates in his office.

The award recognizes the cancer center for measurable success in improving quality and patient outcomes through sustained implementation of evidenced-based patient care initiatives. The zero level for VAP has been maintained for more than 17 months in the medical ICU.  The surgical ICU has recorded near zero measures with more than 14 months of no recorded VAP and only three patients suffering pneumonia during treatment last summer.

In addition to the hospital award, the project also won second place honors at last November’s University of Texas System Clinical Safety and Effectiveness (CS&E) conference in Austin.  Dr. Nates’ work to reduce VAP led to a CS&E project that began in 2003.  

When he began the project, the rate of ventilator-associated pneumonia was 34.2 cases per 1,000 ventilator days, which was double the national average for ICUs.  The aim of the CS&E project was to reduce it by 25% in six months. Once that goal and a subsequent goal of 50% were met, zero cases became the next target.

“When we started, a lot of people were skeptical that we could reduce that rate,” said Nates, the medical director of the ICU.  Our ventilated cancer patients are very sick, and many are immunosuppressed from chemotherapy.”

Interventions to reduce VAP include education of multidisciplinary teams on infection prevention strategies, implementation of the Centers for Disease Control guidelines and Institute for Improvement ventilator bundle initiative including aggressive ventilator weaning protocol, head elevation and others.  The rate declined steadily from 2002 until it was zero in 2010.  

“The main reason for achieving a rate of zero VAPs is that we have been persistent. We have a cohesive and aggressive multidisciplinary team that consists of physicians, nurses, respiratory therapists and infection control specialists who work together toward this common goal.” Nates said.

VAP is a deadly complication that can lead to death.  For MD Anderson, the drop to zero represents dozens of lives saved during the past eight years.  It also represents tremendous savings in patient care.  The average cost of treating a VAP infection is about $57,000.  The cost avoidance of having zero cases totaled more than $4.7 million since the beginning of the project.

The Texas Hospital award is named in memory of Aston, late board member of Baylor Health Care System. The award was presented Feb. 3 at the THA Annual Conference in Austin. For more information on the VAP project, view the CS&E Award Video.

Instruction in Lean Methods Now Part of CS&E

Participants in Session 14 of the Clinical Safety and Effectiveness course that began in January will now receive instruction in Lean methods to improve operations.

The change in the curriculum for the course is an effort to respond to coming changes in health care.  The cancer center will be required to publicly report quality measures starting in 2012.  Health care reform will also eliminate MD Anderson’s ability to bill Medicare fee for service in treating patients.  The cancer center will receive a bundled payment for treating a patient’s cancer.  In addition, insurance companies are proposing a reduction in payments to a level nearer that of Medicare bundled payments.

MD Anderson President John Mendelsohn, M.D., in his State of the Institution Address, told the cancer center that we must look at how we use services such as imaging, laboratory tests, pharmacy, intensive care, and end of life care.  This includes resource utilization (overuse, under use or misuse of resources) and operational efficiency. Based on this mandate, Executive Vice President and Physician-in-Chief Thomas Burke, M.D., asked that Session 14 projects be aligned with this requirement.

For future sessions of CS&E, the Senior Clinical Operations Team will select projects focused on resource utilization and aligned with strategic priorities.  

The focus on utilization also supports work MD Anderson’s Institute for Cancer Care Excellence has undertaken, with Harvard Business School, to use the value proposition to determine the “value” of our care  (outcomes of care divided by cost of care).    Mendelsohn acknowledged that our researchers are working hard to improve outcomes, but we need to look seriously at our resource utilization and our clinic operations to bring the maximum increase in value.  

On Days 2 and 3, CS&E participants will get training in Lean, a methodology focused on eliminating waste in processes.  Participants through value stream mapping of processes and applying tools such as 7 Wastes and 5S (Sort, Straighten, Shine, Standardize and Sustain) will learn that Lean is not reduction of staff or minimizing the standard of patient care, but rather eliminating the frustrations for patients and staff of poor processes.

In addition to the Lean training, CS&E 14 will also use the DMAIC framework to conduct their project.  This framework (Design, Measure, Analyze, Improve and Control) is used as part of Six Sigma quality improvement as well as Lean training.  It is very congruent with Plan-Do-Study-Act framework of past sessions, but is a little more prescriptive during the analysis phase and which helps the teams get to improvements quicker.

Bell Inducted as UT System CS&E Fellow

MD Anderson's Margaret Bell, M.P.H., R.N., left, was inducted as a University of Texas System Clinical Safety and Effectiveness Fellow at last November's CS&E Conference in Austin.

Bell, clinical administrative director for the cancer center's Cancer Prevention division, joins Shawn L Ralston, M.D., of the UT Health Science Center in San Antonio and W. Gary Reed, M.D.,F.A.C.P., of UT Southwestern Medical Center in Dallas as Fellow inductees for 2010. 

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