‘Our goal is to have zero se­ri­ous safety events. If it’s not zero, it’s not ac­cept­able’

Modern Healthcare - - Q & A -

Charles Stokes, ex­ec­u­tive vice pres­i­dent and chief op­er­at­ing of­fi­cer at Hous­ton-based Me­mo­rial Her­mann Health Sys­tem, re­cently be­gan his term as chair­man of the Amer­i­can Col­lege of Health­care Ex­ec­u­tives.

At the lead­er­ship so­ci­ety, Stokes will fo­cus on pro­vid­ing ed­u­ca­tional tools and best prac­tices that help the na­tion’s health­care or­ga­ni­za­tions im­prove qual­ity and ac­count­abil­ity. He has a good per­sonal track record. Two of Me­mo­rial Her­mann’s hos­pi­tals re­cently won the Mal­colm Baldrige Na­tional Qual­ity Award, pre­sented ev­ery year to or­ga­ni­za­tions that demon­strate ex­cel­lence. Stokes was also named to Mod­ern Health­care’s in­au­gu­ral list of Top 25 COOs in Health­care (p. 14). Mod­ern Health­care South­ern Bureau Chief Dave Barkholz re­cently spoke with Stokes about his mis­sion. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: At Me­mo­rial Her­mann, what have you done on the high-re­li­a­bil­ity front?

Charles Stokes: When things hap­pen, every­body knows about it. We openly dis­cuss when we have bad out­comes. It’s about be­com­ing a learn­ing or­ga­ni­za­tion and how you pre­vent these kinds of things from hap­pen­ing in the fu­ture and how you fix bro­ken pro­cesses within the or­ga­ni­za­tion. We started this jour­ney about 10 years ago at Me­mo­rial Her­mann to be­come a high-re­li­a­bil­ity or­ga­ni­za­tion, and we started by ed­u­cat­ing our board. We had na­tion­ally renowned lead­ers like James Or­likoff meet with all of our med­i­cal staff lead­ers and all of our board mem­bers

“It’s about be­com­ing a learn­ing or­ga­ni­za­tion and how you pre­vent these kind of things from hap­pen­ing in the fu­ture and how you fix bro­ken pro­cesses within the or­ga­ni­za­tion.”

in day­long re­treats. And we be­came very trans­par­ent with our board.

So, ev­ery se­ri­ous safety event that hap­pens in our or­ga­ni­za­tion, we told them ex­actly what hap­pened. We have brought pre­vi­ous pa­tients and fam­ily mem­bers into our board­room to say, “Here is what hap­pened to my fam­ily mem­ber,” and let the fam­ily mem­ber tell the board ex­actly what hap­pened, so the board sees a real per­son.

We have a monthly two- to three-hour risk man­age­ment call with ev­ery se­nior leader at Me­mo­rial Her­mann. We dis­cuss ev­ery se­ri­ous safety event that hap­pened in our or­ga­ni­za­tion the pre­vi­ous month, and we con­duct a root cause analysis. We have divi­sion qual­ity com­mit­tee meet­ings with all of our hos­pi­tal lead­er­ship, and we do that on a monthly ba­sis, talk­ing about all the se­ri­ous safety events.

So, we keep it in front of the or­ga­ni­za­tion all the time, and every­body knows that qual­ity and pa­tient safety are our high­est pri­or­i­ties. It’s a core value. Our goal at Me­mo­rial Her­mann is to have zero se­ri­ous safety events. And a lot of peo­ple think well, you know, you treat mil­lions of peo­ple. You have mil­lions of pa­tient en­coun­ters a year. Is zero a re­al­is­tic goal? Well, if it’s not zero, then it’s not ac­cept­able.

Right now, there are some­where around 250,000 events, and, de­pend­ing on the source, up to 400,000, un­nec­es­sary med­i­cal er­ror deaths per year in the U.S. It’s the third-lead­ing cause of death in our coun­try, which is stag­ger­ing. It is the equiv­a­lent of a 737 air­liner crash­ing ev­ery seven hours in the U.S.

Now if that was hap­pen­ing, no­body would fly. There would be no air­planes fly­ing un­til they fig­ured out what was hap­pen­ing, right? We don’t ex­pect when some­body gets on an air­plane that, “Oh, yeah, maybe one a day will go down.” We don’t ex­pect that. We ex­pect no planes to go down. And when one does go down, we do a root-cause analysis about why that air­plane went down. We have to get to the same level of vig­i­lance within health­care to make that hap­pen.

MH: So if you’re go­ing to make some­thing a core value, do you have to align com­pen­sa­tion to pro­mote qual­ity and safety? Does Me­mo­rial Her­mann have in­cen­tives for that?

Stokes: Our in­cen­tive com­pen­sa­tion plans do in­clude qual­ity and safety. In fact, the high­est per­cent­age of our in­cen­tive comp is on qual­ity and safety, even

above the fi­nan­cial as­pect. Let me make one point about se­nior lead­er­ship that is im­por­tant. For an or­ga­ni­za­tion to be­come a high-re­li­a­bil­ity or­ga­ni­za­tion, there’s the con­cept of a just cul­ture.

In a just cul­ture, you do not place blame on em­ploy­ees and physi­cians and peo­ple who make mis­takes due to bro­ken pro­cesses in the or­ga­ni­za­tion. A just cul­ture is one where peo­ple learn from those mis­takes. They’re not pun­ished for mak­ing the mis­takes. What would be pun­ished is if an em­ployee has reck­less dis­re­gard for ev­i­dence-based prac­tices, like mark­ing a sur­gi­cal site.

When em­ploy­ees don’t speak up and stop the process when those things aren’t done, that’s a dis­re­gard for ev­i­dence-based prac­tice, be­cause when those things are done on a con­sis­tent ba­sis, there are fewer er­rors and less harm to pa­tients.

So you want to have an en­vi­ron­ment where peo­ple feel safe stop­ping the line when some ev­i­dence-based prac­tice is not fol­lowed, and there’s no re­tal­i­a­tion, they’re not go­ing to get fired, no physi­cian is go­ing to act in­ap­pro­pri­ately to­ward that em­ployee, and you have to have that if you’re go­ing to have a high-re­li­a­bil­ity or­ga­ni­za­tion, and it’s up to se­nior lead­er­ship to im­ple­ment that con­cept of a just cul­ture within the or­ga­ni­za­tion.

MH: You just added a new po­si­tion, vice pres­i­dent of or­ga­ni­za­tional ef­fec­tive­ness and ex­cel­lence. How does that tie in?

Stokes: We de­cided that in­stead of hav­ing all the in­di­vid­ual hos­pi­tals get­ting on the (Baldrige award) jour­ney, we needed, as an or­ga­ni­za­tion, to adopt the Baldrige cri­te­ria as a way of running our sys­tem. So this past year, we hired Josh Et­tinger, who, along with his fa­ther, has worked as a con­sul­tant to 40% of the health­care Baldrige re­cip­i­ents in the coun­try. He will over­see the im­ple­men­ta­tion of the Baldrige cri­te­ria for our or­ga­ni­za­tion as a whole. Be­cause if you’re a Baldrige or­ga­ni­za­tion, the cri­te­ria are all about ex­cel­lence.

MH: What was your cap­i­tal bud­get this year, and where are you putting your money?

Stokes: Over the past sev­eral years, we’ve put our cap­i­tal in growth, be­cause we had to turn down al­most 2,000 ad­mis­sions last year be­cause of ca­pac­ity is­sues. So we look at this in five-year in­cre­ments. Our strate­gic cap­i­tal bud­get is a lit­tle over $2 bil­lion. In our Katy (Texas) mar­ket, we added a new tower and a new med­i­cal of­fice build­ing. At our Sugar Land fa­cil­ity, we added a new pa­tient tower and a new med­i­cal of­fice build­ing be­cause both of those were at ca­pac­ity a year or so ago. And at our flag­ship hos­pi­tal, Texas Med­i­cal Cen­ter, we’re in the process of open­ing a new pa­tient tower, which will be fin­ished in 2019.

The growth in Hous­ton has slowed a lit­tle be­cause of the de­cline in the oil and gas in­dus­tries. How­ever, it’s com­ing back, and the com­mu­nity is grow­ing at 20,000 or 30,000 jobs a year.

As an or­ga­ni­za­tion, we’re ex­pect­ing to see some­where around the 6% or 7% growth by the end of this year.

MH: You’re spend­ing the bulk of your cap­i­tal on in­pa­tient, and a lot of or­ga­ni­za­tions are fo­cus­ing on out­pa­tient, but your needs must have dic­tated oth­er­wise.

Stokes: No, and we’re very cog­nizant of that. How­ever, right now we’re still turn­ing down pa­tients in cer­tain fa­cil­i­ties. Strate­gi­cally, we’re try­ing to fig­ure out how do we shift pa­tients from Texas Med­i­cal Cen­ter that could be cared for at our other fa­cil­i­ties, but that’s our aca­demic en­ter­prise, and there is some com­plex­ity there in get­ting the aca­demic pa­tient out to our com­mu­nity hos­pi­tals. We are work­ing with our aca­demic part­ner and are in the process of mov­ing some of those ser­vices to ac­com­mo­date the high­erend ter­tiary or qua­ter­nary pa­tient down at TMC.

But you’re ab­so­lutely right. Our am­bu­la­tory strat­egy has changed. We are also in­vest­ing in con­ve­nient-care cen­ters and have eight of those that are ei­ther up and running or they’re be­ing built now, and they’re ge­o­graph­i­cally spread through­out the com­mu­nity. A con­ve­nient-care cen­ter is a 24-hour free-stand­ing ER that has an imag­ing cen­ter and is an­chored by a pri­ma­rycare prac­tice, and it also has phys­i­cal medicine and re­hab space. In some cases, the fa­cil­i­ties have some kind of flex space for other physi­cians to come in and prac­tice.

And the other area, our post-acute care busi­ness, is also grow­ing, whether it’s skilled-nurs­ing beds or re­hab beds. We have grown a lot in our re­hab, we have fran­chised our TIRR brand now to mul­ti­ple hos­pi­tals in the com­mu­nity, so a lot of the growth in the post-acute side of our busi­ness has been pushed out of a TIRR fa­cil­ity, which is also kind of maxed out in ca­pac­ity down in the Texas Med­i­cal Cen­ter.

MH: Has the Hous­ton mar­ket con­sol­i­dated? Have all the hos­pi­tals sort of aligned now or is there still more of that to come?

Stokes: In our mar­ket you have Methodist, CHI St. Luke’s, Me­mo­rial Her­mann and HCA. We are the dom­i­nant four or­ga­ni­za­tions in this com­mu­nity. Per­son­ally, I don’t see any merg­ers or ac­qui­si­tions be­tween the four of them or consolidation be­tween the four of those or­ga­ni­za­tions in our com­mu­nity. I think there’s dis­cus­sion out there about Catholic Health Ini­tia­tives and Dig­nity at the na­tional level. I don’t re­ally know where those dis­cus­sions are, but in­ter­nally within the com­mu­nity, all four of those or­ga­ni­za­tions ap­pear to be very strong, and I’m not hear­ing any­thing about any consolidation right now.

MH: Fi­nally, talk about your health plan. It was re­cently re­ported that you had bought Molina Health­care pa­tients. What’s go­ing on with that?

Stokes: We have made a de­ci­sion not to par­tic­i­pate in Molina. I’ll just leave it at that.

MH: How big is your health plan?

Stokes: We have roughly 70,000 mem­bers in the health plan.

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