As Chief Medical Officer of multi-hospital Memorial Hermann Health System, Dr. Michael Shabot has married the system’s demonstrated operational excellence with an audacious quality and safety agenda. The hospitals now routinely report stellar performance. This story was recorded live during the 2016 IHI National Forum.
Mary Jane Kornacki: I’m here at the IHI Conference, the 28th Annual, in Orlando, Florida. It’s December 4. I’m here with Dr. Michael Shabot, who is a CMO of the Memorial Hermann Health System.
Michael Shabot: Mary Jane, I want to relate a leadership moment that I think was important, and perhaps instructive. When I came to Memorial Hermann in 2007, as the system’s Chief Quality Officer, many quality lapses were apparent to me, and they were apparent to the organization. That’s actually, in retrospect, why they recruited me. There were many lapses, and as I took a look at them in the first few months — January, February, and March — I realized that a wholesale change was needed in the approach so that we built a high-reliability culture.
The opportunity occurred at what Memorial Hermann calls its QCOM meeting, it’s quarterly communication meeting — which was quarterly, but it’s evolved to every half year now. It involves the 600 most senior leaders of a 24,000-strong organization of directors and above. Directors, Vice Presidents, Executive VPs, Senior VPs, CEOs, etc. For this we actually rent out a theater. The presentation that I worked up with the quality department that I led was very different, and it stunned the 600 who were there. In a single slide, I illustrated our new goals. Our new goals were not to reduce harm; they were to eliminate harm. For quality measures, the new goal was 100%, and for harm measures, the new goal was 0%, and that all of our internal incentives would be structured around 100 and 0. And they were.
What was important about that was that it was the beginning of a change and also, that it was supported by our CEO, Dan Wolterman, and by the Board of Directors. It was supported from the very top because the board had already declared that patient safety was going to be the health system’s core value. Of many priorities, it was the core value, and 10 years later, it remains the only core value of the organization. That was the beginning of the road toward high reliability that the organization is still on.
That presentation at QCOM was built around a single slide in the middle of the deck that had new incentive measures at the top. The first reveal was quality measures goal: 100%. The second reveal was harm measures goal: 0%. There was silence in this huge theater, gasps because this was so outlandish and so impossible that they thought that I was perhaps absurd coming from California, a dreamland, and I had transported it to Texas. Well, of course, we didn’t really have it in California either, and it was the beginning point for a high-reliability journey that has resulted in marked reduction of harm and marked improvement of quality all across our organization.
Kornacki: It’s one thing to have a goal. What made you think you could accomplish? Because a goal without a way to get there would raise tension or raise anxiety. Why did you believe you could do this?
Shabot: I believed we could do it because of a reason you may find odd. As I became acquainted with the organization, I found that there was a level of operational excellence beyond anything I had ever experienced in my life. That means how things worked, how the finances were put together, how the organization actually did things on a patient care level in an operational sense was extraordinary. And what I decided to do was to hitch the safety and quality wagon to that operational excellence.
Kornacki: So you knew they could do it.
Shabot: I knew they could do it, but it hadn’t been done for quality. It hadn’t been done. There had been demonstration projects that would improve things for a while and then they would stop the project. Infection rates would go back up. We needed to put in these operational processes that drove these infection rates down to zero, harm rates down to zero, retained foreign bodies down to zero, wrong site, wrong patient surgery. These were processes we put in place. These were not memos or asking people to try harder. We know that doesn’t work. We changed the underlying processes, and that’s what the organization was great at.
Kornacki: When you think back to that day, what’s the single strongest memory you have?
Shabot: The single strongest memory I have is that I was backed 100.0% by our CEO, Dan Wolterman. In every subsequent presentation, whenever he was presenting the state of the system to whether it was the board or to QCOM or an outside audience where we had extraordinary financial and operational and growth success, he always started with safety and quality. Every time. That was most important, and then those other things followed, and Dan said that if we get patient care, safety, and quality right, then growth, financial stability, patient satisfaction, all those things will follow. If we focused on finances or we focused on growth and we didn’t pay attention to our core business — which is taking care of patients — we would not be successful. I think he was right in that.
Kornacki: What was the reaction to that presentation and what people said to you afterward?
Shabot: Afterward, again, directors, VPs, etc. were at that meeting, and they kind of thought that I was nuts or that I was coming in with California dreams or something like that, but what we did was to build on operational excellence by putting in new processes for everything.
We changed the process about how we identified patients for blood transfusion, beginning from drawing the blood for the type and cross, putting in a new red armband with a different number — a blood transfusion number, not the patient’s regular armband number — and that follows the blood all the way through the lab. The units come back and have to match not only the patient’s ID, but that red armband and that number, which is now barcoded, so we have a separate barcode for that. We’ve given 1.2 million transfusions since 2007, and we have not had an acute hemolytic transfusion reaction. We expect never to have one of those again.
We changed the process for identifying sponges in the operating room using some RIFD technology and a different whole process for what happens when the count is off, or may be off agreed upon across the system. In the last 5 years, we have given out 43 awards for hospitals going a year without a retained foreign body anywhere in the hospital, not just the operating room.
We changed the process for taking care of central lines. We changed the process for Foleys, for ventilators. We have whole hospitals going years without a catheter-associated urinary tract infection — something that I thought was impossible, not ever going to happen, giving out these zero awards to hospitals for that. Not just the ICU, the whole hospital.
What’s important about the zero awards is that internally it proved that it was possible. It proved the impossible was possible, and now, it gets proven again and again and again and again. At our Sugar Land Hospital — I was out there a couple months ago — I awarded seven at once for them in different categories. Never done that before. And 2 weeks ago, they were announced as a Malcolm Baldrige National Quality Award winner.
This story was recorded live at the Institute for Healthcare Improvement’s 28th Annual National Forum in Orlando, Florida, on December 4–7, 2016 by Mary Jane Kornacki on behalf of NEJM Catalyst and originally appeared on the NEJM Catalyst website on February 21, 2017. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.