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Leading the Nation in Quality

It's one thing to say you're the best. It's another to prove it.

Empowered to Excel Quality Report 2013

Some awards are based on reputation. Others are based on clinical outcomes readily available from public data sources, including the Centers for Medicare & Medicaid services through Hospital Compare, a consumer-oriented website that provides information on how well hospitals deliver recommended care to their patients. We believe that recognition that rests on measures of an organization's overall performance - patient outcomes and satisfaction, operational efficiency, physician performance, patient safety and financial stability - is the true validation of quality.

Leaders at Memorial Hermann have created a culture of safety that begins at the executive level and extends throughout the organization. In 2006, we implemented a high-reliability organization (HRO) program called "Breakthroughs in Patient Safety," bringing in engineers and other experts from nuclear power, commercial aviation, naval aviation and other HROs to train our employees to perform tasks in a safe, highly reliable manner.

The result is safer, more coordinated care that leads to better clinical outcomes and reduces costs for employers, consumers and society. Our clinically integrated physician network delivers the best value for our patients, who also benefit from our longstanding affiliation with the McGovern Medical School at UTHealth, whose world-class specialists bring leading-edge research from the lab to the bedside.

Empowered to Excel - A Relentless Focus on Quality an Patient Safety

When we embarked on our HRO journey, our goals were 100 percent compliance with evidence-based quality measures and a 0 percent incidence of patient harm - a major opportunity for a system the size of Memorial Hermann. We operate nine acute care hospitals, two rehabilitation hospitals, 19 ambulatory surgical centers and more than 100 other ambulatory facilities, and count 21,500 employees and 5,000 affiliated physicians who provide 732,000 days of inpatient care for 135,000 patients annually. Find a location ››

From the Boardroom to the Bedside

A disciplined approach and an aligned organizational structure have ensured the success of our performance improvement efforts. Our outcomes focus is determined annually by the Memorial Hermann Health System board and senior leadership, and defined in our system strategies, each of which is tied to our vision and mission and backed by specific goals and measures. Outcomes are tied to goals, and performance improvement is developed and executed as close to the bedside as possible.

Transparent Reporting and Continuous Self-Assessment

Results are reported up through Monthly Operating Review (MOR) meetings, giving leadership the opportunity to aid in process streamlining and execution. Our system chief medical officer, system chief operating officer and other senior system executives and facility leaders form action plans for every variance across our entire health system. Each of our facilities organizes performance measures into a dashboard showing results against target goals, and action plans are developed for performance that does not meet goals. Our board reviews quality and patient safety results quarterly through the System Quality Committee, giving top leadership ownership for quality, patient safety and clinical care alongside those who work at the bedside.

Our Quality and Safety Strategy Statement

"To lead healthcare to superior patient outcomes through creation of a high-reliability culture with evidence-based quality and patient safety as our core value." Our strategic plan comprises three domains with specific measures:

  • Clinical Excellence
  • Do No Harm
  • Saving Lives

Physician Support and Leadership

MHMD, the Memorial Hermann Physician Network, is leading the transformation of medical practice in collaboration with patients, payers and caregivers through the use of evidence-based medicine. The 3,600-member physician group has established a culture of physician accountability, and creates and deploys new models of healthcare that are improving the quality, safety and cost efficiency of the care we provide. MHMD's Clinical Programs Committee is the primary source of evidence-based practices, inpatient and outpatient quality metrics, pharmacy and supply vendor decisions for Memorial Hermann. The development of task-oriented Joint Operating Councils has led to a number of major patient safety and quality initiatives, including efforts to reduce or eliminate serious safety events, pulmonary emboli and venous thromboses (life-threatening blood clots), hospital-acquired infections and occurrences of iatrogenic pneumothorax (collapsed lung).

 Communication and Reporting Structure Quality Report 2013

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