By Richard Bankowitz, MD, MBA; Aricca D. Van Citters, MS; and Eugene C. Nelson, DSc, MPH
Each day, people rely on their local hospitals to heal them. But these hospitals are also where thousands will acquire dangerous and potentially lethal infections, adverse drug events, or other harms.
Hospital-acquired infections (HAIs) are one of the top 10 leading causes of death in the U.S., killing more people than AIDS, breast cancer, plane crashes and auto fatalities combined. Many of these infections are preventable using evidence-based, common sense interventions such as handwashing or alcohol-based hand sanitizers to prevent the spread of bacteria and viruses, prophylactic antibiotics or automated infection prevention surveillance. However, even though the science for preventing many common infections is well known, we have not succeeded in reliably implementing them. We can and must do better.
There are pockets of excellence that provide a helpful blueprint for hospitals to follow in the area of harm prevention. For instance, nearly 300 hospitals participating in the QUEST performance improvement collaborative, sponsored by Premier and with technical assistance provided by the Institute for Healthcare Improvement (IHI), selected harm prevention as an area of intense focus, and have spent the last three years working to develop strategies in key improvement opportunity areas, such as central line bloodstream infections (CL-BSI), ventilator acquired pneumonia (VAP), surgical site infections (SSI) and catheter-associated urinary tract infections (CAUTI), among others. But what are the strategies that really work in preventing harm? And can they be implemented without adding unnecessary expenses?
Making the Right Thing the Standard
Hospitals that have made the biggest gains in harm prevention know that the most effective strategies include executing new processes that “hardwire” best practices into the system. As an example, one hospital reduced CAUTIs with standing orders to remove Foley catheters after two days, unless a physician documents the necessity for keeping it in. Interventions such as reminders or automatic stop orders like those described were studied by the University of Michigan, and were shown to reduce the CAUTI rate (defined as episodes per 1,000 catheter-days) by up to 52 percent.
To prevent adverse drug events, another facility required at least two people to independently verify medications so that they could be sure that only the right dose was dispensed, and to the right patient. According to the Institute for Safe Medication Practices, these types of manual redundancies can detect about 95 percent of errors and prevent harmful events from affecting patients.
What both interventions show is that hardwiring process changes into the system is a very effective way of ensuring that best practices become the default standard, and deviations the rare exceptions.
Implementing Care Bundles
Another effective strategy for preventing harm events is the implementation of best practice care bundles, or a small number of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually. According to research, these simple interventions are not only low cost, but high impact. In fact, one U.K. study found that reliable implementation of care bundles could reduce hospital mortality rates by 14.5 percent.
To give an example, a pressure ulcer prevention strategy for many hospitals involves implementing "skin bundles," including creating a skin and wound management team, using a consistent method for assessing skin conditions and redressing wounds every shift, placing at-risk patients on correct surfaces and using pressure release devices in locations where patients were on hard surfaces for extended periods of time (i.e., operating room tables and gurneys). Often, compliance with all the measures in the bundles can be achieved using simple checklists that are signed and reviewed by the care teams to ensure all appropriate care is delivered in a reliable fashion.
Hand Hygiene Visual Cues and Reminders
Many infections and harms are prevented with simple hand hygiene. But ensuring proper hand hygiene across all hospital staff has been a struggle. To combat improper hand hygiene, most hospitals implemented hand hygiene campaigns that included education, reminders, audits and feedback. For example, staff at one hospital used a code phrase to remind colleagues to sanitize their hands (i.e., “Have you seen Hannah?”), and handwashing reminders were placed in prominent places. Still others installed additional alcohol-based hand rub dispensers to make them omnipresent and easily accessible, and monitored compliance with standards using a "Secret Shopper" approach.
Encouraging Everyone to Speak Up
Specific harm prevention initiatives often existed within an environment where all staff members were encouraged and empowered to “speak up” and advocate for better, safer care. Many hospitals implemented training programs or promoted cultures that encouraged communication and teamwork to empower staff. Still others put in place non-punitive responses to errors so that people did not fear reporting incidents. In doing so, many successful harm prevention cultures include caregivers who proactively identify not just errors, but also potential risks. In this way, successful hospitals have been able to implement process or other changes prior to a potential harm affecting somebody.
Executive leaders of high-reliability systems were often committed to improving safety and made this visible to frontline staff. As examples, executive leaders conducted weekly "Patient Safety Walk Rounds" or "Executive Safety Walkarounds" in which they visited clinical and non-clinical units to identify potential safety issues or concerns from frontline staff. These concerns were discussed in a structured leadership meeting and responsibility for each issue was assigned to an executive leader. In another hospital, members of the board of trustees' Quality and Patient Safety Subcommittee conducted monthly rounds of patients, staff and the facility, including the identification and discussion of safety issues. At another hospital, the CEO and other leaders conducted weekly rounds to assess the safety of the hospital facility (i.e., expired supplies, sharps, organization of materials, etc.).
Measuring Harm Rate Over Time
Finally, hospitals that put into place harm measurement systems to measurably reduce harm have found this to be a cornerstone for a successful hospital-wide effort to improve safety. Some hospitals have used the IHI Global Trigger Tool, some have used a Serious Sentinel Event reporting system and some have used the Premier automated harm measurement system to keep a running rate of harm and to signal whether or not efforts to reduce harm are being successful.
The need to have an operational and effective harm prevention program has become an imperative. It’s a key requirement within health reform, tying high rates of harm to steep payment cuts, and is thus important to every hospital. Having an effective harm prevention program is another matter. Creating a culture of safety requires a multi-faceted approach from the highest level executive down to the most junior members on staff to develop an environment for improvement rather than judgment and to make it as easy as possible to do the right thing every time.
Recognizing the inherent challenges of coping with change and correctly framing the exercise in the context of institutional improvement will allow hospitals to deal with roadblocks that inevitably occur along the path toward improved performance and outcomes. It will also afford the opportunity to accelerate an organization’s overall performance improvement initiatives and results.
Richard Bankowitz, MD, MBA, a board-certified internist and a medical informaticist, is the enterprise-wide chief medical officer of Premier healthcare alliance.
Aricca D. Van Citters, MS, is an independent consultant working on a variety of healthcare improvement projects and has more than 12 years of experience conducting qualitative and quantitative process and outcomes evaluations in a variety of healthcare settings. She is an Institute for Healthcare Improvement (IHI) faculty member.
Eugene C. Nelson, DSc, MPH, is professor of community and family medicine at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine. He is an Institute for Healthcare Improvement (IHI) faculty member.