2010 may be known as the year of renewed patient safety efforts, at least if Peter Pronovost, MD, PhD, FCCM, professor at the John Hopkins University School of Medicine, has anything to say about it. He is part of the Quality and Safety Research Group at Johns Hopkins, a small, multi-disciplinary team of individuals committed to improving quality and safety in healthcare by applying science that enhances knowledge and ultimately improves patient outcomes. The group says it is applying health services research to develop tools, educate stakeholders, engage providers, execute interventions, share knowledge and perform rigorous measurement in the patient safety movement, and emphasizes the importance of balancing scientific measurement with real-world practicality.
Pronovost underscored that latter tenet in his keynote address of the Changing Legal and Regulatory Landscape conference held in November and sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC). In his presentation, "Partnering to Improve Patient Safety," Pronovost made a passionate stand for patient safety and quality outcomes in a world where incidents related to patient safety and medical errors cost the U.S. healthcare system anywhere from $17 billion to $29 billion annually, according to the Center for Innovation in Quality Patient Care. And according to the Institute of Medicine of the National Academies, safety and error incidents in hospitals aren’t the result of recklessness; rather, flawed systems, processes and conditions that lead to mistakes or fail to prevent them are the causes.
In his presentation Pronovost described results from a ground-breaking program in Michigan in which he was involved, the Comprehensive Unit-based Safety Program (CUSP), a statewide improvement effort designed to improve patient safety, improve healthcare institutions’ safety culture, as well as reduce mortality, bloodstream infections, aspiration pneumonia and length of stay in intensive care units (ICUs). To accomplish this, a partnership was developed with the Michigan Hospital Association (MHA)’s Keystone Center for Patient Safety to implement a safety program and other interventions in a cohort of hospitals. Specific goals were to implement and evaluate the impact of the CUSP initiative that includes the ICU safety reporting system (ICUSRS) in a cohort of hospitals; to implement and evaluate the effect of an intervention to improve communication and staffing in ICUs, as well as to implement and measure the effectiveness of an intervention to reduce or eliminate catheter-related bloodstream infections (CLABSI) in ICUs, an intervention to improve the care of ventilated patients in ICUs, and an intervention to reduce ICU mortality.
Pronovost says one of the critical components of the program was to learn from one defect a month, or, in other words, address one adverse outcome that would allow stakeholders to dissect what went wrong and how the effort could be prevented in the future. “Asking clinicians to define the defects (adverse patient events) causes them to own the problem locally,” Pronovost says. But to do this, which also involves putting evidence-based practices into play, Pronovost says that all ambiguity must be eliminated. “Ambiguity is the reason why clinicians don’t comply with the evidence,” he says. “People want to do the right thing, but the barriers to compliance must be removed.”
Sometimes, those barriers can be cultural and/or political obstacles in terms of ownership of a task or objective – or getting others to comply. Hospital culture varies dramatically from unit or department, so interventions should be targeted locally to increase ownership by clinicians, Pronovost advises. “The clinicians who observe a breach in practice and report the behavior, such as a nurse who corrects a doctor for not washing his hands, need to feel as though they are supported in that corrective endeavor in order to effect change.”
“Learning from mistakes requires understanding the factors of what happened, why it happened, what can be done to reduce risk, and how to know the risk was reduced, including creating policies and procedures, ensuring that staff know the policy, and evaluating if the policy is used correctly,” Pronovost says.
Once clinicians become more comfortable with identifying and removing barriers, Pronovost says it is critical to take each interventional measure and ask several key questions: How often do we cause harm? Are patient outcomes improving? Has a culture of safety been created? How do we know we have learned from mistakes? Pronovost explains that the CUSP approach calls for five steps: Educate staff on the science of safety, identify defects, assign an executive to adopt the unit, learn from one defect each quarter and implement teamwork tools. And to educate healthcare providers about step 1, the science of safety, Pronovost suggests clinicians take the TRIP approach, which stands for translating evidence into practice, which has its own four steps: Summarize the evidence in a checklist, identify local barriers to implementation, measure performance and ensure all patients get the evidence. In context of CLABSI prevention, the evidence to prevent these infections include removing unnecessary lines, washing hands prior to the procedure, using maximal barrier precautions, cleaning skin with chlorhexidine and avoiding femoral lines. Pronovost says it is imperative that healthcare providers fully understand the system in which they are operating and why standardized work and checklists are key to improving patient outcomes, getting rid of the jargon that can complicate communication, as well as the importance of teamwork and being aware of the evidence showing that teams make smart decisions with diverse input.
“The lessons learned by the Michigan project is that there must be a partnership between infection preventionists and the ICU team; there must be a linking of the evidence, a robust measurement and culture change; the problem must be owned by clinicians; there must be a mental model that these infections are preventable; and that your role is to educate, monitor and investigate.” Pronovost says.
Speaking specifically to infection preventionists, Pronovost says they must give up ownership of the problem of adverse outcomes and infections but rather allow clinicians to partner with them and serve as their technical advisors – and the key to making all of this work is a culture change.
“For infection preventionists, it should be liberating for them to know they don’t necessarily need to own the problem, which can make them feel isolated,” Pronovost says. “For example, when it comes to CLABSI prevention, infection preventionists can partner with the clinicians who actually put these catheters in so that those clinicians ultimately feel as responsible as possible for the patient outcome. Infection preventionists can impart their expertise and their knowledge of the science of how to prevent these infections, how to measure them and make sure these teams are getting reports back about what their infection rates are and working with them to solve the problem. This is preferable to the infection preventionist being seen as the police.”
Pronovost continues, “It’s not to say that infection preventionists should not be actively involved; on the contrary. You could preach all you want but if that clinician putting in that catheter doesn’t also feel it is his or responsibility, or that nurse helping the doctor doesn’t feel empowered to say ‘hey, you didn’t wash your hands,’ there are just not enough infection preventionists watching everything so it has to be a distributed authority. One really effective way to do this is for infection preventionists to visit their ICU and ask clinicians where they see patients being harmed or what’s their risk, and inevitably they will say infection. Now, what you have is the infection preventionist coming in with tools and being the expert to help clinicians address problems instead of it being only the infection preventionist’s problem. I think that subtle distinction is really important. Being the police person only gets you so far; you have to have buy-in from everyone that this is important and that they are responsible for good patient outcomes.”
Pronovost says that the days of “nagging” healthcare workers to comply with sound practices for improved patient safety should be over. “The culture and the mental model that underlies it simply assumes that people are just volitionally not complying – meaning that they know they are right and that they choose not to comply – and that is typically not what is happening. Most clinicians want to do what’s right, but there may be barriers in the way that must be removed. So I think that nagging people over compliance is an exceedingly anemic and ineffective approach. Rather, what seems to be effective is the infection preventionist saying to the clinician, ‘I want to understand your world. So if you aren’t doing something, I know you want to give your patients the safest care and there must be barriers keeping you from doing that.’ And these barriers can be dropped into three buckets – barriers related to the clinician not knowing what to do or being unaware of the evidence; and barriers related to a guideline or a checklist that is too vague – such as, ‘You tell me to do oral care but I don’t know what it is,’ or ‘You tell me to wash my hands but I don’t know if it’s before every patient encounter.’ Then there are system barriers where the physicians want to wear full barrier precautions but the equipment is just not available, so it’s too hard for them to comply. Teasing out these kinds of barriers is very effective and vastly illuminating. Now, you may get to the point where you have eliminated all of those barriers and people still aren’t doing what they should; then you may need to hold people accountable for not complying with evidence-based practices. But for the most part we can get a lot more mileage out of trying to truly understand healthcare workers’ barriers.”
The alarming aspect of compliance is that clinicians are only doing what the evidence shows to do 30 percent of the time, according to Pronovost, who adds, “The key is not to aim for poor performance, as we know these infections are preventable.” But a lack of definitive information addressing how many and which infections are preventable leaves some clinicians uncertain.
“For many diseases and infections, we don’t really know the extent to which they are preventable,” Pronovost says. “We know we are not using the recommended practices probably the majority of the time. But we don’t know if we use them how low infection rates will go. What I have tried to do is move away from arguing about whether they are 90 percent preventable or 100 percent or 40 percent, and create a system where we ensure that every patient gets what the evidence says they should, all the time, and see what our infection rates do. If our rates come down like they did with the Michigan CLABSI project, then we know most of them are preventable. If our rates don’t come down then I think that’s the message to go back to science and say we need a new research agenda, we have to take another look at these strategies because the current knowledge didn’t get us very far.”