The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year--and aim to do even better

An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle

Background: The skin, surface, keep moving, incontinence/moisture, and nutrition/hydration (SSKIN) bundle is a resource to aid in care planning when at risk of pressure injuries. The bundle uses best practices to minimize variations in care. Objectives: The objectives of this quality improvement (QI) pilot project were as follows: (a) increase nurses' knowledge of pressure injury prevention, (b) increase nurses' knowledge of the use of the SSKIN bundle, and (c) to pilot the use of an SSKIN bundle in the clinical setting designed to standardize nursing interventions and documentation. Methods: Nurses completed a module on pressure injury prevention that included a pre- and posttest to determine knowledge. Education on the use of the SSKIN bundle was provided, followed by a posttest to establish understanding and knowledge gained. The bundle was utilized in the acute inpatient rehabilitation unit for 4 weeks, and compliance was assessed using the "all-or-none" approach (100% compliance). At the conclusion of the pilot project, staff nurses completed a post-survey created by the QI leader (Likert scale format). The survey included topics on the ease of learning to use the bundle, improved knowledge, perceived reduction in variation of care, perceived facilitation of discussion on skin, opinions on whether the bundle should be instituted hospital-wide, and incorporation of the bundle into the electronic health record (EHR). Results: There was an increase in pressure injury prevention knowledge from an average score of 88.89% on the pretest to 98.15% on the posttest. The mean score on the SSKIN bundle posttest was 93.75%. The bundle ran for 4 weeks and was initiated for ten patients during 74 shifts. Compliance with all components of the bundle was 77%. Conclusion: A pressure injury prevention initiative, such as the SSKIN bundle, can be a useful tool to help standardize nursing interventions and documentation. Implications for Nursing: Results revealed Nutrition as the component with the highest degree of noncompliance. Practice recommendations include documenting every patients nutrition information, regardless of Braden score.

Hospital costs and factors associated with days alive and at home after surgery (DAH30 )

OBJECTIVE

To assess the relationships of patient and surgical factors and hospital costs with the number of days alive and at home during the 30 days following surgery (DAH₃₀ ).

DESIGN

Retrospective cohort study; analysis of Medibank Private health insurance hospital claims data, Australia, 1 January 2016 - 31 December 2017.

SETTING, PARTICIPANTS

Admissions of adults (18 years or older) to hospitals for elective or emergency inpatient surgery with anaesthesia covered by private health insurance, Australia, 1 January 2016 - 31 December 2017.

MAIN OUTCOME MEASURES

Associations between DAH₃₀ and total hospital costs, and between DAH₃₀ and surgery risk factors.

RESULTS

Complete data were available for 126 788 of 181 281 eligible patients (69.9%); their median age was 62 years (IQR, 47-73 years), 72 872 were women (57%), and 115 117 had undergone elective surgery (91%). The median DAH₃₀ was 27.1 days (IQR, 24.2-28.8 days), the median hospital cost per patient was $10 358 (IQR, $6624-20 174). The association between DAH₃₀ and total hospital costs was moderate (Spearman ρ = -0.60; P < 0.001). Median DAH₃₀ declined with age, comorbidity score, ASA physical status score, and surgical severity and duration, and was also lower for women.

CONCLUSIONS

DAH₃₀ is a validated, patient-centred outcome measure of post-surgical outcomes; higher values reflect shorter hospital stays and fewer serious complications, re-admissions, and deaths. DAH₃₀ can be used to benchmark quality of surgical care and to monitor quality improvement programs for reducing the costs of surgical and other peri-operative care.

Is It Rational to Pursue Zero Suicides Among Patients in Health Care?

Suicide prevention is a major health care responsibility in need of new perspectives. This study reviews Zero Suicide, an emerging approach to suicide prevention that embraces the aspirational goal of zero suicides among patients treated in health care systems or organizations. Zero Suicide is gaining international momentum while at the same time evoking objections and concerns. Fundamental to Zero Suicide is a multilevel system view on suicide prevention, with three core elements: a direct approach to suicidal behaviors; continual improvement of the quality and safety of care processes; and an organizational commitment to the aspirational goal of zero suicides. The rationale and evidence for these components are clarified and discussed against the backdrop of concerns and objections that focus on possible undesired consequences of the pursuit of zero suicide, in particular for clinicians and for those who are bereaved by suicide. It is concluded that it is rational to pursue zero suicides as an aspirational goal, provided the journey toward zero suicides is undertaken in a systemic and sustained manner, in a way that professionals feel supported, empowered, and protected against blame and inappropriate guilt.

Multifocal Clinical Performance Improvement Across 21 Hospitals

Improving quality and safety across an entire healthcare system in multiple clinical areas within a short time frame is challenging. We describe our experience with improving inpatient quality and safety at Kaiser Permanente Northern California. The foundations of performance improvement are a “four-wheel drive” approach and a comprehensive driver diagram linking improvement goals to focal areas. By the end of 2011, substantial improvements occurred in hospital-acquired infections (central-line–associated bloodstream infections and Clostridium difficile infections); falls; hospital-acquired pressure ulcers; high-alert medication and surgical safety; sepsis care; critical care; and The Joint Commission core measures.

Creating Highly Reliable Accountable Care Organizations

Accountable Care Organizations’ (ACOs) pursuit of the triple aim of higher quality, lower cost, and improved population health has met with mixed results. To improve the design and implementation of ACOs we look to organizations that manage similarly complex, dynamic, and tightly coupled conditions while sustaining exceptional performance known as high-reliability organizations. We describe the key processes through which organizations achieve reliability, the leadership and organizational practices that enable it, and the role that professionals can play when charged with enacting it. Specifically, we present concrete practices and processes from health care organizations pursuing high-reliability and from early ACOs to illustrate how the triple aim may be met by cultivating mindful organizing, practicing reliability-enhancing leadership, and identifying and supporting reliability professionals. We conclude by proposing a set of research questions to advance the study of ACOs and high-reliability research.

Introducing the No Preventable Harms campaign: creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention

BACKGROUND

Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention.

METHODS

We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative.

RESULTS

Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives.

CONCLUSIONS

A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.

A simple framework for complex system improvement

The need to rapidly improve health care value is unquestioned, but the means to accomplish this task is unknown. Improving performance at the level of the health care organization frequently involves multiple interventions, which must be coordinated and sequenced to fit the specific context. Those responsible for achieving large-scale improvements are challenged by the lack of a framework to describe and organize improvement strategies. Drawing from the fields of health services, industrial engineering, and organizational behavior, a simple framework was developed and has been used to guide and evaluate improvement initiatives at an academic health center. The authors anticipate that this framework will be helpful for health system leaders responsible for improving health care quality.

A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality

OBJECTIVE

To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm.

STUDY DESIGN

A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured.

RESULTS

Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P < .001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P < .01). Observed hospital mortality decreased from 1.0% to 0.75% (P < .001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly.

CONCLUSION

Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well.

First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals

BACKGROUND

Hospitals can better focus their efforts to prevent health care-associated infections (HAIs) if they identify specific areas for improvement.

METHODS

We administered a 96-question survey to infection preventionists at 71 Ascension Health hospitals to evaluate opportunities for the prevention of catheter-associated urinary tract infection, central line-associated bloodstream infection, ventilator-associated pneumonia, and surgical site infection.

RESULTS

Seventy-one (100%) infection preventionists completed the survey. The majority of hospitals had established policies for urinary catheter placement and maintenance (55/70, 78.6%), central venous catheter maintenance (68/71, 95.8%), and care for the mechanically ventilated patient (62/66, 93.9%). However, there was variation in health care worker practice and evaluation of competencies and outcomes. When addressing device need, 55 of 71 (77.5%) hospitals used a nurse-driven evaluation of urinary catheter need, 26 of 71 (36.6%) had a team evaluation for central venous catheters on transfer out of intensive care, and 53 of 57 (93%) assessed daily ventilator support for continued need. Only 19 of 71 (26.8%) hospitals had annual nursing competencies for urinary catheter placement and maintenance, 29 of 71 (40.8%) for nursing venous catheter maintenance, and 38 of 66 (57.6%) for appropriate health care worker surgical scrubbing.

CONCLUSION

We suggest evaluating infection prevention policies and practices as a first step to improvement efforts. The next steps include implementing spread of evidence-based practices, with focus on competencies and feedback on performance.

Millennial health care: change you can believe in

A millennium is 1,000 years. In little over a decade after the beginning of the new millennium in 2000, remarkable changes have occurred in health-care education and health-care delivery. A new millennial generation of students, trainees, junior faculty, and young practicing physicians has come of age. The numbers of women in medicine have vastly increased. Technology has impacted education with an array of educational content-delivery techniques vastly different from the usual broadcast method of teaching. New curricula have expanded to encompass teamwork with interprofessional education of the entire team. Outcomes of educational efforts now include not only knowledge transfer but also performance improvement. Delivery of health care is also dramatically different. The sentinel driver of the quality and patient safety moment, To Err Is Human, was published only 12 years ago, yet fundamental changes in expectations and measurement for health-care quality and safety have occurred to alter the health-care landscape. Financing health care has become a prime issue in the current state of the US economy. New themes in health-care delivery include teamwork and highly functioning teams to improve patient safety, the dramatic increase in palliative care and end-of-life care, and the expanded role of nursing in health-care delivery. Each issue emanating since the beginning of the millennium does not have a right vs wrong implication. This discussion is an apolitical "environmental scan" with the purpose of illuminating these dramatic changes and then outlining the implications for health-care education and health-care delivery in the coming years.

More quality measures versus measuring what matters: a call for balance and parsimony

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to cover a plethora of quality-performance metrics that may have a limited impact on the things that patients and payers want and need (ie, better outcomes, better care, and lower per capita costs). Here we propose a policy that quality measurement should be: balanced to meet the need of end users to judge quality and cost performance and the need of providers to continuously improve the quality, outcomes and costs of their services; and parsimonious to measure quality, outcomes and costs with appropriate metrics that are selected based on end-user needs.

Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program

RATIONALE, AIMS AND OBJECTIVES

Healthcare professionals need a new skill set to ensure the success of quality improvement in healthcare. The Department of Veterans Affairs (VA) initiated the VA National Quality Scholars fellowship in 1998; its mission is to improve the quality of care, ensure safety, accelerate healthcare re-design, and advance the improvement science by educating the next generation of leaders in quality and safety. We describe the critical need for leadership in quality and safety and interprofessional education, illustrate the curriculum, provide lessons learned by fellows, summarize key lessons learned from the implementation of an interprofessional education approach, and present most recent accomplishments.

METHODS

Narrative review.

RESULTS

As of 2011, 106 program alumni are embedded in the health care delivery system across the United States. Since 2009, when nurse fellows joined the program, of the first nine graduating interdisciplinary fellows, the tailored curriculum has resulted in five advanced academic degrees, 42 projects, 29 teaching activities, 44 presentations, 36 publications, six grants funded or submitted, and two awards.

CONCLUSIONS

The VA National Quality Scholars program continues to nurture and develop leaders for the new millennium focusing on interprofessional education. The nations' health care systems need strong interdisciplinary leaders in advanced quality improvement science who are dedicated to improving the overall quality of health and health care.