By Christopher Cheney
Nearly two decades after the Institute of Medicine published its groundbreaking healthcare safety report “To Err Is Human,” medical errors remain a leading cause of death in this country.
To rise to this challenge, hospitals from coast to coast are engaged in efforts to boost quality and safety such as initiatives aimed at hospital-acquired infections.
“When we got a ‘D’ from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn’t the fanatic level that we have now,” says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia.
Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.
- In November 2018, six of Piedmont’s 11 hospitals received “A” grades in The Leapfrog Group’s Fall 2018 Hospital Safety Grade ratings
- From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%
- One Piedmont hospital has not reported a hospital-acquired infection for more than a year
Hamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.
1. Reallocate staff’s time and focus
One of the first quality and safety initiatives that Piedmont started was reforming quality and safety staff allocation. Hamby says about 80% of the staff’s time was dedicated to surveillance such as chart reviews, rather than improvement projects.
He says the department, which has a staff of about 75, had to change.
“When I started looking at our hospitals and who was charged with quality and safety, they were not working on infections and other elements of the Leapfrog grades. When Leapfrog says hospital-acquired infections are important and people are working on something else, that told me we were working on the wrong things.”
The department’s functions were split into three branches: surveillance, analysis, and improvement. The improvement branch was divided into design and implementation segments.
“We took most of the folks doing the work—most of whom were clinicians reviewing charts—and put people on the design and implementation sides.
Our original resource allocation was about 80% looking for problems and maybe 20% trying to fix problems. We [have now] put it at 50-50,” Hamby says.
2. Commit to a scientific approach
Piedmont’s approach to clinical care is rooted in best scientific practices, Hamby says. “What we have done is to be fanatical about making sure every patient gets every component of the things we know scientifically they should be getting.”
Central lines and other implantable devices are infection risks and hospitals can lower risk through a science-based approach to care, he says.
Hamby says the clinical team only inserts devices when needed and then removes them as soon as it is safe to do so. “You follow all of the procedures that science calls for while the devices are in to prevent an infection, and we measure performance on a patient-by-patient and hour-by-hour basis.”
To prompt clinicians and nurses about care steps, reminders have been built into Piedmont’s EMR, Hamby says. “We are giving frontline caregivers real-time tools that help them remember the things they are supposed to do for the patient.”
3. Standardize care into ‘promise packages’
Piedmont has adopted an expanded approach to clinical care order sets that the health system calls promise packages. Catheter-associated urinary tract infection (CAUTI) is a prime example, Hamby says.
“The promise package is literally everything that you would do. For CAUTI, it’s a policy, it’s a training program, it’s a documentation element in the EMR, and it’s all the dashboards and reporting. You take all that up and call it a promise package,” he says.
When new expanded order sets are rolled out, many members of the quality and safety staff are enlisted to assist in implementation, Hamby says. “We provide elbow-to-elbow support anywhere from seven to 14 days, depending on the complexity of the promise package. We get in the field and sort through the bugs in software or questions the nurses have.”
After a 60-day trial period, effective promise packages become order sets for the entire health system and responsibility for order set compliance is shifted to hospital CEOs.
Compliance to promise packages and other order sets is crucial to quality and safety, Hamby says. “In the old days, we would be happy with 80% compliance,” he says, but Piedmont found it needed to be within the 95%–99% compliance range, especially because of medical departments such as the ICU with significant utilization of implanted devices.
Regular reporting of compliance rates can avert safety events, he says. “It gives you the ability to identify problems in the process measure before it becomes an outcome problem. If I’ve got 10 doctors doing colon surgery and I know who is not compliant to the order set, I can intervene before it leads to an infection.”
4. Reach for zero harm
Piedmont embraced a zero-harm strategy as part of the fallout from the “D” Leapfrog grade in 2014, Hamby says.
“We look at our harm count every month. Our harm count is comprised of four components: hospital-acquired infections, serious safety events, hospital-acquired conditions, and patient safety indicators as described by AHRQ. Every month, we know how many harms we have, and we have programs to address them,” he says.
Benchmarking has no value in the pursuit of zero harm, Hamby says.
“I don’t care if we are the best in the country. If we’re not at zero, we’re not done. I think benchmarking is an excuse for when you can stop working on something. We’re going to keep on working until we get to zero harm,” he says.
Piedmont’s goal is to attain zero harm by 2024, and Hamby says the 10-year time frame is realistic.
“Ten years is a long time, but this is a pretty complicated business. Sick patients, by their very nature, require lots of complicated treatment. Since the IOM report in 1999, as a nation, we have not gotten all that much better.”
If health systems and hospitals can create high-reliability organizations, there should be significant economic and operational gains, he says.
“Let’s just say we woke up tomorrow and no more harm ever happened. One of the things we would realize almost immediately is an increased capacity of the healthcare system to accommodate more people. We would reduce wait times for service,” Hamby says.