BY: JOHN F. ANDERSON, MD
Catholic Health Initiatives Is Encouraging Its Smaller Facilities to Join a Patient-Safety Effort
Dr. Anderson is senior vice president and chief medical officer, Catholic Health Initiatives, Denver.
The Institute for Healthcare Improvement (IHI), Cambridge, Mass., is in the midst of enlisting 4,000 U.S. hospitals in a "5 Million Lives Campaign," its second national initiative to improve the quality performance of hospitals in this country. In the IHI's first effort, the successful "100k Lives Campaign," 3,100 hospitals implemented care improvements, thereby avoiding an estimated 122,000 inpatient deaths.
Achievement of the two campaigns' ambitious goals requires the participation of U.S. hospitals of all sizes. However, participation presents a challenge for many small, rural hospitals, where leaders may hesitate to join the campaign because they don't know how to adapt it to their needs, capabilities, and available resources.
"What makes the IHI campaign so valuable to smaller hospitals is that they usually don't have the resources to develop this type of initiative on their own," said Peg Gilbert, quality improvement coordinator for Saint Francis Medical Center, Grand Island, Neb. "With the 100k Lives Campaign and the 5 Million Lives Campaign, IHI has done all of the research and development of interventions proven to increase patient care and safety. Small hospitals can take that information and find the best way to implement it locally."
Gilbert's hospital is part of Catholic Health Initiatives (CHI), based in Denver, the nation's second-largest Catholic health care system. From the outset of the 100k Lives Campaign in December 2005, CHI encouraged the participation of its hospitals, which range from critical access hospitals in isolated rural areas to urban medical centers with more than 1,000 beds. "We saw the campaign as important to and appropriate for all of our hospitals," said Mary Osborne, director of clinical performance improvement for CHI. "However, there certainly are differences in how our smaller, rural hospitals approach and implement the campaign."
The Current Campaign
The 5 Million Lives Campaign asks hospitals across the United States to improve the care they provide in order to protect patients from 5 million possible incidents of medical harm. The campaign began in December 2006 and will run for 24 months.
IHI's original campaign for improvement in hospital care, the 100k Lives Campaign, promoted the adoption of six interventions, including:
- Deployment of rapid response teams*
- Delivery of reliable, evidence-based care for acute myocardial infarction (AMI)
- Prevention of adverse drug events
- Prevention of central line infections
- Prevention of surgical site infections
- Prevention of ventilator-associated pneumonia (VAP)
The 5 Million Lives Campaign promotes six new interventions targeted at harm, which the IHI defines as "unintended physical injury resulting from or contributed to by medical care." The interventions are:
- Prevention of methicillin-resistant staphylococcus aureus infection
- Reduction in harm from high-alert medications
- Reduction in surgical complications
- Prevention of pressure ulcers
- Delivery of reliable, evidence-based care for congestive heart failure
- Getting governance boards "on board" with the campaign
CHI's Involvement
With CHI's encouragement and support, all 72 of its hospitals have implemented one or more of the recommended interventions. "While our hospitals are diverse in location and size, one of our goals is to evolve our system in such a way that patients can expect the same high level of care and safety regardless of which CHI hospital they visit," said Osborne. "Participation in the IHI campaigns helps us accomplish that."
CHI has a strong presence in a number of urban markets, but it also has an extensive rural presence. In 90 percent of the 33 rural markets CHI serves, it is the sole community provider of health care.
With its significant share of small, rural hospitals, CHI must consider how any systemwide or national campaign will affect these hospitals. Typically, CHI takes an inclusive approach, relying on local board and administrative leaders to allocate appropriate resources and otherwise foster the participation of each hospital. This has been the approach taken by CHI with both IHI campaigns. "With the diversity of our system, we understand the staffing and resource issues that face smaller hospitals," said Osborne. "Still, we signed on to the IHI campaigns as a system, with the expectation that all of our hospitals would participate."
CHI's smaller hospitals quickly understood that the campaign interventions could help them fulfill other requirements. "There is growing alignment between the campaign and the aims of other organizations, such as the Centers for Medicare and Medicaid Services and the Joint Commission [on Accreditation of Healthcare Organizations]," said Connie Kirkpatrick, director of clinical effectiveness at another CHI organization, four-hospital Franciscan Health System, Tacoma, Wash. "Where these groups have measures in common, participation in the IHI campaign can help a small hospital to satisfy them all.
"Small hospitals can essentially use the IHI campaign as a quality program," Kirkpatrick continued. "The campaign helps small hospitals maximize their resources because they don't have to invent tools."
The leaders of CHI's small hospitals understand how participation in the IHI campaign would be perceived by patients. "It shows patients that the hospitals are taking an opportunity to improve patient care," said Osborne. "When you're a patient, you don't care as much about the size of the hospital you're in as you do about the quality of care you receive."
Providing Support
Although CHI encourages its hospitals to participate in the IHI campaign, it does not dictate the implementation of specific interventions. That decision is left to each individual hospital. "This is something CHI understands very well," said Osborne. "Hospital leaders know what is best for their hospitals and for the communities they serve. Our role is to support them and their front-line caregivers so they can choose and implement the interventions that will have the greatest positive impact on patient care."
CHI supports its hospitals' campaign participation in several ways. Osborne, a member of CHI's clinical leadership team, coordinates the flow of campaign-related information to and among the participating hospitals. CHI also provides a national staff leader for each campaign intervention, a knowledgeable source whom hospital leaders can contact for guidance, advice, and ideas. The national staff leader is responsible for identifying and posting resources and tools to the intranet, organizing educational sessions for the intervention, and facilitating the sharing of "best practices."
Clinical leaders across CHI participate in weekly conference calls that often focus on issues related to the 5 Million Lives Campaign. "These calls help spread leading practices," said Osborne. "The presenters are often hospital leaders, and we are careful to balance the perspectives of large hospitals with those of mid-size and small hospitals."
By networking with clinical and quality leaders at CHI's hospitals, Osborne is able to identify "early adopters" of the IHI campaign interventions. For example, Saint Francis Medical Center in Grand Island, Neb., was an early adopter of the rapid response team intervention. "We provided a pathway that other small hospitals, both within and outside of CHI, could follow," said Gilbert. "CHI provided multiple opportunities to share our story."
CHI hospitals also share their leading practices by way of an intranet created specifically to provide information and resources for the IHI campaign and through the system's internal newsletter. To enable colleagues to connect for discussion and brainstorming, CHI has also created an e-mail address list of clinical quality contacts at each hospital. The system's "virtual knowledge" communities help those who are working on common problems share insights and advice.
CHI produces educational materials about campaign interventions, including a handout that hospitals can give to patients and their families explaining the presence and use of rapid response teams. The system also provides a forum for the communication of ideas and progress at its annual National Quality Conference. "The conference provides information and guidance to help us keep improving, and we always come away inspired to move forward," said Gilbert.
Encouraging Smaller Hospitals
For the leaders of small hospitals, the key is determining which interventions will make the greatest difference to their patients. At Saint Francis Medical Center, said Gilbert, "we started by wanting to implement every intervention, but we don't have enough resources to establish multiple task forces. To avoid overloading our staff, we had to determine which interventions would have the greatest positive impact on patient care."
When Saint Francis's leaders reviewed the charts of patients who had code blue calls, they found that the implementation of a rapid response team was likely to have a positive effect on patient mortality.
"It's also helpful for small hospitals to determine if their top five diagnosis-related groups align with the campaign initiatives," said Kirkpatrick. "For example, if a hospital doesn't have many patients with AMI, implementing IHI's VAP bundle could make more of a difference in overall patient care."
"Smaller hospitals must consider what is feasible for them and which interventions will have the greatest positive impact," agreed Billie Turner, vice president and chief nursing officer at Our Lady of the Way Hospital, a critical access hospital in Martin, Ky. At Our Lady of the Way, that meant the implementation of a rapid response team.
Rapid Response Teams
During the 100k Lives Campaign, rapid response teams emerged as the intervention that CHI facilities implemented more than any other. The system received a Robert Wood Johnson Foundation grant to support its creation of rapid response teams. "The foundation was interested in how rapid response teams would be implemented in such a diverse system," said Osborne.
Rapid response teams often include a critical care nurse or intensive care nurse, along with a respiratory therapist and perhaps other clinicians. Our Lady of the Way Hospital, a small facility with no specialized critical care or intensive care nurses, structured its team differently. "We always have a house manager on duty, so we made [house managers] the basis of our rapid response team," said Turner. "The house manager always responds, along with the patient's primary nurse on duty and a respiratory therapist. The rapid response team actually formalizes a process our house managers already followed when a patient's condition deteriorated."
Saint Francis Medical Center also found that its rapid response team brought greater organization and definition to existing patient care activities. "The rapid response team helps our patient flow," said Gilbert. "Our nursing supervisors know exactly what is happening with these patients so they can make sure the team comprises the relevant professionals for the patient assessment. A respiratory therapist is always a member of the team, because airway issues are the most common cause of a call. A critical care or emergency department nurse is also part of the team, which improves the transition if the patient transfers to critical care, as well as the communication of detailed information to the physician."
To ensure that physicians are involved, Turner recommends asking them to establish a hospital's criteria for calling a rapid response team. "It's a very good way to get physicians to understand the function and benefits of the team," she said. "Because our hospital is small, our physicians made the criteria recommended by the IHI a bit broader. We knew that we could always revise the criteria if needed, but we've found that they work well."
Multiple Interventions
Rapid response teams are not the only campaign intervention implemented by CHI's smaller hospitals. At Our Lady of the Way, Turner found that other interventions can prove valuable even when patient populations are small. "For example, because we don't have an intensive care unit, we don't have many ventilated patients," she said. "However, we found that we had a high rate of VAP among our ventilated patients. We implemented IHI's VAP bundle and have seen improvement."
St. Joseph's Area Health Services, a critical access hospital in Park Rapids, Minn., actually implemented all six of the original campaign interventions. "We were already working on initiatives for AMI and VAP care," said Babs Debes, vice president of quality. "We were already discussing prevention of central line infections, surgical infections, and adverse drug events. We heard that implementing rapid response teams was challenging in smaller hospitals, but CHI encouraged us. So, we implemented them all."
Support from clinical leaders was essential to St. Joseph's ability to implement the six interventions. "Our philosophy is that clinical leaders should lead clinical initiatives," said Debes. "My role as a quality leader is to support them with data and processes. We had a clinical leader for each intervention, and medical staff committees provided oversight." Currently, St. Joseph's is working with three initiatives from the 5 Million Lives Campaign: reduction in surgical complications, prevention of pressure ulcers, and evidence-based care for congestive heart failure.
Communications and Awareness
Just as CHI's hospital leaders decide which interventions to implement, they choose how to make employees and medical staff members aware of the campaign. "We have found it's important to emphasize that the campaign interventions and tools are based on science and research," said Kirkpatrick.
"Every time we communicate anything about the IHI interventions, we use the term 'evidence-based,'" Gilbert said. "It's important for our staff to know there is solid research behind every intervention."
Gilbert noted that Saint Francis Medical Center educated its board members about the campaign, too. "Each year, we set quality goals as part of an operational report card presented to our board," she said. "When our rapid response team became part of meeting our quality and patient safety goals, we educated our board members and conducted a community awareness campaign as well."
With any audience, CHI's small hospitals find that repetition helps communicate key messages about the campaign. "We repeat messages about the campaign and the interventions in multiple ways, over time," said Kirkpatrick. "I think this is especially important in smaller hospitals, where many staff members wear multiple hats."
CHI's Results
As a result of CHI's participation in the IHI campaign, along with the implementation of other evidence-based practices, the system's mortality rate dropped 6.25 percent during the 2006 fiscal year. This equates to approximately 450 lives saved.
In addition, the IHI has asked several CHI hospitals, including smaller and rural facilities, to serve as mentors to others. The CHI mentor hospitals are:
- Jewish Hospital and St. Mary's HealthCare, Louisville, Ky.
- Mercy Medical Center, Des Moines, Iowa
- Mercy Medical Center, Nampa, Idaho
- Saint Elizabeth Regional Medical Center, Lincoln, Neb.
- Saint Francis Medical Center, Grand Island, Neb.
- St. Clare Hospital, Lakewood, Wash.
- St. Francis Hospital, Federal Way, Wash.
- St. Joseph Medical Center, Tacoma, Wash.
Recently, CHI provided IHI with a number of resources for rapid response team implementation support, which are available on the IHI's Rural Affinity Group web page.* The resources include sample standing orders; evaluation, communication, and documentation tools; sample policies; education and training materials; and a 2x2 mortality matrix (a diagnostic tool designed to help hospitals identify the local conditions that may contribute to hospital mortality) for facilities that don't have intensive care units.
*Access www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=4# Affinity%Groups, then "Affinity Groups."
As the 5 Million Lives Campaign continues, CHI and its hospitals are also addressing the need to sustain staff members' enthusiasm for the campaign. "The materials CHI provides are visible in our hospital, and that helps remind the staff of the resources available through the campaign," said Turner.
"For a smaller hospital, it's especially important to educate new staff members about the campaign and the hospital's involvement," said Gilbert. "We provide our new nurses with in-depth education on our rapid response team activation criteria, because we want them to know we support asking for a second opinion to prevent adverse outcomes."
Kirkpatrick noted that sustaining enthusiasm is one reason it's important for small hospitals to involve staff members beyond those directly responsible for quality. "When you get clinicians involved in the campaign and the interventions, they gain a sense of personal involvement," she said. "It works alongside the desire of health care professionals to make a difference in patient care and the outcomes of the care provided to their neighbors in the community."