• Section 2: Avoiding Patient Harm

    Nov 01, 2011

    Now that payers are beginning to tie payment to performance, the ROI for preventing patient harm extends beyond the moral and ethical payback. However, as these three providers stress, the primary motivation for improving patient safety is still immensely personal and altruistic.

    Providers have never needed a business rationale for trying to minimize the potential harm-including hospital-acquired infections, treatment side effects, and unnecessary hospital admissions-that can occur to patients. Primum non nocere, afterall, is a core medical ethic. Physicians, nurses, and all clinicians are motivated to "first, do no harm."

    But the individual healthcare professional, no matter how committed to patient safety, can only do so much to reduce hospitalwide infection rates or communitywide emergency department (ED) visits. As the case studies in this section illustrate, systematic approaches are required to achieve dramatic reductions in indicators of patient harm. 

    This is Section 2 in the Fall 2011 Leadership report, Managing Business and Clinical Risks.

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    Some common approaches to reducing patient harm are being used by all three providers featured in this section.

    • Creating an organizationwide culture of safety-while recognizing the need for decentralized approaches
    • Relying on standardized protocols, checklists, and other aides to remember critical patient care steps
    • Empowering physicians, nurses, and other staff to spot and respond as a team to potential patient problems
    • Ensuring that at-risk patients receive proactive care management
    • Spreading successful best practices across units, organizations, and systems

    Payment system changes and increased transparency are beginning to provide business rewards for investing in efforts to improve scores on metrics related to quality and patient safety. On the government front, Medicare's new Inpatient Value-Based Purchasing Program will reward hospitals that provide high-quality care-and penalize those that do not. Private payers are following suit with similar performance-based contracts with providers. At the same time, patients can now go online and compare hospital-acquired infection, mortality, and readmission rates among providers in their communities-giving organizations another business rationale for making value-driven investments in patient safety.

    Case Study

    Empowering Staff to Save Lives

    Half of the ventilator-associated pneumonia (VAP) cases that occur in U.S. intensive care units (ICUs) each year-about 20,000-could be prevented, according to the Partnership for Patients.

    But Sentara Healthcare's VAP track record suggests that many, many more patients could be spared from this serious hospital-acquired infection.

    Since 2002, the VAP rate in the entire 10-hospital Sentara system has fallen by 98 percent, from 124 VAP infections per year to the current rate of just two per year. One of the system's hospitals-Sentara Williamsburg Medical Center-has not had a single VAP incidence in more than seven years. Most other hospitals in the Sentara system, which serves parts of Virginia and North Carolina, are also marking off multiple years with zero VAP incidents.


    Spreading a culture of safety.
    These successes at Sentara Healthcare stem from a patient safety initiative launched at the system's largest facility, Sentara Norfolk General Hospital, in 2002. An assessment identified three common problems that were contributing to safety incidents at Sentara Norfolk, according to a case study by The Commonwealth Fund (Klein, S. and McCarthy, D., Sentara Healthcare: Making Patient Safety an Enduring Organizational Value, March 15, 2011).

    • Inadequate communication
    • Noncompliance with policies
    • Failure to recognize high-risk patient situations

    This assessment informed the development of a Sentara-wide approach to patient safety, which includes four elements:

    • Safety is a core organizational value, and safety performance influences the paychecks of Sentara's top leaders, as well as frontline staff in each hospital
      • Forty percent of the variable pay for Sentara's top 100 leaders is linked to the system's quality and safety measures, as are half of the performance measures in Sentara's bonus program for frontline staff members
    • All employees are encouraged to adopt safety habits that prevent errors (see the exhibit below).
    • Checklists, clinical protocols/guidelines, and other standardized tools are used to simplify work processes and limit the opportunities for human error
    • Root-cause analysis is used to identify problems that contribute to safety incidents so that pinpointed solutions can be identified for systemic improvement


    After a successful pilot at Sentara Norfolk, this four-pronged program was expanded to the other Sentara hospitals in late 2003.

    Staffing for safety. In addition to its zero-VAP record, 150-bed Sentara Williamsburg Medical Center in Williamsburg, Va. has had no central line-associated bloodstream infections in more than four years, and no urinary tract infections in more than two.

    John Kaiser, MD, the lead intensivist who works full-time in the hospital's ICU, believes his job description contributes to the hospital's patient safety record.

    Intensivists are critical care physicians who have special expertise in monitoring ICU patients. Some research has shown that ICUs managed exclusively by board-certified intensivists have significantly lower mortality rates than ICUs with other staffing arrangements (Pronovost, P.J., et al, "Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review," JAMA, 2002, vol. 288, no. 17, pp. 2151- 62).

    Despite the evidence that intensivists may save lives, only about 35 percent of hospitals responding to a 2010 Leapfrog Group survey had intensivists dedicated to the ICU during daytime hours.

    Kaiser and other physicians in a group practice used to share responsibility for covering the hospital's ICU; Kaiser spent about half his time at the hospital and half in his office practice. In 2004, the hospital hired Kaiser to work five days a week in the ICU-with no other job responsibilities-while the other physicians in his former group practice provide night and weekend coverage, as needed.

    In the first quarter after hiring Kaiser, the ICU mortality rate at Sentara Williamsburg dropped by more than 30 percent. In addition, sepsis mortality, line infections, ventilator days, and ICU length of stay all went down. Just as telling: The ICU has maintained these positive outcomes since 2004.

    What exactly changed? "It was the same people taking care of the patients," he says. "The only difference was I am here instead of taking calls, making rounds, and going back to the office."

    The hospital pays Kaiser a fixed salary, which frees him from worrying about whether he is working enough billable visits and tasks. From the hospital's perspective, that salary is covered many times over because, by improving patient safety, the ICU is eliminating the financial risks associated with hospital-acquired conditions and costly ICU stays. Sentara Williamsburg administrator Bob Graves points out that VAP increases ICU length of stay by at least five days. The cost of treating each VAP is estimated at between $11,800 and $25,000.

    Empowering staff. Like other Sentara facilities, the Williamsburg hospital relies on standardized protocols, checklists, and other aides to remember critical and important patient care steps that help prevent VAP and other hospital-acquired conditions. However, the Sentara culture also recognizes physicians, nurses, and other clinicians as experts in their specific fields who are trained to spot and respond as a team to potential patient problems.

    "I encourage the ventilator techs to manage the ventilator flow," says Kaiser. "Of course we discuss it, but if they are managing it, they are much more involved with what's going on. If the nurses think they need to make a suggestion, they know I will listen to them. The more I listen to them, the more involved they become."

    Kaiser's perspective reflects one of Sentara Healthcare's core strategies for creating a culture of safety: encourage "mindfulness" among staff members so they quickly recognize and respond to signals of emerging patient problems. "Sentara has let me do my job, which is unusual in a large corporate structure," says Kaiser.

    Encouraging hospital-specific approaches. While patient safety is a Sentara-wide goal, leaders have decentralized the how-to's of patient safety, leaving many specific action steps up to each individual hospital. The Sentara hospitals share best practices, but each hospital has leeway in determining how it will meet its safety goals. For example, while some Sentara ICUs have dedicated intensivists, others use an electronic ICU remote monitoring system.

    The organization's emphasis on safety has reduced the rate of serious safety events at Sentara hospitals by 80 percent between 2003 and 2010. At Sentara Williamsburg, Kaiser estimates that improved patient safety translates into 40 fewer deaths in the ICU each year than would be expected.

    Case Study

    Reducing Cancer Care Complications

    Since converting to a patient-centered medical home, a Pennsylvania oncology practice has improved the care of its patients-and significantly lowered the overall costs of cancer care by doing so.

    "We're bending the healthcare cost curve by eliminating unnecessary expenditures," says John Sprandio, MD, lead physician at Consultants in Medical Oncology and Hematology (CMOH), Drexel Hill, Pa. "This is better care for our patients, and less expensive care."

    When people talk about the potentially avoidable conditions associated with health care, they generally mean hospital-acquired infections, patient falls, blood clots, etc. While several common chemotherapy side effects-dehydration, diarrhea, nausea, and vomiting-are not entirely avoidable, they can potentially be managed to avoid severe debilitation and hospital intervention.

    Sprandio and his colleagues began reengineering their cancer care processes in 2004. Since then, the practice has demonstrated that it can keep cancer patients out of the hospital and the ED through proactive management of common symptoms related to cancer treatments, underlying diseases, and comorbid conditions. Indeed, the practice has reduced its patients' ED use by 65 percent since 2004 and inpatient admissions by 43 percent since 2008.


    CMOH's experience shows how an independent physician practice can dramatically change healthcare delivery. Between 2004 and 2010, CMOH patients had 55 percent fewer ED visits and 40 percent fewer hospitalizations compared to national benchmarks for chemotherapy patients. As a result, the oncology practice helped patients avoid more than $6.5 million in hospital and ED charges in 2010, according to a CMOH analysis.

    Significantly, the changes in care delivery did not negatively impact patient outcomes. The five-year survival rate for CMOH patients remains the same as the national average, just as it was before care processes were reengineered.

    Borrowing a primary care model. In 2010, CMOH became the first oncology practice to earn the National Committee for Quality Assurance's (NCQA's) imprimatur as a patient-centered medical home. All four CMOH locations have used electronic medical record technology since 2006, and they employ all the tenets of the NCQA's medical home model.

    • A team approach to patient care
    • Care coordination
    • Standardized clinical protocols
    • Patient education, navigation, and engagement

    In addition to reducing costs for patients and payers, the medical home model is saving money for the oncology practice-specifically staffing-related costs. Nationally, on average, oncologists are supported by 8.2 support staff. In comparison, CMOH oncologists only rely on 5.5 support staff per physician. Sprandio attributes CMOH's need for less support staff to three strategies: a team-based approach to care, the standardization of care protocols, and internally developed software tools.

    Just as primary care physicians are standardizing-and improving-the care of patients with diabetes, CMOH has improved the way it identifies and addresses a patient's chemotherapy and cancer-related symptoms. For example, by standardizing the management of diarrhea, CMOH has experienced a 50 percent decrease in patient admissions for the treatment of Clostridium difficile, a persistent bacteria that causes diarrhea. This has also resulted in fewer treatment delays related to that symptom.

    Standardizing education. The practice has also standardized patient education, so that all members of the healthcare team provide patients with consistent information. Part of that education involves helping patients assume more responsibility by asking questions of their caregivers until they understand their medical situations. In addition, patients are taught to monitor their symptoms and promptly report troubling symptoms and side effects to CMOH nurses to avoid potential ED or hospital visits.

    CMOH nurses use symptom management protocols to address patients' concerns-often over the telephone. For example, if a patient calls the phone triage line to ask about vomiting, the nurse will provide education on preventing dehydration, a side effect that frequently sends chemotherapy patients to the ED.

    For more than 75 percent of clinical calls, the patients manage their symptoms at home. Each CMOH office accommodates unscheduled visits, and about 10 percent of calls to the triage line result in such office visits.

    To date, one Medicaid health maintenance organization has an outcomes-based contract with CMOH that supports its medical home services, but Sprandio says national and local payers have expressed interest in innovative arrangements. He believes CMOH will enter into an oncology patient-centered medical home contract with performance-based payments and shared savings.

    "We think we are saving $8,000 or $9,000 a year per chemo patient because of the medical home model," he says. "That is a conservative estimate, and it is substantial."

    Case Study

    Spreading Infection Prevention Successes

    Shortly after Ascension Health launched its systemwide Healthcare That Is Safe initiative in 2003, Mohamad Fakih, MD, asked the system to support a pilot project to reduce unnecessary urinary catheter use at his hospital. Fakih is medical director for infection prevention and control at Ascension's St. John Hospital and Medical Center in Detroit.

    Catheter-associated urinary tract infections (CAUTIs) account for 80 percent of all urinary tract infections in hospitals, and are identified as avoidable hospital-acquired conditions. Although patients in ICUs often require catheters, these devices are frequently inserted-and remain in place-in non-ICU patients more out of habit than medical necessity.

    Noting that many urinary catheters at St. John did not have an appropriate reason for use, Fakih developed a program, with the help of multiple disciplines throughout the hospital, to educate nurses on how to reduce catheter use (see the exhibit below).


    Ascension Health provided $70,000 to St. John to fund the nurse-driven program, which helped cover the salary of a nurse charged with implementing the program over the course of one year. The nurse's responsibilities included providing training to nurses, collecting and evaluating data on catheter use, and rounding with two units a day to evaluate catheter use on a patient-by-patient basis.

    The program nurse educated other nurses during multidisciplinary rounds on the different units to evaluate the presence and need for the urinary catheter. "Whenever the catheter does not meet any criteria for necessity, the nurse recommends removal of the catheter," says Fakih.

    In other words, the patient's nurse owns the process of evaluating the need for the catheter. If the nurse determines that a catheter is not needed, the patient's physician is called to obtain an order for its discontinuation.

    In its first year, the program reduced unnecessary urinary catheters by 45 percent. Further work addressing the placement of urinary catheters in the St. John ED has reduced unnecessary urinary catheter use even more. Five years after the program's inception, urinary catheter use has dropped from 18 percent to 12 percent (not including the ICU, where urinary catheters are more frequently needed).

    Spreading improvements. St. John's success in reducing urinary catheter use provides an example of how a systemwide patient safety program can inspire and support quality innovation at an individual hospital. In addition, it is an example of how a single hospital's patient safety initiative can improve medical practice across a health system-and across the country.

    Since 2007, a toolkit that was developed through the St. John pilot has been used throughout Ascension Health, the nation's largest not-for profit health system. This toolkit includes step-by-step guidelines, training posters, and other materials that help other hospitals adopt the St. John approach to reducing unnecessary urinary catheter use.

    The toolkit has also been adopted by the Michigan Health & Hospital Association (MHA) as a best practice for Michigan hospitals. Most recently, the Agency for Healthcare Research and Quality, in partnership with MHA, began promoting the toolkit as part of the national implementation of the Comprehensive Unit-Based Safety Program to Reduce CAUTIs.

    "This started with $70,000 and a lot of commitment," says Fakih.

    Innovating at the local level. St. John has addressed two types of inappropriate urinary catheter use: those that should never have been placed in the first place and those that were appropriately inserted but no longer needed.

    The direct costs added to a hospitalization because of a CAUTI are estimated at $500 to $1,000. But Fakih says even catheterized patients who do not suffer an infection may have longer inpatient stays-he estimates an additional 0.25 day because they cannot be discharged until they have urinated after catheter removal.

    Ann Hendrich, PhD, Ascension Health's vice president of clinical excellence operations, says St. John inspired all other Ascension Health hospitals to follow its lead in reducing urinary catheter use.

    Nosocomial, or hospital-acquired, infections are one of Ascension Health's priorities for action, identified in the health system's Healthcare That Is Safe initiative. "These are things that we don't want to have happen to us when we go in the hospital because they add needless harm, they are mostly preventable, and they cost the healthcare system and society a lot of money," says Hendrich.

    Ascension Health's Clinical Excellence Team, which includes representatives from all nine of the system's regions, determines the best course of action for a specific safety issue-such as the reduction of urinary catheter use protocols developed at St. John-that falls under a priority for action.

    Each priority for action has an "affinity group"- clinical leaders and other key stakeholders from across Ascension Health-that is responsible for pushing the adoption of best practices to all the hospitals in the system.

    This roll-out approach is responsible for Ascension Health's success in exceeding the original goal of the Healthcare That Is Safe initiative. As of 2010, the 70--hospital system had reduced preventable deaths by 1,500 people annually compared to 2004, and significantly reduced birth trauma and pressure ulcers, as well as hospital-acquired infections (Pryor, D., et al, "The Quality 'Journey' at Ascension Health: How We've Prevented at Least 1,500 Avoidable Deaths a Year-and Aim to Do Better," Health Affairs, April 2011, pp. 604-611).

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