Front-line staff helped reduce adverse drug events by 55 percent and pressure ulcers by 38 percent.
From 2012 to 2016, New Jersey hospitals avoided more than 77,000 cases of patient harm and saved $641 million as part of the national Partnership for Patients initiative. By learning from industry experts and each other, they achieved double-digit improvements in occurrence rates of sepsis, surgical site infections, falls, and other patient safety concerns.
The project began in 2011, when the New Jersey Hospital Association’s (NJHA) Health Research and Educational Trust (HRET) was awarded a federal contract as a hospital engagement network under the Affordable Care Act. A key goal was to create a nationwide learning collaborative to help hospitals improve patient safety and the quality of care. HRET directed the state’s collaborative efforts.
“Our hospital members saw where our state ranked in some of the national quality reports and wanted us to help them improve,” says Betsy Ryan, president and CEO, NJHA. “So, when the opportunity to improve presented itself under the Affordable Care Act, we jumped at it.”
That enthusiasm paid off. Because of their efforts, New Jersey hospitals cut the incidence rates of adverse drug events, blood clots, and early elective deliveries by half in five years. During the same time, they reduced hospital readmissions by 30 percent, saving $581.6 million.
Power in Numbers
Key to the hospitals’ success was recognizing the impact of caregivers at the bedside. “Hospital front-line staff want to do the right thing for the patients, but they don’t always have the resources or training to do this,” says Aline Holmes, senior vice president of clinical affairs. “But with the right help and guidance, they will embrace tools that can help them provide better care.”
To empower front-line staff, NJHA developed 10 “learning action networks” focused on the following areas of improvement:
- Patient flow
- Early elective deliveries
- Bloodstream and urinary tract infections
- Adverse drug events
- Ventilator-associated events and surgical infections
- Catheter-related infections in the emergency department
- Antimicrobial stewardship
- C. difficile reduction
- Fall prevention
The collaboratives hosted regular webinars and conference calls with industry experts to offer evidence-based approaches to avoiding patient harm. To support their efforts, hospital members received tools, including checklists, training manuals, and videos, from NJHA and the Centers for Medicare & Medicaid Services.
The hospitals also developed comprehensive unit-based safety programs (CUSPs), which have gained traction in recent years as the Agency for Healthcare Research and Quality has promoted their use to reduce central line-associated bloodstream infections (CLABSI).
“CUSPs center on engaging front-line staff to get feedback on where harm is occurring at the bedside and getting them involved in designing solutions,” says Shannon Davila, director of the NJHA Institute for Quality and Patient Safety. As part of the initiative, hospitals used CUSPs to reduce bloodstream and urinary tract infections, ventilator-associated events, and surgical infections.
“We wanted to change the hospital culture and environment so that everyone was working as part of a team in which each member’s opinion was valued,” Holmes says. “We also wanted hospitals to implement a process to learn from errors so they don’t happen again.”
Two Key Areas of Savings
From 2012 to 2016, New Jersey hospitals reduced the rate of pressure ulcers by more than one-third, which saved $34.5 million.
Improving staff’s adherence to evidence-based guidelines was key to their success. “We found out through the gap analysis that hospitals were not doing a comprehensive assessment of all of their patients who were admitted,” Holmes says. As part of their improvement efforts, hospitals were required to report a process measure to show that such an assessment took place. They also submitted outcomes, which proved that pressure ulcers decreased as skin assessments and other interventions increased. “It was good feedback to the staff that what they were doing was working,” Holmes says.
New Jersey hospitals also saved $9.4 million by reducing adverse drug events. NJHA formed a provider steering committee that partnered with the Institute for Safe Medication Practices (ISMP) to develop metrics that reflected real practices in the hospitals, Davila says. For example, they measured the number of patients on blood thinners whose levels of the drug were too high, which would allow staff to intervene.
ISMP also helped the hospitals develop different tools to reduce some of the more common adverse drug events associated with blood thinners, diabetes medications, and opioids. For example, they developed gap analysis tools to help hospitals determine how they might increase their adherence to evidence-based practices.
“These tools are powerful because you may think you know what is going on in your hospital, but until you discuss processes with a multidisciplinary group, you may not know all of the improvement opportunities, that exist” Davila says.
NJHA plans to build on its successes, with HRET overseeing its efforts. In 2017, NJHA was selected as just one of 16 hospital improvement innovation networks, which are part of the Centers for Medicare & Medicaid Services’s current Partnership for Patients initiative. The national program aims to further reduce overall patient harm by 20 percent and cut 30-day readmissions by 12 percent. To help reach these goals, NJHA is driving a number of initiatives, including a new collaborative to help hospitals become “high-reliability organizations,” which avoid catastrophic errors by implementing deliberate policies and procedures. Such models have been adopted in aviation and other high-risk industries.
5 Key Improvement Areas for New Jersey Hospitals, 2010* to 2016
Experts with NJHA offer the following advice to other organizations looking to improve patient safety and reduce costs.
Leverage the C-suite. “To gain the most traction, quality improvement programs should be driven by clinicians, rather than administration,” Ryan says. But senior executives can help facilitate process changes. For example, some New Jersey hospital teams that were focused on reducing surgical site infections had difficulty convincing materials management to order more chlorhexidine for skin preparation. Ultimately, they found that engaging their executive champions—often the CEO or COO—helped get them what they needed.
Embrace an “all-teach-all-learn” approach. Several times a year, NJHA hosts face-to-face sessions with the collaboratives to supplement their webinars and conference calls. “We highlight the hospitals that were doing really well so they can share what they are learning with other hospitals in the collaborative,” Holmes says. “Hospitals learn as much from each other as they do from the faculty we bring in.” They also have created listservs for each area of focus to help members ask questions or share policies and procedures.
Use data to drive actions. NJHA has created several databases to help members capture data. They collect both process and outcome metrics and have made a conscious effort to match their metrics to national metrics to reduce the reporting burden on hospitals. Such data is essential for establishing baselines. For example, their antimicrobial stewardship collaborative is collecting data on days of antibiotic therapy to establish a use baseline for New Jersey.
Track the cost savings. As part of their work, NJHA must report to CMS the estimated cost savings from reduced complications using publicly available data. “A lot of the areas that we are working in directly impact the value-based purchasing scores and the types of payment incentives that CMS and private insurers are using in their quality programs,” Davila says. “So there is a dual benefit in showing the financial impact.”
Share your success stories with lawmakers. “Policymakers should know that hospitals are investing in patient quality and safety,” Ryan says. “We are often able to avert onerous legislation by letting policymakers know that we are focused on some of these issues. Legislators will hear the story of a patient gone wrong, but when we are able to come in with our experts and tell them about the good work we are doing, it makes them sit up and take notice.”
Committed to a Safer Future
Although quality improvement efforts can be difficult for organizations to juggle given their other strategic priorities, such projects are worthy of leaders’ attention. “Investing in quality improvement and patient safety bears fruit for providers,” Ryan says. “There’s money saved, but there are also real lives impacted.”