To better understand the goal of Healing without Harm by 2014, it may be helpful to learn of the previous, unprecedented goal to provide excellent care with no preventable injuries or deaths by July 2008. This goal was established in 2002 as part of the effort to transform healthcare with the Call to Action that promised Healthcare That Works, Healthcare That Is Safe and Healthcare That Leaves No One Behind.
As a result, Healthcare That Is Safe identified eight Priorities for Action as the focal points for enhanced patient safety. The primary metric was the reduction of preventable mortality. The other Priorities for Action were:
- falls and fall injuries
- pressure ulcers
- perinatal safety
- nosocomial infections
- perioperative safety
- Joint Commission national patient safety goals
- adverse drug events
- Collecting data to formulate meaningful clinical intelligence
- Sharing process, views, reports clinical content materials for cross platform Electronic Medical Record (EMR) development and deployment
- Support to develop and manage EMR-related clerical projects to engage stakeholder’s process redesign, benefit realization and Systemwide benefit reporting
- Identifying Systemwide data patterns and trends
- Providing clinical informatics expertise
- Creating meaningful links between disparate clinical data
The Clinical Excellence Informatics Group (CEIG) understands that Clinical Excellence isn’t just achieved, but pursued. The CEIG team supports Clinical Excellence by collecting and consolidating Systemwide information and turning it into knowledge that supports a learning organization. CEIG team has a unique set of skills coupled with a systematic approach to achieve these results. By asking the right questions, CEIG can assess the clinical IT options and formulate recommendations.
1. Unprecedented and Bold: Eliminating Preventable Mortality
Patient safety, and, in particular, eliminating preventable deaths continues to be an area of intense focus for hospitals and other entities, including the federal government. Ascension Health has served as a pioneer in identifying and implementing several focused strategies, called Priorities for Action (PFAs), aimed at eliminating preventable deaths. The Systemwide efforts to eliminate preventable mortality led to remarkable progress, including surpassing the stated goal threefold. Upon embarking on this initiative, Ascension Health extensively studied hospital records in a systematic way to determine an appropriate benchmark and set a goal of preventing 900 deaths during the five-year initiative. Ascension Health exceeded its goal by three times by preventing 3,200 deaths through several focused safety initiatives.
In June 2006, Ascension Health developed “The Clinical Transformation of Ascension Health: Eliminating All Preventable Injuries and Deaths” and in March 2007, Ascension Health developed "Eliminating Preventable Death at Ascension Health " for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
2. An Environmental Issue: Addressing Falls With Serious Injury in Healthcare Facilities
Summary
Falls are the most common adverse event reported in hospitals. Falls in healthcare facilities that result in serious injuries can be catastrophic for the patient, family and caregivers. In fact, the Centers for Disease Control and Prevention (CDC) estimates that the total direct cost of fall injuries exceeds $19 billion annually.
Many falls and fall injuries can be prevented. Ascension Health, the largest Catholic and nonprofit healthcare system in the country, committed itself to the elimination of preventable falls and falls with serious injuries as part of a larger patient safety initiative, Healthcare That Is Safe. Through this focused, comprehensive approach, Ascension Health has made strides toward reducing falls with serious injuries and improving patient outcomes.
Approach
Ascension Health’s initiative to address falls with serious injury includes the following in establishing a Systemwide standard of care:
- Assessment and reassessment of patient risk factors.
- Visual identification of patients at high risk.
- Communication of patient fall risk status.
- Education of patient, families and staff about fall prevention.
As part of the development process, Ascension Health analyzed a number of evidence-based measurement tools to assess patient risk factors. The clinical excellence team selected the Hendrich II Fall Risk Model® - a model that has been widely adopted across other hospitals outside of Ascension Health.
Results and Implications
Ascension Health’s 67 acute care facilities have improved processes and reporting around all falls. A 46 percent reduction in falls with serious injuries compared to the national average was achieved by Ascension Health in 2008.
A number of implications and learnings can be applied from Ascension Health’s experience, specifically:
- Systemic implementation of best practices across all areas, including prevention, surfaces, patient care and products – such as double-treaded slippers – are imperative.
- An ongoing commitment to provider training and education is critical to the implementation of the best practices.
- Investment in lighting and floor surfaces as well as in beds and chairs with functional locks, all of which have been proven contributors to past falls, may help prevent falls with serious injury.
It is clear that, with a comprehensive approach of this nature, the incidence of preventable falls and falls with serious injury can be significantly reduced. Reduction of preventable falls and falls with serious injury will have a significant impact on overall patient outcomes, as well as on cost savings.
In July 2007, Ascension Health developed "Preventing Falls and Eliminating Injury at Ascension Health " for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
3. Common, Costly and Catastrophic: Addressing Pressure Ulcers in Healthcare Facilities
Summary
Pressure ulcers, commonly known as bed sores, have been identified by regulatory agencies, patient safety organizations and third-party payors as a “hospital-acquired condition.” Yet the incidence of these ulcers, which can be catastrophic, continues to grow alarmingly, increasing 80 percent between 1993 and 2006, and costing the nation’s healthcare system an estimated $11 billion in 2006.
Pressure ulcers can be prevented. In 2003, Ascension Health, the nation’s largest Catholic and nonprofit healthcare system, committed itself to the elimination of hospital-acquired pressure ulcers, as part of a larger patient safety initiative, Healthcare That Is Safe. Through this focused, comprehensive approach, Ascension Health saw the rate of pressure ulcers plummet to 95 percent less than estimated national rates.
Approach
The Ascension Health Pressure Ulcer Prevention initiatives include the following in establishing a Systemwide standard of care:
- Creating and deploying educational materials to ensure that the more than 100,000 Ascension Health healthcare professionals are employing best practices to minimize the risk of pressure ulcers.
- Establishing strategic partnerships with key vendors to develop other educational materials for caregivers and to develop innovative therapeutic bed frames and surfaces that minimize patient risk.
- Ongoing review and evaluation of skin products and surfaces to ensure the use of state-of-the-art, clinically effective products.
- Providing access to Pressure Ulcer Prevention and Bed e-learning modules through the Ascension Health University Learning Management System.
Results and Implications
Ascension Health’s 67 acute care facilities saw significant improvement in patient outcomes. Incidents in the period between 2003 and 2008 fell steadily, until, in 2008, they were 95 percent below estimated national rates.
Many implications and learnings can be applied from Ascension Health’s experience, specifically:
- Systemic implementation of best practices across all areas, including prevention, surfaces, skin-care products and patient care, is imperative.
- An ongoing commitment to provider training and education is critical to the implementation of the best practices.
- Investment in hardware and surfaces, including regular replacement, is essential to the successful implementation of the best practices.
It is clear that, with a comprehensive approach of this nature, the incidence of pressure ulcers can be significantly reduced. Reduction of pressure ulcers will have a significant impact on overall patient outcomes as well as the bottom line.
In September 2006, Ascension Health developed “Eliminating Facility-Acquired Pressure Ulcers at Ascension Health ” for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
4. Perinatal Safety: Working to Reduce Birth Trauma in Healthcare Facilities
Summary
The unintentional harm to a newborn that occurs during birth and requires medical intervention is referred to as “birth trauma.” While birth traumas are rare relative to all births, they can be physically, financially and psychologically damaging to the baby, family and caregivers when they do occur.
Current literature suggests that most birth traumas, as defined by the Agency for Healthcare Research and Quality (AHRQ), can be prevented. As part of the Healthcare that is Safe initiative, Ascension Health, the largest Catholic and nonprofit healthcare system in the nation, committed itself to birth trauma prevention Through a focused, comprehensive approach to reducing birth trauma, Ascension Health saw a remarkable improvement in birth outcomes; the rate of birth traumas plummeted to 77 percent less than estimated national rates. The result was not only improved birth outcomes, but an annual cost benefit to the System of $11.6 million to be realized across those Ascension Health facilities providing obstetric services.
Approach
Ascension Health began its birth trauma prevention effort by focusing on the high-risk areas of labor and delivery. Analysis of literature from obstetrics and safety science aided development of protocols, practices and models of improvement to attempt to eliminate preventable birth trauma. The safety elements that were adopted became known as the safety elements of Handling All Neonatal Deliveries Safely (HANDS).
Specifically, the Ascension Health HANDS program includes:
- Employment of a structured communications tool called SBAR (Situation, Background, Assessment, Recommendation).
- Collaborative training for electronic fetal monitoring (EFM), using common language between physicians and nurses.
- Use of evidence-based guidelines for starting and assisting labor with the drug oxytocin, including processes such as not allowing the elective induction of labor prior to 39 weeks gestational age for the baby and stopping the use of oxytocine if uterine contractions come too often in a defined timeframe.
- Support of improvements in teamwork and communication through simulation training using computerized birthing simulators.
The HANDS program has proven its effectiveness. In January 2006, three Alpha sites that pioneered the HANDS program began spreading learnings across Ascension Health. By December 2007, Ascension Health’s 43 facilities providing obstetric services saw a 59.6 percent improvement in birth trauma rates. Incidents in the period between 2003 and 2008 fell steadily, until, in 2008, they were 77 percent below estimated national average rates. Additionally, Systemwide neonatal mortality was reduced by 81 percent compared to national averages.
By studying previous obstetric events and classifying them to determine the largest number that could be systematically improved upon, Ascension Health identified four specific areas where the most issues occurred, and systematically worked backward to improve these four areas. There are a number of implications and learnings that can be applied from Ascension Health’s experience, specifically:
- Late pre-term deliveries (gestational age 34-37 weeks) often result in unplanned admission of the infants to NICU resulting in higher costs and longer lengths of stay. Prohibiting elective inductions prior to 39 weeks should result in far fewer late preterm births.
- Investment in simulation tools can help teams to prepare for the unexpected in the rare occurrence of a potential birth trauma situation, so that they can hopefully be avoided.
- Providing access to evidenced based educational content for the front line obstetric team in electronic fetal monitoring (EFM) can help reduce EFM communication and teamwork issues in the future.
It is clear that a systematic approach to reducing the incidence of birth traumas is needed. Reduction of birth traumas will have a significant impact on overall outcomes as well as the bottom line.
In January 2007, Ascension Health developed “Eliminating Birth Trauma at Ascension Health ” for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
5. Reducing Nosocomial Infections
Summary
Nosocomial Infections or Hospital Associated Infections (any infection that originates in an acute care setting such as a hospital) are one of the leading causes of preventable injuries and deaths in hospitals, contributing to increased illness, death, length of hospitalization and cost. Nosocomial infection prevention is a key element of the Ascension Health Call to Action for Healthcare That Is Safe that culminated in July 2008 and continues to be a top priority.
In 2003, Ascension Health made reducing the occurrence of these infections a top priority by focusing primarily on two types of nosocomial infections, central line associated bloodstream infection (CL-BSI); and ventilator associated pneumonia (VAP). The organization established a Systemwide standard of care — a set of practices, processes and products that would prevent nosocomial infections from occurring. Significant improvements were achieved, with Systemwide rates less than estimated national rates for CL-BSI (more than 63 percent less) and VAP (35 percent less).
Ascension Health’s efforts to eliminate nosocomial infections offer useful learnings:
- A steady commitment to ongoing training and education pertaining to prevention processes could pay off significantly with less infections
- Testing and development of best practice bundles and their subsequent dissemination can be an effective way to focus efforts on a particular problem and achieve quick and influential improvements.
- With a focused approach of this nature, the incidence of nosocomial infections can be significantly reduced, thereby having a significant impact on overall patient outcomes
In November 2006, Ascension Health developed “Eliminating Nosocomial Infections at Ascension Health ” for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
6. Common, Costly and Preventable: Addressing Perioperative Complications
Summary
Approximately 33 million operations are performed in the United States each year. Serious adverse events occur in more than 1 million of these patients. The Journal of the American Medical Association published a study in 2003 that found post-operative complications accounted for up to 22 percent of preventable deaths among patients. Indeed, post-operative complications account for up to $9.3 billion annually in healthcare expenditures, likely resulting from the average of 2.4 additional days of hospital stay that typically result from these infections.
Yet, medical evidence tells us that outcomes in surgery can be improved. Because many of these complications are preventable, in 2003, Ascension Health, the largest Catholic and nonprofit healthcare system in the nation, committed itself to improving perioperative safety as part of a larger patient safety initiative. The organization established a Systemwide standard of care — a set of practices, processes and products to improve overall perioperative safety.
Ascension Health has targeted Systemwide adoption of improvement processes and has to date achieved adoption levels of at least 84 percent in all five areas of focus for this initiative.
Approach
Ascension Health has been focusing on improving the incidence of perioperative complications since 2003. This is now also a national effort led by the Centers of Medicare and Medicaid Services (CMS) with a program called the Surgical Care Improvement Project (SCIP), of which Ascension Health is a partner organization.
Specifically, Ascension Health’s perioperative complications initiative focuses on the following areas:
- Communication and teamwork in the operating room, such as emphasizing the importance of pre-procedure briefings and other similar communication interventions.
- Prevention efforts surrounding surgical site infections, such as administering antibiotics to patients one hour prior to surgery.
- Prevention efforts, management and education for deep vein thrombosis (blood clot) events.
- Prevention assessment and education of cardiac events (heart attacks).
- Assessment and education of bleeding risk to prevent post-operative hemorrhage.
Results and Implications
While all Ascension Health hospitals are participating in this initiative on some level, Ascension Health’s first order of business in improving perioperative safety is to gain full System participation in all aspects of the initiative. In the area of perioperative safety, this has been challenging because it has required significant physician information regarding SCIP changes, as well as persuasion of some physicians to follow SCIP guidelines. However, engagement is nearing full capacity in the five target areas, with no one area falling below an average of 84 percent participation.
While the primary metric for any quality or patient safety initiative should always be patient outcomes, the economic impact cannot be ignored. The cost of post-operative complications to the nation’s healthcare system is up to $9.3 billion annually, according to a 2003 study published by the Journal of the American Medical Association. This is likely a result of the average of 2.4 additional days of hospital stay that the study found to typically result from these infections.
This is a conservative analysis of the financial impact. Other studies have cited the cost of serious adverse events resulting from surgeries at $25 billion.
As noted earlier, perioperative complications are still quite prevalent. Additionally, with the aging population, it is anticipated that surgical referrals will increase by 25 percent, costs by 50 percent and costs of perioperative complications by 100 percent. Given these staggering numbers, it is imperative that clinicians involved with patients undergoing surgery know the basics of perioperative diagnosis and management.
A few key implications and learnings that can be applied from Ascension Health’s experience are:
- Widespread support of the Joint Commission requirements for SCIP measures, even beyond Ascension Health, will help to spread their influence and impact.
- An ongoing commitment to provider training and education is critical to the implementation of the best practices.
In May 2007, Ascension Health developed "Eliminating Perioperative Adverse Events at Ascension Health " for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.
7.National Patient Safety Goals
The Joint Commission developed National Patient Safety Goals for every hospital in the country. All Ascension Health hospitals are required to be in compliance with the Joint Commission goals and they have been part of the Journey to Zero since 2003. Quality professionals share best practices and process improvements to continually improve compliance with The Joint Commission standards.
Learn more about The Joint Commission National Patient Safety Goals.
8. Medication Safety: Addressing Adverse Drug Events in Healthcare Facilities
In its 2006 report To Err Is Human, the Institute of Medicine defined an adverse drug event (ADE) as an injury resulting from medical intervention related to a drug. According to the Agency for Healthcare Research and Quality (AHRQ), more than 770,000 people are injured or die each year in hospitals from ADEs. National hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between $1.56 and $5.6 billion annually, costs that typically are absorbed by hospitals.
Yet ADEs can be prevented. Between 28 percent and 95 percent of ADEs can be prevented through the use of computerized monitoring systems that prompt important questions to healthcare professionals when prescribing medications and offer other preventive functions. Additionally, even if an ADE is not preventable, computerized systems can detect them early so that healthcare providers can begin work to lessen effects and severity of reactions. Automatic systems can improve detection considerably. With these systems and a team focus on safety practices, great opportunity exists for improving medication safety.
Medication safety was an element of the Call to Action for Healthcare That Is Safe. In September 2007, Ascension Health developed "Eliminating Adverse Drug Events at Ascension Health " for the peer-reviewed Joint Commission Journal on Quality and Patient Safety. Ascension Health teams created safety improvements focused on areas of high risk, such as blood thinners (heparin), insulin, sedatives, and narcotics. It also created a group to align medication technology and supply chain initiatives for optimal safety and effectiveness.
In this effort, Ascension Health has employed a series of programs to approach the problem in different ways. One approach, called the CLEAR program, gave special focus and support to 10 medication safety standards, including the four aforementioned areas, plus safe handling and storage of medications, standardization of drug concentrations for intravenously delivered medications, precautions with medications that look or sound alike, clear labeling, reporting of errors, and reconciliation of prescriptions from home to hospital to discharge. CLEAR engaged hospital administrators’ attention to ensure these safety efforts had full understanding and support across the hospital.
In addition, Ascension Health established an electronic reporting system, called safERSystemTM, to enable caregivers in every hospital to report errors or safety events for shared learning. Serious events may prompt a Systemwide alert, and identified trends enable teams to focus on improvement opportunities.
A major development was the recommendation to invest in “smart pumps,” for intravenous medication delivery, with standard concentrations in high-risk medications and systems for regular updates. This work involved experts from many departments to collaborate on a system that is medically, technically, financially and operationally effective.
Clearly, with a commitment to information technology and provider training and education, and the development of effective team strategies for safety as part of Healing without Harm, medication safety can be greatly improved.
Other Activity
Time & Motion Study
Recognizing increased demands on the time of frontline hospital staff, while the demand for nurses simultaneously continues to outpace supply, Ann Hendrich RN, MSN, F.A.A.N and Dr. Marilyn Chow, Chief Nursing Officers at Ascension Health and Kaiser Permanente designed a comprehensive, multi-site study to identify how nurses spend their time during their shift. Called the Time & Motion Study - the largest environmental study of its kind - was conducted over a 12-month period, ending in June 2006. Investigators collected data from 767 nurses in 36 geographically diverse hospital medical-surgical units. In all, data as to how nurses spend their time were collected and analyzed from 2,201 nursing shifts comprised of almost 22,000 total nursing hours.
The primary objectives of the study were to identify how nurses spend their time during their shift and to pinpoint environmental variables in the acute-care nursing workplace that can be altered to positively affect the efficiency of nursing care and, ultimately, patient safety. Specifically, the study aimed to determine:
- The amount of time nurses spend on specific activities: nursing practice, unit-related functions, nonclinical activities, and waste
- The distance traveled by the average nurse during a typical shift, and whether this movement is efficient
- The physiologic impact of the work environment on nurses.
The Time & Motion Study results have been published in The Permanente Journal, http://xnet.kp.org/permanentejournal/ and in addition, articles currently appear in Advance for Nurses Quality Time, by Candy Goulette http://nursing.advanceweb.com//Editorial/Search/AViewer.aspx?CC=116383
) and Modern Healthcare - In high demand - Nurses spend most time away from bedsides: study, by Melanie Evans (http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080609/REG/116841512
) and the Proclamation for the Work Environment, based on the study, appeared in the Journal of Nursing Administration.
The study continues to influence hospitals and health care systems in design and care model development at the national and state level through presentation, publications and national organizations.
