New IHI campaign will target medical harm in U.S. hospitals
New IHI campaign will target medical harm in U.S. hospitals
'5 Million Lives' campaign seeks to reach its goal in two years
Looking to build upon the momentum of its successful 100,000 Lives Campaign, the Boston-based Institute for Healthcare Improvement (IHI) has launched the 5 Million Lives Campaign, whose goal is to "protect patients from five million incidents of medical harm over a 24-month period, ending December 9, 2008." The IHI defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or results in death." (IHI provides a more extensive definition of medical harm on its web site, www.ihi.org.)
Hospitals will not have to pay a fee to join the 5 Million Lives Campaign. However, they will be obligated to adopt at least one intervention and to regularly report hospital profile and mortality data throughout the campaign.
IHI claims that in the 100,000 Lives Campaign, 3,100 participating hospitals reduced inpatient deaths by an estimated 122,000 in 18 months. It estimates that 15 million incidents of patient harm occur in U.S. hospitals each year.
The 5 Million Lives Campaign will include 12 interventions. Six of these were the foundation of the 100,000 Lives Campaign — deploying rapid response teams; delivering "reliable, evidence-based care" for AMI; preventing adverse drug events; preventing central line infections; preventing surgical site infections; and preventing ventilator-associated pneumonia.
According to a FAQ on the IHI web site, the six new interventions include the following:
- "Prevent pressure ulcers... by reliably using science-based guidelines for prevention of this serious and common complication;
- "Reduce Methicillin-resistant Staphylococcus aureus (MRSA) infection... through basic changes in infection control processes throughout the hospital;
- "Prevent harm from high-alert medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin;
- "Reduce surgical complications... by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP);
- "Deliver reliable, evidence-based care for congestive heart failure... to reduce readmissions;
- "Get Boards on board... by defining and spreading new and leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating the improvement of care."
'A very large challenge'
"This is a very large challenge, but it would be the biggest improvement in patient safety in the modern health care era," asserted IHI president and CEO Donald Berwick, MD, MPP, speaking before a press gathering at the organization's 18th National Forum in Orlando, FL, in December 2006, during which the campaign was announced. "We are asking all hospitals to do what few have done, but what we know can be done."
The outpouring of support for the campaign, he continued, "has been stunning," noting flagship sponsorship of $5 million by Blue Cross and Blue Shield, and "a very large award" from Cardinal Health.
"We are in wonderful shape," he added. "Already many systems say they will do this; VHA, Inc., and Premier are completely invested in carrying forward."
Berwick was quick to add that IHI is "not alone" in the effort, noting the participation of the National Patient Safety Foundation, the Centers for Medicare & Medicaid (CMS), and quality improvement organizations, among others. "We are able to list 130 organizations that are working on the campaign," he asserted. (Also present at the announcement were officials from the American Hospital Association, the American Nurses Association, the Centers for Disease Control and Prevention, and the Joint Commission.)
But on the ground, the campaign will be led by hospitals, said campaign manager and IHI vice president Joe McCannon. Noting that this new campaign will build upon a structure established in the 100,000 Lives Campaign, he asserted that in that initiative "about 3,100 hospitals participating, representing 80% of the discharges in the country, built a national infrastructure for change."
That infrastructure includes 50 "nodes," and approximately 150 mentor facilities. The nodes, McCannon says, are networking groups of volunteers that "bring together hospitals in the state, or a system, or a rural region, to discuss overarching aims, explain the 12 initiatives, and basically act as coaches and resources. The thing hospitals value most is advice from other hospitals."
McCannon told the press conference that IHI believes there are 40 to 50 patient harm events for every 100 admissions. "So, in the next two years, where we would normally expect to see 30 million harm events, we hope to reduce that by one-sixth."
Just as bad as mortality
Harm, asserts Jeffrey M. Dunn, MD, MBA, FACS, FACPE, senior medical director, clinical performance, for VHA, Inc., in Philadelphia, "Is just as bad as mortality," adding that "It is very appropriate to look at safety not only in terms of lives saved, but also in terms of the number of complications [prevented]."
Quality professionals, he continues, "Have to get away from the idea that if we salvage a patient and they leave the hospital, it's automatically a great success. There is also quality of life; avoiding complications is probably just as important as addressing the mortality issue."
While adding that IHI "is not really talking about brand new things; these are things hospitals should be looking at anyway," Dunn notes that the organization is conducting "a masterful campaign of getting the attention of people to go forward."
Dunn says he is particularly impressed with an oft-repeated statement he attributes to Berwick: "'Some' is not a number; 'soon' is not a time." Says Dunn: "Let's do this now and be accountable."
If the new campaign, like the prior one, "gets hospitals on board to really seriously look at this as partnering with CMS, the Joint Commission, and others, they will have done a very good job," Dunn asserts.
Nevertheless, Dunn admits to some "mixed feelings" about the campaign. "There is nothing really earth-shattering about the indicators or the things they are trying to fix, but why haven't we done it without the help of programs like this?" He queries. "It's almost shame on us that we need things like this."
He adds, "I see our hospitals and quality managers being overwhelmed with programs and indicators by a million organizations trying to get the public's attention. They have to start prioritizing what they do. One thing I hope is that they will not lose focus on their own problems as they start addressing these issues."
Choosing the initiatives
The six new interventions "come out of a number of sources," according to Berwick. "Like our first campaign, there are medical considerations to be recognized. Then, there's epidemiology. We know the profile of harm, and we have picked out the most frequent causes.
For example, we know that of all the injuries in the campaign, almost half are due to medication in some way or another, and almost half of those are from the high-alert meds."
VHA is already involved in many of the six areas, according to Dunn. "We have had and continue to have major programs on MRSA," Dunn says. "We ran a major national symposium last year, and we have a collaborative that continues."
VHA also is looking at medication errors in terms of reconciliation and safety. "And SCIP is a major part of our 'Transformation of the Operating Room' program, which is a collaboration of hospitals," he notes. That program, he explains, includes three major domains: culture, operations, and quality. "Even before SCIP became mandatory, we had adopted and are comparing key measures," he says. In addition, VHA has major programs addressing evidence-based care for CHF and has an ongoing cardiology task force.
Six recommendations
Berwick told the press gathering that IHI is attempting to offer boards the best available list of suggestions on how to do things. "For many boards, safety is not regarded as a governance issue," he conceded, "But we say it's time to change." IHI, he added, is offering these six recommendations:
- Set safety goals.
- Gather the data on their own organization.
- Set up ongoing monitoring systems on safety at the organizational level.
- Work on the environment — policies and culture that create transparency and trust and reduce blame.
- Study — i.e., become students of health care safety.
- Hold the executives accountable.
"We have added two 'must do's,'" Berwick continued. "First, do a chart audit — 20-40 random charts from the last month, studied through our tools. Have a very specific report to the board on all injuries found; I think it will open their eyes. Then, conduct a 'deep dive' patient safety study. It should be conducted and detailed by the chief executive and a board member; it may not be delegated."
The six original initiatives also have been updated — "Some minimally, some fairly significantly," McCannon tells HBQI. "For instance, we have added 'Tips and Tricks' sections to all of our how-to guides," he says. In terms of rapid response teams, he adds, substantive changes have been made.
"We now talk about early warning scoring systems that help detect problems earlier," says McCannon. "Now, the team alone is not the only way of responding; the scoring systems are another tool."
Major changes also have been made in the medication reconciliation guidelines. "Where we focused a lot on admission and transition points in the first 18 months, we are now focused on discharge as well," he says.
Measuring success
While the 100,000 Lives Campaign has received nearly universal praise, some in health care circles have questioned the methodology used to determine how many lives were "saved." Measurement could be even more of a challenge in the 5 Million Lives Campaign, says Dunn.
"It's clearly going to be more difficult to measure," he asserts. "If you look at the reporting to CMS by hospitals, it is clearly understood that documentation and measurement of complications is much more difficult and error-prone than mortality."
Mortality, Dunn notes, is easy to define, but complications are not. "Talk to an orthopod, and ask them if bleeding is a complication or a matter of fact," he poses. "We tend not to document complications, and it will be a challenge in this program to measure what is and is not a complication."
He adds that it "certainly will not be easy to risk-adjust the data and have an absolute number comparing one hospital to another." He adds, "This does not mean we can't keep looking at the data and trying to fix things."
At the press conference, Berwick recommended measuring on two levels. "The first is process — do you know your rates?" he challenged. "Hospital-specific data are not required, but many have to be reported anyway, and compared to national standards. Then, there is the question, 'Are we getting safer?' We do not have a standard way to answer that question. The best we can do now is a random chart review."
Nevertheless, he said that by choosing those random 20-40 charts every month and using IHI's global trigger tool, "It should give you relatively good measures over time. And we should see that number change."
For more information, contact:
Jeffrey M. Dunn, MD, MBA, FACS, FACPE, Senior Medical Director, VHA Clinical Performance, Philadelphia, PA. Phone: (215) 629 8689. Fax: (215) 629 8666. E-mail: [email protected].
Donald Berwick, MD, MPP, President and CEO, Joe McCannon, Vice President, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. Phone: (617) 301-4800. Toll-Free: (866) 787-0831. Fax: (617) 301-4848.
Looking to build upon the momentum of its successful 100,000 Lives Campaign, the Boston-based Institute for Healthcare Improvement (IHI) has launched the 5 Million Lives Campaign, whose goal is to "protect patients from five million incidents of medical harm over a 24-month period, ending December 9, 2008."Subscribe Now for Access
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