Collaboration accelerates safety improvements

Open communications help drive success

The Indianapolis Coalition for Patient Safety (ICPS), established in 2003, has made significant strides in a number of areas through collaborative initiatives, say its leaders. Among its successes to date are:

  • The reduction of ventilator-associated pneumonia (VAP) cases in intensive care units;
  • Improved identification of patients most at risk for heart or respiratory failure before they're in trouble;
  • The establishment of rapid response teams.

The number of VAP cases in the city have dropped significantly, according to ICPS, with some local hospitals going more than a year without a case — and one going without a case of VAP for three years. After the institution of a rapid response team, one member facility reported that "code blues" had dropped 60% in 18 months.

The ICPS comprises chief executive, medical, nursing, and pharmacy officers from Clarian Health, Community Health Network, Richard L. Roudebush VA Medical Center, St. Francis Hospital and Health Services, St. Vincent Health, and Wishard Health Services. In addition, there is participation by entities such as Eli Lilly and Co., WellPoint Inc., Indiana University, Purdue University, and Regenstrief Institute Inc.

'Non-compete' agreement

The coalition got its start when the chief medical officers of the major systems, in concert with Eli Lilly, began talking about how to put on an educational program to heighten awareness of safety in the city, recalls Glenn Bingle, MD, PhD, FACP, chair of the ICPS and Community Health Network vice president for medical and academic affairs. "In planning for that, we realized we could do more than educate the public; we could share information and take on a project together," he explains.

They began studying out-of-state coalitions, and contracted with the National Patient Safety Foundation to facilitate their first meetings, which resulted in the formation of the coalition. "The CEOs all agreed they would not compete on safety issues, and that set in motion the establishment of our agenda," says Bingle.

The ICPS has a working group of CMOs, nursing officers, pharmacy officers, and safety officers that sets the operational and tactical agenda for the improvement projects. "They in turn charter working groups of leaders in each organization to take on the initiative," says Bingle.

"We figured out early on that the more we could cooperate and standardize the better our success would be," says Kathy Rapala, JD, RN, director of the ICPS and Clarian Health's director of risk management and patient safety. Part of what happened over the first few years, she says, was creating a culture of cooperation among the members. "When you work for competitive organizations," she explains, "It takes time for cooperation to jell."

The first joint initiative involved the "do not use" abbreviations, says Rapala. "We added a couple of others [to those of The Joint Commission] based on our expertise and compared culture surveys around the hospitals," she recalls.

Following the model

That model of drawing on the experience and expertise of individual members has continued, notes Bingle — with help from outside organizations as well. For example, the VAP and identification of high-risk patient initiatives were part of the Institute for Healthcare Improvement's 100,000 Lives campaign, and "the coalition decided they would implement all six of the 100,000 Lives initiatives," he says.

Then, the group looked at which facilities had the expertise, or more experience, with a given strategy, and in each case that system was assigned to be the leader. So, for example, Community Health was the leader of the rescue team (rapid response team) initiative, because they had implemented theirs in 1995.

While Community Health shared its model, the individual systems still had to adapt it to their own unique needs, Bingle explains.

"Some of our systems are major teaching institutions, while others are not," he notes. "So what is applicable to one is not applicable to another. For example, in teaching facilities, house officers and fellows are involved [on the teams]."

The work teams openly share the "how-to's" of the programs, says Bingle. They meet regularly, rotating the site. "The frequency depends on how far along we are with implementing the strategy," he says. "In the early stages we meet more frequently; if we are into tactical implementation, then we meet less frequently." Results are shared both in person and electronically.

"As you know, these are process strategies," he continues. "If you implement this process, you have a better chance of improving outcomes — but the efficacy of that strategy often is dependent on a bundle, a series of several processes that if implemented correctly all roll up."

So, for example, with a rescue team you are aiming to reduce the number of codes on the med/surg unit, but at the same time you may also reduce that number in the ICU because patients may be transferred prior to having a code.

Results are positive

Since the ICPS is a collaborative, hospitals will start their programs and show improvement at different rates, with different baselines so it is difficult to state "collaborative-wide" rates of improvement. Still, says Bingle, "a lot of the effects" of the collaborative are already being seen.

"Some members of the coalition have had dramatic reductions in the number of codes in med/surg," he says. In terms of VAPs, "we saw improvement across our own ICUs; one of them has not had a VAP for three years and that continues today. That's pretty spectacular improvement; previously, in a given year we might have had six to 12."

Rapala says the coalition has begun to narrow its focus, after having met with Jim Conway, senior vice president of IHI, who suggested they try to attack fewer areas, but in greater depth. "One thing I've learned as director is that if you have to make a quick decision, you really need the right infrastructure," she says. "This year we've been really trying to ground ourselves in initiatives; one of our member hospitals had a heparin event so as a city we felt they had to lead the way in our anticoagulation therapy initiative."

The ICPS has now formally begun to collect data coalition-wide. "This opens up new issues of validation and how to use the data," says Rapala.

The state of Indiana, impressed by the coalition's achievements, is now looking at a statewide collaborative as well. "We will interface with them," says Bingle. "We believe health care is a regional issue."

He also believes it is a moral issue. "It would really be unethical for us not to share information if we knew a safer way to provide care," he asserts. "We know that 60% of our patients go between each others' systems. How, then, can you improve safety unless you improve it for everybody?"

[For more information, contact:

Glenn Bingle, MD, PhD, FACP, Vice President for Medical and Academic Affairs, Community Health Network, 1500 North Ritter Avenue, Indianapolis, IN 46219. Phone: (317) 355-5381.

Kathy Rapala, JD, RN, Director of Risk Management and Patient Safety, Clarian Health, Indianapolis, IN. Phone: (317) 340-6256. E-mail:]