Iowa collaborative achieves improvement

Hospital-physician cooperation leads to success

Collaboratives have sprung up all over the country, and many boast impressive results. However, few can lay claim to as many accomplishments in a relatively short period of time as the Iowa Healthcare Collaborative (IHC).

On the occasion of its fifth anniversary, the IHC issued a statement summarizing those accomplishments, which included the following:

• 62% of Iowa hospitals have fully implemented rapid response teams;

• 84% of Iowa hospitals fully implemented the acute myocardial infarction (AMI) care bundle;

• 84% of Iowa hospitals fully implemented the surgical-site infection bundle;

• 76% of Iowa hospitals fully implemented the methods to high-alert medications;

• 79% of Iowa hospitals fully implemented the pressure ulcer care bundle;

• 90% of Iowa hospitals fully implemented the heart failure care bundle.

According to the IHC, fewer than 20% of Iowa hospitals had implemented any of these in 2006. And that's not all:

• In 2007, 68% of health care workers had received influenza vaccination; in 2010, that figure was 91%.

• Hysterectomy surgical-site infections have been reduced by 25%, and there has been a seven-fold reduction in central line infections variation.

• Compliance with the Centers for Medicare & Medicaid Services (CMS) AMI bundle of services has increased from 86% in 2005 to 94% in 2009, from 85% to 90% for pneumonia, and from 73% to 90% for surgical care.

• More than 50% of Iowa hospitals use Lean methodology.

A 'professionalism' model

How has the IHC been able to engender so much success in so many areas?

"We really have based our initiatives on a professionalism model," says Thomas C. Evans, MD, president of the IHC. "Our two founding partners, the state hospital association and the physicians, are about promoting 'hospital-ness' and 'doctor-ness.' They focus on their members, and we built a concept's our responsibility as providers to be providing care. We took the tack of 'What if we assumed leadership?' — and we did."

With that "naïve" perspective, says Evans, a former CMO for the largest hospital system in the state and president of the state medical society, he began what he describes as an experiment. "We tried it out, and we said if it worked we'd roll it into a 501(c)(3) — and we did it in a year and a half," he reports.

Evans says the IHC has three cornerstones for improvement:

Aligning and equipping providers: This involves assessing where Iowa hospitals are and where they need to be, looking at national challenges and opportunities for improvement, and offering information through tool kits, conferences, etc.

Responsible public reporting: "We said from the beginning that if we're the ones to deliver care, then we really need to embrace transparency," says Evans. "As scientists we should assume responsibility for statistical reliability; we're the public reporting entity."

Raising the standard of care: "We need to constantly improve care if we want to stay in the game," Evans says.

"We're one big PDSA [plan, do, study, act]," he continues. "We do small tests of change and look at what the data say. We have 100% reporting across the state for our 118 hospitals."

At present, he says, there are 74 measures for public reporting, "re-packaged" from Hospital Compare, the state inpatient data set, and tools from the Agency for Healthcare Research and Quality.

On all cylinders

A model is one thing, but it also requires action on the part of many hospitals to successfully improve in so many areas. Evans takes some of the "blame" for that. "I'm a little manicky. I'm a family doctor by training," he says. "It seemed like every time we started something, another imperative got added to the list. We started with the [Institute for Healthcare Improvement's] 100,000 Lives campaign. We looked at that and asked how much of that should we not be doing, and decided we should be doing it all, so we started a statewide initiative with the expectation that everyone would do everything." So, in March 2006, hospitals were asked to voluntarily report to IHC quarterly on their deployment of bundles. After that, six more bundles were added from the 5 Million Lives campaign.

"In the first campaign, 11% of the hospitals reported full deployment of all six bundles in the beginning, and we're now around 70%," Evans says. "The second campaign started at 22%, and now we're around 70%-80%."

There were times, he says, when he had to "chase" hospitals. "We'd tell them they hadn't reported and that they were, say, one of only 10 hospitals in the entire state that hadn't," Evans says. "No one wants to be an outlier."

Subsequently, he says, IHC added its hospital-acquired infection portfolios, a separate statewide project with an independent reporting vehicle. "Next, we adopted Lean manufacturing techniques," Evans says. The latest project is medical home. "With that, we can begin to work on transitions of care and re-admissions," he explains.

Working together

"We try to do these initiatives together," says Evans. "The hospital association does not lead these initiatives; they found it more effective to stay off to the side. We're the convener and PI coach across the state."

While IHC launches the initiatives, he continues, one of the founding partners is usually who communicates it to the hospitals. "They're told we're creating a statewide paradigm, and that they should be there," Evans explains.

Once an initiative has been selected, he continues, "We build the case for change — what is the current state, what should it be, and what penalties/incentives exist for getting there," says Evans. "Then we identify a series of actions, activities, or steps people should do, and we always try to tie in some objective measures of effectiveness." Wherever possible, he adds, IHC tries to build a return on investment (ROI) strategy as well.

IHC usually builds a "learning community" to help engender success. "We may build a toolkit available to all hospitals, to establish a general context; the learning community is where innovators can opt to participate," Evans explains. "We usually use the 'breakthrough series' model from IHI. We meet and discuss what we're going to do, folks go back to work, we give them more content, they go back to work, we talk about what we've accomplished."

The trick, says Evans, is finding and identifying innovators. "Sometimes we establish innovator workgroups and have them convene regularly by phone," he says.

As initiatives begin moving forward, Evans notes, there are different levels of engagement. "For example, our HAI work group is made up of a few well-equipped infection control professionals who do strategic thinking. Then, we have a monthly conference call for all infection control professionals; we have 70 people on it." The conferees learn about state-of-the-art approaches to preventing HAIs and where things currently stand; then they are given a set of action items. "We have discussions where people share what they've done and how they did it," notes Evans. "Those little huddles keep everyone on the same page."

"There are a number of different ways to participate," adds Steve Gibson, RN, manager of clinical performance improvement at Trinity Regional Medical Center in Fort Dodge, IA. "You can be fully involved in all conference calls, which occur at different intervals depending on the nature of the collaborative. You can meet in person at least once, sometimes twice a year, and always communicate by telephone at least once a month. Everyone has the opportunity to relate what happened in their independent institutions, going around the table, or call in and share what they do, how they managed the program, and what kinds of processes they're following. They share checklists, and talk about what has and hasn't worked for them." This has proved successful, says Gibson, because "you learn from each other."

In addition, he says, the collaborative provides the opportunity to formally benchmark with the other hospitals. "You can see who's doing well," he notes. "Tom might pick up the phone and say that you're at the top on a certain initiative, and ask if you'd like to give a presentation at the next meeting. If so, that becomes part of the agenda for the collaborative."

Inside an initiative

Gibson offers a closer look at an initiative with which his facility has had "pretty good success" — ventilator-associated pneumonia (VAP). "We've not had one incident for two years now," he reports.

The VAP initiative at Trinity Regional started a little more than three years ago, says Gibson. "It came out of an IHI bundle adopted by IHC," he says. "They took the initiative statewide and offered hospitals the opportunity to participate. We focused on the bundles, implemented them, and monitored our process to make sure we were following the bundle until we were up to 100% bundle use."

The progress was monitored in a number of ways, says Gibson. "Part of the process is behavioral driven; for instance, the way you provide oral care, or a ventilator 'vacation,'" he notes. "We had the charge nurses on the [critical care unit] monitor the performance of the nurses caring for the patients to make sure those bundles were in place for each patient on a ventilator. That was the key."

Gibson says he has learned some valuable lessons about getting staff on board. "If you approach things from the standpoint that when you take into account the human characteristic side of the equation, you try to eliminate all variables a practitioner would face when trying to do the right thing," he shares. "You try to put processes in place that make it very natural and easy to do the right thing."

So, for example, if the barrier to providing proper oral care is that it is done at a difficult time of day, "maybe you have to move that to a different time of day," Evans says. In fact, he says, that lesson came out of the VAP initiative.

Checklists are valuable, he continues, because "people can't remember everything, so you say, 'Here are the four, five, or six things you need to do for this bundle. We even went so far as to have reminders on the ventilators themselves that the bed should be in a certain position, so when you walk in the room, if the bed is not at a 45-degree angle, you have a reminder. We actually had little gauges built into the beds eventually."

Another key to success, he says, is that "the lab is actually the bedside, and in a collaborative you have shared, real experiences — results of processes are shared, and you can adapt and adopt processes from different hospitals. In fact, I think the sign for bed elevation was developed by someone else."

[For more information, contact:

Thomas C. Evans, MD, President, Iowa Healthcare Collaborative, 100 E Grand Ave. Suite 360 Des Moines, IA 50309. E-mail:

Steve Gibson, RN, Manager of Clinical Performance Improvement, Trinity Regional Medical Center, Fort Dodge, IA. Phone: (515) 574-6484.]