A low patient safety score at an Atlanta hospital spurred Piedmont Healthcare to revamp infection control systemwide, leading to dramatic improvements that included reducing catheter-associated urinary tract infections (CAUTIs) by 65% over two years.
The effort also involved a wholesale revamping of the system’s quality improvement (QI) department.
Piedmont Atlanta Hospital is the flagship facility of Piedmont Healthcare, a private, not-for-profit system with nearly 600 locations in Georgia, including 11 hospitals. When the Atlanta hospital received a D grade for patient safety from The Leapfrog Group in 2014, Piedmont Healthcare leaders decided that a major QI push was necessary in infection control.
Piedmont Hospital was an enthusiastic participant in the Leapfrog program in its early years, when it was focused on providing employers a consistent way to determine quality and direct their employers to good facilities, notes Leigh Hamby, MD, chief medical officer with Piedmont Healthcare. As Leapfrog’s scope grew, the demands for data became onerous and Piedmont’s concern about the grade waned because it never saw any benefit from employers selecting the hospital, Hamby explains.
But then the D grade in 2014 drew attention from the public and the media, and Piedmont had to respond. “Historically, whenever we had those questions, we’d say the same thing every time: The data are old, and our patients are sicker. The usual excuses,” Hamby says. “But I realized the data are more recent, and I’ve been saying the same thing. I thought we might have a real problem here.”
Not only was it unfortunate to have the system’s predominant hospital tagged with a low patient safety grade, but there was reason to think the problems were not isolated to that one facility, Hamby says.
Internal data indicated patients at the system’s 11 hospitals were at higher risk of surgical site, central line, and MRSA infections than they would be at facilities of similar size.
At about the same time in 2014, Piedmont Healthcare was switching from The Joint Commission to DNV GL Healthcare as its accrediting body, partly because of DNV’s emphasis on continuous QI, and enlisted the accreditor to help with the infection control improvements. Seven Piedmont Healthcare hospitals are now accredited by DNV, with five certified to use the ISO 9001 quality control system.
Piedmont Healthcare also was motivated by the cost of infections within its system. A colon surgical site infection cost the system an average of $8,827 to treat. MRSA infections were higher at $12,302, but the most expensive were central line infections, with each costing Piedmont Healthcare an average $23,203. The effort began with surveying the quality improvement professionals at all the Piedmont Healthcare facilities, Hamby says.
“We found that the people working in the quality departments weren’t working on any of the things that were being evaluated by Leapfrog or even for our own scorecard. They were reporting on things like accreditation issues, use of restraints, all some variation of counting stuff,” Hamby says. “They weren’t doing much improving but they were doing a lot of counting.”
Hamby notes the Piedmont QI department had been operating as instructed and in the traditional manner, counting and sharing data with the departments that could make improvements that affect quality. Piedmont was not trying to blame QI staff for the poor system results, he says. Rather, the health system decided to go in another direction by reorienting the QI department’s efforts in ways they hoped would be more effective in improving quality. Acknowledging the system-wide responsibility for the poor results, rather than holding any one department responsible, was key to the success of the improvement effort, Hamby adds.
All QI Jobs Redefined
That needed to change, so Hamby worked with Anna Ivory, vice president for patient safety and quality at Piedmont Healthcare, to fundamentally redesign the work of the quality department. Surveillance and analysis are valid and necessary components of quality, Hamby says, but Piedmont wanted to flip the balance so that a much higher proportion of the work involved actually improving patient care.
“We can read a chart in 20 minutes and figure out that we should have done this or that differently, but actually getting the problem fixed can take 800 hours. Purely from a math standpoint, you need more people fixing problems than counting problems,” Hamby explains. “We found in some of our early wins that the people who were able to fix things were not the typical quality person with a nursing background, but instead they were process engineers.”
Hamby and Ivory revised all the job descriptions in quality and directed everyone in that department to reapply for their jobs. They also hired new people from outside the healthcare quality arena, particularly industrial engineers, all with a focus on dividing QI more cleanly between surveillance and analysis and the design and implementation of improvement projects.
Today, Ivory explains that there is a group of people responsible for monitoring infections, classifying them, and reporting them. Another group includes infection preventionists who are stationed at the hospitals to drive the improvement efforts.
“We also have the peer review function centralized across our system as part of the surveillance and analysis effort. That group of people handles peer review as part of that quality function,” Ivory says. “The ability to work toward ISO 9001 with DNV was another focus. A lot of the engineers we brought on had knowledge of that type of process improvement from their previous industries.” (See the story later in this issue for more on how Piedmont Healthcare addresses peer review.)
Process Measures Paramount
Piedmont Healthcare also shifted from focusing on outcomes to more process measures, Ivory says. Previously, the hospital’s scorecard was dominated by outcomes but now is broken down more.
“With CAUTI, we were able to develop dashboards that allow the frontline staff on the units to track compliance with the process metrics,” Ivory says. “The shift from looking at outcomes to focusing on process measure improvement definitely contributed to a big reduction in our infections.”
That shift was dramatic, says Michael O’Toole, FACHE, executive director for quality improvement at Piedmont Healthcare, so much so that other business areas of the health system are beginning to focus more on processes than outcomes.
“Before, when we focused on outcomes, that created a lot of popcorn improvement efforts. When you tell 11 hospitals to get better with CAUTI, all 11 hospitals are going to come up with different solutions and request to change the EMR in different ways. They are all going to request different supplies that they think are best,” O’Toole notes. “That creates bottlenecks in the improvement production line. The way we do it is a much more streamlined approach to get the improvement out quicker by having a system team come up with the bundle and process measures. Then, we hold hospitals accountable to them.”
Hamby says hospitals are held accountable for process measures even if their outcomes are good. A hospital CEO who meets with the health system may be proud that his or her facility has had no CAUTIs recently, Hamby says. However, if the data show poor compliance with the process measures, the health system will expect an explanation of how that is going to improve.
“But the opposite is true also. You may have had 10 CAUTIs, but if you’re complying with the process measures at 95%, then that’s back to us on the quality team to redefine standard work,” Hamby adds.
Quality improvement projects in the health system must align with Piedmont Healthcare’s overall goal of zero harm, O’Toole notes. The team categorized all the different types of harm. Using the Pareto principle, they determined that hospital-acquired infections (HAIs) accounted for a significant portion of patient harm. Therefore, all the first efforts by the reconstructed quality team focused on HAI reduction. “Each year, we look at our harm count and decide what category we’re focusing on next. Once a project is identified, we assign a process engineer or process improvement expert to the project, and they go through our PDCA cycle,” O’Toole reports. “We come up with the goals, do a current state analysis, walk with the clinicians to see what the process is, and where the holes in the process are.”
Because the impact of any effort must be measured, the solutions almost always include a change to the electronic medical record (EMR), O’Toole notes. Supply standardization also is a common component, along with dashboards that allow staff and clinicians to see real-time data and correct deficiencies.
The quality program at Piedmont Healthcare also emphasizes the need for peer coaching. (See the story later in this issue for more on the unusual method Piedmont Healthcare uses to implement process changes.)
Promise Packages for Improvement
Piedmont created “Promise Packages” as part of the infection control improvement program, based on the idea that promises to provide the best care by following protocols and best practices in particular areas of care. Each of the 16 Promise Packages is a group of initiatives aimed at reducing infections and improving other issues such as operating room safety or pain management, O’Toole explains.
“It’s a care process model that establishes what the defect is and the standard work to get the best outcome for the patient,” he says. “Once that Promise Package is built out, we have a very thorough implementation plan.”
Previously, Piedmont Healthcare had dozens of CAUTI prevention protocols in place; over time, the system reduced them all down to a single protocol. Physicians also made a point of questioning why patients had catheters, eventually changing the culture so that catheterization was frowned upon unless there was a specific need, even with seriously ill post-surgical patients. Piedmont Healthcare also changed policies so that more patients received daily baths instead of wipes with chlorhexidine pads, and linens were changed daily.
Dramatic Results With HAIs
The health system achieved impressive results between 2016 and 2018:
- The use of Foley catheters for longer than 48 hours declined by 50%;
- CAUTIs dropped by 65%;
- Clostridioides difficile infections dropped by 46%;
- Surgical site colon infections declined by 43%;
- The number of MRSA cases fell by 38%.
The health system also achieved significantly lower infection rates in 2018 than what would have been expected for the system’s case volume: the CAUTI rate was nearly 64% below the expected rate, C. difficile cases were 81% lower, and central line blood infections were 39% lower. In 2016, the MRSA rate was 70% higher than the expected rate for the system; in 2018, it was 20% below the expected rate. The health system estimated that it saved $2 million from the lower infection rates in those two years. Hamby notes that Piedmont Healthcare is only adhering to the same processes that every other healthcare organization is supposed to follow for reducing infections. The difference is the focus on processes rather than outcomes and the level of commitment, he says.
“We found that in almost every project, if you get fanatical about compliance with the standard work, you see tremendous improvement. If you do everything that everyone knows you have to do to reduce CAUTI, your CAUTI rates fall dramatically almost overnight,” Hamby says. “We had talked about it for years, but when we actually got our compliance rates to 70%, 80%, 90%, CAUTI virtually disappeared in a month.”
That was enlightening but also somewhat saddening, Hamby says, because it meant the health system probably had been deluded about how much it was doing to comply with best practices.
Culture Shift Challenging
The challenges along the way included creating the cultural shift toward actually fixing problems and not remaining content to have merely identified them, Hamby says. “There seems to be something inherent in us clinicians that we feel really good if we find a problem, and it doesn’t seem to bother us if we never fix it,” he says.
Piedmont Healthcare ensures that all QI efforts align with its zero harm goal. That means that some well-intentioned staff and clinicians will be told “no” when they suggest a project, Hamby says.
For example, if someone wants a medication reconciliation team but there is no evidence that the issue has caused harm, that issue will be given lower priority than infections that are harming patients, he says.
People often see their project as a moral imperative because someone could be hurt, Hamby says, but Piedmont Healthcare’s policy is to focus on what is hurting people already. That can be difficult for some people to accept, he says.
“We get requests to do something about the possibility of elephants charging down the hallway and running over people, based on some accreditation finding that we’ve never seen before. People get fixated on that because it sounds like a such a terrible thing we have to prevent,” Hamby says. “Getting people to focus on the things that we know are causing problems is the biggest barrier I face on a daily basis.”
The overall approach by Piedmont Healthcare at the system level is winning over some hospital leaders who previously had become jaded by what they saw as QI’s preoccupation with measurements and a habit of dictating changes without understanding their impact.
Hamby says one of the greatest compliments the quality team has received came from a chief nursing officer at one of the hospitals who said, “For the first time in my career, I feel like quality is here to actually help me.”
- Health Catalyst. Designing Hospital Quality Function Around the Value Chain. Published Oct. 26, 2017. Available at: . Accessed Oct. 2, 2019.
- DNV GL Healthcare. Piedmont Healthcare. Case Study: Reducing Infection Rates. Published June 20, 2019. Available at: . Accessed Oct. 2, 2019.
- Leigh Hamby, MD, Chief Medical Officer, Piedmont Healthcare, Atlanta. Phone: (770) 801-2550.
- Anna Ivory, Vice President, Patient Safety and Quality, Piedmont Healthcare, Atlanta. Phone: (770) 801-2550.
- Michael O’Toole, FACHE, Executive Director, Quality Improvement, Piedmont Healthcare, Atlanta. Phone: (770) 801-2550.