System uses 'pyramid' to perfection'

Eastern Maine Healthcare System in Brewer, recent recipient of The VHA Foundation and National Business Group on Health's Patient Safety Leadership Award, pursues its "zero defect" goal by employing various steps in a quality pyramid. (See pyramid.)

"We have said that education is dead as a principal tool for improving performance; it won't get you much past 60%," explains Erik Steele, DO, chief medical officer for the system. "The next phase is data feedback; you get maybe another 20% bump. Then come reminders and queuing."

At Eastern Maine, for example, the staff wear buttons that say, "Remind me to wash my hands." "There are also little pop-up box reminders on the computer, saying 'Did you remember?'" adds Steele. "There are signs on the doors, asking, for example, if the staff member remembered to put on gloves. Order sets fall into this category as well. That gets you another 5%-10%."

Phase IV is initial hard wiring. "We make pre-printed order sets mandatory — so, for example, if you want to admit a person with congestive heart failure, you have to use the order set," says Steele.

"We hardwire reminders into the EMR system with pop-ups you can't shut off. We have double-checks for high-risk procedures; for example, two nurses must validate right patient and right blood type. The universal checklist for surgery is hard wired for right patient, extremity, and so on. That gets you another 4%-5% bump."

Phase V, he continues, is the final go/no-go. "For example, the surgeon cannot have a scalpel to start surgery until the checklist is done. For high-risk medications, we now just take them off the formulary," says Steele.

"That's how you get up to 98%-99% performance," he explains. "The rest is where the culture of safety becomes so important. We think it's now possible to say, 'We want this level of performance in this period of time using this methodology.' We achieve the desired perfection in the desired period of time by rapidly going up this pyramid."