Rapid change starts small, goes big

St. Marys stems drug incidents, lowers LOS

Everyone at St. Marys Hospital Medical Center in Madison, WI, agreed the rate of medication errors was far too high. But, even though they tracked and analyzed medication incidents since the late 1980s, they couldn't get the problem under control. They revised forms and altered the transcription process. All to no avail. So by 1996, the climate was ripe for real change.

That's when the hospital invested $15,000 to participate in the Boston-based Institute for Healthcare Improvement's (IHI) Breakthrough Series on Reducing Adverse Drug Events and Medical Errors. In less than one year, they reduced the troubling near-miss and medication error rates. (Near misses are anything that would result in an error if not caught.) "But first, we had to move away from the crusade to reduce medication errors and into a focused study area," explains St. Marys CQI facilitator Timothy Hallock, MS. (See related story,: "Strategies for quick, lasting change," p. 111.)

"We learned that we had to build a body of knowledge before taking on the large system. We could get a lot more done that way." he says. "We piloted and tested the changes in small units. We didn't try to apply them housewide at first because if they failed, we could screw up the whole system."

In March 1996, the pilot launched on 6 West, a unit with high rates of drugs dispensed as well as high rates of medication incidents. It was a likely venue due to the variety of consulting and attending physicians, experienced nursing staff, and supportive unit director. The interdisciplinary team consisted of four nurses; three pharmacists, including the director of pharmacy; and Sherry Anderson, RN, nursing QI coordinator.

Instead of focusing on general medication errors, the team narrowed its efforts to timely administration IV antibiotics - an area fraught with near misses. Their objectives were:

1. Achieve 100% compliance with a two-hour order-to-start time for IV antibiotic administration and standardized follow-up administration schedule.

2. Designate improvement measures (e.g. percent of first dose within two hours, length of stay, and total charges).

3. Develop improvements for pilot testing.

4. Pilot changes on 6 West.

5. Replicate lessons learned from the pilot to hospitalwide changes.

Hallock says, "We really didn't spend a lot of time getting consensus for the change; we just got them to try it. We found out what worked and what didn't."

Using the Plan-Do-Study-Act (PDSA) model learned at IHI, the team telescoped the change steps into a rapid cycle of sampling patient charts, identifying the near misses and applying solutions. They conducted one PDSA improvement cycle per week so they continuously measured and learned, then designed and tested the next improvement. (For more on rapid change methods, see QI/TQM, April 1998, p. 41, and QI/TQM, August 1997, p. 97.)

Unlike traditional processes where interventions drag on and real outcomes seem too distant to matter, the prospect of short-interval change and improvement captured the team's commitment. "The communication helped people to see how the changes could affect them," Anderson notes. And, the PDSA model is a powerful team builder. (For a time line for the change process, see table, above.)

Stripped down version hooked the team

In sharing the job of data collection and analysis, people grew to understand it better. They collected random samples of five records a week for newly admitted patients who had received antibiotics within the last 24 hours.

This stripped-down data handling process, learned early in the project, hooked the team immediately because it was a relief from the 30- to 50-chart samples and two-day analysis ordeals they started with. They could analyze five charts in 20 minutes a week. "We could see definite trends with five charts," Anderson notes, "because we're not looking for statistically valid data. Historical data are not beneficial. We need to look at the day-to-day incidents."

Although the median number of reported medication incidents during the project only dropped from 75 to 60, the real improvements showed up in timely administration of IV antibiotics. The pilot unit sustained a 100% compliance rate for starting antibiotics within two hours of receiving orders. Hospitalwide, compliance is 97%.

The most remarkable outcomes, however, were in lengths of stay for pneumonia patients (cut nearly two days) and average cost for pneumonia patients (down almost $1,000 per patient). Both of these outcomes improved while the severity of pneumonia patients remained constant. (See graphs, above.)

St. Marys had not calculated its return on its $15,000 investment in the IHI project. However, Hallock says, through regular information sharing with the 20 organizations that participated in the collaborative, St. Marys continually learns additional ways to reduce adverse medication reactions and errors, information that would be hard to place a dollar value on.

Caught up in the euphoria from the project, co-workers still stop Hallock in the halls and tell him "We should do more projects like this all over the hospital." To which Hallock replies, "You can't do it all over the hospital. You have do it right on a small scale first."

In its first application of the PDSA change model, the team found a classroom for changes many St. Marys' employees have dreamed of for years. As Anderson puts it, "We learned volumes!" Here are a few of the lessons she and Hallock report:

· Introduce change to ripe cultures. Don't frustrate your less-than-ready colleagues by trying to pilot changes with them. Instead, show them results from successful changes in other parts of the system and suggest that it could work as well for them.

· Show each constituency how proposed changes will be meaningful to them. For example, physicians resonate to improved patient outcomes while nurses would welcome guidelines for reducing medication incidents on their units.

· Expect a labor-intensive start-up phase. Anderson reports that the staff training and preparation took two to three months. Then, it took another month to build the interdisciplinary team and design workable schedules.

· Make changes user-friendly only after they prove to be effective. Wait until a change has earned its keep by producing the results you want before you invest time in fancy diagrams and widely disseminated instructions.

· "Don't buy a 747 jetliner if all you want is a bag of peanuts." Anderson makes the point that practicality is the hallmark of lasting change. If you're really serious about change, plan it with the people who will have to implement it.