NQF, TJC honor Kaiser implant project

Eisenbergs also go to two other winners

Choosing a pacemaker has its parallels to buying a car: There are different makes and models. You want one that’s safe and reliable and doesn’t break the bank. And every manufacturer says its version is the best. It was the lack of comparative knowledge that led a group of Kaiser cardiologists in the 1990s to suggest tracking patient outcomes with different units so they could see what worked best. That idea led to an implant registry that has tracked orthopedic, cardiology, and vascular devices in more than 300,000 patients and driven Kasier Permanente to make systemwide decisions on which to use, leading to better outcomes and cost savings. The program won the organization the John M. Eisenberg Patient Safety and Quality Award from The Joint Commission and National Quality Forum.

“A successful project has many parents,” says Jed Weissberg, MD, senior vice president of hospitals, quality and care delivery for the Oakland, CA-based system. “The cardiologists may have come up with the idea, but the orthopedists drove the project and rallied colleagues.” They wanted to know how the various implants in knees, hips, and other joints were impacting their patients’ lives, he says. “The point is to reduce pain and improve function, but that’s not usually captured in EHRs.” Few organizations were collecting this information in any kind of systematic way.

In addition, manufacturers were marketing impressive features and charging more for them. But did they do anything more for patients? “We needed a way to follow these people, see how they did, and be able to give prospective patients a real idea of how they would do. We also wanted to be able to use the information to open a dialogue with manufacturers and get them to do the research that would prove the benefits of any new features they were trying to market for us.”

While the project certainly gave the operative team some additional work — forms to fill out, data to collect and track — the potential information boon to them made it an attractive prospect for them. “They had wanted to know about this for years,” Weissberg says. For the health system, they could also get information about the various practices of different providers, see what worked best and who had the better outcomes and then use that data to get physicians to reduce the variability in their approaches.

Initially, there were maybe a dozen vendors that orthopedists were using for implants, he explains. They were asked to whittle that down to two or three. Physicians could go outside those if there was a good reason. “It took a while for them to learn the new practices, but we now regularly use just two makers, with a third for some specialty implants. Less than 5% of our physicians go outside those three.”

He mentions the use of metal-on-metal Birmingham hip resurfacing. While some people thought it was a great idea, Kaiser wasn’t sure. They sent surgeons for the training at their expense. But the volumes weren’t huge, and they opted not to use it. Now, many with that procedure need revisions. For Kaiser, though, the fact that it wasn’t chosen as a treatment means they don’t have to absorb those revision costs.

The data have proved very useful for physicians and patients alike. A risk calculator based on what they collected allows physicians to input demographic, condition, comorbidity, and other data about a patient and the prospective procedure. The doctor can then tell a patient that based on experience with other patients like him or her, this outcome is expected. “It makes consent much more informed,” Weissberg says.

It has also pointed out problems for certain kinds of implants. “We found an increased revision risk with some ball socket sizes — larger sizes had fewer of them. We sent that data around, practices changed, and we have seen reduced numbers of revisions,” he says. The same thing happened with certain uncemented joints and mono-compartmental knee replacements. “For our patients, these techniques don’t work as well, so we encourage doctors to use alternatives.”

What started in orthopedics expanded to cardiology, where they found that batteries in pacemakers weren’t lasting as long as the manufacturers were saying. “That gave us leverage with them,” he says. They also found that leads were wearing out prematurely. “We track how many are being explanted and when, and we can change practices based on that information.”

A study on implanted defibrillators showed that many in the United States weren’t adhering to best practices on when to use them. “But our data showed we were much more in concordance with when to use them, that we were being much more discriminant and sticking to the contraindications list better than others. These are very expensive devices, so it was good to know that we were using them appropriately. That’s what you can find out when you tie this data to the EHR.”

While the initial impetus was to get outcomes data, Weissberg says that increasingly they are using it to understand costs as well, and to use the information to drive down costs.

Even if you can’t create this kind of registry, he says that standardizing your implant inventories and reducing the number of vendors can help you improve quality. “You want to deal with a smaller universe of implants so that you know more easily that you have the right one. You want to make sure that what you do is benefiting the patient, so that all the pain and effort of something like a hip replacement doesn’t go for naught. And you need to make sure that the people doing this work get the information on how they impact patient lives. Collect this data. It pays off.”

A dedicated life

Dana Farber Cancer Institute’s Saul Weingart, MD, PhD, won the individual Eisenberg for his commitment and national contributions to patient safety through publication, education, research and leadership. Among his accomplishments are creating the Harvard Executive Sessions on Medical Error, one of which led to passage of the Minnesota Adverse Event Reporting Law of 2003; extensive research in understanding the role that patients and families can play in advancing patient safety; leading multiple operational improvement projects including implementation of medication best practices across a six-hospital network; development of one of the earliest medication reconciliation programs; development of a Web portal-based incident reporting system for patients; and development of novel curricula in patient safety and online patient safety courses.

He says that within a couple years of the 1999 Institute of Medicine To Err is Human report on medical errors, the medical community has been galvanized to act on patient safety issues. “Before that, it was mostly research and risk managers who had worked in this area. But it became clear after the report that groups like The Joint Commission and the government were interested in addressing safety in a consistent way. There was an increasing alignment and momentum.”

There have been some great breakthroughs in the past decade as a result. The emphasis on infection control and realizing that hospital-acquired conditions are not just “a cost of doing business but can be prevented” is one, Weingart says. Meaningful Use and health IT is another thing that will have a lasting impact on safety and quality. Patient engagement is something he thinks will also make a different.

“What I worry about, though, is that the next generation of improvements will have to come in the way we deal with routine operations of hospitals and clinics,” he says. “When I look at our organization, we have a robust patient safety program and committed culture, but you can over-grow your infrastructure. You have to reinvent yourself because the very burden and volume of clinical care, of regulation and oversight can have a paradoxical adverse impact on what you have to get done.”

He explains, “You have to figure out how to be both mass production and high touch at the same time. No one has cracked it yet.”

That said, he thinks there are things that every organization can do right now to be safer and to make quality improvement better. First, he says to invite patients to be a part of everything you do. “They understand how things can go right, how they can go wrong, and what your vulnerabilities are.” Of particular value are so-called expert patients. Often they are allied with the healthcare industry and have insiders’ knowledge. They often navigate the system better and have better outcomes.

Next, Weingart says to standardize everything you can as much as you can. Embrace technology, but cautiously. And lastly, set ambitious goals. “If there are best practices you want to implement, don’t do it piecemeal. Go for it. Do it all at once.”

Memorial Hermann Healthcare System of Houston is the other Eisenberg award winner, acknowledged for its High Reliability Journey from Board to Bedside initiative. The project focuses on providing compassionate and efficient care by using high-reliability behaviors, evidence-based care, and harm prevention across the system’s 12 hospitals, 19 ambulatory surgery centers, clinics and other ambulatory care locations. Front line staff lead the quality improvement process, and data are collected and reported monthly. The system aims for 100% goals and zero incidence of harm.

While not available for interview by press time, look for an in depth story on this program in a future issue of Hospital Peer Review.

For more information, contact:

  • Jed Weissberg MD, Senior Vice President, Hospitals, Quality and Care Delivery, Kaiser Permanenete, Oakland, CA. Telephone: (510) 625-3659.
  • Saul Weingart, MD, Ph.D., Vice President for Patient Safety and Quality Improvement and Director, Center for Patient Safety, Dana Farber Cancer Institute, Boston, MA. Telephone: (617) 632-4935.