ED Accreditation Update
Culture of no harm fuels improvement, attracts national attention
ED-focused interventions slash LWBS rate, door-to-provider times
Since 2007, Henry Ford Health System (HFHS) in Detroit, MI, has been on a highly publicized quest to eliminate harmful events from the health care experience. The organization is going about this task methodically, first identifying and studying the root causes of harm, and then developing solutions and changing health system practices for the better. The work can be tedious to be sure, but it is also clearly effective.
From 2008 to 2011, administrators report that the health system's "No Harm Campaign" has resulted in a 26% reduction of harmful events and a 12% drop in mortality. While it is true that most hospitals are successfully reducing harmful events, the average annual reduction in harmful events is just 1% or 2%, according to HFHS administrators.
For its efforts, the health system was recently selected by The Joint Commission (TJC) and the National Quality Forum (NQF) to receive the 2011 John M. Eisenberg Patient Safety and Quality Award for innovation and patient safety and quality at the local level. But its campaign is hardly over. The health system is aiming to reduce harmful events by 50% by 2013, an ambitious goal, but one that the organization is on track to achieve, according to William Conway, MD, senior vice president and chief quality officer, Henry Ford Health System, and chief medical officer, Henry Ford Hospital in Detroit, MI.
"We are focused on a couple of high-volume categories this year," he explains, noting that quality teams are applying the health system's data-driven improvement efforts at reducing pressure ulcers and urinary tract infections (UTIs), which are both common events in the hospital setting. "As we approach the 50% mark, the rate [of reduction] is going to slow down a little bit because we tend to harvest a lot of low-hanging fruit initially."
Pressure ulcers and UTIs are just two of roughly 30 categories of harm that the health system regularly tracks in what administrators are calling the "harm index," says Conway. "We have teams working on addressing most of those things," he says, explaining that the ever-present data keep the pressure on these teams to find new ways to reduce harm.
An example of this, says Conway, is the way one of these improvement teams addressed blood stream infections related to catheter use in dialysis patients. "We tried very hard to reduce catheter use, which, for a variety of reasons, was very hard to do," he says. "We kept pressing the group to find a way to eliminate blood stream infections, and so they found an approach that involved closing the catheter at the end of dialysis with an antibiotic solution. This has reduced blood stream infections by 70%." (See also "Building blocks for success in establishing a culture of 'no harm,'" below.)
Lean facilitators drive ED improvements
The ED has been the focus of many of these improvement efforts aimed at reducing harm. For instance, in 2009, the ED at Henry Ford Hospital put its patient flow process under a microscope in an effort to eliminate bottlenecks and reduce the leave-without-being seen (LWBS) rate, which was running at 5% to 6% at that time. "We had a stacked process," explains Joyce Farrer, RN, MSN, the administrator of Network Emergency Services at the hospital. Essentially, the practice of fully registering patients toward the front end of their visit was bogging the system down, she says.
Farrer decided that a team of front-line staff should investigate solutions and actually drive the improvement effort, so she interviewed nurses and techs interested in becoming "lean facilitators," and she tapped four of these candidates to actually participate in an ED collaborative sponsored by the Michigan Hospital Association. The team also had the assistance of Kevin Castile, a management engineer at HFHS who has been working with the ED on its improvement efforts.
A key aspect of the lean team's redesign of the patient flow process was the implementation of bedside registration. However, the ED got stiff resistance to the idea from registrars, who were part of a different department. "We were not getting very far with the registration staff, so we decided that we would train all the nurses to do quick registrations as well as triage," says Farrer. This was a battle in itself, she says, because the nurses were not particularly happy about taking on an additional responsibility. "However, they recognized that something needed to be done," she says.
To get 170 personnel up to speed on how to do quick registrations, the lean team first trained super users, and then the super users worked with the lean team to train the rest of the staff, adds Farrer. At the same time, the lean team reengineered the front end of the care process so that many of the tasks that were traditionally completed at triage, such as medicine reconciliation, for example, were moved to later in the care process so that patients could be placed in a room and connected with a provider as quickly as possible, explains Farrer.
When the ED went live with the new approach in February of 2011, the four-member lean team took charge of driving the implementation. "For the first two weeks, they made sure that they were covering almost every shift, so they were able to talk people through [the new process], and there was a lot of resistance," recalls Castile. "However, having them there to trouble-shoot and help people through made a difference."
Persistence is essential
Since the start date, there have been a number of tweaks to the system, not the least of which is a new willingness on the part of registration staff to complete the registration process for patients at the bedside, using new computers on wheels provided by the ED. "Having the nurses agree to do the quick registrations at triage almost became a bargaining chip," says Castile. "There were a lot of meetings between the ED staff and the registration staff around this issue."
A year after implementation, the LWBS rate has been more than halved to just over 2%, and the average door-to-provider time has gone from 50 minutes to 26 minutes. While there is still occasional staff grumbling about the process, the results have gone a long way toward quieting such discontent. "The nurses still may not think that they should have to do [quick registrations], but they know it was the right thing to do," says Farrer.
Physicians are pleased with the new process, too, primarily because they are getting to the patients sooner, explains Gerard Martin, MD, chairman of the Department of Emergency Services at HFH. However, he credits the success of the approach to the front-line staff who drove the process. "They met every week, they took feedback from everybody, and they took a lot of heat, but they kept coming back and they didn't give up," says Martin. "I think if you don't have dedicated people who are constantly working at this, you may be able to make some changes, but they won't be sustainable. That is the key thing — to sustain it."
- Kevin Castile, Management Engineer, Henry Ford Health System, Detroit, MI. E-mail: [email protected].
- William Conway, MD, Senior Vice President and Chief Quality Officer, Henry Ford Health System, and Chief Medical Officer, Henry Ford Hospital, Detroit, MI. E-mail: [email protected].
- Joyce Farrer, RN, MSN, Administrator, Network Emergency Services, Henry Ford Hospital, Detroit, MI. Phone: 313-916-2600.
- Gerard Martin, MD, Chairman, Department of Emergency Services, Henry Ford Hospital, Detroit, MI. E-mail: [email protected].
Building blocks for success in establishing a culture of "no harm"
Quality improvements are never easy across a large organization, but Henry Ford Health System's "No Harm Campaign" has been able to reduce harmful events by as much as 7% or 8% annually in each of the past four years, according to William Conway, MD, senior vice president and chief quality officer, Henry Ford Health System, and chief medical officer, Henry Ford Hospital in Detroit, MI. As a result, Conway is often asked what the keys are to the health system's success. He breaks his answer down into six categories:
- Get leadership on board: "This is what drives the [No Harm Campaign]," stresses Conway. "Our CEO is very engaged in the effort, as is our board. That kind of attention is very important."
- Be transparent: The health system disseminates data about its performance across the organization. "We don't mask what is happening in one unit or department from another. It is just all laid out," says Conway. "That creates a certain amount of peer pressure to improve performance."
- Work on culture: Process improvements are obviously critical, but if you don't also work on culture change, the positive results will not be sustained, says Conway.
- Be efficient: "We have relied on existing committees so that we don't have to put new structures in place," says Conway. "The chief medical officers and the chief nursing officers in the system are responsible for broad categories, and they are held accountable to improve those." Also, there are 450 safety champions embedded in departments across the health system, says Conway. Leadership can then feed information and talking points to these champions to disseminate in their own settings.
- Think big and choose slogans carefully: Why? Because it's important to capture the interest and the passion of health care workers. To that end "no harm" works better than "safety initiative," says Conway. "You have to get the heart of people involved."
- Borrow and steal: Henry Ford Health System has been involved with five different collaboratives focused on enhancing safety in the hospital setting. "We steal ideas from anybody anywhere," says Conway.
The Joint Commission: Four key root causes loom large in sentinel event data
Broad data serve as an alert for hospitals to focus on their own events
While there are multiple contributing factors to most sentinel events, The Joint Commission (TJC) reports that four key areas — leadership, human factors, communication, and assessment — are at the root of these events with much greater frequency than other causes. This is according to data voluntarily supplied to TJC by accredited health care organizations for the years between 2004 and 2011.
"These are the [root causes] that are most pervasive because they are really core to where risk is, and at a very high level," explains Ana Pujols McKee, MD, the executive vice president and chief medical officer at TJC. For example, McKee notes that the category of "human factors" can pertain to whether an organization has the right level of staff with the appropriate competencies and training to work in a specific environment.
"When an organization makes changes to where it stores and maintains equipment, if the staff is not properly oriented to the new system although the staff might be very capable, they might be totally uninformed about this new system," she says, explaining that this is where problems can begin. In this same example, leadership and communication could also be cited as root causes of the problem, she says.
Assessment can be a huge issue in sentinel events, says McKee, because the evaluation that a clinician makes then leads to a diagnosis, interventions, and the timing and urgency of those interventions. "Let's say that in this process it is overlooked that a patient has an allergy," says McKee, explaining that this error can lead to a serious adverse event. "The way I look at assessment is that it is an opportunity to gather every bit of information and to process that information so that you reduce the risk of injury," she says.
These top four root causes were cited most often as contributing to delays in treatment events that resulted in death or a permanent loss of function. This is an area of particular concern to EDs because time-to-treatment is always a prime focus.
Communication was the most often cited root cause in this category, and that is no surprise, says McKee, noting that part of the problem is the increasing use of personal devices to transmit information. "Whether you are texting or emailing, the assumption is that the information is [delivered] instantaneously and always captured, but the [intended recipient] might be asleep or he may not be carrying the personal device that is being sent the critical information, so technology is complicating this issue," she says.
Similarly, information does not always flow to where it should go in an electronic medical record; it may be buried in a free text section of the EMR, and the clinician may miss it, explains McKee. "This is another human factor area that is implicated," she adds.
The root cause categories are very broad, and should be used mainly as an alert to health care organizations to analyze their own events and practices to see where improvements can be made, says McKee. "Look for the common trends [in your own data] so you can really address them in a focused manner."
- Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer, The Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5000.
New online portal takes aim at health care-associated infections
Health care organizations have a new resource at their disposal to fight against health care-associated infections (HAI). The Joint Commission and the Joint Commission Center for Transforming Healthcare have unveiled the HAI Portal, a site that contains information and tools to help providers curb the incidence of HAIs in their own settings. The site contains both free and for-purchase items, including prevention strategies, performance measures, and infection data related to different settings of care. The HAI Portal can be accessed at: www.jointcommission.org/hai.aspx.
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