Jane Englebright

Organisational culture: variation across hospitals and connection to patient safety climate

Context Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement. Objective To determine if an organisational group culture shows better alignment with patient safety climate. Design Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals. Participants 1406 nurses, ancillary staff, allied staff and physicians. Main outcome measures Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA). Results The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r=0.44 to 0.55, except situational recognition), ScSc (r=0.47) and IA (r=0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics. Conclusions Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisations culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives.

Reduction of Severe Hyperbilirubinemia After Institution of Predischarge Bilirubin Screening

OBJECTIVE: The objective of this study was to demonstrate efficacy of universal predischarge neonatal bilirubin screening in reducing potentially dangerous hyperbilirubinemia in a large, diverse national population. METHODS: This was a 5-year prospective study directed at neonates who were aged ≤28 days and evaluated at facilities of the Hospital Corporation of America with a serum bilirubin level of ≥20.0 mg/dL. This time frame includes periods before, during, and after the initiation of systemwide institution of a program of universal predischarge neonatal bilirubin screening. The primary outcome measures were serum bilirubin 25.0 to 29.9 and ≥30.0 mg/dL. Neonatal phototherapy use during these years was also analyzed. RESULTS: Of the 1028817 infants who were born in 116 hospitals between May 1, 2004, and December 31, 2008, 129345 were delivered before implementation and 899472 infants were delivered after implementation of this screening program in their individual hospitals. With a program of universal screening, the incidence of infants with total bilirubin 25.0 to 29.9 mg/dL declined from 43 per 100000 to 27 per 100000, and the incidence of infants with total bilirubin of ≥30.0 mg/dL dropped from 9 per 100000 to 3 per 100000 (P = .0019 and P = .0051, respectively). This change was associated with a small but statistically significant increase in phototherapy use. CONCLUSIONS: A comprehensive program of prevention, including universal predischarge neonatal bilirubin screening, significantly reduces the subsequent development of bilirubin levels that are known to place newborns at risk for bilirubin encephalopathy.

Emergency department use during the postpartum period: implications for current management of the puerperium.

OBJECTIVE The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge. STUDY DESIGN We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions. RESULTS During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge. CONCLUSION The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

Data-driven process and operational improvement in the emergency department: the ED Dashboard and Reporting Application.

EXECUTIVE SUMMARY Emergency departments (EDs) in the United States are expected to provide consistent, high‐quality care to patients. Unfortunately, EDs are encumbered by problems associated with the demand for services and the limitations of current resources, such as overcrowding, long wait times, and operational inefficiencies. While increasing the effectiveness and efficiency of emergency care would improve both access and quality of patient care, coordinated improvement efforts have been hindered by a lack of timely access to data. The ED Dashboard and Reporting Application was developed to support datadriven process improvement projects. It incorporated standard definitions of metrics, a data repository, and near real‐time analysis capabilities. This helped acute care hospitals in a large healthcare system evaluate and target individual improvement projects in accordance with corporate goals. Subsequently, there was a decrease in “arrival to greet” time—the time from patient arrival to physician contact—from an average of 51 minutes in 2007 to the goal level of less than 35 minutes by 2010. The ED Dashboard and Reporting Application has also contributed to datadriven improvements in length of stay and other measures of ED efficiency and care quality. Between January 2007 and December 2010, overall length of stay decreased 10.5 percent while annual visit volume increased 13.6 percent. Thus, investing in the development and implementation of a system for ED data capture, storage, and analysis has supported operational management decisions, gains in ED efficiency, and ultimately improvements in patient care.

The Chief Nurse Executive Role in Large Healthcare Systems

Community hospitals are most frequently led by nonclinicians. Although some may have employed physician leaders, most often clinical leadership is provided by a chief nurse executive (CNE) or chief nursing officer. Clinical leadership of community hospital and health systems may similarly be provided by a system-level nursing executive or, often, by a council of facility CNEs. The increasingly competitive healthcare environment in which value-based purchasing of healthcare and pay-for-performance programs demand improved clinical performance for financial success has led to reconsideration of whether a council model can provide either the leadership or adequate attention to clinical (and operational) improvement. In turn, community hospitals and health systems look to CNE or chief nursing officer roles at the highest level of the organization as resources that are able to segue between the clinical and operational domains, translating clinical performance demands into operating strategies and tactics. This article explores CNE characteristics required for success in these increasingly responsible and visible roles.

A bundled approach to reduce methicillin-resistant Staphylococcus aureus infections in a system of community hospitals.

&NA; Methicillin‐resistant Staphylococcus aureus (MRSA) infections pose a significant challenge to U.S. healthcare facilities, but there has been limited study of initiatives to reduce infection and increase patient safety in community hospitals. To address this need, a multifaceted program for MRSA infection prevention was developed for implementation in 159 acute care facilities. This program featured five distinct tools—active MRSA surveillance of high‐risk patients, enhanced barrier precautions, compulsive hand hygiene, disinfection and cleaning, and executive champions and patient empowerment—and was implemented during 1Q–2Q 2007. Postintervention (3Q 2007–2Q 2008), 10.2% of patients with high‐risk for infection or complications due to MRSA had nasal colonization. Volume of disposable gown and alcohol‐based hand sanitizer use increased substantially following program implementation. Self‐reported rates, based on NHSN definitions, of healthcare‐associated central line‐associated bloodstream infections and ventilator‐associated pneumonia due to MRSA decreased 39% (p < .001) and 54% (p < .001), respectively. Infection rates continued to decrease during the follow‐up period (1Q–4Q 2009). This sustained improvement demonstrates that reducing healthcare‐associated MRSA infections in a large number of diverse facilities is possible and that a “bundled” approach that translates science into clinical and executive performance expectations may aid in overcoming traditional barriers to implementation.

Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia.

BACKGROUND Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP. OBJECTIVE We recently conducted a national collaborative aimed at reducing health care-associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases. DESIGN This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections. SETTING The setting of the study was 110 ICUs at 61 HCA hospitals. INTERVENTION None. MEASUREMENTS AND RESULTS We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients. CONCLUSIONS We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

Rapid Core Measure Improvement Through a “Business Case for Quality”

AbstractIncentives to improve performance are emerging as revenue or financial penalties are linked to the measured quality of service provided. The HCA “Getting to Green” program was designed to rapidly increase core measure performance scores. Program components included (1) the “business case for quality”—increased awareness of how quality drives financial performance; (2) continuous communication of clinical and financial performance data; and (3) evidence‐based clinical protocols, incentives, and tools for process improvement. Improvement was measured by comparing systemwide rates of adherence to national quality measures for heart failure (HF), acute myocardial infarction (AMI), pneumonia (PN), and surgical care (SCIP) to rates from all facilities reporting to the Centers for Medicare and Medicaid Services (CMS). As of the second quarter of 2011, 70% of HCA total measure set composite scores were at or above the 90th percentile of CMS scores. A test of differences in regression coefficients between the CMS national average and the HCA average revealed significant differences for AMI (p = .001), HF (p = .012), PN (p < .001), and SCIP (p = .015). This program demonstrated that presentation of the financial implications of quality, transparency in performance data, and clearly defined goals could cultivate the desire to use improvement tools and resources to raise performance.

Implementation of standardized pediatric i.v. medication concentrations.

PURPOSE The development and implementation of a comprehensive and standardized list of pediatric i.v. medication concentrations across a large healthcare system are described. SUMMARY In accordance with National Patient Safety Goals, facilities affiliated with the Hospital Corporation of America system had independently standardized and limited the number of drug concentrations in use. This resulted in variation among facilities, which prevented the systemwide standardization of drug dictionaries within the computerized pharmacy and prescriber-order-entry systems, complicated the movement of providers among facilities, and contributed to inconsistency in medication prescribing. A team of experts collaborated to create a comprehensive standard list that included 119 medications and 372 concentrations for pediatric i.v. medications. Implementation of this standard list was driven through a financial incentive from the malpractice insurance provider; facilities that completed the required activities for this optional program could apply for a credit of a portion of their malpractice insurance cost. For the standardization of pediatric i.v. medications, required activities included approval of the standard medication list, incorporation of this list into facility pharmacy dictionaries, and update of all smart pump software to include only the new standard medications and concentrations. Of the 145 facilities that were eligible for the implementation of standard pediatric i.v. medication concentrations, 141 (97%) completed all requirements and received the 2% malpractice insurance cost credit. CONCLUSION The use of a financial incentive strategy, in the form of a malpractice insurance credit, successfully motivated the implementation of standardized pediatric medication concentrations across a large healthcare system.

A Comprehensive Program to Reduce Rates of Hospital-acquired Pressure Ulcers in a System of Community Hospitals.

Objectives The prevention of hospital-acquired pressure ulcers (PrUs) has significant consequences for patient outcomes and the cost of care. Providers are challenged with evaluating available evidence and best practices, then implementing programs and motivating change in various facility environments. Methods In a large system of community hospitals, the Reducing Hospital Acquired–PrUs Program was developed to provide a toolkit of best practices, timely and appropriate data for focusing efforts, and continuous implementation support. Baseline data on PrU rates helped focus efforts on the most vulnerable patients and care situations. Facilities were empowered to use and adapt available resources to meet local needs and to share best practices for implementation across the system. Outcomes were measured by the rate of hospital-acquired PrUs, as gathered from patient discharge records. Results The rate of hospital-acquired stage III and IV PrUs decreased 66.3% between 2011 and 2013. Of the 149 participating facilities, 40 (27%) had zero hospital-acquired stage III and IV PrUs and 77 (52%) had a reduction in their PrU rate. Rates of all PrUs documented as present on admission did not change during this period. A comparison of different strategies used by the most successful facilities illustrated the necessity of facility-level flexibility and recognition of local workflows and patient demographics. Conclusions Driven by the combination of a repository of evidence-based tools and best practices, readily available data on PrU rates, and local flexibility with processes, the Reducing Hospital Acquired–PrUs Program represents the successful operationalization of improvement in a wide variety of facilities.