Laura Winner

How will we know patients are safer? An organization-wide approach to measuring and improving safety

Objective:Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. Design:We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. Setting:Health care institutions. Results:Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. Conclusion:The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.

Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality.

Objective: Few data exist on successes at reducing pediatric catheter-associated bloodstream infections (CA-BSI). The objective was to eradicate CA-BSI with a multifaceted pediatric-relevant intervention proven effective in adult patients. Design: Prospective cohort of pediatric intensive care (PICU) patients with historical controls. Setting: Multidisciplinary PICU. Patients/Participants: PICU patients with intervention targeting PICU providers. Interventions: Multifaceted intervention involving preintervention staff surveys, provider educational program, creation of central catheter procedure cart, guideline-supported central catheter insertion checklist, nursing staff empowerment to stop procedures that breached guidelines, and real-time data feedback to PICU leadership. Measurements and Main Results: We measured rate of CA-BSI per 1000 catheter days from August 2001 through September 2006. Reliable use of evidence-based best practices for insertion of central catheters in our PICU was associated with a statistically and clinically significant decrease in our CA-BSI rate for 24 months postintervention (p < .05). During a portion of this postintervention period, we experienced a dramatic increase in our CA-BSI rate that was ultimately found to be due to the introduction of a new positive displacement mechanical valve intravenous port in April 2004. After removal of this positive displacement mechanical valve, our CA-BSI rate dropped from 5.2 ± 4.5 CA-BSI per 1000 central catheter days to a rate of 3.0 ± 1.9 CA-BSI per 1000 central catheter days. Chart review of postintervention CA-BSI cases revealed that these patients acquired CA-BSI weeks after both PICU admission and after insertion of the most recent central catheter. Conclusions: Our data show that improving practices for insertion of central catheters leads to a reduction of CA-BSI among pediatric patients but not elimination of CA-BSI. More research is needed to identify best practices for maintenance of central catheters for children. In addition, our experience shows that even despite good interventions to control CA-BSI, institutions must remain vigilant to factors such as new technology with apparent advantages but short track records of use.

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.

In this article, the authors describe an initiative that established an infrastructure to manage quality and safety efforts throughout a complex health care system and that improved performance on core measures for acute myocardial infarction, heart failure, pneumonia, surgical care, and children’s asthma. The Johns Hopkins Medicine Board of Trustees created a governance structure to establish health care system-wide oversight and hospital accountability for quality and safety efforts throughout Johns Hopkins Medicine. The Armstrong Institute for Patient Safety and Quality was formed; institute leaders used a conceptual model nested in a fractal infrastructure to implement this initiative to improve performance at two academic medical centers and three community hospitals, starting in March 2012. The initiative aimed to achieve ≥ 96% compliance on seven inpatient process-of-care core measures and meet the requirements for the Delmarva Foundation and Joint Commission awards. The primary outcome measure was the percentage of patients at each hospital who received the recommended process of care. The authors compared health system and hospital performance before (2011) and after (2012, 2013) the initiative. The health system achieved ≥ 96% compliance on six of the seven targeted measures by 2013. Of the five hospitals, four received the Delmarva Foundation award and two received The Joint Commission award in 2013. The authors argue that, to improve quality and safety, health care systems should establish a system-wide governance structure and accountability process. They also should define and communicate goals and measures and build an infrastructure to support peer learning.

The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice.

Academic medical centers (AMCs) could advance the science of health care delivery, improve patient safety and quality improvement, and enhance value, but many centers have fragmented efforts with little accountability. Johns Hopkins Medicine, the AMC under which the Johns Hopkins University School of Medicine and the Johns Hopkins Health System are organized, experienced similar challenges, with operational patient safety and quality leadership separate from safety and quality-related research efforts. To unite efforts and establish accountability, the Armstrong Institute for Patient Safety and Quality was created in 2011. The authors describe the development, purpose, governance, function, and challenges of the institute to help other AMCs replicate it and accelerate safety and quality improvement. The purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste in health care. A governance structure was created, with care mapped into seven categories, to oversee the quality and safety of all patients treated at a Johns Hopkins Medicine entity. The governance has a Patient Safety and Quality Board Committee that sets strategic goals, and the institute communicates these goals throughout the health system and supports personnel in meeting these goals. The institute is organized into 13 functional councils reflecting their behaviors and purpose. The institute works daily to build the capacity of clinicians trained in safety and quality through established programs, advance improvement science, and implement and evaluate interventions to improve the quality of care and safety of patients.

Successful Implementation of a Perioperative Glycemic Control Protocol in Cardiac Surgery: Barrier Analysis and Intervention Using Lean Six Sigma

Although the evidence strongly supports perioperative glycemic control among cardiac surgical patients, there is scant literature to describe the practical application of such a protocol in the complex ICU environment. This paper describes the use of the Lean Six Sigma methodology to implement a perioperative insulin protocol in a cardiac surgical intensive care unit (CSICU) in a large academic hospital. A preintervention chart audit revealed that fewer than 10% of patients were admitted to the CSICU with glucose <200 mg/dL, prompting the initiation of the quality improvement project. Following protocol implementation, more than 90% of patients were admitted with a glucose <200 mg/dL. Key elements to success include barrier analysis and intervention, provider education, and broadening the project scope to address the intraoperative period.

Applying Lean Sigma Solutions to Mistake-Proof the Chemotherapy Preparation Process

BACKGROUND Errors related to high-alert medications, such as chemotherapeutic agents, have resulted in serious adverse events. A fast-paced application of Lean Sigma methodology was used to safeguard the chemotherapy preparation process against errors and increase compliance with United States Pharmacopeia 797 (USP 797) regulations. WORKSHOP STRUCTURE AND PROCESS On Days 1 and 2 of a Lean Sigma workshop, frontline staff studied the chemotherapy preparation process. During Days 2 and 3, interventions were developed and implementation was started. FINDINGS AND INTERVENTIONS The workshop participants were satisfied with the speed at which improvements were put to place using the structured workshop format. The multiple opportunities for error identified related to the chemotherapy preparation process, workspace layout, distractions, increased movement around ventilated hood areas, and variation in medication processing and labeling procedures. Mistake-proofing interventions were then introduced via workspace redesign, process redesign, and development of standard operating procedures for pharmacy staff. Interventions were easy to implement and sustainable. Reported medication errors reaching patients and requiring monitoring decreased, whereas the number of reported near misses increased, suggesting improvement in identifying errors before reaching the patients. DISCUSSION Application of Lean Sigma solutions enabled the development of a series of relatively inexpensive and easy to implement mistake-proofing interventions that reduce the likelihood of chemotherapy preparation errors and increase compliance with USP 797 regulations. The findings and interventions are generalizable and can inform mistake-proofing interventions in all types of pharmacies.

Operating management system for high reliability: Leadership, accountability, learning and innovation in healthcare

The healthcare industry is on the journey toward high reliability. The industry works diligently to improve safety and quality, adopting some vitally important high reliability organization practices. While positive steps forward, these practices tend to be discrete initiatives to address specific challenges, and high reliability remains elusive. The journey taught us to view quality and safety not as a project, or even a portfolio of projects, but as an integrated operating management system. We are learning from industries that are further along on the high reliability organization journey, especially those compelled by widely publicized mishaps. These industries developed international consensus standards for integrated management systems to assure operational safety, quality, and reliability. Healthcare needs to evolve accordingly. Our work is informed by advanced systems engineering and mission assurance methodology, and research in high reliability organizing. The operating management system fosters two fundamental ways of working. First, it organizes processes and practices using a systems engineering approach to anticipate and reduce risks, mindfully standardizing work to prevent mishaps and improve performance. Second, it creates a culture of systems thinking and collaboration, building resiliency to recover from mishaps, when they occur, and promote mindful variation to deal effectively with unexpected situations. We share our motivation and approach to developing the operating management system, implementation examples and results achieved. While there is currently a large gap between idealized, highly reliable operations and current practice in healthcare, our experience demonstrates the benefits of this integrated systems management approach to address contemporary challenges and advance on the journey toward high reliability.

Use of Cascading A3s to Drive Systemwide Improvement

M financial pressures and uncertainty have led to mergers and acquisitions of smaller hospitals by larger competitors across the United States. This practice has resulted in complex, unaligned health care delivery systems, and has shown limited evidence that these mergers have improved the quality of care, or reduced costs. To achieve benefit, large health systems require a governance structure that establishes a line-of-oversight for quality of care from the board to the bedside; a leadership system that clearly communicates the mission and strategic objectives, including the goals and measures; and a management system to cascade the goals and to deploy disciplined performance improvement methods to standardize work, a visual display of performance data, and regular performance reviews. Lean is an effective process improvement and management system, aligning organizations to achieve systemwide strategic goals. When an organization’s governance, leadership, and management systems are aligned, substantial improvement can occur. In this article, we describe a novel use of the A3, called a cascading A3, which our management system uses to align strategy deployment across our health system. The A3 is an integral component of the Johns Hopkins Medicine (JHM; Baltimore) management system. Named for the A3 international paper size of roughly 11” × 17”, its use for improvement originated at Toyota, where managers desired a concise synopsis of the problem identified, the root causes found on investigation, and the resolution on a single page. Rooted in leveraging the wisdom of frontline experts and going to the “gemba” (meaning the place where the work occurs, such as a clinical unit), the A3 promotes both objectivity through data-driven root cause analysis of poor performance and collective selection and implementation of effective interventions to resolve performance gaps. An A3 is more than a structured piece of paper; it is a disciplined way of collaborative problem solving in a work area using scientific thinking. The power of the A3 approach is in the thinking and behaviors it promotes that create a workforce of problem solvers.1 Use of the A3 for point improvement in health care has been described by others.2–4 A3 thinking can also promote strategic alignment up and down the organization through the use of cascading A3s. TOOL DEVELOPMENT

How to Select and Scope a Project

You’ll likely encounter many opportunities to improve patient care delivery processes on a daily basis. In this chapter, we will share the best practices for selecting the “right” project and scope in order to improve your chances of success.

Tales from the Frontline Implementing an E-Prescription Technology

Health Information Technology (HIT) has great potential to enhance patient care and improve efficiency of health care delivery if it is appropriately designed, implemented and used. In 2009 the Office of the National Coordinator (ONC) created Meaningful Use (MU) incentives to promote HIT adoption, which has spurred major investment in HIT, but the program has shown no reduction in use errors. Because the MU program mainly focuses on clinical process measures, with no attention to the processes of system design and implementation, many organizations encounter challenges to attain the MU. Previous studies identified lack of adequate implementation plans, lack of team support, lack of workflow analysis, and lack of dedicated resources as main barriers to MU attainment. We have identified similar concerns, and here present tales from the frontline to show perceptions of end users when our organization rushed through the implementation of e-prescription technology to meet the MU deadlines. Insufficient attention to the design and implementation process has put our organizations at risk. Reactive mitigation solutions were put in place to counteract the identifiable potential risks.