Eliminating perioperative adverse events at Ascension Health.

BACKGROUND: For Ascension Health's Healthcare That Is Safe strategy, Sacred Heart Hospital (SHH) and Columbia St. Mary's (CSM) served as alpha sites to develop strategies to eliminate perioperative adverse events (POAEs). The alpha sites set an interim goal of a 50% reduction of POAEs, then 100%, or elimination of POAEs by July 2008. IMPLEMENTATION: The alpha sites identified a process for data management to establish clear, measurable elements for each of the five strategies of the alpha initiative; created an infrastructure to foster transformational change in the operating room suite; and implemented tactics to measure the success of the five strategies. STRATEGIES AND TACTICS: The sites implemented tactics for five strategies: (1) prevention of errors due to human factors, (2) prevention of surgical site infections, (3) prevention of adverse perioperative cardiac events, (4) prevention of postoperative venous thromboembolism, and (5) prevention of postoperative hemorrhage. RESULTS: Both alpha sites achieved > or = 90% reduction in the POAE rate. DISCUSSION: A number of key learnings were drawn from the alpha experiences, including the need to adjust to evolving definitions and guidelines for implementation and measurement of perioperative care.

Eliminating birth trauma at Ascension Health.

BACKGROUND: Ascension Health identified perinatal safety as one of eight priorities for action in a systemwide effort to achieve zero preventable injuries and deaths by July 2008. IMPLEMENTATION: Three alpha sites developed and implemented transformational practices aimed at eliminating preventable birth trauma. Standardized order sets linked to all major areas of obstetrical care were either updated or developed and then tested and incorporated into the work flow of the labor and delivery units. Best practices were shared via team meetings and conference calls. Each site created systems to ensure that evidence-based practices were reliably followed for high-risk conditions associated with perinatal harm, that robust strategies for communication were adopted, and that collaborative practice was promoted among caregivers. RESULTS: By June 2006, all facilities achieved birth trauma rates that were at or near zero in conjunction with the implementation of these practices. DISCUSSION: Three alpha sites of differing size, patient demographics, and available resources, using a combined uniform and facility-specific approach, achieved a significant reduction in the incidence of birth trauma. Yet each site adopted unique site-specific processes designed to enhance practice on the basis of unit or institutional culture, market challenge, and/or the prospect for success.