Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change.

BACKGROUND: Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost. CONTEXT: Our hospital is located in Northern Mississippi and has a 28 bed Medical-Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001-2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients. KEY MEASURES FOR IMPROVEMENT: Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode. STRATEGY FOR CHANGE: Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily "flow" meeting to assess bed availability; (3) "bundles" (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process. EFFECTS OF CHANGE: Between baseline and re-measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973. LESSONS LEARNED: A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.

Improvement, trust, and the healthcare workforce.

Although major defects in the performance of healthcare systems are well documented, progress toward remedy remains slow. Accelerating improvement will require large shifts in attitudes toward and strategies for developing the healthcare workforce. At present, prevailing strategies rely largely on outmoded theories of control and standardisation of work. More modern, and much more effective, theories of production seek to harness the imagination and participation of the workforce in reinventing the system. This requires a workforce capable of setting bold aims, measuring progress, finding alternative designs for the work itself, and testing changes rapidly and informatively. It also requires a high degree of trust in many forms, a bias toward teamwork, and a predilection toward shouldering the burden of improvement, rather than blaming external factors. A new healthcare workforce strategy, founded on these principles, will yield much faster improvement than at present.

Reducing adverse drug events: lessons from a breakthrough series collaborative.

BACKGROUND: In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications. METHODS: The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed. RESULTS: During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols. DISCUSSION: Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.

Crossing the boundary: changing mental models in the service of improvement.

Assumptions constrain the vision and ability of health care systems throughout the world to achieve unprecedented levels of performance. Leaders who want to accelerate improvement should themselves question these assumptions and provide a context in which others can do so. Six current assumptions are particularly troublesome and particularly worthy of careful reconsideration: (i) that future performance levels will be approximately the same as current levels (rather than believing in the pervasive possibility of breakthrough); (ii) that measurement induces improvement (rather than emphasizing leadership of change as the key to improvement); (iii) that professional and organizational boundaries must be carefully preserved (rather than reducing those boundaries); (iv) that patients are passive and caregivers are active (rather than working from strong notions of equal partnership); (v) that traditional forms of space and equipment are well designed (rather than valuing fundamentally new designs); and (vi) that medical care operates in an environment of scarcity (rather than noticing and employing what it has in abundance).

The total customer relationship in health care: broadening the bandwidth.

BACKGROUND: The health care system is in the midst of a market revolution, driven by cost containment but also fully charged by the idea that competition among providers will lead to reforms that neither the government nor the professions have been able to achieve by themselves. An agenda of "reports to consumers" has been advanced as a bright new hope for improving the health care system. An alternative to this notion of consumerism is far broader--that is the concept of total relationship. THE BANDWIDTH OF TOTAL RELATIONSHIP: In the hands of masters outside the health care domain, the total customer relationship embraces several elements that can be imported into health care and that offer more promise than "report cards," including the following: Customers as assistants in decreasing waste; Mass customization and stratification of need; Shaping demand; Immediate recovery; Delight as the objective; and Customer knowledge and innovation. A CREDO: The next phase of development of total customer relationship might well be guided by a credo including several tenets about the wisdom of those the health care system serves and the nature of its purpose: 1. In a helping profession, the ultimate judge of performance is the person helped. 2. Most people, including sick people, are reasonable most of the time. 3. Different people have different, legitimate needs. 4. Pain and fear produce anxiety in both the victim and the helper. 5. Meeting needs without waste is a strategic and moral imperative.

Quality comes home.

Without a clear focus on the needs and experiences of individual patients, much of the financial and structural reorganization now rampant in health care will be unlikely to yield improvements that matter to the patients we serve. As we change the system of care, five principles can help guide our investment of energy: 1) Focus on integrating experiences, not just structures; 2) learn to use measurement for improvement, not measurement for judgment; 3) develop better ways to learn from each other, not just to discover "best practices"; 4) reduce total costs, not just local costs; and 5) compete against disease, not against each other.

Variability in clinical systems: applying modern quality control methods to health care.

BACKGROUND: Quality health care depends on timely completion of sequences of clinical care. This study evaluated the concepts and tools of quality management for measuring system performance in ambulatory care. STUDY DESIGN: Clinical staff in nine centers of a group model health maintenance organization described the procedure for ordering and completing a complete blood count, mammogram, and surgical consultation. Variability was noted among the processes as intended and as actually performed, as well as inconsistencies reported within and among centers. In two centers investigators tracked performance of key sequences of care and the achievement of other key quality characteristics believed desired by physicians and patients. Computerized patient records and departmental files were the only available sources of data for assessing completion and followup of tests and consultations. Even these data were difficult to obtain and, in many instances, incomplete. RESULTS: Although data were often difficult to obtain, the quality management techniques used were helpful in revealing process failures that appeared to be the result of design flaws built into the clinical systems. CONCLUSION: Robust process designs and improved management information systems for monitoring these processes are recommended to reduce variability and improve the quality of clinical care.

The toxicity of pay for performance.

Despite their superficial logic, systems of merit pay or pay for performance have features that are toxic to systemic improvement. Contingent rewards doled out by supervisors cause decreased focus on customer needs, loss of accurate information about defects and improvement opportunities, avoidance of stretch goals, and decreased innovation. They may also erode teamwork. Pay for performance may mark a naive understanding of the complexity of human motivation.

Eleven worthy aims for clinical leadership of health system reform.

Clinicians ought to be playing a central role in making the changes in the health care system that will allow the system to offer better outcomes, greater ease of use, lower cost, and more social justice in health status. Instead, most of the proposed changes that are today called "health care reform" are actually changes in the surroundings of care rather than changes in the care itself. Clinicians have an opportunity to exercise leadership for the improvement of care, but they must first agree to address the aims of reform and to adopt an agenda of specific changes in their own work that are likely to meet the social needs driving the reform movement. Health services research offers a sound scientific basis for identifying promising improvement aims for clinician-led reform. Eleven plausible aims are these: (1) reducing inappropriate surgery, hospital admissions, and diagnostic tests; (2) reducing key underlying root causes of illness (especially smoking, handgun violence, preventable childhood injuries, and alcohol and cocaine abuse); (3) reducing cesarean section rates to pre-1980 levels; (4) reducing the use of unwanted medical procedures at the end of life; (5) simplifying pharmaceutical use, especially for antibiotics and medication of the elderly; (6) increasing active patient participation in therapeutic decision making; (7) decreasing waiting times in health care settings; (8) reducing inventory levels in health care organizations; (9) recording only useful information only once; (10) consolidating and reducing the total supply of high-technology medical and surgical care; and (11) reducing the racial gap in infant mortality and low birth weight. Health care professions and their professional organizations in concert should embrace these 11 aims, establish measurements of progress toward them, and commit to continuous and fundamental changes in their pursuit.