Quality Initiative
Can We Really Save 5 Million Lives?Hospitals nationwide take the IHI challenge. Leadership—including by trustees—makes all the difference.
At the 2004 national meeting of the Institute for Healthcare Improvement, IHI President and CEO Donald Berwick, M.D., posed a dramatic challenge: If hospitals were to implement evidence-based medicine in six major areas, he said, they could save 100,000 patient lives in 18 months.
Skeptics scoffed. But the response from the hospital field was phenomenal.
IHI had hoped to sign up 1,600 hospitals in what it called the “100,000 Lives Campaign.” Nearly twice that number—some 3,100 hospitals—participated. And by paying attention to the campaign’s six interventions—providing evidence-based care for acute myocardial infarction, deploying rapid-response teams, and preventing adverse drug events, central line infections, surgical-site infections and ventilator-associated pneumonia—hospitals cut patient deaths by an estimated 122,000 in a year and a half.
The time was right, recalls IHI’s Laurel Simmons, director of new health partnerships. “The issue of safety within hospitals had come to the fore. The Institutes of Medicine’s report on medical errors in hospitals, ‘To Err is Human,’ had been published. The media had taken notice. And hospital leaders had to stop believing that medical errors and avoidable deaths did not happen in their institutions,” she says.
The campaign was well-coordinated. “Don Berwick didn’t just stand up on the platform and say, ‘Hey, everybody. Let’s save lives,’ ” Simmons says. “He worked very hard to create partnerships with the American Hospital Association, the American Medical Association, the Joint Commission, the Centers for Medicare & Medicaid Services and a wide range of influential medical organizations to make sure the campaign interventions could fit in with other work hospitals were already doing to meet regulations and requirements.”
IHI set up a network of about 50 nodes, leading-edge hospitals and other quality-oriented organizations that provide technical assistance to hospitals participating in the campaign.
At IHI’s annual meeting this past December, Berwick issued a new challenge by launching the “5 Million Lives Campaign,” which seeks to protect patients from 5 million incidents of medical harm over the next two years.
To the original six interventions, 5 Million Lives adds another six: preventing MRSA infection; reducing harm from high-alert medications, such as anticoagulants, sedatives, narcotics and insulin; reducing surgical complications; preventing pressure ulcers; delivering reliable, evidence-based care of patients with congestive heart failure; and encouraging the participation of governing boards. Again, the response has been remarkable. More than 3,000 hospitals have joined the new campaign—accounting for 80 percent of U.S. hospital beds.
“5 Million Lives makes it crystal clear what’s at stake here,” says Jane Metzger, chair of the board subcommittee on quality at Cambridge Health Alliance, Boston. “It frames things in terms of lives, not avoided events or mistakes, which brings home to everybody that every time something goes awry in a hospital, there is a patient and there is a family affected by it.”
Metzger describes health care as a process that would make an industrial engineer cry because it is so complicated, involves unique, individual patients, and has so many players and so many handoffs among them all. “The process is full of opportunities for the right things not to happen,” she says. The value of the 5 Million Lives Campaign is that it provides a focus on issues that can have a devastating impact. “These are gaps in care that have huge consequences for patients,” she says.
A Leader in Cincinnati
Getting board participation is a critical factor in the 5 Million Lives Campaign. While some hospitals still don’t have a board subcommittee that concentrates on quality, safety and performance improvement, others have been actively engaged in these processes for years.
One of those is Cincinnati Children’s Hospital, a 430-bed pediatric teaching and research institution. It is the second highest National Institutes of Health-funded pediatric research facility in the United States, and it ranks fourth in the country in training medical students in pediatrics, according to CCH board chair Lee Carter.
CCH’s 36-member board has been on a journey since 1996 to transition its core concentration from finance and personnel to quality and safety. In 1996, Carter remembers, the board did not have a patient care committee.
“It occurred to me that we’re in the business of taking care of kids and we really ought to have a board committee that is focused on patient care and the quality of that care,” Carter says. “When I proposed it, the head of pediatrics and the CEO said, ‘What does a board know about patient quality and safety and care?’ But we got started, and it has become, I think, the most important board committee.”
The CCH board realizes that it cannot directly influence surgical-site infections or codes outside the ICU or other quality interventions. But it can pay attention to them. “When the board knows what the current statistics are and sets a goal for reducing bad things from 10 to zero by June 30, 2008, when it measures how the hospital is doing in the interim, when it celebrates improvement and asks, ‘What do we need to do to make things happen if improvement is not happening?’ it shines a spotlight on quality and safety and says to the people in the institution, ‘This is a priority,’ ” Carter says.
The patient care committee at CCH has 20 members—nurses, physicians and trustees—who meet once a month to review specific areas of quality and safety improvement, including patient and staff satisfaction.
The board also has a legal affairs committee, which reviews all sentinel and adverse events. At meetings of the full board, as well as within its executive committee, between 30 percent and 40 percent of board members’ time is spent on issues related to quality and safety.
CCH has partnered with IHI on a variety of activities for the last seven years. It integrates the 5 Million Lives Campaign into its quality structure by setting specific targets for each of the 12 campaign interventions.
CCH already meets a key aspect of board involvement identified by IHI in the 5 Million Lives Campaign: linking executive performance on quality and safety with compensation. Ten years ago, all of CCH’s senior management’s bonus compensation was based on attaining financial results.
“That didn’t make much sense because we’re not a financial institution; we are a health care institution,” Carter says. “So the board agreed to gradually shift bonus compensation to achieving quality-related goals.”
As a result, only 30 percent of bonus compensation is now based on financial goals. Of the 70 percent of bonus compensation that is based on quality, 40 percent is shared by all of senior management, including pediatrics, surgery, finance and personnel. “So all executives are in the same boat, asking if and how they can help with such measures as reducing surgical-site infections,” Carter says. “Everyone is focusing on quality and safety.”
The Cambridge Experience
At the Cambridge Health Alliance, the board subcommittee on quality includes the CEO, chiefs of all clinical departments, representatives from subsidiary boards, and Lucien Leape, a longtime quality expert and adjunct professor of health policy at the Harvard University School of Public Health. The subcommittee functions as the patient-care assessment and accountability body required under Massachusetts law, which means it handles risk management, incident reporting and follow-up, as well as oversees quality goals, reviews quality dashboards for every part of the CHA system, and covers elements of clinical quality and safety as well as operational improvements.
The board reviews a balanced scorecard, which is generated by CHA’s quality management and improvement department. The scorecard is a high-senior-level matrix representing areas that contribute directly to the organization’s mission and values, such as core measures from the Centers for Medicare & Medicaid Services.
“We’re looking at individuals who are coming in with AMI because they have different elements of care that need to be followed,” explains Cindy Reilly, senior director of quality and performance improvement at CHA. “So we look at discharge instructions, medications and treatments throughout that individual’s stay, and we roll that up to the aggregate level in our most senior-level dashboard.”
CHA is active in IHI and other state and national quality efforts. It was part of the 100,000 Lives Campaign as well as an aggressive patient safety collaboration in Massachusetts. So key measures of quality and safety were already in place when 5 Million Lives was launched.
“What 5 Million Lives did was add to the list of our targets, which we immediately elevated in our level of focus and reporting,” Metzger says.
The decision to join 5 Million Lives was a natural outgrowth of the Cambridge Health Alliance’s culture, which watches closely for new national quality and safety initiatives. And the campaign has folded smoothly into the alliance’s overall quality management operation.
“Frankly, most of the interventions on that list had already been elevated to a high level of importance,” Metzger explains. “So the campaign didn’t really represent a major shift in how we do things, or how we structure or resource our quality improvement efforts.”
The program provides CHA with practical guidance. “Once a program like 100,000 Lives or 5 Million Lives gets started, things happen that assist an organization. There are tools, opportunities to share information about what works,” Metzger says. “So the campaign brings with it not just a focus, but advice.”
It also contributes to trustees’ education. CHA’s quality management and improvement department is continually involved in educating board members about quality, guiding them through every aspect of quality and safety measurement, bringing them up to date on the system’s progress, and discussing problem cases. The result: Trustees who are comfortable with topics that not long ago were considered too complex for nonclinicians to grasp. “The board is not afraid of quality anymore,” Reilly says.
How does the 5 Million Lives Campaign add to what active, quality-oriented hospitals such as CHA are already doing?
“It’s a challenge for us to measure very specific events and to become much safer in our institutions than we have been in the past,” Carter says. “And people respond to challenges. They respond to joining in an effort that is collaborative, inclusive and that makes them a part of moving an entire industry to become better-performing and safer. The Institute for Healthcare Improvement has a vision of setting a mark and then measuring it, and that’s what quality and [patient] safety improvement is all about.”—Karen Sandrick is a freelance writer in Chicago. This article originally appeared in the November/December 2007 issue of Trustee magazine.
This article 1st appeared in the February 2008 issue of HHN Magazine.
Related Articles:
Getting Boards on Board
How Can Hospitals Get Involved?
To respond to this article, please click here.
