Framing the Issue:
• Hospital Engagement Networks were created in 2011 with three-year goals of reducing patient harm by 40 percent and readmissions by 20 percent.
• The AHA/HRET HEN is the largest of the 26 and includes 1,500 hospitals and 31 state hospital associations.
• The AHA/HRET HEN hospitals improved quality in 10 core areas by last December, resulting in better care for 69,072 patients with associated cost savings of $201.8 million.
• The Harm Across the Board feature is a composite rate of all individual harm measures except readmissions; it shows hospital leaders and staff their progress over time in reducing patient harm.
At Lea Regional Medical Center in Hobbs, N.M., every internal meeting begins with a safety moment. Whether a front-line staff huddle, a C-suite financial review or the convening of the 11-member community board, spending a few moments on safety at the top of each meeting serves as a reminder of the 201-bed hospital’s core mission: delivering the highest quality medical care to its community.
“It draws our focus back to safety,” says Tim Thornell, chief executive officer. “The safety moment shows that we have a focus and an emphasis on eliminating patient harm.”
A recent safety moment focused on an incident in the medical center’s labor and delivery department. A nurse noticed vital sign changes in a patient and phoned the physician, who gave a verbal order. But the nurse felt strongly that the physician should evaluate the patient in person, so she asked him to come to the hospital. The physician soon arrived and ordered the patient into surgery within five minutes of an examination, where a bleed was discovered and repaired. Working as a team, the nurse and physician prevented patient harm.
Lea Regional, which is the only acute care facility in a community of about 75,000 people on the Texas border, instituted the safety moment in 2012, after the organization joined a Hospital Engagement Network operated by the American Hospital Association and the Health Research & Educational Trust. The AHA/HRET HEN is one of 26 nationwide created in December 2011 with $218 million in grants from the Partnership for Patients, a Health & Human Services initiative to improve patient care. The goals are twofold: to reduce patient harm by 40 percent and readmissions by 20 percent over three years.
Hospitals participating in a HEN must meet ambitious goals across 10 categories of harm reduction: adverse drug events; catheter-associated urinary tract infections; central line-associated blood stream infections; patient falls; obstetrical events, including early-elective deliveries; pressure ulcers; preventable readmissions; surgical-site infections; ventilator-associated pneumonia and venous thromboembolism.
The AHA/HRET HEN, which sunsets at the end of 2014, is the largest in the nation and includes 1,500 hospitals and 31 state hospital associations. Through its achievements, it has demonstrated that engaging staff from top to bottom in quality improvement work and participating in shared learning across institutions in a noncompetitive environment can improve care quality.
Additionally, some HEN members are adopting a single overarching metric called Harm Across the Board, which is used to understand overall harm at each individual hospital. Executives, governing boards and staff are beginning to embrace this tool as a way to better understand the overall quality and safety of their institutions.
As of December 2013, participating AHA/HRET HEN hospitals had improved quality in the 10 core areas, resulting in better care for approximately 69,072 patients with associated cost savings of $201.8 million. Together, the hospitals have reduced:
• Early-elective deliveries by 57 percent
• Pressure ulcers by 26 percent
• Central line-associated infections in intensive care by 23 percent
• Ventilator-associated pneumonia by 34 percent
• Readmissions among patients with heart failure by 13 percent
HEN ‘connects the dots’
Lea Regional is one of 123 hospitals in the AHA/HRET HEN that met national reduction goals set by the Partnership for Patients as of July 9, 2014. These organizations achieved the reduction goals on 90 percent or more of applicable topics on national- or state-aligned measures.
Officials at the hospitals say their success is based in part on the unique structure and support offered by the HEN. The HEN has a strong focus on collaboration and shared learning, as well as involving the front line and C-suite in activities to reduce patient harm in the form of free education and training.
“It really connects the dots for staff and patients,” says Linda Webb, R.N., chief nurse executive at Pulaski Memorial Hospital, a 25-bed critical access hospital in Winamac, Ind., and an AHA/HRET HEN participant that met the national reduction goals. “It forces you to focus on both the process and the outcome that is tied to that process.”
For example, implementing a computerized provider order entry system has reduced the potential for adverse drug events caused by misreading physician handwriting on pharmacy orders for blood-thinning medications for patients with heart failure, she says.
The HRET/AHA HEN has a multifaceted strategy to help participating hospitals achieve their goals. This includes resources and tools in the form of listservs, a website and discussion board; coaching and sharing at national- and state-level collaboratives; helping hospitals to build improvement capacities with national and state improvement leadership fellowships; and other face-to-face and virtual opportunities such as site visits, regional meetings, boot camps and webinars.
A new way to look at harm
Maulik Joshi, president of HRET, says an important aspect of the HEN is the adoption of the Harm Across the Board, or HAB, metric to tell the overarching story of harm reduction at hospitals. The HAB rate is a formula developed by the Centers for Medicare & Medicaid Services for the Partnership for Patients. It is a total composite rate that includes all individual harm measures except readmissions.
All participating HEN hospitals can use the HAB rate to show progress over time in reducing patient harm. The rate is proprietary, but also can be helpful to compare with other hospitals.
The measure guides not only clinical staff, but also C-suite and board members. “I sit on a hospital board and when you look at the total harm rate, you are looking at the bottom line,” Joshi says. “This is just like the financial bottom line. It elevates the conversation in the board room to: ‘What are we doing to reduce harm in all areas of care delivery?’ ”
Preventable death is one metric sometimes used to measure patient safety, but Joshi likens this to the “check engine” light going on in a car. “You don’t know what the problem is, but you know you have to take your car to a mechanic,” he says. “But we all understand patient harm. With the Harm Across the Board rate, boards can say, ‘How are we doing? Are we doing better? And if so, by how much?’ ”
Woman’s Hospital in Baton Rouge, La., uses the HAB rate to inform the 11-member board, executives and staff about progress in reducing patient harm. Woman’s Hospital is another hospital that met HEN national reduction goals.
“Our board and CEO asked us for an overall quality measure they could use,” says Patricia Johnson, R.N., chief nursing officer and senior vice president of patient care at the 168-bed hospital. “The Harm Across the Board rate is something I’ve really appreciated because I can take it to the board members and show them very clearly our progress.”
Pulaski Memorial also uses the HAB rate to track its progress in achieving its patient safety goals, Webb says. From January 2012 to December 2013, the hospital was able to demonstrate that it cut patient harm by 74 percent, tracking total harm per discharge [see The Complete Picture of Patient Safety, Page 28].
Less is more
With the HAB rate, hospitals also submit to the HEN a seven-slide report that includes a monthly topline report on overall harm per discharge, several examples of progress among the 10 core topic areas and “pearls” of wisdom on progress and achievements. The AHA/HRET HEN is committed to having 1,000 participating hospitals complete Harm Across the Board reports by Oct. 30.
John Combes, M.D., president and chief operating officer of the AHA’s Center for Healthcare Governance, says that the HAB rate is a good way to communicate care quality, particularly to trustees. “We have always told boards that they don’t need 60–70 metrics around quality to define quality,” he says.
Hospital trustees are accustomed to evaluating financial performance by looking at the current margin and cash on hand, so they embrace using only a few quality metrics to track patient harm. That could be HAB or hospital-acquired infections, which tend to track closely with other quality measures, Combes notes. Another way to look at patient safety is the percentage of dollars at risk with quality and incentive programs and the rate of return.
“That is a leading indicator for trustees on care quality,” he says. “You don’t want to give boards trends that bounce up and down a lot. At a board level, there should be five to six measures they can track over time.”
Woman’s Hospital officials say the HAB rate allows them to see progress over time and also glean some comparisons to similar independent, specialized hospitals. Sometimes comparisons can be hard to draw because other hospitals in the Baton Rouge area are much larger or have a different core mission.
“Being a specialty hospital, it can be hard to do a lot of comparisons,” says Cheri Johnson, R.N., vice president of perinatal services at Woman’s Hospital. “All of the elements of Harm Across the Board hit inpatient services, so it is a good measurement for everyone. It provides a framework for us to plug in how we are doing and show progress in a meaningful and productive way.”
‘Small ball strategy’
Another legacy of the HEN besides the HAB rate is the creation of the improvement leadership fellowships. There have been more than 1,000 fellows from participating hospitals since 2012. “The improvement fellows are what really drove this success,” Joshi says. “They have this developing expertise as improvement leaders, and that will continue on in the future.”
The HEN also implemented a “small ball strategy” of making sure that improvement work touches all levels in an organization.
“When we started the HEN, we had a lot of national meetings for hospital leaders,” Joshi says. “But with small ball strategy, we go out to the hospitals and talk one-on-one. It’s resource-intensive, but it’s important coaching and mentoring. We hear about the individual challenges. You don’t need home runs all the time. You need to get one hit or two hits and those hits start to add up.”
Webb of Pulaski Memorial says that this strategy has helped tremendously with improvement work. “Resources for education aren’t what they used to be,” she says. “It has allowed us to get more staff involved in the work with face-to-face regional events and also webinars.”
The 123 hospitals that achieved their HEN targets had some things in common, Joshi says. “They had incredible leadership and board buy-in,” he notes. “They spent a lot of time on implementation of best practices instead of developing something new. They also showed exceptional teamwork.”
Indeed, the high-achieving hospitals cited board and C-suite leadership as critical components to success.
“The board helps to set the agenda and the tone,” says Lee Regional’s Thornell.
One of Lea Regional’s major HEN successes was reducing preventable falls. The hospital created a falls committee in September 2012, which looked retrospectively at falls that had occurred at the hospital, and prevention tactics that could be implemented. The committee then worked to re-educate all staff members about fall prevention. Members crafted visual cues to prompt staff about the danger of falls, including a falling star emblem on the doors of patient rooms; they added fall mats to bedsides and created a “sitter” program for closer monitoring of patients at the highest risk for falls. Daily safety huddles also were put into practice.
As a result of these efforts, falls were reduced by 50.8 percent between January 2012 and June 2013. Moderate- to severe-injury falls were cut by one-third. In 2014, falls were reduced by another 30 percent.
Lea Regional also focused on 30-day readmissions. The hospital readmission rate fell to 2 percent in March 2014 from 10 percent in April 2013. Daily case management huddles that gave staff the opportunity to review patients with the highest risk of readmission and develop tailored transition care plans helped to drive readmissions down. Staff also discussed comorbidities or other factors that could contribute to a patient’s inability to be successful at home, and then took steps to remove those obstacles.
New opportunities unearthed
Hospitals officials participating in the AHA/HRET HEN say the program has provided the opportunity and support to tackle longstanding issues and achieve goals. It also has allowed them to find ways to propel existing harm-prevention programs forward.
Woman’s Hospital, for one, was already a leader in reducing obstetrical adverse events, including early-elective deliveries and cesarean sections. The 168-bed hospital delivers about 8,500 babies per year. Prior to joining the HEN, in 2010, Woman’s Hospital initiated a hard stop of elective deliveries prior to 39 weeks.
But the HEN gave Woman’s Hospital the opportunity to compare the protocols at other hospitals around elective deliveries and share what it learned along the way. Staff and administration attended boot camps, webinars and in-person conferences to learn more about reducing elective deliveries. Officials at Woman’s Hospital served as a valuable source of information for other hospitals just starting the process.
Further, staff, executives and the board were able to see opportunities for improvement that they did not before, says Johnson of Woman’s Hospital. “Prior to the HEN, we didn’t think we had an opportunity to reduce 30-day readmissions because we are primarily a labor and delivery center,” she says. “But now, we are working on readmissions related to hypertension and hemorrhage. The HEN helped us to identify this as our biggest opportunity, even though we have a low readmission rate.”
The hospital is now focused on reducing readmissions among patients with pregnancy-induced hypertension with the implementation of targeted discharge planning, medication reconciliation and patient education.
With so many quality improvement activities underway around the nation, one concern was that the HEN would be too broad in scope, with too many focus areas. But Joshi says hospitals have risen to the challenge.
“There is often the concern about taking on too many projects but with the HEN, we are not finding that,” he says. “Hospitals taking on more measures are seeing greater improvement than those doing just a few measures.”
The HEN project concludes at the end of 2014, but leaders at participating hospitals say they will continue the practices they learned from the experience.
Quality improvement is “definitely a journey and it never ends,” says Thornell. “Our administrative team here truly has taken patient safety as creating a just culture.” — Rebecca Vesely is a freelance writer in San Francisco.
HEN Lessons Learned
The Hospital Engagement Network run by the American Hospital Association and the Health Research & Educational Trust and participating hospitals have learned several lessons while meeting their patient safety goals. These include:
• Data reporting is a challenge, as is dispelling the myth that data collection is cumbersome and time-consuming.
• Chief nursing officers are key to spreading improvements and serving as linchpins between executives and front-line staff.
• Hospitals of all sizes face limited resources, and site visits are necessary to gather outcome data and develop positive relationships.
• Organizational leadership, including board members and the C-suite, is critical to success.
• Some measures don’t fit all sizes, and smaller hospitals are developing other methods of measuring quality, such as number of days between incidents.
• Monthly check-in calls can help to improve communication and maintain progress.
• Hospitals and states face varying challenges requiring customized strategies.
• Dashboards and calculators can help to increase awareness and interest.
CMS’ Harm Across the Board template
ospitals participating in the AHA/HRET HEN are adopting a seven-slide reporting system to document high-level progress to reduce harm across the board at their institutions. The template, created by the Centers for Medicare & Medicaid Services for the Partnership for Patients, is a straightforward and visual way to tell a hospital’s harm-reduction story. The HAB template includes:
• Photos and captions of the safety team
• A total harm per discharge chart
• A topic-specific example of a safety breakthrough
• Risk profile in the 10 core topic areas
• A hospital risk scorecard that includes patient volume, total risk and harm-reduction opportunities
• A “pearls” of wisdom page imparting insights on what worked, what was tested and learned, how to advance the topic in the near future, important drivers for change and patient and family engagement.