John Dalton applies a fairly simple rule to patient care at his 48-bed rural hospital: assume that every patient who walks through the door is your mother.
Suddenly, you don't forget to wash your hands before and after every patient encounter. Making sure you've screened the patient for a blood clot doesn't seem so burdensome. Ensuring that the right patient gets the right drug at the right time isn't someone else's job.
That simple yet provocative idea changes everything, says Dalton, president and CEO of Inland Hospital in Waterville, Maine, a part of Eastern Maine Healthcare Systems."We have to start thinking differently," he says. "I always instruct staff to make it simple in our new employee orientation. Let's look at everyone we touch as someone you love."
To be fair, Dalton didn't invent the "your mother" rule. He credits the health system's chief medical officer, Erik Steele, D.O., with that. "Erik is the one who started talking about it," Dalton says. "For us, as an organization, it is not rocket science. The question is, when is it OK to harm a patient?"
The obvious answer is never. And that's the radical approach EMHS has taken to patient safety. Since 2007, the seven-hospital rural health system has embarked on a zero-defect approach to medical errors. In nearly 40 clinical areas, including Centers for Medicare & Medicaid Services core measures and National Quality Forum never events, the health system strives for perfection.
"It changes how you think about all of this," Steele says. "If zero is the goal, you will do things that you otherwise wouldn't."
But it's not enough to just set zero as the goal or institute another training program. Health system leaders are trying to ingrain it into the corporate culture. They are instituting what Steele calls "hard stops," or processes that essentially take the human element out of the equation.
For instance, CMS core measures require that doctors specify why they've ordered the antibiotic vancomycin. There's a hard stop in the computerized provider order entry system that prohibits the physician from initiating the order until a reason is given, explains Cathy Mingo, R.N., quality project coordinator at the medical center.
Another example: venous thromboembolism. More than two million Americans suffer from VTE each year, and more than half of them develop the condition in the hospital or 30 days after discharge, according to the Agency for Healthcare Research and Quality. Most hospitalized patients have at least one risk factor for VTE and 200,000 patients die annually from the complication. VTE largely is considered one of the most preventable causes of hospital-related deaths.
Starting last July, every adult admitted to an EMHS hospital is expected to have a VTE risk assessment documented within 24 hours of admission. If the patient is assessed as high risk, the physician needs to order prophylaxis or document why it wasn't ordered. At the system's flagship hospital, Eastern Maine Medical Center, the computerized records system acts as the gatekeeper, alerting clinicians if these protocols haven't been met. At hospitals that are still evolving from paper, nurses fill that role.
Systemwide, there was a 50 percent improvement in documenting risk assessments between the fourth quarter of FY 2010 and the first quarter of FY 2011. At the medical center, which has CPOE, clinicians failed to document an assessment within 24 hours of admission just twice out of 1,350 adult admissions in February.
"We can educate until we are blue in the face, but we can ensure success better if we build processes that are error proof," Mingo says. "We're trying to build systems that you couldn't fail if you tried."
Ever since the Institute of Medicine shone the spotlight on medical errors back in 1999, health care leaders increasingly have been challenged to create a culture of safety. To be sure, there are success stories. Lately, the most often-cited achievements are those by the Keystone Center, a collaborative between the Michigan Hospital Association, AHRQ, Blue Cross Blue Shield of Michigan, the Centers for Disease Control and Prevention and the Michigan Department of Community Health. The Keystone Center famously has advanced a simple checklist that's led to dramatic error reductions, including health care-associated infections. For instance, the center reports that between 2004 and 2010 hospitals in its intensive care project saved more than 1,830 lives, 140,700 excess hospital days and more than $300 million.
Separate from the Keystone Center, the nationwide focus on infections has led to similar positive results. In late February, the CDC showed that between 2001 and 2009 there was a 58 percent drop in central line bloodstream infections for ICU patients. Up to 27,000 lives were saved as a result. An estimated 3,000 to 6,000 lives were saved in 2009 alone.
"Although we've made huge strides in improving quality and safety over the past decade, and really accelerated that over the past five years, as a field we are still not getting to all of the areas of potential harm to protect patients," acknowledges American Hospital Association President and CEO Rich Umbdenstock.
Figuring out why preventable errors still occur is difficult. Experts point to any number of reasons: humans make mistakes, staff are afraid to speak up if they see a higher-up doing something that may be unsafe, there aren't enough safeguards in place, health care is a complex environment and people usually are multitasking, and more. Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health, says a key factor is that there are very few consequences for hospitals and physicians. Leape suggests efforts by CMS and insurers to withhold payments for medical errors have had a limited impact. It remains to be seen if reforms that are under way— accountable care, bundled payments, additional penalties, value-based purchasing—will provide greater impetus for error reduction, he says.
The iPod Idea
Perhaps the one area that experts say has the most influence over building a culture of safety is vision and leadership.
"We find it over and over again," says Helen Darling, president and CEO of the National Business Group on Health. "If you look at patient safety or anything that requires significant redesign and reengineering, there is strong executive leadership and insistence that this happens in a very comprehensive way."
Darling says that is exactly what Eastern Maine Health Systems has, and is part of the reason that the business group, along with VHA Foundation, bestowed it with the 2009 National Health System Patient Safety Leadership Award. Patient safety has been "embedded into the health system's DNA," adds Lillee Gelinas, chief nursing officer, VHA Inc.
The zero-defect concept is actually part of a much broader vision that EMHS President and CEO Michelle Hood laid out when she arrived in Maine in 2006: to be the best rural health system in the country by 2012.
"We were talking about some big picture system goals," Steele recalls of the discussions in late 2006 and early 2007. "I said, 'We need the iPod idea.' We needed some idea that would define us. In quality, that would be having zero preventable errors in some prescribed areas."
To drive the process, Steele pulled together clinical leaders from throughout the system. They picked the measures for the zero-defect policy. A clinical coordinating committee, which consists of Steele, the chief nursing officer, chief information officer, presidents of each hospital's medical staff and others, continues to meet and lead the effort. The committee provides regular reports to the system's board. On a more local level, affinity groups were established for various disciplines across the system to share best practices. The groups meet monthly.
While EMHS has set systemwide goals, individual hospitals have flexibility to home in on a specific area. At Inland, hand hygiene is a top priority. Compliance with hand hygiene protocols used to hover around 58 percent. No one was proud of that statistic, Dalton says.
"I challenged the staff and said, 'If we are successful, where will we get—80 or 90 percent?' At some point, I would then have to tell the board that statistically there's a good chance we will kill one of our patients in the next three to five years," Dalton says.
The conversation quickly focused on how to get to 100 percent. Staff looked at the barriers to hand hygiene and implemented solutions. More washing and hand sanitizer stations were added. Patients were encouraged to ask clinicians to wash their hands. "Secret shoppers" looked for compliance. Most importantly, proper hygiene became part of everyone's job description, including Dalton's. In 2008, an employee was fired for failing to comply.
Hand hygiene compliance now ranges between 95 and 98 percent. Dalton says that is proof that you can "hardwire" a safety goal.
'This Is What We Want'
There were questions during the early discussions with system executives and the board, Hood says. "Some board members wondered if we really wanted to say something like [we'll eliminate errors] and what if we didn't make the goal?" But ultimately, she says, "the board said, 'This is great, this is what we want.' There really wasn't a need to talk anybody into it."
Board Chair George Eaton II, a partner at the law firm Rudman & Winchell, says the board quickly became interested in how to build appropriate measures, accountability and transparency. From a measurement standpoint, EMHS no longer compares error rates against other hospitals, but rather tracks its own raw data and reports that to the board. Rates or comparative data more easily can be discounted, especially in a rural setting where the number of cases for a certain incident may not be statistically valid or a single case can skew the percentage. But with raw numbers, Dalton says, "that patient mattered to someone."
On accountability, compensation across the system is aligned with the goals. "I offered that up," says Hood, noting that an incentive compensation had been in place for a while, but is now extended to include the safety goals. "Depending on where you are in the hierarchy, more compensation is at risk," Hood says. "It gets the attention of senior leaders. A leader of a subacute area may not have the same goals as the hospital CEO, but they do have quality goals."
Hood even applies this to the business office. There's a goal of zero errors in transcriptions, and materials management has a zero-error goal for fill rates, to name two areas. Hood says it is important to model this behavior if it is constantly being asked of the clinical staff.
Eaton is pretty blunt in explaining the board's view: "Michelle's annual job performance and goals are totally meshed with this proposition. If the goals aren't met, then she is not performing where we need her to perform." He is quick to add his support for Hood and the job she's doing. He believes the system is about 80 percent of the way toward making a full cultural shift, and that the final 20 percent will be aided by technology upgrades, including expanding health information technology to all the facilities. Currently, only two hospitals have CPOE. The other five hospitals will start rolling it out this summer. He also believes the system has to do more to standardize care and reduce variation among locations.
Transparency often can be the hardest part of the accountability equation, but Dalton says it is a critical part of the shift to a total culture change. In fact, he volunteered Inland Hospital in late 2006 to be the first in the system to post its quality and safety scores publicly. At the hospital's Quality Matters website, consumers can find performance data on core measures as well as safety indicators. So a visitor to the site can see that between October and December 2010, Inland was at 100 percent for pneumonia vaccinations, but at 70 percent for providing discharge instructions to heart failure patients. Or, that the hospital had two patient falls per 1,000 patient days. The target is zero. All seven hospitals now have a Quality Matters website where they post quality and safety data, as does the health system.
"It changed the conversation," Dalton says. "I really thought it was the right thing to do. Transparency was a way to shake up the conversation and drive change."