A study published in the September/October issue of the American Journal of Medical Quality documents how a landmark research program in Michigan to reduce central line-associated bloodstream infections in intensive care units did more than save lives and provide a valuable template for other hospitals to follow. Research from Johns Hopkins University shows the program saved hospitals an average of $1.1 million a year — with far greater savings at larger institutions. Peter J. Pronovost, M.D., director of the new Johns Hopkins Armstrong Institute for Patient Safety and Quality, discussed his work on the Michigan project and future efforts with Bob Kehoe, H&HN contributing editor.
What is the significance of the Michigan CLABSI cost-savings study?
In the Michigan study, we knew we reduced infections, we knew that we saved lives, but we didn't know if we could save money. So we conducted a fairly robust cost-benefit analysis to examine whether we delivered cost savings to these hospitals. The study showed there was some cost with preventing the infections — about $3,000 per patient — but the average-sized hospital saved more than $1 million a year; larger facilities saved double or triple that. This really gives us hope that, as we hypothesized, reducing preventable harm not only makes good sense for patients and improving quality, but it makes good business sense for hospitals
Are results available for other organizations Outside Michigan that followed the CLABSI checklist model?
We received funding from the Agency for Healthcare Research and Quality and we partnered with the Health Research & Educational Trust and the Michigan Health & Hospital Association to implement this program state by state across the country. It's really the first national, large-scale, robust quality-improvement program in health care. We've launched in 46 states and, though the data from that project is still under review, the Centers for Disease Control and Prevention reported in March that bloodstream infections in the ICU are down 60 percent across the United States between 2001 and 2009.
That's the good news. The bad news is that most other types of infections haven't budged. What this says to us is that with focused effort and good science you can really move the needle, but in the absence of good science, things aren't likely to change much
Are there implications for other quality-improvement projects?
It gives us great hope that reducing other types of preventable harm likely will result in significant cost savings. The reality is that for most other types of harm we don't have accurate measures, which is key to demonstrating savings. For most other types of harm, we don't know the extent to which they are preventable. This study found that about 70 percent of the instances of harm were preventable and for the vast majority of patients we dramatically reduced these risks.
For many other types of preventable harm, we don't quite know yet the best methods for reducing risks. But we do know the risks associated with a couple of other major killers. For ventilator-associated pneumonia, we found a 70 percent reduction throughout all of Michigan. VAP kills about as many people as does prostate cancer, and we dramatically reduced deaths with current technology. Deep venous thrombosis and pulmonary embolism kill about 100,000 people a year, and we know that most of those deaths are preventable by using routine prophylaxis. So if we were to focus our efforts on some major causes of preventable harm — harms that we know are associated with excess deaths and excess costs — we not only could save lives, but also save money.
We are launching a new project funded by AHRQ to take the exact approach we did with bloodstream infections for both pneumonias and surgical safety.
Any plans beyond these projects?
What we're focusing on now are the major causes of morbidity. You have to pick some ways to prioritize and we're picking those in which people die needlessly. If you look at those teamwork failures, a lot of effort centers on training and teamwork in decubitus ulcers and diagnostic errors. The science of how to prevent diagnostic errors needs to mature. Decubitus ulcers kill thousands of people a year and we don't have great interventions yet, but we're working on it
How can hospitals participate in future projects?
In this collaborative bloodstream project, we spent thousands of hours packaging a program that is good science, but also is practical. The clinicians connect to it and find it useful. Hospitals should use those tools. They were funded by taxpayer dollars and ought to be made available on a broad scale. What we see now, though, is a proliferation of these collaborative projects. Some are more rigorous than others, but the real limitation within hospitals is that often they don't have the resources to implement them. That's where we see a lot of risk in the underpayment to hospitals — that even if these tools are available, some hospitals just don't have the people and infrastructure to implement population-level programs. That really concerns me because we're finally learning the science.
Do you see insurers as part of that solution?
The payers have to realize that paying hospitals less doesn't reduce health care costs by itself. It's a tricky lesson. Health care costs are reduced in two ways that are simple in theory and difficult in reality: You either must improve productivity so you get more output per unit of staff or you reduce the use of services. Paying hospitals less does neither of these. We need much stronger partnerships to find ways to truly control health care costs by improving productivity, by reducing preventable harm and — more importantly — to stop using services that don't add value to patient care. There is clear evidence that a number of therapies, including many of the cancer screenings in patients older than 75, don't provide value; they only add cost or risk of harm to patients. Working together, we're much more likely to develop wise and effective solutions
How will the Armstrong Institute for Patient Safety and Quality improve care and lower costs?
The Armstrong Institute was formed with the realization that if we're going to improve patient safety or advance the science of safety we're going to have to link research, practice and training. We created an organization that links the research group that I was previously running with the operational quality group at Johns Hopkins University School of Medicine to ensure we infuse best science into our quality-improvement work. The institute's mission is to improve patient outcomes continuously and enhance the value of care for all, i.e., addressing disparities around the world by advancing the science of patient safety through discovery, implementation, education, evaluation and collective learning
What are the institute's areas of focus?
The immediate focus will be on the major causes of preventable deaths. We've had national success on bloodstream infections. Pneumonias and surgical safety will be major priorities. We'll work on some of the areas under the CMS effort to reduce preventable harm. We're working a lot on health disparities, to make them visible in all of our quality measures so we can see how we're doing and develop solutions. We're focusing a lot on patient-centered care. This has become a buzzword, but if you unpack it there are really a couple of key behaviors that underlie patient-centered care, such as: Am I involved in my care? Are you meeting my needs? And, do I know enough to take care of myself?
Using our human factors and other scientists, we're moving from this vague concept of patient-centered care to specific behaviors. What it means is rounding every day with doctors or nurses and asking them to participate or make sure before you leave that patients understand their diseases and know what they need to do for follow-up.