The largest federal hospital initiative tackling patient safety and quality of care is under way and the goals are lofty. In two years, we'll know whether the Hospital Engagement Networks — HENs — laid a golden egg or weren't what they were cracked up to be.
The HEN project is funded by the Centers for Medicare & Medicaid Innovation as part of the national Partnership for Patients initiative. Within two years, the initiative aims to reduce 10 targeted hospital-acquired conditions by 40 percent and cut hospital readmissions by 20 percent, saving an estimated 60,000 lives over three years and conserving $50 billion in Medicare funding over 10 years.
More than 3,900 hospitals in 46 states have committed to participate in the 26 HENs, which won $218.8 million in contracts.
"If we don't get a handle on costs, this country will go bankrupt," says Jim Battles, social science analyst for patient safety with the Agency for Healthcare Research and Quality. "And the best place to start is to stop harming people." Reducing adverse events can cut health care costs by 10 percent, he says, which is why "as much as hospital CEOs need to get engaged in patient safety, so must their CFOs. The costs are real. And this is just the beginning."
Plenty of strings are attached to that $218.8 million. HENs are required to identify measures for each of the focus areas and must file monthly, quarterly and annual reports detailing their member hospitals' progress. Then in two years, they must report to CMS their improvements or failures in each of the so-called HEN 10: central-line associated bloodstream infections, adverse drug events, pressure ulcers, injuries from falls or immobility, catheter-associated urinary tract infections, ventilator-associated pneumonia, surgical-site infections, venous thromboembolism, obstetrical adverse events, and preventable readmissions.
The HENs have the capacity to engage 4,800 hospitals and still were recruiting new hospital members this spring. Jack Jordan, deputy director of the Partnership for Patients, says that the 26 networks include an interesting array of projects, ranging from breakthroughs on collaborative models to leveraging regional groups within states. One large HEN comprises a consortium of subcontracted state hospital associations under the American Hospital Association's Health Research & Educational Trust.
"They all have their unique plan for what is most appropriate for their work. We want to help connect them so that we can leverage the whole HEN experience to create a national movement," Jordan says. The time frame is, he acknowledges, "very aggressive."
While nearly four-fifths of the nation's hospitals are directly participating in an engagement network, many others are unaffiliated, but Jordan says they still can benefit from the knowledge sharing. "Once people believe and commit the time, it is very rewarding," he says.
HRET is contracting with 34 state hospital associations and 1,900 hospitals within its HEN. Maulik Joshi, HRET president and AHA senior vice president of research, says HRET will direct leadership engagement activities and performance feedback through its leadership improvement fellowship program, in which hospital executives can learn from peers about the science of improvement and best practices.
Joshi says HRET's network will partner nationally with experts on topic areas and integrate their knowledge into toolkits local hospitals can access. "Our job is to harness those best practices and spread them by taking what has been scientifically validated and is working now," he says. "These HENs offer an opportunity to test and learn, to unleash the innovation and accelerate the pace of change. Having hospital leaders learning from each other will speed the process."
Finally, a fatter pig
The HEN project marks a big leap philosophically and practically from previous government quality improvement and patient safety programs. "It takes an average of 17 years for an innovation or practice to get to the bedside," Battles says. "That's far too long. Here we have this huge investment in a gargantuan research engine, but almost nothing to create the infrastructure to transfer that knowledge from the research bench to the bedside. We've never had the boots on the ground to help hospitals implement the changes necessary to move the needle."
Battles draws analogies from growing up the son of a county agricultural extension agent. Historically, he says AHRQ has studied, measured and shared the results of its research and hoped for a change in behavior. "But a pig never gained weight standing on a scale," he says.
HENS "are the infrastructure missing for the last century. We've known what to do and now we have the tools and resources. We need to think about the network of HENs as the agricultural extension agents of HHS."
The HENs are employing diverse approaches to reducing infections and other targeted conditions, says Keith Kosel, executive director of VHA's Center for Applied Healthcare Studies and program director for its HEN. "Some are planning programs featuring expert speakers, webinars and coaching, while others are task-focused or adopting team training techniques and planning global approaches.
"This is a two- to three-year research study with 26 large organizations trying differing methods to identify and understand what works and what's translatable," Kosel says. "The jury is out whether this will utlimately succeed or not. But hospitals are more incentivized now to undertake these challenges and they have a tremendous palette of expertise to draw upon. By far, this is the largest single initiative focused on patient safety and one of the largest initiatives CMS has ever launched."
For many of the HEN hospital members, these kinds of collaborations are nothing new. A consortium spearheaded by Salt Lake City-based Intermountain Healthcare formed a HEN with some of the world's best known hospitals, including the Mayo Clinic, the Cleveland Clinic and Baylor Health Care System. The partners have worked together for years on quality initiatives.
Lucy Savitz, Intermountain's director of research and education and project director for the consortium HEN, says many of the organizations have participated in AHRQ's ACTION task force, a field-based research model to promote innovation, and the High Value Healthcare Collaborative to improve quality, lower costs and disseminate best practices. "We're very careful about selecting work that has operational utility," Savitz says. "We're taking a systematic, standardized approach that can be easily tailorable at the local levels." Paraphrasing Apple Founder Steve Jobs, she says, "It's mass customization to meet individual personalization."
Nanne Finis, executive director of solutions services for Joint Commission Resources, says JCR's role is to serve as prime contractor working with 50 hospitals, employing process improvement techniques gleaned from Six Sigma and Lean. JCR plans to accomplish that through virtual coaching and technical assistance to its HEN hospitals, which range from stand-alones to system hospitals, academic medical centers to critical access hospitals."We wanted our hospitals to span the spectrum so we can learn what is working within the differing complexities of our organizations," Finis says.
Carolyn Scott, service line vice president for quality and safety for Premier Inc., says there is a real imperative to the HEN efforts. "If a hospital has problems with central-line infections, we need to be on that now," she says. "Success comes one hospital at a time. This is hard work, something not easily done." Premier clinical improvement advisers will work with hospitals on individual improvement plans through peer-to-peer training and knowledge sharing.
Kelly Court, chief quality officer for the Wisconsin Hospital Association, says 123 of her state's 136 hospitals are participating in a HEN; 105 in the association's and the rest in five other HENs. The association is eager to join HRET and its 1,800 network members nationwide. "The bigger network provides us easier access to improvement knowledge and means our specialty hospitals will receive a broader range of information from peer hospitals," she says.
Carolinas HealthCare System's HEN includes 32 owned, managed and affiliated hospitals in North and South Carolina. Roger Ray, M.D., executive vice president and chief medical officer, says care coordinators will engage with hospital leadership in improving measures across the HEN 10. "We had to beef up our software capability to be the measurement arm for everybody for the key measures and develop the capability to receive the streams of data to do a good job of measuring," he notes.
Ray believes the national effort could impact patient safety in dramatic ways. "There is power in being pointed in the same direction," he says. "Sharing the same goals is very energizing and allows you to get very focused."
Carolinas uses quality safety operations councils to bring together staff who concentrate on infection prevention. "They meet regularly to fight the same fight and share best practices. Because of that, we are more able to rapidly spread best practices," he says. "Over the last five years we've been aligning our goals and creating infrastructure for information gathering and keeping score and sharing data."
Barbara Pelletreau, senior vice president of patient safety for Dignity Health (formerly Catholic Healthcare West) in San Francisco, says the system's HEN will bring in C-suite leaders to share the message so they can support the initiative at their own hospitals. The core of its program is developing a culture of safety. "We are going to bring an integrated approach across our 40 care sites in Arizona, California and Nevada," Pelletreau says.
Measuring success and changing cultures
While supportive of the national HEN initiative, some health care policy and process experts are concerned about the program's structure, cost and vulnerabilities.
Peter Pronovost, M.D., a professor of anesthesiology, critical care medicine and surgery at the Johns Hopkins University School of Medicine in Baltimore, says while there is an urgent need to move forward, there's not yet a good way to keep score. "Dedicating resources to improving quality and patient safety are much needed and long overdue. These monies dwarf all previous AHRQ budgets and constitute a huge public investment," Pronovost says. "But these are tax dollars and we'd better be able to say what we did with this money. How do we know at the end of the day that the HEN money was well spent? We need valid measures and data to know whether these hard efforts are bearing fruit."
Eugene Litvak, president of the Institute for Healthcare Optimization, Boston, was hired by the New Jersey Hospital Association's HRET to advise its HEN on process improvement. One issue that Litvak says could doom hard-won clinical improvements is inefficient staffing and scheduling and the role that plays in medical errors.
The New Jersey HEN recognized the link between deeply embedded hospital culture and patient safety. "Others didn't want to touch this hot potato, because it meant having hard conversations with their physicians and smoothing schedules to free up more beds," Litvak says. "New Jersey says it cannot achieve its goals unless it stops putting its hospitals under stress."
Partnership for Patients' Jordan notes every HEN hospital must address culture and leadership issues. He says hospitals are approaching the tipping point on quality improvement. "Many hospitals are taking the lead already. Once you get beyond the 15 to 18 percent already doing it, the mass majority sees that it can do it, too. I hope doing all 10 [hospital-associated conditions] will dramatically change the culture in hospitals across the country."
Joshi says the HEN project represents a shared hope. "It's not about competition, but collaboration. We can only get to those national goals if we do it all together."
Mark Taylor is a freelance writer in Munster, Ind.
• The $1 billion Partnership for Patients initiative was launched in April 2011 by Health & Human Services. The Center for Medicare & Medicaid Innovation is using $500 million of that total to test different models for improving patient care and patient engagement.
• CMS in December 2011 awarded $218.8 million to 26 HEN contractors, which have enlisted nearly 3,900 hospitals to participate in networks.
• Besides the HEN contracts, CMS awarded $10 million to Econometrica, WeberShandwick and Health Services Advisory Group to serve respectively as national content developer contractor; beneficiary and medical professional engagement contractor and evaluation contractor for the HEN project.
• The program aims to reduce the number of hospital-acquired conditions by 40 percent and reduce hospital readmissions by 20 percent by the end of 2013.
• CMS predicts that if American hospitals achieve the Partnership for Patients' goals, it could save 60,000 lives over three years and translate to 1.8 million fewer injuries to hospital patients.
• Reducing readmissions by 20 percent would mean 1.6 million patients will not require rehospitalization within 30 days of discharge. Today, one in five Medicare patients discharged is readmitted within 30 days — about 2.6 million seniors and disabled.
• CMS predicts the program could save Medicare $50 billion over 10 years.
Source: CMS, 2012
From best practice to common practice
Jacqueline Gisch, vice president of quality improvement for Aurora Health Care, says the 15-hospital Milwaukee-based system didn't suffer the freshman jitters when it agreed to participate in the Wisconsin Health and Hospital Association's Hospital Engagement Network.
"We've been doing this for years," she says, noting that in 2003 Aurora began participating in several national quality programs, most recently in the central line-associated bloodstream infections initiative.
Aurora Sinai Medical Center's intensive care unit had recorded only two central blood line infections in the 794 days ending March 1, and none in 226 days. The CLABSI program is being expanded throughout Aurora ICUs.
Staff from Aurora Sinai who worked on the central line infections team will participate on calls with the hospital association HEN's central line team.
Aurora's hospitals run the gamut from large community hospitals to an urban tertiary care facility and several small rural hospitals. However, Gisch says when it comes to adopting best practices, hospital size doesn't matter.
"IHI (the Boston-based Institute for Healthcare Improvement) best practices are agnostic to the type of clinical setting," she says. "It's the right thing to do whether it's a 600-bed academic medical center or a 60-bed rural hospital. There is no marked difference in acceptance factors. A best practice is a best practice and the size of the hospital doesn't make a huge difference in how we approach implementation."
Aurora has developed an internal toolkit to help hospitals understand the project and how to implement evidence-based practices in their units. "We share with each other little tools they developed," Gisch says. "We're really excited about the HEN project because it allows us to collaborate with other hospitals within our HEN and everyone else gets to learn from each other."
Because the kinds of harms included in the HEN 10 don't happen often, it's difficult to find patterns of errors. "That's where the collaboration with other HENs becomes so incredibly useful," she observes. "We learn things others have found useful that we may not have thought about."
Aurora has created systemwide teams around the different health care-associated conditions, bringing together different disciplines and job responsibilities. For example, the pressure ulcer team includes nurses, skin care specialists, emergency department staff and transport. Those teams will develop best practices, performance measurements and the standards to which staff will be held accountable. The systemwide teams bring that knowledge to the site teams within each Aurora hospital.
Turning best practices into common practices requires two important strategies: accountability and a culture of transparency, Gisch says, adding that both individual hospitals and employees are judged in their annual performance reviews on how well they attain quality performance goals.
One of the keys to making process improvement stick is leadership engagement.
• Monitor performance
Nanne Finis,executive director for solutions services at Joint Commission Resources, says leaders should access performance data for the 10 CMS improvement areas. "Then they should methodically mobilize staff and leadership around the need to improve, particularly in the problem areas."
• Accept responsibility
"We have to convince hospital CEOs that they are engaged in a high-hazard business," says Jim Battles, social science analyst for patient safety with the Agency for Healthcare Research and Quality. "It's their responsibility to make health care safe."
• Make staff accountable
Peter Pronovost, M.D., says CEOs need to hold local clinicians accountable — not the quality manager, the people doing the actual work. Be sure they have the resources, time and skills needed, and give them meaningful data and feedback. "If clinicians don't believe it's valid, they won't use it."
• MDs are vital to success
To engage physicians, Roger Ray, M.D., executive vice president and CMO at Carolinas HealthCare System, says the key is how you talk about it. "It shouldn't be about increasing payments and everyone practicing the same medicine, but should focus on the evidence-based practices that will improve outcomes. It's appealing to their altruistic nature and assuring them that you're on same page for improving care."
• Jackie Gisch
The vice president of quality improvement of Aurora Health Care, Milwaukee, says a culture of safety allows staff to feel comfortable voicing suggestions and complaints, and discussing misses and near misses without fear of punishment. "If hospital staff feel uncomfortable expressing their concerns, leadership misses an opportunity to make important changes."