In 2010, Daniel Levinson of the Office of the Inspector General of the Department of Health and Human Services released a report on safety issues for Medicare beneficiaries. After evaluation of numerous patient records, including review by multiple physicians, the report concluded that 13.5% of hospitalized Medicare patients experience at least one adverse event during a hospitalization. An additional 13.5% of all patients experienced an event that led to temporary harm. In the subsequent review by physicians, they noted that 44% of these events were preventable. The total yearly cost estimate appeared to be close to $4.4 billion.
Few clinicians would argue that quality is the most important parameter in health care today. Yet, it is becoming ever more evident that many patients do not receive state-of-theart health care. In a landmark article published in 2006, Asch et al. from the Rand Health group evaluated 30 chronic and acute conditions and used 439 indicators of quality to access if patients had received appropriate care. Unfortunately, overall, only 54.9% of patients received what would be considered recommended care. Some sociodemographic differences existed: Women received 56.6% of care versus men at 52.3%, and those with annual household income greater than $50,000 received 56.6% versus those less than $15,000 at 53.1%. However, what is striking is the low level of achieving recommended care for all the groups studied regardless of the sociodemographic differences.
In 1999, the IOM released a report suggesting that 98,000 patients per year die secondary to inadequate care being rendered. Many subsequent debates ensued regarding the methodologies used to attain these numbers.
However, this report created a call to arms, challenging those individuals and organizations who provide care to improve the quality of care delivered to all patients. Furthermore, it has caused a number of initiatives from a broad base of organizations. In December 2004, the IHI, at its 16th Annual National Forum on Quality
Improvement in Health Care, announced a goal to save 100,000 lives by June 2006. The campaign invited all US hospitals to join in implementing six broad initiatives that have demonstrated efficacy in well-performed clinical trials. These include
1. Prevention of surgical site infections
2. Prevention of ventilator-associated pneumonia 3. Prevention of central line infections
4. Prevention of adverse drug events (ADEs) through medication reconciliation 5. Deployment of rapid response teams
6. Delivery of evidence-based care for acute myocardial infarction
What is particularly impressive about the IHI campaign is the extent of support across a broad range of disparate federal, state, political, and private organizations, including—but not limited to—the CMS, Veterans Health Administration, American Medical Association, American Nurses Association, Centers for Disease Control and Prevention, Joint Commission on Accreditation of Healthcare Organizations, the Leapfrog Group, and multiple others.
Ultimately, the IHI released information suggesting that these initiatives were able to save 122,300 patients. This
P.70 was good news and suggested that progress was indeed being made. Unfortunately, a more recent publication reviewed hospital admissions from 2002 to 2007 in North Carolina hospitals. The authors found a rate of 25.1 harms per 100 admissions with no statistical change over the 5 years of the study. The challenge to implement the IHI recommendations as well as multiple other quality initiatives has caused a number of hospitals and large organizations to create chief quality officer positions that are largely responsible for implementing and monitoring compliance to these programs. In essence, this may be the confluence of patient safety, performance
improvement, utilization review, and other previous orphan committees.
Consistent with the IHI initiatives, other initiatives have come from CMS, including recommendations for optimization of diabetic patients. These include bundles of care much like the IHI central line bundle, in which appropriate care consists of all elements being appropriately performed or delivered within the correct time frame. Unfortunately, as the bundles become more complicated, it becomes more and more difficult for the provider to remember what has or has not been done. This may be yet another opportunity for the EHR to allow both the clinician and the patient to know what tests or interventions need to be performed, thus optimizing the encounter. The Joint Commission has also continued to evolve its recommendations, including core measure sets for venous thromboembolism, the surgical care improvement project, and most recently a core measure set for perinatal care. In addition, there continue to be updates and new releases of National Patient Safety Goals (Table 5.2). We expect that with increasing evidence-based knowledge, many additional quality-driven initiatives will come forward.
Another key safety initiative is the Partnership for Patients, a public-private partnership that aims to improve quality, safety, and affordability. An amazing 3,700 hospitals have signed on to portions of this program whose two primary goals are the reduction of hospital-acquired infections by 40% by the end of 2013 (as compared to 2010) and reducing complications using care transitions to effect a 20% reduction in hospital readmissions.
Twenty-six hospital engagement networks were awarded $218 million to lead these efforts. The patient safety areas of focus include (but are not limited to) the following (many of which an obstetrician-gynecologist may encounter):
1. Adverse drug events
2. Catheter-associated urinary tract infections 3. Central line-associated bloodstream infections 4. Injuries from falls and immobility
5. Obstetrical adverse events 6. Pressure ulcers
7. Surgical site infections 8. Venous thromboembolism 9. Ventilator-associated pneumonia 10. Readmissions
TABLE 5.2 2013 Hospital National Patient Safety Goals
Identify patients correctly
NPSG.01.01.01 Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
NPSG.01.03.01 Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Improve staff communication
NPSG.02.03.01 Get important test results to the right staff person on time.
Use medicines safely
NPSG.03.04.01 Before a procedure, label medicines that are not labeled, for example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up.
NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood.
NPSG.03.06.01 Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Prevent infection
NPSG.07.01.01 Use the hand cleaning guidelines from the Centers for Disease Control and
Prevention or the World Health Organization. Set goals for improving hand cleaning.
Use the goals to improve hand cleaning.
NPSG.07.03.01 Use proven guidelines to prevent infections that are difficult to treat.
NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines.
NPSG.07.05.01 Use proven guidelines to prevent infection after surgery.
NPSG.07.06.01 Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Identify patient safety risks
NPSG.15.01.01 Find out which patients are most likely to try to commit suicide.
Prevent mistakes in surgery
P.71 UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct
place on the patient's body.
UP.01.02.01 Mark the correct place on the patient's body where the surgery is to be done.
UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.
The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.
This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission. org. Copyright © The Joint Commission, 2013. Reprinted with permission.
Because of the breadth of the Partnership for Patients effort and the collaborative nature of the learning, there is real hope that sustainable change may be able to be accomplished.
It was previously believed that organizations with higher caseloads of a particular disease might be better positioned to deliver recommended care. Lindenauer et al. studied this tenet as it relates to pneumonia in the acute care setting. Surprisingly, they found both hospitals and physicians who had a higher caseload of pneumonia patients actually had reduced adherence to recommended guidelines—such as influenza and pneumococcal vaccine administration or early antibiotic administration—and had no better outcomes.
Quality initiatives are currently being led by a number of organizations, including some physician groups. For example, in Washington State, a physician-led group has brought all hospitals to the table to evaluate discrete performance measures regarding cardiac revascularization. Similarly, the California Perinatal Quality Care Collaborative in 1998 targeted improving antenatal steroid use as an initiative. They accumulated baseline data, developed educational materials, and broadly disseminated this information. They concluded that regional collaboration allowed an improvement from a baseline rate of administration of 76% to 86% post implementation.
Callcut and Breslin discuss how private groups, such as the Leapfrog Group, are playing an important role in moving the private regulatory movement forward and suggest that surgeons need to become more active participants in this process of reshaping and redefining our future.
How to best implement quality improvement programs in a given setting is also continuing to be investigated. A recent evaluation of hospital quality improvement implementation and subsequent impact on discrete patient-safety metrics suggested that involvement by multiple units within a hospital might have a negative impact on results. Alternatively, having a higher percentage of physicians involved was associated with better scores on at least two of the four safety indicators. Interestingly, having a higher percentage of hospital staff or senior
management involved had no impact on any of the indicators.
TABLE 5.3 Key Steps for Initiating, Improving, Evaluating, and Sustaining a Quality Improvement Program
Initiating or improving a quality improvement program
1. Do background work: Identify motivation, support teamwork, and develop strong leadership.
2. Prioritize potential projects and choose the projects to begin.
3. Prepare for the project by operationalizing the measures, building support for the project, and developing a business plan.
4. Do an environmental scan to understand the current situation (structure, process, or outcome), the potential barriers, opportunities, and resources for the project.
5. Create a data collection system to provide accurate baseline data and document improvement.
6. Create a data reporting system that will allow clinicians and other stakeholders to see and understand the problem and the improvement.
7. Introduce strategies to change clinician behavior and create the change that will produce improvement.
Evaluating and sustaining a quality improvement program
1. Determine whether the target is changing with ongoing observation, periodic data collection, and interpretation.
2. Modify behavior change strategies to improve, regain, or sustain improvements.
3. Focus on sustaining interdisciplinary leadership and collaboration for the quality improvement program.
4. Develop and sustain support from the hospital leadership.
From Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team. Crit Care Med 2006;34:211, with permission. Copyright © 2006 by the Society of Critical Care Medicine and Lippincott Williams.
Most clinicians have not been trained in how to develop and implement quality improvement programs. Curtis et al. have published a how-to paper that came out of an outcomes task force of the Society of Critical Care Medicine but has wide applicability to many areas of medicine (Table 5.3). The generalized lack of education and training in quality may explain some of the lethargy that Leape and Berwick allude to in their article “Five Years after To Err Is Human: What Have We Learned?.” They suggest that extraordinary quality improvements have been achieved by implementing discrete strategies in specific environments. If each of our organizations could fractionally achieve similar success, the impact on patient care might be quite remarkable.