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HomeMy WebLinkAboutMINUTES - 02052008 - D.3 D.3 02/05/2008 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on February 5,2008 by the following vote: AYES: Gioia, Uilkema, Bonilla, Piepho and Glover NOES: None ABSENT: None ABSTAIN: None ACCEPTED the report from the Health Services Director on the operations of the Contra Costa Regional Medical Center, Health Centers, and Public Health Clinics. I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THEM UTES OF THE BOARD OF SUPERVISORS ON DATE SHOWN. ATTESTE Cullen,Clerk of dkS B d of Supervisors d County Administrator B Contra Costa Regional Medical Center and Health Centers Report to the Governing Body February 5, 2008 The Ambulatory Care System Eight Health Centers � 9 Antioch tkpv 1'01111 Brentwood Richmond& \Linin:: I'ilLbur North Richmond Health Center and Hospital Legal Requirements and Limitations • Title 22,Cal.Code of �i_ Regulations—the organizational"bible" • Licensing,operations. participation in the Medicaid/Medicare system ' .i • "The Joint Commission" • Other regulators a California Title 22 §70001-70923 Licensure . Governing Body M} requirements —Adopt appropriate r. include: bylaws —Physical Plant —Appoint administrator —Administration with appropriate Medical Staff authority —Nursing —Provide physical and financial resources —Services offered _Conform with laws —Quality Assurance —Assure quality of —Patient rights care —Personnel policies Traditional Roles of Trustees ♦ Mission and Strategy ♦ Executive Leadership ♦ Financial Stewardship ♦Quality and Service Newer Roles of Trustees ♦ Driving Quality ♦ Driving Safety ♦ Driving Quality and Safety drives Financial Stewardship .Active involvement with medical staff in development of criteria for medical staff credentialing and privileging ♦Active review and involvement of patient and staff satisfaction Newer Roles of Trustees These"newer roles" have been proven to improve quality and safety. and quality and finance are directly linked. As a result, CMS and The Joint Commission now require trustees to embrace these newer roles. 4 Newer Roles of Trustees •Trustees have a Unique Fiduciary zw" obligation to ensure Quality Minimum standards apply —Determined by CMS, DHS,The Joint Commission, and case law • Separate from BOS responsibilities for other county operations - `a CCRMC's contribution to safer health care: learning, applying and leading. . Featured in 2007 and 2008 Institute for Healthcare Improvement's(IHI) Progress Reports •CCRMC achieved mentorship for 3 of the 12 IHI interventions -Medication Reconciliation -Ventilator Associated Pneumonia -Rapid Response Team Advance for Nurses N, Leading mpl iNMcmmrHvspil maM1kncal cemmr.ua u.s Contra Costa Times: US Hospital Drug Errors Grow •January 7, 2008 Front Page Article •"Contra Costa Regional Medical Center recently earned kudos as one of six hospitals honored nationwide for success in reducing medication errors by the Institute for Healthcare Improvement." More Press Celebrating CCRMC&HC •The Physician Executive • Harvard Medical International online journal •Joint Commission Resources • Stanford School of Business case review Opportunities for Trustee Involvement •Joint Conference Committee • Professional Affairs Committee •The Full Board of Supervisors y ti Next Steps: • Commit to education • Commit to partnering with the staff of CCRMC and Health Centers to continually improve quality and safety •Assist us as we drive better health care for the people of Contra Costa County. Formal Trainings: . Institute for Healthcare Improvement ` Chicago 3' May 29-30 (14 Hours) • California Institute for Health Systems Performance Sacramento June(date to be arranged) 1 day (6 hours) Future •• Explore -• topics depthgreater * Next workshop is February invite you to have this session on the campus of CCRMC and also tour our modern6 INSTITUTE FOR HEALTHCARE IMPROVEMENT status q why health care will never be the same 2 0 0 7 P R 0 G R E S S R E P 0 R T OSF Healthcare System (IMP,4CT member) where the rate of adverse events decreased from 98 per 1,000 patient days in 2004 to 35 per 1,000 patient days in 2006 Communication handoffs—when one clinician describes a patient's condition,needs,or treatment plan to another—are at once powerful and vulnerable transactions.Despite caregivers'best intentions, miscommunication is the root cause of most medical errors.Now,a communication framework borrowed from the nuclear submarine service is changing that. Called SBAR,the framework guides clinicians to communicate about patients by describing the Situation, Background,Assessment,and Recommendation.At OSF Healthcare System in Peoria,IL,SBAR was introduced in 2002 and has spread to all six hospitals,home care,and the OSF medical group.Although there's been no formal measurement,SBAR is credited with helping to decrease adverse events. "Nurses and doctors tend to have different models of communication about patients,"says John Whittinb on,MD,OSF's Patient Safety Officer and Director of Knowledge Management."Nurses are more descriptive,doctors use`headlines."'SBAR,he says,highlights the importance of effective communication and helps people speak the same language,clearly and succinctly. At OSF clinicians receive training in SBAR communication,and anonymous auditors measure how much SBAR is used.Data is submitted to the board quarterly.Not only have adverse events decreased,but Whittington reports that SBAR is useful beyond the clinical areas."I've seen it used in everything from clinical consults to meetings about information systems.It's just a better way to communicate almost everything." Contra Costa Regional Medical Center WIPACT member) where the percent of patients with all medications reconciled on admission rose from 47% in 2005 to 99% in 2006 "We are so jazzed about this,it's like someone invented the wheel,"says Steven Tremain,MD,ABFP, FACPE,Director of System Redesign at Contra Costa Regional Medical Center in Martinez,CA.Tremain is talking about the hospital's new systems for reconciling patients'medications at admission,transfer and discharge as part of a broader initiative to redesign processes to improve reliability. "In the old process,the physician and nurse would each make a list of the patient's medications.Then the doctor would write medication orders on a third sheet.The three sheets were never cross-checked,so there was no way to know if a medication missing from the orders was overlooked or intentionally discontinued." Now,a single form—one that went through many iterations in small tests of change—replaces the three old sheets.The physician indicates for each medication whether it should be continued,modified,or discontinued.It goes to the pharmacy,and the nurse reviews it for accuracy with the patient. Y� "This has been the most meaningful work I've done professionally,"says Tremain. "We can often see how ridiculous some of our processes are,but we are fighting today's battles and don't often have the time or tools Medication reconciliation to fight and win tomorrow's.Without the tools and collaboration through IHI,we'd still be struggling." is one of the most challenging University of Massachusetts Memorial Medical Center operational and cultural shins where 95% of patients' hospital medical records are free of medication reconciliation errors Eric Alper,MD,was Patient Safety Officer at UMass Memorial Medical Center in Worcester,MA,at the that our organization has time when medication reconciliation first became a major focus. He says that the effort to make sure informa- made. Even though we have tion about a patient's medications is accurate when they are admitted,transferred,and discharged is not just another project because it changes the fabric of the organization,including processes,roles and responsibilities. yet to perfect it, we know "Medication reconciliation requires logistical and cultural change,and repeated process redesign at multiple we have significantly levels,"he says,"which is why leadership is so important."Alper says the Center's CEO and chief quality _ officer strongly supported the effort. improved medication safety At UMass,the process was streamlined through the introduction of a new form that combines the medica- for our patients. It is worth tion list and the order sheet,eliminating the need to copy information from one to the other. Residents were given primary responsibility for reconciling medications,solving a medication reconciliation problem that is the effort." common in hospitals:knowing whose job it is. According to Chief Quality Officer Robert IQugman,MD, the effort has paid off: up to 90%of patients have a medication reconciliation form in their chart,and 95%of patients'hospital medical records are free of reconciliation errors. - INSTITUTE FOR HEALTHCARE IMPROVEMENT i ua tYRule ;f How far have we Al 9 f' o n Ar71o �g lcl s rlorl e In the ideal hea / / tf _/ // , / / / ' / -an communication guarantee excellence, continuit and reliabilit . There is lessfocus on role definition andprofessional boundaries, and morefocus on teamwork and ffecommunication. Johns Hopkins Children's Center, where pharmacists on Rapid Response Teams boost effectiveness 0 ne of the interventions of IHI's 5 Million Lives Elizabeth Hunt,MD,MPH,attending pediatric intensivist, Campaign is the Rapid Response Team,a small says that pharmacists play an invaluable role on the team, team of critical care experts available to rush to the helping to prepare medications so nurses can focus on attend- bedside of any patient who shows early signs of deteriorating ing to the parient's immediate needs. "This significantly eases health.Working with the patient's nurse,these teams— the burden of the first responder nurse and the PICU nurses," typically composed of a critical care nurse,a respiratory says Hunt."Now the team keeps functioning while the drug therapist,and sometimes a physician or physician assistant— is prepared, instead of a key player turning away from the can often prevent serious incidents such as cardiac arrest by patient."In addition,says Hunt,pharmacists have quick access intervening at the first sign of trouble. to drugs not apically stocked on patient units. Now,some hospitals are discovering that the Rapid Having a pharmacist available for pediatric Rapid Response Response Team that includes a pharmacist is even more Team calls can be especially important because children's effective,helping to ensure that medications are available,and, medication needs are harder to anticipate than adults. "In where appropriate,to determine the cause of a patient's decline adults,you can pre-prepare some meds,"says Hunt."But and offer expert clinical advice. because children come in so many sizes,you have to draw At Johns Hopkins Children's Center in Baltimore,MD, up the right dose for each child." Contra Costa Regional Medical Center, where the rate of VAP dropped by more than 90% r enior Medical Director Steven Tremain,MD,says that Through teamwork,Contra Costa has been able to improve the culture of interdisciplinary collaboration at Contra care processes and patient outcomes in areas ranging from Costa Regional Medical Center in Martinez,CA, is in reducing surgical site infections to minimizing the complica- part a natural result of the fact that the hospital is owned and tions of heart attacks.Working together to implement the operated by the county."Probably 90%of the people who bundle of steps recommended by IHI to reduce ventilator- work here are county employees,and together we own the associated pneumonia(VAP),staff reduced cases of VAP work,"he says. from 20 per 1,000 ventilator days in 2003,to 1.3 in 2006. But really,there is far more to it.What he describes as To hammer home the importance of the bundle steps, "tremendous collegiality"between doctors, nurses,respiratory Tremain says the head respiratory therapist built a simple therapists—in fact all staff—does not just happen.It is the model of a trachea,and placed a ventilator tube into it.To result of a conscious effort from the top down and the bottom show that the cuff surrounding the tube does not reliably keep up to create a culture of collaboration and teamwork. extraneous material from slipping down into the lungs,he poured pea soup around the tube."In 24 hours it had leaked CONTRA COSTA: VAP RATE past the cuff,"says Tremain."It was a visual cue that reminded PER 1,000 VENTILATOR DAYS everyone on the team to do the bundle elements,because we 25 20 can't assume the cuff forms a perfect barrier. If we do,the 15 patients are in trouble,"says Tremain. 10 5 0 2003 2004 2005 2006 N ' N 'A O 2 w ` h O T , ••����yt,t L..M, 4'�1 ujO 222TTTT / O y� N E"f t�• L OD it•"r.V � Q CD r. • AN All t < y , Y k I ri ' PRSRTSTD U.S.POSTAGE 1 PAID ti +. MERTON PUBLICATIONS 1 � 1 • ADDRESS SERVICE REQUESTED 11 1 ' + + 0 11 14WAMIllif 1-1 if4aActi + 1 " 1 ' 1 ONTROLLING VAFFrom marks on the beds that 11,bcate the proper 30,degree ek-v3tion and posters that .du ate visitors about the practice.to-24-hour oral care ;its(lower right)that make it easy to monitor compliance -------- s-,ith oral care rq,,Jniens.VAP preventum practices have hoaimc highly automatic t.or staff like Frent Yale,R7'. Mg W, J* It NNW Mb,. AWMERM J Wr; lox. 0 W. INC w 44�1- alit sly , 1 y i t all began with the realization that to deliver safe, quality care, the staff at Contra Costa Regional Contra Costa Medical Center in Martinez would need to work Regional Medical not harder,but smarter. Since launching its system 4fUr redesign in 2004,the facility has been designated an Centers role as an Institute for Healthcare Improvement(IHI)Mentor Hospi- tal for high achievement in three areas:medication recon- IHI Mentor Hospital ciliation,ventilator-associated pneumonia(VAP)reduction y not only celebrates and implementation of rapid response teams. But as staff are quick to point out,though their achievements are a solid d its successes, but start,the quest for perfection always will be ongoing. ensures it will Driven by dedication to improvement,Contra Costa buck- led down and embarked on its journey.Tapped by the execu- ivr continue to pursue tive director to lead and champion the project,Steven Tremain, performance MD,ABFP, FACPE, sought a compatriot to complete the "unit"of two that would steer a larger team toward success. improvement "I knew pretty quickly that without someone who shared my 3Y S;'`;LBY EVA\S vision and understood,fully,nursing practice,this would be a total failure,"he said.Quickly,Anna Roth,MS,RN,emerged _ as the ideal candidate."She is very broad in her vision and far- reaching,"Tremain said."She sees possibilities where I am accustomed to seeing limits.She also was eaming her gradu- ate degree in nursing at UCSF and was exposed to all of the gid+-wa,. most modem thinkers about change in clinical settings." A Plan Is Hatched := . c_ - - "If this were manufacturing,we would be R&D,"Tremain _ said of the system redesign duo."You have to have a dedi- cated R&D team that either does its own mini-research or � looks at the results of other people's work to figure out what - rv� you can adopt and adapt from their environment to yours." When Tremain and Roth attended RE's national meeting in 2005, they found what they were looking for.The best practices IHI had developed helped the system redesign team focus their efforts and get started. "There are hundreds of things that need to be improved in healthcare and sometimes that's part of the problem," Tremain explained."There are so many things to improve that your efforts get so diluted you actually don't accom- "' =' plish anything." -. By enrolling some 3,000 facilities in its 100,000 Lives Campaign,IHI also offered Contra Costa a huge pool of m OCTOBER 8,2007 -NORTHERN CALIFORNIA AND NORTHERN NEVADA-ADVANCE FOR NURSES 13 cover story resources and a list of mentor hospitals to tap for advice. `Should I go to this meeting or should I be with my patient?"' "Long before we became a mentor, we went to the mentors,"Tre- Tremain agreed participating in performance initiatives often is < main said. "It allowed us to start at square 2 or 3 instead of square 1. difficult role for nurses to take."Some believe that if you're not up t( We didn't have to repeat their failures; we learned from their failures." your arms in some bodily fluid,you're really not working as a nurse,' Adapting the mentors'methods to Contra Costa's needs offered a valu- he said."There is some risk-taking on the part of these nurses.But the) able advanced starting position. "You may fail, too,"Tremain noted, are driven because they want to make things better for their patients." "but you fail forward." Even now,as a mentor hospital itself,Contra Costa continues to find Anchors Aweigh the experiences of other facilities highly instructive. HE also introduced the facility to the concept of"small tests of change: "Anytime we have that interaction,it's a two-way leaming process rapid cycle improvement,"which Tremain said was particularly critics for us,"Roth said."What we have to offer in the overall collaborative in the complicated implementation of medication reconciliation. The that the campaign brought to all of us is the ability to really interface complexity,he said,arises in part from the sheer numbers of cliniciam with each other and support each other." who need to be brought on board. "You're dealing with every doctor "Mentors like Contra Costa set a great tone," said Jo Ann Endo, every nurse,every pharmacist.In an organization like ours,which is only coordinator of the IHI Mentor Network. "They really talk about not 166 beds,it's still literally 1,000 people you need to get to." just their successes,but the challenges they "You're asking people to change the had along the way,the roads they ended up way they do things,"Roth explained. "Sc taking after changing paths along the way. we needed a nurse right away in that pro- They really model that transparency,open- +' i cess who had credibility on the floors."For ness and honesty about how none of this is - her long history in med/surg and ability tc easy,none of this happens overnight,but it implement small tests of change immedi- can happen very quickly if you approach it ately in her current, small telemetry unit, the right way." Dana Colomb,RN,was the ideal nurse for the job. Building the Ship t The medication reconciliation team started Although Roth and Tremain would be by contacting mentor hospitals, talking to the personnel dedicated exclusively to the - them about their experiences with similar project,they surrounded themselves with a V projects and obtaining copies of their forms. team that would support them in the put- By the end of the team's first"med rec"meet- suit of more efficient,more predictable and ing,they had designed a form they believed more accurate clinical outcomes. A bio- would work.Colomb and a physician on the : e goal of the rapid response teams is not ethicist,the chief of surgery,an IT special- AT THE READYThg p p team took the form to the telemetry floor, only responding to the needs of the patient or the nurses who ist, the director of medical social services tried it out with a single patient and realized are worried, education to t d,but also to spread patient care edihe and Tremain's assistant comprise the team, immediately it needed to be changed. which also serves to keep big-picture ideas nurses in the med/surg area.From left:Virginia S.Paolino,RV, "There was very quick turnaround and grounded and pragmatic. CCRN,Trent Tate,RT,Mary Bautista,RN,CCR-14,Grace wta, we'd go back and say this is the feedback, Another outcome of the IM conference CCRN,CRNI,and Sherrie Gordovez,RN,CCRN. let's try it again,"Colomb confirmed."We was that it emphasized the importance of went through that process so many times involving nurses in the initiatives,Roth said. until we finally came up with something agreeable for everybody Tremain, too, stressed the importance of involving front-line staff — that wasn't labor-intensive, didn't look like just another form, members—"local knowledge experts"—in the system improvements. stood out when it needed to, served the purpose and was as simple "It's not superficial as in `if we get them involved they'll give us buy- as possible." in,"'he said. "No! If we get them involved they'll help design it so it "They changed it six times in the first 14 days,"Tremain said."You actually works; that's the key thing.The input is what drives the suc- can learn a lot ... if the first time you try something it doesn't work, cess,not the flattery of being on the team.They made it better and the it's probably not going to work if you try it 10 more times.Learn what making it better is what drives the buy-in—for everybody. you're going to learn and change it." "The staff nurse is critical, because the staff nurse has the local Through these small tests and rapid adjustments,the medication rec- knowledge of what really happens in patient care and becomes that onciliation team created solutions that worked and moved the entire link to people who often make decisions and think they know what's process forward. going on on the floors but don't." "They brought us a whole new type of measurement,where progress In spite of having to juggle their existing workloads with the work was measured in days and weeks—in some cases,in shifts—instead involved in pioneering the improvement efforts,nurses stepped forward of months and quarters, which is what we were used to," Roth said. and volunteered to lead the charge on the front lines. "Nursing played a role in bringing out that whole new language,or way "In some cases,for a nurse,it's kind of a conflict,"Roth said,explain- of looking at data or progress.Nurses look at patient care measurements ing she would work with management to facilitate management time in 8-hour increments,but administrative processes used to be measured for these nurses to be off the floor. "That's a real struggle for a nurse: in months or quarters." 14 ADVANCE FOR NURSES •NORTHERN CALIFORNIA AND NORTHERN NEVADA•OCTOBER 8,2007 •WWW.ADVANCEWEB.COM/NURSES cover s tory The Next Steps CONTRA COSTA With medication reconciliation under way, rapid response teams HEALTH SERVICES (RRT)and VAP projects were close behind.Again,Contra Costa looked to those who had gone before them. "Initially, when we started the RRT, we made calls to other area facilities,"said Grace Ma,BSN,RN,CCRN,a critical care floor nurse. "We asked them how they are doing it and formulated a plan suitable ' }+ to our facility,learning from their mistakes." r Contra Costa's first RRT was rolled out from critical care; Ma was instrumental in planning and implementing the teams,and is herself the responder on her shifts.The role of the RRTs,as she sees it,is beyond simply getting to the patient in 5 minutes or less. "Our goal is not only responding to the needs of the patient or the - nurses who are worried,our goal is also to spread patient care education to the nurses in the med/surg area,"she explained."Many nurses who Contra Costa Health Services, work in med/surg are very junior nurses, so when the RRT goes out, our people make the difference! we go over their concerns.We always acknowledge their concern as a positive; we don't want them to feel they shouldn't have called us." In addition,she said,it is an opportunity to explain to fledgling RNs Contra Costa Health Services is a comprehensive county health system located the interventions the RRT is using. in the beautiful family-based community of Contra Costa County(San Francisco "If we go to the floor and a patient is really huffing and puffing,we Bay Area). CCHS employs more than 3,500 individuals and is dedicated to would say, `This is really respiratory distress and I will do this with improving the health of all people in Contra Costa County with special attention the oxygen;I will do this for diuresis;this is what we'll do to decrease to those who are most vulnerable to health problems.With the opening of the some of the fluid volume."' Contra Costa Regional Medical Center the people of Contra Costa gained a Although VAP interventions were already being started at Contra vakobte new community resource: a modem state-of-the-art public hospital wdedicated Costa before the IM released its intervention"bundles,"the program to serving the health care needs of all county residents- took an even stronger hold under the system redesign,and the critical With an excellent management team and a growing need for care unit served as the primary backdrop. county health services,NOW is the time to join our dynamic staff. "Not only did they have a tremendous nursing staff on the critical We are seeking RNS on all shifts,per-diem and permanent vacancies care unit,but they also had tremendous nursing leadership,"Roth said. "For 2 or 3 years before,Lisa Massarweh[MSN,RN,CNAA,CCRN], in the following areas: whois now our CNO,already was working on data collection related to Med/Surg • ICUAMCU • ED • Psych • Perinatal VAP.She already had brought those concepts to our facility and those OR • PACU • Pediatric • Float Pool • Detention nurses were working on it,so it wasn't a hard sell on that unit." From marks on the beds that indicate the proper 30-degree elevation Advice Nurse • Utilization Review Coordinator and posters that educate visitors about the practice,to 24-hour oral care ICU/ED Clinical Nurse Specialist kits that make it easy to monitor compliance with oral care regimens, VAP prevention practices have become highly automatic. Psychiatric Clinical Nurse Specialist "We keep good counts of our ventilator days and if we do have sus- Education Training Specialist (RN Educator) picions of VAP—we did have one case back in September 2006—we immediately go back to real-time audits to see why that happened so we Staffing and Inpatient Care Coordinator can make changes immediately,"Ma explained.Twice-a-week multidis- (Knowledge of ANSOS and VANSLYCK acuity systems desired) ciplinary rounds ensure patients are well-monitored and guidelines are We are also seeking exceptional candidates for the following: followed."We go through the patient's whole scenario: what we need, what we're lacking,what we can improve." Pharmacy • Respiratory Care Highs&Lows Occupational Therapy • Physical Therapy Successes notwithstanding,implementing these projects has required Radiology • Medical Records perseverance through many difficulties,not least the fear of change. We offer an excellent benefits package associated "Resistance to change is quite natural,"Ma acknowledged."Person- with all permanent positions! ally, when we started the RRT, my feeling was: Why do we have to teach the nurse to call the nurse? But I listened to the idea and I fol- i To obtain application materials for any of the above listings, lowed through.I really believe it's good for nurses, among ourselves, t' please contact Linda Bates.Professional Recruiter at(925)370-5771. } For more information on the Health Services Department,please visit: to share our knowledge and to educate each other." In spite of her initial skepticism,the RRT has been well received,Ma www.cchealth.org Continued on page 40 NORTHERN CALIFORNIA AND NORTHERN NEVADA•ADVANCE FOR NURSES 15 Equal Opportunity Employer -. i Cover Story Continued from page 15 Sion for the project,as well as auditing and giving positive feedback to reported,particularly among the junior nurses, and has proved highly employees,have been key to the accomplishments. rewarding for her as well. "They really appreciate an extra hand, an "People in general,in life,are so used to getting negative comments extra idea. We have seen patients who were really sick and made it; that it's so nice when someone comes up and says,`I audited your chart if we did not intervene early they might not have or the hospital stay and it was perfect,"'she said. would have been much longer." As Roth noted,credit is due to the many individuals involved, and For Colomb,medication reconciliation has enjoyed some highly sat- the successes they have enjoyed are by no means an endpoint. "This isfying accomplishments,and also challenges. represents a large group of healthcare providers at Contra Costa com- "There was a learning curve,and a behavioral curve,"she said."But mitted to finding better ways to take care of patients,"Roth emphasized. now the admission,transfer and—pretty much—discharge processes "We've learned some things and we've improved in some areas but go so smoothly we rarely hear anything negative."There were times, we're determined to continue that process." Contra Costa will delve she acknowledged, it was difficult to face criticism about the project. deeper into reduction and prevention of infections such as MRSA surgi- "Each member of the committee takes it personally.So on the one hand, cal site infections.Along with establishing reliable care for acute MIs, while I feel passionate and want to help people and want them to under- the ongoing focus will include congestive heart failure care. Work on stand how to do it,sometimes you get a little frustrated." medication safety and reconciliation continues. Getting staff completely bought in to the need for the process was "Nothing has stopped;we've not made it to a destination;we're not tough at the outset, too,she noted. "If we've unfortunately had a sce- declaring victory and we haven't gone into autopilot or slowed down," nano take place and had a bad outcome,it really sticks with you,but to Roth confirmed."We're still in this game,trudging forward and we plan present it in such a way that[shows]this is what we're trying to prevent to do this forever,until we get to perfect patient care." is a very effective way to get people to do what you need them to do." "There can be a misperception that the great teams were born that way, or that all the great teams are a certain kind of hospital. People Secrets Ot Success have certain ideas,especially in the medical world,of who are the top "I believe the major reasons for our success are the hospital's driving performers,"Endo said. "One of the great things the mentor network force,the administrators'belief in promoting the IHI idea and their sup- has done is given an opportunity to organizations like Contra Costa to port,"Ma said."Initially,it was very hard because we had all these new also have some of the spotlight as one[others]can learn from and as a ideas,all these changes rolling out at one time.But,in time,we got the model of great work being done."■ hang of it and we're enjoying the success at the moment." For Colomb, the people on the committee and their level of pas- Shelby Evans is associate editor at ADVANCE. Preparing the Manuscript ADIlANCE for Nurses Feature articles should be approximately 1,200 words(3.5 Writer to 4 pages)in length,depending on subject matter.Articles Guidelines should be submitted via e-mail to lbrzezicki@merion.com. The article should follow the writing guidelines set forth in The Associated Press Stylebook and Briefing on Media Law Contact the editor: (Goldstein,2000)and common English usage.A title page Lisa A. BrzeZicki should be included and contain a suggested title and the name or names of the authors.Degrees and accreditations,professional (800) 355-5627,ext. 1124 titles and current position should be included.Subheadings are Fax:(610) 275-8562 encouraged throughout the article to enhance readability. Or e-mail:ibrzezicki@merion.com All statements based on published findings or data should — be referenced appropriately.References should be listed in numerical order in the text and at the end of the article fol- General Policies lowing the American Psychological Association style.A ADVANCE accepts original articles by members of the nursing maximum of 15 references will be printed with the article.All profession,professional writers and members of related health- references should be recent—published within the past 5-7 care professions.All technical material is reviewed by an edito- years—unless using a seminal text on a given subject. rial consultant prior to acceptance.Once accepted,manuscripts become the property of ADVANCE for Nurses.They may be used Editing in print or online by any of the ADVANCE family of publications All submissions are edited for clarity,style and conciseness in and will be archived online.Once published,articles cannot be accordance with ADVANCE format.Submissions must include reproduced elsewhere without permission from the publisher. the author's name,telephone and fax number for verification. 40 ADVANCE FOR NURSES -NORTHERN CALIFORNIA AND NORTHERN NEVADA-OCTOBER 8,2007-WWW.ADVANCEWEB.COM/NURSES CONTRA COSTATIMES Cont><raCostaTimes.com U.S. hospital drug errors grow Medication mistakes present health risk, drive up health care costs By Sandy Kleffman, STAFF WRITER Article Launched: 01/07/2008 02:37:51 AM PST MARTINEZ — With nearly one-third of adults taking five or more medications, drug errors have become common in American hospitals. For years, the issue received little attention, but now many hospitals are tackling the problem head-on. Some are showing notable results. Contra Costa Regional Medical Center recently earned kudos as one of six hospitals honored nationwide for success in reducing medication errors by the Institute for Healthcare Improvement. Medical errors traditionally have been a taboo subject, said Dr. Oliver Graham, an attending physician at the county-owned hospital in Martinez. But theres been increasing recognition that humans are fallible and that errors will be made. Other businesses have long realized this point. The airline industry has systems to guard against pilot error. Yet only recently has the health care profession embraced the need for similar safeguards, said Dr. Steven Tremain, director of system redesign at Contra Costa Regional Medical Center. At least 1.5 million preventable medication errors occur each year in U.S. hospitals, long-term care facilities and outpatient settings, estimates a 2006 Institute of Medicine report. Medication errors are surprisingly common and costly to the nation, the report concluded. In addition to threatening patients, mistakes drive up health care costs. Each error adds about $8,750 to the price of a hospital stay, one study found, bringing the nations total annual cost for such mistakes to $3.5 billion. The problem has grown more acute because in any given week, four out of every five American adults use at least one type of medicine or dietary supplement. Errors can occur at numerous points during hospitalization and are often the result of breakdowns in communication. Patients may forget or be unable to tell a doctor all the medications they were taking before arriving at the hospital. Or a doctor may compile a list of such medications only to find that others overlooked it. The result can be a prescription for a drug that conflicts with something else the patient is taking. Or a busy doctor may neglect to continue needed drugs during a patients hospital stay. t Nurses who notice the omission are left wondering whether the physician purposely decided against prescribing the medication. Particularly with patients who are on multiple medications at home, its very important to know exactly what those medications are, said Stephanie Bailey, who helped oversee Contra Costa Regional Medical Centers medication team. Errors can also occur as patients transfer from one area of the hospital to another, or during discharge, when a doctor decides what medications should be taken at home. Contra Costa Regional Medical Center began formally tackling the problem in July 2005. It did so after the Joint Commission, which accredits hospitals, announced that it would require institutions to address drug errors as part of its 2007 patient safety goals. The result has been heightened awareness and more aggressive programs at hospitals throughout the nation. Contra Costa Regional Medical Center formed a team of physicians, nurses, pharmacists and pharmacy technicians who met for 45 minutes every week for 21/2 years. The team audited medical charts and found that about 26 percent of the time, a home medication was not mentioned on an admission form. So you wonder why, Bailey said. Now doctors fill out one form, with boxes to check for each home medication listing whether it should be continued, discontinued or modified during the hospital stay. The easy-to-read forms become part of the medical record. Nurses and physicians do not have to hunt through the files to determine a patients medications. The hospital audits its medical records every quarter. As of October, the percentage of home medications not mentioned in admitting orders had plummeted to 1.1 percent, a sign of widespread compliance with the new measures. A pharmacy technician inputs each patients list of home medications on a computer so that a doctor can go to a computer at any time and print the list, Bailey said. After implementing the program in admissions, the tearn set up similar procedures for transfers within the hospital. No longer do physicians simply write continue previous orders. The team also created a form for physicians to fill out listing which medications should be taken after discharge, including the dose and timing. We hope that when (patients) leave the hospital, they have a nice, clearly printed list of medications that is easy to follow, Graham said. Special Report: Quality of Care Survey (hallenges in Patient SafetyandQuality,# Repla(ing Dis(ouragement with Hop-e- By Diane Shannon,MD,MPH IN THIS ARTICLE... Physician leaders say there are ways to tackle some of the obstacles blocking efforts to improve patient "Trying to achieve safety and quality in health safety and quality—but there are no easy solutions. care is continuously frustrating." "We have to care before we can improve, and I don't see a lot of caring." "Improving safety and quality is simply...overwhelming!" Do you identify with the frustrations expressed by these physician leaders?Are their laments depressingly to adhere to program interventions and required documen- familiar?Are you too overwhelmed by the obstacles to talion, that overcoming resistance to standardization was achieving safety and quality in your organization? If so, a major problem, and that their physicians were "too busy an you're not alone. d not taking the problem seriously." A majority of ACPE Quality of Care Survey respondents William Thomas, MD, FACP, executive vice president said they have struggled with finding an appropriate balance of medical affairs at MedStar Health in between what they believe is best for patients and what's Columbia, Maryland, believes that the key to physician engagement is asking best for their health care organization when it comes to implementing patient safety and quality initiatives. "the right question e, the right way." Given the very real obstacles to patient safety and qual- In his experience, physicians are quick become involved when i ity care,what is the best course of action?After all, there are ed no"Get Out of Jail Free"cards for physician executives.You lives arree conceived and implemented in ways that approach the system as awhole—rather than the don't get to bypass safety and quality initiatives just because they're difficult to design and implement. particular portion in which the physician is involved—and We asked four physician executives to share their when they offer opportunities for physicians to help design successes in overcoming the all-too-common obstacles to processes to solve the identified inefficiencies. quality and patient safety. We think you'll find their col- An important role of the physician executive, Thomas asserts, is helping physicians to become involved by lective experience illuminating. We hope it restores your sense of hope. Remember, big change is often realized selecting problems to address for which the solutions will with a series of very small steps. both improve care and provide a benefit to the physi- cians—in time or practice efficiency, for example. Physician engagement Steven Tremain, MD, CPE, FACPE, senior medical director and director of Lack of physician engagement is a substantial barrier system redesign at Contra Costa Regional to effective implementation of quality and safety initiatives, Medical Center and Health Centers, in according to a majority of survey respondents.Almost one Martinez, California, also finds a WIIFM third consider physician resistance to the use of evidence- (What's In It For Me?) focus to be essen- based care to be a major obstacle in their institutions. tial to physician engagement. Only 34 percent reported that physicians were very He described an initiative to improve medication recon- supportive of quality and patient safety improvement proj- ciliation that improved care and reduced paperwork for phy- ects. When asked to share their opinions on the obstacles sicians. Prior to the intervention, medications were listed in at in general, a number complained that physicians refused least three locations: within the history and physical section 16 MAY•JUNE 2007 THE PHYSICIAN EXECUTIVE For physicians who remain , A 1 �, 4 resistant to the motion ofAL standardization of care, likeningfrAir, r. it to"cookbook medicine;" r t" It; r Thomas has this rejoinder: • "We were taught cookbook' a , medicine in training—from our , mentors.That type of`cookbookaIF " 1 medicine'just wasn't written ° iVf'• down." A of the patient's chart,on the physi- Healthcare Improvement (IHI). clan order form,and on the nursing "Don't go in with a stick,"he But what should a physician intake form.Systematic crosschecking warns. "Instead,give physicians leader do when nurses are frus- between the lists was not performed. information and provide them with trated and ready to institute change, Using rapid cycles of change leadership."It's important to provide but physicians are satisfied with the (six cycles within the first two information on improvement method- status quo? weeks), the group created a single ologies as well,according to Tremain. When professionals are at dif- form that is placed on top of the "Don't tell them'to do better,'show fering levels of engagement with an physician order sheet—in the path them how others initiative, Silbaugh tactfully points of their customary work stream. have done it." out that frustration indicates a prob- This forth serves as the history and Barry Silbaugh, lem in the process, a waste or inef- the reconciliation form, and is used MD,MS, FACPE, ficiency, and is reflective of a issue by the nurses to crosscheck with senior health- that needs to be addressed. the intake form. care partner Once the issue is seen in such Since use of the single form was at the Creative a way, Silbaugh finds that physi- instituted two years ago,the percent- Management Group in Sandia Park, cians do step up to the plate. In his age of patients with every medication New Mexico,also believes that educa- experience most physicians have an reconciled on admission has increased tion is a key component to physician innate desire to help fix problems. from 47 percent to 95 percent. engagement. He uses this insight to encourage Another component that He recommends training phy- their engagement. Silbaugh also Tremain finds essential to engage- sicians on the use of a specific steers the attention of nursing and ment is providing physicians with improvement methodology, such medical staff to the patient experi- adequate data—both in the form of as LEAN, Six Sigma, or methodolo- ence—a focus that serves as a com- evidence-based literature on partic- gies developed by the Institute for mon ground for all professionals ular clinical issues and data on the and encourages their support. practice of other physicians. THE PHYSICIAN EXECUTIVE MAY-JUNE 2007 17 Unexplained variance in care was reported to be a major problem by almost one third of survey respondents. Culture of safety Tying executive compensation time for adverse events reports to Two significant obstacles to to improvements in some of these reach senior clinical and risk man- establishing and maintaining a cul- problem areas provided effective agement executives—exemplifying ture of safety exist in health care: a organizational incentives for safety. the importance of a culture of safety pervasive culture of blame that hin- In his work with the safety and quality in rapid "uphill" travel ders acknowledgment of error, and program at a national health care of such information. professional "silos" that slow the system, Silbaugh recommended The team also decided to use a process of instituting change.t addressing critical communication one-page safety alert to warn staff And, as one survey respondent issues by forming rapid response in system hospitals about potential articulated, implementing quality teams at each hospital within the safety issues, whenever an issue improvement programs without a system and improving system-wide of high importance came to their culture of safety doesn't translate communication about safety. attention. At one hospital, an oper- into safety for patients: "I don't First, the formation of rapid ating room nurse discovered that think the difference in a culture of response teams at every hospital in only one of the surgical site marker safety and culture of quality is dis- the system enhanced front-line, or pens used at the hospital was tinct enough yet in people's mind. bedside, communication. Although clearly visible on the skin after a We can be putting quality improve- the composition of the teams at routine surgical prep. This informa- ment measures in place, and still he each hospital varied in size, health tion—along with a picture of the unsafe. We need to do both." professional availability and medi- intact and faded markings—was Silbaugh finds the Hospital cal staff preferences, the goals of emailed to the system hospitals. Survey on Patient Safety devel- each team were the same: respond Use of the non-fading marking pen oped by the Agency for Healthcare quickly to safety issues and have a subsequently increased throughout Research andQ Y Qualit (ARH ; avail- standardized, non-punitive approach the system. able at http://www.ahrq.gov/QUAU to "uphill communication." Richard hospculture/) to be a useful tool for Uphill communication is the Guthrie, MD, med- assessing an organization's culture sharing of concerns or questions with ical director at the at baseline. an individual in a superior role of Ochsner Medical Using the survey helped one authority. The group was awarded a Center in New organization he worked with iden- grant from the Robert Wood Johnson 1k Orleans, looks to tify four key areas of frustration: Foundation to help train clinical lead- other high-risk ers and track results, illustrating the industries for insights applicable 1. Handoffs and transitions importance of this work. to the development of a culture of 2. Teamwork across clinical units Second, Silbaugh and his col- safety in medicine. leagues reviewed the timeliness of Aeronautics is a field that 3. Desire for a non-punitive system-wide communication about maintains a high level of account- atmosphere safety hazards and the appropriate- ability and sets the expectation that 4. Staffing concerns ness of resulting action steps. As the goal for adverse events is zero. a result of this analysis, they were Airlines don't set a goal of reduc- able to trim months off the average ing in-air collisions by 75 percent, 18 MAY•JUNE 2007 THE PHYSICIAN EXECUTIVE i he points out. Instead, they set the the hospital incurred upfront per- back and look at what happened." bar at zero and pursue activities to sonnel and equipment costs to Thomas provided proof of the attain that goal. implement bedside registration, the strength of standardization in reduc- Guthrie admits that creating the changes translated into more ED ing avoidable errors. A system-wide same sort of accountability links visits and an incremental increase in obstetrical physician-nurse team in medicine is challenging due to admissions. In addition, the overall was created at his organization to the complexity and lack of pre- financial impact on the system as a improve perinatal care. The teams dictability inherent in patient care. whole was positive when patients implemented care guidelines that However, he believes that medi- flowed through the ED faster. were conceived as opt-in rather cal staff can be held accountable Tremain said it's critical to have than opt-out protocols. The teams for providing quality care and for your chief financial officer on board worked diligently implementing a reaching measurable targeted goals. with your improvement goals. To variety of initiatives and as a result get funding and dedicated staff reduced the number of obstetric Resources time, he or she must be one of your malpractice claims by approximately stakeholders for change. 75 percent over the past five years. fundLack of resources—time, staff, Tremain pointed out that physi- accoring t a common challenge, Unexplained variance in cians can use their well-honed clini- according to survey responders. As Tremain puts it, "Quality doesn't care cal skills to identify characteristics about a particular case that would come free. Hospitals must dedicate Unexplained variance in care necessitate deviation from a stan- resources to quality and patient was reported to be a major prob- dard care set. safety initiatives."However,dem- lem by almost one third of survey "We need to focus physician onstrating the return on investment respondents and sometimes a skills on the places where patient (ROD on quality and safety initiatives problem by an additional 61 per- exceptions occur or where are no can be difficult.Tremain observes that cent. Many respondents described bundles of care."He predicted that "the cost of these programs is finite, reluctance on the part of physicians once data on physician practices but the return is abstract." at their organizations to providing are made more transparent through It is possible, however, to doc- standardized care. Centers for Medicaid and Medicare ument the savings associated with As one respondent stated, report cards and other means,patients improved quality. Tremain helped "Physicians do not want to follow will seek out physicians who provide facilitate an initiative to reduce ven- the guidelines that we set forth." an individualized connection with the tilator-associated pneumonia(VAP) Another replied similarly, "We patient—and also deliver evidence- in his organization. By implement- have a number of physicians in our based standardized care. ing elements of standardized care multispecialty group that act more with an opt-in protocol, the cases as independent practitioners. When Patient flow problems of VAP declined from 20 per 1,000 it comes to standardizing treatments to 8 per 1,000 ventilator-days. or care plans, they want to do it in Over 90 percent of survey Bundling these elements their own way, rather than use evi- respondents reported that patient together and using an opt-out pro- dence-based medicine." flow is a problem at their institutions. tocol reduced the rate to just 1 case For physicians who remain resis- For the vast majority of physician per 1,000 ventilator-days. Tremain tant to the notion of standardization leaders, backlogs in patient flow, estimates that 9 fewer VAP cases of care, likening it to"cookbook especially from the ED to the inpa- over a two-year period translates medicine,"Thomas has this rejoin- tient floors, is a major headache. into a savings of$400,000 to his der: "We were taught cookbook Silbaugh found that the ED at organization. medicine in training—from our men- one hospital for which he consulted Silbaugh also has documented tors. That type of'cookbook medi- was an optimal setting for a qual- a positive ROI for quality programs cine'just wasn't written down." ity improvement project: both the at institutions with which he's According to Thomas, the goal staff and the hospital CEO were worked. of standardization is not to limit frustrated with the current state of At one hospital emergency care options, but to hold physicians affairs. In addition, the physician department (ED), the staff decided accountable for use of best practices who chaired the ED was interested to find a solution to the high dissat- and for explaining exceptions to in applying improvement principles isfaction with wait times and unac- their use. He added, "If there is a gleaned from other industries. ceptable elopement rates. Although poor outcome, we want you to go THE PHYSICIAN EXECUTNE MAY•JUNE 2007 19 Using value stream mapping maintains, the physician approach for achieving maximum success to find inefficiencies in the care to quality was to be devoted to in quality improvement. Better processes within the ED, the group improving care, becoming well-edu- approaches to quality also require set out to determine the amount of Gated about the relevant issue or the choice of the right end goal. time wasted from both patient and problem, choosing what appeared Rather than striving for a 60 percent staff perspectives. to be the best clinical path, imple- reduction in central line infections, Value stream mapping is a menting the appropriate changes, for example, institutions using this methodology that involves plot- and evaluating how much he or she approach would aim to achieve ting the time spent by a patient or improved the situation. zero central line infections. a staff member over the course of Using this model, physicians The shift to standardized pro- a visit. Time spent is then divided could be pleased with a 60 percent cesses and planning with the end into segments and assessed for reduction in adverse events, regard- goal in mind is essential, Guthrie waste and inefficiency. less of what the ideal goal should believes, for physicians to be able Silbaugh and his colleagues— have been. Such an approach has to provide quality care and to be stopwatches in hand—charted the been ingrained in physicians by effective leaders, because the same course of patients through the ED societal expectations and training. underlying principles applies to and carefully considered what pro- Through experiences in medical both quality and leadership. cesses added the most value to the school, residency, fellowship train- In his organization, Guthrie patient. They also conducted value ing, and practice, physicians are has fostered this shift in physician stream mapping with key members taught, Guthrie asserts, to approach understanding through mentoring. of the ED, literally documenting their each patient as an individual and to Previously, he had 30 to 40 depart- travels on a floor plan of the unit. use an independent provider men- ment chairs directly reporting to The group then used small and tality in choosing among diagnostic him—too many to provide direct rapid cycles of change to evaluate and treatment options. Rather than mentoring. potential improvements. Overall, using the one-patient-one-doctor To remedy the situation, Guthrie the group reduced the average wait model, physicians now must consid- named five associate medical direc- time in the ED by 50 percent—a er in a general sense the best way tors. These physician leaders mentor reduction that has been sustained to consistently and predictably treat and lead the chairs of the various for three years. patients with a particular condition. clinical departments, who in turn Silbaugh found that an initial The modern approach to qual- spread key quality and leadership obstacle to the project was the ten- ity, Guthrie believes, requires the principles to others. The department deny to blame long wait times on development and use of standard- heads work with pre-established other hospital departments—radiol- ized care, with exceptions used annual goals and are held account- ogy, for example. He encouraged only as needed due to patient-relat- able for meeting these goals. the improvement group to keep ed factors. He points out that other Soon Guthrie will begin apply- their focus squarely on the activities high-risk industries start with the ing the same goal-setting and over which they had control. endpoint in mind, decide on target accountability principles to all clini- Interestingly, the group discov- goals, and develop processes based cians, with performance reviews ered that once they addressed the on these targets. based on goals set at the beginning ED inefficiencies, problems in other When adapted to medicine, of the year. Guthrie emphasizes that departments became all the more this would mean approaching goal-setting and accountability are obvious. In this case, the radiology all patients with pneumonia, for not used in a punitive fashion, but department embarked on a similar example, in the same way, unless to provide both physicians and phy- improvement process, following the a patient-related factor indicated sician leaders with clear expecta- lead of the ED staff. the need for a variation from care tions about their roles and priorities, guidelines. Such an approach would honest feedback on their perfor- Physieian executives as involve planning an end goal, such mance, and a means for identifying change agents as "This patient will not die and will opportunities to improve. be discharged in eight days," and The ACPE Quality of Care Guthrie believes that his prima- then planning processes to achieve Survey demonstrates that physicians ry role as a physician executive is to these goals. executives are frustrated by a num- help physicians understand a new This scenario may seem far- ber of barriers to providing quality way of thinking about patient care. fetched, but it well illustrates care and ensuring patient safety Until about a decade ago, Guthrie the type of thinking necessary within their institutions. Fellow phy- 20 MAY•JUNE 2007 THE PHYSICIAN EXECUTIVE r sician leaders have much to teach engage physicians in quality and References about effective ways to overcome safety initiatives? these challenges.l 1 Pizzi LT,Goldfarb NI,Nash DB. • Do I blame other departments to Promoting a culture of Safety.In: In addition to adapting their spe- avoid focusing on areas under ARHQ.Evidence Report No.43.Making cific interventions to your own institu- my control. Health Care Safer:A Critical Analysis ? tion, ask yourself these questions: of Patient Safety Practices.Available at: http://www.ncbi.nlm.nih.gov/books/ • Have I accepted that increased As a physician executive, you bv.fcgi?rid-hstatl.section.61719.Accessed accountability is the way of the have an opportunity to help your March 11,2007. future? physician colleagues navigate • Am I prepared to foster change? the changing environment that is medicine today. And by proactively • Do I have the skills I need to fostering change, you can begin to effectively lead other physicians? replace discouragement with hope • Do I know enough about for the future. improvement methodologies to apply them and to teach them to Diane Shannon,MD,MPH, is a free- others? lance medical writer.She can be • Do I blame individuals for errors reached at dshannon@mdwriter.com that are due to ineffective systems? • Do I know how to ask the right questions in the right ways to AIM HIGH -vino . oppcftunity to discus�essential issues G-,Prnance Stiticture.Leadership Skills.Technology, Get ilions . . HOTEL"Imss SUMMITO_�' IIII THE PHYSICIAN EXECUTIVE MAY•JUNE 2007 21 HMI World Page 1 of 3 1 11ARVAR1) !4F1)1CAL INTER \ A 1 IONAL ip H M I World ...................- NEWS FROM HARVARD MEDICAL INTERNATIONAL PERSPECTIVES IN GLOBAL HEALTH: FORUM t Medication reconciliation helps prevent drug errors Small clinical center uses simple paper-based system to reduce mistakes The Institute of Medicine estimates that at least 1.5 million preventable adverse drug events(ADEs)occur every year in the United States—an average of one medication error for each hospitalized patient per day. Not only do these errors directly affect patient health, but they also cost more than$3.5 billion dollars a year. Eliminating preventable ADEs has become an important objective for health care organizations. However,the goal is a challenging one for several reasons. Medication orders frequently change as patients transition between home and inpatient facilities and between inpatient care units. Orders commonly are written by a large number of different care providers. In addition, processes to find and correct any discrepancies are often lacking. Communication problems are a common cause of medication errors.Of the more than 350 medication errors resulting in death or major injury included in the Joint Commission on Accreditation of Healthcare Organizations(JCAHO)sentinel event database,63%were related to failed communication. Medication errors tend to occur at transition points during the continuum of care.A 1995 study by Bates and colleagues found that almost half of all preventable ADEs in the inpatient setting occurred during ordering,a process that happens at three key transition points: admission,transfer between inpatient care units, and discharge.A more recent study by Cornish and colleagues found that 54%of patients in a general medical unit experienced a medication error at admission, most commonly due to failure of the staff to include a regularly used medication. Medication reconciliation is a process by which a patient's current medication orders are compared with a list of previously taken medications.The process involves three basic steps: http://www.hmiworld.org/hmi/issues/nov-dec07/forum.php 2/5/2008 HMI World Page 2 of 3 1 1. Collecting an accurate medication history 2. Checking that medications and doses are appropriate 3. Documenting all medication changes in the orders and making sure these changes agree with other medication information According to JCAHO, medication reconciliation can prevent drug interactions. omissions,duplications, and errors in dosing. Research has shown that the process can reduce medication errors. For example, a 2006 Canadian study by Vira and colleagues found that the use of medication reconciliation identified and prevented 75%of clinically important medication errors. SOUNDING BOARD: Has your ins'itution undertaken a quality improvement project recently?What were the goals?How was the project organized?What were the outcomes?What key lessons learr-ed might benefit others attempting similar projects?We'd like to hear more about what health care organizations are doing to enhance quality and improve patient safety.Write to us! Indeed,the process of medication reconciliation is no longer optional for many institutions.As of January 2006,the JCAHO National Patient Safety Goals mancate that accredited facilities must have protocols in place for documenting and reconciling medications during the continuum of care.The mandate has prompted many health care organizations to implement medication reconciliation programs. However, putting into practice a process that is new and involves system-wide changes can be challenging. It can be labor-intensive,time-consuming,and costly,especially if new electronic database systems are used. Clinicians and administrators frequently encounter obstacles when implementing a medication reconciliation program.John Whittington, MD of the Institute for Healthcare Improvement notes that the most important of these challenges is confusion due to a lack of clearly articulated roles and responsibilities. Such ambiguity can lead to oversight errors or to turf battles. Other possible challenges include lack of staff engagement or"buy in,"staff concerns about the additional time necessary for the process, and resistance to change. Despite these challenges, some health care organizations have successfully implemented reconciliation programs.Contra Costa Regional Medical Center is an example of one such organization that was able to make medication reconciliation a"win-win"proposition for patients and staff, reducing errors while streamlining the work of clinical staff. Contra Costa Regional Medical Center(CCRMC), located in Martinez,California, comprises a 166-bed hospital and eight federally funded health centers.After the organization decided to implement a medication reconciliation program, a multidisciplinary team—consisting of pharmacists, nurses, physicians,quality management staff, and a nurse program manager from clinical informatics—was charged with putting the process into practice.The team's first step was to develop a plan based on input from four hospitals with advanced medication reconciliation programs already in place.A crucial early decision was the team's choice to divide the intervention into manageable portions, thus avoiding simultaneous execution of a system-wide program. Instead,the team began its work by focusing on reconciliation at hospital admission within a single eight-bed telemetry unit. The team first considered the current workflow: a resident physician or attending physician collected a list of home medications in the chart's history and physical(H&P),a nurse collected a second medication list at his or her admission evaluation,and the physician wrote a third medication list as part of the admission orders—three different lists that were not systematically cross checked.Through small tests of change—testing a process, rapidly assessing it, making necessary changes,and immediately testing again—the team eventually developed a single medication list that replaced the previous three lists. In the revised system,the physician captures the list within the orders;medications are no longer listed within the H&P or nursing admission note. On the order sheet, the physician must indicate for each drug whether it is to be discontinued, continued,or modified.The CCRMC process also captures a list of home medications,which is later used at discharge for planning and reconciliation. Once created,the list is faxed to the pharmacy,where a pharmacy technician enters the information into a database system and a clinical pharmacist reviews the list. After rolling out the project to a 30-bed unit, news about the project and enthusiasm for it spread rapidly. In fact, resident physicians and nurses began using the process in a medical-surgical unit that had not yet received training. (The team asked the staff to temporarily stop using the process,to avoid uncontrolled spread without education.) Once unit-by-unit roll out of medication reconciliation at admission was successfuhy underway,the team focused on reconciliation at transfer.After a s milar series of small tests of change,the team developed a process in which the physician conducts a formal reconciliation when writing orders for the patient's transfer.The orders must indicate whether to continue, discontinue,or modify every medication on the medication list. Finally, the team focused on reconciliation at discharge. Using the small tests of change again,the team developed a process in which the discharging physician reviews the current hospitalization medications and the list of home medications captured at admission.The review process serves as a reminder to specifically inform patients which medications to restart upon discharge and which medications not to restart at home. Full implementation of the medication reconciliation process at CCRMC took two years,from mid 2005 until mid 2007.The time investment has paid off in reduced medication discrepancies at key transfer points.The proportion of pre-admission medications that were unreconciled on admission decreased from 25%at project initiation to 4%after full adoption of the new process. The proportion of medications unreconciled at transfer dropped from 12%to 4%, and the proportion of patients with any hospital medication unreconciled at discharge was reduced from 36%to 21%. http://www.hmiworld.org/hmi/issues/nov-dec07/forum.php 2/5/2008 HMI World Page 3 of 3 According the Steven Tremain, MD,ABFP, FACPE, Director of System Redesign at CCRMC,the team's success was dependent on several factors. First, beginning with a small unit with a regular stable of staff proved to be ideal for pilot testing. Second, the organization combined both"push"and"pull"strategies to engage staff in the intervention.The JCAHO mandate for reconciliation served as a push.The team ensured that several"pull"strategies were in place by involving front- line staff in every step of the project—not only did staff members"own"the system that they helped developed,but also the system was better suited for their particular needs because of their input.The clinical staff wanted to adopt the process, because the intervention eliminated redundant work, making their jobs easier, and it reduced the guesswork errors that had been associated with medication orders. Tremain believes that a key element of the team's success was recognizing the importance of earning staff trust.The team found it absolutely essential to inform staff members of three key pieces of information before beginning any test of change: the specific element of the intervention being tested; the test start date, and the test end date."You must let the front-line staff know that a test of change is not going to continue indefinitely. People are much less resistant to trying something for a defined period of time." For additional information and resources,please click here. --Written by Diane Shannon, MD, MPH for Harvard Medical International EMAIL ARTICLE IIII ©2007 Harvard Medical International Links to external sites should not be construed as endorsement by HMI or Harvard University http://www.hmiworld.org/hmi/issues/nov-dec07/forum.php 2/5/2008 In+monahy Letf �/`anK Medication Reconciliation : Toolkit for Implementing National Patient Safety Goal 8 In}en}ronANy I.�+ Nally- r, Systems, Processes,And Analysis—LESSON 2 process map this may include a medication list that Contra Costa put together a multidisciplinary team to begin is communicated at transfer and exit points.The work on the project.Their kick-off meeting included the communication of the patient's medication list should following critical points: be graphically represented in the process map. • Their project sponsor, the medical center's director of system Case Study: Contra Costa Regional redesign, opened the meeting with his endorsement of the � importance of the project and a review of the project goals. Medical Center In June of 2005, Contra Costa Regional Medical Center • Their team leader spent about an hour educating the group launched its medication reconciliation program. "Our impetus about what medication reconciliation is and sharing came from two converging forces," says Stephanie Bailey, processes that other hospitals were using. M.P.H., director of ancillary services. "First, medication • The team reviewed the hospital's current workflow. reconciliation was a Joint Commission National Patient effect in January 2006. Second, our • The team agreed on a form and a process to begin testing Safety Goal, which took e organization made the decision to commit fully to all the immediately for admission reconciliation. initiatives included in the IHI 100,000 Lives campaign." Three team members—the family medicine resident, nursing champion, and pharmacy representative—agreed to work together on the pilot test, which would be conducted on a CASE AT A GLANCE small medicine unit. Over the next four weeks, they tested, measured, and refined the admission reconciliation process on their pilot unit, changing the form several times. Contra Costa Regional Medical Center The Process Basically, the process for admissions includes two salient Organization facts: Contra Costa Regional Medical points: Center is a 166-bed full-service county hospital in Martinez, California, with a network of eight health centers. 1. The process is paper-based 2. The admitting provider collects the list of medications Purpose of the project: To develop a medication patient was taking at home and uses the same form to reconciliation process consistent with the requirements of order medications on admission The Joint Commission's National Patient Safety Goal 8 j and the Institute for Healthcare Improvement(IHI) 100,000 "When we created our new admission medication Lives campaign. reconciliation form,we knew we had to make it easy for the provider to find the form; otherwise, he or she was unlikely Staff involved: A multidisciplinary team that included to use it," Bailey says. During our testing phase, clerical staff a physician champion, a family medicine resident, a manually stapled the admission medication reconciliation form nurse champion, a nurse informaticist, a staff pharmacist, to the already existing admission order form that providers a pharmacy technician, a quality management were accustomed to using (see Figure 2-7, pages 33 and 34). representative/forms expert, a team leader, and the In fact, clerks placed the admission medication reconciliation director of pharmacy. The team was sponsored by the form on top, so the physician couldn't easily overlook it.That director of system redesign. simple solution was the key to having the providers use the form, so it was built it into the formal process when the team Lessons learned: The most important lesson learned began implementing across the organization. was that for staff to reliably use a new process, work-flow design must make it easy for staff to consistently use the The medication reconciliation process at the point of transfer new process in all sites of care and difficult—or better yet, impossible—for staff to use the old process. within the medical center also includes two relevant points: 1. An electronically printed form contains a list of all active medications as of the moment the form is printed (see Figure 2-8, pages 35 to 37). 31 Medication Reconciliation: Toolkit for Implementing National Patient Safety Goal 8 2. The provider uses this form to order medications on process was used there were very few, if any, unreconciled transfer within the facility. medications on discharge. However,when the team began spreading the discharge reconciliation process to three other At discharge, the medication reconciliation process involves units, staff quickly discovered that the process the team the following three steps: developed was so labor-intensive for the pharmacy that it was 1. An electronically printed form, similar to the transfer impossible to extend the process throughout the hospital _. form in Figure 2-8, lists all home or entry medications without significantly increasing pharmacy staffing levels— and active inpatient medications at the moment the form Which was not practical for the medical center.The original is printed. design of the process called for a pharmacy technician to . 2. The provider uses this form to order discharge input the discharge medicine list (based on the provider's discharge orders) into the computer system and print out the ; medications. 3. Staff provide the patient with a"patient-friendl "lilist for a pharmacist to check before it was given to the yst of patient as pan of discharge patient teaching. [�? discharge medications that includes new medications, previous home medications to be continued, and "After a full year of trying to overcome this obstacle, we've medications to be stopped (see Figure 2-9, page 38). finally made the decision to redesign the process, thereby lessening the impact on the small pharmacy and spreading When the team began to test the new discharge reconciliation the workload to the unit-based nursing staff," shares Bailey. process, team members knew that something had to"direct" The redesign resulted in nurses handwriting the discharge the physician to use the new process instead of the old medicine list on a newly designed two-part form and giving a , process"To do this,we took the existing discharge summary copy to the patient during discharge teaching. "It turns out form and used a large red stamp to make the medications that the nursing staff are embracing this change because of portion of the form unusable," says Bailey(see Figure 2-10, the negative impact pharmacy turnaround time was having page 39).At the same time, the form directed the physician on patient flow," declares Bailey. �–;- to print out the new discharge medication reconciliation form from the clinical system. "We still use the red stamp Educating Staff today," shares Bailey, "but we will soon be formally removing This change required significant nursing staff education and medications from this form."The future plan is for the record reviews with feedback to ensure consistency among discharge medication list to be scanned and available in their nursing staff with correct use of the process.The nurse clinical system to the clinic provider seeing the patient after champion was given time away from patient care to focus on discharge. providing nursing staff education on the redesigned process. Implementation The team's pharmacy representatives,with help from they When the team felt comfortable that the admission medication nurse informaticist, provided education to the pharmacy reconciliation process they developed was effective on the staff. Contra Costa's physician champion for medication pilot unit, they then implemented it on a larger medical unit. reconciliation took responsibility for educating residents As they moved from unit to unit, staff was educated and the and other medical staff members, always emphasizing the process was concurrently measured to see if it was being used correlation between having an effective medication correctly before implementation moved to the next unit. reconciliation process and improving medication safety for Overall, the admission medication reconciliation process patients. "Most physicians are well aware of real stories where was implemented at a rate of one unit per month over eight a patient's safety was jeopardized by an event involving an months. Figure 2-11, page 40, provides a timeline of the unreconciled medication," Bailey says. "We openly discussed implementation process. those cases and tied them to why our project was important." "We did learn a very good lesson when it came to designing Written policies and procedures and one-page summaries to our discharge reconciliation process," Bailey asserts.The highlight key steps for staff were developed and distributed. process the team initially designed and tested on a pilot unit Contra Costa also conducts quarterly chart audits, and worked beautifully after many tests of change and revisions to individual feedback and targeted education is given to staff the process. Measurement activities showed that when the when there is a breakdown in the process. U 32 Y Systems, Processes, And Analysis—LESSON 2 FIGURE 2-7 i Contra Costa Regional Medical Center j Admission Medication Reconciliation and Order Form CONTRA COSTA HEALTH SERVICES ALSO S7`,�RMP ORD EiRS CONTRA COSTA REGIONAL MEDICAL CENTER 1 ADMISSION MEDICATION RECONCILIATION &ORDER FORM (AMROF) 1 LIST prescribed and OTC medications,herbal products, supplements and vitamins/minerals patient currently uses i (prior to admission). Patient reports no home meds,etc. MARK BOX SPECIFY MODIFICATIONS PREGNANT? ❑Yes O No O NA C Continue' 'Herbal products will not be DOSE DC Discontinue continued on admission. DRUG UNIT ROUTE FREQ NI Modify © DC El © DC K © DC 91 © DC 0 �J DC MO © DC MD © DC MO © DC MO © DC R] © DC MO © DC © DC a)- PROVIDER PROVIDER 0 Patient instructed to ask family member to bring in med bottles If home med info G 'Retail Pharmacy: 'Location: not complete: 'When this information is provided,Pharmacy staff will research. SIGN HERE Provider Signature Date/Time PAGE Transcribed by(clerk) Date/Time of Noted by(RN) Date/Time --- MR235-3(3-07)Page 1 Original:Physician Orders Yellow:H&P Pink:Nursing INTERNAL MEDICINE ORDERS continued on page 34 The team at Contra Costa Regional Medical Center created a combined medication reconciliation form that incorporated the existing (and familiar) admissions order form.The provider fills this form out by hand after the patient has been admitted. Source:Contra Costa Regional Medical Center, Martinez,California. Used with permission. 3 Medication Reconciliation: Toolkit for Implementing National Patient Safety Goal 8 FIGURE 2-7 (continued) � I CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER 1 INTERNAL MEDICINE/GENERAL SURGERY ADMISSION ORDERS Date Time I O Admit to inpatient Medicine O Admit to inpatient Surgery O Regular floor O ICU OIMCU O Observation' --- Attending: Resident: Diagnosis: g Allergies/Reactions: Vital Signs: �— Condition: — as' Diet: O NPO O Sips H2O with meds only O Dietitian referral — h Other �- Activity: r N: !_ Labs/Studies: Nursing: O 1&0 O Foley to gravity drainage O Call MD for Temp> 101.5°; BP systolic>180 or<90; Pulse>120 or<60; RR>20 or<10. _ i'. Dressing Change: — DVT prophylaxis: 1 Strongly consider for high risk medical patients with no contraindications O Heparin 5,000 units SC q 12 hours-1 including patients with myocardial infarction,congestive heart failure,cancer. IS prior DVT,or critical illness. If patient bleeding,sequential pneumatic Ted hose C..J SCD .compression device is an alternative.Lovencx 40 mg SC q 24 hr is an alternative. Smoking cessation: Most smokers are able to discontinue smoking in the hospital with no particular problem. [I For those experiencing withdrawal or fear of withdrawal: Transdermal nicotine patch/day: O 7 mg O 14 mg O 21 mg Change patch and site daily. C✓ Start and document patient education: C_1'_" Smoking cessation OCAD C71 CHF ODM OAsthma OOstomy OW'ound care Other: _ O Drug and/or alcohol counseling O Discharge planning issues: O Homeless O Lives alone O SNF O Home health O PT O OT O Speech O PT referral:Freq/Duration_ O OT referral:Freq/Duration, _ O Speech Therapy referral Pain Management: O Tylenol 650 mg PO every 6 hours or per rectum for NPO patients,pm fever,fair to mild pain L O Other. O DSS 250 mg PO BID,for constipation,include for patients on narcotics _ Ly Medications: PRN Meds: O Maalox Plus EX 1 (one)tablespoon PO every 4 hours,pm heartburn Both recommended in all patients over 55,plus all with chronic cardiopulmo- O Phenergan 12.5 mg IM/PO/IV every 4-6 hours,prn nausea/vomiting nary disease,diabetes,renal failure, O MOM 30 mL PO every HS,prn constipation cirrhosis,substance abuse,HIV,or other immune suppressing conditions. O Restoril 15 mg PO every HS,prn insomnia,may repeat xl Flu is yearly,October thru February. Pneumovax 0.5 mL IM,at discharge,per protocol Pneumovax is once with optional T' Flu vaccine 0.5 mL IM,at discharge(Oct-Feb),per protocol repeat in 5-10 years. — ---- —------ —..—..---------------- --- — Noted by Date Time Physician Signature MR235-3(3-07)Page 2 INTERNAL MEDICINE/GENERAL SURGERY ADMISSION ORDERS r r� 11— L 2 a ,�j Systems, Processes, And Analysis—LESSON 2 FIGURE 2-8 Contra Costa Regional Medical Center Medication Transfer Orders Run Date: 07/09/07-0801 PAGE: 1 MEDICATION TRANSFER ORDERS ** INPATIENT USE ONLY Contra Costa Regional Medical Center Patient: Current Location. DOB: SEB: F WT: 50.900 kg HSA. 1.46 m2 ADMITTED: 07/02/0' PHYSICIAN: Primary Dx: ALLERGIh.S: ERYTHROMYCIN NOTE: PLEASE INDICATE CONTINUE, C = CONTINUE DISCONTINUE, OR MODIFY FOR DCa DISCONTI EACH ORDER LISTED BELOW. M . MODIPY y IR - MEDICATION ORDER ... C DC M 9P.CIFY MCDIPICAT-IONS ] ACETAMINOPHEN 325 MG UDTAB Start: 07/03/07 PR ■ (TYLENOL. 325MG UDTABS**) J Dose: 650 MG PO EVERY 4-6 HRS AS NEEDED AL,MGrSIM 500/450/40 30 ML Start: 0"1;03/J' P (MAALOX PLUS XTRA STR 30ML UD--) Dose: 15 ML PO EVERY 4 HOURS AS NEEDED Cosaaents: MAX.RECOM4ENDEU DAILY DOSE IS 12 TEASPS ALBUTEROL* 17 GM INH Start: 07/03/07 PR (PROVENTIL/VENTOLIN INHALER 200 METERED INHI Dose: 2 PUFFS INH EVERY 4 HOURS AS NEEDED Comments: (FOR VP,NTOLIN/PROVF.NTIL) DOCUSATESODIUM 250 MG UDCAP Start: 07/03/07 PR (DSS 250MG CAP) Dos.: 250 NO PO 8I0 PRN CONSTIPATION Comments: DO NOT CRUSH!!! IPRATROPIUM BROMIDE (HPA112.9 GM INHALER Start: 07/03/07 PR. (ATROVENT HPA INHALER) Dose: 2 PUFFS INH EVERY 6 HRS AS NEF.DEO lorazepam 1 MG UDTAH (gnr ATIVAN) Btart: 07/03/07 PR. (ATIVAN(eq) 1 MG UDTAB`*) Dose: 1 MG PO EVERY 6 HRS AS NEEDED Comments: -• Look--alike/Sound-alike alert4*** ••*** THIS DOCUM&NT IS NOT INTENDED POR DISCHARGE MEDICATIONS 1e 1 Pr id.. Signature • NOT TO BE THINNED PROM CHART••• ...ORDERS••* ********** Continued on Page 2********** continued on page 36 The electronic medication reconciliation transfer form list identifies all active medications as of the moment the form is printed. The printed form allows the provider to indicate whether each medication should be continued, discontinued, or modified. Source:Contra Costa Regional Medical Center,Martinez,California.Used with permission. Medication Reconciliation: Toolkit for Implementing National Patient Safety Goal 8 _ 7, FIGURE 2-8 (continued) PAGE: 2 Run Date: 07/09/07-0801 ILT MED I CATION TRP.N S FE R ORDERS ** INPATIENT U SE ONLY Contra Coat. Regional Medical Center Patient: Current Location: DOB: SEX: 1, WT: 50.900 kq BSA: 1,4G m2 ADMITTED: 07/02/07 PHYSICIAN: Primary D.: ALLERGIES: XRYTHRCMYCIN NOTE: PLEASE INDICATE CONTINUE, C = CONTINUE ■--'- DISCONTINUE, OR MODIFY POP. DCDISCONTINU P'— EACH ORDER LISTED BELOW. M=MODIFY ••x** MEDICATION ORDER *'•'• C DC M SPECIFY MODIFICATIONS _II .a phlne SULFATE,INJ 2 MG/1 ML TUBEX Start: 07/03/07 PR (MORPHINE 2 MG/1 MI, 9'UBFS") D..e: 2 MG IVP EVERY 2-3 HOURS AS NEEDED Co. ants: ** Look-alike/Sound-alike alert" - NITROGLYCERIN,SL 0.4 MG/TAB (25 TAB BTL) Start: 07/04/07 PR (NITROSTAT 0.4MG SLTAS 25'S••) D...1 0.4 MS SL Q 5 MIN PRN CP. MR X3 MAX Convventa: EVERY 5 MIN. X3 FOR CHEST PAIN, HOLD FOR SBP<100 [I I PROMETHAZINE HCL' 25 MC/ML Start: 07/03/07 PR (PHENERGAN,INJ 25MG/ML'•) Doe.: 12.5 MG IVF AS NEEDED Covenant.. VESICANT! PUSH VERY SLOWLY OR GIVE THROUGH Q], RUNNING IV LINE. VESICANT T5MAZE2AM IS MG Start: 07/03/07 P (RESTOHf L(GENERIC)15MG UD CAPS) Dose: 15 MG PO QHS AT BEDTIME PRN ASPIRIN,EC 81 MG/ECTAB UDTAB Start: 07/05/07 (ASPSR.LN SIMG EC UO TABLETS) �. L Doae 81 NGP110AiLY I o C.—.t.: DO NOT CRUSH!1! ENOXAPARIN,INJ (RP) 60 MG/0,6 ML start: 07/06/01 -� (LOVENOX 60MG SYRINGE) Doae: 50 MG SQ EVERY 12 SOURS Cononent.: SF,ND REFILL REQUEST TO Q:1• PHARMACY WHNN NEEDED •ex*x THIS DOC7MENT IS NOT INTENDED POR DISCHARGd MZDICATIONS ••••• '�" Provider 9ignatuze —' l� -NOT TO BE THINNED 1'ROM CHART" ---ORDERS"- **#******* Continued on Page 3********** L continued on page 37 L1 Systems, Processes, And Analysis—LESSON 2 FIGURE 2-8 (continued) Run Date. 07/09/07-0801 PAGE: 3 MEDICATION TRANSFER ORDERS ** INPATIENT USE ONLY Contra Costa Regional Medical Center Patient: Current Location: DOB: SEX: F WT: 50.900 kg BSA: 1.46 m2 ADMITTED: 07/02/07 PHYSICIAN: Primary Dz: ALLERGICS: ERYTHROMYCIN NOTE: PLEASE INDICATE CONTINUE, C = CONTINUE DISCONTINUE, OR MODIFY TOR DC DISCONTINU SACH ORDER LISTED BELOW. M a MODIFY •++*+ MEDICATION ORDER **+i.* C DCI N BP.-- MCDIFICATIONS J LOVASTATIN 2D MG Start: 07/03/07 (MEVACOR 20MG UD TABS) Dona: 20 MG PO DAILY MCTOPROLOL 50 MG Start: 07/08/0') (LOPRF.SS0R(GENR) 50MGUD TABS) Dos.: 100 NO PO TWICE A DAY oxycodONE W/ ACETAMINOPHEN 5-325MG UDTAB Start: 07/08/07 (PER000CT TABS 5-325MG UD (eq) Doae: 2 TAB PO FOUR TIMES A DAY ]� Comments: +--+ Look-alike/Sound-alike alert---- ■ VERAPAMIL,SR 120 MG SRTAB/SRCAP Start: 07/05/07 J (CALAN SR 120 MG SRTABS/SRCAP) Doa.: 120 NO PO DAILY Comments: DO NOT CRUSHIII +++'� THIS DOCUMENT IS NOT INTENDED FOR DISCHARGE MEDICATIONS +++++ P-Ldar Signature Data/Sim. Tran-crib.d by (clerk) Data/Time Noted by (RN) Dat./Ti- bed-ti- continued .111 retain their original start and atop dates. • —NOT TO BE THINNEn FROM cHA.aT+•+ +++oRDERs-+- ********* FINAL PAGE OF REPORT ***** 1 i� 1 I Medication Reconciliation: Toolkit for Implementing National Patient Safety Goal a (�T FIGURE 24`- Contra Costa Regional Medical Center Patient Discharge Medicine List Contra Costa Health Services n Contra Costa Regional Medical Center DISCHARGE MEDICINE LIST Call the hospital pharmacy number below with questions about your medicines. Llame a la farmacia del hospital al nurnero de abajo si tiene pregantas sobre su medicamento. 925-370-5200 ext. 4010 shouldNEW MEDICINES: You E Medicine Name&Dose How to Take and When to Take Next Dose Due Nombre&Dosis de Medicamento Como y Cuando Tomar to Si uiente Dosis ' • a E MEDICAMENTOS EN CASA: DebDebe seguir . •• Medicine Name&Dose How to Take and When to Take 777 Nombre&Dosis de Medicamento Como y Cuando Tomar to r e _ 9 Stop These HOME Medicines! - Pare de tomar estos medicamentos en - casa! _ I Patient Signature: _RN Signature: _ DatelTime Bring this list and all your medicines,in their original bottles,to all appointments. Traicia esta lista v tOCIOS sus medicamentos,en las botellas originates,para todas sus citas. MR-376a-4 6107 original-Chart; Copy-patient Page—of Staff provide discharged patients with this list of current medications,which clearly identifies which of the medications they were taking at home before entering the medical center should be continued and/or modified and what new medications they need to start taking at home. Source:Contra Costa Regional Medical Center,Martinez,California.Used with permission. Systems, Processes,And Analysis—LESSON 2 - FIGURE 2-10 Contra Costa Regional Medical Center Discharge Summary and Order Form pok; '(V45 F'cJufc. i5 inCorrec - - mp. error ;n rpub li ca; W%, Run Data: 07/09/07-0801 PAGE: 1 ME D I CATION TRANSFER ORDERS ** I N PATI ENT USE ONLY Contra Cezta Regional Medical Center Patient: Currant Location: DOB: SEB: F MT: 50.900 kq BSA: 1.46 m2 ADMITTED: 07/02/07 PHYSICIAN: Primary Da: ALLERGIES: ERYTHRCMYCIN NOTE: PLEASE INDICATE CONTINUE, C a CONTINUE DISCONTINUE, OR MODIFY FOR DC . DI9CONTI RACE ORDER LISTED BELCH. M -MODIFY ♦ttt♦ NEDICATION ORDER tttt• _ C DC M BP.CIFY MODIFICATIONS ACETAMINOPHEN 325 MG UDTAB Start: 07/03/07 P (TYLENOL 325MG UDTABStt) Daze: 650 MG PO EVERY 4-6 HRS AS NEEDED AL,MG+SIM 500/450/40 30 ML Start: 07/03/07 PR (MAALOX PLUS XTRA STR 30ML UD**) Dona: 15 ML PO EVERY 4 HOURS AS NEEDED Consents: MAX.RECOMMENDED DAILY DOSE IS 12 TE:ASPS ALBUTEROL- 17 GM INH Start: 07/03/07 PR (PROVENTIL/VENTOLIN INHALER 200 METERED INH) Dose: 2 PUFFS INH EVERY 4 HOURS AS NEEDED Conmenta: (FOR VENTOLIN/PROVENTIL) DOCUSATE SODIUM 250 MG UDCAP Start: 07/03/07 P (DSS 250MG CAP) Doze: 250 MG PO BID PRN CONSTIPATION C000nanta: DO NOT CRUSH!!1 IPRATROPIUM BROMIDE (HFA)12.9 GM INHALER Start: 07/03/07 PR (ATROVENT HFA INHALER) Dose: 2 PUFFS INH EVERY 6 HRS AS NEEDED lorazepam 1 MG UDTAB (gnr ATIVAN) Start: 07/03/07 PR (ATIVAN(eq) 1 MG UDTAB'•) Dose: 1 MG PO EVERY 6 HRS AS NEEDED Connenta: t••' Look-alike/Sound-alike alar[•'•' t.... THIS DOCUMENT 29 NOT INTENDED FOR DISCHARGE MEDICATIONS *•�•• Provider Signature - ­NOT TO BE THINNED FROM CHART... ...ORDERS... *#******** Continued on Page 2********** A simple red stamp over an existing section of the discharge summary and order form directs physicians to the appropriate area to complete medication reconciliation at the point of exit. Source:Contra Costa Regional Medical Center,Martinez,California.Used with permission. 33 Medication Reconciliation: Toolkit for Implementing National Patient Safety Goal 8 . - - ---------- --- FIGURE 2-11 Medication Reconciliation Implementation Timeline — er-+ e'-I Our Time Line: Testing, Spreading, Sustairdn.(17 — Year 1 ? 3 A-lonth 1 2 3 4 6 1 2 3 4 6 8 ) 10 11 1? 1 3 3 4 6 7 8 " Pilot Medicine units ➢' Surgical units T _ IM(J /ICL F_. Transfer Rec f}sycluatry units �' Transfer Rec live(all areas) — >f' Peas uluni, — O — Pilot unit(fA) — ICLJ/u�lcu — KEY: Admission Reconciliation Medicine Unit(fB) implemented Transter Reconciliation =- Implemented Surgical L"nit Discharge Reconciliation Implemented Psychiatry Unit — L' This timeline identifies the spread of the medication reconciliation process across Contra Costa Regional Medical Center,distinguishing between admissions,transfer, and discharge stages. — L: Source:Contra Costa Regional Medical Center,Martinez,California.Used with permission. — {Q. Measuring Outcomes Table 2-1, page 41, provides some results from Contra Costa LL Contra Costa is using both outcomes and process measures on those measures. to evaluate the effectiveness of its medication reconciliation a process. Some measures that they use include the following: "I think it's important to highlight that medication reconciliation at Contra Costa was seen, from the beginning, %. • Outcome measure—The rate of medications that are r unreconciled at transition points (admission, discharge and transfer) • Outcome measure—The percentage of patients who have Check the CD °= ALL medications reconciled at transition points (home as The"Admission & Discharge Reconciliation"worksheet medications reconciled on admission and discharge and _ Dashboard"on the CD offer D Data t "Oucomes aa aa active inpatient medications reconciled on transfer) and P Contra Costa's spreadsheet-based tools that can be • Process measure—Assess how reliably the prescribed adapted by your organization to track data on transfer forms for admissions, transfers, and discharges are being reconciliations. used by staff a. 40 Systems, Processes, And Analysis—LESSON 2 TABLE 2-1 Measuring Success with Medication Reconciliation at Contra Costa Regional Medical Center Second Quarter 2007 Results Measure Goal Admission Transfer Discharge Outcome Measure:The rate of 0% unreconciled 1.9% 0% 2.1% medications that are unreconciled at medications transition points Outcome measure:The percentage of 100%of patients will have 94.5% 85% 100% patients who have ALL medications all medications reconciled reconciled at transition points(home medications reconciled on admission and discharge and active inpatient medications reconciled on transfer) Process measure:Assess how reliably 100% use of the forms 96.4% 96% 100% the prescribed forms for admissions, transfers, and discharges are being used as a project requiring a partnership between physicians, • Understanding the communication and handoffs required nurses, and pharmacists," Bailey reports. in a process The team has been working with the same intensity for two • Identifying and understanding risk points in a process years now. "There have been a few times when we've (see Lesson 3 for more detail on risk points) encountered a barrier and become discouraged," shares Bailey. • Identifying steps of the process in which data gathering When that happens, the team brings in the project sponsor, and measurement may take place for quality improvement who helps them focus on the big picture. "At key points,we activities intentionally ask ourselves, `Is the new process safer than the . Facilitating failure mode and effects analysis and/or root old process?'As long as the answer to that question is `Yes,' cause analysis we become energized to continue on," concludes Bailey. Once a process has been identified and a process map agreed Lesson Summary on by a multidisciplinary team, it may require a second look. Process mapping enables end users to visualize how a process Depending on the process involved, and whether the process takes place from start to finish.The ability to visualize a was new or one that had been in place but never mapped process can be used for the following: before, the process map may or may not reflect the actual process. • Orientation and training of new personnel • Identifying critical elements of a process It is not uncommon for individuals to ask, "Is that how we're supposed to be doing that. Or to say, "That's not how we do • Identifying personnel and relationships of personnel in a that." In any event, it is always prudent to continually ask if process the process can be refined.This may be done by carrying out 41 r Medication Reconciliation:Toolkit for Implementing National Patient Safety Goal 8 n- Fr" the specific function in real time, or by analyzing the maps in — question. In either case it is important to continually question C eC1F' eF Cry F'' whether the process can be made safer and more efficient. ` Check the CD for Lesson 2's slide presentation on F` Group Discussion Questions systems, processes, and analysis for medication — 1. How can process mapping help in developing your reconciliation.You can also test your knowledge of F— medication reconciliation process? the concepts presented in this lesson with the quiz for e. 2. What inefficiencies or unintended outcomes were Lesson 2 that also appears on the CD. _ revealed when detailing your process? F 3. Who are the stakeholders in your medication — r reconciliation process? — Reference 4. Who will serve as lead facilitator for process mapping? 1. Dettmer H.W.: Goldratt' Theory of Constraints:A Systems Approach 5. What process mapping tool(s) will you use? to Continuous Improvement.Milwaukee,WI:ASCQ Quality Press, — 1997. r, 0 F : F FL F F F F 42 �"p1�J�Nro`• STANFORD H GRADUATE SCHOOL OF BUSINESS ,rr ♦ i INyt CASE: L-13 DATE: 01/07/08 INSTITUTE FOR HEALTHCARE IMPROVEMENT: THE CAMPAIGN TO SAVE 100,000 LIVES Here is what 1 think we should do. I think we should save 100,000 lives. And I think we should do that by June 14, 2006-18 months from today. Some is not a number; soon is not a time. Here's the number: 100,000. Here's the time:June 14, 2006-9 a.m. —Donald Berwick, M.D., president and CEO of the Institute for Healthcare Improvement 1 On December 14, 2004, Donald Berwick, M.D., president and CEO of the Institute for Healthcare Improvement (IHI), launched an ambitious campaign—to save 100,000 lives from unnecessary death in United States hospitals in the next 18 months. Berwick described six specific life-saving interventions, which if implemented by 1,600 of the approximately 5,000 U.S. hospitals country could meet the Campaign's objectives. The campaign was a resounding success. Hospitals enrolled at a rate far higher than the IHI had anticipated-2,000 signed up within 6 months, and 3,103 enrolled by end of the Campaign. Deaths at participating hospitals decreased by as much as 122,000 during the Campaign. These could not be specifically attributed to campaign initiatives, but the objective had been to help hospitals reduce unnecessary death, and to celebrate all programs that helped hospitals achieve that result. When the 100,000 Lives Campaign ended, it was succeeded by a broader campaign to further improve healthcare by eliminating harm caused by medical institutions and practitioners. When the 100,000 Lives Campaign was launched, the IHI had just 75 employees. It had no authority to compel participation, or to force compliance with its recommended hospital procedures. It had limited financial resources. Yet it played a substantial role in stimulating change among a large number of diverse institutions. How had the IHI been able to play this 1 Plenary address at the 16'h Annual Forum on Quality Improvement in Health Care, Orlando, FL, December 14, 2004. David Hoyt prepared this case under the supervision of Professor Hayagreeva Rao as the basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Copyright©2008 by the Board of Trustees of the Leland Stanford Junior University. All rights reserved. To order copies or request permission to reproduce materials, e-mail the Case Writing Office at:cwo@gsb.stanford.edu or write: Case Writing Office, Stanford Graduate School of Business, 518 Memorial Way, Stanford University, Stanford, CA 94305-5015. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means—electronic, mechanical,photocopying, recording, or otherwise—without the permission of the Stanford Graduate School of Business. Institute for Healthcare Improvement.L-13 p.2 leadership role, and what lessons did the 100,000 Lives Campaign have for others interested in leading organizational and social change? THE INSTITUTE FOR HEALTHCARE IMPROVEMENT The mission of the IHI, as expressed by the manager of the 100,000 Lives Campaign, was "to transform the quality of healthcare and health outcomes globally. We want nothing less than perfect healthcare around the world. ,2 This ambitious, even audacious, objective inspired a dedicated group of professionals far beyond what might have been expected from their small numbers and limited resources. Healthcare had traditionally been based on the expectation that practitioners did not make mistakes. Thus, quality practices that had revolutionized the manufacturing and other industries, had not been widely adopted in healthcare—attempts to improve quality were largely based on exhortations to "do better," rather than the root cause analysis and process redesign to eliminate the potential for defects that was common in other industries. Furthermore, physicians tended to practice based on their personal experience, and what they had learned from mentors. As a result of these factors, care was inconsistent, and had a high number of failures, as compared with other industries. Unlike most other industries, these failures often resulted in death or injury. The Institute of Medicine (IOM) issued a report in 1999 that up to 98,000 people died in hospitals every year as the result of medical error. In In 2001, the IOM called for a fundamental redesign of the medical system, citing a"chasm"between current healthcare and that which was needed.4 The origins of the IHI traced back to Berwick's combined interest in medicine and public policy. While getting his M.D. at Harvard, he also completed the Kennedy School's public policy program. He incorporated both disciplines in his professional career—he saw patients as a pediatrician, taught medical students, and continued work in public policy focused on healthcare. Origins: Quality Tools Applied to Healthcare One of Berwick's early positions was at an HMO, where he studied and measured quality. He found that there were many places to improve, but that doctors were not receptive to his quality findings. He observed that: "The interface of the measurement capacity and the clinical culture was very fraught—it was one of conflict. I was constantly in opposition with the doctors. I'm a doctor, but I would produce a report on wait times or infection rates, and it didn't go down well."5 While at the HMO, he also met with quality professionals from other industries, learning how they identified and addressed quality defects. One important contact was A. Blanton Godfrey of Bell Labs, who was a protege of renowned quality expert Joe Juran and who tutored Berwick on statistical analysis. Berwick began to see health care as a production system that could be addressed by the same quality tools as used in the manufacturing industry. 2 Joseph McCannon,speech at the Stanford Graduate School of Business,November 15,2007. 3 "To Err is Human: Building a Safer Health System," Institute of Medicine, 1999. Summary online at http://www.iom.edu/Object.File/Master/4/177/ToErr-812aizer.pdf(Accessed November 12,2007). 4 "Crossing the Quality Chasm: A New Health System for the 21'`Century,"Institute of Medicine,2001. Summary online at http://www.iom.edu/Obiect.File/Master/27/184/Chasm-8pager.pdf(Accessed November 12,2007). 5 Quotations are from interviews with the author,unless otherwise specified. Institute for Healthcare Improvement:L-13 p.3 Berwick then met another pediatrician with policy and quality interests—Paul Batalden, who had helped establish the community health center program of the Office of Economic Opportunity under Lyndon Johnson. Batalden had written a chapter in a book by quality pioneer W. Edwards Deming. On Batalden's recommendation, Berwick met Deming and took his quality course. In 1986, Batalden and Berwick set up a demonstration project in which 21 health care executives partnered with 21 quality experts in industry and academia. Identifying problems as "defects" was foreign to the healthcare community. Defect analysis, using statistics, trend analysis, root cause analysis, and other tools that were commonplace in manufacturing, was also largely unknown in the health care industry. The demonstration project showed that these tools could be applied to problems in healthcare. Maureen Bisognano, who was a hospital CEO at the time and later became COO of IHI, was one of the healthcare professionals in the demonstration project. She recalled the experience: They matched me up with Florida Power & Light, a utility in Miami. I flew to Miami. I had no idea how to approach a quality problem. I had my own methods, but I had no systems view of how to approach it.... I didn't even know how to select a problem. [After identifying and solving a problem], when I sat down at the end of the day, I said, `How would I have approached this without the electrical people?' I would have done everything the opposite. I would never have been able to accomplish that. Of the 21 teams, Berwick estimated that about two-thirds made some progress, and about one- third made stunning progress tackling a range of problems. The demonstration project continued with funding from a foundation grant. IHI: Its Foundation and Programs Berwick, Batalden, and a group of friends began meeting to study quality systems and healthcare defects (often on the birthday of one of the members, leading the group to call itself the"birthday club"). They put on courses, for which they charged tuition. In October 1991, they set up the IHI as an independent public interest corporation, with seed money from the unspent grant funds, the surplus earned from teaching courses, and an additional foundation grant. The IHI worked to improve healthcare by conducting training programs, collaborating with hospitals and other organizations to identify problems and develop solutions, and to spread awareness. The approach taken by the IHI was not to assign blame for problems, or exhort people to "try harder,"but rather to identify problems and help find ways to change the systems used in order to reduce defects. Berwick considered every defect to be a "treasure," a resource for improvement.6 He felt that it was important to stay positive, to learn from problems and to improve. He was action oriented. He wanted to challenge the system, to provoke it, but also to help—to provide the tools needed for change. 6 Donald Berwick,Escape Fire: Designs for the Future of Health Care (San Francisco: John Wiley& Sons, Inc., 2004),p.xx. Institute for Healthcare Improvement.L-13 p.4 The IHI held an annual conference titled the National Forum on Quality Improvement in Health Care (the "Forum"). The first of these was held in 1989, before the IHI had been incorporated, and had 287 attendees. By 2004, when the 100,000 Lives Campaign was launched, attendance had grown to approximately 4,000. The next year, over 5,000 attended. The IHI Forums were renowned for inspiring, motivating, and providing resources and networking opportunities for improving quality in healthcare. The highlight of each Forum was a plenary lecture by Berwick, an inspiring an charismatic spea.ker.7 The IHI worked closely with a small number of organizations to research, develop, and evaluate health care improvements. It was essential for system changes to be evidence-based. The IHI defined its measurable goals as achieving health care for everyone, with:8 • No needless deaths • No needless pain or suffering • No helplessness in those served or serving • No unwanted waiting • No waste Developing processes to address these issues could be envisioned as a series of concentric circles (Exhibit 1). The innermost was research and development. New ideas were tested by a small group of collaborating hospitals. Ideas that had been proven out in other countries, but that were not practiced in the United States, might also be tested as part of the R&D process. Once tested, revised as appropriate, and proven, the next step was to prototype the ideas in a larger group of hospitals. For this, the IHI established the "IMPACT Network," a group of over 200 health care organizations. After innovations were proven to be useful by the IMPACT Network, information about them was made available to any health care organization. Strategy The 1141's strategic plan identified four core roles: motivate ("will"), innovate ("ideas"), get results ("execution"), and raise joy in work (Exhibit 2). These roles were reviewed across four strategic target segments: transformational leaders, professional educators, researchers, and media/patients and families. The IHI had programs for most combinations of core role and target segment. For instance, the annual forum was designed to motivate transformational leaders. Courses offered by the IHI were intended to both motivate and generate results. Each year, the IHI reviewed the ongoing programs in each segment, and considered new programs. For its own organization, the IHI had objectives for each of the four categories ("motivate," innovate," etc.), plus a fifth category: "stay vital for the long haul." Focus on these issues drove development within the organization. For instance, objectives in the "motivate" category included specific tasks leading toward developing a vision for better health care, tasks that made the IHI a public force for change, and demonstrating success through publishing papers. 7 Berwick's plenary speeches from 1992 to 2002 are reprinted in Escape Fire,ibid. 8 About Us:Our Measurable Goals,htlp://www.ihi.org/ihi/about(accessed October 30,2007). Institute for Healthcare Improvement:L-13 p.5 Objectives in the "stay vital for the long haul" category included succession planning, making sure employees felt that the IHI was a great place to work, and solid financial performance. The IHI designed its programs to have a life cycle. The organization maintained a list of projects in categories that started with concepts. Once accepted, a project moved to the "new" category, then developed to "growing," "mature," "aging," and finally"defunct." Bisognano explained: Every time Don [Berwick] comes up with a new idea, we add it to the conceptual column. Then, about once a month, we sit down with the management team, and we say, `What are we going to take on as new?' When we take on a new idea, we staff it, we set aims, we resource it, and we monitor it... For those in the `growing' column, we have some experience, but still require managerial attention from Don and me. Those in the mature column almost run by themselves. Once a project moves to the aging category, you have one year to either reconceptualize it, or it goes into the defunct column. My method for operating the business is that we want to get 30 percent of our revenue from new things we've created in the last two years. That means we are constantly putting things in the defunct column. Defunct projects were transferred to another organization, or put onto the Web so that they could be accessed for free. According to Bisognano, "This is stuff we give away, because we think they would serve the mission well if others did them, but we have to make more space for new projects." The IHI's effort was not limited to the United States. It had an international scope, working in both developed and developing countries. For instance, it was active in programs for AIDS prevention and treatment in Africa. Its work in the United Kingdom had sufficient impact that Berwick had been honored with the highest award given to non-British citizens.9 The IHI limited its revenue growth to 10 percent per year. It believed that faster growth would place strains on quality, but slower growth would limit its ability to accomplish the mission. Bisognano observed that, "We like to stay small. It's a driver... We have the most un-American business model: stay small but affect the whole world; give things away." The organization was funded primarily by revenue from products and services, such as training courses, attendance at meetings and conferences, membership in IMPACT, and contracts. Less than 20 percent of the IHI's revenue was from grants. Organization When the Campaign was launched, the IHI had a staff of 75. By late 2007, the staff was just over 100 people. The staff was largely composed on young people, although there were a number of highly experienced healthcare professionals. The young members of the staff, 9 In 2005,Berwick was made Knight Commander of the Most Excellent Order of the British Empire in honor of his work to help the National Health Service of the United Kingdom. Institute for Healthcare Improvement.L-13 p. 6 however, typically did not have healthcare backgrounds. Jim Conway, senior vice president, explained: Most of the people here I wouldn't have hired. It's a very sobering realization that most of the people who work here in IHI have not worked in healthcare. There are some "silver hairs" who have. But we needed people with different skill sets... I was about six months into working with the Campaign and I said to them one Monday at the staff meeting that I realized I wouldn't have hired them, and what I would have lost. I think that's a very important part of this campaign. They have not been trained to see the barriers... They don't know what's "impossible." They only look at what makes sense. Much of the deep medical knowledge at the IHI resided in its faculty. The IHI had a faculty network of about 200 medical and quality professionals from around the world who taught courses and provided assistance to the IHI and to those participating in IHI-sponsored programs. The IHI's offices incorporated a theme of"no barriers." No one had a private office—all offices, including Berwick's, were shared by at least two people. Office and conference room walls were made of glass, so that ambient light permeated the entire facility. Most employees had cubicles with low partitions. There was a one hour "all hands" meeting each Monday, which was mandatory for all, including the top managers. Those that were travelling, or worked off-site, participated by Webcast. This meeting covered news, a topical update by one team (which rotated weekly), a management update covering a different topic each week, and a discussion of one of the five strategies for improving health care(such as "joy in work"). THE HEALTHCARE QUALITY PROBLEM There were enormous opportunities to improve healthcare in the United States. The IHI had been working hard on this problem, as had others. Its training courses were attended by an every increasing number of practitioners. Attendance at the annual IHI Forum grew each year. Each year, Berwick gave an inspirational plenary address describing aspects of the problem, ways the problems could be addressed, and motivating attendees to action. Yet despite pockets of excellence, fundamental change in the way the healthcare community approached the issue of quality was elusive. In 1999, the Institute of Medicine (IOM), an organization established under the charter of the National Academy of Sciences with the purpose of providing advice to the country regarding improvement of health, released a publication entitled To Err is Human: Building a Safer Heath System. This report cited studies showing that up to 98,000 people were dying in hospitals every year due to medical errors—more than died as a result of automobile accidents, breast cancer, and AIDS.10 In early 2001, the IOM released a publication entitled Crossing the Quality Chasm: A New Health System for the 21S` Century. This report stated that, "Between the health care that we now have and the health care that we could have lies not just a gap, but a chasm." The healthcare 10 ,To Err is Human,"loc. cit. Institute for Healthcare Improvement.L-13 p. 7 system needed to be fundamentally redesigned around providing health care that was: safe, effective, patient-centered, timely, efficient, and equitable. It provided a set of ten rules for system redesign, which included practicing evidence-based decision making, sharing information, transparency, and safety—all items that Berwick had been preaching for years. To initiate the needed changes, the report recommended that Congress spend about $1 billion over the next several years to fund a set of tools and programs.I I As noted earlier, the issue was not that healthcare professionals needed to try harder—they were working in a flawed system. They did not want to make mistakes that harmed patients—in fact such mistakes devastated and demoralized them. In his plenary address at the 1997 IHI Forum, Berwick noted that, "Every system is perfectly designed to achieve exactly the result that it gets.1112 Performance was a function of system design. If a system made it possible for people to make mistakes, there would be mistakes. A system that was designed to minimize the potential for human error, and to mitigate the consequences for human error when it occurred, would achieve correspondingly improved results. The checklists, redundancy, automation, and other measures incorporated into the air traffic safety system, for instance, resulted in a system with extremely high levels of performance, even though individuals within the system, being human, occasionally made mistakes. Steven Tremain, M.D., of Contra Costa Regional Medical Center (CCRMC) in California commented on the cultural differences between healthcare and other industries: We are built on a 2,000 year old culture, where we are expected as clinicians not to make mistakes. This was true with the FAA until the 1950s, when they started asking, `Why are we crashing so many planes?' If your safety systems are built on the expectations that your pilots and your doctors won't fail, then you are going to have no safety net when they do. The FAA figured out pretty quickly that they were better off designing a system that expects the pilots to fail, and then prevents that failure from causing a disaster—the failure does not have to cause a disaster. We are just beginning that journey 50 years later in healthcare. Just beginning... I've gone around asking doctors if they would get on an airplane when a pilot says, `I don't use checklists. I've been doing this for 20 years.' Would you fly on that plane? The IHI's approach to quality drew from practices in manufacturing and other industries. In its white paper, Improvinf the Reliability of Health Care, the IHI defined reliability as "failure-free operation over time.sl Failures (or defects) occurred when something that was supposed to be done was not done. For instance, if the standard was to provide a surgery patient with prophylactic antibiotics within one hour of a surgical incision, and this was not done within the 11 "Crossing the Quality Chasm,"loc.cit. 12 Berwick,Escape Fire,op.cit.pp. 140-141. Emphasis in the original. 13 Thomas Nolan, Roger Resnar, Carol Haraden, and Frances Griffin, "Improving the Reliability of Health Care," Institute for Healthcare Improvement,p.3. Institute for Healthcare Improvement.L-13 P.8 specified time, it was considered a defect. The defect rate was the number of defects divided by the total number of actions that should have been taken. In the healthcare industry, there was typically about one defect in 10 (10 percent or 10"1), meaning, for instance, that 90 percent of patients received their antibiotics in the specified time. A system that operated with defect rate of 1 in 10, or 10-1, was fundamentally different than a system that operated at a defect rate of 1 in 100 (10), 1 in 1,000 (10-3) or better. IHI observed that systems with 10"1 performance typically had "no articulated common process, and an emphasis on training and reminders." Those with 10-2 performance had "processes intentionally designed with tools and concepts based on the principles of human factors engineering." Those with 10 performance or better had "a well-designed system with attention to processes, structures, and their relationship to outcomes."14 As the IOM had pointed out in Crossing the Quality Chasm, trying harder was not the answer. THE 100,000 LIVES CAMPAIGN Berwick and the IHI had been pointing out the problems, and teaching solutions, for many years. However, improvements were still isolated to relatively few hospitals, or parts of hospitals. In Crossing the Quality Chasm, the IOM stated that it took an average of 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then, adoption was "highly uneven."15 How could proven improvements be broadly and rapidly spread? How could the gap between what was known to work, and what was received by patients,be closed? Berwick put forth a challenge in his plenary address at the annual IHI Forum on December 14, 2004, saying: I'm losing my patience. So, here is what I think we should do. I think we should save 100,000 lives. And I think we should do that by June 14, 2006-18 months from today. Some is not a number; soon is not a time. Here's the number: 100,000. Here's the time: June 14, 2006-9 a.m.... I think the time for discipline has arrived—the time for getting the job done.... We're going to do it with a campaign—a world class campaign. We are going to elect quality.16 With this statement, Berwick launched the 100,000 Lives Campaign to save lives that would otherwise have been lost due to quality defects in hospital care. Using a "Campaign" to Drive Change The campaign approach had been carefully chosen. One of Berwick's sons was an election campaign professional, having worked in many political campaigns. In 2004, Berwick visited 14 Ibid.,p.4. By comparison,airline passenger safety and nuclear power plants operated at 10-6 reliability,or better. 15 Crossing the Quality Chasm,loc.cit. 16 Berwick 2004 plenary address,loc.cit. Institute for Healthcare Improvement:L-13 P. 9 his son, then working on the Kerry presidential campaign. He was impressed by the scale and professionalism of the effort and invited his son and several other senior campaign professionals to spend a day with the IHI staff. They held a day-long seminar on how a campaign operates. The political professionals identified several key aspects of running a campaign: • Some is not a number; soon is not a time. A political campaign has a specific target-50 percent plus one. It has a deadline—election day. Every action is focused on meeting that target,by that deadline. • Get the "hard count." Specific tasks are defined, scheduled, and measured—for instance the number of doors to be knocked on in a weekend, or the number of voters to be driven to the polls on election day. • Simplify the message. The story, and tasks, must be easily understood and communicated. • Welcome everyone. Anyone who wants to help, in any way, is embraced. • Graduated involvement—take whatever help you can get. The important thing is to get people involved, at whatever level they participate. • Message discipline—stay on message. Do not be distracted. These keys to running an effective campaign had some commonalities to the points made by Gloria Steinem when she had visited the IHI to discuss ways to effect social change. Steinem had advised: • Get people together face to face—they need to be in a room where they feel they are not alone. • Build coalitions around issues. • Name the problem—this makes it something real that you can think about and act upon. For instance, "date rape" had always occurred, but was not recognized as a problem until it was given a name. • Use the media. • Use voting. The discussions with campaign professionals and with Steinem helped crystallize the approach that the IHI would take to mobilize action. Where previously there had been pockets of success, Berwick and Bisognano believed that it was time to improve healthcare on a national scale.17 By October 2004 they had decided to launch a campaign at the IHI Forum in December. The campaign would be to save 100,000 lives that would otherwise be lost due to defects in hospital care, within 18 months. The Campaign was funded with about $3.3 million, raised from a group of donors led by Blue Cross Blue Shield of Massachusetts and the Cardinal Health Foundation. (See Exhibit 3 for a list of Campaign sponsors.) The IHI used a model based on three factors it believed necessary for large scale change: will, ideas, and execution. For the 100,000 Lives Campaign, "will" came from a shared recognition 17 One item that the IHI did not adopt in designing the 100,000 Lives Campaign was the necessity to achieve consensus. The IHI was the decision-maker. It sought input from others, but did not delay in order to achieve a shared agreement on Campaign decisions. Institute for Healthcare Improvement.L-13 P. 10 by the health care community that the status quo was unacceptable, with IHI providing inspiration and focus. The IHI generated an initial set of "ideas"—changes that could be implemented by hospitals to reduce unnecessary death. "Execution" was done by implementing change in the hospitals, with considerable support from IHI. To be successful, IHI believed that it: Must help a critical mass of facilities in each state move from awareness of our shared problem to meaningful, transformative action. It is OK if not every participant has enormous success, so long as expectations of what is possible begin to change and all feel they have a part (through demonstrating or learning) in our shared pursuit of excellence. This stands in contrast to mere obedience to some mandate.18 Thus, the effort was to be collaborative. It would enlist hospitals in a shared effort to save lives, encouraging cooperation and the development of national learning network in which participants could benefit from each other's successes. Participating organizations were to be a team, not competitors.19 Will: Launching the 100,000 Lives Campaign Berwick launched the campaign with his speech on December 14, 2004 before about 4,000 healthcare professionals. In this speech, he described the objectives of the Campaign (100,000 lives, 18 months, 1,600 hospitals), and six specific interventions that hospitals could adopt to achieve the objective. He invited hospitals to participate at whatever level they could—even just implementing one of the interventions, if that was all that they could manage. Packets describing the proposed changes, with fully-referenced literature providing the scientific basis for the changes, were on each chair in the hall, and on the IHI website. Berwick acknowledged that attendees were already trying hard, and that other organizations were also working on improving quality standards. He embraced those efforts—the IHI interventions were not the only things that needed changing, but they were specific and evidence-based. He also acknowledged that many doctors and hospitals would feel uncomfortable about a campaign to reduce needless death, since that would be an admission that the current health case system killed people. But, the deaths were real; one had to be honest about them in order to change the systems that caused them. He described the experience of hospitals the IHI had worked with, that had been open about their performance, and that had been working to improve. He admitted that there was an element of faith involved: "We're going to have to say, `Come to the edge.' And lots are going to say, `We are afraid.' And still, we'll say, `Come to the edge.' And we'll push them. And, like Ascension [a hospital system that had been open about needless deaths and their strategy for stopping them], they'll fly." 0 18 Joseph McCannon,campaign manager of the 100,000 Lives Campaign,email communication. 19 See Exhibit 4 for additional sources of information about improvement and spreading change at scale that informed IHI's change methodology. 20 Berwick 2004 plenary address,loc. cit. Institute for Healthcare Improvement.L-13 P. 11 On the stage with Berwick at the launch were a number of people whose support provided validation and credibility for the campaign. The presidents, chairs, or other senior executives of several important healthcare organizations, including governmental agencies, regulatory organizations, healthcare providers, professional organizations, and patient safety advocacy, joined Berwick on stage. Each of these people made comments supporting the campaign. The chair of the North Carolina State Hospital Association commented: "An awful lot of people for a long time have had their head in the sand on this issue, and it's time to do the right thing. It's as simple as that.i21 The head of one of the largest Catholic health care systems added that, "Frankly, `no needless deaths' is fundamental to any healthcare organization, so I think that CEOs should really worry more about not declaring commitment to this goal than to declaring it."22 The president of the American Medical Association, told the audience, in response to a question from Berwick about the fear of publicly exposing existing problems, responded, "I'm one of those doctors that is scared,but I'm even more scared not to know what I'm doing."23 The final panelist, the mother of a girl who had been killed by medical error, said, "I'm a little speechless, and I'm a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine, because that rapid response team would have come... So, I'm happy, I'm thrilled to be part of this, because I don't think you can do it, I know you can do it, because you have to do it."24 (See Exhibit 5 for a list, including a transcript of the full comments of each panelist.) Berwick also listed a number of other state hospital organizations who had signed up for the Campaign. Berwick stated that this was just the start—"this isn't an event; it's a movement."25 Following the 100,000 Lives Campaign would be a number of other "candidates" that the healthcare community could elect, such as reducing pain, driving out waste and excess cost, and eliminating ethnic and racial gaps in care. Berwick invited the audience to a session that evening where they could ask questions and get additional information. He also asked the audience to fill out forms indicating their interest— IHI would follow up with detailed enrollment information. And, he invited them to take Campaign buttons, to show their support. When he closed his speech, Berwick reiterated what the Campaign would do, and looked to the results they would achieve, saying: And, we will celebrate. Starting with pizza, and ending with champagne. We will celebrate the importance of what we have undertaken to do, the courage of 21 Bill Atkinson comments, "Conference Video: 16`h National Forum on Quality Improvements in Health Care," Institute for Healthcare Improvement,December 12-15,2004. 22 Sister Mary Jean Ryan comments,ibid. 23 Dr.John Nelson comments,ibid. 24 Sorrel King comments,ibid. 25 Berwick 2004 plenary address,loc.cit. Institute for Healthcare Improvement:L-13 p. 12 honesty, the joy of companionship, the cleverness of a field operation, and the results we will achieve. We will celebrate ourselves, because the patients whose lives we save cannot join us, because their names can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would have been only beds of weeds. On the beautiful campus of Wellesley College in Massachusetts is a sundial that has this poem inscribed: `The shadow by my finger cast, Divides the future from the past Behind its unreturning line, The vanished hour, no longer thine. Before it lies the unknown hour In darkness and beyond thine power. One hour alone is in thine hands, The now on which the shadow stands.' One hour alone is in thine hands...the now. Let's rt started. Some is not a number; soon is not a time. 100,000 lives. Now.2 One of the initial concerns was that hospitals would not want to admit that patients were being harmed, and were dying unnecessarily. Madge Kaplan, IHI's director of communications, observed, We did get some of that... That was the hospital PR person's worst fear, `Oh! We're going to have to say, "Guess what, all is not well here."' But that did not turn out to be the thing that the media preoccupied itself with... It wasn't just an announcement about harm. It was `what are we going to do about it?' Berwick's initial rough calculation was that to save 100,000 lives in 18 months would require enlisting 1,600 hospitals—a target he announced in his December 14, 2004 speech. The response from hospitals far exceeded expectations, surprising the IHI team. By late February, just two months after the Campaign's launch, over 1,000 hospitals had enrolled, representing all 50 states. By the end of May, the Campaign had enrolled more than 2,000, and by the end of July, it had passed the 2,500 mark. By the June 14, 2006 Campaign deadline, more than 3,100 hospitals had enrolled, representing approximately 75 percent of U.S. hospital beds. About 86 percent of enrolled hospitals sent mortality data to the IHI. 26 Ibid. Institute for Healthcare Improvement.L-13 p. 13 Ideas: Evidence-Based Interventions to Achieve Campaign Objectives Setting forth a bold target was necessary to mobilize the health care community to achieve rapid change. However, it was also necessary to provide the tools to accomplish the objective. It was one thing to say, "reduce unnecessary death," but simply asking hospitals to improve was not sufficient—they did not intend for their patients to die unnecessarily. As the IOM had noted, 'Vying harder" was not the answer. So, having provoked hospitals to change, IHI provided help that enabled them to improve. The six interventions that Berwick described when he launched the Campaign had already been proven to be effective,but were not widely practiced: • Rapid response teams—experts who could be called upon when an unexpected deterioration in a patient's condition was observed • A specific, evidence-based set of procedures to use for acute myocardial infarctions (AMI, or heart attacks) • A set of proven processes for managing patients on ventilators ("ventilator bundle"), to prevent pneumonia which sometimes accompanied ventilator use ("ventilator-associated pneumonia,"or VAP) • A set of practices to prevent infections related to central venous catheters ("central line bundle") • Prevention of infections at surgical sites by using a set of evidenced-based practices and antibiotics • Procedures to prevent severe adverse drug events ("mediation reconciliation"procedures). The interventions were chosen because they were proven to prevent unnecessary death, and because the actions needed to implement them were within the capability of all hospitals. For instance, the"ventilator bundle" consisted of four steps: • Elevation of the head of the bed to between 30 and 45 degrees. There were several simple ways that this could be made easy to do: a locking mechanism could be put on the bed at the appropriate angle, a mark could be made on the wall showing how high the head of the bed should be, or a protractor could be attached to the bed. • Daily "sedation vacations," in which sedation was reduced so that clinicians could assess whether it was time to remove the ventilator. • Providing drugs to prevent peptic ulcer disease. • Using routine procedures to prevent deep vein thrombosis. This set of procedures could be easily incorporated into standard treatment of patients that were on ventilators, and occurrence of VAP could be monitored. Execution: Campaign Organization and Operation Berwick had set forth the task—elect quality. He had given a specific number and time. He had provoked, and he had provided tools to succeed. Now the IHI team set about to win the Campaign. Institute for Healthcare Improvement.L-13 p. 14 Once the decision had been made in October 2004 to launch the campaign in December, the IHI appointed a campaign manager, Joe McCannon. McCannon had been working on the IHI's projects in developing countries, particularly in Africa. He was skeptical—was the medical community ready to embrace a bold idea and take the action needed for success? Without the public demanding action, could the IHI organize the health care provider community to change? Did they have enough time to think through the operational details of launching and running a campaign unlike anything they(or anyone else that they knew of)had conducted? In his plenary speech to at the 1998 IHI Forum, Berwick had concluded by saying, "The IHI was brought into being as an organization based on the firm conviction that what is unhealed today may be healed tomorrow. We say, `Take the leap. We'll build our wings on the way down.`27 In that speech, he referred to diseases that had once been considered incurable, but were no longer a death sentence. "Building our wings on the way down" was a common expression at IHI, and McCannon used it when describing the planning and early days of the 100,000 Lives Campaign. The objectives and broad strategy were clear, but they would have to figure out many of the specifics as they went—they would have to build their wings on the way down. Achieving success, McCannon explained, was about logistics. The Campaign staff's internal motto was: "Amateurs discuss strategy; professionals discuss logistics," an expression borrowed from the U.S. Army. The IHI staff dedicated to the Campaign was never more than ten people (although many others provided help as needed). With this small group, the IHI had to enroll hospitals, provide advice on implementing the Campaign interventions, motivate hospitals, help hospitals overcome problems implementing change, and track mortality data. The team also put systems in place to help participating hospitals create mechanisms in which they could learn from each other. The IHI made the enrollment process as easy as possible, requiring only one simple form, signed by the hospital CEO. Hospitals faxed the signed forms to the IHI, which then entered the hospitals into a database. All hospitals were welcome—they could participate in as few, or as many, of the six interventions as they were able to take on. Their only reporting requirement was to send mortality information, which they already needed to collect for other purposes. There were no fees—enrollment was free, as were how-to guides, PowerPoint presentations, and other resources that hospitals could use to learn about, and implement, the six interventions. To promote the Campaign, the IHI used all the tools it could muster. It made extensive use of email. It set up telephone conference calls for interested hospitals. Kaplan recalled that, "We had a series of calls in the very first few months after the Forum that had easily 800 organizations [participating] to learn about each of the interventions." A Campaign bulletin was distributed weekly. A weekly phone-in program, "Campaign Live," was established as a forum for discussing issues facing participating hospitals. The Campaign Live topics varied, from general implementation issues to sessions that were focuses on specific interventions. Experts in the topic to be discussed would participate, so that callers could both 27 Berwick,Escape Fire,op. city,p. 176. Berwick paraphrased Ray Bradbury:"Go to the edge of the cliff and jump off. Build your wings on the way down."Brown Daily Herald,March 24, 1995. Institute for Healthcare Improvement.L-13 P. 15 share their experiences and problems, as well as seek advice. All materials, including recordings of each Campaign Live program, were available on the Campaign Website. Web-based forums, many moderated by IHI faculty, were set up so that participants could share experiences or ask advice. For hospitals that had limited resources, this IHI support was invaluable—one person responsible for overseeing the Campaign at her hospital referred to the IHI, and the resources made available through the IHI as "my staff." One important aspect of the Campaign was to help people (both staff and hospitals) maintain their energy and focus. Unlike a political campaign, in which the end objective is a simple task (casting a vote), the 100,000 Lives Campaign was complex. Making changes in established practices was not simple, and would not happen overnight. Thus, the IHI had to build enthusiasm among participants, and help them weather the inevitable periods of discouragement. A critical factor in the Campaign was the field operation. While staff at the IHI headquarters in Cambridge, MA played an essential role, the IHI needed a local presence to help the thousands of participating hospitals,many with their own local or regional issues. The Campaign's field manager was a young IHI staffer who had taken a year-long job as Berwick's special assistant before beginning medical school. In September 2005, he and McCannon rented a bus to drive across country and promote the Campaign and learn from the experiences of participating hospitals. (Exhibit 6) Berwick recalled, "I went on the bus for some of the segments, and you drive in these cities and it would be like a [political] campaign. You had rallies and this outpouring of interest. We tapped this energy that no one knew was there." Most of the field operation did not consist of IHI staff, however. Hospitals and other medical organizations served as the field operation. They did this is two ways: as mentor hospitals, and as "nodes." The nodes and mentor hospitals served a bi-directional learning function. They provided a way for hospitals to learn, and for the IHI to learn from the participating hospitals. Innovations at hospitals in any area could become part of the IHI's knowledge base and widely disseminated. The IHI encouraged hospitals that had particular expertise in one of the six interventions to volunteer to be "mentors." By becoming mentors, these hospitals offered to help others in their areas of expertise. Contra Costa Regional Medical Center was an example of a hospital that learned from other hospitals, then became a teacher. CCRMC addressed medication reconciliation as its first Campaign project. It began by getting the forms used at four mentor hospitals and learning their procedures. From this starting point, it [used rapid cycle improvement methodology and quickly] experimented until it developed a set of forms and procedures that worked in its environment. The ability to learn from the experience of the mentor hospitals greatly shortened the development of an effective process at CCRMC. The IHI learned of the results, and (more importantly) [how CCRMC had adopted and adapted the Improvement Model sponsored by the IHI.] Since there were no mentor hospitals for medication reconciliation in the western half of Institute for Healthcare Improvement.L-13 p. 16 the country at the time, the IHI asked CCRMC to become a mentor. The hospital later became a mentor for other two interventions. While mentor hospitals helped with intervention-specific issues, nodes served as Campaign field offices for states or regions. Nodes could be hospitals, hospital systems, government health agencies, state professional associations—any group that could access, influence, and support hospitals and healthcare professionals in its area. Networks developed around these nodes, with hospitals in each network providing support to each other. The IHI initially expected networks to develop along geographic lines, but in some cases they crossed state borders, as multi-state healthcare systems became nodes or joined nodal networks. 28 In Washington State, for instance, the Washington State Hospital Association contacted several groups, including the state medical society and state nurses association, and asked to work together on the Campaign, forming a node. In Vermont, two groups, the Northeast Heath Care Quality Foundation and the Vermont Association of Hospitals and Health Systems formed a node, decided they wanted every hospital in the state to participate, and took the lead in recruiting hospitals. To illustrate the relationship between a node and the hospitals within its network, CCRMC was in a network consisting of "safety net," public, or critical access hospitals in California. The [pedes node] for this network [were was] the Blue Shield of California Foundation [and with the assistance of] the California Institute for Health Systems Performance. Anna Roth, who oversaw the Campaign at CCRMC, commented on the role of the nodes: What they do is basically to run a collaborative. They coordinate calls. We submit interim reports to Blue Shield and to the California Institute. We have some face-to-face meetings, such as one in which organizations from across the state came to CCRMC. They facilitate content knowledge experts to present to the participating facilities. They also disseminate knowledge.... [On conference calls,] you can get into more of the specific regional issues and talk about that node's special concerns. And, the people who are on the phone sharing, they are people you could get in your car and drive to. Having observed the 100,000 Lives Campaign, organizations launched similar campaigns in Canada, the U.K., and Denmark, for which the IHI provided strategic support and advice. The Hospital Perspective The 100,000 Lives Campaign welcomed all hospitals to participate, to whatever degree they could. The barriers to participation were made intentionally low in order to encourage involvement. As one hospital representative said, "Why not? Why wouldn't you participate in something like this? If we do it then we can say that we have some programs in place, and you 28 A current list of nodes,and organizations comprising each node,can be found at: http://www.ihi.org/IHI/Proerams/Campaign/Campaign.htm?Tabld=4#Nodes(Accessed November 12,2007). Institute for Healthcare Improvement.L-13 p.17 don't want to be one of the few in your community that didn't participate."29 But the degree of participation varied widely among the 3,100 enrolled hospitals. CCRMC. Using the Campaign as a Tool for Transformation At one extreme were hospitals such as CCRMC. CCRMC [was is] a public "safety net"hospital that served patients that did not have the insurance or financial resources required by private hospitals. In 2004 it embarked on a program to become the quality leader, seeking to become the hospital that patients would choose, regardless of their financial situation. It assigned one senior physician half time and one senior nurse to work full time on this initiative (Steven Tremain and Anna Roth,both previously mentioned). Tremain and Roth formed a multidisciplinary "system redesign team" to serve as a sounding board. The team included a physician bioethicist, the head of medical social services, the chief of surgery, a person from the IT department, and Tremain's administrative assistant (who was included because she was an outside voice with no medical or clinical background). Tremain and Roth discovered the 100,000 Lives Campaign in June 2005, and used this as the model for improving quality. As Tremain put it, "We are a teaching organization [CCRMC had a residency program for doctors, and a program for nursing students], and we are trying to become a learning organization... These individual six initiatives are the stage on which we're acting out this play of learning how to change." The Campaign also showed where to focus their energy to achieve results. Tremain said, "In this movement for 20 years, I've been hearing people tell us it's not good enough. `You need to do better.' But not where to focus your effort. And no help on how to get there." The IHI provided a place to focus their effort (the six interventions),the science to back it up, and the methodology and tools to accomplish the changes. Roth, the only person dedicated full time to the quality program, extensively used all the resources provided by the IHI, saying, "The IHI team became everything to me... I used every possible thing the IHI had to offer." She participated in conference calls, distributed IHI white papers throughout the organization, regularly called IHI personnel. "They became my team, or I became part of their team. I spoke to them all every day," she recalled. As previously described, she also used the local Campaign node. CCRMC was already working on some of the six Campaign interventions before joining. It began working on the others, beginning with medication reconciliation, which had an upcoming Joint Commission requirement to be met. When working on IHI initiatives, CCRMC typically put together multidisciplinary teams that included all affected groups, including individuals that could test proposed new procedures, and that would be involved in implementation. For instance, the medication reconciliation team included two pharmacists, a pharmacy technician, two physicians, a nurse, a nurse [infeanatien informaticist], and a person who could develop and modify forms. It was led by the hospital's director of ancillary services. New forms and procedures were initially tested on the small ward on which the team nurse worked. 29 Representatives from several hospitals were interviewed to learn about their experiences in the Campaign. Institute for Healthcare Improvement:L-13 P. 18 CCRMC's teams worked to make their new processes easier to use than their old processes, so that people would want to use the new procedures. They also worked to identify and correct failures as early as possible, making rapid cycles of change, testing, and modification. They sought and acted on feedback. Team leaders also shared information between each other. As a result, CCRMC achieved dramatic improvement in each area addressed by IHI interventions. (See Exhibit 7 for results of some of the interventions.) CCRMC became a mentor hospital for three of the six 100,000 Lives Campaign interventions. In addition to achieving quality improvements, the hospital's culture changed. Staff felt empowered. Collaboration increased. Roth observed, "[Before], quality occurred in one place at our organization. Now, quality occurs everywhere." However, Roth also noted that this was just the beginning of a journey, saying "We've not made it to a destination; we're not declaring victory and we haven't gone into autopilot or slowed down... We're still in this game, trudging forward and we plan to do this forever, until we get to perfect patient care."30 Tremain observed that CCRMC was an ideal location for change to succeed, saying that "We have an optimal little incubator to make this happen." The program had strong backing from top management, yet was not imposed on the staff—staff worked together to make the changes. Tremain noted that the staff was predisposed to improving quality, saying "Being public, we have seft e a common calling that doesn't have a whole lot to do with our personal financial status." CCRMC did not have private practice physicians who were (in Tremain's words), "transient owners of the organization. Our physicians are co-owners... This is their job." Commenting on transformation of CCRMC as a result of its participation in the Campaign, he said, "We basically exposed people who were hungry to learn how to do this, and they took it and ran with it." He continued, saying that "What has been created is the belief that it can be done. No longer are the staff victims of the system. No longer do they need to tolerate harm. Harm can be preventable and they can do it." A Range of Hospitals,A Spectrum of Impact At the other extreme were hospitals that signed up for the Campaign, in part to be publicly seen as participating, but only made those changes that they were already working on for other reasons (such as a Joint Commission requirement). One hospital representative commented that, "What they did... to make it successful is that it was not an all or nothing proposition. They allowed you to slice and dice based on what you felt that you were capable to doing." This enabled hospitals to start with one intervention that was relatively simple for them, then to add others later. Success in one intervention made it easier to persuade hospital leadership and staff to attempt subsequent interventions. Hospitals reported that some interventions were adopted more readily than others. In some cases this was a function of the perceived difficulty of the task; in some it was because of resistance of 30 Shelby Evans,"Quality Quest:Contra Costa Regional Medical Center's Role as an IHI Mentor Hospital Not Only Celebrates Its Success,But Insures It Will Continue To Pursue Performance Improvement,"ADVANCE for Nurses, Vol.4,Issue 22,p. 12. Institute for Healthcare Improvement:L-13 P. 19 opinion leaders in the hospital. In the case of hospitals that were already working on their own quality initiatives, they needed to prioritize the work they were already doing with work on new Campaign interventions. In one case, a hospital reported that improvement was needed due to an upcoming Joint Commission survey. It had previously decided not to implement the relevant Campaign intervention, but decided to see if it helped. A hospital representative observed that, "We started actually seeing improvement in patient outcomes. The moment that happened, everybody went, "Okay, maybe this is making a big difference." Tremain noted that CCRMC's culture was ideally suited to embrace change and the IHI initiatives. He observed that an "environment of equality"was essential among multidisciplinary teams if they were to be successful. This was not possible, "if you have a hierarchy or if you have arrogance, particularly among the doctors." This observation highlighted a potential problem at leading academic medical centers, which were staffed by many world-renowned experts. The representative of one such hospital, commented that: [This is] an organization that has prided itself on brilliance at the individual level... But [the individual physician's] world is very specific, and so creating change [here] is incredibly challenging because they all don't talk with one another... Getting physicians here to agree that there's some commonality between them and their colleague has been the biggest hurdle for us to leap. We were finally able to get them to understand that they and their individual brilliance is highly respected, but that standardization helps improve outcomes because the expectation is shared amongst not only just the physicians, but the people who are working with the physicians, and there is less chance of error because you're minimizing variation of practice. While participating hospitals adopted the interventions to varying degrees, and with varying enthusiasm, even when changes were not made as a direct result of the Campaign, hospitals could still benefit. As one hospital representative said, "The 100,000 Lives Campaign wasn't really the catalyst for all of the work that's happened here, but it [the Campaign] certainly helps to support [our work]." Campaign Results In his 2004 speech launching the Campaign, Berwick had noted it would not be possible to identify those people saved by the Campaign. As a result, success in meeting the 100,000 lives objective had to be calculated through statistical analysis. The basic concept was to compare the deaths that would have been expected during the Campaign period (based on hospital performance in 2004) to the actual deaths during the Campaign period reported by participating hospitals. This was adjusted for patient acuity (how sick the patients were) and patient volume over the 18 months of the Campaign.31 31 For a detailed description of the measurement methodology, see Andrew Hackbarth, Joseph McCannon, Donald Berwick,M.D.,M.P.P,"Interpreting the `Lives Saved' Result of IHI's 100,000 Lives Campaign,"Joint Commission Benchmark, September/October 2006,pp. 1-3, 10-11; and Andrew Hackbarth et. al., "The Hard Count: Calculating Lives Saved in the 100,000 Lives Campaign,"ACP Guide for Hospitalists, April 2006. Additional information on Campaign data submission and measurement is available at the IHI website,at: Institute for Healthcare Improvement.L-13 p.20 This was only a first approximation, however. The condition of patients entering hospitals was not constant over time, even for the same hospital—attributes such as patients' age and diagnoses changed over time. The"lives saved" calculation was adjusted based on an analysis of the changes in patients during the Campaign period. On June 14, 2006, 18 months after launching the Campaign, Berwick announced the results: Hospitals enrolled in the 100,000 Lives Campaign have collectively prevented an estimated 122,300 avoidable deaths and, as importantly, have begun to institutionalize new standards of care that will continue to save lives and improve health outcomes into the future. ... The participating hospitals... [have] also proven that it's possible for the health care community to come together voluntarily to rapidly make significant changes in patient care. I have never before witnessed such widespread collaboration and commitment on the part of health care leaders and front line staff to move the system giant steps forward.32 While most celebrated this result, the announcement sparked intense criticism from some in the academic medical community who questioned the measurement methodology and accused the IHI of taking credit for saving 122,300 lives. The University of California at San Francisco (UCSF) and Johns Hopkins published a negative paper about the Campaign in the Joint Commission Journal on Quality and Patient Safety, noting that the Campaign catalyzed efforts to improve safety, but citing concerns about the methodology of calculating the number of lives saved, as well as questioning the promotion of rapid response teams as a standard practice.33 A member of the academic medical center interviewed commented that, "Most hospitals... would have been fine [with the reported results]. But, there are some major academic medical centers that take that stuff quite seriously." This criticism surprised and disturbed the IHI staff, which had not intended to claim that their interventions had been the sole cause of the observed reduced mortality, and agreed that the measurement of lives saved could not be precise—it was an estimate, and even if the actual number was wrong, the magnitude of improvement was worth celebrating. Berwick reflected that: When we finally announced the result, we worded it rather carefully. That is, it is not technically possible to attribute any gains in mortality to the campaign. Many things go on. This wasn't an experiment in any controlled sense. They criticized http://www.ihi.or I/Programs/Campaign/Campaign.htm?TabId=2#DataSubmissionandMeasurement (Accessed January 7,2008). 32 IHI press release, IHI Announces That Hospitals Participating in 100,000 Lives Campaign Have Saved an Estimated 122,300 Lives,June 14,2006. 33 Robert M. Wachter and Peter J. Pronovost, "The 100,000 Lives Campaign: A Scientific and Policy Review," Joint Commission Journal on Quality and Patient Safety,"November 2006,pp.621-627. Institute for Healthcare Improvement.L-13 p.21 our measurements, and they claimed we were taking credit for saving 122,000 lives. I think if I could do it again I would have been much more careful about that moment when we said, `Look, I think is what happened.' I would have been much more direct and clear that we think it happened, but we can't say it was causal. I'm not even sure I would have tried to claim as much precision as we did on the measurement. I would have couched things more. Because we were as excited as anyone—we were just celebrating. McCannon commented that it was important to return the focus to the larger objective, saying, Not being deterred by [the negative comments], while still learning from them, was really important. The first few months, when we were really being attacked by some researchers, it was draining. We ultimately had to take the high road, stepping above it, and saying, `We all agree that we want to improve the quality of healthcare. So, we're not arguing on that topic. That's not something that's even on the table.' Everyone nods, and says, `You're right.' So, we can talk about these details of measurement, but let's not let that break our stride, because if we do that, patients and families will suffer.34 Looking back at the success of the Campaign, McCannon noted the importance of the spirit of collaboration: The shared nature of our goal (and the fact that we did not seek to expose any hospital for poor performance) changed the tenor of the Campaign; it was a positive initiative that called on the best in people, drawing them back to the reasons they first were interested in this work. There was so much untapped energy and so much unleashed joy, centered on the providers' commitment to their patients. NEXT STEPS: THE FIVE MILLION LIVES CAMPAIGN The 100,000 Lives Campaign had built a learning network in which hospitals across the country could, and did, participate. Building on this momentum, the IHI launched the 5 Million Lives Campaign. This new effort expanded on the previous work, with an objective of eliminating 5 million incidents of medical harm over the two year period from December 2006 through December 2008. In addition to the six interventions in the campaign to save lives, six additional interventions were added targeting problems that were not necessarily fatal, but caused harm to patients, such as pressure ulcers (bed sores), surgical complications, and staph infections. Hospitals that participated in the 100,000 Lives Campaign were automatically be enrolled in the new program, unless they asked to withdraw. Only two hospitals dropped out, and additional hospitals joined, so that by the end of 2007, more than 3,700 hospitals were participating. However, the controversy over results impacted the enthusiasm of some academic medical 34 McCannon speech,November 15,2007,loc.sit. Institute for Healthcare Improvement:L-13 p.22 centers. The representative of one said that, "It led to a major credibility problem," and noted that the University Health System Consortium (UHC), consisting of the major academic medical centers, "Caine out very strongly against the 5 Million Lives Campaign." This was based on two considerations, the reaction against the 122,300 saved lives claim, and a concern that it required more resources, which might be better used in other areas. Regardless of the actual number of lives saved, the improvements made by the participating hospitals would have profound consequences, even though those who benefitted would never know. As Berwick had foreseen when he launched the 100,000 Lives Campaign: Though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would have been only beds of weeds.35 STUDY QUESTIONS 1. How did IHI incorporate the key points of running a political campaign into the 100,000 Lives Campaign? 2. Why did the 100,000 Lives Campaign succeed? 3. What did IHI staff do to facilitate success? How did it leverage the efforts of others? 4. Comment on the efficiency of the Campaign on achieving results, compared with the resources employed. 5. What are the prerequisites for using the campaign approach to accomplish social or organizational change? In what settings is this approach appropriate? 6. What should the IHI have done to build on the success of the 100,000 Lives Campaign, and the criticism that followed its concluding report? 35 Berwick,2004 plenary address,loc.cit. Institute for Healthcare Improvement.L-13 p.23 Exhibit 1 Ideas: From Proof to Dissemination IHI described its proof and dissemination model in the form of a series of concentric circles: Dissemination Prototype R&D IMPACT Network Campaign R&D was done in tens of collaborating hospitals. Prototyping was performed by the IMPACT Network, a group of several hundred hospitals. Once a new practice had been proven, it was disseminated to thousands, or millions, of practitioners. A campaign was way of rapidly disseminating new practices. Institute for Healthcare Improvement.L-13 p.24 Exhibit 2 IHI Strategy IHI summarized its 2008-2010 Strategic Plan as follows: Who We Are We are a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide. What We Will Accomplish We will improve the lives of patients, the health of communities, and the joy of the health care workforce. We work with health care providers and others to accelerate the measurable and continual progress of health care systems throughout the world toward: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity. What We Will Become We will be a recognized and generous leader, a trustworthy partner, and the first place to turn for expertise, help, and encouragement for anyone, anywhere who wants to change health care fundamentally for the better. Strategies: 1. Motivate. Build will and optimism for change(with an open door for everyone). 2. Innovate. Invent new solutions (working deeply with a few). 3. Get Results. Drive broad-scale adoption of sound changes (welcoming all who will join). 4. Raise Joy in Work. Help build the future heath care workforce. 5. Stay Vital for the Long Haul. Achieve excellence in loyalty, financial stability, and worklife for IHI. Source: Institute for Healthcare Improvement. Institute for Healthcare Improvement.L-13 p.25 Exhibit 3 100,000 Lives Campaign Sponsors The 100,000 Lives Campaign was funded by$3.3 million provided by the following supporters: Innovation Partners ($500,000 or more) Blue Cross and Blue Shield of Massachusetts Cardinal Health Foundation Leaders ($250,000-$499,999) The Colorado Trust The Gordon and Betty Moore Foundation Rx Foundation Key Supporter ($100,000-$249,999) Baxter International, Inc. Blue Shield of California Foundation Lilo and Gerard Leeds The Robert Wood Johnson Foundation David Calkins Memorial Fund Other supporters contributed in amounts less than $100,000. Source: 100,000 Lives Campaign Supporters(December 14,2004—June 14,2006), hqp://www.ihi.or2/ihi/About/Donors(Accessed July 23,2007). Institute for Healthcare Improvement.L-13 p.26 Exhibit 4 Sources of Information on Improvement and Spreading Change at Scale, and Further Information About the 100,000 Lives and 5 Million Lives Campaigns The following are papers that helped inform the IHI's approach to organizational change at scale. Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992 Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986. Barabasi AL. Linked: How Everything is Connected to Everything Else and What It Means. New York,NY: Plume Books; 2003. Berwick DM. Disseminating innovations in health care.JAMA. 2003;289(15):1969-1975. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 Lives Campaign: Setting a goal and a deadline for improving health care quality.JAMA. Jan 2006;295(3):324-327. Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, 2000. Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 —1982, Organization Science, Vol.8,No. 5, September- October 1997. Dixon,N. Common Knowledge. Boston: Harvard Business School Press, 2000. Fraser S. Spreading good practice; how to prepare the ground,Health Management, June 2000. Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Granovetter M. Strength of weak ties.Am JSocial. 1973; 78:1360-1380. Improvement leader's guide to sustainability and spread. NHS Modernisation Agency. Ipswich, England: Ancient House Printing Group; 2002. Kreitner, R. and Kinicki, A. Organizational Behavior(2"d ed.)Homewood, 11:Irwin,1978. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996. Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines.JAMA, Vol. 265(17); May 1, 1991,pg. 2202-2207. Institute for Healthcare Improvement.L-13 p.27 Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006 McCannon CJ, Schall MW, Calkins DR,Nazem AG. Saving 100,000 lives in US hospitals.BMJ. 2006 Jun 3; 332 (7553):1328-30. Myers, D.G. Social Psychology (3`d ed.) New York: McGraw- Hill, 1990. McCannon, CJ, Berwick DM, Massoud RM. The Science of Large-Scale Change in Global Health.JAMA. 2007;298:1937-1939 Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992. Rogers E.Diffusion of Innovations.New York: The Free Press, 1995. Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998. World Health Organization (HTM/EIP) and Institute for Healthcare Improvement. An Approach to Rapid Scale-up Using HIV/ADS Treatment and Care As An Example. Geneva: WHO; 2004. The following papers provide additional information on the 100,000 and 5 Million Lives Campaigns. Donald Berwick, David Calkins, Joseph McCannon, Andrew Hackbarth, "The 100,000 Lives Campaign: Setting a Goal and a Deadline for Improving Health Care Quality," Journal of the American Medical Association, January 18, 2006, pp. 324-327. Joseph McCannon, Marie Schall, David Calkins, Alexander Nazem, "Saving 100,000 Lives in US Hospitals,"BMJ, June 8, 2006, pp. 1328-1330 Joseph McCannon, Andrew Hackbarth, Frances Griffin, "Miles to Go: An Introduction to the 5 Million Lives Campaign," The Joint Commission Journal on Quality and Patient Safety, August 2007,pp. 477-484 For an in-depth description of the 100,000 Lives Campaign in the popular press, see: Avery Comarow, "Saving Lives: Hospitals Have Signed on to a Six-Part Plan to Avoid a Multitude of Unnecessary Deaths," U.S. News & World Report, July 18, 2005, special report section. Source:HR Institute for Healthcare Improvement.L-13 p.28 Exhibit 5 Panelist Comments at 100,000 Lives Campaign Launch As part of his plenary speech at the 16'h Annual National Forum on Quality Improvement in Health Care on December 14, 2004, in which Berwick launched the 100,000 Lives Campaign, he was joined on the stage by representatives of several important groups. The following are their comments, in response to questions from Berwick. Dr.John Nelson, President of the American Medical Association Asked why the campaign is important to physicians: When you have motivated people with visionary leadership, who want to do the right thing, we can do this. The AMA is excited to be your partner. Over a century ago, Anatole France, who won the Nobel Prize for Literature said, `To accomplish great things, we must not only act, but also dream. Not only plan, but also believe.' We are ready to act. We are ready to dream. We are ready to believe. Because we know we can do this. Asked if physicians will be scared, since the campaign implies that there are currently problems. I'm one of those doctors that is scared, but I'm even more scared not to know what I'm doing. If I have the data, I can act better. At Intermountain Health Care, we've had the data for a long time. Sometimes those data have not put me where I've wanted to be, and I was able to improve. Bill Atkinson, Chair of N.C. State Hospital Association Asked what the hospital association can contribute to the effort: All we want to do is the right thing for the right reasons. Whether the number is 48,000 or 100,000 or a million—whatever the number. This is about one life at a time. If we can reduce one life lost, then we have accomplished what we want to do. But we want to take this as far as it can possibly go. The science and the art exist. An awful lot of people for a long time have had their head in the sand on this issue, and it's time to do the right thing. It's as simple as that. Asked about whether he is afraid of bad press: No we're not. We have to have courage to do the right thing. We're not making widgets. This is about helping people, about having passion for doing the right thing. I believe that we can deal with the press in a positive way. This is an education process, and we're willing to take that on. Institute for Healthcare Improvement.L-13 p.29 Barbara Blakeney, President of the American Nurses Association Asked how nurses will react to the Campaign: Nurses want to make a difference. Many nurses who are leaving nursing today are doing so because they don't feel that they are making a difference. This is a blueprint. This is a proposal that I think the nursing community will enthusiastically get behind and support. 25% of the people in this room today are nurses. We're here because we know that these events, these kinds of strategies can make a difference, and we're very much looking forward to being a part of it. Asked if nurses can be leaders of change, even if the doctors are resistant: I think absolutely— I think especially in those hospitals where nursing and nurses are viewed as a full partner in the provision of care, that those nurses can take leadership, that those nurses can bring forward this data, and make the recommendations and suggestions. Many of the suggestions that are here, many of the interventions, are nursing interventions. And we can do that. We can lead that. With the data that shows the differences when we do this, then we catch the attention of others, and we can drive this message. So, we're looking forward to being able to partner with you on that. Sister Mary Jean Ryan, President and CEO of SSM Health Care (one of the largest Catholic health care systems in the country, and the first health care winner of the Baldrige Award) Asked why SSM would take on this new Campaign, given that they had already won the Baldrige Award: "The [Baldridge] Award was never our goal, so it's not the end of our quality journey, but really a milestone along the way. Our goal has always been about improving patient care every single day. So, how could we not be enthusiastic participants in this effort. Asked about fears on the part of hospital CEOs about a numerical goal, a stake in the ground: Well, I have a short answer, and as a nun, this might shock some of you,but I also have a longer one. The short answer is: `Suck it up.' [Prolonged laughter] Do you still want the long answer? Truly, nothing great is ever achieved without setting goals. Frankly, `no needless deaths' is fundamental to any healthcare organization, so I think that CEOs should really worry more about not declaring commitment to this goal than to declaring it. David Pryor, SVP, Chief Quality Officer of Ascension Health (the largest Catholic health system in the country, and the largest non-profit health system) Institute for Healthcare Improvement.L-13 p.30 Asked why Ascension was a partner in the campaign, since they were already a leader in quality: "The reason that we're doing it is that nothing less is acceptable for those we serve. It's really that simple. Is there a downside? The downside is accepting the status quo as it currently exists. It's simply not acceptable." Asked how Ascension is doing, having already made many of the changes recommended for the campaign: Our early results are early, but they are encouraging. Over half of our ministries [Ascension Health hospitals] are already doing rapid response teams and ventilator bundles, and several other approaches that have already spread, largely through the leadership of our sponsors, our board, and the CEOs of those ministries, as well as those working there. Asked what aids in success: The first is that the commitment has to start from the top. That includes, in our case, our sponsors, our boards, and the CEOs of our ministries. The second is that you do need to create discomfort with the current status quo. The third is that you need to address the cultural barrier, because it really will enable you to unleash the force and the power of the many, many people who work in your facilities that want to make the changes. The fourth is, don't limit yourself to errors. Far more deaths and injuries are preventable than simply errors. The fifth is that results will feed your success. The early results that happen feed those later results, and enable you to attain even greater progress. Dr. Jonathan Perlin, Acting Undersecretary of Health of the Veterans Health Administration Asked what the VA has learned that others can gain from: I think the VA serves as an example that not only is change possible, but system change is possible rapidly. Lagging average performance a decade ago, VA now sets the benchmark in 18 measures of disease prevention quality, and quality in disease treatment. We support these activities based on our experience, such as that with our fully deployed electronic health record and computerized provider order entry. You spoke of medication reconciliation, and after a decision supported computerized order entry with error checking, medications in our system were robotically dispensed and administered with bar code labeling. We are driving error out of the system. And through a partnership with the Department of Health and Human Services, we're making our electronic health record for those who may not be able to get into the game. That will be available in July of this summer [2005]. Asked why the campaign can be helpful to VA, since VA is already a national leader: Institute for Healthcare Improvement.L-13 p.31 Well, Don, I could give you many science-based reasons why we joined you in this initiative, or account the evidence for the individual interventions, but in fact the true reason transcends the science. It is our responsibility to reduce harm. We join you because it's important. Because it's our mission as doctors and nurses and other health professionals. Because it's possible. Because the science does support it. Because it's rewarding to give great care. More importantly, because it's what the patient deserves. For VA, it's because... our brave young men and women in uniform are giving their country their best—it's what we owe them as veterans. Because it's what you'd want for your father, your mother, your sister, your brother, your son, or your daughter. And so, Don, more than a quarter million members of VA's health care team, bolstered by 100,000 trainees and 100,000 volunteers join you in this initiative, in this campaign. Because soon is not a time, and some is not a number. Dr. Steve Jencks, The Centers for Medicare and Medicaid Services Asked how the campaign aligns with where CMS wants to go. About 100 percent. First of all, we really are a public health agency, and we are acknowledging that more and more. Clearly, our impact makes us that. And we believe that we have to be committed to the right care for every person, every time. You've got that commitment here. We believe there's an unprecedented opportunity to make major improvements in care in the next year or two, three, four. We believe that we're not big enough to move the health care system—we may be seen as big enough to make it unhappy, but not big enough to move it— and you have exactly the same belief, in the way you are building partnerships here. And we see that as absolutely vital. We're totally with it, and we're also already engaged in several of the changes that you've identified. Berwick notes that he is counting on the Quality Improvement Organizations to help, and asks if Jencks thinks they will be helpful. Jencks responds, "The QIOs are already under contract to do some of this, and will be under contract to do more of it. They will love the support that they get, and they will give back, in turn, to these partnerships. And they will be happy to work outside of their contracts with people who want to do that." Dr. Dennis O'Leary, President of the Joint Commission on Accreditation of Healthcare Organizations Asked where the campaign fits into his vision and strategy: Well, Don, we've been in this game for a long time, as you know, and I think we need not apologize for where we have been. We've made a lot of progress over the last five or ten years. But we are dealing with a moving target, and for those who now recognize and acknowledge the problems that exist, and who are already engaged in creating and implementing solutions, this campaign is a challenge and an opportunity to get ahead of the power curve. We have the change, I think, Institute for Healthcare Improvement.L-13 p.32 here, to make winners out of everybody—beginning with patients, but also hospitals, physicians, purchasers, and the public itself. The Joint Commission itself is fully committed to this campaign. We bring, specifically, a measurement capability that will permit the demonstration of the achievement of the goals of this campaign, and to give organizations a chance to show their stuff. Asked if the campaign can really save 100,000 lives: "I think we can. It's going to require that most of you participate—that you play in this effort. But, I think we can save 100,000 lives— maybe more than that." Sorrel King, of the Josie King Foundation (an organization working for patient safety, named for King's daughter, who was killed by a medical error at Johns Hopkins) I'm a little speechless, and I'm a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine, because that rapid response team would have come when the nurse wanted, or when I wanted, and she'd be alive. I'm contacted by lots of families who have been affected by medical errors, and I know their stories, I know their situations, and I sat there, and I listened to you [Berwick], and I just said: `Oh, my God, if this had been happening back then, our Josie would be alive, and this person, Justin... would be alive, and all these people that I know, they would be alive.' So, I'm happy, I'm thrilled to be part of this, because I don't think you can do it, I know you can do it, because you have to do it. And to back up Sister Mary Jean's statement, `Suck it up.' Do it, damn you, it's got to happen. I think it's great, and Don, you are so inspirational, and everyone here at IHI is great, and anything I can do to help, I would like to, and it's exciting. Asked for any advice: I hope the rapid response team—can a parent push the rapid response team button, I wonder? Or maybe a patient can push a rapid response team button. If when you go back to your hospitals, and you are facing resistance, you'll figure out what to do. But if you can't figure out what to do, you call me, and I'll forward you some emails from families. I know you can inspire your hospitals, and your doctors, and your nurses, to do this. Because it has to happen. What other advice? Don't get tired, and don't give up, and don't forget to look, listen, and communicate with each other when you are doing all of these great things. Source:Institute for Healthcare Improvement,Conference Video: 16th National Forum on Quality Improvements in Health Care,December 12-15,2004. Institute for Healthcare Improvement:L-13 p.33 Exhibit 6 100,000 Lives Campaign. Bus Tour On September 26, 2005, the 100,000 Lives Campaign bus tour left Boston. It visited many cities as it travelled across the U.S., ending in Seattle on October 14. During this trip, the IHI staff and partners visited Campaign nodes, learned from participating hospitals, and celebrated their successes in implementing the six Campaign interventions. M - 11111W,1 i 1 o i Source: IHI,"The 100,000 Lives Campaign Bus Tour," http://www.ihi.org/IHI/Prop,rams/Campaign/100000LivesCampai2nBusTour.htm(accessed November 9,2007). Images©IHI,reprinted with permission. Institute for Healthcare Improvement:L-13 p.34 Exhibit 7 Results from Contra Costa Regional Medical Center The following are selected charts of progress by CCRMC related to IHI interventions. Medication reconciliation upon discharge. % of Patients with ANY Hospital Medications Unreconciled at Discharge � 40% -- — - 35% --- ------ I 25% 20% � i 15% 10% 5% ----- r 2006 2007 Ventilator-Associated Pneumonia VAP Ibte per 1000 Vent Days 25 20 20 — -— - ---- 15 -15 L ? 10 5 1 5 1.3 0 2003 2004 2005 2006 Institute for Healthcare Improvement.L-13 p.35 Exhibit 7 (continued) Rapid response team impact, as measured by code blues in non-ICU beds, and associated deaths (note that there were no deaths from code blues in non-ICU beds in the most recent period). ■# Code Blues in Non ICU beds ' ■# Deaths from Code Blues Non ICU beds + Y 2005 2006 Source: Contra Costa Regional Medical Center.