The challenge is the high risk of falling by patients in the medical-surgical unit. The goal is to find practical ways for a busy hospital staff to keep the patients on their feet.
On the task is a study team of staff members at Mercy Hospital of Fairfield, Ohio, a 170-bed hospital in a north suburb of Cincinnati. With input from coaches from the Institute for Healthcare Improvement, staff members are working through checklists of best practices, ranging from the proper places for patient intercom devices to procedures for therapists and nurses during patient handoffs.
"The change feels quick, but if we do this for a year, it will be hard to go back to the way we used to do things," said Beth Zimmerman, Mercy Fairfield's director of quality. "We can make our organization stronger, with staff members feeling they can make changes that are more patient focused. That's what makes this exciting."
Mercy Fairfield is one of seven Catholic Health Partners hospitals in Ohio working with IHI's Safety Across the System, a program that seeks to eliminate harm by preventing errors in staff procedures and decision making. The institute, based in Cambridge, Mass., developed the program with 20 hospitals in the United Kingdom. CHP is the first hospital system in the United States to give it a try.
Carol Haraden, an IHI vice president and patient safety expert, said her team chose Cincinnati-based CHP because it has worked with the hospital system before. "We know it's a capable system with good leadership interested in safety," she said.
CHP picked medical-surgical and perioperative care as its areas of concentration. At Mercy Fairfield, the medical-surgical team is working to reduce patient falls. Other teams there and at the other hospitals are testing procedures to prevent pressure ulcers, post-surgical blood clots and surgical-site infections. Administrative teams are working on better management procedures.
"We want to find the best practices," said Haraden. "We can't go on about high quality of care if we can't assure patients that we won't harm or kill them."
Quality improvement agenda
Stephen Grossbart, CHP's senior vice president and chief quality officer, said the 31-hospital system is eager to learn from the institute's staff and its store of knowledge. Specialists from the institute met with all 70 participants at the seven hospitals in March in Cincinnati, and communicate with them through monthly webinars and frequent telephone calls. Institute staff members have visited each hospital to meet with participants and follow their progress.
The first of those meetings was in late June. The institute team went to Mercy Fairfield on July 5. Frank Federico, IHI's executive director, attended the sessions at all seven hospitals. Teams discussed their progress and barriers to their work.
Next month, IHI staff and all CHP participants will gather in Toledo for another general session. CHP has three hospitals in Toledo participating in the safety initiative with IHI.
"This will help us develop more skills and resources to eliminate harm to our patients," Grossbart said. "That may sound like a lofty goal, but we know that harm occurs in hospitals across the nation. I've never met anyone who is okay with harm levels, who says that hospitals are just dangerous places.
"We have to recognize that it occurs in our system. If you can't see it, you can't get rid of it," Grossbart said.
Haraden said two challenges to any test of best practices are administrative support, or lack of it, and the established routines of departments and staff members.
"We have highly complex systems that often are decentralized, with traditions of autonomy," she said. "We do value autonomy. This isn't an effort to check your brain at the door. We want to build upon the best evidence for safety. Historically, we have simply said, 'Try this.' What we want to do is improve an organization's system so that procedures are reliable today, tomorrow and in three months."
Haraden said IHI coaches develop "change packages" that outline the procedures to be tested by hospital staff members. She said the institute then works with the hospital staff on the best ways to put them to use.
In the project on patient falls, she said, one recommended practice is having nurses get patients up for restroom visits on set schedules. "If the patient says she doesn't need to go, then we say, 'Let's give it a shot anyway,'" Haraden said. "The goal is to reduce falls. You're not going to eliminate them short of calling in the fall police. So how do we minimize them?"
Zimmerman said the medical-surgical study group at Mercy Fairfield chose that focus area because many of its patients are at high risk of falling. She said group members noted that adequate communication often was lacking as different caregivers worked with patients. Notes jotted onto charts often aren't enough, she said.
"When you have multiple things going, people try to figure things out as they can," Zimmerman said. "What we developed was a face-to-face handoff with a very direct set of information. The result has been a quick change with better care for the patients."
Included in the improvement is better participation by patients in providing information, she said.
Grossbart said CHP surgical units began using the World Health Organization's checklist in 2008, but had uneven participation. In contrast all seven hospitals in the Safety Across the System initiative are using checklists during all appropriate surgical procedures, with good results.
In one case, he said, the checklist helped a surgical team realize that an antibiotic had been forgotten during preparations. "That may not seem like a lot, but it develops a process with stop lines — you don't proceed until you correct an error," Grossbart said.
Observe, measure and report
Haraden said IHI requests regular reports from study team members. "We have an extensive system of measurements," she said. The teams share their results on an intranet site.
For example, the perioperative team at Mercy Fairfield gathers after each surgery. A nurse asks all participants for information on success and any need for improvement, all of which goes into a regularly updated spreadsheet.
Haraden said it's too early to declare whether the change packages improve patient safety. The project continues into next year. When it's completed, she said, CHP and IHI will publish the results on IHI's website. She said study participants probably will be asked to present their work at IHI's national meeting and other events.
"The whole point is to learn and build the best systems — and then talk about it," Haraden said.
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