Case Study: A Transformational Change Process to Improve Patient Safety at Ascension Health

January 24, 2006

Overview


A large nonprofit health system identified the most common causes of preventable injuries and deaths at its 67 hospitals and launched an initiative to eliminate them within five years. Ascension Health designed a transformational change process to eliminate preventable injuries and deaths within five years by identifying areas that cause or contribute to patient harm and working systematically to define and spread best practices to dramatically improve patient safety in those areas.


Issue: Few interventions have effectively improved patient safety on a large scale and in varied settings. While individual parts of the health care system have benefited from discrete improvements, the system as a whole still does not reliably deliver the safest possible care. Hence, health care organizations seeking to improve patient safety must rely on both local and shared wisdom to implement strategies that will bring about transformational change in systems of care. This case study describes how a large, multi-hospital system defined ambitious patient safety improvement goals and measured its progress in achieving them.

Organization and Leadership: Ascension Health, the largest Catholic and largest nonprofit health care system in the United States, includes 67 acute care facilities staffed by 106,000 associates in 20 states and the District of Columbia. David Pryor, M.D., Ascension Health's senior vice president for clinical excellence, works with clinicians and leaders to advance the system-wide quality agenda.

Objective: Ascension Health designed a transformational change process to eliminate preventable injuries and deaths within five years by identifying areas that cause or contribute to patient harm and working systematically to define and spread best practices to dramatically improve patient safety in those areas.

Implementation Date: Ascension Health issued a Call to Action to launch its system-wide change process in 2002.

Key Measures: Ascension Health hospitals have been developing best practices to support clinical excellence and patient safety in eight priority areas:
  1. preventable deaths,
  2. adverse drug events,
  3. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measures,
  4. pressure ulcers,
  5. nosocomial infections,
  6. perioperative complications,
  7. perinatal safety, and
  8. falls and fall injuries.
Ascension Health is measuring attitudes toward safety and teamwork among its staff using the Safety Climate Survey, a validated instrument adapted from the aviation industry by researchers at the University of Texas that has been administered at hospitals throughout the United States.[1]

Process of Change: Ascension Health has worked toward transformational change by creating a structure for continuous improvement. In November 2002, 120 strategy leaders came together in support of Ascension Health's Call to Action: to provide Healthcare That Works, Healthcare That Is Safe, and Healthcare That Leaves No One Behind. Through this strategy, Ascension Health aims to improve clinical excellence and safety, create innovative, patient-centered healing environments, and expand access to care for the uninsured and underserved. The system is formally committed to safe health care, with a goal of eliminating preventable deaths and injuries by July 2008.

During the next six months, a Clinical Excellence Team representing chief medical officers, chief nursing executives, chief executive officers, and a mission executive developed a Clinical Excellence Destination Statement to guide the pursuit of this goal. The statement, which was adopted by the system's board of directors, incorporates the Institute of Medicine's (IOM) six aims for the health care system—safe, effective, patient-centered, timely, efficient, and equitable care—plus a seventh aim to reflect the system's spiritual mission.[2] It also embraces the IOM's 10 rules for transformation of the health care system and identifies five challenges that must be overcome to achieve transformational change.
Five Challenges to Quality Transformation


Culture —the entire organization must embrace the safety imperative.

Business case —all members of the organization must understand the business (financial) case that supports these changes.

Infrastructure —the organization must invest in infrastructure to support innovation and quality care.

Standardization —Ascension must eliminate unhelpful variation across the health system.

How we work together —the work model must recognize the benefits of diverse approaches to safety while embracing the advantages of collaborative work.


In September 2003, a 39-member planning team, supported by individuals from the Institute for Healthcare Improvement (a strategic partner), identified eight Priorities For Action to achieve the overall safety goal (see Key Measures). To validate these priorities, selected Ascension Health hospitals reviewed medical records of the last 50 patients who had died in the hospital. This review found that, among patients who were not admitted for end-of-life care, about 15 percent of deaths were considered potentially preventable and all involved at least one of the Priorities For Action.

In December 2003, Ascension Health's Clinical Leadership Forum—chief medical officers, chief nursing executives, risk managers, and chiefs of staff from throughout the system—ratified these priorities. All hospitals began work on addressing the first three Priorities For Action: preventable deaths, adverse drug events, and JCAHO core measures.

Eight volunteer "alpha sites" were selected to develop prototype strategies for addressing the remaining five Priorities For Action, and a ninth alpha site was selected to focus on addressing overall mortality. Alpha sites were selected based on their past performance and capabilities—such as resources, time, and leadership—for leading quality improvement. The alpha site selected to address pressure ulcers, for example, had undertaken improvement work on that topic (see sidebar).

In February 2004, the alpha site teams met to agree on how they would work. Each alpha site team developed a "change package" for its priority area that included standard metrics and methods for measuring and improving performance. Each group selected its own short-term process and outcome variables, with all groups working toward improving long-term outcomes such as lower mortality rates. The teams based their approaches both on evidence from the clinical literature and their own experience and used a rapid-cycle prototyping model to test them. (See the sidebar for an example related to preventing pressure ulcers.)

By June 2004, the alpha sites were reporting early results. Within one year, each of the nine alpha sites improved its short-term outcome measure by at least 50 percent. Given this success, their approaches were endorsed by the Clinical Excellence Team for adoption by all Ascension Health hospitals.

To rapidly spread these practices throughout Ascension Health, the Clinical Excellence Team sponsored Affinity Groups organized around each Priority For Action area. The Affinity Groups serve as learning communities, which hospitals voluntarily join for sharing what works and for coming to agreement on standardized metrics, tools, and strategies that will be used to address a priority. As of February 2005, more than three-quarters of Ascension Health hospitals were working on at least five of the Priority For Action areas.

Results: Examples of improvements at Ascension Health hospitals include: Since Ascension Health hospitals implemented the Priorities For Action change strategies, the overall mortality rate for patients not admitted for end-of-life care declined 21 percent across the system from mid-2004 to mid-2005.

Lessons Learned: "We approached quality improvement from a transformational—rather than an incremental—standpoint," explains Pryor. "Transformational change starts with a vision of clinical excellence that engages all audiences—administrators as well as caregivers." Ascension Health's hospitals have been enthusiastic in embracing this vision. Presentations by clinical peers that demonstrate the results achieved by adopting specific interventions provided the motivation for others to adopt them. "The leadership is coming from [the alpha sites]," Pryor notes.

When the transformation process was conceived, it was thought that the alpha sites would determine the best practices, then those practices would be further tested at beta sites, and finally the changes would spread to remaining sites. But the alpha sites' experience has been so positive that the innovations spread quickly in a "viral" fashion, as many other sites learned about the improvements and wanted to adopt them, obviating the need for a beta test strategy.

This process has led to an environment in which "everyone teaches and everyone learns," Pryor says, referring to the sharing of best practices, standardized adverse event information, and implementation strategies. The self-motivation demonstrated by the Affinity Groups reflects an institutional commitment among Ascension Health's clinicians to be mutually accountable to one another.

A fundamental part of Ascension Health's approach to achieving high-quality care involves creating an environment conducive to quality improvement. "The amount of change we're talking about is so large that in order to be successful you have to address the underlying issues in the environment in concert with the work being done," Pryor says.

While all five challenges (see Table) are significant and require resources to address, leaders at Ascension Health believe that improving the teamwork and safety climate is critical to making the parts of the system work together. Investments in information technology provide a supportive infrastructure for these efforts, such as the ability to host online forums linking members of affinity groups. Ascension Health also endorses and participates in the Institute for Healthcare Improvement's 100,000 Lives Campaign, which includes a subset of the system's goals.

Starting with a culture that is open to change also helps speed the adoption of ambitious improvement goals. Before the change process began, many Ascension Health facilities had been working on quality improvement; culture surveys revealed that staff attitudes toward safety and teamwork at Ascension Health were already better than at comparison institutions. A follow-up culture survey is planned for early 2006.

The nature of the intervention, in which alpha sites were selected based on their capability to lead change, does not permit evaluation using a randomized controlled trial. Rather, Ascension Health has made internal before-and-after comparisons to determine whether the "change package" as a whole improved outcomes, with other health care facilities acting as an external comparison group. Although this approach does not measure the effects of individual components of the change package, "it's less important to identify the specific issue than to change the population outcome," Pryor says.

Implications: The ability to prevent patient harm must be considered in the context of current knowledge. "What we expect to be preventable will be changing over time," Pryor notes. "Heart bypass surgery, when first performed in the 1970s, had an expected mortality rate of about 4 percent. Today that rate is about 2 percent. In that context, half of the deaths [that occurred in the 1970s] are now preventable, but nobody would have said that in the 1970s." Already, Ascension Health's work has shown that its early estimate of the preventability of patient injury was on the low side of what, it now sees, can be achieved.

It's essential that hospital CEOs, as they strive to ensure appropriate stewardship of resources, understand the financial investment required to achieve safety improvements. Toward that end, Pryor is working with Ascension Health's chief financial officer to develop detailed models showing the implications of the Priorities For Action on clinical, financial, and operational outcomes.

Nevertheless, Ascension Health is committed to achieving its goal of safe health care and does not demand a given return on its quality improvement investments. "I believe we will find in health care, like other industries, that quality is free," Pryor says, referring to the philosophy espoused by Philip Crosby, a quality management consultant, that good quality will pay for itself by eliminating defects.[3]

For Further Information: Contact Trudy Barthels, director of communications for Ascension Health, at tbarthels@ascensionhealth.org.

References
[1] J. B. Sexton et al. (2000) Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys. BMJ 320, 745–49.
[2] Institute of Medicine (2001) Cossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
[3]P. B. Crosy (1979) Quality is Free: The Art of Making Quality Certain. New York: Penguin Books.

SIDEBAR: Preventing Pressure Ulcers at St. Vincent's Medical Center


St. Vincent's Medical Center, a 528-bed acute care hospital in Jacksonville, Fla., was Ascension Health's alpha site for developing and testing a model for preventing pressure ulcers. The hospital's staff had demonstrated an interest in the issue and volunteered to build on previous work examining this problem. The effort was led by Wanda Gibbons, R.N., vice president for patient care services at St. Vincent's, with support from Polly Jones, director of clinical excellence for Ascension Health.

St. Vincent's convened an expert conference to review the clinical literature and best practices for pressure ulcer prevention. Participants included a physician expert, Wound, Ostomy, and Continence Nurse (WOCN) experts who had authored pressure ulcer prevention guidelines and represented the National Pressure Ulcer Advisory Panel, and a facilitator from the Institute for Healthcare Improvement. This evidence was synthesized into a bundle of practices, captured in the mnemonic SKIN:
  • Surface selection (use of specialty mattress or cushion when appropriate),
  • Keep turning,
  • Incontinence management, and
  • Nutritional management.
The team piloted this approach in two critical care units and a post–open heart surgery unit, both of which tend to have higher rates of pressure ulcers due to patients' cardiovascular complications. After proving the approach in these environments, the intervention was rolled out to additional nursing units every two or three weeks until it was implemented hospital-wide.

Nursing staff in each unit receive comprehensive education on skin care and pressure ulcer prevention practices and give feedback on their experience with products (e.g., diapers, pressure stockings, etc.) they find to be effective in promoting these goals. Nurses are instructed to perform skin assessments every shift and consult a WOCN if they detect any skin redness or breakdown. The WOCN determines if the patient has a pressure ulcer and grades its severity.

Incidence and prevalence data are recorded in a database together with risk factors and comorbidities for ongoing monitoring. A multidisciplinary team, including a nurse manager, nutritionist, and pharmacist, meets weekly with nursing managers to review pressure ulcers cases. For each case the team asks: What went well, what could we do better, and how could we prevent this occurrence in the future? By following these practices, St. Vincent's has achieved a 50 percent reduction in the rate of iatrogenic pressure ulcers.

Through education, monitoring, and debriefing, the hospital has changed the culture so that nurses now see pressure ulcer prevention as part of their nursing practice and take pride in it. Some critical care nurses were initially skeptical about devoting time to skin care when high-tech care for vital body systems seemed to demand all their attention. They became motivated as they saw that pressure ulcer prevention practices could be achieved without jeopardizing primary outcomes.

St. Vincent's presented its model at a summit in June 2005 that brought together three nurses from every Ascension Health hospital. Participants shared best practices and formally endorsed the SKIN bundle as a standard of nursing practice for all Ascension Health facilities, effective January 2006. The system's nursing executive community lead this effort, which set a goal of eliminating iatrogenic pressure ulcers by December 2006. Following the summit, a work team developed an implementation toolkit that includes a PowerPoint presentation, posters, forms, and guidelines for each facility.

A voluntary Pressure Ulcer Affinity Group continues to hold monthly conference calls, supplemented by an online forum, through which facilities can share new ideas about what works best for education and implementation of the SKIN bundle.

Gibbons and Jones offer several lessons learned from their experience:
  1. Start with small changes, see what happens, and refine your approach as you go. "Pilots don't have to be perfect," notes Gibbons.
  2. Involve staff to spot processes that need to be changed.
  3. Use debriefings for continuous, nonpunitive learning.
  4. Secure executive leadership to ensure that there is protected time to work on improvement and that initial interest is sustained over time.
  5. Celebrate results, for example by counting days free of pressure ulcers, recognizing good ideas shared by nurses, etc.
January 2006

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.