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Engaging Hospitals in Rapid-Paced Quality Improvement

Summary: Through its Partnership for Patients Initiative, the Centers for Medicare and Medicaid Services awarded $218 million to 26 "hospital engagement networks." These groups are charged with helping U.S. hospitals achieve a 40 percent reduction in hospital-acquired conditions among Medicare beneficiaries and a 20 percent reduction in hospital readmissions in just two years' time. This issue of Quality Matters looks at the training these organizations are providing and the early results.

 

By Martha Hostetter and Sarah Klein

Ever since the 1999 publication of the Institute of Medicine's landmark report, To Err Is Human: Building a Safer Health System—which found widespread evidence of safety problems in U.S. hospitals—researchers and clinicians have been focused on finding ways to avoid patient harm, including falls, hospital-acquired infections, and medication errors. This work has yielded a number of promising interventions over the last decade, but they have not been widely nor reliably implemented. One reason is the challenge of "spread": while finding the safest way to care for patients in a research trial is one kind of challenge, finding the safest way to care for every patient, every time, on every floor of every hospital is a challenge of an altogether different order.

To help address this, the Centers for Medicare and Medicaid Services (CMS) has funded 26 "hospital engagement networks," to provide training and technical assistance to some 3,700 short-term, acute-care hospitals—71 percent of all such hospitals across the U.S.—as they implement programs to keep patients from getting injured or avoidably sicker while in the hospital, and to help them heal without experiencing complications.1 

The HENs, as they are colloquially known, vary by size and membership. The largest, led by the American Hospital Association's affiliate the Health Research and Educational Trust, includes 1,600 hospitals, many of which are organized around state hospital associations. The second largest, run by Premier Inc., a national alliance of hospitals and health systems pursuing high-quality, efficient care, includes some 450 hospitals, while other groups target particular hospital types, including safety-net hospitals, academic medical centers, and children's hospitals.2 In aggregate, the HEN hospitals are expected to achieve two overarching goals by the end of 2013:

  • a 40 percent reduction in hospital-acquired conditions among Medicare beneficiaries; and
  • a 20 percent reduction in hospital readmissions among this Medicare beneficiaries.3 

These are ambitious goals to accomplish in a highly compressed time frame (CMS only awarded the HENs grant funding in December 2011.) But CMS officials say the quality improvement literature demonstrates rapid improvement is possible and the intent of the program is not to develop new ideas, but to use the HENs as what CMS terms "mobile classrooms" that spread best practices to hospitals of all sizes and types and build momentum to tackle longstanding patient safety concerns. Its model is similar to the Institute for Healthcare Improvement's 100,000 Lives campaign, which used an extensive network of quality-focused organizations to act as field offices for local efforts to improve patient safety and reduce harm. Several observers find the similarity unsurprising as both initiatives were developed under the leadership of Don Berwick, M.D., former CMS administrator and, before that, the president and CEO of the Institute for Healthcare Improvement.  

The HENs are using a combination of strategies to encourage safer care. Most are providing hospital leaders with general training in quality improvement (e.g., processes for conducting root cause analyses and Plan-Do-Study-Act cycles) along with guidance on implementing best practices to avoid hospital readmissions, such as improving medication reconciliation or discharge education. In addition, the hospitals are encouraged to work on preventing nine hospital-acquired conditions (HACs): 

  • adverse drug events;
  • catheter-associated urinary tract infections (CAUTIs);
  • central line–associated blood stream infections (CLABSIs);
  • injuries from falls and immobility;
  • obstetrical adverse events;
  • pressure ulcers;
  • surgical site infections;
  • venous thromboembolism; and
  • ventilator-associated pneumonia (VAP).   

Each HEN is permitted to choose the measures with which it will track hospitals' progress on reaching the program’s goals—a decision that may complicate benchmarking among HENs—and must set up a Web-based data portal to enable reporting. CMS will use its own data to evaluate the effectiveness of the HENs as a group. It also plans to reward those that help hospitals achieve the target with a third year of funding. 

This issue of Quality Matters describes the various approaches taken by a selection of the HENs and reports on their early challenges and achievements.

Health Research and Educational Trust

Half of the hospitals in the nation's largest HEN, the Health Research and Educational Trust's 1,600-hospital network, are critical-access facilities and small, rural hospitals—the kinds of facilities that may not have the internal capacity nor resources to manage large-scale improvement activities. Like most of the HENs, HRET is engaging hospitals through a combination of in-person training sessions and virtual events such as webinars and coaching calls. The aim is to facilitate peer-to-peer learning and support the implementation of best practices, such as use of the ventilator bundle to prevent ventilator-associated pneumonia or hard-stop policies to prevent early elective deliveries.

In addition, HRET is seeking to build capacity for change at participating hospitals through its Improvement Leader Fellowship program, which by the end of 2012 trained about 900 medical directors, physicians, nurses, and other frontline staff in leadership, culture change, teamwork, patient engagement, and spread.

The Wisconsin Hospital Association, one of the state hospital associations working under the HRET network, has attracted 108 hospitals, the vast majority of the state's facilities. Kelly Court, M.B.A., the association's chief quality officer, credits the high participation rate to the state's long history of collaboration on public reporting. Hospitals were also promised that they would not need to implement any new measures; they would only report data to the association that they were already collecting for other needs. In return, the association sends quarterly progress reports to all of the hospitals' CEOs, including graphs benchmarking their institutions' performance against others. It will then use the data from this first year of work to target its activities for 2013. 

HRET has been able to report some results of its efforts thus far, including a 28 percent relative rate reduction of CLABSIs for 302 hospitals and a 15 percent relative rate reduction in CAUTIs for 290 hospitals. 

Premier Inc.

Like HRET, Premier works with a large number of hospitals in rural, or non-urban communities (roughly 80 percent of its 450 hospitals fall in these categories.) Each participates in virtual and in-person collaboratives and webinars. They also receive visits from "quality improvement advisors," who are nurses with experience working for state-level QIOs or other quality improvement organizations.4 To keep tabs on their progress, all participating hospitals receive run charts showing whether they are on target to meet the goals they set. 

In the first six months of the program, Premier has seen a 7 percent reduction in readmissions and a 7 percent reduction in harms across its network. Monica Barrington, R.Ph., M.P.H., Premier's vice president of engagement and delivery, says the most successful hospitals tend to have leaders who prioritize the program. "It really starts at the top in the behaviors that are modeled and in the things that are deemed to be important," she says. To assess that, the clinical improvement advisors look to see "Are they doing walkarounds? Are they participating in the daily huddles? What is the first topic of conversation at the board meetings? How transparent are they about performance and how quickly do they jump on a safety issues?" she says. 

Ascension Health
All 70 of Ascension Health's hospitals are participating in the nonprofit health system's engagement network. While Ascension has been working to "get to zero" on many of these hospital-acquired conditions for the past several years, the HEN approach offers some additional benefits, says Ann Hendrich, R.N., Ph.D., vice president of the health system's clinical excellence operations. Most crucially, Ascension's hospital leaders have reached agreement on standard process and outcome measures to assess their performance, and will have national benchmark data to gauge their progress. 

Ascension has also asked its member hospitals to tackle all of the HACs—rather then focusing on just a few at a time, as some hospitals in other networks are doing. "We think that's very important," says Hendrich. "Hospitals can get a linear focus and improve something—but as soon as they take their eye off of it, the results can drop. As a high-performing hospital, you should perform well across all of these conditions, not just have the fewest falls or adverse drug events." Ascension has asked its hospitals to report their performance on a composite measure across nine conditions plus readmissions to assess how reliably they are delivering safe care in all instances, for every patient.

With HEN funding, the health system also created a clinical "app" that lets frontline providers quickly look up basic information about each of the HACs and read about best practices for avoiding them. 

Ohio Children's Hospitals' Solutions for Patient Safety
The Ohio Children's Hospitals' Solutions for Patient Safety includes 33 children's hospitals from around the nation. The network grew out of a learning collaborative that was formed among Ohio's eight children's hospitals as a partnership with the business community to improve health care quality and control costs. From 2009 to 2011, the eight hospitals together achieved a 60 percent reduction in surgical site infections among designated cardiac, neurosurgery, and orthopedic procedures through the use of a surgical care bundle and a 40 percent reduction in adverse drug events through the use of a trigger tool and focus on narcotics and laxatives ordering. 

Once the collaborative became a HEN, it reached out to other top-performing children's hospitals beyond Ohio, which it identified with help from the National Children's Hospital Association and a survey in which applicant hospitals described their quality improvement experience and infrastructure. Starting with a group of leading children's hospitals helped the network build momentum during its first year of work, explains Jessie Cannon, Ohio Children's Hospitals' Solutions for Patient Safety director. Among other strategies to engage leaders, network CEOs commit to holding daily briefings to review significant safety or quality issues from the last 24 hours; look ahead to anticipated safety or quality issues in next 24 hours; and follow-up to provide status reports on issues identified.

Having a network focused on pediatric settings has also been critical. "A lot of the evidence on how to reduce hospital-acquired conditions is from the adult world," says Cannon. The group has been helpful in identifying best practices, including use of the "maintenance bundle" for central line care in children, since pediatric patients often need catheters much longer than adult patients, and a general focus on partnering with parents to ensure patient safety. "In addition to submitting outcomes to us, we've also asked hospitals to tell us what they're doing—what processes they are using, what care bundles, and how reliably they are implementing them. At the end of the day, we can look at what has worked well and be in a position to make recommendations for other hospitals as we expand." The group is set to add 50 more children's hospitals to its network in 2013. Early results thus far include a reduction in surgical site infections and falls among participating hospitals.

UHC 

Seventy-seven of UHC's 116 academic medical center members joined its HEN. All members are invited to join its various improvement collaboratives, which focus on different topics, with individual invitations going to lower performers. UHC also conducts site visits to such organizations to determine what recommendations or support it can provide. 

The collaboratives include monthly calls for the participants led by subject matter experts. Hospital teams perform a gap analysis, set improvement targets, and identify barriers to success then share monthly progress reports with UHC. After six months, teams join a "knowledge transfer" Web conference to share their experiences, lessons, and achievements. UHC members have improved on 11 of 16 metrics being tracked.

NAPH Safety Network

America's Essential Hospitals' HEN for safety-net hospitals, the Essential Hospitals Institute (formerly the National Public Health and Hospital Institute's NAPH Safety Network), includes 29 safety-net hospitals, many of which face acute challenges including limited resources for staffing quality improvement initiatives and data collection. Like other HENs, the NAPH Safety Network has worked to find cross-cutting solutions for reducing readmissions and patient harms, and provides that training through webinars, site visits, and occasional in-person meetings. A key feature of its program is training for CEOs to help them engage in quality improvement efforts. One CEO told the group she was stunned to find her hospital had seven different teams that thought it was their responsibility to reduce preventable hospital readmissions, says James L. Reinertsen, M.D., a consultant who provides leadership training in quality and patient safety for the NAPH Safety Network and other organizations. One of the benefits of having high-level leaders involved is that it helps to identify such duplication and lack of coordination, which is highly prevalent, he says.

One of the public hospitals in the HEN, MetroHealth Medical Center in Cleveland, brought the chairman of its board of trustees along to a NAPH leadership training session in August. Al Connors, M.D., MetroHealth's chief medical officer, says the training has changed the way the board interacts with hospital leaders. "We had strong commitment from our board before," he says. "The difference now is I think they've started to realize they can get more involved in setting safety goals, monitoring them, holding us to targets. In the past, they may have let the doctors and nurses define quality. Now they realize you don't need to be experts in health care to do that. The expectations are higher, and it has kind of electrified all the teams working on this."

Lessons and Challenges

According to CMS, those HENs making rapid progress thus far tend to be transparent in their use of data, enabling participating hospitals to benchmark their performance. Others have effectively used friendly competitions among hospitals. The agency also notes that one of the other early benefits of the program has been the tendency of participating hospitals to institute policy changes, such as the introduction of a hard-stop policy for early elective deliveries, if leading hospitals in the HENs are doing so. 

While having financial and technical support from CMS has helped, according to many HEN leaders, they are still concerned about the pace of the program—especially because it required them to launch their work before receiving clear directions on measurement methods. While many say they understand the challenge CMS was under to get the program moving quickly, they believe they might have accomplished more if they had more guidance at the outset. Others worry that the political pressure on CMS and the HENs to produce results might lead to an overemphasis on the successes of the interventions, rather than the failures, which can be equally instructive.

Evaluating the effectiveness of the program is also made more complicated by the fact that CMS has several improvement initiatives under way, making it difficult to ascertain the effects of any one program and consider their potential opportunity costs.

"I think the key thing to ask about this program is: are the federal dollars well spent relative to other potential activities, such as support for enhanced infrastructure for patient safety, or even expanded measurement of safety outcomes," says Dennis Scanlon, Ph.D., professor of health policy and administration at Penn State University. "You can educate people so much, but that doesn't substitute for having resources needed to implement changes—for example to hire an extra nurse to dedicate staff time to activities such as medication reconciliation or making sure that information is provided to facilities receiving patients upon discharge, or collecting information from other facilities upon admission."

These concerns notwithstanding, many agree that the ambitiousness of the program would be a benefit in helping hospital leaders realize they could accomplish more than they might think. It also requires the hospitals to engage a large number of staff in the efforts, and has thus far involved small and/or rural hospitals as well as known leaders. Others point to the benefits of forcing the hospitals "to walk and chew gum"—to focus on many different safety topics at once and to strengthen their overall approach to quality improvement through investment in staff and resources, and use of techniques such as Lean.

"When you take a singular focus like on CLABSIs, you can make some pretty significant strides," says Maulik Joshi, M.H.S.A., Dr.P.H., HRET's president. "But when you scale it to a level of 10 topics, you can't do all 10 unless you've got physician and leadership engagement, made connections to governance, [and have] begun to think about harm as a different way of measuring performance."

Ultimately, a key to the program's success will be whether hospitals are able to sustain their improvement over time, says MetroHealth's Connors. "It's not so hard to get people to focus on a problem," he says. "The challenge is to get everything finished. Often we get a new policy made but we don't get it implemented fully, or we get it implemented but we stop monitoring the results in a few months. Keeping everyone interested takes showing them results, showing them we're paying attention, and helping fix obstacles that stand in the way."

Notes

 1 Each HEN receives funding through the $1 billion Partnership for Patients initiative, which was created through the Affordable Care Act. The amount varies by HEN and is based on budgets prepared by the HENs when applying for the program. Joining a HEN is free to hospitals, though expenses they incur for staff time may not be reimbursed.

 2 The complete list of 26 HENs can be found in a December 14, 2011 CMS Fact Sheet, available at on the CMS site.

 3 Compared with 2010 levels. A previous issue of Quality Matters reported on the other half of the Partnership for Patients effort, the Community-Based Care Transitions Program, which aims to support patients once they leave the hospital.

 4 CMS contracts with a private organization, known as a quality improvement organization, in each state. These organizations are tasked with improving care for Medicare beneficiaries. 

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