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Q&A: The Big Tent Approach to Quality Improvement and Patient Safety

By Sarah Klein

IMPORTED: __media_3B1FF2F919AC4C96992E8324E6792C00.jpg While some Hospital Engagement Networks (HENs) concentrate on specific geographic regions or particular types of hospitals such as safety-net facilities, Intermountain Healthcare's HEN includes 107 hospitals from across the U.S., ranging in size from small, rural hospitals to major tertiary care facilities and academic medical centers, including Dartmouth-Hitchcock, Baylor Healthcare System, and the Mayo Clinic. Quality Matters asked Lucy Savitz, Ph.D., M.B.A, director of research and education at the Intermountain Healthcare Institute for Health Care Delivery Research and project director for the Intermountain-led HEN, how integrated health care systems can help such a diverse group improve patient safety and quality.  

Quality Matters: Intermountain Healthcare is more advanced than many other institutions in terms of quality improvement, outcomes measurement, and clinical practice redesign. How do you adapt that experience to help smaller hospitals that may lack Intermountain's resources?

Savitz: We tailor our training materials [available at] to three groups of hospitals: those that are just getting started, those that are working harder, and those that are working ahead of the curve. We're trying to be as flexible as possible, recognizing that hospitals aren't just working on the HEN project; they are pursuing meaningful use certification of their electronic medical record systems. Others are establishing accountable care organizations. In some areas, they may be able to work on the higher-order things, and others are telling us all we can really do is just get started.

Quality Matters: How do you help them do that?

Savitz: It's very much a trickle-down approach. We have a core set of leading delivery systems—including Intermountain, Baylor Healthcare System, Denver Health, Mayo Clinic, Providence Health and Services, and Dartmouth Hitchcock Medical Center—that have been working together for years on applied research. We basically said, let's harvest best-in-class practices, review the literature, and synthesize that learning. We then created training webinars for each of 10 areas of focus, such as preventing pressure ulcers and patient falls. These are followed by conference calls in which the HEN's hospitals call in to talk to the experts and the other hospitals. These are very rich calls. We also survey our hospitals on a quarterly basis to see what sort of issues they are confronting to find out how we can be more helpful. 

Quality Matters: What have you learned about the challenges the hospitals are encountering?

Savitz: One of the big issues is measurement, particularly around CMS' early elective delivery (EED) measure, which all hospitals are required to report on beginning this month. It's not as clear-cut as we would hope. For example, some hospitals have multiple reports of gestational age and don't know which one to use or do not have electronic access to the information. There's also some concern that certain diagnostic codes that would justify an early elective delivery are not excluded as they should be. We are in the process of writing a white paper to compile the issues we've uncovered in reporting on EED. In addition to aggregating and reporting measure data, we collect success stories across the 10 areas to show what is possible for all types of facilities.

Quality Matters: CMS has set some ambitious goals to meet within two years. Do you have any concerns about the pace? 

Savitz: The thing that worries me is that it can take some time to show substantial changes in safety metrics. Take patient falls: we at Intermountain went back and looked at the interventions that have been put in place to reduce injurious patient falls—from 2005 on. We saw small improvements when we had training or had distributed patient education materials. But the real thing that made a difference was buying new beds that had integrated alarms. That takes more time because it's a capital budgeting issue. Other things like building a reminder in the EMR, for instance to trigger staff to remove a catheter at a specified time, is not something that happens overnight. At my organization—and we are one of the more sophisticated—that can take months. It doesn't mean you aren't doing something, or you are not going through the channels to make that happen. I hope we'll see some patience and recognition of these challenges. 

Quality Matters: Are there other things need to be resolved to ensure the program's success?

Savitz: One of the issues our core partners identified was with the nomenclature and need for a taxonomy that people use in talking about patient safety and risk mitigation. Just the term root cause analysis (RCA) is problematic—it doesn't mean the same thing to every person. You would think it does, but it doesn't. We looked at the words people use to describe adverse events or sentinel events and we came up with 15 different terms that are used. This creates a problem with measurement and with our ability to assess patterns in pooled data across hospitals/systems in order to identify targeted safety solutions. The other issue we found with RCAs is that because they are so time-intensive, people tend to focus on rare sentinel events at the expense of not having additional resources or energy left over to look at the larger numbers of minimally harmful or potential patient safety events that are really preventable. We saw that as a common problem that emerged in our discussions. 

Quality Matters: How would you like to see these problems addressed?

Savitz: CMS has provided us with the resources to identify issues, like the need for a taxonomy to support communication and guide promising improvement efforts. As we identify issues, the next step is to act. When possible, we can leverage HEN resources to address identified problems. But the HEN contracts are not intended for research; in addressing these types of problem areas, we will need to apply for external funding or collaborate with delivery system partners to conduct unsponsored research.

Quality Matters: If you could change one thing about the program, what would you do?

Savitz: I would like to have U.S. Department of Health and Human Services Secretary Sebelius and Marilyn Tavenner, acting director of CMS, prepare a short DVD aimed at hospital/delivery system leadership and boards of directors. The messaging should be around the national priority and government expectations for HEN commitment, improvement activities, and accomplishments thus far—a kind of call to arms if you will. These hospital leaders should be congratulated on their commitment to safety and quality at a time when the industry faces declining reimbursement, increasing regulatory requirements, major information technology build-up, and a slow economy.

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