If you could save a life by washing your hands, would you? What if that meant stopping to wash your hands 50 times a day?
In the hurly-burly of the typical hospital setting, even the most dedicated health care workers are sometimes less than vigilant about observing simple procedures proven to improve patients' well-being: Doctors forgo masks. Nurses neglect to check the elevation of a patient's bed. Hands go unwashed.
Busy health care workers might justify cutting corners to save time and question just how much of a difference one mask can make. But a recent experiment in data reporting at the Veterans Affairs Department's North Texas Health Care System, near Dallas, found that small, routine actions by medical professionals can dramatically affect patients' health.
The initiative was part of an ongoing effort by VA's Veterans Health Administration to improve patient safety. After establishing processes to reduce medication errors, VHA turned its attention to intensive care units, which house the most vulnerable patients and account for about 10 percent of the beds at most hospitals.
"If you're in an intensive care unit with an infection, your expected mortality is around 50 percent," said Dr. William Yarbrough, a staff physician at the VA North Texas Health Care System and an associate professor at the University of Texas Southwestern Medical School. "Patients [in ICU] are sicker and more vulnerable to anything that goes wrong."
Beginning in early 2006, VA directed its hospitals to reduce infections in patients connected to ventilators and central venous catheters - long, thin flexible tubes used to supply medication or fluids. The directive was in accordance with the Institute for Healthcare Improvement's 100,000 Lives Campaign, which has sought to promote best practices as a means of saving or extending the lives of 100,000 people in an 18-month period that ended in July 2006.
To comply, the VA System in Dallas turned to its ICU patient management system - CliniComp's Essentris, an electronic medical record and clinical documentation application for critical-care environments. About 15 percent of ICUs in the VA system have such specialized software.
Health care workers used the system to document whether they were following prescribed procedures for washing their hands, disinfecting the site before inserting a catheter, and using sterile masks, gowns, gloves and caps. Nurses used computer checklists to record health care workers' compliance with the standards of care.
"It's sort of like the copilot doing the pilot check" before a flight, Yarbrough said.
But not every takeoff was smooth. "We did have to have a certain culture change for the nurses and the doctors to watch each other," he said. "The nurses had to have enough assertiveness to correct the doctor who did not follow all the guidelines. It improved communication, but there were a few bumps."
Patients on ventilators run the risk of developing pneumonia, so the system was configured to track the elevation of patients' heads (lying flat increases risk), the use of drugs to prevent deep vein thrombosis, the level of sedation (a risk factor) and attempts to remove patients from ventilators as soon as it is safe to do so.
"We're making people more cognizant and vigilant about their own practices," said Steve Rypkema, clinical information systems administrator at the VA North Texas Health Care System. "We are changing our own behavior."
As a result, infection rates plummeted. On the medicine side of the ICU, bloodstream infections attributed to central venous catheter insertions decreased from 9.9 per 1,000 patient days in 2005 to 0.6 in 2006. On the surgical side, the infection rate declined from 5.8 to 2.8 per 1,000 patient days.
"I think we were all pretty surprised that this worked so well," Yarbrough said.
Ventilator-associated pneumonia rates in 2006 were 1.4 per 1,000 patient days on the medicine side of the ICU and 0.8 per 1,000 on the surgical side. The hospital did not track those rates before 2006.
The computerized system determined, however, that patients were on ventilators 53 percent more days than had been estimated.
Yarbrough is hopeful that statistical proof of the benefits of best practices will spur more health care workers to adopt them.
"It requires approximately 10 years for something that has been shown [to work] in a randomized trial to get into common practice," he said. "This is a way for VA to improve that lag time."
The U.S. medical system has few peers. With its financial resources, sophisticated diagnostic equipment, pharmaceutical advances and other features, the nation’s health care system is world-class. If you suffer from a serious medical condition, you could do much worse than to see a doctor or check into a hospital in this country.
Yet U.S. health care has tended to register an unhealthy number of preventable errors. In its landmark report, “To Err Is Human: Building a Safer Health System,” the Institute of Medicine estimated the number of unnecessary mistakes that result in death at about 100,000 annually. Other studies have put the figure even higher.
Documented errors include removing healthy limbs and organs, prescribing drugs in combinations that are known to cause adverse reactions and leaving medical items inside surgical patients.
Experts often blame the high-stress, fast-paced culture that typifies health care environments.
“In health care, there is this interesting [tension] between efficiency and error reduction,” said Paul Keckley, executive director of the Deloitte Center for Health Solutions. “We’re pressed to do everything as fast as we can. We’re also pressed to be as perfect as we can. Sometimes people make compromises to accommodate one or the other. It can cause problems.”
In recent years, safety specialists have begun to look beyond environmental considerations to underlying aspects of the medical culture that compromise patients’ well-being. Researchers have found that poor communication, inconsistent coordination of efforts and an unhealthy deference to authority compromise safety.
To overcome such cultural obstacles, experts have turned to organizations outside the health care field. The best safety and quality models tend to come from organizations that operate in fast-paced, high-stress environments that require exacting standards — such as NASA, the automobile industry and the military.
Adopting those organizations’ methods has promise for U.S. health care because they typically rely on team building, better coordination of disparate organizational components, rigorous standards and procedures, shared responsibility, and the empowerment of workers who have been stifled by hierarchies.
The same techniques that have reduced plane crashes and improved car manufacturing are already lowering post-operative mortality rates. Rethinking airline accidents In the 1970s, aviation suffered a series of tragic crashes, culminating in the collision of two Boeing 747 airliners that killed 583 people on Tenerife in Spain’s Canary Islands. Investigators found that many of the crashes were caused not by catastrophic equipment failure but by poor communication, ineffective leadership, faulty procedures, insufficient standards and flawed decision-making. Warnings that went unrecognized or unheeded often preceded crashes. Information about close calls, which could have been used to prevent future accidents, tended to be shared in an ad hoc fashion, if it was shared at all.
“There was no system to say, ‘Whoa. Gee, this could happen again. Let’s do something about it,’” said Jennifer Baer, administrator of health care quality and patient safety at the University of Texas Medical Branch (UTMB) in Galveston.
To protect against those newly identified crash factors, aviation experts worked with NASA and the Federal Aviation Administration to devise crew resource management (CRM), a checklist-based communications system for commercial and military fliers. One of the system’s primary goals is to ensure that flight crews function as smoothly integrated teams that adhere to well-articulated standards.
“It’s very clear,” Baer said. “There’s no room for flying by the seat of your pants.”
Intrigued by CRM’s success in th e aviation field, UTMB joined the ranks of health care organizations that have a apted the philosophy to the needs of their comm unity.
With the help of LifeWings Partners, a Memphis, Tenn.-based company that offers CRM training to medical organizations, UTMB introduced the program in its operating rooms. Following a series of training sessions, the medical center formulated checklists that mirror flight crews’ cockpit preparations.
Teams of doctors, nurses, pharmacists, administrators and others developed preoperative protocols to ensure the proper recording of patients’ allergies, blood types and other critical factors, and the availability of blood units, antibiotics and necessary equipment.
At every phase of treatment, including the movement of patients among the center’s various sectors and teams, caregivers use a standardized list of behaviors and checklists to guide them. Many of the requirements go beyond what the Joint Commission — the accrediting agency for almost 15,000 health care organizations and programs in the United States — requires.
Just as aviation crews had to overcome their reluctance to question pilots’ authority and presumed infallibility, medical teams learned to object when doctors proposed actions that could be harmful to patients.
Before CRM, “you didn’t question pilots,” Baer said. “Now the pilot makes it clear that he expects people to speak up. In health care, physicians are considered leaders of the team, and in certain cultures, people might be hesitant to question them. In crew resource management training, we teach people to do that.”
UTMB health care providers who have received CRM training report higher levels of teamwork and communication. Moreover, patients’ outcomes have improved. Incidents of objects, such as surgical sponges, left inside postoperative patients have declined from seven in 2005 to zero in 2006. Post-surgical mortality has declined from above-average rates to levels that are lower than average.
Vinette Langford, director of MedTeams at Dynamics Research, said the health care community has embraced the aviation industry’s approach to safety because it works. She recalled a medical error averted during an Army field training exercise at Fort Polk, La. A soldier had an allergic reaction, and a sleep-deprived doctor examined him at the field medical unit and mistakenly ordered 125 milligrams of Benadryl, five times the customary dose. An unlicensed medic who had undergone CRM training spoke up and challenged the doctor, who repeated his order.
Invoking CRM’s two-challenge rule, the medic again objected, and “it finally clicked [with the doctor] that he was misspeaking,” Langford said. “Whenever a person on a team has a legitimate concern, they have the right and responsibility to speak, intervene and question whoever is about to do an unsafe action and question the legitimacy of it.” Safety engineering at VA James Bagian enjoys a challenge. He holds degrees in mechanical engineering and medicine, worked as a flight surgeon, and became an astronaut. At NASA, he investigated the 1986 Challenger explosion and later flew space shuttle missions himself. In his free time, he participates in skydiving and mountain rescues.
Bagian couldn’t resist an opportunity to improve patient safety at the Veterans Affairs Department.
“I thought this would be a great opportunity,” said Bagian, who in 1999 became chief patient safety officer and director of the National Center for Patient Safety at VA’s Veterans Health Administration. The overarching goal of the center is “to develop and nurture a culture of safety…[and the] reduction and prevention of inadvertent harm to patients as a result of their care,” according to the center’s Web site.
Bagian’s first order of business was to onduct a cultural survey of VHA’s health care providers. What he found has informed his ongoing pursuit of improved patient safety.
“Everyone thought they were safe,” he said. “T ey thought it was the other hospital or other division that wasn’t. If everybody thinks that the problem lies somewhere else, they are waiting for someone else to change.”
He adopted an engineering philosophy that takes into account human capabilities and limitations when designing products, systems and processes. Borrowing from NASA and the nuclear power industry, Bagian crafted an approach that emphasizes teamwork and the prevention of adverse events that compromise patients’ safety.
He de-emphasized blame because catastrophic failure can rarely be attributed to one misstep. It is more likely to result from complex interactions throughout an entire system. Therefore, Bagian set out to create fault-tolerant systems that could withstand inevitable human errors.
“I was always frustrated that in health care, the approach to how to deal with problems was very old-school,” he said. “It wasn’t a systems-based approach. It was pretty antiquated and revolved around ‘who did it and let’s blame them.’”
To encourage employee buy-in, Bagian established an internal, confidential reporting system. Except in cases of intentionally unsafe behavior — such as criminal conduct and providers working while under the influence of alcohol or drugs — employees can report events without fear of reprisal. In addition, NASA manages an external reporting system that gives VHA’s employees an additional layer of anonymity.
In the first year after the policies’ implementation, the number of adverse events and close calls that workers brought to the attention of managers increased by a factor of 30. Reporting rates have increased yearly thereafter as well, Bagian said. He added that the increasing number of reports is a sign that the culture of safety is improving, not that more adverse events are occurring.
He also established multidisciplinary teams that conduct root cause analysis investigations of adverse medical events and close calls. The goal is to determine what happened, why it happened and how to prevent it from occurring again.
Traditional means of improving patient safety often misidentify the causes of errors and fix the wrong problems, Bagian said. Consider a common medical event: falls. Older people are more likely than younger ones to take a tumble, and their falls often have serious consequences. So health care providers should strive to prevent falls, right? Yes, but they should really focus on reducing the risk of fall-related injuries, Bagian said. In the first year of an initiative in that area, VA reduced patients’ falls by 31 percent and their injuries from falls by 62 percent.
Since overhauling the way it thinks about patient safety, VA has come to be recognized as a national leader in patient safety and quality care. It has outshone its private-sector counterparts in surveys of quality conducted by the New England Journal of Medicine, the Annals of Internal Medicine and the National Committee for Quality Assurance.
Safety by Toyota In the quest to improve patient safety, a number of U.S. health care organizations — including the Virginia Mason Medical Center in Seattle, the Cleveland Clinic, the University of Iowa Hospitals and Clinics, and Intermountain Healthcare in Salt Lake City — are experimenting with the principles of production that made Toyota the world’s largest car company.
The Toyota Production System (TPS) emphasizes the elimination of waste, which is defined as activities that increase costs without adding value. Other characteristics of the system are a commitment to constant improvement, team-based problem solving, obsessive attention to customer satisfaction, an the integration of people and technology into a smoothly functioning system.
Adapted to health care, such an approach would regard medical errors as resulting from inefficiency and impediments to patients’ treatment and satisfaction. Medical mistakes are waste, and waste must be eliminated.
A key tenet of TPS is a rigorous review of business practices, an exercise that goes by several names: lean manufact ring, shared baselines and kaizen. Loosely translated, kaizen means continuous improvement. It can also signify the process of taking something apart and putting it back together in a better way.
Intermountain Healthcare has applied the principles of TPS to a number of areas, including cardiac care. The organization assembled a cross-functional team and asked it to map the treatment of patients with heart disease, from check-in to discharge.
To identify waste, team members would “measure [cardiac care] much the way a business might measure a product,” said Ron Wince, president and chief executive officer of Guidon Performance Solutions, a company that seeks to improve clients’ business processes. “They looked at points of delay, points of potential failure, what patients say they do or don’t like.… If you follow what patients experience, you’ll find the breakdowns between handoffs and information flow and protocols.”
“Avoiding error is only part of the puzzle,” Keckley said. “Coordinating care is probably our bigger challenge. When you go to Starbucks and they ask you what you want, they repeat your order. If you’re having a frozen drink, they check something on the cup. In the health care system, we do a fair amount of checking, but we’re not doing handoffs as well as we need to. The information systems that are supposed to prevent you from doing something bad or harmful are not readily available.”
Such reviews invariably reveal systemic problems, such as incorrectly documented paperwork, failure to complete preoperative lab work on time and other problems that can compromise or delay surgery. Wince recalled an operating room technician who wasted considerable time walking along hospital corridors in search of equipment needed to perform procedures. The kaizen review showed that he was logging 5,000 miles annually.
As a result of Intermountain’s review of its cardiac care procedures, the organization has “been able to cut open-heart surgery mortality rates almost down to nil,” Wince said. “Initially, it’s a kind of structure. Eventually, it becomes a way of life.”
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
