Community Health Network Reduces Deadly Infections Through Culture Of Reliability


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Community Health Network Reduces Deadly Infections Through Culture Of Reliability

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Community Health Network Reduces Deadly Infections Through Culture Of Reliability

  1. 1. Making the Case for Quality June 2008 Community Health Network Reduces Deadly Infections Through Culture of Reliability by Janet Jacobsen Just a decade ago the intensive and cardiac care units in Community Health Network’s five hospitals At a Glance . . . treated a case of ventilator-associated pneumonia (VAP) every eight days—typical for a 10-bed medical/surgical critical care unit. With mortality rates for VAP at nearly 60% and with each case • Community Health Network adding thousands of dollars in incremental costs, a prescription for reducing VAP was urgently needed. (CHN) achieved stunning results in reducing cases About Community Health Network of ventilator-associated pneumonia (VAP) Established in 1956, Community Health Network (CHN) is a leading not-for-profit health system through its trail-blazing based in Indianapolis, Indiana. The network consists of five hospitals, including a dedicated heart prevention efforts using specific bundles of care. hospital, urgent care centers, the Indiana Surgery Center, 70 primary care physician practices, nursing homes, and other healthcare facilities. CHN provides 867 staffed hospital beds and employs more than • Four of the network’s critical care or coronary 10,000, as well as 1,000 physicians. care units have reported no cases of VAP for at least The Campaign to Reduce VAP two years, and one unit has eliminated all cases With mortality rates approaching 60%, ventilator-associated pneumonia (VAP) is one of the most of this deadly infection dreaded infections that can strike a hospital patient. According to the Institute for Healthcare since December 2003. Improvement (IHI), VAP affects up to 15% of intensive care unit (ICU) patients who are so weakened • Looking to maintain and by illness or trauma that they need mechanical help from a ventilator to breathe. If the ventilator further improve prevention tube that pumps life-saving air into vulnerable lungs becomes contaminated or the patient aspirates efforts, CHN turned to lessons from the nuclear contaminated fluids or secretions from the oral or gastric areas, it can act as a pathway for bacteria and power industry to learn secretions to enter the respiratory tract, paving the way for a potentially deadly VAP. more about human reliability, thus adding CHN estimated the average cost per patient with VAP was $22,000 based on six additional days the “people” part of the on a ventilator.1 With each of the network’s seven intensive and cardiac care units averaging one puzzle to its already case of VAP every eight days, the potential cost avoidance for eliminating VAP across the network successful VAP bundle. totaled a staggering $6 million annually. Determined to save lives and reduce these costs, CHN set a networkwide goal nearly a decade ago to reduce cases of VAP by 50% from its baseline measure. The network became a pioneer in working to reduce VAP, as it was one of a few select healthcare organizations chosen to help develop and test reliability metrics in the campaign against VAP in 2000. It was during this time that the groundbreaking notion of bundles of care became mainstream. What is a “bundle of care”? The IHI defines a bundle of care as a specific tool with clear parameters. Bundles typically include a small number of scientifically robust elements that, when taken together, create significantly improved healthcare outcomes. IHI developed the bundle concept to help healthcare providers more reliably deliver The American Society for Quality Page 1 of 4
  2. 2. the best possible care for patients undergoing particular treatments, helps increase the reliability of that measure, it solidifies the such as mechanical ventilation, that have inherent risks. behavior and helps build reliability into the system. Demonstrating Impressive Results Today, a typical VAP bundle includes the following core elements: • Keeping the patient’s head elevated to at least 30 degrees As shown in Figure 1, once the network’s hospitals deployed • Providing appropriate sedation the VAP bundle strategy, the number of cases quickly began to • Giving preventive treatment for peptic ulcer disease decline, particularly when ventilator pathway order (VPO) sheets • Providing preventive treatment for blood clots were introduced. VPO sheets are standardized, evidenced-based orders that support the VAP bundles. Additional decreases in the Most hospitals also use one or more of these additional elements number of VAP cases are linked to the reinforcement of process as part of VAP prevention: measures beginning in 2005. • Performing rapid shallow breathing index testing or Two critical care or coronary care units have been VAP free spontaneous breathing trials for at least two years, two additional units have reported no • Following stringent oral care protocols cases in three years, and the ICU at Community Hospital East • Keeping tight control over the patient’s blood glucose levels in Indianapolis has been completely VAP free since December 2003, as shown in Figure 2. CHN’s formula for success in battling VAP is unique among Achieving these milestones was a motivating force for other leading hospitals, according to Theresa Murray, network clini- units in the network and helped solidify a culture of reliability. cal nurse specialist for critical care for CHN. She explains that at the network’s hospitals, nursing staff members “own” the responsibility for a patient’s comfort and mobility. As such, the Figure 1—VAP Eradication in Seven Critical Care hospitals do not employ the concept of a “sedation vacation” or Units turning off a patient’s comfort medication to the point that he or she becomes agitated and uncomfortable. The other unique ele- 6.00 ment to the network’s VAP bundle involves using a continuous circuit for a patient’s ventilator breathing tube. The network has 5.00 +3s successfully implemented several techniques that help maintain 4.00 a closed circuit with the breathing equipment, which reduces Ratio (Per 1000) +2s the chance of introducing harmful bacteria that could eventually 3.00 cause a patient to develop VAP. +1s 2.00 Linking Process Measures to Outcomes Mean 1.00 Early in the network’s campaign against VAP, leaders came to –1s understand that it was crucial to build frequent bedside process 0.00 10/01/2004 01/01/2003 04/01/2003 07/01/2003 10/01/2003 01/01/2004 04/01/2004 07/01/2004 01/01/2005 04/01/2005 07/01/2005 10/01/2005 01/01/2006 04/01/2006 07/01/2006 10/01/2006 01/01/2007 04/01/2007 measures into the system as a feedback loop for patient caregiv- ers. “We very strongly believe that this particular outcome [cases of VAP] is a bedside-caregiver-sensitive outcome. It really is about the staff understanding the linkage between process mea- sures and the outcome measures,” says Murray. 6.00 5.00 A prime example of such a process measure is keeping the ven- Network tilated patient’s head elevated to 30 degrees; this links directly VPOS 4.00 Ratio (Per 1000) Reinforcement to the outcome—the number of cases of VAP. CHN leaders of metrics and 3.00 including Murray looked at all of the staff members who “touch” bedside staff education ventilated patients, such as the radiology technician who may 2.00 Mean take chest X-rays. That technician needs to understand the criti- cal importance of leaving the patient with the head of the bed 1.00 elevated at 30 degrees, explains Murray. She recalls asking the 0.00 question, “Who else touches the patient?” over and over again 10/01/2004 01/01/2003 04/01/2003 07/01/2003 10/01/2003 01/01/2004 04/01/2004 07/01/2004 01/01/2005 04/01/2005 07/01/2005 10/01/2005 01/01/2006 04/01/2006 07/01/2006 10/01/2006 01/01/2007 04/01/2007 to ensure that all caregivers who come in contact with ventilated patients clearly understand the importance of the 30-degree rule. Murray believes that when staff members view their perfor- Once the hospitals in Community Health Network began implementing the VAP bundles mance as a process measure and can see that their performance in their critical and coronary care units, the number of cases of this deadly infection dropped dramatically. Further gains in the battle against VAP were realized when the importance of metrics and bedside education was reinforced beginning in fall 2005. The American Society for Quality Page 2 of 4
  3. 3. a single-attention resource and can only think about one thing As Dr. Glenn Bingle, network vice president for medical and academic affairs, explains, “Once you have a unit that’s reached at a time, so there is a tendency to have a slip-and-lapse type perfection, nobody can deny that it can happen. When you’ve error. When we work in groups we look out for each other so overcome that barrier and staff see that you’ve gone for an entire the probability of a lapse becomes much smaller,” states Clapper. year without a case of VAP, then it sets the bar for others.” Interestingly, these concepts come from the nuclear power indus- try. It’s estimated that at one time nearly 70 percent of nuclear Adding a New Piece to the Puzzle—The People Bundle power equipment failures were actually human error issues that eventually showed up in a piece of equipment, perhaps in the While the hospitals’ early work centered on the process, or way it was designed, maintained, or operated. “what” to do to reduce VAP, in the past year the campaign has grown to include the human factor to help staff more reliably Bingle says that some of the people-bundle concepts, such as perform that “what.” After a long history of working with root coaching, were already in practice but now are given a greater cause analysis, Bingle says network leaders felt there was room focus. He sees the value of the people bundle as it encourages for improvement in the area of human factor analysis when look- staff to ask questions such as, What did you change? What did ing at the root causes of serious events of harm. In 2006, CHN you do to get that to be so reliable? “The main thing is getting began a relationship with Healthcare Performance Improvement the accountability loop hard-wired so the system is continually (HPI), a consulting group based in Norfolk, Virginia. With HPI’s guidance, CHN began working to improve the culture of patient reinforcing that. If you don’t, then performance can start safety by focusing on staff accountability and reliability. slipping back to previous outcome measures,” notes Bingle, who oversees clinical quality throughout CHN. The network’s hospitals are now tackling patient safety issues and learning how to help staff improve their abilities to prevent Reinforcing the Cultural Change errors and reduce the number of events that could involve harm to patients, such as VAP. In 2007, the concept of using “people Looking back on the tremendous strides made in the network’s bundles” to support the VAP bundles began to take shape. The campaign against VAP in the past 10 years, CHN leaders point people bundle is simply a set of habits and practices that help to three key factors: prevent errors. “Helping the individual practitioner become more effective makes clinical bundles [such as the VAP bundle] more • Collecting and sharing data with staff consistent and accurate,” notes Craig Clapper, senior partner and • Communicating senior leadership support of the campaign chief operating officer at HPI. • Celebrating success Table 1 details several error-prevention techniques that CHN When the first unit in the network recorded 30 consecutive days staff members now practice. A key element of the people bundle with no cases of VAP, every staff member in that unit received is the STAR technique, which encourages employees to stop for a free movie ticket enclosed with a handwritten note of con- a second, think before they act, and review. Clapper, an ASQ gratulations from senior leaders. “When you are asking people to Certified Quality Manager, says that cross-monitoring or peer change their practice and then they do that, it makes a difference checking is another vital piece of the people bundle. “People are to then reward and celebrate that. It continues to reinforce those Figure 2—Community Hospital East Intensive behaviors,” Bingle explains. Care Unit, Rate of Ventilator-Associated Pneumonia Table 1—Safety Behaviors for All Staff at Community Health Network 6.00 I commit to . . . 5.00 By practicing . . . (error prevention technique) (safety behavior) Support the team Peer checking and peer coaching 4.00 +3s Ratio (Per 1000) Attention on task Self-checking using STAR (stop, think, act, and review) • Reflect and verify 3.00 +2s • Know and comply with red rules, protocols, policies, and Focus on best procedures 2.00 practice +1s • Speak up using ARCC (ask a question, request a change, voice a concern, chain of command) 1.00 Mean • Three-way repeat back and read back • Clarifying questions 0.00 Effective • Phonetic and numeric clarifications 01/01/2003 04/01/2003 07/01/2003 10/01/2003 01/01/2004 04/01/2004 07/01/2004 10/01/2004 01/01/2005 04/01/2005 07/01/2005 10/01/2005 01/01/2006 04/01/2006 07/01/2006 10/01/2006 01/01/2007 04/01/2007 07/01/2007 10/01/2007 01/01/2008 communication • Handoff communication format • SBAR (situation, background, assessment, and request) communication format Community Health Network-Indianapolis Developed by the staff safety behavior task force of Community CHE ICU (2ST) Rate of Ventilator-Associated Pneumonia by Quarter Hospital North and the Indiana Heart Hospital The American Society for Quality Page 3 of 4
  4. 4. References Leaders at CHN are hopeful that the success of VAP bundles of care supported by the people-bundle concept can apply to 1. Resources used to determine the $22,000 estimate included: other areas of healthcare. Bingle says the key is in understanding how to transition the behaviors and passion that went into the D.K. Warren, et al., “Outcome and Attributable Cost of VAP effort to other process bundles that can equally influence Ventilator-Associated Pneumonia Among Intensive Care Unit patient outcomes. He notes that while they don’t have the magic Patients in a Suburban Medical Center,” Critical Care Medicine formula for this, the network is working intensely in the areas of 31, no.1 (2003): pp. 312-3. sepsis and glycemic controls. J. Rello, D.A. Ollendorf, G. Oster, M. Vera-Llonch, L. Bellm, Bingle and other senior leaders at CHN understand that achieving R. Redman, M.H. Kollef, “Epidemiology and Outcomes of VAP positive results such as those demonstrated in the VAP campaign in a Large U.S. Database,” Chest 122 (2002): pp. 2115-21. takes cultural change. He explains that in the healthcare field it’s especially difficult to change people’s behaviors unless you C.S. Cocanour, et al., “Cost of Ventilator-Associated Pneumonia convince staff that what they’ve been doing for years might be in a Shock Trauma Intensive Care Unit,” Surgical Infections 6 tweaked a little for improvement. “It’s important to imbed those (2005): pp. 65-72. behaviors that you want to be different and create an infrastructure with processes, protocols, and reliability built into the culture to M.N. Kollef, et al., “Epidemiology and Outcomes of Healthcare- create a safety net for staff to be successful,” states Bingle. Associated Pneumonia: Results From a Large U.S. Database of Culture-Positive Pneumonia,” Chest 128 (2005): pp. 3854-62. For More Information About the Author • To learn more about Community Health Network, visit the organization’s Web site: Janet Jacobsen is a freelance writer specializing in quality and • For the latest strategies on healthcare improvement, visit the compliance topics. A graduate of Drake University, she resides Institute for Healthcare Improvement’s Web site at in Cedar Rapids, Iowa. • Additional information about quality tools in the healthcare setting is available through ASQ’s Healthcare Division: • To access patient safety, research reports, or quality improvement tools for healthcare settings, go to the Agency for Healthcare Research and Quality Web site: • For further information about the work of Healthcare Performance Improvement, visit the organization’s Web site: • Contact Dr. Glenn Bingle at or Theresa Murray at or at 317-355-4258 for further information on Community Health Network’s VAP campaign. The American Society for Quality Page 4 of 4