Community Health Network Reduces Deadly Infections Through Culture Of Reliability
Making the Case for Quality
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
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 www.asq.org Page 1 of 4
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
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
a closed circuit with the breathing equipment, which reduces
Ratio (Per 1000)
the chance of introducing harmful bacteria that could eventually
cause a patient to develop VAP. +1s
Linking Process Measures to Outcomes Mean
Early in the network’s campaign against VAP, leaders came to –1s
understand that it was crucial to build frequent bedside process 0.00
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
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
Ratio (Per 1000)
to the outcome—the number of cases of VAP. CHN leaders of metrics and
including Murray looked at all of the staff members who “touch” bedside staff
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
question, “Who else touches the patient?” over and over again
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.
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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
I commit to . . .
5.00 By practicing . . . (error prevention technique)
Support the team Peer checking and peer coaching
Ratio (Per 1000)
Attention on task Self-checking using STAR (stop, think, act, and review)
• Reflect and verify
• Know and comply with red rules, protocols, policies, and
Focus on best
+1s • Speak up using ARCC (ask a question, request a change, voice
a concern, chain of command)
Mean • Three-way repeat back and read back
• Clarifying questions
Effective • Phonetic and numeric clarifications
communication • Handoff communication format
• SBAR (situation, background, assessment, and request)
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 www.asq.org Page 3 of 4
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: www.ecommunity.com. 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 GBingleMD@community.com
or Theresa Murray at email@example.com or at
317-355-4258 for further information on Community Health
Network’s VAP campaign.
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