Back Row, From Right: Michael LeRoy, CIO, DMC; Thomas Malone, M.D., President, Harper University Hospital and Hutzel Women's Hospital; Valerie Gibson, COO, Harper University Hospital and Hutzel Women's Hospital; Mirjana Lulic-Botica, Clinical Pharmacist Specialist, Harper University Hospital and Hutzel Women's Hospital. Front Row, From Right: Lisa Gulker, Director, Patient Services, Harper University Hospital and Hutzel Women's Hospital; Patricia Natale, CNO, DMC; Kathleen McLaughlin, Clinical Nurse Specialist, Hutzel Women's Hospital

When executives at the 2,000-bed Detroit Medical Center (DMC) agreed to spend $31 million on an EMR and roll it out across eight hospitals in 13 months, no one blinked. That's because the health system had in place a culture focused on collaboration, continuous quality improvement, and technology-facilitated innovation.

But when the decision to implement closed-loop medication administration came up, a number of thorny issues arose, specifically with regard to its implementation in the neonatal intensive care unit (NICU) at Hutzel Women's Hospital. (That facility, together with Harper University Hospital, forms a key anchor within DMC's downtown campus; combined, the two encompass 685 beds.) As is the case at NICUs nationwide, clinicians faced multiple obstacles in implementing barcode-scanning-based medication administration for its smallest patients. Hutzel has neonates who can weigh less than 1 pound, so working with standard-sized barcodes is impossible.

“For me, this was a show-stopper; we just had to figure out with a core team how to do this,” says Valerie Gibson, R.N., who at the time was vice president of patient care services, Harper-Hutzel Hospitals (since then, Gibson has been promoted to chief operating officer for Harper-Hutzel). “So we launched a sub-project to make this work,” she says, adding that a major challenge was executing the project while simultaneously launching an EMR across its facilities.

And Lisa Gulker, R.N., director of clinical transformation at Harper-Hutzel, adds, “There wasn't an automatic assumption that it was doable.”

If it was deemed doable, it would have to be doable for all patients, according to Michael LeRoy, senior vice president and CIO of Detroit Medical Center. He explains that, “As part of the EMR launch, DMC made a conscious decision to include not only physician orders and a whole list of capabilities, but also medication scanning. And if we did medication scanning, it was not only going to be for our adult patients at Harper-Hutzel, but also for our NICU patients, because that population needed to be safe just like our adult population.”

As a result, everyone went to work, with teams led by LeRoy and Gulker. It quickly became clear that the patient band itself was a big obstacle to overcome. It needed to be small enough for premature ba bies, and had to be composed of materials suited for the humid climate and other special conditions of the neonates' isolettes. Fortunately, IT professionals and clinicians were able to work together through several iterations until they had designed a patient wristband for the neonates that met all requirements.

The IT group's work on the wristband was reinforced by other innovations, including the implementation of wireless scanners. As it turned out, using corded barcode scanners was simply too complicated for the NICU, giving rise to physical-use challenges (reaching over and around objects) and infection-control issues.

Many issues had to be dealt with, notes Kathleen McLaughlin, N.N.P., an advanced practice nurse who worked on the project. “There are special issues in the NICU,” she points out, “including the fact that patient bands used there have to withstand the humidity in the isolettes; the fact that our term babies suck on their wrists and their feet, so the bands have to withstand that element; and they have to withstand what we call the ‘pee-and-poop’ test. So we did a three-week trial here, trying out various test bands.”

LeRoy with workstation

Ultimately, the solution that worked best in the NICU - the use of two-dimensional barcodes, leveraging an “Aztec” barcode design - was implemented system-wide.

At the same time, clinicians in the NICU worked with the organization's clinical pharmacists and IT staff members to develop order sets and other elements related to dosaging.

Neonatal clinical pharmacist Mirjana Lulic-Botica, R.Ph., explains how it all began. “It really started with the order sets the physicians were going to use,” she says. “We almost wanted a separate catalog for the NICU.”

And, referring to the broad range of potential medication problems, she adds, “We didn't want anything that would cause problems with inappropriate product picks. So I had the opportunity to work with Kathleen (McLaughlin) on building order sets. We didn't even know at first what the system would look like, so we started by using Word texts. So Kathleen and I and our teams developed initial order sets based on disease state,” and then worked with the neonatologists and pharmacists on staff to build files, create the medication ordering system, and interface the various system elements.

Patricia Natale, R.N.

The result? “We've eliminated many different kinds of errors that once occurred across the system, but especially in the neonatal area,” Lulic-Botica reports.

One key element, from the pharmacy standpoint, is that the organization can now package and label every medication possible in clearly marked dosages. “We want to make sure that the final product the nurse has is ready to go, in terms of its ability to be attached to a feeding tube or otherwise administered.”

Lulic-Botica and her colleagues have thus measured, labeled and barcoded medications to an extraordinary extent, and have taken the additional step of color-coding labels, so that all medications destined for the NICU have blue barcoded labels on them, while those for adult patients have white.

Such intensive work on the pharmacy side means, “We've eliminated the decimal-point errors, the dosaging errors,” that still plague most NICUs. And when combined with the system-wide EMR/CPOE implementation (using Kansas City, Mo.-based Cerner Corporation), Lulic-Botica says the organization is also benefiting from the elimination of transcription and communication errors and clinical decision support capabilities.

At the same time, McLaughlin points out that the entire initiative “forced us to standardize our practices,” to achieve a single standard across all four NICUs in the Detroit Medical Center system. From the beginning, McLaughlin says, “We agreed that we would establish one standard of care, and it would be evidence-based.”

Clinicians must drive

It is very important to consider the magnitude of what has been done and why at Detroit Medical Center, says Thomas Malone, M.D., who became president and CEO of Harper-Hutzel last September. Malone, who for years practiced as a neonatologist, says the real breakthroughs in patient safety come with the implementation of comprehensive systems such as EMR and CPOE. It is that kind of innovation that has made DMC a safer place for patients, he says, noting that recent high-profile cases have made the public more aware of patient safety risks.

Of course, Malone says, “We were planning to do this completely apart from the headlines anyway. This was a part of our development of a system-wide standard of care. But what has amazed me has been talking to other executives from other hospitals that have physician order entry and scanning at the bedside, but they haven't linked those systems. And the reason they haven't done so is because of the difficulty involved.”

What's clear at DMC is that LeRoy takes a team approach to everything, including working hand-in-hand with the clinician leaders.

Malone says that such an approach pays dividends. “What made this (initiative) so successful is that it was a clinically driven project supported by a strong IS team,” he says. “At the end of the day, everything done was done to support our clinical vision. And that's why all of our clinicians bought into the implementation, because they knew it was IS supporting our clinical practice as opposed to IS handing them implementations.”

Malone adds, “Mike (LeRoy) is very supportive. What he does with his team is that he sits down with you and figures out a way to support the rest of the hospital.”

Sidebar

A First-Hand Look at Innovation

In a visit this February to the Detroit Medical Center, one thing was exceptionally clear: the culture of the organization is one of true teamwork, collaboration, the tearing down of silos and unnecessary hierarchies. Additionally, DMC prizes evidence-based clinical practice, constantly striving for improvement in care quality, patient safety, and caregiver efficiency and effectiveness.

Just ask Lisa Gulker, R.N., director of clinical transformation at Harper University Hospital/Hutzel Women's Hospital, the clinician who helped lead the EMR/CPOE/medication administration initiative at Detroit Medical Center. Asked about the success of the initiative, she points out that Harper-Hutzel CEO Thomas Malone, M.D., Detroit Medical Center CIO Michael LeRoy, CNO for Harper-Hutzel Patricia Natale, R.N., and then-vice president of patient care services Valerie Gibson, R.N., (now COO for Harper-Hutzel) were hands-on during the rollout of the core clinicals implementation. Those four executives “sat with super-users twice a day for two weeks at every one of our eight sites, which meant that they were working 14-hour days during that period,” Gulker points out. “That said to the staff this was really, really important. And it's a level of commitment which I don't know if hospital staffers see in many places.”

What's more, adds Kathleen McLaughlin, N.N.P., an advanced practice nurse at Hutzel Women's Hospital who worked on the project, “That involvement helped very much with bringing out the lessons learned” in the initiative. Those four executives “asked what we had learned during the rollout, and what we could change.” Further, when the other three DMC NICUs rolled out the initiative following Hutzel's go-live, “We built on that, so it was very much a team approach.”

None of this team spirit is accidental, says Natale. “The culture of the DMC really folds over into how we do clinical transformation. The commitment we have is to present to the clinician information that is living, in the EMR, and appears for the clinician at the point of care. It's really all about patient care, patient safety, and ever-increasing excellence.”

In fact, she says, “As we get better and better in terms of using these clinical information systems, we ought to know with increasing certainty that what we produce is what we need to produce. And that's what energizes all of us. We want to be known as the place for patient safety, predictable excellence, and the quality of the practice environment.” Not surprisingly, the DMC folks are using performance improvement methodologies - including Lean management and Six Sigma - to improve care quality, patient safety, and clinician workflow/efficiency.

IT has a critical role to play in all this, says CIO LeRoy. “We're here to facilitate what the clinicians need to do, to advance them to where they need to go. And in order to do that, it requires a three-legged stool of collaboration among physicians, other clinicians, and IT. As it turns out, we in IT are always sitting at the table in important meetings. We want to hear their requirements and help them accomplish what needs to be accomplished.”

Put simply, CEO Malone says, “The reason it works is because the culture here is a team culture and multidisciplinary. And the only reason this works is because of doctors, nurses, and pharmacists all working together. The end point of this project, in particular, was improved patient safety around medication administration. At the end of it, for me, as a neonatologist, there's nothing better than feeling that patients are safer.”

And while it might be easy to talk about team culture and multidisciplinary collaboration, those priorities are having an effect on nurse recruiting at DMC. COO Gibson hosts breakfast every month for nurse new-hires. “When I ask them how things are going, one of the first things they mention is the electronic medical record. A few months ago, I had 25 of them in the room together and, as a group, they basically said, ‘We came to the DMC because you have an EMR. Many hospitals advertise in the newspaper that they're electronic, but they don't even have CPOE.’ Over and over they're telling us in these new-hires breakfasts that our EMR, CPOE, and nursing documentation capabilities are a major reason they're coming to work here.” - M.H.

Healthcare Informatics 2009 April;26(4):28-33