Last week, the National Quality Forum’s National Priorities Partnership came together to talk about creating and sustaining successful multidisciplinary teams within healthcare organizations to further patient safety. One organization, The Children’s Hospital at Providence (Anchorage, Alaska), shared its story about how it strove toward eliminating central line infections in the NICU (Neonatal Intensive Care Unit).
Wendy Vernon, M.P.H., senior director, National Priorities, National Quality Forum, gave an overview of her organization’s efforts in last fall to give input to the Department of Health and Human Services (HHS) to make the National Quality Strategy for Quality Improvement in Health Care (NQS) more actionable through:
- Identification of goals and measures
- Recommendation of strategic opportunities
- Consensus across key leaders about where they should drive their organizations
Part of the purpose of NQS is to make patient safety a priority, Vernon said. “Specifically for the Partnership for Patients goals, they have identified some targets in terms of aiming to reduce hospital-acquired conditions by 40 percent [compared to 2010], which is a pretty ambitious goal,” she said.
Other goals for Partnership for Patients, a public-private partnership to help improve the quality, safety, and affordability of healthcare put forward by the Obama Administration, include reducing preventable hospital admissions and readmissions, and reducing harm from inappropriate or unnecessary care. By the end of 2013, Vernon said, the goal is for preventable complications during a transition from one care setting to another to decrease so that all hospital readmissions can be reduced by 20 percent.
Vernon also laid out nine areas of focus for the Partnership for Patients program:
- Catheter-associated urinary tract infections (CAUTI)
- Central line-associated blood stream infections (CLABSI)
- Injuries from falls and immobility
- Adverse drug events
- Obstetrical adverse events
- Pressure ulcers
- Surgical site infections (SSI)
- Venous thromboembolism
- Ventilator-associated pneumonia (VAP)
Although Vernon said there is no “silver bullet,” to improving patient safety, a key to achieving these goals is to engage leadership and listen to patients and families and work together. “We cannot work in isolation,” said Vernon.
Case Study: The Children’s Hospital at Providence NICU/Pediatrix Medical Group
To exemplify how multidisciplinary teams can come together in real practice, The Children’s Hospital at Providence NICU (Anchorage, Alaska), along with the Pediatrix Medical Group, a Sunrise, Fla.-based pediatric subspecialty physician services company, shared its story about how it worked toward eliminating central line associated blood stream infections (CLABSI) in the NICU. This collaborative effort earned The Children’s Hospital at Providence the 2010 John Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety.
In 2002 and 2003, the collaborative analyzed what could prevent CLABSI, and from 2004 to 2006, the collaborative focused on the implementation, enforcement, and auditing of best practice protocols and policies, such as hand hygiene, full barrier precautions, line care, and more.
Jack Jacob, M.D., staff neonatologist, Pediatrix Medical Group, said that focusing on evidence-based practices was the key to this collaborative’s success. “There is a lot of evidence here that tiny premature babies have immune deficiency,” he said. “We had to overcome this in creating the mental model that central line infections were preventable, and one of the ways we did this is to share with our staff sepsis free days and bringing daily attention to this issue amongst our staff.”
Starting in 2005, The Children’s Hospital at Providence participated in the Vermont Oxford Network “Your Ideal NICU” program, which was a collaborative of 12 NICUs around the state. Jacob said that one of the things his team learned was the importance of microsystem principles to improve care. From a series of nine articles entitled “Microsystems in Health Care” published in Joint Commission Journal on Quality and Safety" (2002-2003), the concept of a microsystem, which is any kind of small unit within a hospital or an outpatient setting that is considered part of a macrosystem (the hospital), was set forth. The articles pointed out that the outcome of a macrosystem can be no better than the outcomes of the many microsystems of which it is composed.
“We tried to develop a rich information environment,” said Jacob. “We kept a detailed database on every case of sepsis. We analyzed and learned from the data. We used concept of web of causation to understand the many contributors of sepsis, and we had a lot of reflective, informal conversations with nursing and other staff around the NICU and we learned from these conversations.”
“We had brainstormed all the list of contributing [causes] of our line sepsis,” added Debra Sims, R.N., clinical supervisor, Children's Hospital at Providence. “We have an interdisciplinary and professional practice team of nurses, practitioners, educators, physicians. They came up with this list.”
By implementing practice-based principles, the collaborative was able to decrease its CLABSI rate by 60 percent in the 2004 to 2006 time period. One of the most valuable tools employed by the collaborative was regular reflective conversations, or as Sims called them, “fireside chats,” which were critical in developing an ownership culture.
“Through reflective conversations with the nursing staff we learned that priming IV fluid at the bedside by the nurse was not working, so we got creative and tested a hypothesis that making certain changes would help,” said Sims. The hypothesis was tested by giving the priming IV fluid task to nurse externs, student nurses who had completed sterile process education in school. By giving this task to a limited group of people, it decreased variation around IV fluid change times, said Sims. The externs came up with a playbook for priming lines with photos and directions, which then led to further standardization.
Jacob pointed out that to lead change in an organization, and getting “buy-in” is the wrong way to do that. He said that the concept of ownership is the way his organization worked towards change management. He said that it’s important for project leaders to make an effort to involve all the people as early as possible that will be involved later on in the implementation, so there is no need for buy-in for the simple reason that there is already ownership.
“One part that isn’t talked about is your physician culture,” said Jacob. “Physicians are really socialized to do individualized patient care, whereas what’s called for now is more group decision-making and process improvement. There’s a real cultural shift involved in how physicians view their work and then developing a learning culture in the day-to-day work you do.”
