Recent experience–at first from just a handful of hospitals, but now from hundreds–shows that this pessimism is unfounded. Many kinds of errors can be completely eliminated; “zero defects” is possible. Some hospitals are, for example, achieving once impossible success at eliminating certain kinds of infections and medication errors. There is no reason these successes can’t be widely replicated, maybe everywhere.
In 2000, the Robert Wood Johnson Foundation, in cooperation with the Institute for Healthcare Improvement (IHI), challenged hospitals to apply for grants to help them “pursue perfection” in their safety, reliability, patient focus, waiting times and efficiency. More than 200 hospitals applied; seven were chosen as grantees in what became the Pursuing Perfection Project. After five years, each was still far from “perfect,” but their achievements clearly raised the bar for all U.S. hospitals.
Two of the grantees–Hackensack University Hospital in New Jersey and McLeod Regional Medical Center in Florence, S.C.–used strict protocols and guidelines and automated systems to ensure that nearly 100 percent of all heart-attack patients received needed medications, driving heart-attack death rates down below 5 percent, compared with the U.S. average for Medicare patients of 10 percent. Cincinnati Children’s Hospital Medical Center revolutionized its approach to children with cystic fibrosis and diabetes by giving patients and families much more power to make decisions about their own care, such as adjusting their own medications or creating their own schedules for therapy visits and treatments in the hospital. Complications dropped by 30 to 50 percent.
In Whatcom County, Wash., St. Joseph Hospital used “nurse navigator” coaches (to help coordinate information and plans among physicians and institutions) and a patient-controlled personal health record called the Shared Care Plan for chronically ill patients that defined specific goals and plans that every doctor and nurse involved would abide by. These measures reduced expenses for emergency visits and hospital admissions by an average of $3,000 per patient per year by keeping patients healthy at home. HealthPartners, an integrated-care system in Minneapolis, cut re-admission rates for congestive-heart- failure patients in half by making absolutely sure that medications were correctly prescribed and fully understood by patients every time.
Encouraged by the success of the Pursuing Perfection Project and published scientific studies, the IHI launched the 100,000 Lives Campaign in December 2004 to enlist at least 2,000 U.S. hospitals in an effort to prevent needless in-patient deaths by implementing six proven patient-safety practices that could save an estimated 100,000 lives over 18 months.
What were the practices? Nurses and other hospital workers could call Rapid Response Teams on an emergency basis when they become worried about a patient, instead of waiting for the patient to have a cardiac arrest. Medication Reconciliation processes reduced the chance of errors in medication when patients entered the hospital, were moved from one part of the hospital to another, or when they were discharged. Highly reliable heart-attack treatments (similar to those at McLeod and Hackensack) were put in place. Procedures to reduce the risk of three types of serious, sometimes fatal, infections were implemented. These included bloodstream infections from plastic intravenous catheters, surgical-wound infections and pneumonias associated with mechanical ventilators.
One big idea in the 100,000 Lives Campaign was the “all-or-none” scoring of reliability. For example, a hospital either did everything right for a patient on a ventilator machine, or it scored a “zero.” No partial credit.
The results of the 100,000 Lives Campaign, announced in June 2006, were astounding. More than 3,100 hospitals enrolled–accounting for almost 80 percent of all hospital admissions in the United States. Most introduced more than one of the six changes, and 39 percent instituted all six. Using data submitted by the hospitals, the IHI estimated that approximately 122,000 fewer patients died during the 18-month period of the campaign than would have been expected (IHI emphasizes that it’s not possible to attribute this change to the campaign alone, since many efforts to improve care are now ongoing in the United States). Twenty-four hospitals have gone for a year–and some for two years–without a single case of ventilator-associated pneumonia in their intensive-care units, and 12 hospitals have gone for a year with no cases of central intravenous line infections. The IHI will relaunch the campaign in December, with a new set of changes and goals.
Another major hospital-safety effort is the Keystone Project, which is run by the Michigan Hospital Association (MHA) and Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins University. Under Keystone, 127 intensive-care units in Michigan and five in other states have also dramatically raised the standard of safety. Sixty-eight ICUs totally eliminated blood infections associated with central intravenous catheters. For six consecutive months, they abolished pneumonia in patients on ventilators. Compared with the preceding year, the Keystone team estimates that more than 1,578 lives were saved, reducing hospital days by 81,000 and saving $165 million. Hospitals in Rhode Island, New Jersey and Maryland have taken up the challenge and are replicating the Keystone Project locally. Others will follow.
These projects are raising the bar for everyone. According to the Centers of Disease Control and Prevention, 2 million Americans get hospital infections each year. They do not need to. Rates in Norway and Sweden are nearly zero. Why should we accept as inevitable that patients have to die or suffer from hospital-acquired infections, wrong-site surgery, unreliable heart-attack treatment, medication errors–and myriad other forms of error and unreliability in care–when we can now name hospitals that have eliminated or drastically decreased each of these forms of harm? These hospitals have taken away the excuses. Every hospital–every board, executive and clinician–now has to ask, “If they can, why can’t we?”
The old “benchmarks”–80 or 90 percent success at implementing guidelines and protocols–are no longer acceptable. No one would tolerate cars that started 90 percent of the time, or tax accountants that got 90 percent of the Form 1040 lines right. We consumers demand a whole different level of excellence in those cases. It’s time to expect the same of health care.
