Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care

Last week the Institute for Healthcare Improvement (IHI) released a white paper describing current frameworks of providing patient centric care. Within the document is also an assessment of primary and secondary drivers as well as descriptions of practices at exemplar organizations.

This IHI white paper can be download here.

The following are excerpts from IHI's document description:

In response to growing interest from the hospital community in better understanding and improving the experience of patients and their families during hospitalization, the Institute for Healthcare Improvement (IHI) conducted an in-depth review of the research, studied exemplar organizations, and interviewed experts in the field. Our aim was to identify the primary and secondary drivers of exceptional patient and family inpatient hospital experience (defined as care that is patient centered, safe, effective, timely, efficient, and equitable), as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey’s “willingness to recommend” the hospital.


The project identified five primary drivers of exceptional patient and family inpatient hospital experience of care: leadership; staff hearts and minds; respectful partnership; reliable care; and evidence-based care.

Berwick Testifies to the Senate Finance Committee

On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.

The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945

Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf

Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf

Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf

Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx

Ventilator Bundle Adjusted: Daily Oral Care with Chlorhexidine

The following was posted on the IHI website regarding adjustments to the ventilator bundle made in May 2010. You can read the update (as well as implementation tips) in its entirity here.

You can read the updated description of the IHI Ventilator Bundle here: here



Daily Oral Care with Chlorhexidine
IHI added this element to the Ventilator Bundle in May 2010 following continued review of the literature and use of the element in the IHI Ventilator Bundle in Scotland for over a year. The recommended chlorhexidine solution strength is 0.12%.

Dental plaque biofilms are colonized by respiratory pathogens in mechanically ventilated patients. Dental plaque develops in patients that are mechanically ventilated because of the lack of mechanical chewing and the absence of saliva, which minimizes the development of biofilm on the teeth. Dental plaque can be a significant reservoir for potential respiratory pathogens that cause ventilator-associated pneumonia (VAP). Chlorhexidine antiseptic has long been approved as an inhibitor of dental plaque formation and gingivitis. As early as 1996, DeRiso and colleagues published a study that provided evidence to support the use of 0.12% chlorhexidine oral rinse as a prophylactic measure to reduce nosocomial respiratory tract infections in cardiac surgery patients. [1]

Since that time there has been much discussion about the utilization of chlorhexidine as an important adjunct to oral hygiene, but there have been few studies published that provide firm evidence that the use of chlorhexidine as a decontamination antiseptic reduces the incidence of ventilator-associated pneumonia. Chlorhexidine has been studied in two strengths: 0.12% and 0.2%. The US Food and Drug Administration recommends 0.12% oral chlorhexidine for use as mouth rinse. In a meta-analysis published in 2007 by Chan and colleagues in the British Medical Journal, eleven studies were evaluated for effect of oral decontamination on the incidence of ventilator-associated pneumonia and mortality in mechanically ventilated adults. Results of that analysis concluded that oral decontamination of mechanically ventilated adults using chlorhexidine is associated with a lower risk of ventilator-associated pneumonia. [2]

There is little if any evidence of other oral care processes having an effect on the development of VAP, but it makes sense that good oral hygiene and the use of antiseptic oral decontamination reduces the bacteria on the oral mucosa and the potential for bacterial colonization in the upper respiratory tract. This reduction in bacteria has been shown to reduce the potential for the development in ventilator-associated pneumonia for patients on mechanical ventilation.

References:

1. DeRiso AJ, Ladowski JS, DillonTA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109:1556-1561.
2. Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. British Medical Journal. 2007;10:1136.

Additional Reference:
Munro CL, Grap MJ, Jones DI, McClish DK, Sessler CN. Chlorhexidine, tooth brushing and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care. 2009 Sep;18(5):428-437.

Thoughts on Pay-for-Performance

IHI Open School posted this video on their blog yesterday. It is very thought provoking.

The title of this RSA Animate is: Drive: The surprising truth about what motivates us. It is based on a talk by Dan Pink.

(note: This is a youtube video. If you don't see anything below, it is probably being blocked)

HCA achieved >96% Healthcare Worker Flu Immunization!!!

At the March 2010 meeting of the 5th Decennial International Conference on Healthcare Associated Infections, the Hospital Corporation of America reported that they were able to achieve >96% healthcare worker vaccination for seasonal influenza.

The Institute for Healthcare Improvement posted the powerpoint presentation on its website yesterday. You can find it here: http://www.ihi.org/IHI/Topics/HealthcareAssociatedInfections/InfectionsGeneral/EmergingContent/ImplementationFluVaccineStrategy.htm

The conference website has posted an abstract. It is copied and pasted below:

Abstract Title: Implementation of a Successful Seasonal Influenza Vaccine Strategy in a Large Healthcare System

Background: As part of a comprehensive seasonal influenza prevention strategy, the Hospital Corporation of America (HCA) implemented a program that required employees who could infect or become infected by a patient to receive the seasonal influenza vaccine or wear a surgical mask in patient care areas. HCA is the nation's largest provider of healthcare services, composed of locally managed facilities that include 163 hospitals, 112 outpatient centers and
368 physician practices in 20 states. The strategy was announced by the corporate CEO and Chief Medical Officer. A core group representing emergency preparedness, infection prevention, human resources, legal, pharmacy, communications, and supply was formed. This core group recommended strategy, provided tools, resources, and regular flu updates for the program. The reason for the program, as well as implementation strategies were relayed in a webcast to all facilities. Non vaccine strategies, such as cough and sneeze etiquette, proper hand hygiene, proper cleaning techniques, and hazards of Presenteeism were also introduced. Human resources policies were changed to accommodate time off needed by employees ill with the flu. Prior to the program, seasonal influenza vaccine rates for the 2008-2009 influenza season varied from a low of 20% to a high of 74% (Mean 58%).

Objective: To review the strategies and outcomes of a comprehensive seasonal influenza prevention program to include vaccination and declination rates.

Methods: Concurrent analysis. Consents and declinations were documented in a corporate wide electronic database.
Results: As of November 1, 2009, 140,599 employees were offered the seasonal influenza vaccination, with 135,584 accepting, or 96%. This correlates to clinical employees (98,067 total with 94,530 accepting.) A total of 5,015 employees declined the seasonal influenza vaccine. Reasons for declination were allergy (12%), contraindicated (7%), Fear (4%), pregnant (1%), religion (3%), and no reason given (73%).

Conclusions: The program resulted in a 65% increase in employee vaccine rates. Vaccine rates at unionized facilities were 95%; in non-unionized facilities they were 97%. A comprehensive vaccine strategy which includes vaccine or surgical mask use is successful in increasing vaccination rates.

IHI Assembles Leadership Resources to Assist with Crisis Management

The Institute for Healthcare Improvement (http://www.ihi.org/) recently assembled a set of resources to assist hospital executives with effective crisis management.

At the core of the resources page is a power point presentation (and soon to be publication) from Jim Conway, Senior VP of IHI, summarizing what a well coordinated crisis management plan would look like when put into action. The page is then peppered with a series of resources and links to other sites describing recent adverse events and how they were handled.

The Jim Conway presentaton is here.

The IHI resource site is here.

AHRQ Tools and Resources to Prevent HAIs.

In early September, the AHRQ released a webpage highlighting research and resources related to the prevention of hospital acquired infections. This is an excellent site that links to tools and resources for both healthcare providers as well as healthcare consumers.

You can find the website here.

Three Indiana Regions Identified as "Low-Cost, High Quality".

The Institute for Healthcare Improvement recently concluded a "How did they do that?" conference where invited healthcare leaders from regions around the US identified as "Low-Cost, High Quality" met in Washington, DC to talk about their experiences.

Although no region from Indiana participated in this meeting, the IHI did publish their methodology in identifying eligible regions. You can find that document here.

Based on their methodology, approximately 70 regions were identified as "Low-Cost, High Quality". The list of regions can be found here.

Three Indiana regions were named in this document. They are:

• Fort Wayne
• Muncie
• South Bend

Opening slides that compare "Low-Cost, High Quality" regions to "all others" from this meeting can be found here.

Maybe the three large Central Indiana health systems can learn a thing or two from the the three Indiana regions above?

IHI Global Trigger Tools (Second Edition)

The IHI recently released a document describing the concept of Global Trigger Tools to identify adverse events that are unreported through the usual voluntary event reporting systems.

The description of the document is here.

...or you can go directly to the document here. You may need to log in to the IHI website to download the document.

In my previous hospital, I was able create a monitoring system that would scan the EMR from the previous day to look for these events. If a person with limited SQL programming skills can do this (via an ODBC connection to the back-end tables of the EMR), you can be sure that EMR vendors in the future will be offering such a module (at a high cost no doubt!).

Having such a global trigger function in your organization via EMR is a great way to add a little more objectivity in what was a voluntary, subjective, and political function in the past.

ISBAR?

The IHI posted a tool from Rhode Island Hospital that they call ISBAR.

At first glance, this appears to be the same as SBAR with I (Identify) inserted at the beginning of the process.

The full text as well as the tool itself can be downloaded from the IHI website at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/ISBARTripTick.htm

You will need to be logged into the IHI website to download the tool.

Carbapenem-Resistant Enterobacteriaceae

The IHI today posted CDC guidelines regarding Carbapenem-Resistant Enterobacteriaceae (CRE) on its website.

You can find IHI post here.
You an go directly to the CDC guidelines here.

Excerpt of IHI posting:

Infection with carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing enterobacteriaceae is emerging as an important challenge in health care settings. This threatens to become a problem akin to MRSA. Institutions must be alert for this and other very resistant organisms (ESBL, CTX producing gram negatives, etc.) and not limit foci to C. difficile and MRSA.

Kaiser Permanente MedRite Program

The IHI recently posted a summary of the Kaiser Permanente MedRite Program. Components of this program to reduce medication errors included:

1. Step-by-step workflow of RNs to administer medications.
2. No Interruption Wear - no one should interrupt the RN wearing the NIW sash unless there is an emergency.
3. Sacred Zone - no one should cross or talk to an RN when they are in this zone marked in front of the area where medications are pulled/prepared.

The description of this program can be found at the IHI website here. The tools of this program (including overview, leadership change package, nurse change package, and project manager package) can be found here. Note that logging into the IHI website is required to access these tools. If you have not yet registered for access to the IHI webpage, you are missing out on a lot of quality improvement resources.

The WHO Campaign for Safe Surgery turns into "The Sprint"

• On June 25, 2008 the World Health Organization launched its "Safe Surgery Saves Lives" campaign.
• On December 20, 2008, Don Berwick calls upon all hospitals participating in the IHI 5 Million Lives Campaign to also participate in "The Sprint" by adding "one more change at a breathtakingly short time" - "adopt and use the WHO Checklist in at least one OR in every hospital in the next 90 days."
• The Indiana Hospital Association recently posted on its "Patient Safety Update" webpage that it is supporting the campaign. "To participate, hospitals need only test the list in one operating room, by one surgical team, one time before April 1." It also says that Indiana is only one of a few states to have committed to testing the checklist.

The scope of the WHO's Checklist for Safe Surgery is broader than the Joint Commission's Universal Protocol to Prevent Wrong Site, Wrong Procedure and Wrong Person Surgery (tm).

Joint Commission's Universal Protocol: Universal Protocol

WHO's Checklist: WHO Checklist

WHO's website (with additional tools and resources): WHO Safe Surgery Website

IHI Campaign website: IHI Campaign Site

How long do you think it will be before the Joint Commission starts to adopt elements of the WHO's checklist?