Aim for safety of planes, nu­clear plants

Modern Healthcare - - Front Page - Dan Wolter­man and Dr. M. Michael Shabot

Hos­pi­tals should aim to be­come high-re­li­a­bil­ity or­ga­ni­za­tions

Ev­ery­one counts on high-re­li­a­bil­ity or­ga­ni­za­tions to en­sure their safety when fly­ing on com­mer­cial air­lines or trav­el­ing near nu­clear power plants. Air traf­fic con­trol, nu­clear sub­marines, nu­clear air­craft car­ri­ers and naval avi­a­tion all have well-de­served rep­u­ta­tions for high­re­li­a­bil­ity op­er­a­tion.

But can hos­pi­tals be eval­u­ated by HRO stan­dards? In gen­eral, the an­swer seems to be no, be­gin­ning with the In­sti­tute of Medicine’s 2000 pub­li­ca­tion of To Err is Hu­man and con­tin­u­ing to the 2010 re­port by HHS’ in­spec­tor gen­eral’s of­fice that 13.5% of Medi­care ben­e­fi­cia­ries suf­fer a pre­ventable se­ri­ous ad­verse event dur­ing hos­pi­tal stays.

In 2006, the Me­mo­rial Her­mann Health­care Sys­tem in Hous­ton em­barked on a quest to be­come an HRO. The high-re­li­a­bil­ity pro­gram is a key el­e­ment of Me­mo­rial Her­mann’s drive to pro­vide “Best of the Best” care and be ranked in the up­per few per­centiles of all health sys­tems in the coun­try. The Me­mo­rial Her­mann sys­tem has nine acute-care hos­pi­tals, in­clud­ing an aca­demic med­i­cal cen­ter, a chil­dren’s hos­pi­tal, two re­ha­bil­i­ta­tion hos­pi­tals, 19 am­bu­la­tory surgery cen­ters and 100 am­bu­la­tory lo­ca­tions.

The HRO pro­gram is called “Break­through in Pa­tient Safety,” or BIPS. En­gi­neers and other ex­perts from nu­clear power, com­mer­cial avi­a­tion and other HROs trained all health sys­tem em­ploy­ees to per­form tasks in a safe, highly re­li­able man­ner. Among other safety be­hav­iors, em­ploy­ees were trained to take a one-sec­ond stop be­fore tak­ing an ac­tion, be­cause a onesec­ond stop has been proven to re­duce er­rors by 90%. That be­hav­ior is called STAR for Stop, Think, Act and Re­view.

BIPS was re­quired for ev­ery­one, so even­tu­ally 20,000 em­ploy­ees re­ceived train­ing. New in­ter­nal goals re­warded 100% com­pli­ance with CMS/Joint Com­mis­sion core mea­sures and 0% oc­cur­rences of hos­pi­tal-ac­quired in­fec­tions, pa­tient-safety in­di­ca­tors and hos­pi­ta­lac­quired con­di­tions, also called “never events.” HRO meth­ods were ap­plied to blood sam­pling and blood ad­min­is­tra­tion. Check- lists were im­ple­mented in all in­ten­sive-care units and op­er­at­ing rooms. Me­mo­rial Her­mann worked with the Joint Com­mis­sion’s Cen­ter for Trans­form­ing Health­care to rad­i­cally im­prove hand hy­giene.

In 2010-11, the re­sults of these ini­tia­tives be­came ap­par­ent. Zero cases of blood in­com­pat­i­bil­ity (trans­fu­sion re­ac­tion) oc­curred from Jan­uary 2007 to present among a pop­u­la­tion of 867,000 ad­justed ad­mis­sions, 4.3 mil­lion days of care and nearly 500,000 trans­fu­sions. Sev­eral hos­pi­tals had gone for years with­out a ven­ti­la­tor-associated pneu­mo­nia or a cen­tral-line-associated blood-stream in­fec­tion. Se­ri­ous med­i­ca­tion er­rors de­creased to zero most months while nearly a mil­lion med­i­ca­tions per month were be­ing ad­min­is­tered. Many of our hos­pi­tals had gone a full year with­out the oc­cur­rence of a par­tic­u­lar HAI, PSI or HAC.

A new award, the Me­mo­rial Her­mann High Re­li­a­bil­ity Cer­ti­fied Zero Award, was cre­ated to honor hos­pi­tals go­ing 12 months be­tween ad­verse events. Blood in­com­pat­i­bil­ity and air em­boli were ex­cluded be­cause they had long since achieved HRO sta­tus. In April 2011, 28 re­cip­i­ents of Cer­ti­fied Zero Awards were an­nounced.

Prior to the BIPS ini­tia­tive, these HAIs, PSIs and HACs were oc­cur­ring al­most monthly in Me­mo­rial Her­mann hos­pi­tals. The Cer­ti­fied Zero Award has crys­tal­lized Me­mo­rial Her­mann’s de­ter­mi­na­tion to be­come a high­re­li­a­bil­ity or­ga­ni­za­tion in all re­spects, pro­vid­ing safe and efficient care to ev­ery pa­tient and fam­ily. In 2011, the Me­mo­rial Her­mann board adopted a sim­ple mantra: “Pa­tient safety is our core value.” Me­mo­rial Her­mann’s staff and physi­cians are work­ing ev­ery day to live up to that stan­dard. Dan Wolter­man is pres­i­dent and CEO of Me­mo­rial Her­mann Health­care Sys­tem. Dr. M. Michael Shabot is the sys­tem’s chief med­i­cal of­fi­cer. Edi­tor’s Note: A longer ver­sion of this col­umn is avail­able at mod­ern­health­



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