Spe­cial re­port: Di­verse HENS flock to com­mon safety prob­lems

Hospi­tal en­gage­ment net­works—call them Hens—tasked with am­bi­tious goals for re­duc­ing read­mis­sions and hospi­tal-ac­quired con­di­tions

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On the morn­ing of March 27, a group of 46 qual­ity im­prove­ment pro­fes­sion­als gath­ered in a brightly lit con­fer­ence room on the ground floor of a large ho­tel near Chicago’s O’hare In­ter­na­tional Air­port.

The at­ten­dees, rep­re­sent­ing 18 hos­pi­tals from across the coun­try, were at the event to learn more about how to pre­vent ad­verse events such as pa­tient falls and pres­sure ul­cers, and how to keep their dis­charged pa­tients from be­ing read­mit­ted to the hospi­tal un­nec­es­sar­ily. Over the course of the day, they milled around, mov­ing from one ses­sion to an­other, where, seated around U-shaped ta­bles, they brain­stormed about creative ways to drive im­prove­ment and they stud­ied “blue­prints,” step-by-step vis­ual rep­re­sen­ta­tions of proven best prac­tices.

Ushma Lakhani, a clin­i­cal qual­ity spe­cial­ist at 226-bed Sher­man Hospi­tal in El­gin, Ill., said she came to the meet­ing look­ing for new strate­gies to combat catheter-as­so­ci­ated uri­nary tract in­fec­tions. “Events like this are great be­cause we have the op­por­tu­nity to net­work and share ideas,” Lakhani said.

Lynn Vescio, di­rec­tor of per­for­mance im­prove­ment at 373-bed Jef­fer­son Re­gional Med­i­cal Cen­ter, Jef­fer­son Hills, Pa., listed med­i­ca­tion safety among her hospi­tal’s top pri­or­i­ties.

Lakhani, Vescio and the other par­tic­i­pants are mem­bers of Irv­ing, Texas-based VHA’S hospi­tal en­gage­ment net­work, a col­lab­o­ra­tive group of more than 200 hos­pi­tals work­ing to iden­tify and dis­sem­i­nate best prac­tices.

VHA is one of 26 hospi­tal en­gage­ment net­works, or HENS, cho­sen by HHS as part of its $1 bil­lion Part­ner­ship for Pa­tients ini­tia­tive. An­nounced in April 2011, the part­ner­ship is a far-reach­ing cam­paign, in­volv­ing thou­sands of hos­pi­tals, agen­cies, con­sumer groups and other en­ti­ties in the public and pri­vate sec­tors.

The ini­tia­tive—and the Hens—have two over­ar­ch­ing goals: Re­duce hospi­tal-ac­quired con­di­tions by 40% and pre­ventable all-cause 30day read­mis­sions by 20% by the end of 2013, us­ing data from 2010 as a base­line. Reach­ing those tar­gets, HHS says, could re­sult in 1.6 mil­lion fewer read­mis­sions, 1.8 mil­lion fewer pa­tient in­juries and 60,000 lives saved over the next three years. HHS also pre­dicts Part­ner­ship for Pa­tients could save Medi­care as much as $50 bil­lion over the next decade.

To those ends, in De­cem­ber 2011, HHS awarded a to­tal of $218 mil­lion in two-year con­tracts—with a third op­tional year—to the HENS, or­ga­ni­za­tions the gov­ern­ment says will serve as “mo­bile class­rooms” and coaches for hos­pi­tals in their net­works, tar­get­ing 10 core ar­eas of fo­cus, such as pres­sure ul­cers, cen­tral line-as­so­ci­ated blood­stream in­fec­tions, ven­ti­la­tor-as­so­ci­ated pneu­mo­nia and ob­stet­ri­cal ad­verse events.

The HENS in­clude state hospi­tal as­so­ci­a­tions, such as the Min­nesota Hospi­tal As­so­ci­a­tion; health sys­tems, such as 76-hospi­tal As­cen­sion Health and 38-hospi­tal Dig­nity Health; and na­tional or­ga­ni­za­tions, such as Premier and the Amer­i­can Hospi­tal As­so­ci­a­tion-af­fil­i­ated Health Re­search and Ed­u­ca­tional Trust.

“HENS are just one part of the much larger ef­fort,” says Dr. Paul Mcgann, co-di­rec­tor of the Part­ner­ship for Pa­tients and chief med­i­cal of­fi­cer for cam­paign lead­er­ship at the Cen­ter for Medi­care & Med­i­caid In­no­va­tion, which over­see the HENS. “We see them as an in­te­gral part of the Part­ner­ship for Pa­tients, which in­cludes na­tional, state and lo­cal part­ners, all work­ing to­gether in con­cert and in syn­ergy to achieve the two aims.”

While many liken the Part­ner­ship for Pa­tients to past col­lab­o­ra­tive ini­tia­tives such as the In­sti­tute for Health­care Im­prove­ment’s 100,000 Lives and 5 Mil­lion Lives Cam­paigns, gov­ern-

ment of­fi­cials and lead­ers from the HENS say this sweep­ing ef­fort goes even fur­ther.

“I don’t think you could iden­tify an­other pro­gram that has tried to achieve these kinds of goals in this time­frame,” says Michael Sil­ver, se­nior vice pres­i­dent of cor­po­rate op­er­a­tions at Health­in­sight, Las Ve­gas, a not-for-profit or­ga­ni­za­tion se­lected by the Ne­vada Hospi­tal As­so­ci­a­tion to work as a sub­con­trac­tor on its HEN.

Keith Kosel, ex­ec­u­tive di­rec­tor of VHA’S HEN ini­tia­tive, echoes Sil­ver, say­ing the Part­ner­ship for Pa­tients is dif­fer­ent in its scale and its at­ten­tion to cul­ture, con­text and “how you en­gage peo­ple to solve prob­lems.”

There is a down­side to set­ting the bar so high. Per­haps not sur­pris­ingly, the ini­tia­tive’s tar­gets sound lofty—and even unattain­able, given the time al­lot­ted—to some in the field. “They’re very, very ag­gres­sive, but hav­ing ag­gres­sive goals drives peo­ple to think about prob­lems in a dif­fer­ent way,” says Dr. Wil­liam Con­way, se­nior vice pres­i­dent and chief qual­ity of­fi­cer of Detroit­based Henry Ford Health Sys­tem.

For its much-lauded No Harm cam­paign, launched in 2007, six-hospi­tal HFHS has tried to re­duce harm by 50% by 2013, Con­way says.

“Whether we hit a nu­mer­i­cal tar­get is not as im­por­tant as whether we make as much progress as we can as quickly as we can,” he says. “That’s a politi­cian’s an­swer,” he added, laugh­ing.

HHS of­fi­cials say they were gal­va­nized by na­tional data show­ing base­line in­jury rates of 145 hospi­tal-ac­quired con­di­tions per 1,000 dis­charges and a na­tional base­line read­mis­sion rate of 14.4%—fig­ures they call un­ac­cept­able. They ar­rived at the pro­gram’s two goals by re­view­ing safety lit­er­a­ture and iden­ti­fy­ing the most suc­cess­ful in­ter­ven­tions and cor­re­spond­ing preven­tion rates, Mcgann says.

“Make no mis­take, these are am­bi­tious goals and achiev­ing them will be very chal­leng­ing,” says Den­nis Wag­ner, the other co-di­rec­tor of the Part­ner­ship for Pa­tients and the In­no­va­tion Cen­ter’s as­so­ci­ate di­rec­tor for cam­paign lead­er­ship. “But we are con­fi­dent that we can do it.”

Dr. Don­ald Ber­wick, for­mer head of the CMS and cur­rent se­nior fel­low at the Wash­ing­ton­based Cen­ter for Amer­i­can Progress, ac­knowl­edges that the CMS drew heav­ily on the work of IHI, Premier and other or­ga­ni­za­tions when craft­ing the Part­ner­ship for Pa­tients.

“The con­cept of col­lab­o­rat­ing with a net­work has be­come stan­dard for the rapid spread of im­prove­ment,” he says.

Ber­wick, who co-founded the IHI and served as its long­time leader be­fore as­sum­ing the top spot at the CMS in 2010, says the ini­tia­tive’s goals are “strin­gent but achiev­able.” The real hur­dle, he con­tends, will be spread­ing pock­ets of suc­cess­ful im­prove­ment across the en­tire coun­try.

“It will be a mat­ter of will,” Ber­wick says. “These tar­gets can be reached; there is very lit­tle ques­tion of that. But if we make progress and don’t hit the goals, we should rec­og­nize what we ac­com­plished and learn lessons go­ing for­ward. Dis­cour­age­ment should not be a part of this process.”

Fast out of the gate

In the five months since the con­tracts were an­nounced, the HENS have hit the ground run­ning, Wag­ner says.

“We awarded the con­tracts on Dec. 9 and we were in the first face-to-face meet­ings on Dec. 12, three work­ing days later,” he says. “Some HENS con­vened their first learn­ing ses­sions within 30 days of the awards. That is light­ning fast.”

The HENS have since en­rolled a to­tal of more than 4,000 acute-care hos­pi­tals, Wag­ner adds.

“We had let­ters to hospi­tal CEOS al­ready drafted and ready to go be­fore we even knew we got the award,” says Dr. Carol Koe­ble, se­nior vice pres­i­dent of the North Carolina Hospi­tal As­so­ci­a­tion, which was cho­sen as a HEN, and ex­ec­u­tive di­rec­tor of the North Carolina Cen­ter for Hospi­tal Qual­ity and Pa­tient Safety.

North Carolina’s Hen—called the North Carolina-virginia hospi­tal en­gage­ment net­work be­cause of its part­ner­ship with the Virginia Hospi­tal & Health­care As­so­ci­a­tion—now has 117 mem­bers, 83 from North Carolina and 34 from Virginia.

In the rush to re­cruit hos­pi­tals, a few states have even seen com­pe­ti­tion among HENS, Koe­ble says. In Virginia, for in­stance, some hos­pi­tals chose to join the net­works of na­tional HENS, such as Premier, VHA and HRET, while sev­eral aca­demic med­i­cal cen­ters af­fil­i­ated with Chicago-based UHC chose to join its HEN.

“We did court some hos­pi­tals, and we got many to come aboard,” Koe­ble says. “The most im­por­tant thing, though, is that all hos­pi­tals par­tic­i­pate in a HEN, no mat­ter which one it is.”

North Carolina’s HEN has cho­sen to tackle its du­ties us­ing in­ten­sive col­lab­o­ra­tives ad­dress­ing con­di­tions such ve­nous throm­boem­bolism, as well as less-in­ten­sive learn­ing net­works tar­get­ing ar­eas of harm such as pres­sure ul­cers and ad­verse drug events. Some hos­pi­tals are par­tic­i­pat­ing in all ac­tiv­i­ties, while oth­ers—par­tic­u­larly smaller ones—can choose from a nar­rowed list of top­ics.

Tran­syl­va­nia Re­gional Hospi­tal, a 25-bed crit­i­cal-ac­cess hospi­tal in Brevard, N.C., has signed up to tar­get seven ar­eas, in­clud­ing sur­gi­cal-site in­fec­tions, says Scotta Orr, the hospi­tal’s di­rec­tor of qual­ity and ac­cred­i­ta­tion.

“Smaller hos­pi­tals are re­quired to meet the same guide­lines as larger ones but with fewer pa­tient and fewer em­ploy­ees, so the peo­ple here have to wear many hats,” Orr says. “If we can get best prac­tices and tools that some­one has al­ready

in­vested in, such as pa­tient ed­u­ca­tion or a check­list, that saves us a great deal of time.”

The Michi­gan Health & Hospi­tal As­so­ci­a­tion, also cho­sen as one of the 26 HENS, de­cided to build on its ex­ist­ing qual­ity-im­prove­ment in­fra­struc­ture, well known for its suc­cesses in ar­eas such as cen­tral line-as­so­ci­ated blood­stream in­fec­tion preven­tion.

“We have an ad­van­tage be­cause we al­ready have the con­tacts and we have the teams en­gaged,” says Brit­tany Bo­gan, di­rec­tor of health­care in­no­va­tion at the as­so­ci­a­tion’s Key­stone Cen­ter for Pa­tient Safety & Qual­ity.

The larger na­tional HENS have also taken their own ap­proach to meet­ing the pro­gram’s goals. HRET, which se­cured $75 mil­lion from HHS and has en­rolled more than 1,600 hos­pi­tals in 31 states, has rolled out its enor­mous HEN us­ing part­ner­ships with state hospi­tal as­so­ci­a­tions, says Maulik Joshi, HRET’S pres­i­dent.

State hospi­tal as­so­ci­a­tions do their own re­cruit­ing while HRET co­or­di­nates the im­prove­ment ac­tiv­i­ties, ex­plains Joshi, who says the part­ner­ship with state as­so­ci­a­tions is HRET’S “se­cret sauce.”

At HRET’S re­cent HEN week, held April 30May 4 in Chicago, roughly 400 at­ten­dees from hos­pi­tals across the coun­try came to learn more about safety cul­ture, the sci­ence of im­prove­ment and how best to de­sign re­li­able pro­cesses. It was the sec­ond such two-day meet­ing this year, with one more sched­uled by the end of 2012, Joshi says. “We want to work with all of our hos­pi­tals on the 10 harms but we also want to build up their ca­pa­bil­i­ties so they can con­tinue to im­prove in other ar­eas,” he adds.

The HENS’ var­ied strate­gies are one of the pro­gram’s strengths, says Mcgann, co-di­rec­tor of the Part­ner­ship for Pa­tients. In the past, gov­ern­ment-led im­prove­ment ini­tia­tives of­ten had a one-size-fits-all ap­proach that didn’t take into ac­count re­gional and pop­u­la­tion dif­fer­ences.

This time around, he says, the HENS had to make it clear in their ap­pli­ca­tions how they would ad­dress ob­sta­cles and re­duce harm in their regions. For in­stance, the Washington-based Na­tional Public Health and Hospi­tal In­sti­tute, an­other HEN, re­lies on a much dif­fer­ent strat­egy than does, say, a health sys­tem HEN such as San Fran­cisco-based Dig­nity Health, he says.

“We are very tight and fo­cused on the two aims but we are tak­ing a dif­fer­ent ap­proach on the ‘how,’” Wag­ner says. “We’re seek­ing in­no­va­tion, di­ver­sity and real-time data shar­ing. That will be a huge as­set na­tion­ally.”

Along with a num­ber of jokes about golden eggs, the HENS also re­port some early suc­cesses.

The Washington State Hospi­tal As­so­ci­a­tion’s HEN, which has about 100 par­tic­i­pat­ing hos­pi­tals from Washington, Ore­gon and Alaska, re­cently un­veiled its suc­cess at curb­ing early elec­tive de­liv­er­ies of ba­bies be­fore 39 weeks, says Carol Wag­ner, the as­so­ci­a­tion’s se­nior vice pres­i­dent for pa­tient safety. Dig­nity Health also tar­geted early elec­tive de­liv­er­ies and re­duced its rate from 7% in April 2011 to 2%, as of Jan­uary.

Other HENS have seen re­duc­tions in falls, pres­sure ul­cers and other ar­eas, ac­cord­ing to HHS. “This re­ally is un­prece­dented in Amer­i­can health­care,” Mcgann says. “We have vast fed­eral align­ment, a con­tract en­gine worth $1 bil­lion and ex­ter­nal part­ner­ships, all work­ing to­ward these two goals.”

Keith Kosel, ex­ec­u­tive di­rec­tor of VHA’S hospi­tal en­gage­ment net­work, leads a pre­sen­ta­tion dur­ing a re­cent ed­u­ca­tional event for mem­bers of the HEN.

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