‘ZERO HARM’

New $500 mil­lion pro­gram aims to elim­i­nate all pre­ventable er­rors as an­other wave of re­ports knocks in­dus­try’s pa­tient-safety record

Modern Healthcare - - FRONT PAGE - Maureen McKin­ney

Imag­ine a hospi­tal where the in­ten­sive-care unit’s myr­iad de­vices are linked and seam­lessly ex­change data, where pa­tients’ fam­i­lies use iPads to track clin­i­cians’ real-time ad­her­ence to ev­i­dence-based guide­lines, and where a pa­tient’s loss of dig­nity is viewed as a pre­ventable harm on the same or­der of mag­ni­tude as a fall or a blood­stream in­fec­tion.

It might sound far-fetched to some, but the Gor­don and Betty Moore Foun­da­tion, a char­i­ta­ble or­ga­ni­za­tion based in Palo, Alto, Calif., is bet­ting that those changes are fea­si­ble now and can go a long way to­ward trans­form­ing the health­care sys­tem.

On Aug. 28, the foun­da­tion of­fi­cially launched its Pa­tient Care Pro­gram, a grant-mak­ing ini­tia­tive set to al­lo­cate as much as half a bil­lion dol­lars dur­ing the next decade to­ward elim­i­nat­ing pa­tient harm.

Ad­verse events af­fect as many as 1 in 3 pa­tients, and the re­sult­ing harm causes tens of thou­sands of pa­tient deaths each year and costs the health­care sys­tem bil­lions. And de­spite im­prove­ment ef­forts, mount­ing ev­i­dence points to high rates of com­pli­ca­tions and pre­ventable deaths (See re­lated story, p. 7).

Nu­mer­ous large-scale ini­tia­tives have been un­der­taken in re­cent years to ad­dress the prob­lem, in­clud­ing HHS’ Part­ner­ship for Pa­tients, a $1 bil­lion cam­paign launched in April 2011 that aims to re­duce hospi­tal-ac­quired con­di­tions, im­prove tran­si­tions of care and re­duce Medi­care costs by up to $50 bil­lion over 10 years.

But the lead­er­ship of the Gor­don and Betty Moore Foun­da­tion say their ini­tia­tive’s twopronged ap­proach, which em­pha­sizes mean­ing­ful pa­tient and fam­ily en­gage­ment as well as reengi­neer­ing of hospi­tal sys­tems and pro­cesses, is what sets it apart. “By de­vel­op­ing and con­nect­ing these two crit­i­cal as­pects of health­care, we be­lieve that health­care will be bet­ter, more cost­ef­fec­tive and more re­spect­ful for pa­tients and their fam­i­lies and the health­care pro­fes­sional who serve them,” Steven McCormick, the foun­da­tion’s pres­i­dent, said in a news re­lease.

A core tenet of the pro­gram is the idea that team­ing in­dus­trial en­gi­neers and other pro­fes­sion­als with clin­i­cians will en­able hos­pi­tals to cre­ate high-re­li­a­bil­ity sys­tems, thereby re­mov­ing the need to rely on in­di­vid­ual acts of hero­ism to achieve good out­comes, said Dr. Ge­orge BoLinn, the Pa­tient Care Pro­gram’s chief pro­gram of­fi­cer. And smartly de­signed, re­con­fig­ured sys­tems will give physi­cians and nurses far more time to com­mu­ni­cate with pa­tients and their fam­i­lies, a crit­i­cal and of­ten-un­tapped re­source in pro­vid­ing high-qual­ity care, he added.

Even well-in­ten­tioned clin­i­cians of­ten think they know what pa­tients want, James Guest, pres­i­dent and CEO of Con­sumers Union, said at a foun­da­tion event for the pro­gram’s launch. “But you don’t re­ally know what pa­tients want un­less you ask and lis­ten, un­less you re­ally pay at­ten­tion with­out pre­con­ceived no­tions,” he said. “Ev­ery pa­tient needs to be lis­tened to.”

Bo-Linn cited re­search that found that nearly half of pa­tients re­port feel­ing a loss of dig­nity and re­spect when deal­ing with the health­care sys­tem. “If some­one gets an in­fec­tion and it heals, the phys­i­cal part is gone,” he said. “But if pa­tients feel like they were not lis­tened to, like they could not speak up, that loss of dig­nity will last far longer. And those pa­tients will likely not want to en­gage fur­ther in ad­vo­cat­ing for a health­care de­liv­ery sys­tem that de­liv­ers on the prom­ise of safe care.”

The Pa­tient Care Pro­gram also is unique be­cause it doesn’t tar­get spe­cific types of harm, said Dr. Peter Pronovost, di­rec­tor of the Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins Univer­sity, Bal­ti­more. In­stead, it starts with an end point in mind—elim­i­nat­ing all types of pre­ventable harm, be­gin­ning in the ICU set­ting—and works back­ward from there, he said.

Pronovost is well-known for a pro­gram he led that sig­nif­i­cantly re­duced rates of cen­tral line-as­so­ci­ated blood­stream in­fec­tions. But even that work fo­cused on only one type of harm, and the pro­to­cols it re­quires are an added burden for busy clin­i­cians, he said.

The foun­da­tion kicked off the ini­tia­tive with an $8.9 mil­lion grant to Johns Hop­kins’ Arm­strong In­sti­tute to im­prove ICU care.

Pronovost, who will lead the ef­fort, said the money will be used to cre­ate a “a mini-Bell Labs” that will draw ex­per­tise from the univer­sity’s schools of medicine, nurs­ing, engi­neer­ing, pub­lic health, busi­ness and ap­plied physics to re-imag­ine care.

The goal is to cre­ate an ICU where mon­i­tor­ing de­vices, in­fu­sion pumps and other ma­chines can “talk” to each other and make ad­just­ments as needed, treat­ment plans—some­times con­sist­ing of as many as 200 steps—are stan­dard­ized and au­to­mated, and in­for­ma­tion tech­nol­ogy sys­tems alert clin­i­cians to risks of harm.

As part of that ef­fort, re­searchers will

de­sign open-source mid­dle­ware that will link ICU de­vices. Pronovost said he en­vi­sions an ICU in which pa­tients’ fam­i­lies make rounds with physi­cians, as­sess treat­ment plans and pro­vide feed­back.

Pa­tient-safety ex­perts lauded the pro­gram for its sys­tems ap­proach and for its em­pha­sis on pa­tient and fam­ily em­pow­er­ment. Diane Pi­nakiewicz, pres­i­dent of the Bos­ton-based Na­tional Pa­tient Safety Foun­da­tion, praised the foun­da­tion’s rep­u­ta­tion for fund­ing for­ward­think­ing and scal­able projects. “Their ded­i­ca­tion to pa­tient dig­nity is so re­fresh­ing,” she said. “Pa­tients and their fam­i­lies have not been wel­comed to the con­ver­sa­tion in the past and that has been a missed op­por­tu­nity.”

She also said the pro­gram’s tar­get of “zero harm” is the right one. “That’s ex­actly the end point we need to have in our minds at all times,” she said.

It’s not the first time the foun­da­tion has ad­dressed health­care safety. Cre­ated in 2000 by In­tel Corp. co-founder Gor­don Moore and his wife, the or­ga­ni­za­tion, whose as­sets to­tal more than $5.5 bil­lion, fo­cuses on sci­ence, en­vi­ron­men­tal con­ser­va­tion and pa­tient care. In 2003, the foun­da­tion es­tab­lished the Betty Irene Moore Nurs­ing Ini­tia­tive, which has awarded more than $100 mil­lion in grants to im­prove nurs­ing care in com­mu­ni­ties sur­round­ing San Fran­cisco and Sacra­mento, Calif.

But the Pa­tient Care Pro­gram will run in­def­i­nitely and as a na­tional pro­gram will be much larger in scope, McCormick said. The pro­gram also en­lists the help of a num­ber of strate­gic part­ners, in­clud­ing Con­sumers Union, Stan­ford Univer­sity and Unit­ed­Health Group.

Re­searchers at the Univer­sity of Cal­i­for­nia at San Fran­cisco also se­cured a $2.1 mil­lion grant from the foun­da­tion to study work­flow pat­terns, in­ter­per­sonal com­mu­ni­ca­tion and other as­pects of care in ICUs. Led by Dr. Scott Reeves, di­rec­tor of UCSF’s Cen­ter for In­no­va­tion in In­ter­pro­fes­sional Health­care Ed­u­ca­tion, the team will spend two years ob­serv­ing four hospi­tal ICUs in each year. “We want to get a deep un­der­stand­ing of what re­ally goes on in the ICU, what works well and what doesn’t,” he said.

The In­sti­tute of Medicine and the Na­tional Academy of Engi­neer­ing also are part­ner­ing with the foun­da­tion on the ini­tia­tive, said Dr. J. Michael McGin­nis, a se­nior scholar at the IOM. Their con­tri­bu­tions will in­clude pro­vid­ing a forum where pro­fes­sion­als in medicine and engi­neer­ing can learn more about their fields and find ways to col­lab­o­rate, he said.

Dr. Don­ald Ber­wick, se­nior fel­low at the Cen­ter for Amer­i­can Progress and for­mer CMS ad­min­is­tra­tor, said the Pa­tient Care Pro­gram marks a mat­u­ra­tion in the health­care in­dus­try’s ap­proach to im­prove­ment. Ber­wick co-founded the Cam­bridge, Mass.-based In­sti­tute for Health­care Im­prove­ment, whose sys­tems-based ap­proaches pro­vided much of the foun­da­tion for the Pa­tient Care Pro­gram.

“For the first cou­ple of decades, the work in pa­tient safety and process im­prove­ment fo­cused on in­di­vid­ual dis­eases and risks,” Ber­wick said. “That was an im­por­tant time when we were cut­ting our teeth. What is hap­pen­ing now, though, is an un­der­stand­ing that ex­cel­lence is a sys­temic prop­erty and that means be­ing able to re­make sys­tems in their en­tirety. That’s the next step for the qual­ity move­ment.” TAKE­AWAY: A $500 mil­lion safety ini­tia­tive is bank­ing on the power of pa­tients, fam­i­lies and en­gi­neers to trans­form care.

JAY MALLIN PHOTO

Ni­cole James, far right, a pa­tient ad­vo­cate, speaks about her hospi­tal ex­pe­ri­ences and the need for pa­tient-cen­tered care. The Gor­don and Betty Moore Foun­da­tion an­nounced the Pa­tient Care Pro­gram, which will fo­cus on safety and pa­tient care.

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