BOSTON - Reducing preventable harm in hospitals often starts with small, low-tech steps: brushing the teeth of patients on ventilators; using low-rise beds and socks with safety treads on both sides; completing a surgical time out before mounting a blade on a scalpel.
Those small steps have yielded big results at Beth Israel Deaconess Medical Center - from a 90 percent reduction in ventilator-associated pneumonia since 2006, to progress in reducing patient falls with injury and in helping to avoid wrong site surgeries. They are some of the key lessons learned and implemented after the hospital declared the then "audacious goal" to eliminate preventable patient harm by 2012.
"The health care community in this country noticed when BIDMC declared its audacious goal in 2008," said Kevin Tabb, MD, BIDMC's President & CEO. "And now, everyone is watching to see what has happened. I am so proud of the work of every person in this medical center, to do the right thing every day, in large and small ways, for our patients."
In 2008, the governing boards BIDMC and Beth Israel Deaconess Hospital-Needham voted to
eliminate preventable patient harm, and set out on a five-year journey. Tabb said the medical center will continue its journey toward eliminating preventable harm, reporting on its progress toward that goal as well as its efforts in other key areas of quality and patient satisfaction.
That reporting effort includes public tracking of patient experience and satisfaction; quality and safety performance reports; efforts to improve the quality of care; and specific clinical service volumes and outcomes. Some measures are now mandated for public reporting, others are voluntary disclosures.
"Once you aim to reduce preventable harm, it makes little sense to do anything less than set the goal at "zero" says Mark Zeidel, MD, Chief of BIDMC's Department of Medicine and a member of the BIDMC Board of Directors. "What amount of harm would be 'OK'"?
"We've had some great victories, but it's also made us realize that the work will never be done and there's always the next opportunity to find a way to prevent harm and that means our strategies are constantly evolving," adds Kenneth Sands, MD, BIDMC's senior vice president of health care quality.
"Many leaders set bold goals, but then they don't tell anybody just in case they don't achieve them," says Jim Conway, a Distinguished Advisor to the Lucian Leape Institute at the National Patient Safety Foundation in a video report on BIDMC's progress. "What you have done is told everybody. So you have made yourself exquisitely accountable to achieve your goals."
"The concept of harm is a challenging one for us as clinicians, doctors and nurses, to be comfortable with," says Julius Yang, MD, PhD, a hospitalist and medical director of inpatient quality in the Silverman Institute for Health Care Quality.
"We certainly never mean to cause harm. We come to work every day and I think we largely guided our professional careers around avoiding harm. But by presenting the work in terms of preventing harm, it forced us to challenge how we look at the work that we do everyday."
As part of its progress report to the community, BIDMC has
posted a video on its public website that chronicle three stories that represent how the issue is being addressed:
Preventing ventilator-associated pneumonia
Ventilator-associated pneumonia is a problem that can affect between 10 to 20 percent of intensive care patients who need assistance breathing. Bacteria can collect in the breathing tube and work its way into a patient's lung and contracting VAP can double a patient's risk of dying.
By implementing a VAP bundle of five specific, seemingly small steps - elevating a bed at 30 degrees, brushing a patient's teeth daily, preventive treatment against stress ulcers and deep vein thrombosis as well as daily "sedation vacations," when patients are awakened daily to see if they can come off the vent - BIDMC achieved a 2,000-case reduction of VAP since 2006. Factoring in the $20,000 cost to treat a case of VAP, this translated into $40 million not spent. With so many patients leaving the hospital sooner, the medical center was also able to forego construction of a new $8 million ICU.
Michael Howell, MD, MPH, an intensivist and director of BIDMC's Center for Health Care Delivery Science, says the success to date has prompted a deeper examination of the VAP definition itself.
"We are 99 or 100 percent compliant with all known science about how to prevent ventilator- associated pneumonia, and we still have ventilator associated pneumonias. But we're at the point where it's nearly impossible to learn from them because the definition is imperfect. As we get a better definition that we can apply more reliably, we can learn new things about how to prevent VAP that we can begin to spread in our own practice and across the country."
A similar back-to-basics approach was applied to
reducing falls with injury, some of the most common, disabling, and expensive health conditions encountered by adults, especially older adults. In a hospital, a typical fall rate in general and medical-surgical units is four to five falls per 1,000 patient days.
"Over the years we've really looked at every fall and looked at if there was something different we could do to prevent that fall and we've added many different strategies over the course of the last five years to enhance our fall prevention standards," says Kim Sulmonte, RN, BIDMC's Associate Chief Nurse of Quality and Safety." Those strategies revolve around supplies and equipment, process changes and patient education and communication."
Sulmonte acknowledges "we've not reached our goal. Our goal really is zero falls with injury and we will continue to refine our standard over time and reviewing each case to see if there's anything we can do differently to prevent falls in the future."
As a result of these efforts, BIDMC's total of preventable falls with serious injury has decreased from a high of 10 in 2009 to 3 in 2010, 1 in 2011 and 1 through mid-September 2012.
Instituting a new time out procedure in surgery
The staff-based approach also led to an innovative way to ensure that the "time-out" - a universal safety protocol to prevent wrong site surgery - is taken before every surgical procedure. At the suggestion of a OR nurse, scalpel blades cannot be attached to the handle until the time-out is performed, an extra step of prevention so that an operation cannot begin until the surgical team completes a checklist.
"Every member of this medical center asks themselves how each and every interaction with a patient is an opportunity to improve the next," explains Elliot Chaikof, MD, PhD, chief of the Roberta and Stephen R. Weiner Department of Surgery, who notes the time-out change "was accepted with enthusiasm throughout the surgical service and has become a standard of care at the Beth Israel Deaconess Medical Center."
While BIDMC remains on the road toward the elimination of preventable harm, Conway believes the progress to date has been laudable.
"What we've learned and I believe Beth Israel Deaconess has learned is that the fact that errors don't erode trust; what erodes trust is how the organization responds after the event."
Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit