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Hospital aims to eliminate mistakes

Strategy to end preventable harm considered a model

Email|Print| Text size + By Jeffrey Krasner
Globe Staff / January 17, 2008

Beth Israel Deaconess Medical Center has launched an ambitious quality-improvement effort aimed at eliminating within four years all harm to patients that it considers preventable, such as falls, infections caused by intravenous lines, and medication errors.

The Harvard teaching hospital in Boston and its suburban hospital in Needham have already begun measuring ways in which they endanger patients and plan to publish the results quarterly. The goal is to reach the top 2 percent of hospitals in patient satisfaction. Currently, Beth Israel Deaconess ranks in the top 12 percent for patient satisfaction, according to nationwide surveys.

"This is aggressive," said Paul Levy, chief executive of Beth Israel Deaconess. "We're pushing beyond the level of care at which regulators are comfortable."

Many hospitals have worked for years to eliminate medical errors and reduce the number of preventable infections. Beth Israel Deaconess's program is different from most in that it sets a specific goal. It hinges on training the board of directors about healthcare quality and medical errors and getting them personally involved in making clinical improvements. In addition, a portion of senior managers' bonuses will be tied to making improvements.

The hospital is one of five healthcare organizations that have signed on to a program originated by Blue Cross Blue Shield of Massachusetts, the state's largest health insurer. The others are Mt. Auburn Hospital in Cambridge, New England Baptist Hospital in Boston, Cooley Dickinson Hospital in Northampton, and Atrius Health of Newton, the parent of physicians groups that include Harvard Vanguard Medical Associates. Beth Israel Deaconess became the first of the group to finalize its commitment when the board passed a resolution last month saying it would "eliminate all preventable harm" by the end of 2011 and be in the top 2 percent of hospitals for patient satisfaction by the same date. The board of Beth Israel Deaconess Needham Hospital adopted the same goals.

"We want to create and support examples of transformational change in hospital quality and safety," said Andrew Dreyfus, executive vice president for healthcare services at Blue Cross Blue Shield of Massachusetts. "We're looking for shining examples of organizations willing to take risks and make changes."

Preventing medical errors in hospitals is seen as one of the ways to improve healthcare and control costs, which continue to increase at a rate of about 10 percent a year. Cleve L. Killingsworth, chairman and chief executive of Blue Cross Blue Shield of Massachusetts, has long championed such improvements. Blue Cross set up two-day workshops for the participating institutions' directors to spend time with hospital staff and watch how errors happen.

"If hospital trustees place the same scrutiny on clinical performance as they do on financial performance, that would accelerate change," Dreyfus said. "Preventable harm should be just as important a measure as an institution's bond rating, operating margin, or endowment size."

The group is part of a two-year "demonstration program" that could be expanded across Massachusetts, he said. The insurer gave each institution a $1.5 million grant to cover some of the costs of making the changes, including hiring a consulting firm to perform an initial assessment of each hospital's performance.

"The program developed in Massachusetts is the first such program in the US, and the whole country wants to know how they can get this training," said Jim Conway, senior vice president of the Institute for Healthcare Improvement, a Cambridge nonprofit. "These institutions are absolutely at the leading edge."

Conway's group developed part of the curriculum presented to directors at Beth Israel.

Dr. Ken Sands, Beth Israel Deaconess's senior vice president of healthcare quality, said the first step in the new program will be to gauge the hospital's current performance to determine "all the differing ways patients get hurt." He said the hospital would express errors in stark terms that can easily be understood by the public.

"It's one thing to say our central line infection rate was 2.3 percent and our fall rate was 3 per 1,000 patient days," he said, using hypothetical statistics. "It's another to say we harmed 49 people last month. It makes it more tangible."

Its first report will be published this spring.

Like many other hospitals, Beth Israel Deaconess has long sought new ways to prevent harm. For instance, in an attempt to stop infections from central intravenous lines, it devised a kit that includes all the equipment to install the line, and a checklist of steps to follow. A central line is a large needle inserted into a major blood vessel and used as a portal for infusions, injections, or to withdraw blood. A slip in protocol - such as forgetting to sterilize the skin - can leave a patient vulnerable to infections that can be life-threatening. The rate of central line infections at Beth Israel Deaconess fell from 2 per 1,000 patient days in the fourth quarter of 2006 to 1.44 per 1,000 patient days in the fourth quarter of 2007.

Using the hospital's website to show how well the program is going "serves as a management tool so people hold themselves accountable to a higher standard," said Levy. "When you have that outside target, it cuts through the bureaucracies and the petty jealousies."

Efforts to eliminate preventable harm have already had success at some hospitals. Cincinnati Children's Hospital Medical Center gives itself a public report card on quality measures. For instance, in September patients on a ventilator or breathing tube contracted pneumonia at a rate of 1.1 for every 1,000 ventilator days, compared to nine for every 1,000 ventilator days in the second quarter of 2005, according to that hospital's website.

Dr. Uma Kutagal, Cincinnati Children's senior vice president of quality and transformation, said that over the last six years, the hospital has reduced infections and pneumonia, "virtually eliminated" infections from central intravenous lines, and reduced mortality in the pediatric intensive care unit.

Jeffrey Krasner can be reached at krasner@globe.com.

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