- Email: [email protected]
Implementing a Patient Safety and Quality Program Across Two Merged Pediatric Institutions
The Joint Commission Journal on Quality and Patient Safety Root Cause Analysis
Implementing a Patient Safety and Quality Program Across Two Merged Pediatric Institutions Erika Abramson, M.D.; Daniel Hyman, M.D., M.M.M.; S. Nena Osorio, M.D.; Rainu Kaushal, M.D., M.P.H.
S
ince the late 1980s, changes in the health care structure and reimbursement in the United States have led to sharp increases in the number of hospital mergers. More of them occurred between 1990 and 1996 than throughout the 1980s.1 Academic centers were among the health care organizations that responded to the changing health care climate by using consolidation as a strategy to improve efficiency and reduce costs.2 Increasingly, research has focused on the successes and failures of these mergers, in particular the financial implications for both hospitals and patients. Less attention, however, has been paid to the impact of these mergers on patient safety and the quality of care delivered.3 In 1997, the New York Hospital and The Presbyterian Hospital underwent a full-asset merger to become New York City’s largest medical center, known as the New YorkPresbyterian Hospital (NYPH). Designed to allow each hospital to share in each other’s expertise and technology, the merger aimed to improve care while decreasing costs for patients. The medical center maintains academic affiliations with two medical schools—Cornell University’s Joan and Sanford Weill Medical College, originally associated with the New York Hospital, and Columbia University College of Physicians and Surgeons, associated with The Presbyterian Hospital. Both the New York Hospital and The Presbyterian Hospital had comprehensive pediatric services before the merger and have since expanded them. The Komansky Center for Children’s Health (KCCH) is a children’s hospital within a hospital located at the Weill Cornell Medical Center. The Morgan Stanley Children’s Hospital (MSCH) is a freestanding children’s hospital at the Columbia University Medical Center. In recognition of the challenges of delivering consistently safe and effective health care to children at two structurally different campuses, an integral focus of the Children’s Service Line at NYPH—a bicampus senior clinical and hospital leadership group that reports to the chief operating officer (COO) for Children’s Health—has been the formation of a Patient Safety and Quality Program to achieve these goals. In this article, we
January 2009
Article-at-a-Glance Background: Academic centers are among the health care
organizations that have used consolidation as a strategy to improve efficiency and reduce costs. In 1997, the New York Hospital and The Presbyterian Hospital underwent a fullasset merger to become New York City’s largest medical center, known as the New York-Presbyterian Hospital (NYPH). In 2006, recognition of the challenges of the Children’s Service Line at NYPH led to the formation of a Patient Safety and Quality Program to deliver consistently safe and effective health care. Creating a Bicampus Pediatric Quality and Safety Team:
Each campus has a children’s quality council, an interdisciplinary group that discusses and prioritizes safety and quality issues. The quality councils from each campus report directly to a bicampus children’s quality steering committee formed to ensure that similar safety practices and standards are implemented across both children’s hospitals. A safety subcommittee, which primarily coordinates and follows up on leadership safety walk rounds, and a significant-events subcommittee, which reviews morbidities and mortalities, report to each hospital’s quality council. Program Priorities and Initiatives: The bicampus pediatric quality and safety program is organized around five broad themes: improving the culture of safety, reducing the frequency of health care–acquired infections, reducing harm in the health care setting, using information technology to improve the quality and safety of care provided to patients and families, and measuring the effectiveness of care in key areas. Two sample initiatives—building family engagement and prevention of adverse medication events— illustrate the program’s successes and challenges. Conclusions: Developing a pediatric safety and quality program across two campuses has been challenging but has led to important improvements at both organizations.
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The Joint Commission Journal on Quality and Patient Safety review the creation and structure of the bicampus pediatric safety and quality program, including some of the obstacles we have faced and lessons learned from the process. We also discuss the status of our program’s evolution, our program priorities, several key initiatives, and future directions. This information can be used to inform other institutions pursuing similar efforts.
Organizational Overview NYPH provides care to more than 20% of New York City, serving a socioeconomically and ethnically diverse patient population. KCCH, a children’s hospital within a hospital located in the Upper East Side of Manhattan, includes a 30-bed general inpatient pediatric unit, a 50-bed neonatal intensive care unit (NICU), a 20-bed pediatric intensive care unit (PICU), and a pediatric burn center. MSCH, a freestanding children’s hospital located in Washington Heights, is the highest-volume pediatric medical center in Manhattan, with 103 general pediatric beds, 41 PICU beds, and 58 NICU beds.
established in 2006, and chief children’s quality officer at NYPH [D.H.], formally established in 2007. The retreat, which featured presentations from two national experts in children’s health quality, was organized around five broad themes: creating a culture of safety, medication safety, using data to measure performance and drive improvement, aligning hospital and academic imperatives within the field of quality and safety, and collaborating across organizational boundaries. Although each campus had different priorities coming into the partnership, leaders at both organizations recognized the importance of working toward common goals and identified these common goals as top priority areas. To follow up from the retreat, a series of actionable, operational items was developed to provide a road map for efforts going forward. One item addressed development of the structure for the current pediatric quality and safety program, which has since then led the pediatric quality and safety efforts at NYPH.
Program Structure Creating a Bicampus Pediatric Quality and Safety Team Until 2006, there was only limited and nonstructured crosscampus collaboration in pediatric safety and quality initiatives. Both campuses were participating in national quality improvement (QI) collaboratives, including efforts to reduce hospitalacquired bloodstream infections and opiate-associated adverse drug events; however, each hospital site was working independently on these endeavors. Recognition by senior leadership of shared common goals, opportunities to collaborate in quality and safety initiatives, the need for similar standards among merged institutions, and the potential for academic progress led to efforts to create a bicampus structure for advancing pediatric quality and patient safety. Senior leadership also recognized that peer organizations were investing heavily in quality and safety as core strategic initiatives and that NYPH would benefit from safety and QI efforts, especially given the increasing accreditation and regulatory oversight by The Joint Commission, the Centers for Medicare & Medicaid Services, and New York State. In an effort to create a plan for the partnership going forward and to generate hospital staff buy-in, a bicampus leadership retreat attended by hospital leadership and staff from all disciplines involved in caring for children was held in 2006 that focused exclusively on pediatric quality and safety. The timing of the retreat coincided with the development of two new positions: director of quality and patient safety for KCCH [R.K.], 44
January 2009
The current pediatric quality and safety program structure includes an entirely new set of committees serving both individual campuses as well as bicampus service line needs and is structured to achieve functional goals. Senior leadership of both the hospital and the two pediatric departments have been critical to not only the establishment of these efforts but even more so their early successes. The involvement of senior leadership underscored the priority placed on quality and safety and helped to quickly effect change by allocating personnel and resources necessary to enhance safety and reduce risk. Faculty involvement, in particular, was dependent on and influenced by support from the chairs. Several staff members have also been hired to support quality and safety activities, including quantitative support of measurement activity. Their roles have continued to evolve with the further development of our quality and safety program. Each campus now has its own children’s quality council, an interdisciplinary group that meets to discuss and prioritize safety and quality issues. The quality councils from each campus report directly to a bicampus children’s quality steering committee that was formed to ensure that similar safety practices and standards are implemented across both children’s hospitals (Figure 1, page 45). A safety subcommittee, which primarily coordinates and follows up on leadership safety walk rounds, and a significant-events subcommittee, which reviews morbidities and mortalities, report to each hospital’s quality council. These groups ensure that quality and safety issues are identified
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety Pediatric Safety and Quality and addressed in a timely manner. Other important committees that have been formed include a bicampus Organizational Structure measurement committee, which helps to define and measure clinical outcomes at both campuses, and a bicampus pediatric information technology (IT) committee, which recommends IT improvements and studies their effects on quality and safety. The structure of parallel and bicampus committees allows each campus to address important issues internally while encouraging collaboration and ensuring that ideas will be disseminated at both institutions. The committees require that physician leaders on both campuses together achieve consensus to help ensure uniform standards. In addition, serving on each of these committees Figure 1. The Pediatric Safety and Quality Program at Morgan Stanley Children’s are physicians, nurses, pharmacists, and other hospital Hospital and the Komansky Center for Children’s Health includes several individual personnel. Participation also occurs from other depart- and bicampus committees. IT, information technology. ments involved in the care of children, such as surgery, anesthesiology, and radiology, to help ensure that multiple per- providers perceive blame for errors or react negatively to crispectives are identified by people actively involved in caring for tiques to one in which teamwork is viewed as essential and patients and that solutions for problems are realistic in the con- everybody feels a responsibility to make the hospital safe. At both MSCH and KCCH, a formalized structure for family partext of current organizational operations. ticipation, the family advisory council (FAC), has been estabProgram Priorities and Initiatives lished. The process by which these councils were formed, their Our bicampus pediatric quality and safety program is current- accomplishments, and the barriers faced at each site, however, ly organized around five broad themes, which have evolved are quite different. Their development is illustrative of the benfrom the themes of the 2006 bicampus leadership retreat: efits and limitations of cross-campus collaboration. 1. Improve the culture of safety. After a series of false starts, the FAC effectively started at 2. Reduce the frequency of health care–acquired infections. MSCH in 2005, led initially by the efforts of parents, with sup3. Reduce harm in the health care setting. port from hospital leadership. After an initial period centered 4. Use IT to improve the quality and safety of care provided on recruitment and the development of an organizational structo patients and families. ture, it implemented a number of important endeavors. In the 5. Measure the effectiveness of care in key areas. past three years, the FAC at MSCH developed resources for A series of specific initiatives target each of these program parents and worked with staff to spread the idea of family-cenpriorities. A detailed review of two sample initiatives—building tered care and family-centered rounding. It has successfully crefamily engagement and prevention of adverse medication ated a comprehensive guidebook for parents, written from a events—helps illustrate the successes and challenges faced by parent’s perspective, and Parent TIP sheets on hospital safety our integrated program. Building family engagement is an goals. Parents also have become active participants on multiple important part of our efforts to improve the culture of safety, committees, such as the children’s quality council, the ethics and the prevention of adverse medication events is part of our committee, and the bereavement committee. effort to reduce harm in the health care setting, as well as to use Formation of the FAC began at KCCH in October 2006, IT to improve quality and safety of care. initially led by staff members interested in spreading the successes seen at MSCH. During the early formation of the FAC BUILDING FAMILY ENGAGEMENT at KCCH, the FAC at MSCH became an invaluable resource An integral and evolving part of efforts to improve the hos- because of its experiences one year earlier. Bylaws, organizationpital’s culture of safety has been the expanding role of family al structures, and strategies were adapted from MSCH and led members. Involving parents has been important on both cam- to an FAC capable of quickly launching successful initiatives. puses as a step in shifting from a culture in which health care The KCCH FAC has created a welcome guidebook for parents January 2009
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The Joint Commission Journal on Quality and Patient Safety for the inpatient units and has started a parent-to-parent support group that provides monthly luncheons on multiple units. It has created a Web page for recruiting new members, and parents participate on the children’s quality council and the bereavement committee. In a role similar to that played by the FAC at MSCH, it was involved as family faculty in orienting new interns to provide the parent perspective of family-centered care. Despite their successes and ongoing progress, both FACs have faced significant challenges. Initially, the MSCH FAC spent much of its time navigating administrative issues and trying to increase staff participation. Its lessons learned helped the FAC at KCCH navigate these processes much more quickly. At KCCH, the primary challenge has been increasing parent participation. Both councils also struggle with financial resources and the tremendous time and effort it takes to have a functioning FAC, particularly when there is no paid coordinator and participation is voluntary. Both FACs have increasingly begun to work together to share ideas for overcoming these barriers.
PREVENTING ADVERSE MEDICATION EVENTS Published literature underscores the importance of this focus; a 2006 report by the Institute of Medicine estimates that at least 1.5 million preventable adverse drug events (ADEs) occur each year, with preventable ADEs defined as injuries that result from errors in the medication process (prescribing, dispensing, transcribing, administering, or monitoring of a medication).4 These events have been shown to occur frequently in children, and although the medication error rate is similar in hospitalized children and adults, the rate of potential ADEs is three times higher in children.5 In an effort to reduce the risk of medication errors, significant resources have been dedicated to detecting and addressing both near misses and actual adverse drug events. To date, much of the detection has been through the voluntary Web-based medical error reporting system (MERS) in place at both campuses. These reports complement the mandatory reporting of serious errors. Throughout the year, staff members of all disciplines are reminded about the importance of filling out MERS reports. Following modifications to MERS made on the basis of staff feedback, MERS reports have more than doubled at both MSCH and KCCH. Detailed reports analyzing each campus’s MERS reports are generated and reported quarterly to the quality councils at each campus. Patterns of MERS reports have been used to identify a number of issues including ordering errors (recognized in the pharmacy and corrected) stemming in 46
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part from issues with the computerized physician order entry (CPOE) system. A task force was chartered to identify both the root causes and solutions to this problem at KCCH. Because of the quality steering committee’s integrated bicampus structure, significant-event information and patterns of errors are quickly disseminated to both campuses. In this way, lessons learned from errors at one campus translate to changed practice and policies at both campuses to ensure one uniform standard of care. NYPH has also invested considerable financial resources in technology development and improvement as a major strategy for reducing pediatric medication errors. Both campuses have CPOE with pediatric-specific clinical decision support, and research at KCCH has shown reductions in overall errors, drugchoice errors, significant events, and events rated as serious or life threatening.6 Pediatric-dosing defaults (which address the most common use of each drug and take into account such factors as gestational age, postnatal age, and weight) were initially established in 2002 for 193 commonly prescribed medications; the system is continually undergoing iterative refinements. These efforts are led by the bicampus pediatric IT committee. Cross-campus collaboration was initially limited by the fact that MSCH and KCCH used different inpatient computer systems until 2007. Sources of error or improvements to one system were often product-specific and isolated to one campus. As a result of the bicampus IT committee structure, with a single inpatient computer system at both sites, changes to one campus’s pediatric dosing table now drive changes at the other campus.
ONGOING INITIATIVES In addition to working on building family engagement and preventing adverse medication events, the bicampus pediatric safety and quality program has led a number of other efforts addressing the five broad program priorities. Among other initiatives, both campuses have implemented bimonthly leadership safety walk rounds; actively participated in a hospitalwide multidisciplinary campaign known as “Operation Come Clean” to improve hand hygiene; and participated in a number of Child Health Corporation of America (CHCA)–sponsored clinical improvement collaboratives designed to reduce central venous catheter (CVC)–associated blood stream infections (BSIs), improve recognition of changes in patient condition, and reduce ADEs. The bicampus pediatric safety and quality program has also led efforts to reduce harm in the health care setting by targeting a number of high-risk areas, such as patient transitions. An electronic medication reconciliation form with-
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety in the patient’s electronic health record was developed that is identical in both organizations, and staff were trained in the SBAR (Situation-Background-Assessment-Recommendation) model of communication used to improve and standardize communication during handoffs. These bicampus efforts have produced a number of early successes. For example, participation in the CHCA collaborative to reduce CVC–associated BSIs led to a 65%–75% decrease in rates of infection at both PICUs, and the PICU at KCCH went for more than one year without a CVC–associated BSI. Substantial reductions were also seen in the NICUs at both hospitals. These decreases have been sustained. In addition, SBAR has now been implemented throughout MSCH after being piloted in the NICU, and at KCCH, SBAR was piloted in the pediatric burn unit and is now being implemented on multiple units.
Discussion KEYS TO SUCCESS Effectively integrating safety and quality practices across two structurally and programmatically distinct pediatric divisions, including one freestanding children’s hospital and one children’s hospital within a larger hospital, required a critical evaluation of variation in practices, benefited from collaboration and review of experiences and successes at other organizations, and ultimately challenged the status quo so as to achieve safer and more effective practice. Senior leadership support from both COOs and the pediatric chairmen was crucial to the success of the bicampus program. These leaders consistently set expectations regarding the most important goals for the program and helped maintain a singular focus on delivering the safest and most effective care to every child and family, irrespective of the campus at which the child received that care. Leaders also worked to promote crosscampus collaboration across divisions that before the merger had previously been naturally competitive in recruiting for faculty, fellows, and residents. This cultural change did not, of course, occur overnight. Regular meetings of hospital leaders, departmental chairs, and divisional faculty were held to discuss quality and safety goals and create plans to achieve them. These discussions were invaluable in building trust, gaining consensus, and overcoming barriers. Over time, the efforts to ensure optimal care for all children at NYPH have resulted in numerous collaborative initiatives and a generally cooperative culture in which goals are shared and strategies coordinated. The expectation that both organizations would provide the same quality of care and could learn from each other’s efforts despite
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the fact that one of them was significantly smaller and physically part of a larger hospital was also essential. Pediatric safety and quality leaders at both campuses also have focused efforts on developing relationships with departmental chairs and the clinical leaders of those involved in the care of children, including surgeons, anesthesiologists, radiologists, and laboratory workers. Members from each of these departments are active participants in the quality councils and other committees involved in safety and quality. This collaboration is essential, particularly at KCCH, because many of the ancillary staff are more frequently involved in the care of adults as opposed to children. In addition, the quality and safety leaders on each campus have close professional relationships and are committed to working together.
BARRIERS Integrating the pediatric safety and quality program across two institutions has been challenging. Implementing change within well-established infrastructures is difficult. We have encountered both perceived and real differences in the nature of care delivered, because people are often wedded to the ways that issues are approached, regardless of the outcome. Tremendous time and commitment are required at an individual and organizational level to overcome these perceptions and effect real change. The combination of education, incorporating staff input to adapt policies to best meet the needs of both organizations, and senior-level mandates when necessary are all strategies that we have used. It is also challenging to overcome the historical competition for resources, recruitment, and recognition. Allocating resources across two campuses that differ in size and expertise is difficult and remains a struggle. This includes finding resources to allow faculty to pursue academic advancement in quality and safety-related work. There has also been a tendency to believe that an integrated hospital cannot contribute to processes at a much larger freestanding children’s hospital. Yet, each of the two institutions has contributed new practices to the other, which has been increasingly viewed as routine and beneficial. Differing electronic health records also have been a barrier. Until recently, both campuses had different inpatient and outpatient computer systems, so that problems were not always comparable or improvements could not easily be translated across organizations. Now, changes to the CPOE system and pediatric dosing table can be made in parallel. This problem has not been resolved in the outpatient setting. In addition, differences between the pediatric divisions make some initiatives not feasible for both campuses or make some
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The Joint Commission Journal on Quality and Patient Safety initiatives easier at one site. For example, given the MSCH’s much greater volume of patients, it is the only campus to have participated in initiatives such as the CHCA surgical site infection reduction collaborative. In contrast, some initiatives have been more easily accomplished at KCCH, which, for example, has achieved 100% use of electronic documentation for five years, while the increase in use of electronic documentation has been much more gradual at MSCH.
FUTURE DIRECTIONS Although still in its early stages, the bicampus pediatric safety and quality program has effected real change since 2006 and has been a leader within the NYPH system as a whole in the adoption of practices such as family-centered rounding, leadership safety walk rounds, and the advancement of IT. The program will continue its bicampus efforts going forward and will engage in additional opportunities for collaboration. During the next few years, the program will continue to work on the current priority areas and will expand its efforts on the basis of actual safety events and near misses. For example, as part of the effort to prevent adverse medication events, we plan to identify events and near misses by the use of trigger tools, in which specific actions (such as the ordering of certain drugs or certain abnormal laboratory values) serve as triggers to conduct detailed chart review.7,8 We will also be adopting uniform smart infusion pumps and bar-coding technology to reduce medication errors. Another important focus will be on efforts to further research in quality and safety, including career tracks for faculty interested in this field. At Weill Cornell Medical College, the division of quality and clinical informatics, created in 2008, includes several pediatric faculty members dedicated to health services research. Multiple junior faculty members are mentored in quality and safety projects at both campuses, and a number of cross-campus collaborative research projects related to safety and quality are ongoing. A clinical scholar endowment was also created at KCCH to support faculty work in quality and safety efforts. We are also looking to increase collaboration using databases allowing for comparative benchmarking and intend to continue to strengthen our partnership with parents, whose insight and efforts to date have been invaluable.
Conclusions
goals, creating leadership positions in quality and safety and filling these positions with leaders committed to collaborating, building staff buy-in, and obtaining leadership support from the highest levels have all been crucial factors in the program’s success. Overcoming entrenched organizational practices and determining how best to allocate resources are two of the biggest challenges we continue to face. With the large number of merged hospitals formed in the past few decades, identifying strategies to successfully integrate bicampus programs is important to inform other organizations undergoing similar efforts. J Erika Abramson, M.D., is Instructor, Department of Pediatrics, Weill Medical College of Cornell University; and Assistant Attending Pediatrician, New York-Presbyterian Hospital, New York City. Daniel Hyman, M.D., M.M.M., formerly Chief Children’s Quality Officer and Chief Medical Officer for Ambulatory Care, New YorkPresbyterian Hospital; Assistant Clinical Professor of Pediatrics and Public Health, Weill Cornell Medical College; and Assistant Professor of Pediatrics, Department of Pediatrics, College of Physicians and Surgeons of Columbia University, New York City; is Chief Quality Officer, The Children’s Hospital, Aurora, Colorado. S. Nena Osorio, M.D., is Assistant Professor of Pediatrics, Department of Pediatrics, Weill Cornell Medical College, and Assistant Attending Pediatrician, New York-Presbyterian Hospital. Rainu Kaushal, M.D., M.P.H., is Chief, Division of Quality and Clinical Informatics; Associate Professor of Pediatrics and Public Health, Weill Cornell Medical College; Director of Pediatric Quality and Patient Safety, Komansky Center for Children’s Health, New York-Presbyterian Hospital; and a member of The Joint Commission Journal on Quality and Patient Safety’s Editorial Advisory Board. Please address requests for reprints to Rainu Kaushal, [email protected].
References 1. Spang H., et al.: Hospital mergers and savings for consumers: Exploring new evidence. Health Aff (Millwood) 20:150–158, Jul.–Aug. 2001. 2. Mallon W.: The alchemists: A case study of a failed merger in academic medicine. Acad Med 78:1090–1104, Nov. 2003. 3. Gering J., et al.: Taking a patient safety approach to an integration of two hospitals. Jt Comm J Qual Patient Saf 31:258–266, May 2005. 4. Institute of Medicine: Preventing Medication Errors. Washington, DC: National Academies Press, 2006. 5. Kaushal R., et al.: Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120, Apr. 25, 2001. 6. Holdsworth M.T., et al.: Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. Pediatrics 120:1058–1066, Nov. 2007. 7. Resar R.K., et al.: Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 12(suppl. 2):ii39–ii45, Dec. 2003. 8. Resar R.K., et al.: A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf 32:585–590, Oct. 2006.
Developing a pediatric safety and quality program across two campuses has been challenging but has led to important improvements at both organizations. Establishing common 48
January 2009
Volume 35 Number 1
Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
Implementing a Patient Safety and Quality Program Across Two Merged Pediatric Institutions Erika Abramson, M.D.; Daniel Hyman, M.D., M.M.M.; S. Nena Osorio, M.D.; Rainu Kaushal, M.D., M.P.H.
S
ince the late 1980s, changes in the health care structure and reimbursement in the United States have led to sharp increases in the number of hospital mergers. More of them occurred between 1990 and 1996 than throughout the 1980s.1 Academic centers were among the health care organizations that responded to the changing health care climate by using consolidation as a strategy to improve efficiency and reduce costs.2 Increasingly, research has focused on the successes and failures of these mergers, in particular the financial implications for both hospitals and patients. Less attention, however, has been paid to the impact of these mergers on patient safety and the quality of care delivered.3 In 1997, the New York Hospital and The Presbyterian Hospital underwent a full-asset merger to become New York City’s largest medical center, known as the New YorkPresbyterian Hospital (NYPH). Designed to allow each hospital to share in each other’s expertise and technology, the merger aimed to improve care while decreasing costs for patients. The medical center maintains academic affiliations with two medical schools—Cornell University’s Joan and Sanford Weill Medical College, originally associated with the New York Hospital, and Columbia University College of Physicians and Surgeons, associated with The Presbyterian Hospital. Both the New York Hospital and The Presbyterian Hospital had comprehensive pediatric services before the merger and have since expanded them. The Komansky Center for Children’s Health (KCCH) is a children’s hospital within a hospital located at the Weill Cornell Medical Center. The Morgan Stanley Children’s Hospital (MSCH) is a freestanding children’s hospital at the Columbia University Medical Center. In recognition of the challenges of delivering consistently safe and effective health care to children at two structurally different campuses, an integral focus of the Children’s Service Line at NYPH—a bicampus senior clinical and hospital leadership group that reports to the chief operating officer (COO) for Children’s Health—has been the formation of a Patient Safety and Quality Program to achieve these goals. In this article, we
January 2009
Article-at-a-Glance Background: Academic centers are among the health care
organizations that have used consolidation as a strategy to improve efficiency and reduce costs. In 1997, the New York Hospital and The Presbyterian Hospital underwent a fullasset merger to become New York City’s largest medical center, known as the New York-Presbyterian Hospital (NYPH). In 2006, recognition of the challenges of the Children’s Service Line at NYPH led to the formation of a Patient Safety and Quality Program to deliver consistently safe and effective health care. Creating a Bicampus Pediatric Quality and Safety Team:
Each campus has a children’s quality council, an interdisciplinary group that discusses and prioritizes safety and quality issues. The quality councils from each campus report directly to a bicampus children’s quality steering committee formed to ensure that similar safety practices and standards are implemented across both children’s hospitals. A safety subcommittee, which primarily coordinates and follows up on leadership safety walk rounds, and a significant-events subcommittee, which reviews morbidities and mortalities, report to each hospital’s quality council. Program Priorities and Initiatives: The bicampus pediatric quality and safety program is organized around five broad themes: improving the culture of safety, reducing the frequency of health care–acquired infections, reducing harm in the health care setting, using information technology to improve the quality and safety of care provided to patients and families, and measuring the effectiveness of care in key areas. Two sample initiatives—building family engagement and prevention of adverse medication events— illustrate the program’s successes and challenges. Conclusions: Developing a pediatric safety and quality program across two campuses has been challenging but has led to important improvements at both organizations.
Volume 35 Number 1
Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
43
The Joint Commission Journal on Quality and Patient Safety review the creation and structure of the bicampus pediatric safety and quality program, including some of the obstacles we have faced and lessons learned from the process. We also discuss the status of our program’s evolution, our program priorities, several key initiatives, and future directions. This information can be used to inform other institutions pursuing similar efforts.
Organizational Overview NYPH provides care to more than 20% of New York City, serving a socioeconomically and ethnically diverse patient population. KCCH, a children’s hospital within a hospital located in the Upper East Side of Manhattan, includes a 30-bed general inpatient pediatric unit, a 50-bed neonatal intensive care unit (NICU), a 20-bed pediatric intensive care unit (PICU), and a pediatric burn center. MSCH, a freestanding children’s hospital located in Washington Heights, is the highest-volume pediatric medical center in Manhattan, with 103 general pediatric beds, 41 PICU beds, and 58 NICU beds.
established in 2006, and chief children’s quality officer at NYPH [D.H.], formally established in 2007. The retreat, which featured presentations from two national experts in children’s health quality, was organized around five broad themes: creating a culture of safety, medication safety, using data to measure performance and drive improvement, aligning hospital and academic imperatives within the field of quality and safety, and collaborating across organizational boundaries. Although each campus had different priorities coming into the partnership, leaders at both organizations recognized the importance of working toward common goals and identified these common goals as top priority areas. To follow up from the retreat, a series of actionable, operational items was developed to provide a road map for efforts going forward. One item addressed development of the structure for the current pediatric quality and safety program, which has since then led the pediatric quality and safety efforts at NYPH.
Program Structure Creating a Bicampus Pediatric Quality and Safety Team Until 2006, there was only limited and nonstructured crosscampus collaboration in pediatric safety and quality initiatives. Both campuses were participating in national quality improvement (QI) collaboratives, including efforts to reduce hospitalacquired bloodstream infections and opiate-associated adverse drug events; however, each hospital site was working independently on these endeavors. Recognition by senior leadership of shared common goals, opportunities to collaborate in quality and safety initiatives, the need for similar standards among merged institutions, and the potential for academic progress led to efforts to create a bicampus structure for advancing pediatric quality and patient safety. Senior leadership also recognized that peer organizations were investing heavily in quality and safety as core strategic initiatives and that NYPH would benefit from safety and QI efforts, especially given the increasing accreditation and regulatory oversight by The Joint Commission, the Centers for Medicare & Medicaid Services, and New York State. In an effort to create a plan for the partnership going forward and to generate hospital staff buy-in, a bicampus leadership retreat attended by hospital leadership and staff from all disciplines involved in caring for children was held in 2006 that focused exclusively on pediatric quality and safety. The timing of the retreat coincided with the development of two new positions: director of quality and patient safety for KCCH [R.K.], 44
January 2009
The current pediatric quality and safety program structure includes an entirely new set of committees serving both individual campuses as well as bicampus service line needs and is structured to achieve functional goals. Senior leadership of both the hospital and the two pediatric departments have been critical to not only the establishment of these efforts but even more so their early successes. The involvement of senior leadership underscored the priority placed on quality and safety and helped to quickly effect change by allocating personnel and resources necessary to enhance safety and reduce risk. Faculty involvement, in particular, was dependent on and influenced by support from the chairs. Several staff members have also been hired to support quality and safety activities, including quantitative support of measurement activity. Their roles have continued to evolve with the further development of our quality and safety program. Each campus now has its own children’s quality council, an interdisciplinary group that meets to discuss and prioritize safety and quality issues. The quality councils from each campus report directly to a bicampus children’s quality steering committee that was formed to ensure that similar safety practices and standards are implemented across both children’s hospitals (Figure 1, page 45). A safety subcommittee, which primarily coordinates and follows up on leadership safety walk rounds, and a significant-events subcommittee, which reviews morbidities and mortalities, report to each hospital’s quality council. These groups ensure that quality and safety issues are identified
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety Pediatric Safety and Quality and addressed in a timely manner. Other important committees that have been formed include a bicampus Organizational Structure measurement committee, which helps to define and measure clinical outcomes at both campuses, and a bicampus pediatric information technology (IT) committee, which recommends IT improvements and studies their effects on quality and safety. The structure of parallel and bicampus committees allows each campus to address important issues internally while encouraging collaboration and ensuring that ideas will be disseminated at both institutions. The committees require that physician leaders on both campuses together achieve consensus to help ensure uniform standards. In addition, serving on each of these committees Figure 1. The Pediatric Safety and Quality Program at Morgan Stanley Children’s are physicians, nurses, pharmacists, and other hospital Hospital and the Komansky Center for Children’s Health includes several individual personnel. Participation also occurs from other depart- and bicampus committees. IT, information technology. ments involved in the care of children, such as surgery, anesthesiology, and radiology, to help ensure that multiple per- providers perceive blame for errors or react negatively to crispectives are identified by people actively involved in caring for tiques to one in which teamwork is viewed as essential and patients and that solutions for problems are realistic in the con- everybody feels a responsibility to make the hospital safe. At both MSCH and KCCH, a formalized structure for family partext of current organizational operations. ticipation, the family advisory council (FAC), has been estabProgram Priorities and Initiatives lished. The process by which these councils were formed, their Our bicampus pediatric quality and safety program is current- accomplishments, and the barriers faced at each site, however, ly organized around five broad themes, which have evolved are quite different. Their development is illustrative of the benfrom the themes of the 2006 bicampus leadership retreat: efits and limitations of cross-campus collaboration. 1. Improve the culture of safety. After a series of false starts, the FAC effectively started at 2. Reduce the frequency of health care–acquired infections. MSCH in 2005, led initially by the efforts of parents, with sup3. Reduce harm in the health care setting. port from hospital leadership. After an initial period centered 4. Use IT to improve the quality and safety of care provided on recruitment and the development of an organizational structo patients and families. ture, it implemented a number of important endeavors. In the 5. Measure the effectiveness of care in key areas. past three years, the FAC at MSCH developed resources for A series of specific initiatives target each of these program parents and worked with staff to spread the idea of family-cenpriorities. A detailed review of two sample initiatives—building tered care and family-centered rounding. It has successfully crefamily engagement and prevention of adverse medication ated a comprehensive guidebook for parents, written from a events—helps illustrate the successes and challenges faced by parent’s perspective, and Parent TIP sheets on hospital safety our integrated program. Building family engagement is an goals. Parents also have become active participants on multiple important part of our efforts to improve the culture of safety, committees, such as the children’s quality council, the ethics and the prevention of adverse medication events is part of our committee, and the bereavement committee. effort to reduce harm in the health care setting, as well as to use Formation of the FAC began at KCCH in October 2006, IT to improve quality and safety of care. initially led by staff members interested in spreading the successes seen at MSCH. During the early formation of the FAC BUILDING FAMILY ENGAGEMENT at KCCH, the FAC at MSCH became an invaluable resource An integral and evolving part of efforts to improve the hos- because of its experiences one year earlier. Bylaws, organizationpital’s culture of safety has been the expanding role of family al structures, and strategies were adapted from MSCH and led members. Involving parents has been important on both cam- to an FAC capable of quickly launching successful initiatives. puses as a step in shifting from a culture in which health care The KCCH FAC has created a welcome guidebook for parents January 2009
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The Joint Commission Journal on Quality and Patient Safety for the inpatient units and has started a parent-to-parent support group that provides monthly luncheons on multiple units. It has created a Web page for recruiting new members, and parents participate on the children’s quality council and the bereavement committee. In a role similar to that played by the FAC at MSCH, it was involved as family faculty in orienting new interns to provide the parent perspective of family-centered care. Despite their successes and ongoing progress, both FACs have faced significant challenges. Initially, the MSCH FAC spent much of its time navigating administrative issues and trying to increase staff participation. Its lessons learned helped the FAC at KCCH navigate these processes much more quickly. At KCCH, the primary challenge has been increasing parent participation. Both councils also struggle with financial resources and the tremendous time and effort it takes to have a functioning FAC, particularly when there is no paid coordinator and participation is voluntary. Both FACs have increasingly begun to work together to share ideas for overcoming these barriers.
PREVENTING ADVERSE MEDICATION EVENTS Published literature underscores the importance of this focus; a 2006 report by the Institute of Medicine estimates that at least 1.5 million preventable adverse drug events (ADEs) occur each year, with preventable ADEs defined as injuries that result from errors in the medication process (prescribing, dispensing, transcribing, administering, or monitoring of a medication).4 These events have been shown to occur frequently in children, and although the medication error rate is similar in hospitalized children and adults, the rate of potential ADEs is three times higher in children.5 In an effort to reduce the risk of medication errors, significant resources have been dedicated to detecting and addressing both near misses and actual adverse drug events. To date, much of the detection has been through the voluntary Web-based medical error reporting system (MERS) in place at both campuses. These reports complement the mandatory reporting of serious errors. Throughout the year, staff members of all disciplines are reminded about the importance of filling out MERS reports. Following modifications to MERS made on the basis of staff feedback, MERS reports have more than doubled at both MSCH and KCCH. Detailed reports analyzing each campus’s MERS reports are generated and reported quarterly to the quality councils at each campus. Patterns of MERS reports have been used to identify a number of issues including ordering errors (recognized in the pharmacy and corrected) stemming in 46
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part from issues with the computerized physician order entry (CPOE) system. A task force was chartered to identify both the root causes and solutions to this problem at KCCH. Because of the quality steering committee’s integrated bicampus structure, significant-event information and patterns of errors are quickly disseminated to both campuses. In this way, lessons learned from errors at one campus translate to changed practice and policies at both campuses to ensure one uniform standard of care. NYPH has also invested considerable financial resources in technology development and improvement as a major strategy for reducing pediatric medication errors. Both campuses have CPOE with pediatric-specific clinical decision support, and research at KCCH has shown reductions in overall errors, drugchoice errors, significant events, and events rated as serious or life threatening.6 Pediatric-dosing defaults (which address the most common use of each drug and take into account such factors as gestational age, postnatal age, and weight) were initially established in 2002 for 193 commonly prescribed medications; the system is continually undergoing iterative refinements. These efforts are led by the bicampus pediatric IT committee. Cross-campus collaboration was initially limited by the fact that MSCH and KCCH used different inpatient computer systems until 2007. Sources of error or improvements to one system were often product-specific and isolated to one campus. As a result of the bicampus IT committee structure, with a single inpatient computer system at both sites, changes to one campus’s pediatric dosing table now drive changes at the other campus.
ONGOING INITIATIVES In addition to working on building family engagement and preventing adverse medication events, the bicampus pediatric safety and quality program has led a number of other efforts addressing the five broad program priorities. Among other initiatives, both campuses have implemented bimonthly leadership safety walk rounds; actively participated in a hospitalwide multidisciplinary campaign known as “Operation Come Clean” to improve hand hygiene; and participated in a number of Child Health Corporation of America (CHCA)–sponsored clinical improvement collaboratives designed to reduce central venous catheter (CVC)–associated blood stream infections (BSIs), improve recognition of changes in patient condition, and reduce ADEs. The bicampus pediatric safety and quality program has also led efforts to reduce harm in the health care setting by targeting a number of high-risk areas, such as patient transitions. An electronic medication reconciliation form with-
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety in the patient’s electronic health record was developed that is identical in both organizations, and staff were trained in the SBAR (Situation-Background-Assessment-Recommendation) model of communication used to improve and standardize communication during handoffs. These bicampus efforts have produced a number of early successes. For example, participation in the CHCA collaborative to reduce CVC–associated BSIs led to a 65%–75% decrease in rates of infection at both PICUs, and the PICU at KCCH went for more than one year without a CVC–associated BSI. Substantial reductions were also seen in the NICUs at both hospitals. These decreases have been sustained. In addition, SBAR has now been implemented throughout MSCH after being piloted in the NICU, and at KCCH, SBAR was piloted in the pediatric burn unit and is now being implemented on multiple units.
Discussion KEYS TO SUCCESS Effectively integrating safety and quality practices across two structurally and programmatically distinct pediatric divisions, including one freestanding children’s hospital and one children’s hospital within a larger hospital, required a critical evaluation of variation in practices, benefited from collaboration and review of experiences and successes at other organizations, and ultimately challenged the status quo so as to achieve safer and more effective practice. Senior leadership support from both COOs and the pediatric chairmen was crucial to the success of the bicampus program. These leaders consistently set expectations regarding the most important goals for the program and helped maintain a singular focus on delivering the safest and most effective care to every child and family, irrespective of the campus at which the child received that care. Leaders also worked to promote crosscampus collaboration across divisions that before the merger had previously been naturally competitive in recruiting for faculty, fellows, and residents. This cultural change did not, of course, occur overnight. Regular meetings of hospital leaders, departmental chairs, and divisional faculty were held to discuss quality and safety goals and create plans to achieve them. These discussions were invaluable in building trust, gaining consensus, and overcoming barriers. Over time, the efforts to ensure optimal care for all children at NYPH have resulted in numerous collaborative initiatives and a generally cooperative culture in which goals are shared and strategies coordinated. The expectation that both organizations would provide the same quality of care and could learn from each other’s efforts despite
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the fact that one of them was significantly smaller and physically part of a larger hospital was also essential. Pediatric safety and quality leaders at both campuses also have focused efforts on developing relationships with departmental chairs and the clinical leaders of those involved in the care of children, including surgeons, anesthesiologists, radiologists, and laboratory workers. Members from each of these departments are active participants in the quality councils and other committees involved in safety and quality. This collaboration is essential, particularly at KCCH, because many of the ancillary staff are more frequently involved in the care of adults as opposed to children. In addition, the quality and safety leaders on each campus have close professional relationships and are committed to working together.
BARRIERS Integrating the pediatric safety and quality program across two institutions has been challenging. Implementing change within well-established infrastructures is difficult. We have encountered both perceived and real differences in the nature of care delivered, because people are often wedded to the ways that issues are approached, regardless of the outcome. Tremendous time and commitment are required at an individual and organizational level to overcome these perceptions and effect real change. The combination of education, incorporating staff input to adapt policies to best meet the needs of both organizations, and senior-level mandates when necessary are all strategies that we have used. It is also challenging to overcome the historical competition for resources, recruitment, and recognition. Allocating resources across two campuses that differ in size and expertise is difficult and remains a struggle. This includes finding resources to allow faculty to pursue academic advancement in quality and safety-related work. There has also been a tendency to believe that an integrated hospital cannot contribute to processes at a much larger freestanding children’s hospital. Yet, each of the two institutions has contributed new practices to the other, which has been increasingly viewed as routine and beneficial. Differing electronic health records also have been a barrier. Until recently, both campuses had different inpatient and outpatient computer systems, so that problems were not always comparable or improvements could not easily be translated across organizations. Now, changes to the CPOE system and pediatric dosing table can be made in parallel. This problem has not been resolved in the outpatient setting. In addition, differences between the pediatric divisions make some initiatives not feasible for both campuses or make some
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The Joint Commission Journal on Quality and Patient Safety initiatives easier at one site. For example, given the MSCH’s much greater volume of patients, it is the only campus to have participated in initiatives such as the CHCA surgical site infection reduction collaborative. In contrast, some initiatives have been more easily accomplished at KCCH, which, for example, has achieved 100% use of electronic documentation for five years, while the increase in use of electronic documentation has been much more gradual at MSCH.
FUTURE DIRECTIONS Although still in its early stages, the bicampus pediatric safety and quality program has effected real change since 2006 and has been a leader within the NYPH system as a whole in the adoption of practices such as family-centered rounding, leadership safety walk rounds, and the advancement of IT. The program will continue its bicampus efforts going forward and will engage in additional opportunities for collaboration. During the next few years, the program will continue to work on the current priority areas and will expand its efforts on the basis of actual safety events and near misses. For example, as part of the effort to prevent adverse medication events, we plan to identify events and near misses by the use of trigger tools, in which specific actions (such as the ordering of certain drugs or certain abnormal laboratory values) serve as triggers to conduct detailed chart review.7,8 We will also be adopting uniform smart infusion pumps and bar-coding technology to reduce medication errors. Another important focus will be on efforts to further research in quality and safety, including career tracks for faculty interested in this field. At Weill Cornell Medical College, the division of quality and clinical informatics, created in 2008, includes several pediatric faculty members dedicated to health services research. Multiple junior faculty members are mentored in quality and safety projects at both campuses, and a number of cross-campus collaborative research projects related to safety and quality are ongoing. A clinical scholar endowment was also created at KCCH to support faculty work in quality and safety efforts. We are also looking to increase collaboration using databases allowing for comparative benchmarking and intend to continue to strengthen our partnership with parents, whose insight and efforts to date have been invaluable.
Conclusions
goals, creating leadership positions in quality and safety and filling these positions with leaders committed to collaborating, building staff buy-in, and obtaining leadership support from the highest levels have all been crucial factors in the program’s success. Overcoming entrenched organizational practices and determining how best to allocate resources are two of the biggest challenges we continue to face. With the large number of merged hospitals formed in the past few decades, identifying strategies to successfully integrate bicampus programs is important to inform other organizations undergoing similar efforts. J Erika Abramson, M.D., is Instructor, Department of Pediatrics, Weill Medical College of Cornell University; and Assistant Attending Pediatrician, New York-Presbyterian Hospital, New York City. Daniel Hyman, M.D., M.M.M., formerly Chief Children’s Quality Officer and Chief Medical Officer for Ambulatory Care, New YorkPresbyterian Hospital; Assistant Clinical Professor of Pediatrics and Public Health, Weill Cornell Medical College; and Assistant Professor of Pediatrics, Department of Pediatrics, College of Physicians and Surgeons of Columbia University, New York City; is Chief Quality Officer, The Children’s Hospital, Aurora, Colorado. S. Nena Osorio, M.D., is Assistant Professor of Pediatrics, Department of Pediatrics, Weill Cornell Medical College, and Assistant Attending Pediatrician, New York-Presbyterian Hospital. Rainu Kaushal, M.D., M.P.H., is Chief, Division of Quality and Clinical Informatics; Associate Professor of Pediatrics and Public Health, Weill Cornell Medical College; Director of Pediatric Quality and Patient Safety, Komansky Center for Children’s Health, New York-Presbyterian Hospital; and a member of The Joint Commission Journal on Quality and Patient Safety’s Editorial Advisory Board. Please address requests for reprints to Rainu Kaushal, [email protected].
References 1. Spang H., et al.: Hospital mergers and savings for consumers: Exploring new evidence. Health Aff (Millwood) 20:150–158, Jul.–Aug. 2001. 2. Mallon W.: The alchemists: A case study of a failed merger in academic medicine. Acad Med 78:1090–1104, Nov. 2003. 3. Gering J., et al.: Taking a patient safety approach to an integration of two hospitals. Jt Comm J Qual Patient Saf 31:258–266, May 2005. 4. Institute of Medicine: Preventing Medication Errors. Washington, DC: National Academies Press, 2006. 5. Kaushal R., et al.: Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120, Apr. 25, 2001. 6. Holdsworth M.T., et al.: Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. Pediatrics 120:1058–1066, Nov. 2007. 7. Resar R.K., et al.: Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 12(suppl. 2):ii39–ii45, Dec. 2003. 8. Resar R.K., et al.: A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf 32:585–590, Oct. 2006.
Developing a pediatric safety and quality program across two campuses has been challenging but has led to important improvements at both organizations. Establishing common 48
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