SSM Health Care Clinical Collaboratives: Improving the Value of Patient Care in a Health Care System

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The collaboratives are quite similar to those of the Institute for Healthcare Improvement (Boston), with the notable exception of the continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. PERFORMANCE IMPROVEMENT IN HEALTH CARE ORGANIZATIONS

SSM Health Care Clinical Collaboratives: Improving the Value of Patient Care in a Health Care System ANDREW L. KOSSEFF, MD SHELLEY NIEMEIER, BSN, MHA

he value of collaborative improvement work in health care is apparent.1–6 In November 1998 SSM Health Care (SSMHC) launched a series of clinical collaboratives. Collaborative improvement seemed particularly well suited to the system. SSMHC, a large Catholic health care system with 19 acute care hospitals (that is, entities) in Missouri, Illinois, Wisconsin, and Oklahoma, had been committed to continuous quality improvement (CQI) principles and practices since 1990. All administrators and hospital employees and many medical staff physicians have received CQI training, so the need for training for

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these collaboratives was minimal. Fifteen of these entities have participated in the Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaboratives since they were established in 1995. The hospitals and SSMHC have benefited greatly from that participation. SSMHC clinical collaboratives are modeled after the IHI Breakthrough Series and incorporate rapid-cycle improvement methods.7 The concept was to harness the expertise within SSMHC and combine that with the learning from the IHI model to accelerate clinical improvement work in the system. SSMHC entities continue to be actively involved in IHI collab-

Andrew L. Kosseff, MD, is Physician Consultant to the SSMHC Quality Resource Center, and Shelley Niemeier, BSN, MHA, is Consultant to the SSMHC Quality Resource

ton, MN), for his thoughtful ideas about SSMHC, and Kay Johnson, SSMHC Corporate Communications, for invaluable help in editing. The authors are indebted to the Institute for Healthcare Improvement (Boston) for its support in the adaptation of the Breakthrough Series model. Please address requests for reprints to Andrew L. Kosseff, MD, SSM Health Care, 477 North Lindbergh Blvd, St Louis, MO 63141; phone 314/994-7748; fax 314/994-7863.

Center, St Louis. The authors wish to thank Dr Gordon Mosser, CEO of The Institute for Clinical Systems Improvement (BloomingCopyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations

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THE JOINT COMMISSION Article-at-a-Glance Background: In 1998 SSM Health Care (St Louis) began a series of clinical collaboratives modeled after The Institute of Healthcare Improvement (Boston) Breakthrough Series. There are now four collaboratives, with 46 teams in progress, and four additional collaboratives are scheduled. Collaborative topics and structure: Each collaborative consists of three phases: the prework, active, and the continuous improvement phases. The structure of the collaboratives is quite similar to that of the Institute for Healthcare Improvement Breakthrough Series. However, the SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. Results of collaboratives in progress: Entity teams participating in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In Col-

oratives because this involvement adds a further dimension to the improvement work. The mission of SSMHC clinical collaboratives is “to provide an environment conducive to the discovery and development of clinical improvements that can be easily and rapidly diffused so that all SSMHC entities and patients can benefit from the improved value of care.” This article describes the development, structure, results, and characteristics of success and failure in clinical improvement projects in SSMHC.

Collaborative Topics The selection of collaborative topics appears to be critical. Since participation in SSMHC clinical collaboratives is voluntary, the topics must be important to our entities to gain their participation. Topic selection is based on a number of considerations, including ■ known performance gaps (such as secondary prevention of ischemic heart disease); ■ system or entity data (such as improving prescribing practices); ■ clinican input; ■ SSMHC system leadership approval; ■ national health care agenda issues (such as enhancing patient safety); and ■ previous success in other collaborative efforts.

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laborative 1—Improving the Secondary Prevention of Ischemic Heart Disease—the participating entities showed significant improvement in cholesterol screening and treatment. In Collaborative 2—Improving Prescribing Practices—the collaborative teams also showed significant improvement, with a combined cost savings of approximately $450,000 per year. Collaboratives 3—Using Patient Information to Improve Care and Assure Success—and–4—Enhancing Patient Safety Through Safe Systems—are under way. Summary: The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. The collaboratives provide an environment for clinicians to constructively participate in improvement of patient care.

Our collaborative topics range from a very narrow (for example, secondary prevention of ischemic heart disease) to a broad focus (for example, using patient information to improve care), and we have discovered benefits from each type of endeavor. Narrowly focused topics tend to stimulate similar projects and process change sharing between participating entities. Broadly focused topics lead to more innovative projects. Collaborative topic flexibility allows SSMHC to develop a collaborative quickly when the need arises. Such a circumstance occurred after the publication of the Institute of Medicine (IOM) report To Err Is Human,8 which focused attention on medical errors. Within 2 months of its publication, we developed a collaborative, Enhancing Patient Safety Through Safe Systems, to accelerate the error reduction work already in progress at SSMHC. It was particularly rewarding that many of the SSMHC entities actually requested that such a collaborative be started. Table 1 (p 7) shows the topics and timetable for the SSMHC collaboratives.

Structure of the Collaboratives Each collaborative consists of three phases: the prework, active, and the continuous improvement phases (Figure 1, p 8). The structure of the collaboratives is quite similar to the IHI Breakthrough Series, but the

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Table 1. Timetable for Collaboratives

Collaborative Topic

Starting Date

Enrolled Entities

Improving Secondary Prevention of Ischemic Heart Disease

12/98

4

Improving Prescribing Practices (IPP)

5/99

10

Using Patient Information to Improve Care and Assure Success (UPI)

11/99

14

Enhancing Patient Safety Through Safe Systems (EPS)

3/00

18

Improving Treatment and Decreasing Readmissions for Patients with Congestive Heart Failure (CHF)

12/00

Reducing Open Heart Surgery Infections

2/01

Improving the Treatment of Community-Acquired Pneumonia

6/01

Improving the Treatment of Asthma

1/02

SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. Prework Phase The prework phase, the official start for each collaborative, begins with system leaders sending an invitation to all SSMHC entities. The invitation includes a brief note about the importance of the proposed collaborative topic and how it relates to SSMHC’s mission and values. Having the invitation sent by system leadership is an important statement about the collaboratives’ central role in the functioning of the system. Other items included in the invitation are the goals for the collaborative projects, relevant literature supporting the improvement work, a list of change concepts to help teams get started, specification of baseline data to be collected, and a registration form. Directors are recruited for each collaborative, representing experts in the SSMHC system who have a particular interest in the topic. Usually the directors are practicing physicians but on two occasions, members of system leadership volunteered for this position, which reinforced the collaboratives’ importance and made a critical connection between clinical improvement work and SSMHC strategic plans. During the prework phrase two or three conference calls occur to help participants become acquainted, to help teams collect baseline data and develop project goals, and answer questions. An intranet Listserv is established and is used to evaluate relevant literature, discuss team issues, and share data.

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Active Phase In the 6- to 8-month-period of the active phase, the teams are expected to accomplish the project goals that result in measurable improvement. This phase begins with Learning Session 1 (LS1), which is 6-hour face-to-face meeting at the SSMHC corporate office in St. Louis. The day begins with a presentation by Sister Mary Jean Ryan, FSM (President/CEO, SSMHC) and William Thompson (Senior Vice President, Strategic Development, SSMHC). Their remarks reinforce the importance of the collaborative work and include a review of the details and goals of the particular collaborative. Following this, a collaborative director or an outside expert discusses the importance of the work ahead. Teams are then asked to make brief presentations of their baseline data collected during the prework phase. Interactive dialogues between teams are encouraged. Each team is assigned a coach (either a collaborative director or facilitator), and the teams spend the afternoon with the coaches, working on their aims for the collaborative projects. The measurable project aims of each team are related to the overall collaborative goals but reflect specific entity needs related to the baseline data. Goal attainment is based on the individual team aims. LS1 concludes with a discussion of the next steps for the collaborative. Following LS1, the teams return to their entities to work on projects. During the intervening months the teams have monthly conference calls, Listserv discussions, and individual team coaching to support the work. The active phase concludes with Learning Session 2 (LS2), which is a second 6-hour meeting at the SSMHC corporate office. By this time, most teams

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THE JOINT COMMISSION SSMHC Clinical Collaboratives

Start of collaborative

Design collaborative

Prework phase

Send out invitation

Form team and collect data

LS1

Project work and completion

Active phase

New entities join

LS2

Continuous improvement phase

Data collection every 3 months

Conference calls every 2 months

Figure 1. The clinical collaboratives include three phases: prework, active, and continous improvement. LS, learning session.

have successfully reached their goals. The structure of LS2 is different from that of LS1. At LS2, each team is asked to make a 15-minute oral presentation about its project and to construct a simple project results display (that is, storyboard). Members of SSMHC leadership attend this learning session, as they are very interested in and supportive of the teams’ work. The day is a celebration of the work of the collaborative. LS2 concludes with a discussion of the next phase of the collaborative, the continuous improvement phase. At LS2, teams are asked to fill out evaluation forms, which have been extremely useful in making improvements in the collaborative design. Within a month of

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LS2, a results booklet is produced that includes the collaborative teams’ accomplishments and the process changes they used to reach the goals. The results booklet is disseminated throughout the system. Also, an article summarizing the results is published in Network, the systemwide employee newsletter. Continuous Improvement Phase The final phase is designed to maintain the gains of the collaborative, to encourage new goals in the collaborative topic, to create a network of system experts, and to involve new entities in the collaborative. Entities not in the collaborative are invited to join at this

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point. When they join, they receive a Collaborative Care Package, which includes the results booklet and copies of any SSMHC protocols, CARE PATHWAYS®, or orders that teams in the collaborative used to reach their goals. The Listserv and the conference calls continue to occur every two months. Data collection is continued quarterly to monitor and maintain gains. Results of Collaboratives in Progress Entities’ participation in SSMHC collaboratives is voluntary, so an important measure of satisfaction with the program and topics chosen is the number of entities that enroll in each collaborative. Figure 2 (p 10) shows the progressive increase in enrollment from an initial 4 entities in the first collaborative to 18 entities in the fourth collaborative. Entity teams that participate in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In ther first collaborative, when the teams came to LS1, some did not even have the baseline data collection completed. In the fourth collaborative, by LS1, the teams all had baseline data, and some had started to make tests of change. Collaborative 1: Improving the Secondary Prevention of Ischemic Heart Disease (Secondary Prevention*) Secondary prevention of ischemic heart disease was selected for the initial collaborative because of known national performance gaps, evidenced-based information showing the benefits of secondary prevention, and the large volume of cardiac care provided by SSMHC hospitals.9–30 The collaborative’s goal is to improve processes so that 95% of patients with myocardial infarctions (MIs) receive appropriate aspirin and beta-blocker therapy and that 95% of patients have a cholesterol and low-density lipoprotein (LDL) level taken within six weeks of the myocardial infarction. If the LDL is greater than 125, treatment should be instituted. Baseline data indicated that most of the participating hospitals did very well in treating patients with aspirin and beta blockers, but they needed to improve cholesterol screening and treatment, so these issues * Abbreviated name.

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became the major focus of the collaborative. Figure 3 (p 11) shows the combined results of the collaborative with significant improvement in cholesterol screening and treatment. Hospital A elected to decrease the time from admission to the time of administration of aspirin for MI patients. The emergency department staff were not aware that the time to aspirin administration was so long (7.4 hours) until the baseline data were collected. This prolonged time was related not only to delay in administration but inadequate documentation. After the baseline data were presented, the emergency room staff developed a better system that ensured rapid aspirin administration and definite documentation. In addition, a process was developed in the cardiac catheterization lab that required aspirin administration and documentation before cardiac procedures could proceed. These improvements were complemented by development of a CARE PATHWAY® for patients with MI patients (Figure 4, p 12). Hospital B made major gains by changing the admission orders on units where patients with MIs were admitted (Figure 5, p 13). Many physicians believed that a cholesterol level obtained when a patient was experiencing a heart attack is not valid. However, the literature suggests that if the cholesterol level is obtained within 24 hours of the occurrence of an MI, it is reasonably accurate and the hospitalization provides an important opportunity for assessing the cholesterol level.31–34 The team presented this new concept to all involved staff before implementing process changes. After the team reached agreement with the physicians, a new standing order was developed: Obtain a fasting lipid profile at admission or in the morning if the patient is not fasting at admission. The order was constructed so that if a physician did not want the lipid profile to be done, he or she had to actively cross out that order. That simple order change led to a significant improvement in the percentage of MI patients who had cholesterol levels noted in their charts. However, the real objective of cholesterol screening was to increase the number of patients who were appropriately treated for elevated cholesterol levels, and the team was disappointed that treatment with lipid-lowering agents did not initially increase. The team then encouraged nurses to screen MI patients for elevated cholesterol or LDL levels and to inform a patient’s physician of the elevated levels. With this

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THE JOINT COMMISSION SSMHC Clinical Collaboratives 20

Number of Entities

15

Entities participating 10

New entities Entities reaching goal

5

0 Secondary Prevention

IPP

UPI

EPS

Collaborative Figure 2. This figure shows the number of entities, new entities, and those reaching their goals in each collaborative. Data on goal achievement are not available for the Using Patient Information to Improve Care and Assure Success (UPI) and Enhancing Patient Safety Through Safe Systems (EPS) collaboratives because they are in the active phase.

further change, the percentage of patients treated with lipid-lowering agents increased significantly. Improved lipid screening and treatment of elevated cholesterol levels should result in lower cholesterol and LDL levels in MI patients. Figure 6 (p 14) shows the data from two of the collaborative hospitals. Total cholesterol and LDL levels have improved only slightly. This disappointing result may be related to the fact that the measurements are done on hospitalized patients with MIs, and it may take more time before the results of improved cholesterol treatment are clearly reflected in patients returning to the hospital. Even since the conclusion of the active phase in July 1999, the teams have continued to collaborate by Listserv and have conference calls every two months. Data are collected every quarter. Three new teams have joined during this phase.

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Collaborative 2: Improving Prescribing Practices (IPP) The topic for the second collaborative—IPP—was selected because of rapidly escalating pharmacy costs, as well as demonstrated successes in certain areas of costeffective prescribing.35–43 This topic was more open ended than that of the first collaborative. The goal for the collaborative was to have each entity team make ≥ 25% improvement in its entity’s prescribing practices. The medication issue(s) chosen for improvement involved one of the top five medication classes (by cost or frequency of doses) used in each entity. Ten entity teams joined this collaborative, and the active phase was completed in January 2000; 80% of the collaborative teams reached their goals. The combined cost savings realized by the collaborative will be approximately $450,000 per year. The teams paid close attention to quality indicators, making sure that quality was main-

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Three Hospitals: Secondary Prevention Documentation of Lipid Levels and Treatment with LLAs 80%

Percentage of MI Patients

70% Cholesterol measured 60%

Treated with LLA

50%

40%

30% BL Jan–Mar 99

AP Apr–Jul 99

CIP Aug–Oct 99

CIP Mar–Jun 00

Time of Data Collection Figure 3. Composite results from all three teams in the collaborative show significant improvement in having lipid levels in patients’ hospital

charts and treating patients with lipid-lowering agents. MI, myocardial infarction; LLA, lipid-lowering agent; BL, baseline; AP, active phase; CIP, continuous improvement phase.

tained or improved. Although the improvement projects were quite varied, four teams worked on common issues. Hospital D decreased the use of a costly anesthetic agent, propofol, in postoperative intensive care unit (ICU) patients on ventilators (Figure 7, p 15). This was accomplished by focusing ICU nurses and cardiovascular surgeons on better pain control and by using alternative sedating agents and nonpharmaceutical methods for reducing patient anxiety. Interestingly, propofol use subsequently decreased in ICU patients who had not had surgery and were ventilated. The project got under way just as a new cardiovascular surgery group started at Hospital D. The new surgeons were very positive about the project, and their participation was critical to its success. Hospital E decreased the use of albumin in cardiovascular surgery patients by substituting het-

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astarch, a more available and less costly alternative (Figure 8, p 16). Cardiovascular surgeons were presented with literature which showed that hetastarch could be safely substituted for albumin. The surgeons then agreed to change intraoperative orders and to use hetastarch. After this change was made, ICU nurses were encouraged to use hetastarch with postoperative patients. Hospital E used quality indicators to ensure that this process change did not jeopardize patient outcomes and safety (Figure 9, p 17). On the basis of Hospital E’s success in decreasing albumin use in postoperative cardiovascular surgery patients, Hospital F took on a similar project. However, it encountered significant nurse resistance, which was overcome by an open dialogue that highlighted current literature about the safety and efficacy of hetastarch (Figure 10, p 18).

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THE JOINT COMMISSION Hospital A: Secondary Prevention Collaborative Time from Admission to Aspirin Administration Time (Hours) for Aspirin Administration to MI Patients

8

7

6 Time of aspirin administration 5

4

3

2

1 BL Mar 99

AP Jul 99

CIP Mar 00

Time of Data Collection Figure 4. Hospital A improved the time from patient admission to the administration of aspirin for patients with MI by introducing process changes in the emergency department and the cardiac catheterization lab and by implementing a CARE PATHWAY ®. MI, myocardial infarction; BL, baseline; AP, active phase; CIP, continuous improvement phase.

Collaborative 3: Using Patient Information to Improve Care and Assure Success (UPI) The third collaborative’s active phase is currently under way. The aim is to improve essential qualities that patients seek in a health care organization44–51: 1. Patients seeing a caregiver that they know and trust and who listens carefully; 2. Compassionate communication between the caregiver and patients and their families; 3. Health care workers providing consistent, clear information to patients and their families; 4. Coordination of care so that patients feel that all health care providers are working together; and 5. Exceptional attention to and communication about pain management. The UPI collaborative’s goals are for each entity team to make a ≥ 25% improvement in any of the five essential qualities and/or develop a new process that

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addresses the five essential qualities. Most of the teams have used baseline data from the standardized SSMHC Patient Satisfaction Survey. Planned projects range from improving discharge instructions to patients to ensuring that ICU patients receive consistent information from their multiple caregivers. Collaborative 4: Enhancing Patient Safety Through Safe Systems (EPS) The fourth SSMHC collaborative was designed to be a systemwide response to the IOM report To Err Is Human, which describes the significant problem of medical errors.4,6,8,41–43,52–57 This collaborative was not planned in the original schedule of collaboratives but was easily designed and launched within eight weeks of the release of the IOM report. The collaborative’s goal is to have each entity team make ≥ 50% improvement in a signifi-

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Hospital B: Secondary Prevention Collaborative Documentation of Lipid Levels and Treatment with LLAs 100%

90%

Percentage of MI Patients

80% Lipid levels in chart 70%

Treated with LLA

60%

50%

40%

30% BL—Jan 99

AP—Jul 99

CIP—Dec 99

CIP—Apr 00

CIP—Aug 00

Time of Data Collection Figure 5. Data from one hospital showing the percentage of patients with MI who had lipid profiles in their charts and the percentage of MI patients

treated with LLAs. Data represent a 30-chart review sample of all patients admitted with acute MI. A standing order that MI patients have lipid profiles resulted in improvement in the percentage of charts with lipid (cholesterol) levels. The improvement in percentage of patients treated with LLAs occurred because more cholesterol levels were in the charts and nurses were educated to alert physicians about high cholesterol levels at the time of patient discharge. MI, myocardial infarction; LLA, lipid-lowering agent; BL, baseline; AP, active phase; CIP, continuous improvement phase.

cant patient safety issue within 5 months. Eighteen of 21 entities in the SSMHC system are registered, and their projects will include reducing coumadinrelated medication errors, decreasing patient falls, and improving the safety of conscious sedation.

Improvements in Collaborative Design Based on Team Evaluations Consistent with CQI philosophy, we have used the Plan-Do-Study-Act (PDSA) cycle to improve the SSMHC collaboratives. When we started the collaboratives, we asked each team for a monthly progress report. Based on team feedback regarding the extra work this report represented, the collaborative facilitators decided that if the teams participated in the monthly conference calls, the coaches would write the progress report for the teams and include the report in

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the minutes of the call. This decreased the work for the teams and also improved conference call participation. The learning sessions are limited to 6 hours so team members can travel into and out of St Louis in one day. The learning session agendas also tend to be full. Frequently we have had to shorten lunch and other break times to accommodate what we thought were important parts of the learning sessions. However, many teams indicated in their evaluations that lunch and other breaks were very important informal networking times. Now, we always plan to provide as much time as possible for this networking. At each collaborative’s LS2, teams are asked to make a 15-minute presentation to share and celebrate their project results. Participant evaluations indicated that these presentations required too much preparation and caused significant anxiety. Based on

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THE JOINT COMMISSION Hospitals A and C: Secondary Prevention Collaborative Average Total Cholesterol and LDL Levels in MI Patients

Average Total Cholesterol and LDL

250

200 Hospital A total cholesterol Hospital A LDL 150 Hospital C total cholesterol

100

50 BL Jan–Mar 99

AP Mar–Jul 99

CIP Mar–Jun 00

Time of Data Collection Figure 6. Total cholesterol and LDL levels from two collaborative hospitals are shown. Further improvement will likely be seen as the collaborative progresses. MI, myocardial infarction; LDL, low-density lipoprotein; BL, baseline; AP, active phase; CIP, continuous improvement phase.

this feedback, we now provide a presentation template for teams to use in preparing the these project talks and their project results display or storyboard. Our experience has reinforced the value of using participant feedback to improve the collaborative design.

Discussion We have been encouraged with the measurable results from the SSMHC collaboratives. The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. There is a delicate balance to reach between providing enough structure to help teams achieve success and creating an environment that encourages voluntary participation and innovation in the collaboratives.

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An additional benefit of the collaboratives has been the opportunity to observe 46 improvement teams and learn what factors contribute to successful improvement work and what problems predict failure. These factors are strikingly similar to those observed by Leape et al.54 Careful selection of improvement projects is important. Successful teams use baseline data, which are clear and collected rapidly, to show their institutions’ performance gaps and, ideally, external benchmarks which indicate that the process can be done better. By the time the baseline data are presented to stakeholders, successful teams already have developed proposed tests of change that are supported by medical literature. Clinicians receive clear information to know why they should switch from the status quo. Leape et al stated that “successful teams chose practical interventions and moved early into changing a process.”54(p 328)

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Hospital D: Improving Prescribing Practices Collaborative ICU Propofol Use 12

Thousands of Milliliters/Dollars

10

8

Total ml used Cost/dollars

6

4

2

0 BL Q1 99

AP Q2 99

AP Q3 99

AP Q4 99

CIP Q1 00

CIP Q2 00

Time of Data Collection Figure 7. The decrease in propofol use at Hospital D is shown. The decrease occurred in ICUs where a protocol was developed that focused on

alternative sedative drugs and emphasis on pain control for ICU patients on ventilators. Gains have persisted into the CIP of the collaborative. ICU, intensive care unit; BL, baseline; AP, active phase; CIP, continuous improvement phase.

Successful process changes are simple and constructed so that accomplishing the desired outcome is easier than maintaining the status quo. Small tests of change in pilot areas prove to be very effective. Positive reinforcement of team progress by coaches and leadership is quite helpful. Ensuring endorsement and involvement of senior management (administrators and physician leaders) are important hallmarks of success for our collaboratives and the IHI Breakthrough Series. In the SSMHC collaboratives this has been approached at two levels. At each collaborative’s learning sessions, SSMHC’s president/CEO and a senior vice president make opening remarks. They highlight the importance of the collaborative work to the SSMHC system and emphasize the collaborative’s goals. This administrative presence has a powerful effect on the collaborative’s work. The second level of leadership involvement is addressed at the entity level. Each team is supported

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and endorsed by its entity’s administration. If a team seems to be faltering, support from coaches and senior management can be very powerful. It is important to involve the appropriate persons in the project. There must be a physician champion who can promote the process changes to the medical staff. One of the SSMHC teams, working on appropriate indications for vancomycin prophylaxis in surgery, had recruited a physician champion. The physician dropped out of the project halfway through, which made the project work much more difficult. It is also vital to include all disciplines involved in a process to be on the project team. It is our experience that while it is critical for physician participants on the team to agree with the proposed clinical changes, it is frequently the nonphysicians (nurses, pharmacists, and so on) who really drive the improvement effort and are most often the team leaders. These

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THE JOINT COMMISSION Hospital E: Improving Prescribing Practices Use of Albumin in Cardiovascular Surgery 3.0

2.5

Units per Case

Albumin/case 2.0

Hetastarch/case

1.5

1.0

0.5 BL Jan–May 99

AP & CIP Sep 99–Mar 00 Time of Data Collection

Figure 8. Hospital E was able to reduce albumin use in cardiovascular surgery patients by construction an intraoperative protocol substituting

hetastarch for albumin. In addition, the intensive care unit nurses were detailed about using hetastarch in postoperative patients. The net cost saving was $92,000 per year. BL, baseline; AP, active phase; CIP, continuous improvement phase.

observations are similar to those of Leape et al,4 who advised that the teams must be interdisciplinary (but include a physician champion) and that anyone on the team who is committed to the process change can serve as its leader. Another success factor lies in providing an opportunity for universal input before the process changes are implemented. Simply notifying people of the changes after they have been finalized will not work. Most of our successful teams have given all stakeholders in the process a chance to comment about the project—at educational meetings, through a position paper, and/or at a departmental meeting. As the process users are alerted to the project, they become a real part of the improvement process and may suggest important changes in design. Building specific quality indicators into the project is important, particularly when the project is

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mainly directed to cost savings. Clinicians will be reluctant to change processes for cost reasons alone unless it can be explicitly shown that quality is at least maintained or improved. In one of the teams that was was working on reducing the use of albumin and using hetastarch instead during cardiovascular surgery, the surgeons were willing to try this new protocol but had justifiable concerns about the quality of patient care. By carefully monitoring quality indicators such as mortality, length of stay, and bleeding complications, the team was able to reassure the surgeons that the practice change was safe for patients. Our experience with team failures is also similar to that of Leape et al. Teams that lack leadership support, get mired in data collection, or try to develop a complete solution rather than simple, incremental process changes are likely to fail. One other reason for failure is change in team personnel. The loss of an

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Hospital E: Improving Prescribing Practices Albumin Use in Cardiovascular Surgery—Quality Monitors

Days/Units/Percentage

9 8

SICU LOS days

7

LOS days

6

FFP units/patient Amicar units/patient

5

Mortality %

4

Platelet units/patient 3 2 1 0 BL Jan–May 99

AP & CIP Sep 99–Mar 00 Time of Data Collection

Figure 9. Hospital E followed quality indicators as the switch from albumin to hetasarch occurred. It was important to make sure that mor-

tality and LOS in the hopital and in the SICU did not increase. There was also a concern that bleeding complications might increase with the use of hetastarch, so the use of platelets, FFP, and amicar was also monitored. The data indicate that quality indicators have remained constant with the switch to hetastarch, although there has been a slight increase in platelet use. LOS, length of stay; SICU, surgical intensive care unit; FFP, fresh frozen plasma; BL, baseline; AP, active phase; CIP, continuous improvement phase.

important team member or physician champion predicts trouble. We believe that it is possible to identify “teams at risk” early in the collaborative and to coach them to avert the project’s failure. One aspect of collaborative improvement work that demands attention is the need to maintain gains. Frequently teams do remarkable project work, but because of other issues in their organization, attention to the project falters and gains are lost. To specifically address this issue, SSMHC collaboratives include the continuous improvement phase, which lasts indefinitely. Teams participate in bimonthly conference calls and collect project data every quarter. To date, the continuous improvement phase appears to be accomplishing this goal. In the Secondary Prevention collaborative, whose active phase concluded in June 1999, all three entities continue to track data, and all are

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showing stability or improvement of process changes. In addition, the collaborative entities are considering enhancement of their work such as monitoring of mortality data, promoting cholesterol treatment in diabetic patients, and working on a protocol for treatment of acute atrial fibrillation. It was also hoped that the continuous improvement phase would be used to spread the improvements throughout SSMHC. Teams that had not been initially involved in the collaborative are invited to join at the start of the continuous improvement phase. However, response to this invitation has been disappointing, with only three new entities joining— and only one of those participating actively in—the Secondary Prevention collaborative. Perhaps there is reluctance to join when the “older” teams are so far ahead. To deal with the crucial issue of spread of

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THE JOINT COMMISSION Hospital F: Improving Prescribing Practices Collaborative Use of Albumin and Hetastarch in Cardiovascular Surgery 300

Units of Albumin/Hetastarch Used

250

200

Hetastarch Albumin

150

100

50

0 BL Q1 99

BL Q2 99

AP Q3 99

AP Q4 99

CIP Q1 00

CIP Q2 00

Time of Data Collection Figure 10. Hospital F decreased the use of albumin in cardiovascular surgery by using a similar protocol to that of Hospital E. The success at

Hospital E was a strong incentive for Hospital D to undertake this project. BL, baseline; AP, active phase; CIP, continuous improvement phase.

process changes from collaborative projects, starting in January 2001, SSMHC will sponsor a series of clinical summit conferences in an effort to stimulate true system change and amplify the collaborative work. Each of these one-day meetings will focus on a particularly important improvement issue. Each will be constructed to clearly delineate the need for change and show what changes from the collaborative projects have made a difference. Following each summit we will set up conference calls and quarterly data collection to monitor changes.

Summary The SSMHC collaboratives have provided a useful addition to longstanding QI work at SSMHC. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. We have been able to develop and use our internal expertise in the

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SSMHC system. The collaboratives provide an opportunity to create a network of experts on the topics. The Listserv and conference calls create a natural environment for sharing. Most importantly, the collaboratives provide an environment for clinicians to constructively participate in improvement of patient care. J References 1. Kilo C: A framework for collaborative improvement: Lessons from the Institute for Healthcare Improvement’s Breakthrough Series. Qual Manag Health Care 6(4): 1–13, 1998. 2. Kilo C, et al: Beyond survival: Toward continuous improvement in medical care. New Horiz 6(1): 3–11, 1998. 3. Kilo C: Improving care through collaboration. Pediatrics 103:384–393, 1999. 4. Leape L, et al: Reducing adverse drug events: Lessons from a

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