Can Health Care Ever Be Safe? Ideas from the “5 Million Lives Campaign”

1. Can Health Care Ever Be Safe?Ideas from the “5 Million Lives Campaign” Donald M. Berwick, MD, MPP Institute for Healthcare Improvement International Forum on Quality and Safety in Health Care Palau de Congressos de Catalunya Barcelona, Spain: April 18, 2007

3. 100,000 Lives Campaign Objectives(December 2004 – June 2006) • Save 100,000 Lives • Enroll more than 2,000 hospitals • Build a reusable national infrastructure for change • Raise the profile of the problem - and our proactive response

4. Components of a Campaign • Platform • Communications • Field Operations • Measurement • Fund-Raising

5. The 100,000 Lives Planks Rapid Response Teams Reliable Care for Acute Myocardial Infarction Medical Reconciliation Prevent Central Line Infections Prevent Ventilator Associated Pneumonias Prevent Surgical Site Infections The Campaign Platform

7. Campaign Field Operations Structure: “Nodes” Introduction, expert support/science, ongoing orientation, learning network development, national environment for change IHI and Campaign Leadership Ongoing communication Local recruitment and support of a smaller network through communication/collaboratives NODES (approx. 75) *Each Node Chairs 1 Network Mentor Hospitals Implementation (with roles for each stakeholder in hospital and use of existing spread strategies) FACILITIES (2000-plus) *30 to 60 Facilities per Network

9. Rapid Response Results: Henry Ford Hospital

10. Rapid Response Results: Benedictine Hospital 43% Reduction

11. MRT Preventable Code Events Results at One Year 73% decrease P < 0.05 Rapid Response Results: Cincinnati Children’s Hospital and University of Cincinnati

12. Ascension Health Mortality Reduction

13. The 100,000 Lives Campaign Scorecard • An estimated 122,000 lives saved by participating hospitals (through work on the Campaign but also through other improvements and work on complementary initiatives) • Over 3,100 hospitals enrolled • Over 78% of all discharges • Over 78% of all acute care beds • Over 85% of participating hospitals sending IHI mortality data

14. The 100,000 Lives Campaign Scorecard • Participation in Campaign Interventions: • Rapid Response Teams: 60% • AMI Care Reliability: 77% • Medication Reconciliation: 73% • Surgical Site Infection Bundles: 72% • Ventilator Bundles: 67% • Central Venous Line Bundles: 65% • All Six: 42%

15. We Aim to Achieve Care That Is… • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

16. IHI’s “No Needless” List No needless deaths No needless pain No helplessness No unwanted waiting No waste …for anyone

17. The Next Campaign Reduce Harm

18. The Next Campaign Reduce Harm… but what do we mean by “harm?”

19. Our Definition of Medical Harm Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, whether or not it resulted from a medical error, and whether or not it occurred within a hospital.

20. The Next Campaign Reduce Harm… but how much harm will we reduce?

21. Logic Chain: Step 1 How Many Admissions per Year in the US? 37 Million Admissions Source: The AHA National Hospital Survey for 2005

22. Logic Chain: Step 2 40 to 50 Patient Injuries per 100 Hospital Admissions Source: IHI “Global Trigger Tool” Guiding Record Reviews How Often Are Patients Injured by Care?

23. How Often Are Patients Injured by Care? Review by Brent James % Life Threatening or Fatal Sample Size Injury Rate % Judged Preventable ~34,000 13.6% HMPS (1984 data) 3.7% 58% 6.6% Utah-Colorado (1992 data) 15,000 2.9% 53% Australian AE (1992 data) 2,353 16.6% 69.8% 22.3% Australian AE at LDSH 10.2% (?) 20.8% Canada AE (2000 data) 3,745 7.5% 36.9% (fatal)

24. The “NCC – MERP” Framework • The capacity to cause error • Did not reach the patient • Did not cause the patient harm • Required monitoring to confirm it resulted in no harm to the patient and/or required intervention to preclude harm • Required intervention • Required hospitalization • Permanent patient harm • Sustain life • Patient’s death Source: Index of the National Coordinating Council for Medication Error and Reporting and Prevention http://www.nccmerp.org/pdf/indexColor2001-06-12.pdf

25. Category “E” Temporary Injury from Care Requiring Intervention EXAMPLE OF AN “E” “An elderly woman was started on antibiotics for a skin infection without taking into consideration she was on an anticoagulant. She got an injection, and that led to a large and painful bleed into her thigh muscle.”

26. Category “F” Temporary Injury from Care Requiring Initial or Prolonged Hospitalization EXAMPLE OF AN “F” “A retired farmer had a hip replacement. On the second night after the operation he got confused and fell out of the bed, and dislocated his new hip. He was taken back to the operating room for repair and he went home a few days later than originally planned.”

27. Category “G” Injury from Care Leading to Permanent Patient Harm EXAMPLE OF A “G” “A 59 year old man had elective heart bypass surgery. He went home in three days, but he came back to the office with a fever and infection in his chest incision. This required several additional operations and weeks of antibiotics. He was left with a markedly deformed chest.”

28. Category “H” Injury from Care Requiring Intervention to Sustain Life EXAMPLE OF AN “H” “A 64 year old lung cancer patient had elective surgery. One hour after the surgery, he was found unresponsive and with a very low blood pressure. He was resuscitated and brought to the operating room to fix a bleeding artery.”

29. Category “I” Injury from Care Contributing to or Causing the Patient’s Death EXAMPLE OF AN “I” “A 55 year old bus driver needed anticoagulation for atrial fibrillation. Three days after starting, he suffered a massive bleed into his brain – a stroke. He died six days later.”

30. “Global Trigger Tool” Finding Injuries of Severity “E” through “I”

31. The Sensitivity of the Trigger Tool Review by Brent James IHI Global Triggers vs Utah-Missouri Confirmed events: IHI found: Utah-Missouri found: Utah-Missouri false (+): 171 160 72 21 (93.6%) (42.1%) (22.6%)

32. Why Do We Find So Many? 40 to 50 Injuries per 100 Admissions • Include Levels “E” through “I” • Most others start at “F” • Global Trigger Tool increases efficiency of search • Do not distinguish “preventable” from “non-preventable” given current knowledge • Include out-of-hospital events that lead to admission

33. The Global Trigger Tool at LDS HospitalReview by Brent James 35.1% of all admissions had at least one adverse event 9.1% of all hospital admissions resulted from outpatient care-associated adverse events • LDS Hospital; 325 patients; October 2004; • Seven trained abstractors; all charts independently reviewed twice

34. Logic Chain: Step 3 37 Million Admissions X 40 Injuries per 100 Admissions = 15 Million Injuries per Year How Many Injuries in the US?

35. Logic Chain: Step 4 Approximately 3.5 Million If we could replicate best performance across the existing Campaign population, how many injuries might we expect to avoid?

37. “The 5 Million Lives Campaign” • Lives “Bettered” • Lives “Unharmed” • “Safer” Lives

38. The 5 Million Lives Campaign • Campaign Objectives: • Avoid five million incidents of harm over 24 months; • Enroll more than 4,000 hospitals and their communities; • Strengthen the Campaign’s national infrastructure for change, and transform it into a national asset; • Raise the profile of the problem (and of hospitals’ proactive response) with a larger, public audience.

40. Reduction in Injuries 100% Percent Reduction in Injuries 17% 5 Million Lives 0 Now 1 Year 2 Years Time

41. Reduction in Injuries 100% Percent Reduction in Injuries 34% 5 Million Lives 17% 0 Now 1 Year 2 Years Time

42. Improving Patient Safety at Mayo Clinic (Adverse Events per 1000 Patient Days – All Sites)

43. “Some Is Not a Number; Soon Is Not A Time” Five Million Better Lives December 9, 2008 9:00a.m. How?

44. The 100,000 Lives Planks Rapid Response Teams Acute Myocardial Infarction Medical Reconciliation Central Line Infections Ventilator Associated Pneumonia Surgical Site Infection The 5 Million Lives Planks Pressure Ulcers Congestive Heart Failure High Alert Medications Surgical Complications (“SCIP”) Methicillin-Resistant Staphylococcus aureus “Boards on Board” The Campaign Platform

45. The Campaign Platform …plus numerous other interventions that hospitals must introduce in order to contribute to meeting our aim.

46. 5 Million Lives Campaign The “Planks” – Starter Set • Prevent Pressure Ulcers

47. Pressure Ulcers

48. Burden of Pressure Ulcers • Prevalence in acute care = 15 % • Incidence in acute care = 7 % • 5-7% of all acute hospital admissions • 2.5 million patients treated each year • Nearly 60,000 die each year from complications • $11 billion dollars per year Sources: How-to-guide & JAMA systematic review by Reddy 2006, referenced a national pressure ulcer Advisory panel (2001) “Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future: An Executive Summary Of the National Pressure Ulcer Advisory Panel Monograph

49. An Example of What Is Possible…St. Vincent’s Medical Center Decrease of 71% Source: Joint Comisision Journal on Quality and Patient Safety The Clinical Transformation of Ascension Health: Eliminating All Preventable Injuries and Deaths Clinical Excellence SeriesDavid B. Pryor, M.D. Sanford F. Tolchin, M.D. Ann Hendrich, M.S., R.N. Clarence S. Thomas, M.D. Anthony R. Tersigni, Ed.D.

50. Reducing Pressure Ulcers For All Patients: • Conduct a Pressure Ulcer Admission Assessment for All Patients • Reassess Risk for All Patients Daily • Inspect Skin Daily • Manage Moisture – Keep the Patient Dry and Moisturize Skin • Optimize Nutrition and Hydration • Minimize Pressure For High Risk Patients: