A very major patient safety initiative has been underway for a few years now at the Altamonte Springs, Fla.-based Adventist Health System, a 44-hospital-campus integrated health system operating in 10 states, and which encompasses 7,700 licensed beds, 9,050 physicians (of whom 1,436 are employed physicians), and 55,000 employees. At Adventist Health System, Loran Hauck, M.D., senior vice president for clinical effectiveness and chief medical officer, has been helping to lead his colleagues in an evidence- and consensus-based ongoing initiative to reduce and eliminate hospital-based incidents of patient harm.
In early August, Dr. Hauck and his colleague, David Stockwell, M.D., an associate professor of pediatrics and a critical care specialist at National Children’s Health System in Washington, D.C., and vice president of clinical services at Pascal Metrics, a Washington, D.C-based software vendor with which the Adventist Health System leaders have partnered in their initiative, presented a webinar sponsored by the Scottsdale Institute entitled “Real-Time ID of At-Risk Patients at Adventist Health System,” in which the described in detail Adventist Health System’s patient safety initiative. And a short time after that, HCI Editor-in-Chief Mark Hagland interviewed Dr. Hauck to get his further perspectives and insights on the initiative.
During the August 6 webinar, Dr. Hauck explained that “This journey really started in 1996, when our CEO hired me to begin to implement evidence-based practices. We began to go live in 2005 with Cerner Millennium. In 2006, we began doing an annual safety culture survey, and we’ve been doing it for nine years. Peter Pronovost [Peter Pronovost, M.D., Ph.D., director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, as well as Johns Hopkins Medicine’s senior vice president for patient safety and quality] asked me in about 2009 whether we’d be interested in participating in a follow-up study to a Keystone Study on central line infection prevention originally done by the Michigan Hospital Association and published in the New England Journal of Medicine. At the conclusion of the Adventist Health System study, they achieved an average of 0.4 infections per 1,000 device days or line days.
Loran Hauck, M.D.
"We implemented the IHI [the Cambridge, Mass.-based Institute for Healthcare Improvement] Global Trigger Tool methodology for 24 AHS hospitals in 2009. By 2010, after one year of data,” Hauck told webinar attendees, “we had identified the most frequent ways patients experienced harm: hypoglycemia induced by insulin therapy; over-sedation with opioids and sedatives; falls with injury; catheter-associated urinary tract infections – those were the biggest causes. So beginning in 2010, we started system-wide collaboratives around those most frequent harms, and began to implement system-wide work in those areas. We also began talking to hospital leadership at board and medical staff retreats about safety and harm. By 2012, all our hospitals were fully live on Cerner Millennium with electronic evidence-based physician electronic order sets and interdisciplinary plans of care. Then in 2012, we implemented barcoding at the point of medication administration.”
Dr. Hauck went on to say, “Then, somewhere in the fall of 2012 or winter of 2013, I met David Classen [David Classen, M.D., an assistant professor of medicine at the University of Utah, and currently CMIO of Pascal Metrics] at a national conference—he was a speaker and I was on a panel discussion. In private we got to talking about some of the tools we had available in AHS that would lend themselves to extending the work that David had done at Intermountain Healthcare and later Kaiser Permanente of Northern California to use the EHR [electronic health record] to electronically identify risk factors that might be indicative of harm. We had four nurses reviewing 20 charts from 24 hospitals every month for four years; 21,000 charts were reviewed using the Global Trigger Tool Methodology. Pascal helped us to develop a more robust analytics database using the Pascal Health Data Bench, more robust than the homegrown tool we had started with. And, starting in January 2013,” he added, “we stopped using the IHI methodology and began building and moving towards real-time trigger detection.”
Among the contrasts that Dr. Hauck noted in the webinar, between retrospective safety information and real-time safety information based on patient clinical data, were the following: retrospective safety information involves interventions after the event; systems detect only a fraction of all events (from random sampling); and retrospective data-gathering is very labor-intensive. Meanwhile, real-time safety information based on clinical data involves automated detection of harm; and it has the ability to trend and prioritize, and lets its users learn from all identified defects (every patient, every day, real time). What’s more, in contrast to the use of retrospective safety data, which does not improve overall patient safety or create a culture of measurement and improvement, using real-time data offers a “socio-technical” approach to patient safety improvement, with a focus on learning systems and creating a culture of learning and safety, and the enablement of actionable safety insights.
Among the types of harm that Dr. Hauck and his colleagues have been measuring are temporary harms that require intervention but do not increase lengths of stay; and severe harms, which fall into one of four categories: temporary harms that prolong hospitalization; permanent patient harms; harms that cause life-sustaining intervention; and harms that contribute to patient deaths.