Evidence-Driven Quality Improvement, the Ascension Way

Tell us a bit more about your efforts around patient safety and care quality.                  
 
Ascension Health has an intensive program, Healing without Harm by 2014, which is focused on inculcating principles of high reliability and reduction of all preventable harmful events in our complex care processes in which all the Health Ministries are involved. While such error measurement and reduction projects obviously involve informatics and clinical processes, they are heavily focused on operational and associate interactions in culturally safe environments to communicate technically and interpersonally in the interest of safest clinical practices.

What are some of the elements involved in the program?
 
Key to Healing without Harm by 2014 is coordination of care efforts regardless of the domain or environment where care is delivered, and intensive education and training about the best ways for reliable communication in the interest of patient safety; the goal being to eliminate any kind of error, and potential for error, within the complex care delivery processes. All of our associates, from the frontline to the executive suite, and regardless of profession, are involved in an intensive program that teaches principles of high reliability, values and standardizes error or potential error reporting, evaluate events carefully and is aimed at creating a culture of safety.

Has clinical IT been an important support and facilitator in that area?
 
Clinical Informatics tools and data are critical to most care processes and therefore can play a vital role in assuring safer practices and eliminating potential mistakes when well implemented. This has been repeatedly noted in literature detailing benefits of HIT. It is of supreme importance, recently emphasized in the IOM report on IT and patient safety, that informatics and EMR projects not be undertaken without careful consideration of the process they impact, if improvements rather than degradation of maximally safe practices are to be achieved. We do not see informatics or electronic health records as soloists in the performance of highly reliable optimal quality care, but rather as fundamental instruments in a much larger orchestra of care delivery artists. Yes, it’s an integral part. Informatics can bolster safety with regard to communication, legibility, clinical decision support, checklists, protocols, alerts and reminders, but only if it enables safe workflow and provides relevant information and process support to caregivers focused on high reliability service delivery.
 
Does your ongoing rollout of evidence-based order sets support the unified processes?
 
We believe so. Order sets are merely one kind of clinical decision support tool that must be developed or adopted in concert with EMR implementations and, in particular, CPOE. From a quality and safety perspective, such sets or protocols can, and have been, used in varying ways in our paper world.  Now we have powerful new tools to allow clinicians to do their work more quickly and reliably, based on evidence-supported clinical content that can be evolved and tailored to incorporate and disseminate best practices, act as reminders and evidence informers, function as safety checklists, indicate costs, suggest appropriate practices, coordinate care, collect clinical information, speed and smooth workflow and record regulatory information..

A foundation set of collaboratively developed order sets are being adopted in varying degrees, depending on what the Health Ministries—about 30—need, what their physicians are prepared to accept, and how incorporation of the order sets is to be embedded in the EMR platform. A Health Ministry may use a foundational set in en-toto, created, or they can modify or author material themselves (across a facility), making sure that regardless of the socialization techniques, they contain key clinical process elements. Each EMR clinical leadership team is choosing how they want to incorporate the order sets and the key process indicators. The project leaders collaborate and communicate in multiple levels of clinically driven governance from facility to System level that support our safety and quality efforts in concert with our Clinical Excellence, clinician integration and other key System committees overseeing the progress.
 
When it comes down to it, you can’t tell physicians what to do, but you can bring them together, correct?
 
Physicians are autonomous creatures and not particularly amenable to being told what to do, but my experience has been that when facts, logic, workflow and high reliability principles are convincing, they are quite willing to collaborate and strive for excellence together. In addition to clinician team collaboration at facility and Health Ministry levels, we have seen shared vision and leadership drive remarkable cohesion in the interest of best care. We’ve also collaborated across healthcare systems with Catholic Healthcare West and Adventist (East) Health, to develop what we called Care Collaborative order sets.  The Care Collaborative provides 1,200 condition-based, procedure-based, and convenience-based, order sets, derived from Zynx and used throughout the three systems.