Nearly two years ago, more than 200 hospitals that are members of Premier Inc., a nationwide hospital alliance headquartered in Charlotte, N.C., joined together in a new care quality improvement and efficiency improvement initiative called QUEST. As part of that initiative, participating hospitals are sharing data with each other in order to reduce mortality and harm. Premier executives estimate that more than 14,000 lives and $1 billion dollars have been saved in the first 18 months of the QUEST project.
One element in the QUEST initiative has been an effort to reduce healthcare-acquired infections, which have become a point of intense interest in healthcare. Salah S. Qutaishat, Ph.D., CIC, FSHEA, Premier’s director, surveillance and epidemiology, has been leading the healthcare-associated infection (HAI) effort within the QUEST initiative. Dr. Qutaishat spoke recently with HCI Editor-in-Chief Mark Hagland regarding the results and learnings so far from that HAI reduction work, as well as the strong links between IT facilitation and success in that area.
More information on the QUEST program can be found here.
Healthcare Informatics: What is the core strategy or philosophy behind Premier’s being involved in working on HAI reduction?
Salah S. Qutaishat, Ph.D.: It really goes back to the 1999 release of the “Crossing the Quality Chasm” report from the Institute of Medicine. That’s when most of us in infection prevention realized that there are conditions that are preventable, and that the impact of preventing them would be huge. That’s when everyone had to stop and think about what was happening. And consumers, too, got involved. But we took it upon ourselves to ask, how do we prevent those conditions? And Premier led the way in looking at collaborative efforts to prevent healthcare-associated infections. And one component is central line-associated bloodstream infections. And in the past 10 years, our members have been involved in a number of efforts in that area.
HCI: I’ve found in my research that the hospitals that have been successful have developed clinical protocols, and processes and policies.
Qutaishat: Yes. Hospitals involved in this work have spent a lot of time collecting data and surveilling. The really successful ones have instituted methodologies and have learned from each other on how to successfully implement policies and processes. It’s really about changing clinician behavior and taking a team approach to care. Traditionally, medicine has been practiced by individuals, and there’s a hierarchy that’s a problem.
HCI: And physicians in particular in the past haven’t been questioned or challenged regarding their behaviors, right?
Qutaishat: Yes, I fully agree. And the hospital teams that have worked forward based on evidence have made sure that every clinician was involved, every clinician group, so that there was buy-in. They’ve been establishing methods to stop someone when needed. I worked in a hospital system in Milwaukee prior to joining Premier. And part of our success was in that we treated every infection as a sentinel event. And part of the process is, whenever one of those events is examined by a team, to look at process failure and analyzing process. And many hospitals are using that type of methodology now.
Premier’s methodology is to create a collaborative that involves sharing success stories, sharing knowledge, and sharing data—creating the gold standard in prevention. And we all know that there’s that competitive edge that humans have. So when they compare themselves to others and see that the bar is getting higher and higher, we all strive to get there. And that is the power of collaboratives and of organizations like Premier.
HCI: In the organizations that have made progress in quality areas like this one, my research and reporting have found that there has been an expression of leadership pushing things forward; in other words, executive and clinician leaders take personal risk and responsibility to compel progress forward in patient safety and care quality. Do you agree?
Qutaishat: Yes, absolutely, there always is a champion, usually on the physician side. And without a champion, those kinds of initiatives don’t succeed, they struggle. Here’s a real example: At the health system in Milwaukee where I worked, we did what we called preventive care rounds. And I was a part of those teams. Now, Foley catheters and urinary catheters are devices necessary for many patients, but they have to come with an expiration date. And we had a simple question we posed: Is it needed today? And the fear of asking the surgeon was always there; but we found a way to alleviate that fear. And the literature shows that 30 percent of the time, the surgeons didn’t even realize that the Foley catheter was inside the patient.
HCI: A part of it is process, and a part of it is questioning, right?
Qutaishat: Yes. It’s a process, and what Premier hospitals are doing is the daily assessment of the need for that device. And I think you’re familiar with all those checklists needed to improve quality. The daily checklist of, is it necessary or not?
HCI: And how do the electronic health record (EHR) and automation play a role in this, and data analytics?
Qutaishat: Here’s an example of what automation can do. In my presentations, I talk about Wal-Mart and their inventory system; and their strength is in having the product on the shelf at all times. In fact, they were able to help identify a large outbreak of diarrheal disease in Milwaukee in the 1980s, based on the purchase of a particular medication there, and their ability to track the purchase of that medication. But most healthcare facilities are still largely paper-based. Automation allows physicians and other clinicians to see history, so they can see their actions in the context of history; but it also allows for the creation for smart alerts. And in the infectious disease world, we have a suite of software; but I’m intimately familiar with infection prevention software.
Where things are moving is towards infection prevention. And automation allows us to spend less time on the identification of infections, and more time on their prevention; it also creates those automated alerts to allow us to review cases in a timely manner. To prevent a central line-associated bloodstream infection, most of the time, we wait until the infection occurs. But there are triggers that can be created for early intervention, such as through blood cultures. So in addition to properly placing a central line and properly maintaining a central line, if a patient is suspected of having an infection that has initiated, we can intervene earlier.
HCI: What should CIOs know about this?
Qutaishat: I wrote an e-mail the other day about embracing technology. There’s been a disconnect until now in healthcare between what the CIO will lead and what the clinician is willing to adopt. And we are bridging that gap. But it requires identifying the clinical needs, and helping clinicians understand the value of automation in improving patient outcomes.
HCI: It seems to me that this is a perfect time, given separate pushes from both healthcare reform and ARRA-HITECH [American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act], to move forward in this area.
Qutaishat: Yes, and in addition to embracing technology, there’s a behavioral change that has to take place, and that’s not easy.