IHI expands its horizons as it plans 'next step' campaign
February 1, 2009 6 minutes read
IHI expands its horizons as it plans 'next step' campaign
Organization seeks to portray total hospital 'as a system'
Buoyed by the success of the 5 Million Lives Campaign, the Cambridge, MA-based Institute for Healthcare Improvement (IHI) is set to tackle its "next frontier," in the words of Donald M. Berwick, MD, MPP, president and CEO of IHI. Berwick was one of several panelists who spoke at a press teleconference during the IHI's 20th annual National Forum on Quality Improvement in Health Care, in Nashville, TN, on Dec. 10th, 2008. The forum marked the culmination of the 5 Million Lives Campaign.
"As we chart our course for future activity, we've seen the enrollment of over 4,000 hospitals, or 80% of all hospital beds in the nation, in the 5 Million Lives Campaign; there has been a wonderful outbreak of activity and downloads," said Joseph McCannon, IHI vice president and 5 Million Lives campaign manager. "Perhaps the most exciting legacy is the development of what we call the National Learning Network — field offices and nodes all around the country, including 200 mentor hospitals. What we observed in activity and energy was, without reservation, very promising and exciting, but the key question is how can we make certain we are actually changing outcomes and seeing improvements and a positive impact on patients and their families?"
Accordingly, he noted, IHI studied what occurred at the intervention level, and the results were "very encouraging." For example, he reported, pressure ulcers dropped more than 70% in New Jersey, and in Rhode Island central line infections fell more than 40%. "On the national level, over 65 hospitals have gone for a year without a case of ventilator-associated pneumonia," he added. "We sense that great things are possible and our confidence is growing."
A new way forward
McCannon conceded that IHI is not yet able to say how many incidents of harm have been avoided through the campaign. "There are striking levels of success, but we need to find a new way forward with hospitals," he says.
And what is that new way? "With our network in place, we have a chance to build on this success," said Berwick. "One response would be to the immediate crisis in finance. Infection has been in the background, but diseases like urinary tract infections are quite dangerous, extremely expensive, and highly preventable. A third opportunity is coming out of the work of Atul Gawande, MD, a surgeon and director of the World Health Organization's Global Patient Safety Challenge. His global trial on a surgical checklist is an attempt to standardize risk processes. (For more on Gawande's initiative, see sidebar.)
"But the larger context is that it is now possible to do something we first tried years ago — the challenge of actually seeing a total hospital as a system," he continued. "We are actually beginning to map the hospital as a production system with over 100 processes, and we are working with hospitals on that much more ambitious total transformation."
What Berwick called the "IHI Improvement Map" is "the next morphing of the 5 Million Lives Campaign," he explained. "The map is a map of processes; it does not exist now, but in the months ahead, we will see the attempt to describe a hospital as a set of processes — both clinical and leadership processes — that we put on the map."
The good news, said Berwick, "is that we can do this as an assembly, a highly cooperative group; we hope in six months to be able to put on the table a picture of a hospital and say that is what we are going to work with."
"While the 5 Million Lives Campaign comes to a close today, this group of hospitals has resolved itself to move from discreet clinical interventions to the health and performance of an entire organization," added McCannon. "We have the beginning of measures for many factors — for example, mortality and harm — but we need to think about efficiency, equity, and all the ways we describe the highest-performing hospitals."
Berwick's biggest interest, he said, is in mortality. "I think we have a good measure, but there needs to be a national consensus; the same goes for harm," he observed. "I hope in six months we will all move toward a nationally accepted metric of hospital safety."
New administration: 'Good news'
The incoming Obama administration spells good news for these ambitious goals, said Berwick, in response to a question from HBQI. "I expect good news; there are clear signals from all the principals involved," he said. "You can read it in [incoming Secretary of Health and Human Services'] Tom Daschle's book; Kennedy and others have a strong interest in improving care and a deepening understanding of the coverage issue that needs to be solved — and that one way is to link coverage to improved care." The president of the United States, he added, "also has the opportunity to influence the activities of the VHA and the Department of Defense and other organizations that give care directly; this presents a tremendous opportunity."
Berwick did not even appear deterred by the prospects of a deepening recession.
"We do know that improving care in many, many forms reduces costs; that is not always true, but almost always," he noted. "We have not been as disciplined as we wish had been over the years in measuring hard dollar returns, but some organizations have been. Now, it has become more important and more crucial to move to make sure that part of health care is improving."
Berwick added that one of a series of priorities recently enumerated by the National Quality Forum was reduction of overuse. "We have consensus statements from specialist societies themselves about things that are overused," he observed. "If we can unite, these will all be very important areas of endeavor. I see an opportunity because this is a time to be lean and effective."
Gawande agreed that the bottom line has become more important than ever. "In 2007, about 50% of U.S. hospitals were in the red," he noted. "If we have a jump of 4 million to 5 million uninsured there will be hundreds of insolvent hospitals by the end of the coming year, but we do not have the capacity we had 10 years ago for a hospital to be in any way certain that it could reduce costs without hurting quality."
In the absence of a national health system, he continued, only initiatives such as those promulgated by IHI provide the opportunity to make changes that improve quality and lower costs. "Over the next year I can tell you that surgery departments will freeze hiring or cut staff," he predicted. "They fear uninsured patients will sink them well before reform even comes. A lot of hospitals are looking for tools to let them improve quality and manage their costs." Quality improvement, he insisted, is the answer. "[The state of Michigan] saved $200 million when they reduced infections by two-thirds," he observed.
Hospitals are willing
The good news, said Berwick, is that hospitals have responded enthusiastically to the initiatives. "Last night we had receptions for our lead organizations across the country," he shared. "In the South Carolina state hospital association, there was a leader from an important hospital that was just becoming aware of the UTI bundle and the introduction of a tools checklist, and right there in the room they began to work on how as a state they would adopt it. I believe we are seeing deployment at a rate not seen before."
McCannon likewise enthused about participation in the "Boards on Board" component of the 5 Million Lives Campaign. "It's among our most popular assets; more than 2,100 hospitals publicly committed to it," he said. "This was a statement that leadership is engaged in quality in a new way; this will put quality on the front burner for years to come."
That will be critical if hospitals are to successfully meet the next challenges, he continued. "I think [leadership commitment] is crucial," he asserted. "Our theory is, if we really want to make meaningful clinical improvement you need consistent leadership in the organization as its backbone."
Finally, said Berwick, the uncertainty that currently exists will hopefully be short-lived. "Any period of uncertainty creates conservatism," he conceded, noting that the list of quality players and goals is "very long, and you can't tell what's going to last for the long haul and are therefore not sure where to put your efforts."
However, he added, clarity is coming, "and I think you will see better and better alignment. The NQF, through its Priority Partner process, has things going very well with their first list of six priorities; it won't be long before we will be able know what 'plays' will be called."
[For more information, contact:
Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. Phone: (617) 301-4800. Toll-Free: (866) 787-0831. Fax: (617) 301-4848.]
Buoyed by the success of the 5 Million Lives Campaign, the Cambridge, MA-based Institute for Healthcare Improvement (IHI) is set to tackle its "next frontier," in the words of Donald M. Berwick, MD, MPP, president and CEO of IHI.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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