One of the hallmarks of the Institute for Healthcare Improvement’s work has been its use of the Breakthrough Series model, in which teams from many hospitals form Collaboratives and work together on a specific improvement goal. Collaboratives offer participants a specific set of steps — called a change package or sometimes a “bundle” — that have been shown to improve outcomes when reliably implemented. Teams learn from experts and from each other as they implement and refine the steps over a defined period of time.
For very large organizations — particularly multiple hospital systems — launching a Collaborative that brings teams from across the organization together around shared goals can be a highly effective way to accelerate widespread improvement.
A case in point is the Child Health Corporation of America (CHCA), an alliance of 43 leading pediatric hospitals in North America focused on collectively improving their clinical, financial, and operational performance. Prior to the Institute of Medicine’s first patient safety report in 2000, To Err Is Human, executives and clinical leaders from children’s hospitals were already working together through CHCA to improve health outcomes for America’s children.
In 2004, in an effort to expand improvement across all 43 CHCA hospitals, CHCA sent employees to IHI’s Breakthrough Series College to prepare the hospitals to facilitate a new series of Collaboratives. This intensive three-day program helped bring about noteworthy results across the CHCA alliance:
- 13,478 adverse drug events (ADEs) were prevented between April 2005 and March 2006, at a net savings of nearly $2.6 million. Sixty-one percent of hospital teams exceeded the goal of a 50 percent reduction.
- 112 catheter-related bloodstream infections (CR-BSI) were prevented between April 2005 and December 2005, at a net savings of nearly $1 million. Thirty-eight percent of hospital teams exceeded the goal of a 50 percent reduction. A 12-month 2006 sustain and spread effort averted an additional 276 infections resulting in an additional net savings of $2.2 million. Fifty-two percent of teams reported that they had sustained the gains.
- Compliance with the surgical infection prevention (SIP) interventions increased from 56 percent to 86 percent between August 2006 and May 2007. Four hospitals achieved 95 percent compliance with the processes; 60 percent of the participating teams achieved sustainable improvements and began a robust spread process in July 2007.
- 15 hospitals decreased their emergency department (ED) length of stay between September 2006 and June 2007. Two hospitals achieved a 25 percent reduction or greater; five hospitals exceeded a 10 percent reduction in ED length of stay.
Current CHCA Collaboratives are focused on eliminating codes and associated mortality on inpatient units and improving patient throughput by effectively managing capacity demands.
Bringing Joy Back to Work
Headquartered in Shawnee Mission, Kansas, CHCA functions as a cooperative, owned and operated by 43 children’s hospitals. “Our main focus is on making our hospitals safer, more effective, and more efficient,” says Director Michelle Lunbeck, MHSA. CHCA provides a variety of services to Owner Hospitals, including group purchasing, insurance services, data analytics and education, in addition to knowledge sharing through peer groups. CHCA’s mission is to provide value-added business support services and act as a catalyst to enable its hospitals to improve quality and enhance performance.
“About three years ago, the children’s hospital executives who sit on our board directed us to further advance our performance improvement efforts,” says Lunbeck. “IHI’s Collaborative model was a natural fit for what we wanted to do.”
Since CHCA started facilitating improvement efforts with its hospitals in the late 1990s, participants dealt with the creative tension that exists between research and rapid improvement. “The existing spirit of collaboration didn’t always translate into rapid results,” says Manager Tina Logsdon, MS. “In 2004, we were again feeling the irresistible pull to create new knowledge using a research model, which requires a lot of time to determine what the project should be about and what data should be collected,” says Logsdon. “At the same time, there was pressure from the CEOs to improve performance based on current knowledge and to achieve that performance faster; the Breakthrough Series gave us an incredibly comprehensive model that helped us to meet those goals. People responded beautifully.” Today, the chief executive officers from CHCA hospitals remain supportive that Collaboratives should not be designed for the purposes of long-term scientific research, rather they should be designed to yield immediate improvement results.
CHCA staff members attended the Breakthrough Series College in two waves ― one group in 2004; a second in 2006. They learned how to choose topics; develop materials and run Learning Sessions; prepare and support participating teams; and how to apply the science of fostering and spreading improvement. The six Collaboratives they have run since then have included 20 to 30 multidisciplinary teams each.
“Collaboratives bring back joy to people’s work,” says Logsdon says. “It is a real thrill when data start to show that real change is possible.”
An IHI Breakthrough Series Collaborative is typically between 6 and 15 months in duration and consists of two to three face-to-face Learning Sessions over the course of the Collaborative. Learning Sessions bring representatives from each team together to learn from expert faculty and each other about improvement methods in their chosen topic area. In the weeks or months between Learning Sessions — called Action Periods — the teams use what they’ve learned to implement change. They keep in touch with one another through regular conference calls and informally through phone calls and email, and report to the group on their progress at the next Learning Session.
Logsdon attributes the success of the Collaborative model to its structure — the combination of Learning Sessions and Action Periods — and its tools — change packages, measures, and monthly reports.
Beyond that, says Logsdon, the conceptual breakthrough of Collaboratives involves two key ideas: enabling colleagues to work together across institutions, and getting away from trying to achieve broad consensus before the work can begin. “It’s important to get the right people at the table, the real experts. Then everyone is willing to let limited small groups decide about aims and measures,” she says.
“How Did You Do It?”
Lucile Packard Children’s Hospital at Stanford in Palo Alto, California, a CHCA hospital, has achieved great results from its participation in CHCA’s Collaboratives, says Patient Safety Program Manager Sandy Trotter. “We decreased our catheter-associated bloodstream infections in the NICU by 25 percent in the first year,” she says. “And before we started, people thought we were already as good as we could get.”
The Collaboratives facilitate confidential sharing and comparing among hospitals, says Trotter, which serves as an important catalyst to change. “When you are in a Collaborative where sharing is protected, the physicians can see how their colleagues are doing at other hospitals they respect. We could see, for example, that Cincinnati Children’s Hospital Medical Center had gone four months with no catheter-associated bloodstream infections in the NICU, and their kids are just as sick as ours, so we could turn to them and say, ‘Okay, how did you do it?’”
Data that prove what is possible, combined with caregivers’ natural desire to provide the best possible care, is strong leverage, agrees Pat Richardson, MA, RCP, Patient Safety and Improvement Officer and Director of Quality and Safety at Children’s Healthcare of Atlanta. “When we first started, a lot of our doctors said, ‘You can’t get to zero bloodstream infections.’ The CHCA data really helped convince our physicians that we could bring our rate down.” A little competitiveness with colleagues at other institutions doesn’t hurt either,” she adds.
James Cappon, MD, FAAP, CPHQ, Medical Director of Quality and Patient Safety at Children’s Hospital of Orange County (CHOC) in California, says it can also be a relief to discover your organization is not the only one struggling with certain challenges. Cappon thinks Collaboratives are especially valuable for pediatric hospitals because they enable participants to see aggregate data that can be especially illuminating. “Only about one in 10 inpatient health care experiences involves children,” he says. “So no individual organization in pediatrics has enough data to really make progress alone. The Collaboratives allow us to see much bigger numbers that help us make change.”
CHOC was able to dramatically decrease its rate of catheter-related bloodstream infections, among other successes. “We wanted to get to half or a quarter of our rate,” recalls Cappon. That rate had typically hovered just below two infections per month in the PICU. “Now we’ve gone 177 days without a single one. As critical care physicians, we are trained to expect infections. But now we’re seeing that many times they can be avoided completely.” The hospital has now spread the catheter-care best practices to the NICU, emergency department, surgical services, and interventional radiology.
One of the keys to the success of Collaboratives, say participants, is that they keep the momentum of improvement work moving. “It’s so easy for priorities to shift,” says Sandy Trotter. “Knowing that the group will be waiting for your data pushes you to stay on track.”
It’s a positive kind of peer pressure, says Beth Rowett, MA, MHA, CPHQ, Executive Director of Quality and Patient Safety at Children’s Hospital of Orange County. “When you try to do something internally, you might feel happy making incremental improvements from year to year,” she says. “When you begin to look at other hospitals, you sometimes see that your incremental improvements are small.”
On the other hand, says Rowett, working with other hospitals can also highlight your strengths. “You may have some best practice in place and you don’t even realize you have something you could share with others.” The Collaboratives help participants put their performance in perspective. “This can be really helpful when you set your targets, otherwise you are working in a vacuum.”
Customizing the Basics
While Collaboratives offer all teams a basic change package to implement, they also support a flexible approach to the application of those steps. What works in one organization may need to be modified in another, and teams learn how to make those changes.
At Lucile Packard Children’s Hospital, for instance, the team engaged front-line staff by making a video. “We made a movie with staff showing people inserting and maintaining catheters incorrectly and asked people to identify how many things were done wrong,” says Sandy Trotter. “It is so obvious when you see it, and everyone recognized things they were doing wrong.” Then the film showed the right procedures. “By teasing out the steps, you really focus people’s awareness on what they are doing.”
At Children’s Healthcare in Atlanta, Senior Process Improvement Consultant Amber Cocks says, “The [change packages] are great, but once we have those steps in place, we look for other things to modify.” For example, she says, the ICUs set up standardized ways to change dressings. “The NICU even had a specific team that would change the dressings, so it is done the same way every time.”
It’s the philosophy of continuous improvement that is infectious, say participants, and the camaraderie supports the work. Says Orange County’s James Cappon, “We find ourselves asking more and more, ‘What are the other children’s hospitals doing?’”
04/08/2008
