Changing health care is a big job. So big, in fact, that no one — and no one organization  — can do it alone. That’s why IHI is working with an extensive network of quality-focused organizations throughout the country to help US hospitals achieve the goals of the 100,000 Lives Campaign. It’s a group effort that is in fact changing the world of health care, often in remarkable ways.

To help manage the flow of information, learning, and activities associated with the Campaign, IHI has tapped existing organizations throughout the nation to act as “Campaign Nodes.” These health care entities, which serve as local field offices for the Campaign, take different forms: large systems, hospital associations, medical societies, and networks already joined by common purpose, such as Quality Improvement Organizations (QIOs), which are contracted by the Centers for Medicare & Medicaid Services (CMS) to raise standards of health care.  Each Node offers support to anywhere from 50 to a few hundred hospitals grouped by geography, system, membership, or affinity such as pediatric hospitals or rural hospitals.

“IHI is a small organization with big goals,” explains Alexi Nazem, IHI’s Campaign Field Operations Manager. “We can’t drive the entire 100,000 Lives Campaign on our own. And we also don’t want to duplicate existing resources by developing regional offices. Health care is a chaotic landscape, and we don’t want to add to that. So we approached existing quality-oriented organizations to see if they wanted to partner with us and act as local drivers of our national campaign.” More than 50 said yes.

The Nodes’ Campaign-related functions fall into two broad categories, says Nazem. “First, we rely on them for communication, both disseminating information to their network and getting information back to us. Second, we look to them to help with education and collaboration. We ask them to provide opportunities for their network hospitals to learn and work together.”

Like many of the improvement initiatives IHI promotes, there is no single “right way” for the Nodes to accomplish these goals. Their tactics vary, says Nazem, but many share similar characteristics. “They are creative, generous, and very hard working,” he says.

Here are profiles of just a few of the Nodes and the unique ways they’ve carried out their role in the Campaign.

The Washington State Node has the distinction of being the Campaign’s first. In fact, says Nazem, this Node inspired the very concept. “A group of health care organizations had come together on their own,” he says, “and fully embraced the Campaign. They asked for our support and offered us theirs.”

Known as The Washington Network, this group includes a diverse collection of organizations: Qualis Health (a QIO), Washington State Hospital Association, Northwest Organization of Nurse Executives, Washington State Department of Health, Washington State Nurses Association, Washington State Medical Association, Washington State Pharmacy Association, Service Employees International Union District 1199NW, United Staff Nurses Union (UFCW/#141), and the Rural Healthcare Quality Network.

“Each of the members plays an important part independently in improving care,” says Carol Wagner, RN, MBA, Executive Director of Washington State Hospital Association’s Patient Safety Program. “But by pooling our resources and expertise, we can all achieve greater results.”

The Washington Network helps hospitals sort through the challenges of trying to respond to multiple national and state quality initiatives. “We help them see where the work aligns, where certain initiatives overlap and intersect. It makes the effort hospitals put into quality improvement even more rewarding when they can see how those efforts meet multiple standards,” says Sharon Eloranta, MD, Medical Director at Qualis Health. Eloranta served as one of IHI’s three 2004-2005 George W. Merck Fellows.

With grant funding from The Robert Wood Johnson Foundation and the Washington State Department of Health, the Hospital Association and Qualis Health have created “Safe Table Learning Collaboratives,” so named because the contents of discussion are protected by a state confidentiality statute, making the tables safe for open dialogue. These intense group learning experiences, free of charge to Washington hospitals, have enabled hospitals to collaborate on Campaign-related initiatives such as Rapid Response Teams and eliminating hospital-acquired infections. Carol Wagner says the Collaboratives have helped accelerate change and the development of higher standards throughout the state.

The Washington Network has also created a range of communication mechanisms to keep the flow of information going both ways, including a CEO and trustee newsletter, a listserv that fosters the exchange of ideas and suggestions among hospitals, and a website [www.100kliveswashington.org] that offers in-depth “how-to” resources in a variety of formats. In addition, the nurses’ unions have included in their publications several articles that relate to the value of the Campaign interventions.

These resources, as well as the Network’s strong leadership, explain why all of Washington State’s 100 hospitals are committed to the Campaign. “Washington was the first state of its size to reach 100 percent hospital enrollment in the Campaign,” says Nazem. Vermont, with 15 hospitals, was the first state of any size to do so.

Nazem says the Washington State Node has been particularly successful at getting hospitals to submit Campaign-related data to IHI, which “is not a trivial task.” About 95 percent of Washington State’s hospitals are reporting mortality data to IHI, compared to 83 percent  of Campaign hospitals nationally.

“The key is getting the message out to everyone about how important this is,” says Carol Wagner. “We took the Campaign’s motto to heart: ‘Some Is Not a Number, Soon Is Not a Time.’” Wagner says that the success of the Network’s efforts ensure that the structure will remain in place to take on new challenges, after the Campaign’s milestone of June 14, 2006. 

Arizona Node leaders are doing a lot with little. “They don’t have much funding specifically for the Campaign, but they are doing an incredible amount of work,” observes Nazem.

What they lack in money they make up in enthusiasm. Barbara Averyt is Project Director of the Arizona Hospital and Healthcare Association (AzHHA). “Our board had set patient safety as our priority, so we launched straight into the 100,000 Lives Campaign without hesitation,” she says.

The Campaign effort in Arizona is fueled by monthly patient safety calls for patient safety officers of all participating hospitals, which includes about 80 percent of those in the state. “The calls are short — about 30 minutes — and very specific,” says Averyt. Topics have ranged from calculating mortality data to working with legislators on issues involving patient safety.

The Node distributes a monthly newsletter to reach a broader audience of hospital staff and front-line improvers, as well as interested parties from organizations outside of health care. The Node also hosts monthly education sessions known as Topic Collaboratives. At these information-packed gatherings, which last just 90 minutes, a local hospital “expert” presents his or her experiences with a specific Campaign intervention, followed by a question-and-answer period. Topics have included Rapid Response Teams, building the business case for patient safety, Internet resources on patient safety, the pros and cons of bar-code medication administration, and strategies to reduce AMI mortality.

Averyt says these meetings accomplish several goals. “They profile and honor hospitals for the hard work they are doing, and they are very effective at walking others through a particular improvement journey, because there is no one better at that than someone who has been in the trenches doing it.”

One of the additional goals of the Campaign in Arizona, says Averyt, is to standardize certain practices across all the state’s hospitals, including practices not directly covered in the Campaign. “Because of our Node status, we have become the ‘go-to’ organization for patient safety,” says Averyt. “That has allowed us to look beyond the six Campaign interventions to other things we should be doing.”  

Currently, Averyt says one effort centers around broadening the use of SBAR (Situation, Background, Assessment, and Recommendation), a framework for communicating about patients used by Rapid Response Team members, among others. 

Other efforts include standardizing the use of color-coded patient wristbands, as well as patient medication lists. Averyt says that all caregivers, but especially the many traveler nurses employed by Arizona’s rapidly expanding hospital sector, are vulnerable to error when hospitals do the same things differently. “We did a survey and found that throughout Arizona hospitals there are eight different colors of wristbands that mean ‘Do Not Resuscitate.’ That is a set-up for error. Standardization in this area would make a great impact.” And AzHHA’s “Safe and Sound Initiative” aims to prevent medication errors by promoting the use of a standardized, patient-carried medication list. The form is available to providers and consumers for free online [www.themedform.com]. 

The Arizona Node is also thinking ahead as it collaborates with the Arizona Board of Nursing and nursing schools to integrate the science of patient safety curriculum into nursing education. “Nursing students learn about patient safety issues from the get-go,” says Averyt. “But taking it one step further and introducing ‘systems thinking’ is our goal. The nursing education community heard our message and readily joined us in this goal and is working to develop the curriculum.”

Averyt says the network that the Campaign spawned is a lasting one. “IHI introduced the concept and we’ve hardened the cement. When the next initiative comes along, our network of patient safety officers is strong and ready.”

Alexi Nazem refers to the North Carolina Node as a pioneer. “They have done so many distinctive things, and have been very generous with their expertise.”

The North Carolina Hospital Association (NCHA) serves as the state’s Campaign Node, in collaboration with the North Carolina Medical Society, The Carolinas Center for Medical Excellence, NC Area Health Education Centers Program, NC Office of Rural Health & Resource Development, VHA Central Atlantic, and Premier, Inc.

NCHA Vice President Jeff Spade says his organization committed to a quality performance agenda well before the Campaign began. “We felt that hospitals in North Carolina needed to take the lead on quality improvement,” says Spade. So NCHA applied for and received a $5 million, five-year commitment in December of 2004 from The Duke Endowment to create and fund the North Carolina Center for Hospital Quality and Patient Safety. “The Center fosters a culture of quality and safety and provides workshops, conferences, collaboratives, and other forms of training for the state’s hospitals.” The Center has sponsored a wide range of Campaign-related learning opportunities, bringing in expert speakers from IHI’s faculty.

Spade says one of the Center’s first steps was to form strategic partnerships with leadership organizations in North Carolina devoted to health care quality, as well as with IHI, launching an active recruitment campaign for hospitals to join IHI’s IMPACT network. As a result, many of the state’s hospitals were already aware of and committed to several of the Campaign interventions before the Campaign was officially launched. This is why Alexi Nazem refers to the North Carolina Node as “part of our Campaign brain trust,” because they served as something of a beta site for the Campaign’s development. The same strong and focused leadership that helped create the Center is a key reason that 100 percent of North Carolina hospitals are committed to the Campaign.

Nazem says the North Carolina Node exemplifies the generosity he sees in many Nodes. “They developed a fantastic online survey for hospitals [www.100kprogress.org, requires login and password] to detail their progress on each intervention,” he says. “It really helps us know what’s going on in the field. It required a lot of programming, and they said they would share it with any other Node that would like it.”

Spade, whose enthusiasm and energy are contagious, says he’s been excited by the level of commitment in his state and the progress he sees among its hospitals. “The hospitals are very focused on implementing real change that can save lives,” he says. Spade says that data collected from the state’s hospitals showed that, through 15 months of the 18-month Campaign, an estimated 2,145 lives had been saved by the 109 North Carolina hospitals enrolled in the Campaign. Spade expects that the rate of improvement has accelerated as the Campaign and its initiatives have progressed. 

Spade also says he and the health care leaders in his state are enthusiastic about the Campaign as a concept because it is “a grand experiment on whether a common commitment by providers on a national basis to focus on implementing tested initiatives can make a difference. I think we will learn that a common commitment and a determined focus have a huge potential to make a significant difference in quality and safety.”

And as in other states, Spade makes it clear that the work will go on, just as the Campaign hopes it will, after the milestone on June 14, 2006.  “Our Node infrastructure and our partnerships existed before the Campaign, and now have even more staying power. We are committed to the partnerships in our state that make improvement possible.” He has good reason to be optimistic about the future: Blue Cross and Blue Shield of North Carolina recently made a $3 million contribution to the North Carolina Center for Hospital Quality and Patient Safety “to enhance the efforts of the hospitals implementing nationally recognized quality improvement measures outlined in the Institute for Healthcare Improvement's 100,000 Lives Campaign.”

Known as Delmarva, this region is served by a Node that has been thinking about the long-term future from the start: Its local effort is called “The 100,000 Lives Campaign and Beyond.” The Delmarva Foundation, the Quality Improvement Organization for Maryland and the District of Columbia, in partnership with CareFirst Blue Cross/Blue Shield, offers hospitals in Maryland, northern Virginia, Delaware, and the District of Columbia free access to Collaboratives focused on improving patient safety. Through The Robert Wood Johnson Foundation funding, Delmarva Foundation has also teamed with the Association of American Medical Colleges in providing a Rapid Response System Collaborative for hospitals in Maryland, Pittsburgh, and Ohio. 

“One of the great things about Collaboratives is peer-to-peer learning that gets the whole region moving in the same direction,” says Maulik Joshi, DrPH, President and CEO of the Delmarva Foundation.  

IHI’s Alexi Nazem says the Delmarva Node is one of only a few that are running full-fledged Collaboratives in the IHI mold. “It’s a great way of implementing change,” says Nazem. “The coordinators of the Collaboratives are in constant contact with the hospitals, and they really know what’s going on with them. They have also been very generous with their experience as a Node, and have even hosted sessions for other Nodes on how to run a Campaign Collaborative.”

Joshi says it’s important to align the Campaign efforts with other hospital initiatives, to reduce or eliminate competing priorities. This is why the Collaboratives they offer don’t necessarily track to the six specific Campaign interventions, but rather to areas of clinical interest such as the OR, the ED, or the ICU. “If you are in the OR Track, you are getting into prevention of surgical site infection, which is part of the Campaign but is complementary with other hospital safety initiatives,” explains Inga Adams-Pizarro, Project Manager at the Delmarva Foundation.

“Our Collaborative series starts and ends with culture,” says Joshi, “because building a culture of safety is as important as knowing the details of the interventions.”

Joshi says that 93 percent of the hospitals in the region are participating in a Collaborative. “Some hospitals are considerably smaller than others, but come with a lot of drive and desire to implement change,” he says. He also notes that strong CEO leadership throughout the region is a key reason for the success of the Campaign. “They compete for market share, but they put quality in a different category,” he says. “When a hospital CEO tells me it’s been 14 months since his hospital had a case of ventilator-associated pneumonia, that’s the application of true leadership, because it shows that the front-line staff are working on something that is valuable to the people at the top, and vice versa.”

Joshi is inspired by the progress being made on the front lines. “Yesterday I learned about a hospital that implemented Rapid Response Teams on Monday, and by Thursday had had two calls that averted AMIs,” he says. “It is great to hear those stories of change.” Meanwhile, the State of Maryland has asked the Delmarva Foundation and the Maryland Hospital Association, which co-leads the Maryland Patient Safety Center, to launch a Collaborative on perinatal care.

Indiana

The Indiana Node is the The Indiana Health&Hospital Association (IHHA), which coordinates quality and patient safety activities for its 167 member hospitals. It has provided them with a steady source of educational opportunities regarding Campaign interventions. And in Indianapolis, they have also been able to tap into an extraordinary level of collaboration that already existed among local health care organizations.

IHHA has provided regular newsletters and written communications, as well as a series of educational briefings for hospital teams from throughout the state to learn about how to implement or fine-tune the six Campaign interventions in their institutions. Typically attended by more than 100 people, these one-day sessions are led by faculty experts, many from IHI, who provide detailed how-to information. The meetings also provide plenty of opportunity for attendees to share ideas and experiences among themselves. “At every session we have both a national or regional expert, as well as a local expert,” says Betsy Lee, Patient Safety Consultant to IHHA. Often the local experts are identified through regular meetings among IHHA, leaders from the regional VHA Node (affiliated with the national community hospital alliance), and the state’s QIO, Health Care Excel.

A strong working partnership among these three organizations has been instrumental in getting the state’s hospitals enrolled and engaged in the Campaign. About 93 percent of Indiana’s short-term acute-care hospitals are enrolled.

Another key factor was the outstanding work of the Indianapolis Coalition for Patient Safety. When the Campaign began, the Coalition jumped on board without hesitation, creating citywide work teams for each of the six Campaign interventions. “The Indianapolis Coalition for Patient Safety was formed several years ago,” says Bernice Ulrich, Vice President of IHHA. “The CEOs from the six largest hospitals in the city came together and agreed that they were not going to compete on patient safety. They were going to collaborate.”

“The spirit of collaboration is very strong,” says Ulrich. So strong, in fact, that the partnerships established by the Coalition and through the Campaign are expected to continue. “These citywide teams, and others around the state, have connected not only around the Campaign interventions but are also establishing clinical peer networks for sharing best practices in other areas,” says Ulrich. “The work teams will continue to work together after June 14.”

Alexi Nazem says this fulfills a secondary Campaign goal. “We want to create infrastructures that will remain in place to help people implement change in the longer term. The Indianapolis Coalition is a perfect example of this.”

The largest of the Nodes, the New York State Node is led in part by an extraordinary Partnership Committee that includes representatives from 18 statewide organizations. “These are organizations you might think would have been working together all along, but in some cases weren’t,” says Alexi Nazem.

“This group is absolutely crucial to getting alignment, developing enthusiasm, allowing innovation, and fostering education,” says Kathy Ciccone, RN, MBA, Vice President for Quality and Research at the Healthcare Association of New York State (HANYS), which leads the New York State Node.

The Partnership Committee, led by Mary Cooper, MD, JD, Chief Quality Officer at New York Presbyterian Hospital, includes not only representatives from acute-care organizations, but also from physician, nursing, and business groups; health plans; consumer groups; and the Department of Health. “Everyone was given a voice at the table from the beginning,” says Cooper. “Everyone had a role in the planning, so the successes were wholly integrated.”

The Committee met both virtually and in person on many occasions, most memorably with IHI CEO Donald Berwick, MD, at the Campaign’s New York kick-off, and again in two statewide meetings that included a total of 700 people. “Seeing the excitement people were feeling at these meetings was a great return on the time they were investing in helping to plan, promote, and celebrate this work,” says Cooper.

Aggressive communication has also been a critical element of the strategy, says Ciccone. “We use a lot of communication vehicles, including teleconferences, publications, press conferences, and publicity.” The communications programs support the strong educational component that has also been a focus for this Node.

“We complemented IHI’s education efforts with our own series of teleconferences on the Campaign interventions and promulgated that across the state,” says Nancy Landor, RN, MS, Director for Strategic Quality Initiatives at HANYS and coordinator of the Node. Now Landor says they are in the process of developing educational CDs on each of the Campaign’s interventions to share more broadly. “The state medical society will provide CME credits for the CDs,” she adds, exemplifying the value of the strong partnerships that the Campaign has promoted.

The combination of regular electronic and written communications, site visits, regional meetings, and statewide conferences has resulted in high Campaign participation — more than 90 percent of the state’s hospitals — and growing successes. “The first year was about recruiting, teaching, and supporting the early innovators,” says Nancy Landor. “Now the amount of spread and the levels of success are exponentially increasing. Hospitals that signed up for one intervention are now doing three. We have seen a huge explosion of activity in recent months.”

Mary Cooper says that the level of effort on the part of HANYS staff is the key to the Campaign’s success. “They did a lot of the fundamental work that otherwise the hospitals would have had to devote to this,” she says. “HANYS provided the support, algorithms, and contacts. The more they generated, the less the hospitals had to do to accomplish their goals. I can’t emphasize strongly enough how critical that has been to allowing all this to happen.”

IHI’s Alexi Nazem says that the level of commitment in the New York Node is remarkable. “They are always coming up with new and innovative ways to serve as a Node,” he says. “We are learning from them and we are spreading their ideas to other Nodes. They are very much in tune with what’s going on in the field, which is a vital characteristic of a successful Node, and just one of the things they do particularly well.”

06/09/2006