Successful improvement efforts generally have two valuable payoffs: the end result and the learning gained along the way. Such is the case at Metropolitan Hospital (Grand Rapids, Michigan, USA) where adverse drug events (ADEs) on admission have been virtually eliminated, and a whole new approach to problem solving is now described as “a way of life.”

Metropolitan, or Metro as it is known, is a 238-bed not-for-profit teaching hospital serving Grand Rapids and its surrounding communities. Metro is part of a community of health care providers that is committed to collaborative improvement work, which is why the Grand Rapids health care community joined IHI’s IMPACT network as a group. Five local hospitals, two large physician groups, Grand Valley State University, and two third-party payers work together, across competitive lines in some cases, to help one another move forward toward better care for the community they serve.

“We meet regularly as a community to share our successes and struggles,” says Regina Ricketts, RN, Metro’s Quality Management coordinator. “We are competitors, but we have always had good relationships, and we have pursued a number of joint ventures together through the years. It’s good for us, and good for our community.”

For Metro, the focus on medication safety was a continuation of work they had been doing for years. “We had a very effective medication safety team in place before we joined IHI,” says Regina Ricketts, RN, Metro’s Quality Management coordinator. “We were already working our way through the 194 safe practices identified by the Institute for Safe Medication Practices (ISMP) in 2000.” Based in Huntington Valley, Pennsylvania, USA, the ISMP is a non-profit organization that provides education about adverse drug events and their prevention.

Ricketts says that the hospital’s focus on medication safety enabled them to bring their total compliance rate with the ISMP practices to 86.7 percent in two years’ time. But, she says, they still wanted to bump their commitment up a notch. So in 2003, they joined IMPACT and enrolled in an IHI Medication Safety Collaborative.

IHI asked the teams in the Collaborative to work toward four goals:

1. Reduce unreconciled medications on admission by 75 percent
2. 50 percent of personnel will achieve an "Excellent" safety climate score
3. Reduce narcotic/sedative ADEs by 75 percent
4. Conduct FMEA (Failure Mode and Effect Analysis) of narcotic/sedative prescribing process and reduce derived risk profile number (RPN) by 75 percent

The aim was to achieve two of the four goals in a year. At Metro, staff achieved all four goals within nine months, thanks, says Ricketts, to the “running start” they had gotten from their medication safety work prior to the Collaborative.

“Even when we attended the Collaborative’s first Learning Session,” recalls Ricketts, “we called home throughout the session to line up small tests of change for when we returned. We were ready to hit the ground running as soon as we got home.”

This was possible because Metro had already worked to create a culture of safety and non-punitive error reporting. In 2000, Ricketts had petitioned the hospital’s board of directors for support for a non-punitive medication error reporting system. “They gave me a beautiful written resolution,” she says, “and we began publicizing it to staff through our intranet and our internal publications and committee structure. We created a very simple medication event reporting form, and the staff grew to feel very comfortable with the form. The resulting process changes and lack of punitive focus led staff to trust that our culture was, in fact, non-punitive.”

It was a sound strategy. By the end of 2000, Ricketts says that medication event reports had increased tenfold.

Staff worked together to make changes to processes that were highlighted by the event reports, says Ricketts. “There were many opportunities for staff to be involved in data collection and process changes,” she says. “Everyone became aware that this was at the forefront of our culture.” So much so, in fact, that in 2002 the board of directors issued a broader resolution, calling for a system-wide culture of safety in all things, not just the use of medication. 

But change was sometimes slower and more cumbersome than desired, says Ricketts, in part because they were trying to make changes in broad sweeps. As a result, some problems seemed intractable.

But then, reports Ricketts, a breakthrough occurred. “At the first Learning Session, we learned about small tests of change. It was a revolutionary concept for us, and met a tremendous need. We realized we didn’t have to make changes that were going to impact a lot of people and invite resistance.”

Now, for example, they could stop trying to figure out how to change the entire allergy documenting system at once. “Before, we would have tried to change all the documentation and get it through the appropriate committees, etc, etc,” says Ricketts. “With small tests of change, we tried a change with one nurse and one patient. We began small and worked quickly. Now,” she says, “small tests of change are a way of life.”

Ricketts has seen the value of this “way of life” first-hand. “Every time you do a cycle of change it becomes evidence-based,” she says. “The frontline staff are empowered to suggest and try changes, and they guide the process. Instead of telling 100 people to do something differently, you work with someone who’s willing. They embrace it, and more willing people jump on board, and that’s how change spreads. Small tests of change bring you to the tipping point and then the changes roll through at their own pace, not because you forced them on people.”

Communication and trust are key, says Ricketts. Metro communicated continually not only about the value of improved medication safety, but also about the value of small tests of change to improve safety. Incentives helped encourage people to get on board, adds Ricketts. “We had a rewards system for people who tried small tests of change,” she says. These included chocolates, and letters of thanks. “These made a big difference,” says Ricketts.

Some of the specific changes Metro made to reach the four goals of the medication safety Collaborative were less significant than the lessons learned along the way, says Ricketts. For instance, staff worked tirelessly to develop “the perfect form” to help reconcile medications on admission. “We spent an entire quarter developing the right tool,” recalls Ricketts. “And our reconciliation numbers didn’t improve much. We realized that we needed to refocus on our real goal:  the process of reconciling medications, not developing the perfect form.” In fact, she says, the form is still a work in progress. But the education they provided staff regarding the importance of reconciliation at admissions and at every handoff was “extensive and very important to our success,” says Ricketts.

To improve safety of narcotic use, Ricketts says they revised epidural orders, as well as patient-controlled analgesic (PCA) orders, to make allowances for differences in patients’ weight and age. They created colorful, multi-lingual warning signs to attach to all PCA pumps warning family members not to touch. They developed a pre-printed pain-management physician order form, covering all the pain medications that are not given through an epidural or PCA. “The order form includes appropriate dosing and warnings, and eliminates wide-range dosing and encourage use of the most appropriate medications,” says Ricketts. It also replaces handwritten orders, a common source of errors.  And they implemented automated medication dispensing systems that provided nurses with ready access to reversal agents, something that wasn’t the case before.

Ricketts says the hospital continues to work on spreading what works to more and more units. And while they are still working on the details of some change ideas, they are firmly committed to the process of change. “We are still refining and working on reconciliation,” she says. “We are still tackling high-alert drugs and we’re implementing a Demerol abatement program.”

Peter Haverkamp, RPh, Director of Pharmacy Services, led his department in spearheading the technological aspects of improving and enhancing Metro’s pharmacy management and dispensing systems.  Haverkamp will present the story of Metro’s journey to success at IHI’s National Forum on Quality Improvement in Health Care in December.

Ricketts advises other hospitals interested in improving safety to work from both directions at once. “It’s important to start from the bottom up with small tests of change, so frontline employees are creating and implementing the best ideas. But it’s also essential to work from the top down, making sure that safety and improvement work are supported at the very highest level of the organization. One without the other just isn’t enough,” she says. “Combined, it’s really a winning strategy.”