When It Comes to Clinical Quality, Everybody Makes the Team

As Director of Facilities and Materials Management for Columbus Regional Hospital (CRH) in Columbus, Indiana, Dave Lenart, PE, MBA, knew he played a role in patient satisfaction. His 110-person staff changed light bulbs, unclogged toilets, cleaned rooms, painted walls, and performed all the tasks needed to maintain a comfortable environment. When it came to providing the best patient care, however, that was strictly up to the clinical staff, Lenart thought. So his ears perked up during a CRH management meeting in late 2005 when he heard CEO Doug Leonard declare that the 225-bed hospital would never reach its full potential until every employee contributed to improving the quality of patient care.
Lenart was intrigued by the challenge, but a little uncertain about where his departments fit in. “It wasn’t clear to me how our work was connected to patient outcomes,” he says. Then Lenart heard Thomas Sonderman, MD, Chief Medical Officer and Patient Safety Officer, present IHI’s 100,000 Lives Campaign (now the 5 Million Lives Campaign) to the non-clinical staff. “Each of the Campaign’s six interventions involved saving lives by implementing specific processes of care. I could relate to that.” To help Lenart identify specific ways in which his workers — who range from housekeepers to copy machine operators — could help improve patient care, clinicians, including Clinical Nurse Specialist Jennifer Dunscomb, RN, MSN, explained how processes of care affect clinical outcomes.
One simple example was hand washing. “Caregivers need to wash their hands every time before touching patients or they increase the risk for hospital-acquired infections,” says Dunscomb. Lenart and Dunscomb reasoned that, if a sink is non-functional, caregivers might be tempted not to comply with hand washing or, more likely, Dunscomb says, “they’ll use the sink in the next room, which increases the odds of cross-contamination from one patient to another.” To lessen those odds, Lenart’s team committed to fixing sinks in 24 hours or less.
In January 2006, when Lenart began tracking performance, only 77 percent of sinks were fixed within 24 hours of a report. By March, performance had jumped to 100 percent. Except for a dismal December — 44 percent — when the holidays interfered with work schedules, performance has held steady in the low 90s. Beginning in April 2007, housekeeping staff will contribute to better hand hygiene in another way: they’ll monitor caregivers’ compliance with the hospital’s hand washing guidelines. “The two members of our workforce are often in the room together. Inviting housekeepers to complete surveillance helps to enhance reliability of data reporting,” explains Dunscomb.
Asking each of CRH’s non-clinical departments for their input has generated an abundance of ideas, says Dave Lenart. Operating room thermostats are now repaired within 24 hours so that temperature can be properly controlled during procedures to reduce the risk of surgical site infections. To help prevent pressure ulcers, housekeeping staff check for friction-causing defects in the vendor-washed linens. The hospital’s copy shop destroys obsolete forms, enlarges fonts, and ensures that all patient care orders are single-sided to head off mistakes with printed materials that carry important clinical instructions.
As CRH’s CEO Doug Leonard predicted, all these efforts have raised the level of expectations and goals throughout the hospital. “When the whole organization is hooked in, it’s a kind of enlightenment,” he says.
IHI Vice President Pat Rutherford, MS, RN, who heads the Transforming Care at the Bedside (TCAB) project, is not surprised by the enthusiastic buy-in from non-clinical staff. “Once individuals are considered to be part of the team and acknowledged for their contributions, the previously untapped potential at the front lines can now make significant contributions to quality improvement efforts. Pay and benefits are certainly important, but adding meaning to one’s work can go a long way to motivate all staff to do their best.”
CRH’s conviction that including everyone is key to improving clinical quality and patient safety is increasingly shared by all hospitals. 
At Ascension Health’s Seton Family of Hospitals, eight facilities serving 1.4 million people, non-clinical departments have been part of brainstorming sessions on patient care since 2004. One of ten TCAB project sites, Seton’s monthly progress meetings include representatives from every department.
Following one session in which non-clinical staff cited their most important contributions to patient care — nutritious food, clutter-free rooms, accurate admitting information — the hospital issued badges to employees that herald each person’s departmental role along with the slogan, “I’m a caregiver, too.” Says Mary Viney, RN, MSN, CNAA, Seton’s Vice President of Nursing Systems Accreditation, “It’s a stair-step effect. Everything and everyone supports everything and everyone else when you’re trying to raise your level of achievement.” Even volunteers have gotten into the act, offering to distribute and collect satisfaction surveys to save the time of nurses, who had been doing it. “And we find the number of returned surveys is better now, too,” says Viney.
Many patients in the 37-bed medical/surgical unit at Long Island Jewish Medical Center in New Hyde Park, New York, are over 65 — some over 100 — and debilitated by pneumonia, heart disease, or dementia. With the consequences of a fall particularly severe in this population, the unit declared itself a “fall-free zone” in early 2005. A 12-minute training video, entitled “It’s Everyone’s Responsibility,” was commissioned depicting situations in which a frail or confused patient was trying to get to her feet. The message, says Barbara Popkin, Director of Patient Care Services, was that “everyone has to be a patient advocate.” The film was shown to the entire staff, including transport, housekeeping, and maintenance, offering them suggestions on how to help keep patients safe.
Says Popkin, “We primarily want to drive home the message to call a nurse if there’s time. Otherwise, they [non-clinical staff members] need to intervene themselves to keep a patient safe.” To help identify patients at high risk of falls when they are out of bed or outside the unit for tests or consultations, the hospital issued patients “Ruby Slippers” — red slipper-socks with treads on the soles. The result: between 2005 and 2006, falls decreased from 4.5 per 1,000 patient days to 3 per 1,000 patient days — a drop of 33 percent. “Of course, we’re aiming for zero,” says Popkin, “and we’re getting there.” In the third quarter of 2006, the unit went 66 days without any falls.
Other techniques for averting patient mishaps are evident hospital-wide, including a new lighting system for all bathrooms that automatically turns on the light when the door is opened. “Engineering came up with that one,” says Popkin, “and every unit wanted it.”
Windham Community Memorial Hospital, a 79-staffed-bed facility in Willimantic, Connecticut, is busier than it has been in its 75 year history, says Mary Withey, MSN, APRN, Infection Control Coordinator. To make sure that nothing falls between the cracks, the hospital counts on every staff member doing what is needed. “Bringing clinical and non-clinical staff together fosters community and communication and encourages everyone to take responsibility,” according to Withey. Indeed, the hospital’s Building and Premises Rounds, which are used to inspect and evaluate all areas of the facility including clinical areas, is headed by Rich Cooper, a non-manager from the Environmental Services Staff. “We chose him because he just really knows the job,” says Withey.
As with all hospitals, Infection Control is a major focus at Windham. Rooms occupied by patients with infectious conditions were routinely scrubbed down with disinfectant cleaners before being reassigned to another patient. However, a nursing staff member noticed that the rooms’ privacy curtains remained — generally washed only on a separate pre-arranged schedule or if noticeably soiled. The nurse brought her concern to the Infection Control Coordinator and a group of staff members, including members of the Environmental Services Department, got together to develop a plan to address the issue. “Now we wash the curtains every time an infectious patient vacates a room,” says Robbie Maneri, Supervisor of Environmental Services.    
Another work group composed of clinical and non-clinical staff examined cleaning practices in the operating room. Special cleaning projects, for example, the OR storage carts and other non-essential equipment, were cleaned on an “as-needed” basis but are now cleaned on a regular schedule. “I’m not sure we’re cleaning them any more or less than we did before,” says Maneri. “The difference is that we’ve formalized the authority and accountability to make performance visible and trackable.”
Maneri also asserts that appearances contribute to quality of care. Currently, he’s on a quest to find cleaning products that produce spotless floors. For example, he says, “Microfiber mops don’t splash.” The point, says Maneri, is “to send a message that we’re proud of what we do and how we do it.”
During IHI’s 100,000 Lives Campaign, Beth Israel Medical Center’s two campuses in New York City set out to reduce infections introduced by the equipment that pumps life-saving fluids and drugs into gravely ill patients. “Reducing central line infections inspired us to enlist everyone, not just clinical staff, in reducing all hospital-acquired infections,” says Brian Koll, MD, Hospital Epidemiologist and Chief of Infection Control.
One immediate improvement: Materials Management made sure that all required sterile supplies were available in one sterile cabinet. After consulting with housekeeping and transport staff on other ways to keep pathogens on equipment at bay, the combined 1,000-bed facilities introduced new cleaning protocols. Each day, housekeepers receive a list of patients and their rooms. Rooms are color-coded (see chart below) to tell the cleaners when to use special protocols for patients harboring multidrug-resistant organisms or other infectious conditions. Rooms occupied by such patients are sanitized with a 1:100 bleach solution while the patient is in residence, but scrubbed down with a 1:10 solution once the patient vacates. Wheelchairs are cleaned with sanitary wipes between patients, as are IV poles.
 Contact Precautions at Beth Israel Medical Center, New York
The new protocols come with a paper trail. Stickers saying “I’m clean” are affixed to newly sanitized equipment, and a form that must be signed by both a housekeeper and a nursing supervisor attests to the required bleach cleanings. How do the supervisors know, for sure, that the room has been cleaned according to the protocol? “Easy,” says Koll. “Their noses can tell.”
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