Spend time with hospitalists and their competitive natures readily emerge. Striving for excellence in clinical care, hospital efficiency, and patient satisfaction, they are their hospitals’ beacons for attracting patients from referring physicians. As hospitalists’ capabilities grow, they hone pathways and procedures, improving their hospitals over time. What would happen if those hospitalists systematically shared their collective knowledge?
That’s what’s happening for hospitalists from nine health systems in southeast Michigan. Transcending their individual pursuits of excellence, they have united as Hospitalists as Emerging Leaders in Patient Safety (HELPS), a unique two-year consortium to improve patient safety regionally. Through large and small group meetings, HELPS is defining and tackling paramount patient safety issues, and collecting and sharing data about what works best.
A $117,000 grant from the Blue Cross/Blue Shield Foundation of Michigan awarded in 2005 to the University of Michigan Health Systems (UMHS) spurred the regional collaboration. Co-principal Investigator Scott Flanders, MD, UMHS’ chief of the hospitalist service and an SHM board member, conceived the project several years ago.
“What galvanized me is when I realized that we are a relatively small number of hospitalists overseeing a large number of patients—between 80,000 to 85,000 admissions annually,” he explains. “Those numbers indicated that we need to share our knowledge, treatment guidelines, and processes if we are to significantly improve patient safety.
—Scott Flanders, MD
“I assumed that many hospitalist groups wanted to improve patient safety,” continues Dr. Flanders. “But we were all working in isolation and were too busy caring for our patients to take the time to collaborate with colleagues in other programs.”
Dr. Flanders and HELPS’ other co-principal investigator, Sanjay Saint, MD, MPH, a hospitalist who heads UMHS’ Patient Safety Enhancement Program, were willing to spearhead a regional patient safety initiative with input from fellow hospitalists and patient safety officers. The Blue Cross/Blue Shield Foundation grant allowed the hospitalists to meet face-to-face periodically, target patient safety concerns, share hospitalist medicine group initiatives, collect data, and disseminate findings and best practices among the participants.
Dr. Saint and his colleagues provided one template for change. By using reminders and automatic order sets to prompt doctors to remove urinary catheters in a timely manner and by using anti-bacterial catheters, the team has shown that it can reduce bloodstream and urinary tract infections among its patients.
Drs. Flanders and Saint outlined a broad range of targets for the consortium hospitalists, including eliminating medication errors, creating a culture of safety, increasing the use of prophylactic medications for surgical patients, improving intensive care practices including pneumonia prevention, and examining end-of-life care practices such as pain management and the use of advance directives. Focusing on the elderly, who often fare poorly during hospitalizations, HELPS is looking for ways to prevent falls and delirium for that patient population. Through regular meetings, the hospitalists are developing techniques and benchmarks for performing quality improvement research and compiling lessons learned.
Nora Maloy, who works for Blue Cross/Blue Shield Foundation and who is Michigan’s senior program officer, positions the hospitalist collaboration as part of her foundation’s broader initiative to improve patient safety in response to the Institute of Medicine’s 1999 “Crossing the Quality Chasm” report that 98,000 unnecessary deaths occur annually in U.S. hospitals.
“We are very excited about the HELPS initiative,” says Maloy. “We hope to see outcomes data and best practices emerge from the nine different systems in the project, and to support a hospitalist consortium that can serve as a national model.”
At early meetings the hospitalists developed this process for their work together:
- Identify a common problem to study;
- Present data on the individual hospitalist or hospitalist group’s experience with the problem and a patient safety initiative to correct it;
- Create a steering committee and a team to research and present data on the initiative;
- Capture and organize data;
- Have an on-site visit from a principal investigator who participates in rounds and discusses data collection capabilities;
- Present to the group key steps in performing the patient safety initiative;
- Implement the initiative in as many of the nine hospitals that want to participate;
- Collect data from the larger group and report to the consortium; and
- Disseminate results through other regional and national meetings, and peer-reviewed journals.
HELPS’ funding frees participating hospitalists to attend quarterly meetings. Reflecting on their busy professional lives, Dr. Flanders says that groups are participating on different levels.
“We know that some hospitalist groups are stable, and they will propose initiatives, collect data, etc.,” he explains. “Other groups that may have recruiting and turnover issues and are just surviving won’t be able to do so, but their attendance at the meetings is very important. There are also small ad hoc meetings for those working on specific patient safety projects.
Took the Challenge
Bobby Lee, MD, director of inpatient medical education at the 600-bed Oakwood Hospital and Medical Center in Dearborn, Mich., eagerly joined the consortium when he realized that a large number of patients were being managed by a small number of hospitalist physicians.
“Scott [Flanders] and Sanjay [Saint] were very inclusive of hospitalists from different programs,” says Dr. Lee. “They articulated what’s important to us as hospitalists—that we bring something special to a hospital, to make it a safer place than when we got there.”
Sharing an Idea
Dr. Lee’s initiative, “Preventing Failure to Resuscitate,” addresses the issue that—on average—between 66% and 70% of patients outside the ICU on whom a code blue is called have alterations in their vital signs six to eight hours before the code. Dr. Lee’s solution was a rapid response team (RRT), developed after process analysis and data collection. And he has shared the initiative with HELPS.
“We did a literature review and then collected historical data on code blues at Oakwood,” explains Dr. Lee. “I took the data to our director of accreditation, an RN, and we felt that we could do better.”
After conducting several small pilot projects on different units to determine optimal staffing, equipment, and medications necessary for a quick response to a code, Dr. Lee presented his findings to Oakwood’s senior management, who committed the necessary resources. That includes a CCU nurse, respiratory therapist, either a hospitalist or intensivist, and a medical service resident—four teams in all for 24/7 coverage.
“There were a surprising number of models and variables we had to look at, such as streamlining lab results, getting test results to the bedside faster, and getting emergency boxes with the right pharmaceuticals on each unit,” adds Dr. Lee.
One interesting twist was Oakwood’s inclusion of hospitalists from private hospital medicine groups on the RRT. “Involving both community-based and academic medicine hospitalists has fostered a culture of inclusiveness, and that works,” says Dr. Lee. His final word: “We can’t leave our patients on the edge of the quality chasm. For not a lot of money, an RRT can help us help someone survive a code blue, and beat the odds that only 17% of code blues live to be discharged from the hospital.”
As the HELPS team continues on its two-year journey to better patient safety, the hospitalists will share what works, what doesn’t work, and what obstacles need to be removed. Overall, though, the HELPS’ vision that a small number of hospitalists joining together can have a huge effect on the care of upward of 80,000 patients has already succeeded. TH
Marlene Piturro is a frequent contributor to The Hospitalist.