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accountability

Hospital-acquired infections: How do we reach zero?

This week, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.

First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections. About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the infections, the CDC researchers reported in the New England Journal of Medicine.

On the bright side, those numbers are less than half the number of hospital-acquired infections that a national survey estimated in 2007. And a second report issued this week found significant decreases in several infection types that have seen the most focused prevention efforts on a national scale. Noteworthy was a 44 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2012, as well as a 20 percent reduction in infections related to 10 surgical procedures over the same time period.

These infections were once thought to be inevitable, resulting from patients who were too old, too sick or just plain unlucky. We now know that we can put a significant dent in these events, and even achieve zero infections among the most vulnerable patients. At Johns Hopkins, we created a program that combated CLABSI in intensive care units through a multi-pronged approach—implementing a simple checklist of evidence-based measures while changing culture and caregivers' attitudes through an approach called the Comprehensive Unit-based Safety Program (CUSP). The success was replicated on a larger scale across 103 Michigan ICUs and then later across most U.S. states, with impressive results.

These and similar successes have changed caregivers’ beliefs about what is possible, and inspired more efforts to reach zero infections.

What will it take to attain this goal—or at least get much closer?

We need policymakers to continue providing support so that we can mature the science of improving patient safety. We need their help to create valid and widely accepted performance measures, as well as advance implementation science so that we can learn how best to translate medical evidence into everyday bedside practice.

Hospitals have a big role, of course. As organizations, they must focus on the safety and quality of care with the same rigor and accountability that they bring to their financial performance. Almost without fail, hospital CEOs can tell you if their organization is meeting its budget goals. There are financial specialists at various levels of the organization, and there are consequences for poor performance. When it comes to patient safety, however, those structures rarely exist, even when the desire to reduce harm is strong. Some hospital CEOs I've met didn't know the infection rates at their facilities. Sometimes those rates are known only by the infection prevention department.

What we need are chains of accountability that link everyone in a hospital—from the board to the frontline staff—so that everyone has a shared understanding of their organizational goals, knows their role in meeting them, and gets feedback (such as dashboards) on how they are performing. Those organizations also need the internal capacity—health care professionals with the appropriate training—to carry out their roles in this chain. It sounds simple, but clearly it’s not. Over the past year, Armstrong Institute researchers worked with the VHA hospital engagement network on a demonstration project that sought to create those accountability structures at 10 U.S. hospitals. The initial results are encouraging, with 92 percent of participants reporting that they felt their organization has made improvements in targeted areas, such as surgical site infections (SSIs). It’s breathtaking what we can accomplish when everyone is working toward the same goal.Read More »Hospital-acquired infections: How do we reach zero?

Company churns out burritos, French toast — and inspiration for health care

This year I am participating in an executive fellowship that is designed to expose leaders in various industries to the Baldrige Framework, a model for organizational excellence. As part of the program, the fellows visit companies that received the coveted Malcolm Baldrige National Quality Award, administered by the U.S. Department of Commerce. Recently, we toured Cargill, a large, Minnesota-based company that has about 75 business units, and spent time with two of them: Cargill Kitchen Solutions, which largely makes egg products for McDonald’s, schools and many other customers; and Cargill Corn Milling, a maker of corn syrup, animal food and ethanol.

We not only talked to leaders and reviewed their strategic plans, but visited the plant. We spoke to employees on the floor, as food was prepared on a massive scale: eggs being cooked by the thousands, breakfast burritos being assembled and placed on conveyor belts, French toast cooked, stacked and placed into boxes.

As we talked to leaders, toured the plant and reviewed their strategic plans, I was struck by three things.

First, everything and everybody was focused on the customer. The customer was at the center of every discussion, every decision and every strategy. From the CEO to the managers to people on the shop floor, they talked about meeting customers’ needs. Usually it was the first thing out of their mouths, and they used the impact on customers as a scale for weighing every decision. Indeed, many staff, from senior leaders to line operators making an hourly wage, said, We know who pays our paycheck; it’s the customer. If we want a paycheck, we better meet their needs.Read More »Company churns out burritos, French toast — and inspiration for health care

Health care needs greater accountability, not excuses

Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

Read More »Health care needs greater accountability, not excuses