Will Improvements Sustain During Hard Times?

Posted on Jan 1st, 2009 at 3:48pm.

During the past 2 or 3 years, a number of hospitals and other health care systems have made signficant, measured improvements in quality and safety. In scores of ICUs, ventilator pneumonias are now rare. MRSA transmissions and other nosocomial infection rates have been cut dramatically. Mortality rates, both raw and risk-adjusted, have decreased by as much as 25% or more. And these improvements in safety and quality have not been an accident. They have been the result of focused attention, fresh ideas, and effective, engaged leadership. Also...they have been achieved during very good financial times, at least for hospitals.

The question for 2009 is: will these improvements sustain through the budget cutbacks that almost all health care systems are now experiencing? Or, as hospitals cut nurse staffing and slash budgets for education, travel, and quality infrastructure, will we see safety levels start to decline, nosocomial infection rates creep back upward, and hospital deaths start to climb? I don't know about you, but I think we're facing a major safety challenge, right now. And I think there are several practical steps every health care system might take to hold the ground that's been gained on quality and safety, despite the current financial crisis. Here are three ideas.

1. Keep the Board's attention on safety: Now, more than ever, it's critical to keep your Quality and Safety report (with measures of your rates of harm, infections, deaths...etc.) first on the Board agenda, not at the end of it. If the rates start to slip, the Board will start asking hard questions, and that's a good thing. Question: where is the Quality Report place on YOUR board's agenda?

2. Talk about it: I've been in far too many senior leadership meetings during the last 2 or 3 months during which staffing and other budget cuts were proposed and approved, without a single voice asking the question: "How can we do this, safely?" I don't want to be the skunk at the CFOs' picnic, but Linda Aiken's work clearly tells us that if all we do is reduce nurse staffing, we will reduce safety levels, and mortality rates will increase. We simply must talk about this issue, and find ways to take waste out of our nurses' and other professionals' work, if we are ever to reduce staffing costs SAFELY. Question: Have you been in a cost-reduction meeting recently? Has anyone raised the question of safety? If not, why not?

3. Go transparent with our measures of safety: A small number of brave organizations such as the Beth Israel Deaconess in Boston publicly display specific measures of "preventable harm" (www.bidmc.harvard.edu).  I would bet on those organizations' ability to stay the safety course during a financial crisis. Their commitment is too public, and too important now to too many stakeholders, to be permitted to backslide. On the other hand, if a hospital keeps its safety measures hidden from view, who would notice if the measures started to slip? Question: Has your organization made this sort of public commitment, with highly visible data on measures such as infection and complication rates? If not, why not?

I'd like to hear your answers to these sorts of questions. I'd also like to hear your ideas for how to sustain the hard-won gains you've made in safety over the past few years.

Posted on a snowy New Year's Day in Alta, Wyoming.



I agree that it is a heightened challenge at this time. Here are a couple of ideas from our experience to date, of what might help keep leadership attention on quality and safety. We work with a group of CEO/senior leaders from 23 community-based, not-for-profit healthcare systems from 6 states in the eastern US, who meet around our Board table about three times a year, and we have seen their commitment to quality and safety remain a focus of their attention (so far!). Last October they began their Board meeting sharing and venting about the deteriorating economic state of their communities and the impact on their organizations and plans, and sharing ideas for cost containment. We heard, as expected, tactics such as postponing certain capital equipment acquisition and taking a hard look at unprofitable or redundant services, and some other tactics, less expected and very gratifying: continuing to reduce hospital-acquired infections, and looking at ?stuff, not staff?, including a microsystem-based approach to involving staff looking at every little supply item used perhaps wastefully, and working more closely together with the medical staff on (high cost) clinical-preference supply utilization. After the discussion on the economic reality they proceeded with their next steps on their Board-directed quality agenda. Upon reflection at the end of the meeting they noted that the flow of discussion from economics to quality went well and helped them keep things in perspective. So perhaps just having the opportunity to ?get it out of their systems? enabled them to acknowledge the economic hardship but freed them up to pursue what they know is right and important: to keep their eye on the ball for quality and safety. This group of leaders decided about two years ago that they could come together with a common focus on quality and safety and realize a larger impact than they could on their own. They have used a part of every Board meeting to advance the work of leadership influencing the culture of safety and high reliability and to monitor the progress of their hospital teams on reducing hospital-acquired MRSA toward an aggressive, aggregate 3-year goal that they set. Within this group there are some very vocal leaders who are passionate advocates for safety and quality. So perhaps having this ongoing, peer forum has also helped them keep the focus on quality and safety: peer pressure/peer support. Regarding transparency, one of these leaders got his Board?s approval to post hand hygiene compliance rates overall and by nursing unit on the large screen display unit in the main hospital public lobby atrium.

Posted by MH (Jan 21st, 2009 4:14pm)

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