IHI kicks off new patient safety initiative

Hospitals will try to prevent 5 million medical injuries in the next two years. Meanwhile, a journal article questions how IHI measures results.

By Kevin B. O’Reilly — Posted Jan. 1, 2007

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Flush from the success of persuading more than 3,000 hospitals to implement systems changes aimed at saving 100,000 lives in 18 months, the Institute for Healthcare Improvement last month set out a new and perhaps even more ambitious goal.

Nearly two years after asking hospitals to implement six interventions, the influential Cambridge, Mass., nonprofit group is asking hospitals to carry out an additional six interventions. The dozen combined changes are aimed at preventing 5 million medical injuries over the next two years. IHI estimates that there are 15 million "incidents of harm" every year. The label includes preventable adverse events, medical errors and injuries contributed to by medical care or the absence of indicated care.

The group's new Protecting 5 Million Lives From Harm initiative targets common medical injuries such as pressure ulcers, staph infections and surgical complications. At the same time, IHI officials are asking the 3,100 hospitals that signed up for the 100,000 Lives Campaign to continue implementing that plan's interventions. Those systems changes included deploying rapid response teams at the earliest sign of a patient's decline and preventing central-line infections. All of the hospitals that signed on to the last campaign, which account for more than 75% of U.S. hospital beds, have been carried over to the 5 Million Lives initiative. IHI hopes for a total of 4,000 hospitals.

"If achieved, this would be the biggest improvement in patient safety in modern health care," said IHI President and CEO Donald M. Berwick, MD.

IHI's suggested medical interventions have been mandated by the Centers for Medicare & Medicaid Services or the Joint Commission on the Accreditation of Healthcare Organizations, or recommended by government agencies and patient safety groups. The program seeks to speed the pace at which hospitals implement them.

The one nonclinical plank in the campaign, called Boards on Board, is unique to IHI's campaign. It calls for hospital boards of directors to devote at least 25% of their time to quality and safety issues and to base senior executives' compensation partly on quality performance.

The campaign also calls on each participating hospital's CEO and a board member to do a "deep dive" examination of a single case where a patient was harmed and make a one-hour presentation at a board meeting.

"The dedication from the front lines, from nurses and physicians, is encouraging," said Joe McCannon, IHI vice president and 5 Million Lives Campaign manager. "Now the key is making sure that the leadership and governance structures are just as engaged."

Health insurers and medical groups greeted the new campaign warmly. The BlueCross BlueShield Assn. kicked in $5 million to help fund the initiative, which provides free how-to guides on the suggested interventions and outcomes measurement. Medical supplier Cardinal Health also gave more than $1 million, while the Aetna Foundation gave more than $250,000. The AMA, which served as a partner in the 100,000 Lives Campaign, has not yet signed on to the new plan. AMA board Chair Cecil B. Wilson, MD, said the Association is reviewing the campaign interventions and "will continue to look for ways to work with IHI and with physicians across the country to find even more ways to incorporate increased safety into every patient encounter."

Calculating the numbers

The 15 million "incidents of harm" estimate comes from IHI's experience of doing selected chart reviews in hospitals using its "trigger tool" to identify harm to patients. These reviews show that there are 40 to 50 injuries per 100 hospital admissions, ranging from temporary harms requiring minor intervention and no hospitalization to permanent injuries or death. One patient could experience multiple incidents in a single stay. The injury rate multiplied by the 37 million hospital admissions every year yields the 15 million annual injuries figure, though researchers say about 90% of these incidents are minor and temporary.

Exactly how many of these injuries are preventable is one reservation patient-safety experts have voiced about IHI's work. Robert Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center, said recommended care sometimes can result in patients being harmed. The campaign targets high-alert medications such as anticoagulants, for example, that, while clinically recommended in cases of atrial fibrillation, can cause strokes. (See clarification)

Dr. Wachter co-authored a November 2006 Joint Commission Journal on Quality and Patient Safety article taking IHI to task for what it called lax measurement methods. While the group claimed that its 100,000 Lives Campaign helped spare 122,300 lives by comparing hospitals' previous mortality data to data from the 18-month campaign period, Dr. Wachter said the figure could not be attributed to the campaign because hospitals could choose not to report data and because there was no control group.

"I fear that we may see a similar issue in two years that we saw with the announcement of '122,300 lives saved' -- that is, widely promoted and uplifting results that lack a strong scientific underpinning," Dr. Wachter said. (See clarification)

IHI said the 100,000 Lives Campaign results, announced in June 2006, have not yet been submitted for peer review because researchers are still getting Medicare data for a control group of nonparticipating hospitals. Andy Hackbarth, senior engineer at IHI, said the 100,000 Lives Campaign was not an academic exercise "testing the efficacy of an intervention. It was essentially measuring progress over time."

IHI is finalizing how it will measure progress in the 5 Million Lives Campaign, Hackbarth said, though it is likely to involve sample chart reviews using IHI's trigger tool.

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Targeting harm

The Institute for Healthcare Improvement's plan to prevent 5 million medical injuries over the next two years calls on hospitals to continue implementing the six interventions from the 100,000 Lives Campaign as well as carrying out six new steps:

  • Prevent methicillin-resistant Staphylococcus aureus infections using proven infection control practices throughout the hospital.
  • Reduce harm from high-alert medications such as anticoagulants, sedatives, narcotics and insulin.
  • Prevent pressure ulcers.
  • Reduce surgical complications by implementing changes recommended by the Surgical Care Improvement Project.
  • Deliver evidence-based care for congestive heart failure to reduce readmissions.
  • Get hospital boards of directors to prioritize quality improvement and patient safety.

Source: Institute for Healthcare Improvement, 5 Million Lives Campaign

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In this story, two statements attributed to Robert Wachter, MD, were unclear. His concern about the Institute for Healthcare Improvement's focus on high-alert medications is that, for example, anticoagulants can cause intracerebral bleeding even when used appropriately for patients with atrial fibrillation. Also, he said, IHI's 122,300 lives saved figure from its previous initiative could not be fully attributed to the campaign, because death rates in American hospitals were plummeting independently and because many of the "lives saved" were extrapolated from nonreporting hospitals.

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