Published in the September 2008 issue of Today’s Hospitalist
IF SEVERAL DOZEN HOSPITALS cut their rates of central-line infections and ventilator-associated pneumonia by more than 60% in less than two years, most people would take note. Throw in the fact that many of those hospitals are competitors, and the results become even more impressive.
That’s exactly what happened when a collaborative of 39 hospitals in the San Francisco Bay Area joined forces under the aegis of the Beacon Collaborative. Because of its tremendous successes “the infection control and VAP initiatives alone have saved nearly 200 lives across participating hospitals in 21 months “the three-year-old group is being held up as a model to spur not only regional cooperation, but the use of healthy competition among hospitals to improve the quality of care.
Every quarter, the collaborative brings together hospital representatives, typically quality and patient safety directors, front-line nursing staff and the “occasional” nursing executive or medical affairs VP. The group also conducts monthly Web conferences and other forms of electronic communication.
In what can be loosely described as show-and-tell sessions, participating hospitals are urged to share their solutions and the fruits of experiments. Bruce Spurlock, MD, executive director of clinical acceleration for the collaborative, says that during these sessions, hospitals share simple yet effective strategies. One example: putting red tape on the wall behind an ICU bed to visually indicate when the head of the bed is elevated the recommended 30 degrees, to help prevent pneumonia. “It’s really about testing, change and experimentation,” Dr. Spurlock explains.
There’s another key to the collaborative’s success, Dr. Spurlock says. From the start, the group has been committed to keeping data collection to a minimum. Otherwise, the thinking went, hospitals would not only feel overwhelmed by data collection duties, but nervous about the prospect of sharing proprietary data with competitors.
In the case of infections, for example, participating hospitals report actual infections rates (and rates per number of device days when ventilators or central lines are used). With its pneumonia initiative, however, the group encouraged hospitals to track compliance with the Institute for Healthcare Improvement’s ICU ventilator bundle. But the collaborative did not require them to share those data because the gathering burden would be too high.
Dr. Spurlock, who has helped launch collaborative efforts in other regions, says that keeping the collaborative’s initiatives from becoming too complex highlighted the contribution that smaller hospitals can make to quality improvement. “You’d be surprised how often a small hospital comes up with a solution that all the other big hospitals are now implementing because they never thought about it,” he says.
Beacon Collaborative’s participants decided that infection rates were a good place to start for two reasons. For one, reducing rates of central-line infections can occur rapidly, even with modest adherence to chosen interventions. That gives rise to early successes, which encourages participants to go back to their institutions with good news in hand.
Dr. Spurlock says that one participating hospital has been so successful in reducing central-line infections that it now posts those data in its lobby.
“The collaborative is a great outlet for local hospitals to pat themselves on the back and to share their stories with other colleagues in the Bay Area,” Dr. Spurlock says. “That creates a sort of ‘soft competition’ that collaboratively builds on the natural competition among people. It’s been very powerful.”
The second reason the group chose central-line infections and VAP? The interventions are largely based on checklists and driven by nurses, which makes them easier to implement than complex initiatives that involve multiple departments and groups of stakeholders.
When an intervention needs to engage individual physicians and multiple care teams, settings or patient units, it’s much harder to get off the ground. While some of the hospitals in the collaborative are moving toward taking on much tougher projects, such as MRSA and sepsis initiatives, Dr. Spurlock says those are more complex and require more sophisticated implementation strategies.
Avoid competitive services
Focusing on relatively simple initiatives was a key to the group’s success, Dr. Spurlock says. But it was also important to make sure that competition between the various hospitals didn’t interfere with its goals.
The group sticks with initiatives that are not key areas in which local hospitals typically compete, he explains, so data sharing isn’t be an obstacle. “Central-line infections rates are not something hospitals use as a way to get people to their hospital,” Dr. Spurlock says. “We found openness about that issue.”
That story might be far different if the collaborative had targeted areas like coronary artery bypass graft effectiveness or examined “high-margin practices” like orthopedic procedures.
“People won’t open up if they don’t feel safe, and this collaboration business does mean sharing vulnerabilities,” he adds. “But we found it was initially easy to get people who’ve had a fair amount of success to talk, the early adopters in central-line infection reduction and other ICU initiatives. They tended to help the people who were at an earlier stage.”
Where hospitalists come in
The project’s success has led some member hospitals to address more ambitious initiatives like measuring the use of evidence-based therapies for stroke care and preventing harm from high-risk medications. Dr. Spurlock cautions, however, that there is one potential deterrent to success in these wider initiatives: the collaborative’s relative lack of physician involvement.
“We tend to have only a handful of docs who show up at our meetings,” he says. “That’s been one of our ‘a ha’s’ over the past three years.”
To increase physician involvement, the collaborative has created a physician leadership council. The group is also considering staging short Web conferences and using video technology to reach out to doctors. “We’re looking at this as a small test of change,” Dr. Spurlock says.
And while the collaborative hasn’t collected any data examining the performance of hospitalists in the group’s initiatives, Dr. Spurlock is convinced that hospitalists should play pivotal roles in the more difficult, complex interventions participating hospitals will undertake that target issues like medication safety, sepsis and MRSA.
“These require much greater physician participation to make them successful,” he explains, “so hospitalists may be the key players in those areas.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.