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One hospital finds that a light touch is the best way to improve quality

January 2006

Published in the January 2006 issue of Today’s Hospitalist

When it comes to improving patient care, one hospital has discovered that a light touch can not only lead to decreases in mortality, but also keep staff interested in change. As anyone who has tried to boost clinical performance knows, that’s no small achievement.

Over the last five years or so, Tallahassee Memorial Hospital has tackled nearly every major quality improvement project under the sun. The 770-bed facility in Tallahassee, Fla., has made strides in areas like tightening glucose control, improving the care of myocardial infarction and taking patients off ventilators sooner.

No newcomer to quality improvement, the hospital is one of 13 institutions worldwide that’s taking part in the Pursuing Perfection project, led by the Institute for Healthcare Improvement and funded by the Robert Wood Johnson Foundation. That initiative, which began in 2001 and is entering its last phase, haste ambitious goal of helping U.S. health care reinvent itself by designing newer, safer and more efficient systems of care.

Tallahassee’s impressive results in the quality improvement arena, however, tell only part of the story. To effectively reinvent how it cares for patients, the hospital has had to help reshape the way its clinicians approach not just quality, but patient care.

Glucose control

Clifton Bailey, MD, director of critical care services, says that the hospital’s low-key approach to changing care has been a key in its success. He cites the initiative to improve glucose control levels as one example.

After working with clinicians to develop a glucose-control protocol, the hospital rolled the project out gradually, starting with CABG patients and then phasing it into the medical-surgical ICU. While the protocol makes very specific recommendations “it says that blood sugar levels should optimally fall between 70 mg/dL and 100 mg/dL “the hospital decided to refrain from telling nurses and physicians how to reach that goal.

“The most important thing was saying what we expect,” Dr. Bailey explains. “The less important thing was how to get there.”

It’s an example of how the hospital uses a nonprescriptive approach to changing behaviors. “We encouraged everyone to use the protocol,” Dr. Bailey says, “but we didn’t say it was the only way to skin the cat. We said here’s where we are and here’s where you can be if you use the protocol. This has been an extremely low-key process, and the bedside nurses have been the key.”

Success breeds success

If there was no pressure on clinicians to use the protocol, what motivation did they have to change their ways? Dr. Bailey says that the initiative gained momentum as word about its effectiveness spread.

“Once we got results in specific units,” he recalls, “we put those results out. Then we started measuring everyone’s performance by units and also by groups of doctors. We said this is what can be done, and this is where your area is.”

The results speak for themselves. Before the glucose control initiative started in 2002, patients’ blood sugars were in optimal range about 33 percent of the time. A mere 18 months after the initiative had begun, that number had risen to nearly 60 percent. Dr. Bailey says the hospital’s approach demonstrates how reporting data can produce not only immediate results, but also change clinicians’ thinking.

“If you have a reason for something to be done and you can provide data showing that improving it makes a difference, everybody changes,” he explains. “Everybody is now much more willing to change than they were three years ago. Little bits of success breed more success.”

Lessons about decreasing mortality

Tallahassee has successfully used a similar strategy to improve other clinical areas, from ventilator management to AMI care. But perhaps the most impressive proof of the hospital’s success in the quality improvement arena can be found in its efforts to lower mortality rates.

In 2002, for example, the mortality rate in the NSICU came to just over 11 percent of discharges. By the end of 2004, that rate had improved to 8.15 percent.

What did Tallahassee do to drive down its mortality rates? While the hospital used very specific strategies to improve areas like glucose control, there was no master plan to reduce mortality. Instead, the hospital’s success in that area was a culmination of all its efforts to improve quality.

“That’s a number you can monitor,” Dr. Bailey says of mortality reductions, “but not one you can aim for. There isn’t any way to get there. A decrease in mortality takes place because you do six things right or better, and that translates into a 0.5 percent gain. Mortality reduction has to be a byproduct of other processes.”

It’s another lesson that veterans of the quality improvement movement like Tallahassee have learned over time: Choose projects that will produce results, not overly ambitious goals like reducing mortality.

Choose mortality reduction as a quality improvement goal, Dr. Bailey warns, and you’ll fail. “You need something that’s concrete, doable and will succeed,” he explains. “You don’t want to pick something that’s going to lose.”

Big change in thinking

Avoiding overly ambitious projects not only produces immediate results, but it helps generate long-term buy-in about the value of quality improvement initiatives among clinicians.

Dr. Bailey says that looking back, it’s startling how much the attitudes of everyone working at the hospital have changed. “This whole process has been an eye-opener for me,” he explains, “that you can live with something and it doesn’t seem to be going wrong, even though there are tremendous opportunities for improvement.”

As one example of just how much the culture has changed at Tallahassee, Dr. Bailey says that staff no longer simply track events that happened last month. They now keep an eye on events that happened last week and even today.

“We’ve gone from looking at how we did last year to how we did last month and how we are doing now to how the patient that we admitted last week is doing right now,” he explains. Dr. Bailey says he has also found noticeably less resistance to change among most clinicians, something that is evident in the hospital’s current initiatives.

In one of its current quality improvement initiatives, for example, Tallahassee is trying to speed up its care of sepsis. Among other things, the hospital is encouraging clinicians to arrive at a diagnosis of sepsis within two hours and then begin treatment within four hours.

Dr. Bailey says the initiative has been very well received, in part because of the hospital’s long history with quality improvement. When clinicians forget to refer to a patient’s sepsis, he notes, they are likely to say, “That’s a good point, I forgot to do it that time,” or “I should have labeled that chart as sepsis instead of UTI.”

Dr. Bailey adds that the sepsis program is just the latest example of how the hospital’s strategies pay off.

“The things we want them to do are not very complicated,” he explains. “There’s no change in therapy, just that instead of doing something in 12 hours, we want it done in six hours.”

Edward Doyle is Editor of Today’s Hospitalist.