Improvement at Full Scale: The 5 Million Lives Campaign

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Improvement at Full Scale The 5 Million Lives
Campaign

• Donald M. Berwick, MD
• Institute for Healthcare Improvement
• American College of Surgeons
• 2007 NSQIP National Conference
• Phoenix, AZ June 26, 2007

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Major Biomedical Successes in Hand

• Acute Lymphoblastic Leukemia
• Coronary Heart Disease
• Acute Myocardial Infarction
• Erythroblastosis Fetalis
• Diabetes Mellitus
• Asthma
• Organ Transplantation

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Complex Cardiac Surgery A Case Study of Playing
with Fire

• Miraculous mitral valvuloplasty
• Torn urethra from intraoperative insertion
• Inappropriate dose of coumadin
• Transition home Lasix doubled at discharge
• Extreme difficulty rising from bed
• Lost five kilograms in 24 hours
• Lasix to furosamide not understood
• Magnesium and potassium replacement
• No instructions to discontinue Lasix
• No information to primary care doctor
• Surgeon I did my job now its up to you.
• Medications Lasix, Lopressor, Magnesium,
  Potassium Iron, Coumadin, Simvastatin, Pain,
  Prostate

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Defects.for example

• 45 of needed care is not received
• 22 of chronically ill adults report a serious
  error in their care
• 74 of chronically ill adults say the system
  needs fundamental change or complete
  rebuilding
• Case-mix adjusted hospital death rates vary 400
• Resource use in the last six months of life
  varies gt500 among 77 top-rated US hospitals
• Per capita annual health care costs
• US 6000
• Sweden 2800

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QUALITY PATIENT-CENTERED, TIMELY CARE
Difficulty Getting Care on Nights, Weekends,
Holidays WithoutGoing to the ER, Among Sicker
Adults in Six Countries, 2005
Percent of adults who sought care reporting
very or somewhat difficult
GERGermany NZNew Zealand UKUnited Kingdom
CANCanada AUSAustralia USUnited
States. Data 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults (Schoen et al. 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
41
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Medical, Medication, and Lab Errors Among Sicker
Adults, 2005
QUALITY SAFE CARE
Percent reporting medical mistake, medication
error, or lab error in past two years
International comparison
United States, by race/ethnicity,income, and
insurance status
UKUnited Kingdom GERGermany NZNew Zealand
AUSAustralia CANCanada USUnited
States. Data Analysis of 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults Schoen et al. 2005a.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
36
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International Comparison of Spending on Health,
19802004
EFFICIENCY
Average spending on healthper capita (US PPP)
Total expenditures on healthas percent of GDP
Data OECD Health Data 2005 and 2006.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
58
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Increases in Health Insurance PremiumsCompared
with Other Indicators, 19882005
ACCESS AFFORDABLE CARE
Percent
Estimate is statistically different from the
previous year shown at plt0.05. Estimate is
statistically different from the previous year
shown at plt0.1. Note Data on premium increases
reflect the cost of health insurance premiums for
a family of four. Historical estimates of
workers earnings have been updated to reflect
new industry classifications (NAICS). Data
KFF/HRET Survey of Employer-Sponsored Health
Benefits 2005.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
56
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ACCESS UNIVERSAL PARTICIPATION
Access Problems Because of Costs in Five
Countries, Total and by Income, 2004
Percent of adults who had any of three access
problems in past year because of costs
Did not get medical care because of cost of
doctors visit, skipped medical test, treatment,
or follow-up because of cost, or did not fill Rx
or skipped doses because of cost. UKUnited
Kingdom CANCanada AUSAustralia NZNew
Zealand USUnited States. Data 2004
Commonwealth Fund International Health Policy
Survey of Adults Experiences with Primary Care
(Schoen et al. 2004 Huynh et al. 2006).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
49
10
Percentage of National Health ExpendituresSpent
on Health Administration and Insurance, 2003
EFFICIENCY
Net costs of health administration and health
insurance as percent of national health
expenditures
a
b
c

a 2002 b 1999 c 2001 Includes claims
administration, underwriting, marketing, profits,
and other administrative costs based on premiums
minus claims expenses for private
insurance. Data OECD Health Data 2005.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
69
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Mortality Amenable to Health Care
LONG, HEALTHY PRODUCTIVE LIVES
Mortality from causes considered amenable to
health care is deaths before age 75 that are
potentially preventable with timely and
appropriate medical care
Deaths per 100,000 population
International variation, 1998
State variation,2002
Percentiles
Countries age-standardized death rates, ages
074 includes ischemic heart disease. See
Technical Appendix for list of conditions
considered amenable to health care in the
analysis. Data International estimatesWorld
Health Organization, WHO mortality database
(Nolte and McKee 2003) State estimatesK.
Hempstead, Rutgers University using Nolte and
McKee methodology.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
6
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Infant Mortality Rate, 2002
LONG, HEALTHY PRODUCTIVE LIVES
Infant deaths per 1,000 live births
International variation
State variation
Percentiles
2001. Data International estimatesOECD Health
Data 2005 State estimatesNational Vital
Statistics System, Linked Birth and Infant Death
Data (AHRQ 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
7
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Variations in Spending Across Regions (Elliott
Fisher)
Variations in per-capita spending across U.S.
regions. Each color grouping includes
approximately one fifth of the Medicare
population.
Fisher et al. Ann Intern Med 2003 138 273-298
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Variations in Spending Across Medical Centers
Variations in spending for patients with severe
chronic disease across U.S.News and World
Reports top 15 Honor Roll Academic Medical
Centers. "How can the best medical care in the
world, cost twice as much as the best medical
care in the world?"   (Uwe Reinhardt)
Spending per Medicare beneficiary with severe
chronic disease (Last 2 years of life, 2000-2003)
120,000
100,000
UCLA Medical Center 72,793 New York-Presbyterian 6
9,962 Univ. of Pennsylvania 61,290 Johns
Hopkins 60,653 UCSF Medical Center 56,859 Brigham
and Womens 53,123 Univ. of Washington 50,716 Univ.
of Michigan 49,367 Mass. General 47,880 Barnes-Je
wish 44,463 Duke University Hosp. 37,765 Mayo
Clinic (St. Mary's) 37,271 Cleveland Clinic 35,455
80,000
Inpatient Part B spending per decedent
60,000
40,000
20,000
Most of the differences in spending are due to
differences in volume (or intensity), not price.
For example, 66 of the variation in spending
across academic medical centers can be explained
by the number of inpatient days and physician
visits alone.
Dartmouth Atlas of Health Care
www.dartmouthatlas.org
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What Do Highest Quintile Cost Regions Get for an
3000 Extra per Capita per Year?

• COSTS AND RESOURCE USE.
• 32 More Hospital Beds per Capita
• 65 More Medical Specialists
• 75 More Internists
• More Rapidly Rising per Capita Resource Use
• QUALITY AND RESULTS
• Technically Worse Care
• No More Major Elective Surgery
• More Hospital Stays, Visits, Specialist Use,
  Tests, and Procedures
• Slightly Higher Mortality
• Same Functional Status
• Worse Communication among Physicians
• Worse Continuity of Care
• More Barriers to Quality of Care
• Lower Satisfaction with Hospital Care
• Less Access to Primary Care
• Lower Gains in Survival

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Scores Dimensions of a High Performance Health
System
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
4
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We Aim to Achieve Care That Is

• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Unprecedented Month-by Month Increases in Number
of Organ Donors
Collaborative Starts Here
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100,000 Lives Campaign Objectives
(December 2004 June 2006)

• Save 100,000 Lives
• Enroll more than 2,000 hospitals in the
  initiative
• Build a reusable national infrastructure for
  change
• Raise the profile of the problem - and our
  proactive response

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The Campaign Planks -- Six Changes That Save
Lives

• Deployment of Rapid Response Teams
• Delivery of Reliable, Evidence-Based Care for
  Acute Myocardial Infarction
• Medication Reconciliation
• Prevention of Central Line Infections
• Prevention of Surgical Site Infections
• Prevention of Ventilator-Associated Pneumonias

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Preventing Central Line Infections

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Appropriate catheter site and administration
  system care
• No routine replacement

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Central Line Associated Bloodstream Infections
(CLABs)(from Rick Shannon, MD, West Penn
Allegheny Health System)
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The 100,000 Lives Campaign Scorecard

• An estimated 122,000 lives saved by participating
  hospitals (through work on the Campaign but also
  through other improvements and work on
  complementary initiatives)
• Over 3,100 Hospitals Enrolled
• Over 78 of all discharges
• Over 85 of participating hospitals sent IHI
  mortality data
• Participation in Campaign Interventions
• Rapid Response Teams 60
• AMI Care Reliability 77
• Medication Reconciliation 73
• Surgical Site Infection Bundles 72
• Ventilator Bundles 67
• Central Venous Line Bundles 65
• All six 42

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Rapid Response Results Henry Ford Hospital
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Rapid Response Results Benedictine Hospital
43 Reduction
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MRT Preventable Code Events
Results at One Year
73 decrease
P lt 0.05
Rapid Response Results Cincinnati Childrens
Hospital and University of Cincinnati
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Ascension Health Mortality Reduction
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Campaign Field Operations Structure
Introduction, expert support/science, ongoing
orientation, learning network development,
national environment for change
IHI and Campaign Leadership
Ongoing communication
Local recruitment and support of a smaller
network through communication/collaboratives
NODES (approx. 75)
Each Node Chairs 1 Network
Mentor Hospitals
Implementation (with roles for each stakeholder
in hospital and use of existing spread strategies)
FACILITIES (2000-plus)
30 to 60 Facilities per Network
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IHIs No Needless List

• No needless deaths
• No needless pain
• No helplessness
• No unwanted waiting
• No waste
• for anyone

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The Next Campaign

• For every unnecessary death there is much more
  error, injury and pain.

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The Next Campaign

• WERE GOING AFTER HARM

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The Next Campaign

• WERE GOING AFTER HARM
• but what do we mean by harm?

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Our Definition of Medical Harm

• Unintended physical injury resulting from or
  contributed to by medical care (including the
  absence of indicated medical treatment), that
  requires additional monitoring, treatment or
  hospitalization, or that results in death.
• Such injury is considered harm whether or not it
  is considered preventable, whether or not it
  resulted from a medical error, and whether or not
  it occurred within a hospital.

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The Next Campaign

• WERE GOING AFTER HARM

but how much harm will we reduce?
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Logic Chain Step 1

• How Many Admissions per Year?

37 Million Admissions Source The AHA
National Hospital Survey for 2005
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Logic Chain Step 2
How Often Are Patients Injured by Care?

• 40 to 50 Patient Injuries per 100 Hospital
  Admissions
• Source IHI Global Trigger Tool Guiding Record
  Reviews

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The NCC MERP Framework

• The capacity to cause error
• Did not reach the patient
• Did not cause the patient harm
• Required monitoring to confirm it resulted in no
  harm to the patient and/or required intervention
  to preclude harm
• Required Intervention
• Required Hospitalization
• Permanent Patient Harm
• Sustain Life
• Patients Death

Source Index of the National Coordinating
Council for Medication Error and Reporting and
Prevention http//www.nccmerp.org/pdf/indexColor2
001-06-12.pdf
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Logic Chain Step 3
How Many Injuries in the US?

• 37 Million Admissions
• X
• 40 Injuries per 100 Admissions
• 15 Million Injuries per Year

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Logic Chain Step 4
If we could replicate best performance across
the existing Campaign population, how many
injuries might we expect to avoid?

• Approximately 3.5 Million

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The 5 Million Lives Campaign

• Campaign Objectives
• Avoid five million incidents of harm over the
  next 24 months
• Enroll more than 4,000 hospitals and their
  communities in this work
• Strengthen the Campaigns national infrastructure
  for change and transform it into a national
  asset
• Raise the profile of the problem - and hospitals
  proactive response - with a larger, public
  audience.

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The Campaign Platform

• The 100,000 Lives Planks
• Rapid Response Teams
• Acute Myocardial Infarction
• Medical Reconciliation
• Central Line Infections
• Ventilator Associated Pneumonia
• Surgical Site Infection

• The 5 Million Lives Planks
• Pressure Ulcers
• Congestive Heart Failure
• High Alert Medications
• Surgical Complications (SCIP)
• Methicillin-Resistant Staphylococcus aureus
• Boards on Board

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The Campaign Platform

• plus numerous other interventions that hospitals
  must introduce in order to contribute to meeting
  our aim.

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Why Do We Find So Many?

• 40 to 50 Injuries per 100 Admissions
• Include Levels E through I
• Most others start at F
• Global Trigger Tool increases efficiency of
  search
• Do not distinguish preventable from
  non-preventable given current knowledge
• Include out-of-hospital events that lead to
  admission

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The Global Trigger Tool at LDS Hospital Review
by Brent James
35.1 of all admissions had at least one
adverse event 9.1 of all hospital
admissions resulted from outpatient
care-associated adverse events

• LDS Hospital 325 patients October 2004
• Seven trained abstractors all charts
  independently reviewed twice

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5 Million Lives Campaign The Planks Starter
Set

• Prevent Pressure Ulcers

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Pressure Ulcers
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Burden of Pressure Ulcers

• Prevalence in acute care 15
• Incidence in acute care 7
• 5-7 of all acute hospital admissions
• 2.5 million patients treated each year
• Nearly 60,000 die each year from complications
• 11 billion dollars per year

Sources How-to-guide JAMA systematic review by
Reddy 2006, referenced a national pressure ulcer
Advisory panel (2001) Pressure Ulcers in
America Prevalence, Incidence, and Implications
for the Future An Executive Summary Of the
National Pressure Ulcer Advisory Panel Monograph
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An Example of What Is Possible St. Vincents
Medical Center
Decrease of 71
Source Joint Comisision Journal on Quality and
Patient Safety The Clinical Transformation of
Ascension Health Eliminating All Preventable
Injuries and Deaths Clinical Excellence Series
David B. Pryor, M.D. Sanford F. Tolchin, M.D. Ann
Hendrich, M.S., R.N. Clarence S. Thomas, M.D.
Anthony R. Tersigni, Ed.D.
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Reducing Pressure Ulcers
For All Patients

• Conduct a Pressure Ulcer Admission Assessment for
  All Patients
• Reassess Risk for All Patients Daily
• Inspect Skin Daily
• Manage Moisture Keep the Patient Dry and
  Moisturize Skin
• Optimize Nutrition and Hydration
• Minimize Pressure

For High Risk Patients
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Category E
Temporary Injury from Care Requiring Intervention

• EXAMPLE OF AN E
• An elderly woman was started on antibiotics for
  a skin infection without taking into
  consideration she was on an anticoagulant. She
  got an injection, and that led to a large and
  painful bleed into her thigh muscle.

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Category I
Injury from Care Contributing to or Causing the
Patients Death

• EXAMPLE OF AN I
• A 55-year-old bus driver needed anticoagulation
  for atrial fibrillation. Three days after
  starting, he suffered a massive bleed into his
  brain a stroke. He died six days later.

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Improving Patient Safety at Mayo Clinic (Adverse
Events per 1000 Patient Days All Sites)


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Prevent Surgical Complications

• Institute for Healthcare Improvement

This document is in the public domain and may be
used and reprinted without permission provided
appropriate reference is made to the Institute
for Healthcare Improvement.
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Basis Adopt SCIP

• Surgical Care Improvement Project
• - National quality partnership of
  34 organizations focused on improving surgical
  care
• - IHI member of Steering Committee
• SCIP goal reduce the incidence of surgical
  complications nationally by 25 by 2010

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Our Goal

• Reduce surgical complications by 25 percent by
  December 2008 by reliably implementing the
  changes in care recommended by SCIP

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Four Key Interventions

• Surgical Site Infection Prevention
• Beta Blockers for Patients on Beta Blockers Prior
  to Admission
• Venous Thromboembolism Prophylaxis
• Post-Operative Pneumonia Prevention
• for Ventilated Patients (Vent Bundle)

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Impact of SSI
Pairs matched for procedure, NNIS index,
age General inpatient surgical population 22,
742 procedures included
Kirkland. Infect Control Hosp Epidemiol.
199920725.
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Reduce Surgical Site Infections

• Appropriate use of antibiotics
• Appropriate hair removal
• Postoperative glucose control (major cardiac
  surgery patients cared for in an ICU)
• Postoperative normothermia (colorectal surgery
  patients)
• These components of care are supported by
  clinical trials and experimental evidence in the
  specified populations they may prove valuable
  for other surgical patients as well.

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What Is Happening Here?

• Unprecedented Reliability
• Unprecedented Teamwork
• Unprecedented Transparency
• These are transformative principles that reach
  far beyond the notion of a Campaign.

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The 5 Million Lives Campaign

• Campaign Objectives
• Avoid five million incidents of harm over the
  next 24 months
• Enroll more than 4,000 hospitals and their
  communities in this work
• Strengthen the Campaigns national infrastructure
  for change and transform it into a national
  asset
• Raise the profile of the problem - and hospitals
  proactive response - with a larger, public
  audience.

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Support Going Forward

• Launch events with nodes, mentors and hospitals
  around the country
• Detailed How-to Guides on each of the
  interventions, frequently asked questions (FAQs)
  and lots of new material in the Campaign area of
  IHI.org
• Matrix describing alignment with other national
  improvement leaders and initiatives (e.g., GWTG,
  JCAHO, AHRQ, CMS, CDC, NQF, Leapfrog, NPSF)
• Ongoing national educational calls on all of the
  existing and new interventions (schedule at
  IHI.org)

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Some Early Returns

• Outstanding national call attendance
• Unprecedented downloads of intervention materials
• Very strong interest in MRSA, Pressure Ulcer and
  Boards on Board interventions
• Powerful local activity through field offices
• Increased action in rural affinity group
• Some academic dialogue
• National Action Day- June 20, 2007

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My Hope for ACS

• Will
• Ideas
• Execution

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My Hope for ACS Leading Improvement

• Will
• Declare the need for improvement
• Welcome data and measurement especially locally
• Foster bold goals
• Ideas
• Maintain a commons for innovations
• All Teach All Learn
• Increase patients voice
• Execution
• Professionalism includes assistance in changing
  systems
• Reach across disciplinary boundaries
• Support the role of governance in improvement
  Boards on Board

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The Big Question

• Will we help drive a massive national reduction
  in harm?
• Thats the exciting work aheadmoving from
  enrollment and orientation to execution.