Prioritizing a Commitment to Improvement
In the late 1990s, Cincinnati Children’s Hospital (CCH) underwent a number of organizational changes, including the hiring of a new CEO, James Anderson, and creating a revised vision statement: “To be the leader in improving child health.” These changes paved the way for the hospital’s first quality improvement project, which was the use of care protocols to manage asthma, bronchiolitis, and fever of unknown origin for pediatric patients in the emergency department (ED). Hospital leaders were well aware that if the protocols were successful in improving care management in the ED, there would likely be a significant reduction in hospital admissions and a resultant loss of revenue. Despite the possible negative financial consequences, the hospital chose to move ahead with the project.
Anderson sums it up this way: “We took the stance that we didn’t want to build our business model on services that weren’t needed. Instead, we wanted to focus on providing services that add value.” By implementing the care protocols, the hospital reduced admissions for these conditions by 30% to 50% (Anderson 2012). According to Anderson, the embracing of these improvement projects reflected the “institutional support for radical change to take better care of kids even at the expense of reduced revenue.”
Interestingly, the hospital’s revenue actually increased by 15% during the period of time the protocols were implemented, as freed-up bed capacity allowed the organization to accept more admissions for more complicated conditions. These conditions were reimbursed at a higher rate than the three for which admissions declined.
An Impetus to Improve Public Reporting
In 2001, CCH was one of seven organizations across the country to receive a Pursuing Perfection grant from the Robert Wood Johnson Foundation. The grant provided financial support for performance improvement, to which the organization was committed, but it also required full transparency with patients as a condition for its acceptance. With initial concern and then growing confidence, the organization began publicly reporting safety data on its website, including the rates of surgical site infections and ventilator-associated pneumonia, mortality rates, and other data. In addition, the organization began posting on its intranet the number of days since the last serious safety event and the last employee lost-time accident, emphasizing to employees the organization’s commitment to safety. Over time, the culture of the organization shifted to one that strongly valued patient and employee safety and transparency.
A Commitment to Transparency Between Clinicians and Patients
The commitment of CCH to transparency with patients was tested in 2001, when data from the Cystic Fibrosis Foundation showed that CCH— previously believed to be among the top in the country—actually ranked at the 20th percentile for cystic fibrosis (CF) care. According to Anderson, organizational leaders were anxious about revealing this information to the parents of patients with CF, but pressed forward because of their commitment to the organizational vision of being the leader in child health.
The hospital called a meeting of the parents, shared the data, and offered to assist them in finding care elsewhere, if they desired. Alternatively, if the parents elected to stay with CCH, they could help the organization improve. All of the families chose to stay at CCH (Gawande 2004). The organization applied best practices gleaned from top CF centers in the country and radically changed CF care. Today, the program consistently achieves key performance goals of cystic fibrosis care (e.g., relating to lung function and nutritional status) that are well above the national average and is ranked within the top five pediatric hospitals in the United States for pulmonary care (Cystic Fibrosis Foundation 2014; USNews & World Report 2014).
Addressing Communication to Improve Transparency Among Clinicians
As part of the Pursuing Perfection initiative, CCH began assessing ways to increase communication between clinicians and individual patients and their families about their care. They began a program of rounding with family involvement, and they monitored feedback from all involved parties, including nurses, residents, attending physicians, and family members. Based on the feedback, they modified the process and within a year had implemented family-focused teaching rounds throughout the hospital (AHA 2013).
In addition, the hospital is part of the multi-site I-PASS Study initiated in 2010 that is assessing ways to improve information handoffs between clinicians. The study involves the implementation of a standardized process, called the I-PASS Handoff Bundle, for communication between clinicians to reduce errors. A study of the project demonstrated a 30% reduction in medical errors, as well as lower rates of verbal and written miscommunication (Starmer et al. 2014).
Back to top
Building Trust to Improve
Transparency Among Organizations
The experience with transparency and the existing safety culture at CCH helped pave the way for the OCHA members to follow the experience of CCH and embrace transparency among themselves for data coming out of shared safety initiatives.
Initially, according to Anderson, there was little enthusiasm at the board level of OCHA member hospitals for initiatives that could adversely affect the hospitals’ financial status. With time, however, executives at the hospitals made the case for participation and the boards gave their consent. The group began by convening a meeting of the chief executives, medical officers, and nursing officers from the six hospitals for a presentation by a patient safety expert from Seattle Children’s Hospital. As a result of the meeting, the group selected metrics and processes for managing an improvement plan.
In 2005, the group began its first initiative: a project to eliminate preventable cardiac and cardiopulmonary arrests, or “code blues,” outside of intensive care units (ICUs). A significant barrier at first was the concern of each hospital about sharing safety data with competing organizations. Executives were wary that competitors might use the disclosed data to their own marketing advantage and were worried about the potential effects on their organization’s reputation in the marketplace. Anderson found that this barrier was effectively removed with a series of conversations with the other executives, during which he described the experience of CCH and reiterated the goal of “standing together for improved care for kids.”
Eventually, the group began sharing data and best practices. By using transparency and working together, the hospitals achieved an average reduction of 46% in code blues outside the ICU. According to Anderson, the initiative was a huge breakthrough for the group in that it displayed the willingness and ability of competing hospitals to work together to collectively improve patient safety. “Prior to this project, organizations were not thinking about the benefits of collaborating.” In time, the hospitals became more comfortable with sharing data and best practices, and the degree of transparency increased. Eventually, the group members embraced the notion of helping each other improve to meet their mutual commitment to advancing safety in pediatrics.
Anderson asserts that transparency was instrumental and essential for improving pediatric care at CCH and within the OCHA member hospitals. “Transparency communicated to stakeholders within our hospital and within the collaborative that the first priority was taking care of children by providing high quality and safe care. Transparency also supplied the process and outcomes data that fueled a strong determination to improve.”
Back to top
Postscript: Expanding Improvement Beyond Ohio
Based on their track record with transparency and improvement, the now eight hospitals in OCHA were invited in 2011 to join 25 other pediatric hospitals from across the country to form the Children’s Hospitals’ Solutions for Patient Safety (SPS) network. By 2013, the group had expanded to include 78 hospitals in 33 states and the District of Columbia.
With an overarching goal of reducing or eliminating harm to children during care, SPS is guided by five tenets:
- Executive leadership is critical and must be supported through opportunities for skills development.
- The mission of improving outcomes for children informs the network hospitals’ actions; outcomes are achieved through a focus on quality improvement methods and reliability principles.
- Network hospitals commit to:
- Refraining from competing on safety
- Sharing lessons learned with others
- Building a “culture of safety”
In 2014, the network hospitals committed to three shared goals by year’s end:
- 40% reduction in hospital-acquired conditions
- 20% reduction in readmissions
- 25% reduction in serious safety events
While active in the SPS, the eight OCHA member hospitals also continue to collaborate through the Ohio Children’s Hospitals’ Solutions for Patient Safety.
Back to top
Anderson J. 2012. Governance, leadership, management, organizational structure and oversight principles and practices. In: Batalden P, Foster T, eds. Sustainably Improving Health Care: Creatively Linking Care Outcomes, System Performance and Professional Development. Milton Keynes, England: Radcliffe Publishing.
Gawande A. 2004. The bell curve: what happens when patients find out how good their doctors really are? New Yorker. Dec 6.
Cystic Fibrosis Foundation. 2012. Care center data. Available at: http://www.cff.org/LivingWithCF/CareCenterNetwork/CareCenterData. Accessed Sep 8, 2014.
US News and World Report: Health. 2014. Top-ranked pediatric hospitals for pulmonology. Available at: http://health.usnews.com/best-hospitals/pediatricrankings/pulmonology. Accessed Sep 8, 2014.
American Hospital Association. 2013. Engaging Health Care Users: A Framework for Healthy Individuals and Communities. Chicago: American Hospital Association; 2013. Available at: http://www.aha.org/research/cor/content/engaging_health_care_users.pdf. Accessed Sep 8, 2014.
Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD. 2014. Changes in medical errors after implementation of a handoff program. N Engl J Med. 371:1803–12.