Ascension Health's Dr. Pryor Identifies Three Steps to Save Lives, Improve Quality

St. Louis-based Ascension Health has achieved significant patient safety improvements through a comprehensive quality improvement strategy implemented in 2003. The health system's success is detailed in a study, "The Quality 'Journey' at Ascension Health: How We've Prevented at Least 1,500 Avoidable Deaths a Year — And Aim to do Even Better," published in Health Affairs. According to the study, Ascension Health had 5,000 fewer deaths in 2010 than would be expected based on a mathematical model. This number includes 1,500 fewer actual deaths; the remaining 3,500 fewer deaths are represented by Ascension's ability to offset a higher expected death rate from caring for sicker patients, shown in the case-mix index.

Ascension Health CMO David Pryor, MD, the study's lead author, shares three of the key steps to improving quality and safety.

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1. Engage caregivers. Dr. Pryor says all levels of an organization need to be committed to quality and safety for any quality initiative to be successful. "It starts with the board and senior leadership, [but] is dependent on the engagement of frontline caregivers." He says Ascension's leaders gained hospital employees' and physicians' buy-in for improving quality of care relatively easily. "Most individuals who go into healthcare want to improve quality; it matches up well with their particular orientation."

One challenge in this area for Ascension was coordinating the quality and safety programs across the system. Ascension Health includes 69 acute care hospitals in 20 states and Washington, D.C., 113,000 associates and 25,000 physicians. "How to implement the changes in those organizations will vary depending on the particular environment," Dr. Pryor says. For example, Dr. Pryor says one strategy Ascension uses to reduce preventable deaths is rapid response teams. While in tertiary care settings the rapid response team may include a resident, intensive care unit nurse, respiratory therapist and other individuals, a critical care access hospital may have only an ER physician and nurse available to respond.

To implement changes across the health system, alpha sites or lead hospitals provided leadership for one specific area of improvement that were then spread to other programs. "What's required is clear direction and focus," Dr. Pryor says. Ascension had identified eight "priorities for action": reducing mortality; improving performance on the Joint Commission's national patient safety goals; preventing adverse drug events; avoiding birth trauma; reducing the incidence of pressure ulcers, falls and fall injuries and hospital-acquired infections; and reducing perioperative complications.

2. Build appropriate infrastructure.
To successfully improve quality and safety for the entire Ascension system, leaders needed to build an infrastructure through which hospitals could share information, according to Dr. Pryor. Developing a communication structure allowed Ascension members to "learn from each other and create an environment where they could teach and learn," Dr. Pryor says. This infrastructure included a series of meetings, webinars and electronic communication platforms. Through a variety of communication methods, the hospitals were able to share results transparently so they could learn and implement best practices.

3. Create a high-reliability culture. One of Ascension's goals is to create a high-reliability culture. "The principle of creating a high-reliability culture is that caregivers see their role as a member of a team; delivery of care becomes a team sport and enables [caregivers] to interact across multiple domains," Dr. Pryor says. Developing a high-reliability culture is part of Ascension's strategy to reach its 2014 goal, "Healing without Harm." Specifically, Ascension aims to reduce serious safety events by 40 percent by 2014.

To create this culture, Ascension is shifting from a focus on its eight priorities of action to serious safety events, which Dr. Pryor and his co-authors define as "deviations from practice that cause serious or moderate harm"; precursor safety events, in which errors occur but do not harm patients; and "near misses." Shifting caregivers' focus will require "an extensive process of training throughout the organization," according to Dr. Pryor.

He compares a high-reliability culture to a system of "stoplights" through which caregivers' teamwork prevents errors from resulting in patient harm. He cites the example of requiring two individuals to check two forms of a patient's identification before a transfer or high-risk procedure, medication or blood administration. "Everyone is really busy in a hospital," Dr. Pryor explains. "Having two people checking two forms of identification helps identify instances in which the wrong individual gets the wrong medication or transfusion," he says.

"We have programs that not only clearly identify those stoplights, but [also] safety coaches who are specifically trained in making sure we're able to observe behaviors and provide feedback around adherence for specific behaviors," Dr. Pryor says.

Part of the high-reliability culture also involves causal analyses of errors in different areas of care to identify changes that would provide the most benefit to the system. In the study, Dr. Pryor et al. describe this method as the "Swiss cheese model" because analyzing how errors across a system combine to cause harm is similar to finding where the holes of several cheese slices line up. Since 2007, seven sites within Ascension have piloted this program and have reduced rates of serious safety events by 50-90 percent, according to the study.

Developing a high-reliability culture is part of Ascension's strategy to reach its 2014 goal, "Healing without Harm." Specifically, Ascension aims to reduce serious safety events by 40 percent by 2014.

Dr. Pryor is confident that health systems and hospitals across the United States can learn from Ascension's experience and use these strategies to improve quality and safety in their organizations. "In many ways, Ascension is a microcosm of American healthcare," he says. "The success we've had is demonstrative that it is possible for significant advances to occur in healthcare. All healthcare organizations are in a process of learning. We hope to share the lessons we've learned in different approaches, just as others have shared with us."

Learn more about Ascension Health.

Read the Health Affairs abstract on Ascension's quality improvement program.

Related Articles on Healthcare Quality and Safety:

Meaningful Internal Benchmarking Activities for Small Organizations

High Reliability in Healthcare: Q&A With Dr. Mark Chassin of The Joint Commission

6 Ways to Decrease Sharps Injuries and Needle Sticks in the OR

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