News: HENs Help Hospitals Spread What They Already Know
January/February 2013
News
HENs Help Hospitals Spread What They Already Know
Hospitals in the United States are more than halfway through two years of a federally funded program to rapidly increase improvements in healthcare delivery using tools and techniques that have already proven successful. The program, the Hospital Engagement Network (HEN), started in December 2011 and is designed to show results in two years, at which point the effort may be funded for an additional year.
The funding—$218 million—comes from the Affordable Care Act (ACA), through the U.S. Dept. of Health and Human Services to the Centers for Medicare & Medicaid Services (CMS) Innovation Center, which was established to test and develop delivery methods to improve the quality and cost-effectiveness of healthcare. HEN funding was awarded to 26 state, regional, and national hospital system organizations across the country. Hospitals may—but are not required to—join a HEN to work collaboratively on ten clinical topics identified by the CMS’s Partnership for Patients program as areas for improvement:
- adverse drug events,
- catheter-associated urinary tract infections (CAUTIs),
- central line–associated blood stream infections (CLABSIs),
- injuries from falls and immobility,
- obstetrical adverse events,
- pressure ulcers,
- surgical site infections,
- venous thromboembolism,
- ventilator-associated pneumonia (VAP), and
- preventable readmissions.
Hospitals are encouraged to tackle all ten topics by December 2013. The program is designed to foster and support improvement work—without specific rewards or penalties. Some of the 10 events and conditions, however, also appear on the CMS list of “never events,” for which hospitals do not receive reimbursement, and CMS started penalizing hospitals for 30-day readmissions for certain conditions in FY 2013. The goals of the HEN program are the same as the two-fold goal of the Partnership for Patients: to reduce inpatient harm by 40% and hospital readmissions by 20% by the end of 2013 (compared with data from 2010).
The largest HEN in the country is operated by the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association. The HRET-HEN includes 31 state hospital associations, representing approximately 1,600 hospitals, of which almost half are small—50 to 75 beds or less.
HRET’s president, Maulik Joshi, DrPH, points out that the HENs are designed to support work many hospitals already have underway.
It’s all voluntary for hospitals. We often point out that in today’s environment, with value-based purchasing, meaningful use, and [preventing] readmissions, hospitals are already working on these topics. This is a way to help support that work.
Spread, Scale, and Acceleration
If hospitals are already engaged in improving these areas, some may ask, “Why do we need a federal program?” The answer is spread, scale, and acceleration. There is increasing awareness and frustration that despite more than a dozen years of advancements in safety and quality, we don’t seem to have a reached a “tipping point” where the improvements begin to represent the norm. Everyone would like to see “best practice” become “common practice.” The HENs are designed to boost how quickly hospitals can implement best practices and share what they have learned with others, to help boost their performance, too.
In a white paper titled, A Framework for Spread: From Local Improvements to System-Wide Change, the Institute for Healthcare Improvement (IHI) describes why “spread” is important and difficult to achieve:
Pockets of excellence exist in our health care systems, but knowledge of these better ideas and practices often remains isolated and unknown to others…Organizations face several challenges in spreading good ideas, including the characteristics of the innovation itself; the willingness or ability of those making the adoption to try the new ideas; and characteristics of the culture and infrastructure of the organization to support change.
It’s not that we don’t know how to mitigate errors and prevent them from harming patients; often, patients are harmed by problems for which we have solutions that aren’t used universally and reliably. IHI’s well-known “100,000 Lives Campaign” was an exercise in spread—a successful attempt to implement known improvements in care rapidly, widely, systematically in order to fully reap the benefits of known best practices. It’s not surprising that the Partnership for Patients, a public-private partnership funded by the ACA and operated by CMS, is reminiscent of the 100,000 Lives Campaign. Both programs were launched by Don Berwick, MD, who was co-founder, president and CEO of IHI before becoming administrator of CMS in 2010. Berwick’s recess appointment to CMS ran out at the end of 2011, but his approach to spreading improvement continues.
To achieve the 40% and 20% reduction goals, the HENs must also employ scale and acceleration. In this context, “scale” refers to pursuing increasingly ambitious, effective implementations and multiple improvement projects simultaneously. The concept of acceleration is obvious enough, especially as the deadline, December 2013, is now on the horizon. HRET’s Joshi describes the challenge:
Improving on one topic—pressure ulcers, falls, etc—is one thing. To reduce harm by 40% and readmissions by 20%, we’re talking about improving a portfolio of ten topics. That’s a real lesson learned. How do you scale up? As a leader and clinician, how do you engage and know how to manage working with a portfolio of projects? This is a challenge and opportunity with the HENs.
Leadership
To achieve these goals, hospitals need to have leadership visibly engaged at the top and embedded at many levels, not only in large academic medical centers but also in small community hospitals. Marie Cleary-Fishman, now vice president of performance improvement at the Illinois Hospital Association, knows from many years of experience as a senior leader in quality for a large healthcare system that it’s common for clinicians and managers to find themselves leading improvement initiatives without needed training and education in quality and safety. As part of the HRET-HEN, the IHA is concentrating on developing these leaders in large numbers (see “Top-Down/Bottom-Up Approach,” page 10).
More than 900 individuals have participated in the HRET-HEN Improvement Leader Fellowship, which is intended for frontline individuals working on safety and quality improvement. The Fellowship is a year-long program and includes three two-day meetings where fellows learn improvement science—in Joshi’s words, “anything from the basics of PDSA to pragmatic measurement, designing your aim statement, reliability science, TeamSTEPPS, teamwork training, sustainability, and spreading improvement.” The fellowships also include webinars and ongoing participation in a dedicated listserve.
In addition to the fellowships, the HRET-HEN sponsors national collaboratives on specific topics taken from the Partnership for Patients’ list. They invite teams from across the 31 state associations to come together for a full day of presentations and project design. The meetings occur every three to four months, between which there are ongoing coaching calls.
A program called the Patient Safety Immersion Initiative, offered by the National Patient Safety Foundation, is also available to all HRET HENs, the primary HENS, as well as non-HEN organizations. (For more information, see page 12)
Measurement and Results
Even prior to participating in HENs, some hospitals complained that they are over-burdened with requirements to report data to a growing number of federal and state agencies, accrediting organizations, medical boards, safety and industry monitors, etc. Joshi at HRET-HEN and Cleary-Fishman at IHA say they have made simple, non-redundant reporting a priority. For now, it appears that there is flexibility and pragmatism in the approach to data collection, with various systems created at the local, state, and national level.
Collecting and analyzing the data from disparate sources and evaluating whether or not the HENs have hit the 40% and 20% reduction targets will be an interesting chapter of its own later this year. According to Joshi,
We don’t want measurement wars; we want harmonization. This is an improvement effort, not a standardization effort. If you have a readmit measure that you’ve been tracking on CHF, and your really focused on that, continue to report it. We’d like you to broaden beyond that, but at least continue to report on the same so we can see improvement over time in that area.
We know that improvement can be difficult to measure. In this case, it may be impossible to discern how much credit to give to the HEN for improvement on something, pressure ulcers for example, that a hospital was already working on.
At this point it is clear that HENs have turned up the heat on improvement efforts across the country. The program already means that more hospitals have more staff at all levels trained in improvement and safety science, hospitals and individuals have shared their questions and stories with new colleagues near and far, and the safety and quality of healthcare continues to improve. Soon we will know if the HENs have gotten us closer to that tipping point.
References
For more information
HRET’s Hospital Engagement Network
www.hret-hen.org
CMS Innovation Center
www.innovations.cms.gov/
CMS Partnership for Patients, including Hospital Engagement Networks
http://partnershipforpatients.cms.gov
A Top-Down/Bottom-Up Approach to Improvement
A Conversation with Marie Cleary-Fishman, Vice President for Performance Improvement, Illinois Hospital Association
Which HEN has the Illinois Hospital Association (IHA) joined and how is it participating?
IHA is a member of the HRET-HEN, and we have 59 hospitals in Illinois that are participating with us, focusing on improving all 10 conditions with the goal of reducing inpatient harm by 40% and hospital readmissions by 20% by.
One of the things we’re doing that may be a little different than others in the HRET-HEN is that we’re focusing on disseminating a toolkit for improvement, building the “bench strength” within those 59 organizations so they can continue to do this work beyond the 10 topics in the HENs. If we limit ourselves to achieving specific improvements in certain clinical areas, and don’t change the culture, we may not sustain the work or succeed at spreading improvement across the organization, beyond our original clinical focus.
This is consistent with HRET’s philosophy. They are offering training called Improvement Leader Fellowships as well as Collaboratives to work on the Partnership for Patients’ 10 areas. In Illinois, we’ve ramped up that notion of improvement leaders by working with the nonprofit National Patient Safety Foundation (NPSF) to deliver foundational patient safety education, access to a patient safety community, and professional advancement certification — all under the banner of the Patient Safety Immersion Initiative—to as many hospital staff as possible.
As we thought about what our 59 hospitals need, we decided to concentrate on leadership, culture change, performance improvement, and really build strength in those areas. That effort doesn’t replace or distract us from the 10 conditions—that’s not it at all! – the Initiative is in fact strongly supportive of this work and is designed to enhance consistent and shared knowledge of the practice of patient safety The clinical experts in each hospital are working with the resources HRET has pulled together and the clinical resources they have locally to work on those areas. At IHA, we’re concentrating on the leadership and culture work HRET is doing through the fellowship.
Through the HRET-IHA HEN, we’re able to offer each of our 59 hospital members the opportunity for five of their hospital staff members to participate in the Patient Safety Immersion Initiative, which is comprised of membership in the American Society of Professionals in Patient Safety, the NPSF Online CE/CME Patient Safety Curriculum, and the opportunity to sit for the Certified Professional in Patient Safety (CPPS) credentialing exam. As of January 2013, approximately 220 individuals have started the self-directed educational program. One key goal will be to pass the certification exam prior to the HEN closing in Dec 2013.
We believe that changing culture is a top-down, bottom-up process. We’ve coached the hospitals to think seriously about who would benefit most from this opportunity. This knowledge and training is needed throughout organizations—not just on the front line, not just in the quality department. We’ve challenged hospitals to think that through as they chose their five people for this program.
IHA was the first organization to leverage this unique program in partnership with NPSF, and we’re so pleased to see that other HENs are following suit and joining us in the Initiative. I’m told that non-HEN organizations are embracing this program as well.
And what about the top-down part of your program?
As for the top-down approach, we originally offered an opportunity for two hospitals to participate in a board-level extension of the NPSF Initiative, which involves having the CEO, board chair, and board members commit to an ongoing patient safety engagement. The premise and promise of this effort is that optimizing hospital governing body decision-making to ensure the provision of safe care and drive resultant operational and financial improvement is well-served by leadership with a common, foundational knowledge of patient safety issues and science. I wondered if it would be a struggle to find boards willing and able to make the commitment. At a leadership summit in the fall, our executive director, Dr. Derek Robinson, conducted a session on board engagement and shared this opportunity with the audience—key healthcare leaders in Illinois—and the response we got was amazing. As a result, we have five hospital CEOs in the Illinois HEN who have committed to this board engagement opportunity. One of the hospitals is a long-term acute care hospital, the only one in the IHA HEN. We’re very excited that they are engaged in this work.
How much communication is there among the IHA HEN hospital members? And at the national HRET-HEN level?
I’m glad you asked; this is an important point. In the collaborative model, there is cross-pollination on these issues that I’m not sure we’ve seen previously. For example, the state hospital association leads are collaborating and sharing within the HRET-HEN at a level that is much more frequent and intense than before. This cross-pollination is going to help with the sustainability and spread of these improvements. We can all work on improvement in isolation, but that means we’re all reinventing the wheel. Now, we’re maximizing the resources we have in human intelligence, databases, and systems and we’re building on top of other learning. It makes things go faster and further.
The same thing is happening at the individual hospital level inside and outside the state. I can give you an example. More than 40 hospitals were involved in Illinois in the HRET CAUTI collaborative prior to the HEN. We were looking for one of those hospitals to volunteer to host a site visit for people from HRET, and one hospital raised its hand. They said they knew they were doing really good work, but they weren’t 100% confident they were doing as much as possible. They recognized the value of having experts in the topic assess what they were doing with CAUTI. A team from HRET came out and spent a day with this hospital. The evaluation and subsequent feedback gave the hospital and staff the confidence to go and spread the work they were doing within the hospital. Additionally, that hospital then accepted an invitation to present its work at an Illinois meeting we had on CAUTI. Next, they ended up presenting to the national HRET-HEN, and another state asked them to come and present to their hospitals.
All of that came from one hospital’s effort to improve CAUTI on one unit! It’s a great story of spread. If these collaboratives and these structures weren’t in place, these opportunities wouldn’t take place. There’s a snowball effect from all the learning, sharing, and collaborating that took place. That’s what is really exciting. In my experience, this represents a new level of sharing. We need to continue to challenge hospitals to tell their stories. They may think they don’t have anything to share. They’re making small improvements, small changes, and they don’t think their story is “good enough.” One of the things we’re trying to teach is that it is good enough. You’re efforts are good enough, and people want to hear these stories.
What kind of help do hospitals want from the HEN with these projects?
I’ve been in the association world just for two years. Prior to IHA, I spent 34 years as a senior leader in quality for a large healthcare system. In my role at IHA, I can do things for hospitals that I know they don’t have time or resources for. I’ve had requests for educational help from clinicians who are working in quality departments for the first time. We’ve worked with a partner to provide a quality boot-camp, which we’ve opened up to the IHA HEN for anyone who’s new to their position in quality. We’ve had about 14 individuals go through that one-week boot camp. That’s been really positive and something we’re going to work to develop further and hopefully offer as an ongoing opportunity. We’re trying to develop ongoing support for people in those positions—webinars, conferences, etc. The more we can help provide tools, the better we’ll do with healthcare improvement in Illinois.
Patient Safety Immersion Initiative
Community
American Society of Professionals in Patient Safety
ASPPS is a multidisciplinary, individual membership society established to advance patient safety as a distinct and vital healthcare discipline and to build an engaged community dedicated to the delivery of safe patient care.
Education
Online Patient Safety Curriculum
This 10-module, online course provides the context, key principles, and competencies associated with the discipline of patient safety, and how these tenets and skills are applied in everyday practice.
Professional Advancement
Certification for Professionals in Patient Safety
The CPPS credential establishes the standard for patient safety competency and distinguishes health care professionals who meet knowledge requirements in safety science, human factors engineering, and the practice of safe care.
For more information, visit www.npsf.org.