Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit.

Healthcare waste-the inappropriate use of healthcare resources that provides no benefit to patients yet contributes to cost and even harm-is a potentially significant contributor to high healthcare costs. This project aimed to apply a new locally modified Institute for Healthcare Improvement (IHI)-developed waste identification tool to measure the prevalence of and reason for the inappropriate use of intensive care unit (ICU) beds, one type of potential waste. Unnecessary days (i.e., waste) and their causes in a 16-bed "closed" medical ICU (MICU) and a 10-bed "semi-closed" transplant surgical ICU (TSICU) were identified by physicians over a 3-month period. Data on 513 patients admitted to both ICUs for a total of 1,631 patient-days demonstrated that 15% of MICU days and 25.8% of TSICU days were unnecessary. Although causes of waste in each ICU differed, delays in transfer of patients out of the ICU, end-of-life decision-making, and delays in procedures were among the commonest. Determination of waste also varied among physicians, ranging from 4.5% to 27.7% in the MICU and 0%-37.5% in the TSICU. This study found that the IHI waste tool can be effectively used to identify waste in the ICU, which is common and varies based on the ICU type and physician perceptions.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension.

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.

Using real-time demand capacity management to improve hospitalwide patient flow.

BACKGROUND: The Joint Commission's accreditation standard on managing patient flow, effective January 2005, served as a call to action for hospitals, yet many hospitals still lack the processes and structures to admit or transfer patients to an inpatient bed on a timely basis. In 2007 the University of Pittsburgh Medical Center (UPMC) at Shadyside, a 526-bed tertiary care hospital, began testing and implementing real-time demand capacity management (RTDC) at an initial pilot site. The hospital had identified improved patient flow as a strategic goal in 2002, but a series of patient flow projects failed to result in improvement. IMPLEMENTING RTDC: Standard processes for the four RTDC steps-Predicting Capacity, Predicting Demand, Developing a Plan, and Evaluating a Plan--and standard structures for unit bed huddles and the hospital bed meetings were developed. The neurosurgery (NS) service line's ICU and stepdown unit were designated as the first pilot sites, but work was quickly spread to other units. RESULTS: Improvements were achieved and have been sustained through early 2011 for all measures, including (1) the unit-based reliability of discharge predictions; (2) overnight holds in the postanesthesia care unit, a problem eliminated two months after RTDC work began; (3) the percentage of patients who left without being seen (LWBS), routinely < 0.5% by May 2008; (5) the emergency department median length of stay for admitted patients, routinely < 4 hours after March 2008; and (6) aggregate length of stay (ALOS), generally maintained at < 5.75 days. CONCLUSIONS: RTDC represents a promising approach to improving hospitalwide patient flow. Its four steps, integrated into current bed management processes, are not an add-on to the work needing to be accomplished everyday.

'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today-voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators-fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvement's Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.

Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients.

OBJECTIVE: To assess the performance characteristics of the Institute for Healthcare Improvement Global Trigger Tool (GTT) to determine its reliability for tracking local and national adverse event rates. DATA SOURCES: Primary data from 2008 chart reviews. STUDY DESIGN: A retrospective study in a stratified random sample of 10 North Carolina hospitals. Hospital-based (internal) and contract research organization-hired (external) reviewers used the GTT to identify adverse events in the same 10 randomly selected medical records per hospital in each quarter from January 2002 through December 2007. DATA COLLECTION/EXTRACTION: Interrater and intrarater reliability was assessed using κ statistics on 10 percent and 5 percent, respectively, of selected medical records. Additionally, experienced GTT users reviewed 10 percent of records to calculate internal and external teams' sensitivity and specificity. PRINCIPAL FINDINGS: Eighty-eight to 98 percent of the targeted 2,400 medical records were reviewed. The reliability of the GTT to detect the presence, number, and severity of adverse events varied from κ=0.40 to 0.60. When compared with a team of experienced reviewers, the internal teams' sensitivity (49 percent) and specificity (94 percent) exceeded the external teams' (34 and 93 percent), as did their performance on all other metrics. CONCLUSIONS: The high specificity, moderate sensitivity, and favorable interrater and intrarater reliability of the GTT make it appropriate for tracking local and national adverse event rates. The strong performance of hospital-based reviewers supports their use in future studies.

Rethinking emergency department visits.

Efforts to date have been unable to reverse the trend of increased emergency department utilization. The Institute for Healthcare Improvement has developed a framework for reducing avoidable emergency department visits on the basis of the formation of local coalitions. These coalitions include interested partners approaching improvement by integrating community resources and nonmedical solutions. Targeted patient populations are identified via homogeneous characteristics. Open-ended interview questions are used to identify possible community and nonmedical solutions to complement medical strategies. This article describes the framework and process of testing. If validated, this approach will have significant policy implications.

Does reducing length of stay make a business case?

The business case for improving quality and safety of health care, the authors contend, critically depends on savings in fixed rather than variable costs.

Basics of quality improvement in health care.

With the rapid expansion of knowledge and technology and a health care system that performs far below acceptable levels for ensuring patient safety and needs, front-line health care professionals must understand the basics of quality improvement methodologies and terminology. The goals of this review are to provide clinicians with sufficient information to understand the fundamentals of quality improvement, provide a starting point for improvement projects, and stimulate further inquiry into the quality improvement methodologies currently being used in health care. Key quality improvement concepts and methodologies, including plan-do-study-act, six-sigma, and lean strategies, are discussed, and the differences between quality improvement and quality-of-care research are explored.

In-room display of day and time patient is anticipated to leave hospital: a "discharge appointment".

BACKGROUND: We learned from a focus group that many patients find discharge to be one of the least satisfying elements of the hospital experience. Patients cited insufficient communication about the day and time of the impending discharge as a cause of dissatisfaction. OBJECTIVE: In partnership with the Institute for Healthcare Improvement, Improvement Action Network collaborative, we tested the practicality of an in-room "discharge appointment" (DA) display. SETTING AND PATIENTS: Eight inpatient care units in 2 hospitals at an academic medical center (Mayo Clinic, Rochester, MN). INTERVENTION: DA displayed on a specially designed bedside dry-erase board. MEASUREMENTS: The primary outcome was the proportion of discharged patients who had been given a DA, including same-day DAs. Secondary outcomes were (1) the proportion of DAs scheduled before the actual dismissal day and (2) the timeliness of the actual departure compared with the DA. RESULTS: During the 4-month period, 2046 patients were discharged. Of those, 1256 patients (61%) were given a posted DA, of which 576 (46%) were scheduled at least a day in advance and 752 (60%) departed from the care unit within 30 minutes of the appointed time. CONCLUSIONS: With a program for in-room display of a DA in various hospital units, more than half the patients had a DA set, and most of the DA patients departed on time. Further investigation is needed to determine the effect of DAs on patient and provider satisfaction.

A trigger tool to identify adverse events in the intensive care unit.

BACKGROUND: The Institute for Healthcare Improvement has tested and taught use of a variety of trigger tools, including those for adverse medication events, neonatal intensive care events, and a global trigger tool for measuring all event categories in a hospital. The trigger tools have evolved as a complimentary adjunct to voluntary reporting. The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail. METHODS: Sixty-two ICUs in 54 hospitals (both academic and community) engaged in IHI critical care collaboratives between 2001 and late 2004. Charts were selected using a random sampling technique and reviewed using a two-stage process. RESULTS: The prevalence of adverse events observed on 12,074 ICU admissions was 11.3 adverse events/100 patient days. For a subset of 1,294 charts from 13 ICUs which were reviewed in detail, 1,450 adverse events were identified, for a prevalence of 16.4 events/100 ICU days. Fifty-five percent of the charts in this subset contained at least one adverse event. DISCUSSION: The Trigger Tool methodology is a practical approach to enhance detection of adverse events in ICU patients. Evaluation of these adverse events can be used to direct resource use for improvement work. The measurement of these sampled chart reviews can also be used to follow the impact of the change strategies on the occurrence of adverse events within a local ICU.

Making noncatastrophic health care processes reliable: Learning to walk before running in creating high-reliability organizations.

Health care clinicians successfully apply proven medical evidence in common acute, chronic, or preventive care processes less than 80 percent of the time. This low level of reliability at the basic process level means that health care's efforts to improve reliability start from a different baseline from most other industries, and therefore may require a different approach. This paper describes The Institute for Healthcare Improvement's (IHI) current approach to improving health care reliability, including a useful nomenclature for levels of reliability, and a focus on improving reliability of basic health care processes before moving on to more sophisticated high reliability organization concepts. Early IHI work with a community of health care reliability innovators has identified four themes in health care settings that help to explain at least a portion of the gap in process reliability between health care and other industries. These include extreme dependence on hard work and personal vigilance, a focus on mediocre benchmark outcomes rather than process, great tolerance of provider autonomy, and failure to create systems that are specifically designed to reach articulated reliability goals. This paper describes our recommendations for the initial steps health care organizations' might take, based on these four themes, as they begin to move toward higher reliability.

Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.

BACKGROUND: A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January 2004, teams of critical care clinicians from 61 health care organizations participated in a collaborative on improving care in the ICU. METHODS: ICU team members posted data monthly on a Web-based extranet and submitted narrative descriptions describing the changes tested and the strategies implemented. RESULTS: For the 35 units that consistently collected data on ventilator bundle element adherence and VAP rates, an average 44.5% reduction of VAP was observed. DISCUSSION: The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability. The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs.

Patient flow in hospitals: understanding and controlling it better.

Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is an inevitable, but regrettable, part of the care process. For years, hospitals responded to delays by adding resources--more beds and buildings or more staff--as the only way to deal with an increasingly needy population. Furthermore, as long as payment for services covered the costs, more construction and more staff allowed for continued inefficiencies in the system. Today, few organizations can afford this solution. Moreover, recent work on assessing the reasons for delays suggests that adding resources is not the answer. In many cases, delays are not a resource problem; they are a flow problem. The Institute for Healthcare Improvement has worked with more than 60 hospitals in the United States and the United Kingdom to evaluate what influences the smooth and timely flow of patients through hospital departments and to develop and implement methods for improving flow. Specific areas of focus include smoothing the flow of elective surgery, reducing waits for inpatient admission through emergency departments, achieving timely and efficient transfer of patients from the intensive care unit to medical/surgical units, and improving flow from the inpatient setting to long-term-care facilities.