Perspectives on Safety
Implementing a Patient Safety Program at a Large National Health System
Hospitals and health systems across the United States are struggling to put strategies and structures in place to improve patient safety at their institutions. This article will share the safety and quality journey of Adventist Heath System (AHS), the largest Protestant not-for-profit health care system in the United States.
Background and Philosophy
AHS consists of 36 hospital campuses in geographically varied locations, ranging from small rural facilities to large tertiary urban medical centers. The AHS hospitals are located in ten states. Seven of these hospitals have fewer than 100 beds, twelve have between 100 and 250 beds, and four have more than 250 beds; the total number of beds in the system is 6156. The largest AHS hospital includes approximately 2000 beds on seven campuses, making it essentially a "health system within a health system." In calendar year 2006, AHS hospitals had 302,784 admissions.(1)
The AHS journey toward high quality and reliability, patient safety, and cost effectiveness began with the vision of two key AHS executives. The first, Donald Jernigan, PhD, served as AHS's Executive Vice President in the mid-1990s. The second was Tom Werner, who became the CEO of AHS in 1999. Both of these leaders had a passion for excellence and a strategic vision that embraced the above goals. Both also recognized that, in a health care system as large and diverse as AHS, the journey needed to be incremental and methodical.
Structure and Organization
AHS hospitals are individually managed facilities, with local Boards of Directors, administration, and medical staff. The AHS corporate office provides multiple support services to the system hospitals. The corporate Office of Clinical Effectiveness (OCE), led by the Chief Medical Officer, has responsibilities for patient safety, quality, computerized provider order entry (CPOE) content development and maintenance, clinical decision support and outcomes measurement, and direction and support for other system-wide clinical initiatives. The OCE provides clinical support to each hospital as requested. There is no line of authority between the hospitals and the Office of Clinical Effectiveness. Because of this, it was vital that local hospitals "bought into" the corporate vision for quality, safety, and efficiency—a fully top-down approach was destined to fail.
Nevertheless, it was also important for the central corporate vision to be bold and clinically meaningful to local personnel. For example, the 2007 AHS Corporate Clinical priorities are:
- Implementing and optimizing clinical information systems
- Developing a culture of reliability and patient safety
- Hospital and medical staff alignment that supports mission, quality, and patient safety initiatives
- Alignment of AHS clinical outcomes and quality measures with national trends in data reporting and transparency
To achieve this goal of linking local efforts to central leaders and resources, we established a corporate clinical committee structure. This structure provides wide representation and participation from the system hospitals on multiple clinical committees, all of which ultimately report to the Corporate Clinical Council. This structure creates forums where clinical issues are discussed, actions approved, and implementation planned at the corporate level. Most germane to this paper, a Patient Safety/Evidence-based Practice Committee helps to formulate and implement evidence-based corporate quality and patient safety initiatives and recommends that certain initiatives be incorporated into our Annual Corporate Accountabilities, which determine the bonuses of senior leaders.
One of the most important activities in our patient safety efforts has been our biannual Patient Safety/Evidence-based Practice Summit. Attendees include physicians, other clinicians, and operations leadership from all AHS hospitals. Nationally renowned experts on patient safety and evidence-based practice have presented at these Summits. In addition, individual hospitals have presented their experiences and outcomes from their work in a variety of areas, including safety culture assessment, teamwork and communication, and designing for high reliability. Our Summits facilitate networking and relationship-building between hospitals' attendees. We believe that they have been critical to our success, by allowing for sharing of ideas, success stories, and challenges.
Milestones on Our Patient Safety Journey
Early Engagement and Education
In 1996, AHS began a strategy of using evidence-based best practices and physician engagement to improve quality, patient safety, and cost effectiveness. Initially, this program involved creating paper order sets and clinical pathways for selected diseases and conditions. Our study on pneumonia patients using this strategy showed an improvement in patient outcomes, as measured by a reduction in mortality, acute renal failure, use of mechanical ventilation, length of stay, and cost per case.(2)
After the 1999 Institute of Medicine (IOM) report To Err Is Human (3) was released, our CEO responded by challenging each AHS hospital to add patient safety to our Corporate Clinical Accountabilities. In 2000, we began a program of requiring each hospital to implement one major patient safety initiative annually. In the years since the initial IOM report, AHS has developed and endorsed (at the corporate level) several significant strategic initiatives; these were integrated into the annual Clinical Accountabilities for every AHS facility. One example is our current 3-year initiative (2007–2009) to improve hyperglycemia management in our hospitals using IV insulin infusion therapy. This initiative is being rolled out initially in intensive care units (ICUs) but will eventually be expanded to telemetry and step-down units, surgery and postanesthesia care units (PACUs), labor and delivery floors, and emergency departments.
To succeed in these ambitious plans, we needed to engage and educate our physicians, other clinicians, and executive leadership. Our plan to achieve this included leveraging biannual corporate clinical meetings to further the quality and safety agenda. Beginning in 2004, we brought in a series of nationally recognized experts (including Drs. Jim Reinertsen, Michael Leonard, Allan Frankel, Bryan Sexton, Bob Wachter, and Charles Denham) to speak to our leadership, both local and corporate, at these meetings. Moreover, we have held additional focused sessions for hospital physician leaders, again bringing in nationally known speakers (such as Dr. Ken Kizer and Michael Millenson) to carry this message.
The Role of Computerization
Since 2004, AHS has been implementing an electronic medical record (Cerner Millennium) at every hospital campus in the system. This implementation will be completed in February 2008. We believe that a systemwide electronic health record (EHR) is an essential foundational element for achieving safe and reliable care, and we plan a series of initiatives that will leverage this foundation. But we also know that information technology will not, by itself, achieve this result.
In addition for laying the groundwork through our systemwide EHR, in 2005 we initiated a parallel project of creating evidence-based content for our CPOE system. We set a goal to create CPOE content for 80% of our admission diagnosis/procedures and for the majority of emergency department presenting symptoms. This massive project will be completed by early 2008. At that time, we will have approximately 365 pre-built electronic order sets with imbedded hyperlinks to the supporting evidence. Pilot CPOE sites will go live by the end of 2008. Zynx Health is the AHS vendor for electronic evidence-based content, order set development, and the maintenance of the order set content, which will be regularly reviewed and updated perpetually as the evidence changes.
The Link to the Institute for Healthcare Improvement
In December 2004, Dr. Donald Berwick, president of the Institute for Healthcare Improvement (IHI), came to Orlando, Florida, for IHI's annual National Forum. In an emotional appeal, Dr. Berwick challenged hospitals to join IHI in a campaign to save 100,000 lives from needless deaths. AHS leaders, many of whom were present at the IHI conference, immediately recognized this as a major patient safety opportunity. In February 2005, our CEO, Tom Werner, called a special meeting of corporate and regional leaders in Orlando (our corporate home). At that meeting, AHS agreed to actively participate in IHI's 100,000 Lives Campaign. Also, at that meeting our corporate CEO proposed increasing the portion of each hospital CEO's total annual Accountability that was related to clinical quality and patient safety from 10% to 25%—another major milestone in our patient safety journey. In addition to 100% hospital participation in the IHI campaign, the Office of Clinical Effectiveness operated as an IHI "system node" and provided coordination between 100,000 Lives Campaign representatives and system hospitals.
In 2004, AHS Corporate representatives attended the IHI's Patient Safety Officer training program in Boston. After that meeting, we adopted a curriculum built on the "Achieving Safe and Reliable Healthcare" (4) framework. Each AHS hospital was asked to identify a facility Patient Safety Officer (PSO). Subsequent PSO training sessions have been held corporately, regionally, and at individual local hospitals to disseminate this knowledge and training.
In addition to these efforts, the AHS Office of Clinical Effectiveness joined the IHI IMPACT community as a corporate member. This membership provides a conduit for a relationship with international experts in patient safety, along with hospital leaders throughout the United States. Select AHS hospitals were asked to join specific IMPACT Communities for improvement. Criteria used to select hospitals for membership included commitment of the leadership team, organizational readiness to embrace a significant change in culture and practice, and available resources. Based on the success of our initial IMPACT engagements, we have allowed additional AHS hospitals to join IMPACT communities.
Beginning in 2005, baseline measurement of organizational safety culture was obtained utilizing 2 culture survey tools. Most of our hospitals chose to utilize the Safety Attitude Questionnaire (SAQ).(5) Aggregate response rates for the SAQ were greater than 80%. Dr. Bryan Sexton attended various corporate meetings to provide context and meaning to the survey results. Our largest hospital chose to utilize the AHRQ culture survey tool.(6) Dr. Edwardo Salas from the University of Central Florida assisted with analysis of their survey results.
Focus on a Specific Service Line
On top of these efforts, after our Risk Management Department found system-wide opportunities for improvement, we implemented a corporate patient safety initiative in obstetrical services. A system-wide review of obstetrical practices at each hospital was undertaken by the consultants, Drs. Eric Knox and Kathleen Simpson. A corporate OB Task Force was created, chaired by one of our regional Chief Medical Officers. From the Knox and Simpson reviews at each hospital, 11 common problems were identified. The Task Force spent the next year creating a strategy for mitigating risk and improving fetal and maternal safety around those 11 issues. Finally, we convened an OB Summit that brought together at least one obstetrician and one nurse from the obstetrics department of each of our hospitals. National speakers plus our own OB Task Force leadership presented the results and recommendations. Each hospital is now in the process of implementing these patient safety measures locally.
A Link to the Johns Hopkins Safety Group
AHS is currently participating with the Johns Hopkins Quality and Safety Research Group in a randomized control trial funded by the Robert Wood Johnson Foundation. AHS was selected to participate in this study because of significant findings of the Michigan Keystone project, which found a tremendous and statistically significant reduction in central line–associated bloodstream infections with the systematic implementation of a series of evidence-based practices.(7) One very interesting finding of the Keystone project was that faith-based community hospitals enjoyed the greatest improvement in the least amount of time. In part due to the relationship between AHS and the Johns Hopkins research team, AHS was selected to participate in a focused study to eliminate central line catheter–related bloodstream infections (CRBSI) in adult ICUs by September 15, 2008. In addition, the study seeks to identify the causal relationship between specific national nursing measures such as Nursing Turnover, Nursing Skill Mix, and Nursing Hours Per Patient Day and CRBSI rates. Every one of AHS's adult ICUs are participating. This kind of broad engagement—from the Board of Directors to front-line clinical staff—is further evidence of AHS's ongoing commitment to safety and of our success in linking our corporate strategic focus with activities at each of our member institutions.
Alignment with the National Quality Forum's "Safe Practices"
The revised 2006 National Quality Forum (NQF) Safe Practices (8) harmonizes important safety initiatives and measures among Joint Commission, NQF, Centers for Medicare and Medicaid Services (CMS), AHRQ, IHI, and Leapfrog. The revisions include clearly defined process, outcome, structure, and patient measures. Each of the 30 safe practices is assigned points based on defined criteria. A total of 1000 points are available to earn, based on the Leapfrog methodology. Safe Practice #1, "Improving Patient Safety by Developing and Creating a Culture of Safety," constitutes 30% of the total points for all of the current 30 Safe Practices. We believe that the NQF emphasis on safety culture is the right one; in our view, the creation and maintenance of such a culture are essential for the successful, sustainable implementation of the remainder of the Safe Practices. For 2008–2009, AHS is focusing its Corporate Clinical Accountabilities on becoming fully compliant with Safe Practice #1.
In 2008, AHS is planning for each hospital to conduct a self-assessment of their current degree of compliance with the 30 Safe Practices using the NQF scoring assessment tool. Future corporate patient safety initiatives will be built around systematically implementing and achieving full compliance with the current 30 and future NQF Safe Practices.
Mortality as an Outcome Measure
Since 2001, we have tracked our unadjusted system and hospital mortality as the "ultimate outcome measure." Compared to a Thomson Healthcare (Solucient) national database of more than 20 million discharges, AHS system mortality from 2001 through 2006 experienced a relative reduction of 17% (Figure), compared with the national relative mortality reduction of 13.8% (Kaveh Safavi, MD, JD, e-mail communication, September 2007). We believe that this improvement is reflective of many of the activities outlined above.
The path to a totally safe hospital or health system can be best described as a journey. This report has described steps from our particular journey at AHS. We have done much and made significant progress, but considerable work remains to be done. In a challenging health care environment, replete with financial, operational, and human resource issues, it takes the combined commitment of the board, administration, physicians, other clinicians, and support staff to make a patient safety vision into a reality.
This report has described one large and diverse health system's structure and strategy to advance a patient safety agenda. We offer it in the hope that others, particularly those in large, multisite systems, might benefit from the experiences and lessons learned along our journey.
Loran Hauck, MDSenior Vice President, Chief Medical OfficerAdventist Health System
Jan Jacob, MBA, RNCorporate Patient Safety OfficerAdventist Health System
1. Adventist Health System 2006 Annual Report. Adventist Health System Web site. Available at:
http://www.ahss.org/desktopmodules/documentlibrary/document.aspx?ItemID=196 Accessed December 18, 2007.
3. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building A Safer Health System. Washington, DC: National Academy Press; 2000.
4. Leonard M, Frankel A, Simmonds T, Vega K. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, IL: Health Administration Press; 2004. ISBN: 1567932274.
8. Safe Practices for Better Healthcare 2006 Update: A Consensus Report. Washington DC: National Quality Forum; 2007.
Figure. AHS system mortality from 2001 through 2006 compared to a Thomson Healthcare (Solucient) national database of more than 20 million discharges.(Go to figure citation in commentary)