Like many hospitals across the country, Barnes-Jewish Hospital in St. Louis is implementing several patient safety and quality initiatives to improve the patient care experience. The hospital, which has more than 1,100 beds, is an academic medical center that also serves as a safety net hospital for the St. Louis region. As such, the hospital serves a broad range of patients, which "presents some challenges in terms of having a focused safety and quality program," says John Lynch, MD, CMO of Barnes-Jewish Hospital. Dr. Lynch shares how the hospital overcame this challenge by standardizing practices.
Lean management drives continuous improvement
The diversity of the patient population at the hospital led it to develop a framework of strategic priorities that have six goals, two of which are safety and quality. Specifically, the hospital aims to be the safest hospital in the country and the highest quality hospital. To reach these goals, the hospital employs lean management, an industrial engineering technique designed to eliminate waste, standardize processes and drive continuous improvement. "Lean and six sigma techniques promote continuous improvement and just as importantly sustain results in a way we've never been able to do using more traditional quality improvement techniques," Dr. Lynch says.
Using the lean model, Barnes-Jewish Hospital creates standard processes for patient care while allowing for variation at the individual level when appropriate. Variation at the patient level can benefit the patient because intervention can be tailored to his or her specific needs, according to Dr. Lynch.
Physicians embrace lean
Physicians at Barnes-Jewish Hospital have embraced the lean approach because of its outcomes and sustainability. "Involving our physicians and physician partners has been key to where we had success," Dr. Lynch notes.
In addition to current physicians, the hospital also works to prepare the next generation of providers by training residents in lean practices. Barnes-Jewish Hospital requires residents receive four hours of lean training and then participate in a process improvement project in an area of interest.
Lean produces good outcomes
1. Central line-associated blood stream infections. One improvement project at the hospital focused on reducing CLABSIs. Before the intervention, each of the hospital's seven intensive care units approached the reduction of CLABSIs with different methods. All seven units had deployed an evidenced-based check list-driven approach to the management of central lines — but still there was variation. Under lean, all ICUs standardized their practices in insertion, maintenance and follow-up. The clinicians who insert central lines were trained in a simulation to use evidence-based, standard practices. For instance, insertion requires a gown, gloves and sterile field. The nurses who maintain the catheters have a standardized schedule for changing dressings and the hubcaps of the line. In addition, clinicians were trained to question the patient's need for continuing use of a central line daily using a standard checklist, as prolonged central line use raises the risk of infection. This process resulted in a dramatic drop in CLABSIs, according to Dr. Lynch.
2. Diabetes medication errors. Another area of focus at Barnes-Jewish Hospital was medication errors, a project under the preventable harm initiative at the hospital. Data showed that the most common medical error at the hospital was related to diabetes care and the use of insulin, causing hypoglycemia. To prevent these errors, the hospital created a pharmacy expert system that identifies patients at high risk for hypoglycemia through an algorithm. Then, the system triggers an alert to the head nurse or supervisor on the floor through the computerized order entry system. The algorithm also makes suggestions to reduce the risk of low blood sugar. This program reduced low blood sugar occurrences by 75 percent and is now being rolled out at other hospitals under the parent organization BJC HealthCare.
3. Pressure ulcers. The hospital implemented a rapid improvement event to reduce pressure ulcers. Nurses scored patients' risk for pressure ulcers using a list of standard risk factors, including advanced age, low body mass, lack of sensory perception and positive smoking history. The score then directed the nurse to interventions based on the specific level of risk. This initiative reduced pressure ulcers 25 to 40 percent across pilot projects in different BJC HealthCare hospitals.
4. Transitions of care. Barnes-Jewish Hospital also used lean to improve transitions of care. As an academic medical center, the hospital's residents have restricted work hours, which meant transitions of care were fairly frequent. Transitions of care can occur between the emergency room and ICU, the ICU to a step-down unit, a step-down unit to the floor and the floor back to home or another facility. In addition to transitions among inpatient providers, handoffs occur between outpatient and inpatient settings, such as between an ambulatory care center and a hospital.
One of the most important factors in successful handoffs is clear communication. The hospital built a tool into its electronic medical record system that gives a description of a patient's plan of care, medication list, recent labs and other information that is useful when moving patients to a new care environment. This tool provides a standardized framework for the conversation between healthcare providers during a handoff. "We worked diligently with our IT folks to develop and leverage our investment in electronic medical records to develop tools that support a culture of increased communication," Dr. Lynch says.
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