Martin Kollef, M.D., had a problem in his intensive-care units and no guidelines for how to solve it.
So Kollef, the director of intensive care at St. Louis' Barnes-Jewish Hospital, took it upon himself to find a way to shorten the average time it takes to wean patients from mechanical ventilation.
He wrote a protocol for nurses and respiratory therapists, applied for and received a small grant and conducted a rigorous trial of his algorithm.
The results cut the average time on the ventilator to 35 hours from 44. That led not only to large financial savings to the hospital but to a speedier recovery with fewer complications for patients.
And that little project is but one of five that Kollef has developed with assistance from the Innovations in Healthcare Program, sponsored by Barnes-Jewish's parent, BJC Health System. Since its inception in 1995, the program has dished out $371,696 to support 22 small quality-improvement projects.
Kollef's project, multiplied many times and on many levels inside BJC hospitals and doctor's offices and throughout the community, has given rise to a culture of quality entrepreneurship within BJC's far-flung operations.
That culture has won the system the 1999 National Quality Health Care Award, granted by the National Committee for Quality Health Care, based in Washington.
"They captured the essence of a number of systems where they had really achieved quality, measured it, provided outcomes," said Catherine McDermott, president and chief executive officer of the NCQHC. "More than any of the other applicants, they made the case for why their quality initiatives were successful."
The award will be presented Feb. 2 in Washington at the NCQHC's annual conference.
BJC's application stood head and shoulders above the rest, McDermott said, by virtue of its longevity and its outcome measurements. Unlike some projects, which are putting quality measurements into place, BJC's mature program is generating data that are recycled to improve quality continuously.
BJC's formal application includes charts and graphs demonstrating real results from quality efforts. Inpatient heart failure mortality, for example, was at 5% in 1995. In 1998 it was at 4%. Unscheduled admissions after ambulatory procedures were around 1% at the end of 1994. By mid-1998 they were around 0.3%.
Likewise, a computerized dose checker has helped reduce medication dosing errors by 50% since 1994.
A surgical site infection initiative trimmed orthopedic and cardiac infections by 75% in 1997 over historical rates.
That infection-control project, says Claiborne Dunagan, M.D., vice president for system quality, epitomizes how quality was used to create an infrastructure that would unify all the hospitals in the system for a common purpose. The infection-control coordinators meet regularly and standardize practices. "They help train one another. They are cheerleaders for one another. They have standardized their surveillance systems and outbreak investigation techniques," Dunagan said. They've also formed a SWAT team for rapid response to nosocomial infection outbreaks.
Dunagan is co-director of the Center for Healthcare Quality and Effectiveness, a think tank inside BJC that runs the Innovations in Healthcare Program. Anyone who has an idea submits a two-page abstract. A small steering committee, made up mostly of Washington University Medical School faculty, decides where the study design will work and provide value to the rest of the system, Dunagan said.
"Then we ask people to come back with a more detailed proposal," he said. "It's shorter than a National Institutes of Health grant, but it's fairly detailed. The methods have to be rigorous." Several of the projects have been published in peer-reviewed journals.
Dunagan estimates the various improvements developed through these grants have saved the system between $2.2 million and $3.1 million.