Ascension Health wrapped up an ambitious five-year initiative to eliminate all preventable deaths and patient injuries with mixed results.
The 72-hospital Catholic system said it achieved its goal of eliminating all estimated preventable deaths, but medical mistakes are still occurring in the system.
The initiativeinvolving broad cultural, financial and operational shifts across one of the nations largest not-for-profit systemsended this month with executives saying they are increasingly humbled by what they discovered throughout the five years. Despite its estimate showing Ascensions undertaking prevented about 2,700 deaths, three times the programs goal of 900, Ascension believes there is more work to be done, said David Pryor, Ascensions chief medical officer.
Ascensions initiative raises questions about the scope of medical errors, as the healthcare industry studies the pervasiveness of preventable deaths. Ascension executives found over the course of the effort that its original estimates for the number of preventable deaths was too lowit met its goal of preventing 900 deaths over the entire initiative period in the first year. As the initiative went on, the definition of what is preventable injury or death required Ascension to change its benchmark, Pryor said.
Since 2002 Ascension has focused on specific priority areas: mortality, adverse drug events, infections, falls and the Joint Commissions National Patient Safety Goals. The system measured reduced mortality by the percentage of deaths prevented among patients not admitted for end-of-life care. Various hospitals within the system were chosen as pilot sites for testing the reduction efforts in each of the areas, but now all hospitals have implemented all the interventions, Pryor said.
The idea was not to reinvent the wheel: The system used a combination of standards and techniques recommended by other organizations, such as the Institute for Healthcare Improvements medical bundles and the National Quality Forums performance measures, Pryor said. We have begged, borrowed and took everything we could, he said.
As a result of the interventions, Ascension reduced its rates below national averages in six clinical areas, improving more in some than in others, according to figures provided by the system. Incidents of birth trauma, neonatal mortality and pressure ulcer reductions saw the most improvement, with rates falling 74%, 79% and 95%, respectively, relative to estimated national rates. Ventilator-acquired pneumonia, blood-stream infections and falls with serious injury proved more difficult to control, falling 56%, 32% and 54%, respectively.
Implementing change was not cheap. Through the pressure ulcer program, Ascension found many patients experienced skin breakdown because they were lying on surfaces not intended for long-term use. The health system spent $60 million on new beds, frames and surfaces to combat the problem and saw a large reduction in pressure ulcers across the system, Pryor said.
Ascension did not measure success in terms of bottom line profit improvements, but other costs were affected. Malpractice operational costs are down 56%, and workers compensation from patient handling injuries was cut in half, Pryor said. In addition, the health systems bond rating improved to AA+.
While Ascension considers itself to have met its goal, Pryor acknowledged that improvement efforts must be made constantly. There is no other acceptable goal than eradicating errors, but the question is: Are all injuries and deaths preventable? he asked.
But without focusing on obtaining zero, the incredible reductions in mistakes would not be reached, advocates say. While truly reaching zero is seemingly impossible, as a goal, its an incredible motivator, said Diane Pinakiewicz, president of the National Patient Safety Foundation. The effort Ascension has put into creating evidence for its interventions and measuring effectiveness is remarkable, she said. They focused on it, and they put discipline around it.
When the program started, caregivers were asked to review charts and use their own discretion in determining whether errors were preventable or potentially preventable. It was intentionally left vague, and patterns began to emerge out of practitioners findings, Pryor said.
Leadership, information sharing and clear expectations were the strongest drivers of the initiative, Pryor said. Ascension used a distributed leadership model to disseminate key elements of interventions to reduce errors. While the system indicated it expected results, it left implementation up to the caregivers in each of the hospitals, Pryor said. For instance, a 20-bed hospital in the system could not implement infection control the same way a 500-bed facility would, he said. How to approach improvement must be very different. The people who know how to develop strategies are the people working there."