A new standard

Everyone counts on high-reliability organizations to ensure our personal safety when we fly on commercial airliners or travel near a nuclear power plant. Air traffic control, nuclear submarines, nuclear aircraft carriers and naval aviation all have well deserved reputations for high-reliability operation.

In 2006, the Memorial Hermann Healthcare System in Houston embarked on a quest to become an HRO. The high-reliability program is a key element of Memorial Hermann's drive to provide “Best of the Best” care and be ranked with the upper few percentiles of all hospitals and health systems in the country. The Memorial Hermann system has nine acute-care hospital campuses, including an academic medical center, a children's hospital and two rehabilitation hospitals, other inpatient facilities, 19 ambulatory surgery centers and approximately 100 ambulatory locations.

The HRO program is called “Breakthrough in Patient Safety,” or BIPS for short. Engineers and other experts from nuclear power, commercial aviation, naval aviation and other HROs were brought in to train all health system employees to perform tasks in a safe, highly reliable manner.

Among other safety behaviors, employees were trained to take a one-second stop before taking an action like injecting a medication, because a one-second stop has been proven to reduce errors by 90%. That behavior is called STAR for Stop, Think, Act and Review. The one-second stop has saved countless lives.

The training was required for everyone, so eventually, more than 20,000 employees were trained in classrooms away from their job sites. BIPS-themed motivational and reminder materials were placed in public hallways and all patient rooms. Internal goals were set that rewarded 100% compliance with CMS/Joint Commission Core Measures and 0% occurrences of hospital-acquired infections, patient-safety indicators and hospital-acquired conditions.

A comprehensive electronic health record was implemented for all patient-care areas, including computerized physician order entry in all hospitals, automated computerized decision support and bar code bedside medication administration. HRO methods were applied to blood sampling and blood administration. Checklists were implemented in all operating rooms, and Memorial Hermann worked with the Joint Commission's Center for Transforming Healthcare to radically improve hand hygiene.

In 2010 and 2011, the results of these initiatives began to be apparent. When blood transfusions for the January 2007-December 2010 time period were tallied for a population of 867,000 adjusted inpatients and 4.3 million days of care, more than 493,000 transfusions had been administered with zero cases of blood incompatibility—that is, no transfusion reaction. Another HAC, air emboli, also had not occurred during those four years. Several hospitals had gone for years without a ventilator-associated pneumonia or a central-line-associated blood-stream infection. Serious medication errors decreased to zero most months even though upwards of a million medications per month were being administered.

In February 2011, it was noted that one of Memorial Hermann's busier community hospitals had gone a year since its last iatrogenic pneumothorax case. The physicians of Memorial Hermann Southeast Hospital had adopted the evidence-based safety technique of using real-time ultrasound guidance for central-line insertion in over 95% of cases. A new award, the Memorial Hermann High Reliability Certified Zero Award was created to honor this achievement. The award was called “certified” because these results are formally certified in monthly reports to the CMS.

When all safety records were carefully reviewed, two other Memorial Hermann hospitals had achieved zero iatrogenic pneumothorax cases for a year or longer, as well as eight community emergency departments that care for more than 330,000 patients a year. In addition, when other records were reviewed, various Memorial Hermann hospitals had earned a total of 28 Certified Zero awards for avoiding patient-safety indicators or hospital-acquired conditions for a year or more. Blood incompatibility and air emboli were excluded from these awards because they had long since achieved HRO status. The following High Reliability Certified Zero awards were announced in April:

• Zero central-line-associated bloodstream infections (one hospital)
• Zero ventilator associated pneumonias (five hospitals)
• Zero retained foreign bodies (six hospitals)
• Zero iatrogenic pneumothorax cases (three hospitals and eight community emergency departments)
• Zero pressure ulcers, stages III & IV (seven hospitals)
• Zero hospital-associated injuries (one hospital)
• Zero deaths among surgical inpatients with serious treatable complications (two hospitals)
• Zero birth traumas (two hospitals)

Prior to the BIPS initiative, these patient-safety indicators and hospital-acquired conditions were occurring almost monthly in Memorial Hermann hospitals. In March, the CMS published a national hospital listing for eight hospital-acquired conditions occurring in the October 2008-June 2010 time period. The Memorial Herman system had 48 possible entries because four of our nine hospital campuses report under a single Medicare provider number. Thirty-one of the 48 entries were zero, and more would have been zero if coding errors had been corrected in a timely way (this problem was subsequently addressed).

The Certified Zero Award has crystallized Memorial Hermann's determination to become a high-reliability organization in all respects, providing safe and efficient care to every patient and family. Although all illnesses and injuries cannot be cured at present, it is possible to take excellent care of patients without adding any illness or injury, and that is our goal. In 2011, the Memorial Hermann board adopted a simple mantra: “Patient safety is our core value.” Memorial Hermann's staff and physicians are working every day to live up to that standard.

Dan Wolterman is president and CEO of Memorial Hermann Healthcare System, Houston. Dr. M. Michael Shabot is its chief medical officer.