Laying the groundwork for quality

On the morning of March 27, a group of 46 quality improvement professionals gathered in a brightly lit conference room on the ground floor of a large hotel near Chicago's O'Hare International Airport.

The attendees, representing 18 hospitals from across the country, were at the event to learn more about how to prevent adverse events such as patient falls and pressure ulcers, and how to keep their discharged patients from being readmitted to the hospital unnecessarily. Over the course of the day, they milled around, moving from one session to another, where, seated around U-shaped tables, they brainstormed about creative ways to drive improvement and they studied “blueprints,” step-by-step visual representations of proven best practices.

Ushma Lakhani, a clinical quality specialist at 226-bed Sherman Hospital in Elgin, Ill., said she came to the meeting looking for new strategies to combat catheter-associated urinary tract infections. “Events like this are great because we have the opportunity to network and share ideas,” Lakhani said.

Lynn Vescio, director of performance improvement at 373-bed Jefferson Regional Medical Center, Jefferson Hills, Pa., listed medication safety among her hospital's top priorities.

Lakhani, Vescio and the other participants are members of Irving, Texas-based VHA's hospital engagement network, a collaborative group of more than 200 hospitals working to identify and disseminate best practices.

VHA is one of 26 hospital engagement networks, or HENs, chosen by HHS as part of its $1 billion Partnership for Patients initiative. Announced in April 2011, the partnership is a far-reaching campaign, involving thousands of hospitals, agencies, consumer groups and other entities in the public and private sectors.

The initiative—and the HENs—have two overarching goals: Reduce hospital-acquired conditions by 40% and preventable all-cause 30-day readmissions by 20% by the end of 2013, using data from 2010 as a baseline. Reaching those targets, HHS says, could result in 1.6 million fewer readmissions, 1.8 million fewer patient injuries and 60,000 lives saved over the next three years. HHS also predicts Partnership for Patients could save Medicare as much as $50 billion over the next decade.

To those ends, in December 2011, HHS awarded a total of $218 million in two-year contracts—with a third optional year—to the HENs, organizations the government says will serve as “mobile classrooms” and coaches for hospitals in their networks, targeting 10 core areas of focus, such as pressure ulcers, central line-associated bloodstream infections, ventilator-associated pneumonia and obstetrical adverse events.

The HENs include state hospital associations, such as the Minnesota Hospital Association; health systems, such as 76-hospital Ascension Health and 38-hospital Dignity Health; and national organizations, such as Premier and the American Hospital Association-affiliated Health Research and Educational Trust.

“HENs are just one part of the much larger effort,” says Dr. Paul McGann, co-director of the Partnership for Patients and chief medical officer for campaign leadership at the Center for Medicare & Medicaid Innovation, which oversee the HENs. “We see them as an integral part of the Partnership for Patients, which includes national, state and local partners, all working together in concert and in synergy to achieve the two aims.”

While many liken the Partnership for Patients to past collaborative initiatives such as the Institute for Healthcare Improvement's 100,000 Lives and 5 Million Lives Campaigns, government officials and leaders from the HENs say this sweeping effort goes even further.

“I don't think you could identify another program that has tried to achieve these kinds of goals in this timeframe,” says Michael Silver, senior vice president of corporate operations at HealthInsight, Las Vegas, a not-for-profit organization selected by the Nevada Hospital Association to work as a subcontractor on its HEN.

Keith Kosel, executive director of VHA's HEN initiative, echoes Silver, saying the Partnership for Patients is different in its scale and its attention to culture, context and “how you engage people to solve problems.”

There is a downside to setting the bar so high. Perhaps not surprisingly, the initiative's targets sound lofty—and even unattainable, given the time allotted—to some in the field. “They're very, very aggressive, but having aggressive goals drives people to think about problems in a different way,” says Dr. William Conway, senior vice president and chief quality officer of Detroit-based Henry Ford Health System.

For its much-lauded No Harm campaign, launched in 2007, six-hospital HFHS has tried to reduce harm by 50% by 2013, Conway says.

“Whether we hit a numerical target is not as important as whether we make as much progress as we can as quickly as we can,” he says. “That's a politician's answer,” he added, laughing.

HHS officials say they were galvanized by national data showing baseline injury rates of 145 hospital-acquired conditions per 1,000 discharges and a national baseline readmission rate of 14.4%—figures they call unacceptable. They arrived at the program's two goals by reviewing safety literature and identifying the most successful interventions and corresponding prevention rates, McGann says.

“Make no mistake, these are ambitious goals and achieving them will be very challenging,” says Dennis Wagner, the other co-director of the Partnership for Patients and the Innovation Center's associate director for campaign leadership. “But we are confident that we can do it.”

Dr. Donald Berwick, former head of the CMS and current senior fellow at the Washington-based Center for American Progress, acknowledges that the CMS drew heavily on the work of IHI, Premier and other organizations when crafting the Partnership for Patients.

“The concept of collaborating with a network has become standard for the rapid spread of improvement,” he says.

Berwick, who co-founded the IHI and served as its longtime leader before assuming the top spot at the CMS in 2010, says the initiative's goals are “stringent but achievable.” The real hurdle, he contends, will be spreading pockets of successful improvement across the entire country.

“It will be a matter of will,” Berwick says. “These targets can be reached; there is very little question of that. But if we make progress and don't hit the goals, we should recognize what we accomplished and learn lessons going forward. Discouragement should not be a part of this process.”

In the five months since the contracts were announced, the HENs have hit the ground running, Wagner says. “We awarded the contracts on Dec. 9 and we were in the first face-to-face meetings on Dec. 12, three working days later,” he says. “Some HENs convened their first learning sessions within 30 days of the awards. That is lightning fast.”

The HENs have since enrolled a total of more than 4,000 acute-care hospitals, Wagner adds.

“We had letters to hospital CEOs already drafted and ready to go before we even knew we got the award,” says Dr. Carol Koeble, senior vice president of the North Carolina Hospital Association, which was chosen as a HEN, and executive director of the North Carolina Center for Hospital Quality and Patient Safety.

North Carolina's HEN—called the North Carolina-Virginia hospital engagement network because of its partnership with the Virginia Hospital & Healthcare Association—now has 117 members, 83 from North Carolina and 34 from Virginia.

In the rush to recruit hospitals, a few states have even seen competition among HENs, Koeble says. In Virginia, for instance, some hospitals chose to join the networks of national HENs, such as Premier, VHA and HRET, while several academic medical centers affiliated with Chicago-based UHC chose to join its HEN.

“We did court some hospitals, and we got many to come aboard,” Koeble says. “The most important thing, though, is that all hospitals participate in a HEN, no matter which one it is.”

North Carolina's HEN has chosen to tackle its duties using intensive collaboratives addressing conditions such venous thromboembolism, as well as less-intensive learning networks targeting areas of harm such as pressure ulcers and adverse drug events. Some hospitals are participating in all activities, while others—particularly smaller ones—can choose from a narrowed list of topics.

Transylvania Regional Hospital, a 25-bed critical-access hospital in Brevard, N.C., has signed up to target seven areas, including surgical-site infections, says Scotta Orr, the hospital's director of quality and accreditation.

“Smaller hospitals are required to meet the same guidelines as larger ones but with fewer patient and fewer employees, so the people here have to wear many hats,” Orr says. “If we can get best practices and tools that someone has already invested in, such as patient education or a checklist, that saves us a great deal of time.”

The Michigan Health & Hospital Association, also chosen as one of the 26 HENs, decided to build on its existing quality-improvement infrastructure, well known for its successes in areas such as central line-associated bloodstream infection prevention.

“We have an advantage because we already have the contacts and we have the teams engaged,” says Brittany Bogan, director of healthcare innovation at the association's Keystone Center for Patient Safety & Quality.

The larger national HENs have also taken their own approach to meeting the program's goals. HRET, which secured $75 million from HHS and has enrolled more than 1,600 hospitals in 31 states, has rolled out its enormous HEN using partnerships with state hospital associations, says Maulik Joshi, HRET's president.

State hospital associations do their own recruiting while HRET coordinates the improvement activities, explains Joshi, who says the partnership with state associations is HRET's “secret sauce.”

At HRET's recent HEN week, held April 30-May 4 in Chicago, roughly 400 attendees from hospitals across the country came to learn more about safety culture, the science of improvement and how best to design reliable processes. It was the second such two-day meeting this year, with one more scheduled by the end of 2012, Joshi says. “We want to work with all of our hospitals on the 10 harms but we also want to build up their capabilities so they can continue to improve in other areas,” he adds.

The HENs' varied strategies are one of the program's strengths, says McGann, co-director of the Partnership for Patients. In the past, government-led improvement initiatives often had a one-size-fits-all approach that didn't take into account regional and population differences.

This time around, he says, the HENs had to make it clear in their applications how they would address obstacles and reduce harm in their regions. For instance, the Washington-based National Public Health and Hospital Institute, another HEN, relies on a much different strategy than does, say, a health system HEN such as San Francisco-based Dignity Health, he says.

“We are very tight and focused on the two aims but we are taking a different approach on the ‘how,'” Wagner says. “We're seeking innovation, diversity and real-time data sharing. That will be a huge asset nationally.”

Along with a number of jokes about golden eggs, the HENs also report some early successes.

The Washington State Hospital Association's HEN, which has about 100 participating hospitals from Washington, Oregon and Alaska, recently unveiled its success at curbing early elective deliveries of babies before 39 weeks, says Carol Wagner, the association's senior vice president for patient safety. Dignity Health also targeted early elective deliveries and reduced its rate from 7% in April 2011 to 2%, as of January.

Other HENs have seen reductions in falls, pressure ulcers and other areas, according to HHS. “This really is unprecedented in American healthcare,” McGann says. “We have vast federal alignment, a contract engine worth

$1 billion and external partnerships, all working toward these two goals.”

TAKEAWAY: Hospital engagement networks, charged by HHS with reducing harm and readmissions as part of the Partnership for Patients initiative, may face difficulties meeting the program's ambitious goals.