Patient Safety First: A California Partnership for Health – A Peer-to-Peer Learning Collaborative for Healthcare Improvement

Jessica AR Williams1, M.A.; Mia Arias2, MPA; Heather M Kun3, Sc.D., M.S.; J. Eugene Grigsby4,III, Ph.D.; Julia Slininger5, RN, BS, CPHQ; Alicia A. Muñoz6, MAS FACHE;  Jenna Fischer7

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1. National Health Foundation, 515 South Figueroa Street, Suite 1300, Los Angeles, CA 90071, (213) 538-0707, [email protected]

2. National Health Foundation, 515 South Figueroa Street, Suite 1300, Los Angeles, CA 90071, (213) 538-0743, [email protected]

3. National Health Foundation, 515 South Figueroa Street, Suite 1300, Los Angeles, CA 90071, (213) 538-0753, [email protected]

4. National Health Foundation, 515 South Figueroa Street, Suite 1300, Los Angeles, CA 90071, (213) 538-0754, [email protected]

5. Hospital Association of Southern California, 515 South Figueroa Street, Suite 1300, Los Angeles, CA, (213) 538-0766, [email protected]

6. Hospital Association of San Diego and Imperial Counties, 5575 Ruffin Road, Suite 225, San Diego, CA 92123, (858) 614-1541, [email protected]

7. Hospital Council of Northern and Central California, 877 Ygnacio Valley Road, Suite 210, Walnut Creek, CA 94596, (925) 746-5106, [email protected] 

Summary

Patient Safety First is a collaboration between hospital associations, a health plan, and a nonprofit organization in California that has been a pioneer in aiming to improve quality and reduce costs.  At its inception in 2010, PSF set ambitious three-year goals to be able to consistently measure progress and drive improvement in targeted areas. At the end of three years, significant improvements were made towards its original goals in the areas of sepsis mortality, ventilator-acquired pneumonia (VAP), central line blood stream infections (CLBSI) and elective deliveries prior to 39 weeks gestational age. Over 3,576 lives have been saved as a result of reducing sepsis mortality and an estimated $64 million in healthcare costs were avoided as a result of this initiative.

Background

Since the 2000 Institute for Healthcare Improvement report, To Err is Human[1], patient safety has become a growing national priority with the demand for improving patient safety coming from all areas in healthcare, including individual hospitals, hospital systems, and quality improvement authorities such as the Agency for Healthcare Research and Quality, The Joint Commission, and National Quality Forum. Based on heightened awareness in the healthcare industry and the need for coordination among California’s patient safety efforts, Patient Safety First…A California Partnership for Health was launched in January 2010.

Patient Safety First was developed to improve the quality of care provided to Californians, save lives and reduce healthcare costs. Anthem Blue Cross provided $6 million over three years to fund this initiative. Patient Safety First partners include the Hospital Association of Southern California, Hospital Council of Northern and Central California, Hospital Association of San Diego & Imperial Counties, National Health Foundation and Anthem Blue Cross. Each organization plays an important role in the strategic planning and implementation of Patient Safety First.

With more than 180 hospitals participating, Patient Safety First was the largest statewide collaborative effort focused on patient safety in the nation from 2010-2012. Not only unique in its size and scale, Patient Safety First is distinctive in that it brings together a health plan, hospital associations, a non-profit organization and private and public hospitals as partners in an effort to improve care, health outcomes and reduce healthcare costs.

The Patient Safety First focus areas were determined by partners at the start of the project through a collaborative decision making process. The initiatives were chosen as a result of Regional Hospital Associations’ existing patient safety efforts, the continued need for improvement in targeted areas and an internal assessment of potential impact. Patient Safety First had five main focus areas: sepsis mortality, ventilator-associated pneumonia, central line blood stream infections, catheter associated urinary tract infections and perinatal gestational age deliveries under 39 weeks.

Estimates of the overall annual direct medical costs to hospitals of healthcare associated infections range from $28.4 to $45 billion[2]. According to the Centers for Disease Control and Prevention, hospital-acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year in American hospitals[3]. Between 1999 and 2005, 6.0% of all deaths were associated with sepsis—it is the 10th leading cause of death in the United States[4]. Despite recommendations from The American College of Obstetricians and Gynecologists that no elective delivery should be performed before the gestational age of 39 weeks, studies report that the rates at some hospitals are above 25%, and some almost 40%. Early elective deliveries are associated with several negative health consequences such as increased neonatal morbidity, increased admissions to neonatal intensive care units, and increased hospital costs[5].

Mechanisms for Change

In order to facilitate improvement in the aforementioned focus areas, Patient Safety First adopted components of the Institute for Healthcare Improvement Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement developed in 1995[6]. This model is a validated learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area. The key elements of the Breakthrough Series adopted by Patient Safety First include:

• Facilitating Learning Sessions: These sessions are face-to-face meetings through which peer-to-peer learning takes place amongst participating hospitals. Both expert faculty and peers present and share evidence-based practices and strategies for improvement.  Lessons learned as well as barriers and success stories from hospitals are shared in breakout sessions and through informal dialogue and networking.

• Model for Improvement:  This model was developed by Associates in Process Improvement and identifies four key elements of successful process improvement: specific and measureable aims, measures of improvement that are tracked over time, key changes that will result in the desired improvement, and a series of testing “cycles” during which teams learn how to apply key change ideas to their own organizations. Patient Safety First hospitals are encouraged to use this process within their organizations to facilitate change and improvement.

• Measurement and Evaluation: Regular measurement and assessment are critical to ensure and sustain successful improvement. Patient Safety First requires hospitals to enter data for its initiatives and makes real-time reports available to hospitals. NHF conducts data analysis and reports out aggregate results to all stakeholders.

Hospitals were recruited to join Patient Safety First by their regional hospital associations (see Figure 1).  At the regional level, hospitals engage in one-on-one consultation, in-person meetings, and webinars/online trainings. Since inception, the Hospital Association of Southern California has held 47 meetings/trainings. The Hospital Council of Northern and Central California has held 69 meetings/trainings. The Hospital Association of San Diego & Imperial Counties has held 24 meetings/trainings. Peer-to-peer learning occurs through multidisciplinary hospital teams, peer-to-peer networking and expert speakers. Hospital teams use the knowledge gained through Patient Safety First programs to implement best practices in their hospitals. In order to measure outcomes and progress, hospitals submit outcomes data into the project database that is maintained by the National Health Foundation (NHF).

Three Year Goals

Patient Safety First hospitals submitted metric-specific data on a quarterly basis to NHF through a secured, password protected web-based data collection and reporting system. Data definitions were standardized prior to data collection[7]. Hospitals provided data from 2009 as a baseline for evaluation.

The three year goals for PSF were as follows:

  • Ventilator-Associated Pneumonia (VAP): Hospitals will reach a rate of zero
  • Central Line Blood Stream Infections (CLBSI): Hospitals will reach a rate of zero
  • Catheter Associated Urinary Tract Infections (CAUTI): Hospitals will reach a rate of zero
  • Sepsis Mortality: Statewide 30% reduction in sepsis mortality
  • Perinatal Gestational Age Deliveries: Hospitals will reduce elective deliveries prior to 39 weeks to 5% or less

Project-to-date Findings: Quality Improvement

To measure progress over three years, the difference in the average rates from 2009 (baseline) to 2012 was calculated using data from hospitals that reported every quarter from 2009 through 2012. These averages were compared using a paired t-test. The probability of Type I error (p-value) that is viewed as statistically significant is 5% or less. For the perinatal outcome, no 2009 data could be obtained, so the 2010 rate is used as the baseline[8]. The results of the analysis are given in Table 1. In summary, we found that:

  • There were 1.27 fewer VAP cases per 1,000 ventilator days in 2012 than in 2009 (p<0.01), representing a 57% reduction towards the goal of a zero VAP rate.
  • There were 0.29 fewer CAUTI cases per 1,000 catheter days in 2012 than in 2009 (p=0.21), representing a 24% reduction towards the goal of a zero CAUTI rate.
  • There were 0.97 fewer CLBSI cases per 1,000 central line days in 2012 than in 2009 (p<0.01), representing a 43% reduction towards the goal of a zero CLBSI rate.
  • There were 5.96 fewer Sepsis deaths per 100 sepsis cases in 2012 than in 2009 (p<0.01), representing a 26% reduction, nearly meeting the goal of a 30% decline over 3 years.
  • Elective deliveries prior to 39 weeks represented 9.94% of all deliveries in 2010, but only 2.57% of deliveries in 2012 (p<0.01), representing a 74% reduction, meeting the goal of 5% or less within 3 years.

Of these averages, the difference for ventilator-associated pneumonia, central line blood stream infections, sepsis mortality, and early elective deliveries were statistically significant at less than 5%. The average differences of the catheter associated urinary tract infections were not statistically significant at the 5% level.

Project-to-date Findings: Costs Avoidance

In addition to measuring the changes in health outcomes, we also conducted a costs avoided analysis. The cost avoidance analysis uses paired data for 2009-2012 to provide the most accurate assessment of cost reduction generated during the three years of the Patient Safety First initiative. Cost avoidance calculation is based on the business case analysis model documented by Dr. Richard Brilli for preventing ventilator-associated pneumonia in pediatric ICU.[9] The major components of the calculation are:

  • Cost Avoided = Average cost per case x Number of avoided cases
  • Number of avoided cases = Expected number of cases – Observed number of cases
  • Expected number of cases = (Observed number of cases in referent year) x (Number of device-days in comparison year)/(Number of device-days in referent year)

The average cost per case for each outcome was taken from the literature[10]. Costs from the literature were adjusted using the Medical Care component of the U.S. Paired hospitals reported data for all quarters in each year. All costs are shown in 2012 dollars.

The numbers of cases were taken from hospitals that reported data in every quarter in 2009 through 2012. Table 2 gives a summary of costs avoided in 2010-2012 for HAI and sepsis outcomes. The amount of costs avoided overall, using paired data for 2010-2012, was $63,804,021. The largest share of the cost avoidance is from decreases in Sepsis mortality, estimated to be $35,631,264. Estimates of cost avoidance for central line blood stream infections and ventilator-associated pneumonia are $12,249,571 and $7,741,616 respectively. The estimated cost avoidance from changes in average catheter associated urinary tract infections rates is $176,258. The estimated cost avoidance from decreases in the amount of elective deliveries prior to 39 weeks was $8,005,312.

Limitations

A core focus of Patient Safety First is to promote the adoption of evidence based patient safety practices. According to the Agency for Healthcare Research & Quality patient safety practices are a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures[11]. While Patient Safety First promotes these practices, it is not the intent of this project to be prescriptive in determining which of these interventions hospitals should adopt to improve safety and quality of care within their unique settings. In this same vein, the project does not track the degree to which each hospital implements specific best practices and/or strategies for improvement, of which, there are varieties shared at the collaborative meetings to address the Patient Safety First initiatives. Moving forward it will be important to focus on strategies or best practices that individual hospitals are using and measure use of these best practices in relationship to improvement. This will entail more focused one-on-one work and assistance for hospitals facing challenges in making progress.

The percent of hospitals that entered data for any measure was 80% in 2010, 88% in 2011, and 87% in 2012.  While hospital participation is high overall, there are fewer number of hospitals who entered paired data (data for consecutive years and quarters) for any measure. Because the results are based on hospitals that reported paired data, they may not be generalizable to all hospitals in the collaborative.

Discussion and Next Steps

While changes to hospital incentives and practices that occurred during the time of Patient Safety First cannot be completely ruled out, we did find some evidence that health outcomes for hospital associated infections, sepsis mortality, and early elective deliveries could be reduced in the context of a statewide collaborative. On average, all of the measures except CAUTI improved over the course of the collaborative and the differences were statistically significant.

In light of the passage of the Affordable Care Act, the Centers for Medicare and Medicaid Services is pushing to improve quality while reducing cost which entails adequate quality improvement programming and measurement of quality indicators nationally and statewide. Hospitals now have a financial incentive to improve quality as focus moves from volume to improved outcomes. With the passage of the Affordable Care Act, various mechanisms for reimbursement of hospitals based on quality will be available including value based purchasing and new accountable care organizations (Medicare) and Medicaid quality/cost based reimbursement structures.

Because of the initial success of Patient Safety First hospitals, the “low hanging fruit” has been picked in terms of improvement. Therefore, to ensure sustained impact, Patient Safety First must engage hospitals in new initiatives that will benefit from quality improvement activities and resources and work with emerging statewide patient safety efforts to avoid repetition and to maximize impact. As Patient Safety First enters into a second phase with renewed funding, it will continue concentrating on some of its existing initiatives and add initiatives that are increasingly important to hospitals including C. Difficile and Surgical Safety with a focus on eliminating retained surgical sponges/towels. These new initiatives, along with a continued emphasis on leadership, teamwork, and organizational culture, have the potential to further enhance patient safety at participating hospitals, reduce costs and save lives. 

Figure 1. Patient Safety First Intervention Process

Table 1. Average Difference in Rates 2009 and 2012 using Paired Data

Outcome

# Hospitals with paired data

Average Rate 2009

Average Rate 2012

Absolute Difference

p-value

Percent Difference

VAP cases/1,000 ventilator days

50

2.21

0.94

-1.27

<0.01

57%

CAUTI cases/1,000 catheter days*

25

1.19

0.9

-0.29

0.21

24%

CLBSI cases/1,000 central line days

47

2.24

1.27

-0.97

<0.01

43%

Sepsis deaths/100 sepsis cases

49

22.58

16.62

-5.96

<0.01

26%

Outcome

# Hospitals

Average Rate 2010

Average Rate 2012

Absolute Difference

p-value

Percent Difference

Elective deliveries prior to 39 weeks/100 live births

31

9.94

2.57

– 7.37

<0.01

74%

Table 1 Notes: The second column reports the number of hospitals that submitted complete data for the given outcome (rows) in 2009-2012. For elective deliveries prior to 39 weeks this number reflects hospitals submitting data from 2010-2012.  CAUTI results not statistically significant.

 

Table 2. HAI and Sepsis Costs Avoided in 2010-2012

Outcome Costs Avoided in 2010-2012
VAP  $      7,741,616
CAUTI  $       176,258
CLBSI  $      35,631,264
Sepsis Mortality  $      22,130,044
Total  $     55,798,709

Table 2 Notes: All costs are in 2012 dollars. Costs from the literature were adjusted using the Medical Care component of the U.S. Paired hospitals reported data for all quarters in each year (2009, 2010, 2011, and 2012).



[1] National Research Council. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000.

[2] Scott, R. Douglas. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta, GA: The Centers for Disease Control and Prevention, 2009. Available online at: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf.  Accessed Jan. 22, 2013.

[6] The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003.

[7] For more information please contact PSF administrators.

[8] This also matches the later implementation of this initiative.

[9] *Brilli, RJ et al. “The business case for preventing ventilator-associated pneumonia in pediatric intensive care units”, The Joint Commission Journal on Quality and Patient Safety, 34 (11) 629-637.

[10] Warren DK, Shukla SJ, Olsen MA et al. “Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center.” Crit Care Med.2003; 31: 1312-1317.

Angus DC, Linde-Zwirble WT, Lidicker J et al. “Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care.” Crit Care Med. 2001; 29: 1303-1310.

Tambyah PA, Knasinski V, and Maki DG. “The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. “ Infection Control and Hospital Epidemiology. 2002; 23: 27-31

Kilgore M and Brossette S. “Cost of bloodstream infections.” Am J Inf Control. 2008; 36: S172.e1-S172.e3

[11] Making Health Care Safer: A Critical Analysis of Patient Safety Practices, http://www.ahrq.gov/clinic/ptsafety/summary.htm