‘No Harm Campaign’ Improves Quality and Saves Lives

As a 2011 recipient of the Malcolm Baldrige National Quality Award, the Henry Ford Health System in Detroit has achieved recognition as a top-performing organization for excellence in innovation, efficiency, and quality improvement. The highest priority of our quality improvement work is to become a harmless organization. As a member of the Institute for Healthcare Improvement (IHI)’s “100,000 Lives” and “5 Million Lives” campaigns, we used IHI’s 12 evidence-based interventions as well as other initiatives to reduce harm.

During 2004–2008 our systemwide mortality rate decreased by 29 percent. At that time we developed our own “No Harm Campaign” to integrate national, local, and homegrown efforts into one systemwide initiative to reduce harm. During 2008–2011, our systemwide mortality rate decreased by another 12 percent, and our combined inpatient harm rate decreased by 26 percent. This reflects a reduction of 337 harm events per month, even while adding a new hospital and increasing the total number of patient days in the period measured.

Developing the No Harm Campaign

The journey to reduce harm in health care gained momentum across the United States when the Institute of Medicine reported in 1999 that up to 98,000 deaths each year are caused by medical errors. Like other hospitals and health systems across the nation, we joined national and local initiatives and struggled with how to respond cohesively as one system.

The Henry Ford Health System includes six hospitals, 29 medical centers, and the Henry Ford Medical Group with more than 1,200 physicians in more than 40 specialties. The system’s flagship, Henry Ford Hospital, in Detroit is an 802-bed tertiary care, level-one trauma center, and education and research complex. The challenge to create a systemwide, cohesive quality effort came from our system’s board of trustees in 2007 with the mandate to focus on eliminating harm from the health care experience.

Our CEO, Nancy Schlichting, leads our System Quality Forum that developed and oversees the No Harm Campaign. The campaign’s aim is high: to decrease harm events by 50 percent during 2008–2013. Components of the campaign focus on enhancing our culture of safety, improving the quality and clarity of clinical communications, identifying top causes of harm overall and at individual points on the continuum of care, and redesigning care to eliminate common causes of harm.

Defining harm measures

We use a broad definition of harm: any unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital.

No comprehensive set of harm measures yet exists for U.S. hospitals. For our system’s facilities, we identified a comprehensive set of measures for harm reduction: infection-related, medication-related, procedure-related, and other preventable harm. These harm measures, comprised of hundreds of medical codes, combine to create a unique aggregate harm score. The harm score for each hospital overall and by category is transparent to all stakeholders within the system in an effort to create and spread best practices for harm reduction across the system.

Infection-related harm: This includes all health care-acquired infections, catheter-related bloodstream infections (CRBSI), urinary tract infections, surgical site infections, and ventilator-associated pneumonia. Examples of interventions include increased hand hygiene surveillance, improved adherence to isolation precautions, enhanced antimicrobial stewardship, and use of catheters with built-in urometers to reduce infection risk.

Interventions to reduce CRBSI in hemodialysis patients with tunneled catheters have used an innovative antibiotic lock protocol after each patient’s dialysis session. Started at one dialysis unit, use of the protocol decreased the average rate of CRBSI by almost 85 percent, avoiding an estimated 69 infections. The protocol was spread to three other units, resulting in a 24.5-percent reduction in mortality for dialysis patients. This improvement initiative reduced infections to below the national benchmark and reduced hospitalizations and unnecessary vascular access procedures which also translated into significant cost savings.

Medication-related harm: This focuses on drugs at high risk of causing medication-related events, such as insulin, anticoagulants, and narcotics, among others. The optimal measure is the “in range” management of these risky medications. For insulin, for example, glycemic control protocols were spread systemwide before 2008. The newest protocol, piloted in 2009 and spread in 2010, along with the change in the Intensive Care Unit (ICU) drip protocol, led to a 43-percent reduction in hypoglycemia.

Procedure-related harm: This includes all coded complications directly related to medical and surgical procedures. To improve the quality of surgery, our hospitals joined the National Surgical Quality Improvement Program in 2006. In 2009, system hospitals implemented the World Health Organization checklist and debrief sessions even for conscious sedation standards. Results showed that a comprehensive surgical services program led to 60-percent reduced mortality and 19-percent reduced length of stay.

Other preventable harm

Falls and pressure ulcers: Patients or visitors may experience accidental falls while in the hospital. We measure all falls with injury. Patients who are bedridden are at higher risk of developing pressure ulcers on the skin. Our hospitals adopted an evidence-based, nurse-rounding protocol designed to reduce harm from falls and pressure ulcers. Nurses use a standardized checklist for each patient during hourly rounds. In addition, special beds with enclosed canopies have proven useful for preventing falls by patients with certain behavioral conditions.

Health-care acquired acute renal failure: Kidney failure may be caused by sepsis, dehydration, or medications. For example, radiology imaging studies using contrast material may cause kidney damage. Henry Ford Radiology implemented one of the most aggressive programs nationally to protect kidney function from contrast-induced harm. The systemwide program includes avoiding unnecessary imaging studies, giving fluid to patients at risk of using contrast material, and aggressively tracking patients who are given contrast.

Deep vein thrombosis and pulmonary embolism: Recently, 17 hospitals across Michigan began a collaborative to prevent deep vein thrombosis and pulmonary embolisms in medicine patients, which has long been a focus at our system. Early data show that Henry Ford Hospital has the best rates of medical prophylaxis in the state.

Overuse of sedation and ventilators in ICU care: ICUs have been working to improve protocols that reduce the use of sedation and allow patients to spend less time on ventilators. With ongoing use of the ventilator bundle, multidisciplinary daily rounds, and additional education on the prevention of ventilator-associated pneumonia, the 68-bed medical ICU, the largest in Michigan, had five consecutive months during 2010–2011 without a single ventilator-associated pneumonia. Mobilization of vented patients to maintain core strength and allow faster recovery is currently being tested.

Employee injuries: Employee harm from contaminated-source needle-sticks and from job-related injuries such as falls and back injury may occur from various environmental or work-related conditions.

Birth trauma: Our health system participates in national and local collaboratives to reduce harm and improve patient safety, such as the Michigan Health and Hospital Association’s Keystone Center Perinatal, Emergency Department, and Operating Room Care Collaboratives.

Building a culture of safety

Henry Ford Health System implemented a multistrategy, stepped approach to build a culture of safety. These steps include establishing a common safety language through Patient Safety 101, a program designed to provide basic safety training to all employees. Efforts to create safe environments include changing the error management approach, training employees to understand human limitations that contribute to error, and efforts to promote speaking up about safety concerns. In June 2008 we launched a Safety Champion Program to develop and empower frontline safety experts; currently more than 350 trained safety champions are deployed throughout the system. System-level communication strategies implemented include a system blog, group e-mail, a safety champion newsletter, e-learning and classroom education, and quarterly development forums.

Safety champions model and mentor safe practices, share information at staff meetings, and participate in quality and safety improvement work. They reinforce safety initiatives implemented throughout the system, such as hand hygiene and “speak up” efforts. Employee surveys in 2006, 2008, and 2010 showed steady improvement in culture of safety scores. The 2010 survey results showed that clinical units with safety champions had statistically significant greater improvement in culture of safety scores when compared to units without safety champions. Overall employee engagement scores were also higher for units with safety champions, compared to units without safety champions.

Continuing to spread “no harm”

Aspects of the No Harm Campaign, especially culture change, are being spread to all sites of care within the Henry Ford Health System. Residential facilities aim to reduce falls and pressure ulcers. Dialysis centers work to reduce infections. All facilities focus on medication safety and eliminating employee harm.

Since the start of the No Harm Campaign in 2008 and despite these trying financial times, Henry Ford Health System leaders and employees have worked to build the knowledge base and infrastructure required to implement new process improvements to eliminate harm. All system hospitals, for example, must define, measure, collect data, and analyze “harm events” in the same way before new processes can be tested, verified, refined, standardized, and spread throughout an organization for lasting change. This early critical work takes time to reach the point where all parts of the system reach simpatico—a tipping point—after which new process improvements and results gain momentum for faster spread and continued innovation.

For more information, visit our website or read our No Harm Report.

About The Author