In 2004 Dr. Brian Koll was searching for a method to speed culture change at his institution, Beth Israel Hospital in New York, New York. Dr. Koll is the Chief of Infection Control, and in order to meet the hospital’s goals, as well as his personal ones, he knew he would need to find a new means to engage practitioners and change the culture.
Beth Israel’s CEO and the COO had recently joined the Institute for Healthcare Improvement’s 100,000 Lives Campaign, and Dr. Koll had some audacious targets, including a zero percent surgical site infection rate and intensive care units free of ventilator-associated pneumonia. He was already working with interprofessional teams, so it was natural to consider including learners in his efforts. Additionally, many health professionals in training at Beth Israel take permanent positions there after graduation, so Dr. Koll felt that engaging them in quality improvement work during their education would help him create the organizational culture he was aiming for more quickly.
And that’s exactly what he did. Dr. Koll assembled improvement teams that included learners from all different areas: medical students, nursing students, pharmacy interns, internal medicine residents, and administrative interns. To motivate them he gave a “recruitment speech,” full of stories and examples from both inside and outside of health care. These presentations emphasized the need for quality and safety initiatives, as well as the successes.
The approach worked. Today, Dr. Koll gives these presentations several times a year at the venues for each profession, each talk tailored to the particular motivations for that profession.
Once students and residents have been recruited, they are integrated into the current project groups, such as methicillin-resistant Staphylococcus aureus (MRSA) prevention, Clostridium difficile (C. difficile) monitoring, prevention of central line infections, and surgical site infections. Learners also receive a “Process Improvement 101” talk, to arm them with the basic skills they will need to make a difference. According to Dr. Koll, students “bring an energy and openness” to the table. In addition to working alongside practitioners, those in training become active participants in the interprofessional teams, working independently and reporting back to the teams.
For example, learners have been active participants in Beth Israel’s “Red Rules” program devised by the CEO and CMO. “Red Rules” involves handing out “tickets” for breaking safety and quality rules. Anyone at Beth Israel — from housekeeping staff to attending physicians — can give (or receive!) a ticket for an infraction such as failing to wash their hands between patient exams. These tickets have allowed everyone to become involved and invested in quality, from attendings and charge nurses to custodial staff and volunteers. Receiving a ticket means that you’ve been issued a warning and your name is added to a list of “offenders.” After your second ticket, your name is sent to your superior, and those who get a third ticket have their names forwarded to either the Chief Medical Officer or Chief Executive Officer. In 2007, 319 tickets were handed out. Five people, including nurses, transporters, and physicians, were noted to be “repeat offenders” for lack of appropriate hand hygiene or compliance with infection prevention practices such as removal of gloves between patients. In the first three months of 2008, 36 tickets have been handed out. There have been no repeat offenders.
Involving students and residents has not always been easy. “At first I was told I was crazy,” says Dr. Koll. Clinicians of all disciplines told him that you could not have a zero percent infection rate, that these tragic outcomes were inevitable. Additionally, finding the time and the incentives to motivate the students to work on quality improvement was very challenging. In response, Dr. Koll worked with affiliated schools and educators, from deans to clerkship directors, to make quality improvement a base of knowledge that students are expected to master.
Another barrier is the high turnover of students; some may be at the hospital for only four weeks. Dr. Koll addressed this issue by creating better continuity, meaning once students complete a project, and move on, they’re still notified about how the work is progressing. Dr. Koll keeps learners on the listserv so that they can see the strides that have been made as a result of their efforts. This feedback loop has proven to be an important way to bridge the gap that comes with rotating learners.
Finally, to justify the importance of expending energy and funds on students and residents, Dr. Koll has found it crucial to highlight the business case associated with quality improvement efforts. As an example, to reduce bloodstream infections in patients in critical care units, an initial cost outlay of $30,000 was made to create a process with use of special kits and monitoring tools to ensure compliance with insertion and maintenance practices. In addition to this expense, which was approved by the hospital administration, the interprofessional teams, including learners, were expected to add this work to their already busy schedules. The resource outlay was cost effective, with savings of over $2 million dollars during the past few years due to the reduction in infection rates, as well as lives saved from prevention of these infections.
Outcomes have been impressive for Beth Israel. Two critical care units have not had a bloodstream infection in over one year, with one unit maintaining a zero bloodstream infection rate for over two years. The last ventilator-associated pneumonia in the Pediatric Intensive Care Unit was almost 18 months ago, and the Surgical Intensive Care Unit has gone 10 months without such an outcome. Drug-resistant organisms such as MRSA have been reduced by 65 percent and C. difficile by 20 percent. Hand hygiene compliance has been above 90 percent, with many units achieving 100 percent compliance with infection prevention practices for one year or more.
More importantly, the culture change that Dr. Koll craved is beginning to take shape. Learners have found that involvement in quality improvement can have a lasting effect. Dr. Xin Pang, a resident at Beth Israel, found the work not only interesting but inspiring. She felt that one key to success was the organization of the project, from the lectures to the expectations. Now Dr. Pang feels empowered to improve the system and help her patients on an entirely new level.
Dr. Koll is now able to ask students what they would like to work on as they rotate through Beth Israel. This work with learners has also paved the way for regional initiatives and improved improvement efforts between hospitals and systems in the greater New York area. And now at Beth Israel a bad outcome is considered a systems failure, not an inevitable side effect of care delivery. “It actually makes people sad” to see such a result, says Dr. Koll. “What I am really proud of is that people took this to heart.”
Take-Home Points from Beth Israel:
- Involving students and residents in quality improvement can improve projects.
- Motivating learners and arming them with the tools for success can have a lasting effect.
- Working with educational leaders can embed quality improvement into the expectations for learners.
- Involving learners can speed the development of a culture of safety.
04/16/2008
