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16 March 2017
The Quality Management conference at Arab Health 2017 provided an interesting and illustrative discussion regarding issues and ideas that hospitals in the future need to consider as they move to be leaders in the field. One focus was on children’s hospitals, but would be applicable to all hospitals. One such discussion utilized experiences from his own hospital – Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center – to highlight the important issues. Children’s Hospital of Pittsburgh (CHP) is one of the top ten children’s hospitals in the United States and one of the first fully digital hospitals with a paperless record management system for patient data, order entry and distribution, results reporting, imaging, and more.
The framework for achieving the goal of being a top hospital consists of a number of policies and practices:
- A safe environment for patients and employees
- A strong program of infection control
- Team-based care
- Patient centric and family-focused care
- Recognizing and accommodating the need for high acuity, critical care
- Automation of routine as well as complex tasks
- Integration of pre- and post-hospitalization ambulatory care
Hospitals of the future will be known for
- Measuring everything
- Using predictive analytics to improve care
- Using continuous quality improvement
- Developing and implementing Pathways of Care
- Incorporating research into standard care
- Providing patients and providers with access to information though many portals
- Utilizing hospitalists and advanced practice providers
- Strategic planning
An environment of safety is a reporting environment. Hospital leaders need to know where there are problems and need front line staff to provide them with this information. However, front line staff will only report events when they believe that it is important, that they and their colleagues will be safe without recrimination to report, that the information provided will be used to make a positive change, and that they will receive feedback on process change and results. CHP launched a program in 2012 to address the culture of reporting at all levels: patients, staff, faculty, and administration. Reporting rates have improved dramatically with physicians now reporting 190 events/quarter when previously the reporting rate was less than 50. Review of the types of events that have been reported indicates the numbers of “Near Misses” has increased as has “Reached the Patient, but no Harm”. This is the desired trend, so that these events can be analyzed and plans put in place to prevent similar events. There have been no “Serious Events” which of course is an important goal.
CHP has also addressed the Culture of Safety by joining a national collaborative of 110 children’s hospitals around the country called Solutions for Patient Safety. All hospitals in the collaborative share data on selected Hospital Acquired Conditions (HACs), such as central line associated blood stream infections, ventilator associated pneumonia, etc. The hospitals share their management “bundles” which are created to decrease incidence of these HACs as well as how well the bundles have performed. The group then defines best practice. Since joining the collaborative in 2023, serious harm events have decreased by 50%.
Programs to prevent spread of infection in hospitals are critical to achieve the best patient outcomes. Good hand hygiene is one of the most effective ways to prevent spread of infection, especially in a hospital environment. CHP initiated a Hand Hygiene Program in 2013. The slogan of this program is “Wash In, Wash Out” to remind all practitioners to clean their hands every time they enter and leave a patient room. Compliance was monitored and reported. Hand hygiene compliance rates have increased from about 70% in 2013 to over 98% today. It needs to be emphasized that this type of program requires constant reinforcement.
Antibiotics have transformed the practice of medicine. However, 20-50% of all antibiotics prescribed in the United States acute care hospital are either unnecessary or inappropriate, leading to increased drug side effects and antibiotic resistance. Antibiotic stewardship is a coordinated program that promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. As described by Newland and Hersh1, the core strategies of an antimicrobial stewardship program include (1) prospective audits with intervention and feedback, (2) formulary restriction and preauthorization, and (3) a multidisciplinary team. At CHP the Antibiotic Stewardship Program began in 2010 and has been very successful. For example, the use of one of the targeted drugs – vancomycin – has decreased by 25%. At a national level, institutions with Antibiotic Stewardship Programs have had a larger decline in antibiotic usage than hospitals without such programs.
Team-based care with the focus on communication between the provider team and the patient and family should be a focus area. At CHP “family-centered rounds” are the standard patient rounding technique where the patient and family are important members of the team. There is better awareness of the overall care plan provided by the medical team with increased discussion and planning about discharge date/time. In addition, hospitals should develop an environment to assure patient-centric and family-focused care. Examples of how to achieve this from CHP include flexible family visiting hours, a strong child life program, music therapy, and even therapy dogs. Consideration should be given to adjusting the physical environment of the hospital for patients and families, e.g. child-friendly decoration of x-ray and other imaging rooms, a library and business center for parent, and an outdoor “Healing Garden.”
Hospitals of the future should be prepared to accommodate and care for high acuity/critical care patients. Children’s Hospital of Pittsburgh moved to a new hospital in 2009. In that move, the number of critical care beds increased by 3%, but by 2016 that number has increased by about 10%. The Case Mix Index (CMI) at the hospital over this time increased from 1.44 to 1.70. A CMI difference of 0.1 significantly impacts hospital operation.
In the hospital of the future everything should be measured and reported with automation being key. The goal of these programs is the rapid identification of a clinical problem before it becomes critical. An example at CHP is the Early Warning System using the Pediatric Rothman Index. This index identifies a patient’s condition in real-time using an easy to understand composite score that is readily available from the Electronic Health Record. If significant change of a patient’s status is noted using the Rothman Index, a “Condition E” is generated, i.e. an Early EMR-based recognition of clinical deterioration, alerting the team that immediate action is needed. Other examples of automated identification of serious health problems requiring prompt attention include identification of a child in the emergency department who satisfies screening criteria for sepsis or a child with suspected abuse.
Pathways to Care are evidence-based clinical algorithms defining the best management of a clinical problem. These pathways provide a way to reduce variation and increase consistency with the ultimate goal of improved care and better outcomes. At CHP the pediatric surgical team developed a Pathway of Care for the management of appendicitis after noting considerable variation among the surgeons in the division. After implementation of the Pathway, average length of stay for uncomplicated appendicitis decreased by 5 days and for complicated appendicitis by 2 days. Pathways can also lead to cost savings. For example, in the year after implementation of the appendicitis pathway there was a cost savings of over $60,000. When multiplied by many different new Pathways in the hospital, there is potential for very significant decreases in cost of care.
Other immediate and long-term initiatives will be important for hospitals of the future to consider and plan for. For example, in this electronic age considerable attention needs to be directed to how to use the EMR, the internet, and social media to communicate with patients. For children of the future, there should be a major investment in research. Finally, hospitals need to carefully construct a strategic plan for the future which addresses timing of implementation of the policies and practices that will ensure the best patient care and the reputation of the hospital as a leader in the field.