FOR IMMEDIATE RELEASE
October 29, 2009 

St. John’s marks decade of progress in patient quality and safety since release of Institute of Medicine’s “To Err is Human” Report

In November, 1999, the Institute of Medicine released its landmark report, “To Err is Human: Building a Safer Health System,” that captured the attention of the public, policymakers and the media. The report was certainly a call to action for hospitals and health care providers.

Since that time, St. John’s Health System has taken continual improvement programs and made significant progress in efforts to improve patient safety and quality. Efforts have resulted in reduced mortality rates, sustained improvement in lowering infection rates and enhanced patient safety throughout St. John’s facilities.

St. John’s adopted the six aims detailed by the Institute of Medicine and employed them as principles for quality and safety initiatives. The six aims include:

Safety – avoiding injuries to patients from the care intended to help them.

Effective – providing services based on scientific evidence to those who may benefit, and avoiding underuse and overuse respectively.

Patient-Centered – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Timely – reducing waits and sometimes harmful delays

Efficient – avoiding waste, including waste of equipment, supplies, ideas, and energy

Equitable– providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

“We have taken numerous steps to develop a culture of safety within our organization,” said Dr. Alex Hover, senior vice president clinical excellence. “Including significant progress in creating an environment where nurses and doctors feel they can talk about mistakes and near misses without fearing retribution. This culture fosters a team approach to care, according to Dr. Hover, helps identify potential faulty systems, processes and conditions. Project teams work together to redesign health care processes so it is harder for people to do something wrong and easier for them to do it right.

The development of evidenced-based care practices has also been a core component of efforts to improve the quality of patient care. These practices help ensure the right care is delivered at the right time to the right patient.

St. John’s has been in the national spotlight in this area as one of 10 institutions in the country selected to participate in a national Centers for Medicare and Medicaid Services (CMS) physician group practice demonstration project. This 5-year project aims to show that focusing evidenced based care practices can improve care and save money. St. John’s has consistently hit its quality of care measure benchmarks while reducing the cost of Medicare for the community served according the CMS accounting over three years now.

Measuring and reporting out quality data indicators improves care, Dr. Hover said. “We’ve made a commitment to measure quality and safety through a series of scorecards that help us understand where our opportunities for improvement are. We have both internal measures and we compare ourselves to national benchmarks”

Dr. Hover suggested the following as having the most significant impact on improving quality and safety for St. John’s patients:

1.   Public commitment to having zero “never events.” Never events are those events that never should occur, like amputation of the wrong limb, or transfusing patients with the wrong blood type. This goal was adopted by all Sisters of Mercy (Mercy) Health System facilities with the goal being to have zero “never events”. St. John’s Health System Board of Directors over see our results in detail at quarterly meetings.

2.   Safety education and new safety processes and for physicians and nurses – just a few examples include: 1) an online incident reporting system that makes it for staff to report concerns for patient safety, 2 ) adoption of “red rules” a concept adopted from other high risk industries. Red rules are very specific instructions and steps that must completed each time for high risk procedures. Any nurse or staff can stop the procedure if they see a safety concern or missed step. 3) a series of regular actions (checklist) that must occur anytime a patient receives blood, or has invasive tests or treatments.

3.   Safety survey - is a periodic survey of all physicians, nurses and co-workers asking anonymously to rate the hospital and their departments for how well we are doing making our care better and safer. The results help prioritize our programs and projects.

4.   Use of other safety tools, such as Root Cause Analysis, that are analytical processes that allow hospitals to uncover why a problem may have occurred so we can prevent it in the future. Failure Mode Analysis is a way to look at a process prospectively that sheds light on what could go wrong in order to prevent it from happening.

5.   Adopting key evidenced/based care practices – “bundles” of specific care steps or treatments designed around types of patients with common conditions that have been shown to improve outcomes. If our physicians agree that certain treatments are to be given for a condition, then we look at how we deliver the care to be sure it happens each and every time.

6.   Adoption of an electronic health record (EMR) – is in its early stages but has the promise of helping clinicians with care delivery. Already our EMR has given clinicians the ability for to share information immediately on patients, provide alerts of drug allergies, and better coordinate care. While, we have some way to go to mature our use of the EMR, we think the ability to provide reminders and safety alerts in the future will further improve our care.

7.   Partnering with other expert organizations such as Mercy’s Safety Center and the Institute for Healthcare Improvement. - To speed up our transformation, we modify and adopt proven safety engineering from other industries and medical literature. We participate in safety programs that are Mercy –wide initiatives and we participate in learning projects with Dr Don Berwick’s Institute for Healthcare Improvement that is a medical industry leader in safety and quality of care improvement.

According to Jon Swope, Executive Vice President St. John’s Health System, “It’s a program and systemic change that has been our work over the past decade,” The commitment to safety has come from our system leadership, our Board of Directors, our nurses, physicians and co-workers.  Safety training and project teams dedicated to improvement have created this new culture of safety. Adverse events, unfortunately may still happen, but these initiatives have helped us greatly reduce that chance and we are working toward our goal of zero.”

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