Safety in numbers

Carol Haraden of the Institute for Healthcare Improvement spoke to Andy Brown, The Health Foundation's Web and Publications Editor, about her vision of patient safety.

Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing healthcare today. Up to 10 per cent of patients admitted to hospital, and 40 per cent of those admitted to critical care, acquire one or more infections while undergoing treatment. This affects over 1.4 million people worldwide. In England, there are over 100,000 cases of hospital-acquired infections per year, which are estimated to cost £1 billion and directly cause over 5,000 deaths (1). 

One organisation that is working to improve patient safety is The Institute for Healthcare Improvement (IHI). Based in Cambridge, Massachusetts, the IHI is a not-for-profit organisation which aims to improve healthcare throughout the world. The IHI has been working with The Health Foundation for the past three years on its successful Safer Patients Initiative, with a goal of improving patient safety in hospitals across the UK.

Carol Haraden is vice president of the IHI, where she is responsible for patient safety. On a recent visit to the UK, Carol spoke to us about her vision for patient safety and what the IHI was doing to implement it.

Bottom of the pile

Carol describes patient safety as being at the bottom of a hierarchy of patient needs. "If you were taking a flight and I said 'what would you like to see in an aeroplane?', you wouldn't even say 'my first priority is that we'd land'," she explains. "That's an assumption that you'd make. You might say bigger seats, better service or arriving on time. So you're looking at those characteristics of a system that most patients talk about, and that is equity, effectiveness, timeliness."

Unlike the airline industry, however, people now have to ask questions about some of the most basic assumptions about healthcare. "Patients will rarely say 'I want to prescribed the right medication'," Carol continues. "That's an assumption, but it's an assumption that frighteningly does not hold. More and more patients are having to back up and say 'I want to be sure I don't have the wrong leg cut off' when they never would have considered that before. We've always done wrong site surgery, it's just now we're talking about it publicly.

"People are really having to go back and think about their most basic requirements from healthcare," she says. "At the most basic level, if healthcare providers can't ensure that patients will come out of hospital alive, then none of the other treatments or services they provide will matter."

Five million lives

In the United States, the IHI recently launched the '5 Million Lives' campaign, an initiative to protect patients from 5 million incidents of medical harm over the next two years. This is building on the success of the previous '100,000 Lives' campaign, which enlisted over 3,000 US hospitals to tackle patient safety and saved an estimated 122,000 lives in 18 months.

"The 5 Million Lives campaign is not just about mortality, it's about harm reduction," Carol comments. "One big area we're looking at is superbugs such as MRSA and VRE. We know the cost in terms of human lives, disability and finances. Why we keep coming back to money, of course, is that there isn't an exhaustible pot. If we're spending money treating people with hospital acquired infections, it's going to come from somewhere else.

Central to the campaign is a focus on hand hygiene. "We've learnt from experience that this is not just about putting up alcohol dispensers," Carol says. "You can put a dispenser next to every bed and theoretically that should make a difference but if people don't recognise this as a problem, it won't make any difference.

"So we try to build that will by helping people to understand their accountability and helping them see the link between things like MRSA and what they do on a daily basis. What we need to do is change habits. It needs to be automatic, just like when you get in the car and you put on your seatbelt."

Carol points to the Safer Patients Initiative as a good model for how to measure hand hygiene. "You need to look at the number of opportunities for hand washing," she explains. "For five minutes a day you observe x number of opportunities and that becomes your metric. At the end of the day, you add those up and you have a sense of how many times that day you washed your hands, against the number of times you should have done it. You're looking to see that ratio improving."

Different systems

The IHI is working on projects to improve patient safety in the US, UK and around the world, giving Carol the opportunity to observe the strengths and weaknesses of different healthcare systems. She highlights the different approaches to clinical measurement in the US and UK as a key factor in improving patient safety.

"Where I see the biggest difference is that in the US hospitals collect data routinely throughout the year," Carol observes. "In the UK, the audit processes look at just a two or three month window when anything anomalous could be going on. It could be anomalously bad or anomalously good, but it's not an accurate picture of your organisation.

"Along with the measurement system comes knowledge of your capability. So we know that hospitals have a much greater sense of where their problems are in the States than they do here. Just because they know, doesn't mean they're necessarily any more interested in fixing them, but that self-knowledge is important."

One of the first tasks of the Safer Patients Initiative was therefore to build data collection systems. "In the UK at the moment, most data is for judgement - there's very little for improvement," Carol says. "With waiting list initiatives and star ratings, all the data you're collecting is going to be used either for or against you. So there's a real fear of data in the NHS. People think 'once we have it, someone's going to ask us for it, and they're going to use it against us'."

Carol is trying to change that mentality. "We talk about data for improvement, versus data for judgement. Nobody is going to see the data we collect except the individuals themselves and their cohort," she explains.

Class of 2004

This new approach is already bringing dividends. Carol highlights recently released results from the Safer Patients Initiative, which show impressive safety improvements at the first four UK hospitals that joined the scheme in 2004.

"In Luton and Dunstable, they've done a really great job with their outreach team." she says. "Their early warning scoring system has really improved their mortality rate. In Down Lisburn in Northern Ireland, they've done a tremendous amount of work in reducing their surgical site infections. This requires a lot of really tough changes but they're near 100 per cent right across the board.

"Conway's intensive care work has been outstanding," she continues. "They have virtually eliminated central line infections and substantially reduced rates of ventilator-acquired pneumonia. There are also decreases in length of stay and cost per case in the intensive care unit, all due to those reductions in infections.

"Finally, Tayside's prototype MRSA unit has reduced infection rates to near zero - as are several other units. The nurse at the orthopaedic unit, Marie Mitchell, declared an MRSA-free zone and put up signs to tell everybody. When I asked her 'what would you do if one of your patients was infected with MRSA?' she said 'I'd be personally devastated'. That's the level of accountability you need in a leader, because it sets the tone for the whole unit," Carol concludes.

References
(1) 'Clean Care is Safer Care: a worldwide priority', Didier Pittet and Liam Donaldson, The Lancet, 2006 (366; 1246-1247)