Here at Cooley Dickinson, as in many health systems, improvement of performance has been a front-line effort with some great results. Leaders in all organizations spend a lot of time looking across the whole place from the balcony, seeking to align work so that the whole system improves. Too often, improvement remains a localized event in an isolated area, dependent upon a few motivated individuals working hard and diligently. But the major outcome measures of care stubbornly do not move.
In teaching performance improvement, frameworks help organize and prioritize our work. They also help me understand "where I am," when leading or participating in a performance improvement team. A recent experience confirms for me the wisdom of using the framework to align work and accomplish significant whole system improvement.
There is controversy in the medical literature about the comparability of various measures of mortality. But there is no doubt that risk-adjusted death rates for diseases are important measures of the outcome of clinical care, and certainly have value to compare ourselves to our historic performance when we use the same methodologies.
Whole System Measures
At Cooley Dickinson, we use whole system measures. Then we drill down to the drivers of those whole system measures, seeking to understand where the greatest opportunities for improvement are, as that is where to focus to dramatically influence our outcomes. Last year, we determined that despite a better than average mortality rate across all illnesses we care for, the mortality rate for sepsis (bacterial infection of the bloodstream) was too high. Leaders in the organization like me, watching whole system measures, use the framework of improvement to ask the question "what is driving this outcome?"
Putting together people from the front lines, people who understand data from the quality department, and people in the middle of the organization who can influence resource allocation, we derived a list of the most important drivers of sepsis mortality. Clinicians challenged the data, and improved our measures by appropriately distinguishing mortality of those not expected to survive from those expected to survive. The performance improvement team identified eight aims that they postulated would improve sepsis mortality. In the framework, our critical care clinicians, led by a physician-nurse dyad, developed the will and ideas to make improvement in the drivers. Assisted by senior leadership executive sponsorship, and analysis through the quality department, they executed improvements across the eight aims. The passion of the clinician leaders engaged clinicians. They looked at processes outside of the critical care unit, to improve early detection and intervention.
Dramatically Improved Sepsis Mortality
Over an eight-month period stunning results occurred: The mortality rate from sepsis improved to 7.2%, which is 36% below expected and approximately 10 % better than the 17% national rate that the Centers for Disease Control reported in 2008. As hypothesized from the drivers, the overall mortality rate for the hospital as a whole, excluding palliative care patients, dropped from observed approximately equaling expected, to observed mortality 36% below expected. The smiles on the faces of our critical care staff, and the stories of improvement, confirm the magnitude of this change.
The framework for improvement emphasizes developing the will and ideas before executing. Observing the critical care team, I note that these dramatic results reinforced their enthusiasm for improvement and spilled over into other improvements, such as standardizing a massive transfusion protocol, and developing and implementing a post resuscitation hypothermia protocol to improve neurologic outcomes of patients after cardiac arrest.
The iterative interactions at multiple levels in the organization keep the improvement efforts aligned. These include senior leaders watching whole system measures, middle management and medical staff leadership seeing cross-functional improvement opportunities and continually updating the drivers, and front-line improvement teams standardizing and improving the care. I am proud to work in a system of improvement that works!
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