• Article
  • January 13, 2014

4 Quality Improvement Ideas Hospitals Can Implement

These children's hospital improvement teams led remarkable initiatives that are changing the way their hospitals work, from culture to communication.

Children’s hospitals are distinct in the specialty care they provide to children, but they face the same issues that plague the entire health care industry: patient discharge delays, care variation, avoidable medical errors and communication breakdowns between providers. These issues cost hospitals, patients and families far more than money. While one person with a vision can drive change, it takes a team to make real improvement stick, especially in a large system. Four children’s hospital improvement teams stayed the course—over several years—for something they believed would make a difference for their patients. The Children’s Hospital Association is proud to recognize these hospitals for their important contributions to pediatric health care, and their case studies could help your hospital achieve similar results. Meet the 2013 Pediatric Quality Award winners: Cincinnati Children’s Hospital, Duke Children’s Hospital, Seattle Children’s Hospital, and Nationwide Children’s Hospital. 

Overall winner and waste reduction category winner 
Eliminating discharge delays

Bed capacity management is a critical issue for hospitals because inefficient discharges impact patient flow, slow care and increase costs. But when patients and their families are ready to check out at Cincinnati Children’s Hospital Medical Center, they’re not waiting around to get back to their lives. Previous projects at the hospital focused on discharging a certain percentage of patients at a specific time of day to free up beds. However, system inefficiencies persisted leading to delayed admissions and transfers. 

In 2011, unpredictable discharges and lengthy delays were still roadblocks for efficient patient flow. A longer than necessary length of stay (LOS) meant higher costs for everyone involved. The project team set out to develop standard discharge criteria for 11 common inpatient diagnoses based on available evidence and expert consensus. Today, this information is embedded in the electronic medical record allowing for a new discharge process that is focused on patient needs first, discharging them when they are medically ready. And this new process is a reflection of the hospital’s commitment to making things easier for families. “We may work on many different things, but if it doesn’t work for families—a core principle—we have to change,” says Christine White, M.D., MAT. 

Now, nurses can monitor and signal when patients meet discharge goals. Physicians can better prioritize early rounding. Interventions streamline pharmacy prescription filling processes and improve discharge efficiency. Communicating patient needs became consistent between all care providers, regardless of time of day. Today, at least 80 percent of eligible patients are discharged within two hours of meeting criteria. “The project was focused on patient needs first, so we discharge when patients are ready, not when we need the bed,” White says. By decreasing waste associated with inefficient discharges, the new process uncovered substantial cost savings to families, health plans and the hospital. More existing beds are available for higher acuity patients. And decreased LOS supports the global aim of reducing cost of care. 

With these changes, Cincinnati Children’s improved patient flow and decreased costs. As a result, the hospital saw a 38 percent increase in patients discharged within two hours. This resulted in a $5.9 million estimated cost savings. “We made assumptions about how things should work, but until we walked through it ourselves and experienced the process, we couldn’t see how it impacted our patients,” White says. “We always need to work from the patient’s perspective.” 

Clinical care category winner 
Improving rounds with communications interventions

Communication errors and teamwork breakdowns are the leading causes of medical errors, resulting in poor outcomes, prolonged LOS and higher costs. To combat this, Duke Children’s Hospital in Durham, N.C., sought to improve communication during daily rounds and reduce medical errors. These efforts led to a 34 percent increase in provider satisfaction and 82.7 percent team agreement with physicians’ stated daily goals. “Rounding happens everywhere, but people don’t do it effectively,” says Kyle Rehder, M.D., assistant professor, Division of Pediatric Critical Care Medicine. “We’re not taught how to do it. Communication is considered a native skill—you’re either good at it or not. We haven’t looked at how to actually develop the skill.” To solve the communications issues, the project team started by taking pediatric intensive care unit (PICU) staff members back to the basics of daily rounding. It’s often the only time the entire team meets to discuss a patient’s plan of care. Communication is especially critical as health care providers of different disciplines and training levels transition care, and breakdowns were causing preventable medical errors. Within nine months, the rounding approach changed provider behaviors and the PICU culture of safety. “The faces of caregivers might change, but we know that care will remain the same,” Rehder says. 

With minimal resources and common sense interventions developed by a multidisciplinary group, the project team developed a consistent process that put key providers on the same page. These initiatives include a new resident daily progress note format, a performance improvement dashboard, and use of a bedside whiteboard to document daily goals. The process also encouraged families—who were previously excluded from rounds—to express concerns and ask questions about the plan of care. 

Team agreement on goals increased 25 percent by removing common communication barriers, such as bedside nurses multitasking during rounds and interruptions during patient presentations. Additional communications, such as the inclusion of bedside nurse input or reading orders back also helped the unit reach its goals. The unit started to take ownership of the process, as modeled during one chaotic week when several errors were made. Nurses tied the errors back to a variation from the protocols, and they submitted reports to demonstrate patient impact. 

Organizational transformation category winner 
Standardizing care protocols with clinical pathways

Standardizing care means pediatric patients consistently receive the safest and most effective care for their conditions. Seattle Children’s Hospital is an example of how reduced variation in care can decrease costs. The hospital now has 39 clinical pathways in use, and 67 percent of practitioners have used one or more of the pathways. “Standard processes are sometimes viewed as robotic processes that smother the creative process,” says Darren Migita, M.D., pediatric hospitalist. “But we’ve found just the opposite. By building your foundation on standard work, you can see very quickly what is effective and what is not—this fosters creativity rather than stifling it.” 

Every child is different, but often the diseases aren’t. Evidence-based practices—interventions tested and proven to work—mean pediatric patients consistently receive the safest and most effective care for their conditions. But a lack of clinical care standards hampered Seattle Children’s ability to identify improvement opportunities. Individual variation in practice made it difficult to analyze data trends and understand which interventions were most effective. With a mission to reduce variation and improve patient safety in mind, Seattle Children’s began building clinical pathways in 2008. Five years later, 39 pathways guide providers in treatment plans for patients with a predictable clinical course. The guidelines standardize care for 13 medical specialties and six different surgical subspecialties. They also incorporate crossdiagnosis and cross-setting pathways that standardize treatment at every point of care. A patient is considered “on pathway” if he or she meets the defined patient population definition and the pathway-specific orderset is activated. Every pathway demonstrates improvement along the Institute of Medicine’s Dimensions of Care, which promotes using evidence-based practices to strengthen clinical systems. 

This multiyear project has helped Seattle Children’s health care providers reduce variation that could be the underlying cause of patient harm, but the effort is far from over. Reducing variability in care remains a core focus throughout the organization, with 16 additional pathways in queue. This work has the potential to change the way other children’s hospitals approach patient care. “Standardization is truly the mother of improvement,” Migita says. 

Patient safety category winner 
Moving to no preventable harm

In almost every industry, getting to zero errors is a lofty aspiration. In health care, it means patient harm never happens. For Nationwide Children’s Hospital in Columbus, Ohio, zero harm was the only appropriate goal. To achieve this, Nationwide launched an initiative to prevent hospital-acquired harm—a serious issue impacting every hospital—and expanded its quality improvement infrastructure to accommodate more than 150 harm-related projects. The result was that over a three-year period, the hospital reduced its serious safety event rate (SSER) by 83 percent, preventable harm events by 55 percent, and risk-adjusted all cause hospital mortality by nearly 40 percent. In addition, the hospital decreased harm-related costs by $1.8 million—a 22 percent reduction. Safety and teamwork scores significantly improved, too. The hospital has sustained these results for more than a year. “As detection and reporting systems improved, we began to hear about more things than we did before,” says Richard Brilli, M.D., chief medical officer. “People are willing to change their behavior and habits if they have a sense that someone cares, and the fixes actually result in better outcomes.” 

To eliminate all preventable harm that could result in serious consequences for patients—from hospital-acquired infections to pressure ulcers—the project team executed a simultaneous attack on all eight domains of harm, and it adopted the characteristics of a high-reliability organization. At the start of the project, more than 500 significant harm events were detected (including serious safety events) in just one year. The numbers reaffirmed the importance of patient safety and provided a strong foundation for learning. Nationwide selected error prevention tools that formed the basis of the Error Prevention Basic Training Course provided to 8,000 employees and Leadership Methods Training for 600 hospital leaders. Four years later, the hospital has dramatically changed patient safety protocols to show consecutive months of zero errors in multiple domains. 

To achieve these goals, it comes down to transforming outcomes for every patient Nationwide treats. With staff awareness and training, clinical variation decreased, errors became less frequent and outcomes improved. The hospital’s commitment to causing zero harm remains a strong underlying message in everything team members do. “Our patients are safer, no doubt about it,” Brilli says. 

Making strides

These stories—and 82 other projects—show how children’s hospitals are making changes that put patients first. From preventing discharge delays to standardizing care protocols, hospitals made strides in making patients safer. When it comes to solving problems in their organizations, they stand out for their commitment to doing things differently.

Send questions or comments to magazine@childrenshospitals.org.