Issue link: https://beckershealthcare.uberflip.com/i/273133
5 to achieve a compliance rate of 95 percent, and has sustained that level of performance for more than a year. In 2013, the organization-wide aver- age compliance rate was 98 percent. So how did the health system achieve these results? Reframing improvement goals To start, the hospital's leaders shifted the organiza- tion's prior goal of reducing HAIs to eliminating HAIs. "For a long time, our efforts with regard to [per- formance metrics] were around being in the 90th percentile plus," said Mr. Priselac, explaining that we're traditionally used the 90th percentile equat- ing to high performance. But, Mr. Priselac and other leaders at Cedars-Sinai realized that the theoretical best performance for HAIs was "0" infections, and that should be the goal for the organization, not a 5 or 10 percent reduction in the infection rate. With this mindset, the leaders worked to garner agreement among medical and staff leaders that hand hygiene was a critically important metric for the organization, if it truly intended to eliminate HAIs, says Michael Langberg, MD, senior vice president of medical affairs and CMO. "Many people believed HAIs were just a necessary part of being cared for in a complex environment, and we had to break through that way of think- ing," he adds. Ensuring accountability Medical staff and other leaders agreed that hand hy- giene was necessary to meet the organization's goals of zero infections, and hand hygiene compliance was incorporated as a performance measure. Employees or medical staff who routinely fail to follow the or- ganization's rules for hand hygiene — "gel in and gel out" every single time you enter and leave a patient room, regardless of whether or not your touched anything or anyone — may receive disciplinary ac- tion. In the most egregious of cases, a medical staff member could lose privileges for repeated failure to follow hand hygiene protocols. Medical staff was slower to adapt to the new per- formance measure than hospital employees. Ef- forts to gain buy-in from the physicians turned a corner after the system began distributing monthly data comparing medical staff compliance with other departments in the hospital. "The medical staff was seeing their number lag behind the rest of the organization," and the physicians ultimately adopted the measure, explains Dr. Langberg. Measurement Finding ways to reliably measure hand hygiene per- formance consumed most of Cedars-Sinai's hand hygiene work. While the system examined several automated systems, including those that featured personalized RFID identifiers, leadership deter- mined the technology would require too much time to implement and had too high an error level. "We look forward to a time when we will be able to deploy one of those automated resources in our environment reliably," explained Dr. Langberg, but added at the time Cedars-Sinai investigated automated options, the team felt such tools "were not ready for primetime." Instead, the organization opted to use trained nurse observers who use direct observation to measure compliance on a departmental and individual basis. Performance improvement Once the organization had a method to obtain re- liable data on compliance, it set out to implement and test various improvement initiatives. Lead- ers listened to front-line workers on where sani- tizer should be placed, and facilities staff ensured each patient room had a dispenser and that each dispenser was in the same place in every room. Processes were amended to ensure the dispensers were continually refilled. The fire department was even brought it to assess the safety of the volume and location of the dispensers, since hand sani- tizer contains alcohol, which is highly flammable. Dr. Langberg shared an example of a specific im- provement project the hospital undertook, which he says was only made possible after its shift to eliminating infections. During a performance improvement discussion, someone mentioned privacy curtains as a possible source of contamination. Its curtains were tested, and 30 percent of those cultured were found to contain antibiotic-resistant organisms. On top of that, the team discovered that when physicians and employees entered a room, they'd touch the privacy curtain subconsciously. That is, when asked if they'd touched the curtain, they said no, but observation revealed that a majority of had actually done so. The infection control team searched for literature on how to care for the screens, but it didn't exist. They replaced all privacy curtains in the organiza- tion with new ones with a bacteria-resistant coat- ing, and set protocols for how often the curtains would be laundered. The organization could have easily opted not to pursue a fix; it would have still had infection rate performance in the high 90 th percentile. But, its new focus on zero made any and all efforts to re- duce infection a priority. "If we were going to get to zero, we realized we had to eliminate this," says Dr. Langberg, even though it is impossible to know if or how eliminating the privacy curtain organisms would impact the overall HAI rate. "We'll never be able to prove it, but we really believe it played a role in the reduc- ing organism burden in our environment, which is critical to getting to the zero infection goal." The organization hasn't yet reached its goal of zero infections, but it is getting close. "We don't hold ourselves accountable only for rates of infection; we hold ourselves accountable for each and every infection we have," says Dr. Langberg. "They are really far and few between, but each of them is different and each one de- serves a root cause analysis." With any improvement effort, he says, a critical element for success is a broader conceptualization of the reason for the effort. "It wasn't about hand hygiene; it was about saving lives," he says. "Hand hygiene is the intermediate piece that is ultimately accountable for lives saved." n The Road to Eliminating HAIs: Hand Hygiene Improvement at Cedars-Sinai (continued from cover) The negotiated prices hospitals received from private health plans varied widely across markets; after accounting for the complexity of services provided, the researchers found the highest-price hospital in a market was typically paid 60 percent more for each inpatient stay than the lowest-price hospital. High-price hospitals tend to be larger, be major teaching hospitals and belong to health systems with significant market shares, according to the study. They also tend to offer specialized services such as level one trauma care. One possible explanation for the dissonance between outcome-based and reputation-based rankings for high-priced hospitals is that these hospitals provide high-quality care but treat patients who are in poorer health and are more socioeconomically disadvantaged. High-price hospitals could also have built their reputa- tions on tertiary care (which isn't factored into existing outcome measures) but don't excel at routine inpatient care. Or they might be highly esteemed among clinicians but are ultimately undeserving of their reputations. Further in- vestigation is needed to pinpoint the reason, according to the study. Study co-author Chapin White, PhD, a RAND Corp. senior policy researcher, says these findings have notable implications for health plans look- ing to contain costs by directing patients to pro- viders with lower prices. "There does seem to be an opportunity for health plans to steer patients to lower-priced hospitals without necessarily sacrificing on quality," he says. "There's more and more pressure to figure out some way to keep premiums down. There are huge price differences between different hospitals, and if a plan is sending people to lower-priced hospitals, it's going to be able to offer a lower premium." However, high-price hospitals' dominant mar- ket positions, large size and membership in even larger systems make it hard for payers to negotiate lower prices, according to the study. And, because high-price providers have the best reputations, creating narrow networks that exclude them would likely displease health plan enrollees and physicians, according to Dr. White and his co-au- thors. Furthermore, it could leave patients signed up for the plan without in-network access to spe- cialty services. For instance, few medium- or low- price hospitals provide level one trauma care. "If you're running a health plan and you're negotiat- ing with hospitals, there are going to be some hospi- tals, particularly big hospitals that offer specialized services, where it's going to be really difficult for the health plan to leave that hospital out," says Dr. White. According to Dr. White and his colleagues, it re- mains to be seen whether health plans will some- how be able to gain the upper hand in negotiating lower prices with larger hospitals that currently dominate their markets. If they don't, "radical approaches" such as restrictions on contracts be- tween hospitals and health plans and state-based rate setting may gain popularity as a way to rein in costs and health insurance premiums. n High-Price Doesn't Mean High-Quality for Hospitals (continued from cover)