Theme Issue Editorial
Improving patient safety in intensive care units in Michigan

https://doi.org/10.1016/j.jcrc.2007.09.002Get rights and content

Abstract

Purpose

The aim of this study was to describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of an intervention on teamwork climate in intensive care units (ICUs) across the state of Michigan.

Materials and Methods

This study used a collaborative model for improvement involving researchers from the Johns Hopkins University and Michigan Health and Hospital Association. A quality improvement team in each ICU collected and submitted baseline data and implemented quality improvement interventions. Primary outcome measures were improvements in safety culture scores using the Teamwork Climate Scale of the Safety Attitudes Questionnaire (SAQ); 99 ICUs provided baseline SAQ data. Baseline performance for adherence to evidence-based interventions for ventilated patients is also reported. The intervention to improve safety culture was the comprehensive unit-based safety program. The rwg statistic measures the extent to which there is a group consensus.

Results

Overall response rate for the baseline SAQ was 72%. Statistical tests confirmed that teamwork climate scores provided a valid measure of teamwork climate consensus among caregivers in an ICU, mean rwg was 0.840 (SD = 0.07). Teamwork climate varied significantly among ICUs at baseline (F98, 5325 = 5.90, P < .001), ranging from 16% to 92% of caregivers in an ICU reporting good teamwork climate. A subset of 72 ICUs repeated the culture assessment in 2005, and a 2-tailed paired samples t test showed that teamwork climate improved from 2004 to 2005, t(71) = −2.921, P < .005. Adherence to using evidence-based interventions ranged from a mean of 25% for maintaining glucose at 110 mg/dL or less to 89% for stress ulcer prophylaxis.

Conclusion

This study describes the first statewide effort to improve patient safety in ICUs. The use of the comprehensive unit-based safety program was associated with significant improvements in safety culture. This collaborative may serve as a model to implement feasible and methodologically rigorous methods to improve and sustain patient safety on a larger scale.

Introduction

The need to improve quality and safety in health care is imperative. However, evidence is scarce regarding how to successfully improve [1], [2], [3]. The Institute of Medicine (IOM) created a compelling case for patient safety in its To Err is Human report [4]. However, consensus on patient safety goals, priorities, methods, and measures for safety initiatives is slow to emerge [4]. Although the IOM followed-up with a strategy for health system redesign in Crossing the Quality Chasm, evidence of improvement is still limited [5], [6], [7]. Assessing and improving safety culture is a safety strategy recommended by the IOM and National Quality Forum [8], [4].

The mission of the Keystone Center for Patient Safety and Quality, founded by the Michigan Health and Hospital Association (MHA), is to translate evidence into clinical practice. After researching the literature and attending patient safety conferences, the Keystone executive director (C.G.) approached the director of the Quality and Safety Research Group at the Johns Hopkins University (P.J.P.) to discuss collaboration on a grant to improve patient safety. In this article, we describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of the comprehensive unit-based safety program (CUSP) on teamwork climate in intensive care units (ICUs) throughout the state of Michigan, United States.

Section snippets

Study design

This project, called the Keystone ICU Project, was based on a collaborative model [9], [10] between the Quality and Safety Research Group, the MHA-Keystone Center for Patient Safety and Quality, and participating Michigan hospitals. An improvement collaborative involves participation of multiple health care organizations in a structured program aimed at improving an aspect of clinical care. It involves group meetings and conference calls to learn about best practices, share experiences, and

Results

At the project launch in October 2003, 108 ICUs representing 77 hospitals agreed to participate; 5 of 77 hospitals were out of state but part of a health care system with corporate headquarters in Michigan. In January of 2005, a 2-week enrollment window was provided for new hospitals or ICUs to join the project. There were 5 new Michigan hospitals with 19 ICUs that joined, bringing the total number of participants to 82 hospitals and 134 ICUs; data for the 19 ICUs are not reported here

Discussion

The Keystone ICU Project is the first rigorous effort to improve ICU quality and safety, which has been implemented throughout an entire state. In this study, baseline performance of evidence-based practices known to improve care for mechanically ventilated patients were inconsistently applied across ICUs reporting data. Unfortunately, we encountered a large degree of missing baseline data, which prompted a more detailed data quality control plan [16] and a discussion with the ICU teams. We

Acknowledgments

The authors would like to acknowledge the tremendous efforts of the ICU teams in Michigan (list of participating hospitals in Appendix 1). Their leadership and courage in this innovative effort reflect an unrelenting passion and dedication to improve quality and safety for their patients. We continue to be inspired by their example. We also thank Christen Fullwood from the Quality and Safety Research Group for her coordination of research efforts related to the SAQ affiliated. We also

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    This project was funded by an Agency for Healthcare Research and Quality (grant 1UC1HS14246) and the Michigan Health and Hospital Association.

    1

    Listed in Appendix 1.

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