Originally posted December 3, 2018 by |Dr. Elizabeth Adams
I recently heard a colleague remark that achieving zero hospital acquired conditions is an impossible feat; a rather futile effort at best. Having worked in healthcare as a nurse and executive for almost 30 years, the notion of zero harm is worth further reflection, after all there has been a tremendous amount of work dedicated to preventing hospital acquired conditions, and I have held grieving family members in my arms after the death of a loved one, and sat at their bedside after a preventable hospital injury.
The Joint Commission has been advocating the idea of healthcare adapting methods from high-reliability organizations in other industries, like air travel, nuclear power and amusement parks, for several years. These are industries where Zero Harm is taken very seriously, as an expectation, not merely a flimsy inspirational goal or buzz word. Mark Chassin, the CEO of The Joint Commission remarked that no one in healthcare is happy where the industry is on quality improvement. Chassin urges, “The lesson for healthcare is not to be satisfied with modest improvements. Aiming for zero harm is the first step toward achieving it.” I have to agree with his aim as aspiring for less than zero harm, implies that the patients who have suffered harm were not statistically relevant.
John was 34 years of age at the time of his death. He was the type of guy who would light up a room, with joy and laughter. He once shared with me that “life is what you make of it”, and he lived true to this moral. He was a beautiful, talented person with dreams and aspirations. He went to an outpatient clinic where he had a peripheral inserted central catheter (PICC) implanted in his arm to receive antibiotics; less than a week later he experienced fever, chills and nausea. He was later found laying on his bathroom floor unconscious. He was transported by ambulance to a local hospital where he was found to have staphylococcal sepsis. Whomever had inserted his PICC line introduced staph into his blood stream, and this ultimately led to his death. Every patient who has suffered from a hospital acquired condition has a face and name. Surely, everyone who has had a loved one in the hospital desires zero harm; no one believes their loved one should be the exception to Zero Harm. I did not expect my brother would die at the age of 34 from a preventable infection, most likely caused by poor competency, or lack of attention to rigorous standards to prevent infections.
So, is Zero Harm a futile or worthy goal? There are organizations who have achieved zero central line associated blood stream infections (CLABSI), Sutter Rose in California went 7 years without a CLABSI, an active participant in work related to High Reliability, and partnership with The Joint Commission. Since the inception of the Zero Harm Campaign, according to AHRQ, an estimated 125,000 fewer patients died in the hospital and approximately $28 billion in health care costs were saved as a result of reductions in Hospital Acquired Conditions. The greatest results have been achieved in organizations with a commitment to Zero Harm and have participated in work by The Joint Commission and The Agency for Healthcare Research and Quality. work directly related to the Zero Harm campaign.
The journey to Zero Harm must remain a constant vigilance grounded in evidenced based research, and a commitment to high reliability. Highly Reliable organizations have leadership who are deeply committed to Zero Harm, a fully functional culture of safety, and processes that are hardwired to keep patients safe. These organizations are never comfortable with complacency, they are relentless in their pursuit to keep their patients safe, and look for opportunities to go above and beyond for their staff’s success and patient safety. They adopt the mindset that one patient, not a statistic or number, is too many to have a hospital acquired condition. These organizations are highly transparent, and even bold enough to put the patient’s picture up during staff meetings, and call them by name when they have suffered from a hospital acquired condition. They share lessons learned and ask their teams directly, “what are your going to do to keep the next patient safe?” Then, they relentlessly monitor, measure and work to improve outcomes. These are the organizations who can achieve Zero Harm for your family and mine.
Again, every patient has a name and a face; they are trusting us in their care. Making a 100% commitment to keeping our patients safe is a worthwhile endeavor. This week, my little brother had a PICC line placed to treat a surgical site infection caused by Staph that he most likely picked up in an ER, or in the operating room during his surgery. I am reassured by the progress made in the Surviving Sepsis campaign; we have made tremendous success in identifying, and rapidly treating sepsis over the last 20 years since my older brothers death. No one is immune to the risk of a hospital acquired infection, the impetus is on the organization and team members to maintain safety, to stand guard for safety.
In two days, I will be flying to New Orleans and I pray that the airline and pilot have a 100% commitment to Zero Harm and rigorously work to achieve and maintain safety. When you work with your healthcare teams, ask who is your “John” or brother to safeguard and ensure 100% commitment to quality care at all times, and evaluate your organization culture of safety and journey to High Reliability; are you comfortable with your culture of safety and if not, what changes need to take place.