Funded in part by the Health Foundation in the U.K., the collaboration between researchers at the University of Pennsylvania, Johns Hopkins University and the University of Leicester has led to a deeper understanding of how patient safety initiatives like the Michigan program can succeed.
“Explaining Michigan: developing an ex post theory of a quality improvement program” by Mary Dixon-Woods and Emma-Louise Aveling of the University of Leicester, Charles Bosk of the University of Pennsylvania and Christine Goeschel and Peter Pronovost of Johns Hopkins University is published in the June edition of Milbank Quarterly.
The researchers found that one of the Michigan program’s most important features is that it explicitly outlined what hospitals had to do to improve patient safety, while leaving specific requirements up to the hospital personnel. A critical aspect of the program was convincing participants that there was a problem capable of being solved.
“It was achieved by a combination of story-telling about real-life tragedies of patients who came to unnecessary harm in hospital and using hard data about infection rates,” said co-author Charles Bosk, a professor of sociology in Penn’s School of Arts and Sciences and a senior fellow in the Center for Bioethics at Penn.
“We knew this program worked. It not only helped to eliminate infections, it also reduced patient deaths,” said program leader Peter Pronovost of the Johns Hopkins University School of Medicine, named one of Time Magazine’s 100 most influential people in 2008 and a MacArthur Fellowship recipient. “The challenge was to figure out how it worked”.
Infection rates were continuously monitored at hospitals participating in the program, making it easier for hospital workers to track how well they were doing and where they needed to improve.
The authors conclude that that there are important lessons for others attempting patient safety improvements. Checklists were an essential component but not the most important component of the Michigan program.
“It was much more than that,” said lead author Mary Dixon-Woods, professor of medical sociology at the University of Leicester. “It involved a community of people who over time created supportive relationships that enabled doctors and nurses in many hospitals to learn together, share good practice and exert positive pressure on each other to achieve the best outcomes for patients.”
The Michigan program, also known as the Keystone study, was designed to minimize the risk of patients getting catheter-related bloodstream infections in intensive care units. Each year, about 80,000 patients in the U.S. get these infections. Between 30,000 and 60,000 of them die. During the 18-month period when the Michigan program was implemented in 103 hospital intensive care units, infection rates dropped 66 percent, resulting in estimated savings of 2,000 lives and $200 million.