A structured approach to improving patient safety: Lessons from a public safety-net system

Denver Health is a public, academic health system, a model integrated system of care, and Colorado's principal safety-net institution. It serves a third of Denver's citizens including the most vulnerable, with 75% of its patients having incomes below 185 percent of the federal poverty level, two-thirds being ethnic minorities and almost one-half are uninsured. These patient characteristics embody health care disparities which typically impede the intended outcomes of a system's quality and safety interventions [1]. In reality, however, it was precisely these challenges which inspired Denver Health's leadership to embark upon a relentless journey towards quality improvement seven years ago [2]. Specifically, in consideration of a safety-nets limited resources in the setting of a population of socially disadvantaged and clinically complex patients, Denver Health's quality program was impelled to focus on creating programs to manage high-risk and high-opportunity clinical situations. Although Denver Health's renewed structured approach to quality and safety began seven years ago, a number of foundational elements were already in place including most importantly an integrated health care system which provides seamless continuity of care in the setting of a system of care which is staffed by an employed physician medical staff. This employed-physician model promotes alignment of goals across the enterprise and helps implement new quality and safety interventions [2]. Quality and safety interventions Some of Denver Health's recent programs to manage high-risk/high-opportunity areas include our unique rapid response system to prevent "failure to rescue" [3,4]. Indeed, a recent study of postoperative mortality stressed "failure to rescue," rather than the number of complications, as the key variable in explaining differences in mortality rates cross hospitals [5]. Using our "clinical triggers" to identify clinical deterioration, we were able to reduce our cardiopulmonary arrest rate and the number of patients requiring transfer back to an intensive care unit within 48 hours after having been previously transferred to a hospital ward [3]. In addition, we instituted hospitalist co-management for all patients on the orthopedic service, patients on low-volume inpatient surgical subspecialty services and patients on the psychiatry service with significant medical comorbidities. Moreover, a formal and robust antibiotic stewardship program was established. This approach spawned new programs including mandatory infectious disease consultation for certain serious infections, concurrent feedback to a prescribing team when multiple antibiotics were used for the same patient and formal infectious disease consultant rounds with intensive care unit teams. As a result Denver Health's antibacterial drug use was the lowest of thirty-five U.S. academic health centers reporting through the University Health System Consortium (UHC) [6]. Moreover, proper treatment of infections has increased - and adverse consequences from illness have decreased - for the highly virulent and prevalent staphylococcus aureus bacteremia [7]. Another high-risk condition in hospitalized patients, and the leading cause of potentially preventable death, is represented by venous thromboembolism (VTE). By designing and implementing an evidence-based risk-assessment tool and clinical practice guideline, embedded into admission order sets in the computerized physician order system (CPOE), the compliance with the VTE prophylaxis guideline was drastically increased [8]. Denver Health's performance in preventing venous thromboembolism climbed to the top 10 percent nationwide [8].