International team works out secrets of one of world's most successful patient safety programs

A team of social scientists and medical and nursing researchers in the United States and the United Kingdom has pinpointed how a programme, which ran in more than 100 hospital intensive care units in Michigan, dramatically reduced the rates of potentially deadly central line bloodstream infections to become one of the world's most successful patient safety programmes.

Funded in part by the Health Foundation in the UK, the collaboration between researchers at the Johns Hopkins University, the University of Leicester and the University of Pennsylvania, has led to a deeper understanding of how patient safety initiatives like the Michigan programme can succeed.

"Explaining Michigan: developing an ex post theory of a quality improvement programme" 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 2011 edition of Milbank Quarterly.

"We knew this programme worked. It not only helped to eliminate infections, it also reduced patient deaths," said programme leader Peter Pronovost of the Johns Hopkins University School of Medicine, who was named as one of Time Magazine's 100 most influential people in 2008 and was the recipient of a MacArthur Fellowship, or 'genius grant,' from the John D. and Catherine T. MacArthur Foundation. "The challenge was to figure out how it worked".

The researchers found that one of the Michigan programme'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 programme was convincing participants that there was a problem capable of being solved together.

"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.

Infection rates were continuously monitored at hospitals participating in the programme, 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 necessarily the most important element of the Michigan programme.

"The programme was much more than a checklist," 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."

"What we have learned is that it is the local teams that deliver the results", said Dr Bosk. "But they need to be well supported by a core project team, who have to focus on enabling hospital workers to get things right. That means providing them with scientific expertise to justify the changes they are being asked to make, and standardising measures so they are all collecting the same data. It also means trying to figure out why simple changes that make life better are so difficult for health care delivery systems to do. Getting the whole programme to work, rather than compliance with a single one component, is the key to making health care safer for patients."

"No one discipline has the answer to patient safety problems. We have to bring together contributions from clinical medicine and the social sciences to make real progress in this area" added Dr Provonost. This month, Dr. Pronovost was named director of Johns Hopkins' newly formed Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality.

1. Explaining Michigan: developing an ex post theory of a quality improvement programme" by Mary Dixon-Woods (University of Leicester; Charles Bosk (University of Pennsylvania); Emma-Louise Aveling (University of Leicester); Christine Goeschel (Johns Hopkins University) and Peter Pronovost (Johns Hopkins University) is published in the June 2011 edition of Milbank Quarterly. One of the leading US academic journals in health policy, Milbank Quarterly has been published for over 80 years.

2. The Michigan study (also known as the Keystone study) involved a comprehensive programme to minimize the risk of patients getting catheter-related bloodstream infections in Intensive Care Units (ICUs). Each year, around 80,000 patients in the US get these infections, and between 30,000 and 60,000 of these patients die. When the programme was implemented in 103 ICUs in Michigan for 18 months, infection rates dropped by 66%, resulting in estimated savings of $200 million and 2,000 lives saved. The results were published in the New England Journal of Medicine on December 28, 2006. A recently published follow-up study in the British Medical Journal compared hospital mortality in patients admitted to the Michigan ICUs before, during, and after the programme. Patients in hospitals participating in the Michigan programme were significantly more likely to survive a hospital stay.

3. Mary Dixon-Woods, Professor of Medical Sociology, and Emma-Louise Aveling, Research Associate, are both based at the Social Science Research Group in the School of Medicine in the University of Leicester. Rated in the top 20 UK universities, University of Leicester has a pioneering reputation in the area of patient safety and quality of care. The Research Group's work on patient safety is supported by the Health Foundation, a London-based charitable foundation working to improve quality of healthcare.

4. Peter Pronovost is a professor and director of the Quality and Safety Research Group at the Johns Hopkins School of Medicine in Baltimore, USA. He leads the World Health Organization's evaluation work to improve patient safety measurement and leadership globally, and serves in an advisory capacity to the World Alliance for Patient Safety. He was chosen by the editors of Time Magazine as one of their 100 most influential people in 2008. He was also, in 2008, named a MacArthur Foundation fellow, an award given to "talented individuals who have shown extraordinary originality and dedication in their creative pursuits and a marked capacity for self-direction". These fellowships are also known as "genius awards".

5. Charles Bosk's work on patient safety is supported by a Health Investigator Award from the Robert Wood Johnson Foundation and Veterans Affairs Health Services Research and Development Service.

6. Christine Goeschel was the Michigan lead for the ICU project prior to joining the Pronovost research team at Hopkins in 2006.

7. The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK. For more information visit www.health.org.uk

1. Mary Dixon-Woods, Professor of Medical Sociology, University of Leicester. Email: md11@le.ac.uk. Tel: + 44 116 2297262

2. Peter Pronovost, Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Quality and Safety Research Group. Email: ppronovo@jhmi.edu Tel: + 1 410 5023231

3. Charles Bosk, Professor of Sociology, University of Pennsylvania. Email: cbosk@sas.upenn.edu Tel: : + 1 610-212-1738

4. Christine Goeschel, Assistant Professor, Quality and Safety Research Group, Johns Hopkins University. Email: cgoesch1@jhmi.edu 410 955 0034(o);