1. Saver, Cynthia RN, MS


The Institute for Healthcare Improvement estimates that hospitals participating in the 100,000 Lives Campaign saved more than 122,300 lives in 18 months. In this first of a two-part series, we'll examine how the results were calculated and the impact on quality and the bottom line.


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The largest football stadium in the world is in Ann Arbor, Mich., and has a capacity of 107,501. What if you could fill that stadium with people whose lives had been saved by you and your colleagues? The 3,103 U.S. hospitals enrolled in the 100,000 Lives Campaign not only filled the stadium, but overflowed it. The goal of the Campaign, spearheaded by the Institute for Healthcare Improvement (IHI), was for participating hospitals to save 100,000 lives between December 2004 and June 2006. On June 14, 2006, Donald Berwick, MD, MPP, president and CEO of IHI, announced the remarkable news-an estimated 122,300 lives were saved, exceeding expectations.


Nurse leaders were an integral part of the Campaign's success, according to Berwick. "It's been striking to me how crucial strong nursing leadership has been and how critical it's been to the Campaign," he says.


The IHI is a not-for-profit organization leading the improvement of healthcare throughout the world. It developed the 100,000 Lives Campaign to reduce morbidity and mortality in the United States through six interventions: deploy rapid response teams, improve care of patients with acute myocardial infarction, prevent adverse drug events through the use of medication reconciliation, and prevent central line infections, surgical site infections, and ventilator-associated pneumonia. You can read more about the Campaign in "Best-practice protocols: Every second counts," in the June 2005 issue of Nursing Management.


This month, we bring you an update on the results, the impact of the Campaign on quality and finances, and what the future holds. Next month, we'll hear from nurse leaders working on each of the six interventions about their experience with the Campaign, tips, barriers, and outcomes.


A successful initiative

It's not just lives saved that's impressive. Far surpassing its original goal of enrolling 2,000 hospitals, as of June 2006, 3,103 hospitals are participating in the Campaign. Approximately 80% of patient discharges in the U.S. occur in Campaign hospitals. More than one-third of the participating hospitals are implementing all six interventions, and 86% of enrolled hospitals have submitted mortality data to the Campaign.


An important force behind the Campaign's success has been the unprecedented cooperation among its 20 partner organizations-including government agencies (e.g., Centers for Medicare & Medicaid Services), associations (e.g., American Nurses Association), accrediting bodies (e.g., Joint Commission on Accreditation of Healthcare Organizations), health systems (e.g., VHA Inc.), and other organizations committed to quality improvement (e.g., The Leapfrog Group). The current phase of the Campaign is called "Celebrate!! Accelerate!!" Before we get to that, let's look at how IHI calculated lives saved.


Calculating "lives saved"

Calculating lives saved was a complex procedure that required analysis, extrapolation, triangulation, assumptions, and even a little speculation.


Here's a closer look at the process used to calculate the number of lives saved. The goal was to determine the difference between the number of expected hospital deaths (the number of deaths that would have occurred had no improvements in care been made since 2004) and the number of actual hospital deaths during the Campaign period. Expected death rates were calculated by applying a risk-adjustment factor to the 2004 mortality rates (which hospitals submitted to IHI) to account for the fact that the average hospital patient in 2005 and 2006 was "sicker" than the average 2004 hospital patient. These mortality risk-adjustment data were provided to IHI by CareScience, Premier, and Solucient. Not all hospitals submitted complete data through June 2006 at the time of the analysis, so IHI projected data for the missing hospital months. The average hospital submitted mortality data through March, and 14% failed to submit any mortality data.


On the basis of these calculations, IHI estimated that 122,300 lives were saved during the 18-month time frame. The 95% confidence interval, which describes the possible statistical error given the number of patients in the submitted data, was plus or minus 2,074 lives saved. More appropriate to consider, however, is the range of the result given different methodological choices, including differences among the three risk adjustment analyses and different ways of projecting out to non-submitted months of data. This range was between approximately 115,000 lives saved and 149,000 lives saved. Because the analysis was limited to in-hospital mortality, these numbers include patients who survived their hospital stay (who wouldn't have in 2004) but might have subsequently died in a nonhospital setting.


The complexity involved made the results an easy target for critics. Soon after the June 14 announcement, experts weighed in on their validity. Some of these experts were quoted in a June 29 article in The Wall Street Journal. One went as far as to compare the Campaign's extrapolation technique to estimating the divorce rate and waist size of an entire class by assessing those who showed up for a high school reunion.


Here's a summary of the criticisms of IHI's method of calculating lives saved:


- IHI shouldn't have used the performance of hospitals submitting mortality data to project the performance of hospitals that didn't submit mortality data.


- IHI relied on self-reporting of mortality data by hospitals, and hospitals might have submitted incorrect or manipulated data.


- IHI used risk-adjustment science, which is still a fairly young field and not considered to be infallible.



In addition to questioning the details of IHI's method for calculating lives saved, some critics have argued that it's inaccurate to attribute results to the Campaign alone because many initiatives are in progress (e.g., Leapfrog, the American Heart Association's "Get with the Guidelines" initiative, the Centers for Disease Control and Prevention guidelines). To this point, IHI has stated that it never intended or claimed to isolate the effect of the Campaign, for both practical and philosophical reasons. IHI recognizes that many hospitals were already working on initiatives to improve care; IHI also believes that all lives saved, regardless of the precise cause, are important to its mission.


Berwick admits the difficulties involved, but notes that all estimations were based on conservative figures. "We're not claiming perfection in this number and we're not claiming the Campaign did all this. But there has been a change and people's lives have been saved. I think the Campaign has been a major propeller for that change."


Although the Campaign has generated some debate, the fact remains that thousands of lives were saved. What's more, hospitals have boosted their efforts to improve the quality of care thanks to a new support structure, a benefit patients will see well into the future.


Quality care boosts bottom line

A little more than half of U.S. hospitals are enrolled in the 100,000 Lives Campaign. If you aren't working at one of them, it may be due to concerns about possible monetary investment in an era of cost containment. Fortunately, the Campaign costs little to implement. Berwick says the IHI's philosophy was to choose low- or no-cost interventions that could be implemented with existing resources. Certainly some monetary investment is needed to cover items such as time for training and meetings, but the costs are relatively small. In fact, Berwick says nurse managers claim the interventions reduce resource needs. When a hospital has a rapid response team, for example, patients either avoid an ICU stay or aren't as ill when they're transferred. That creates cost savings. More than 90% of hospitals implementing rapid response teams haven't hired new staff to do so.


Quality and the bottom line

If you're still not convinced, consider this: Quality care can actually increase your bottom line. That's the perspective of William J. Ward, Jr., MBA, from the department of health policy and management at Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Ward reminds us that most costs in a hospital are fixed, and nursing salaries make up the biggest fixed cost. For too long the mantra for managing financial challenges has been cost reduction, but Ward recommends what he calls "expense maximization"-optimizing the effectiveness of what you're currently spending to increase throughput.


To accomplish this, hospitals need to treat employees as assets, not expenses, which is how they've traditionally been viewed. Once you take this view, it makes sense that a hospital will maximize its financial return by increasing the number of patients employees care for. That doesn't mean piling on the work; instead it means reducing length of stay through improvements in quality.


Ward explains: "We've tried to push more patients through the pipe, but that just blocks it even more. Think of quality as unblocking that pipe, so that patients can go through faster. Length of stay goes down so you can take care of more patients." Decreased length of stay (LOS), combined with more patients, translates into revenues. Ward points out, for example, that if LOS falls from 5 to 4 days, a hospital can increase capacity by 20% for almost free. More supplies or another nurse or two may be needed to handle the additional fixed amount of work associated with each new patient, but this is more than offset by the boost in case revenue-revenue that goes straight to the bottom line. He cites the example of Norman Regional Hospital, Norman, Okla.: When it decreased LOS by 14%, the hospital saw a 14% increase in net revenue.


Naysayers may counter that some hospitals don't have more patients they can "run through the system." Ward says that, for the most part, only the very small hospitals (fewer than 25 beds) lack the pool of patients in the community for increased throughput. But it makes sense to concentrate on improving throughput and the bottom line for the majority of hospitals because their contribution to healthcare costs is significant. (See "Raising the bottom line" on page 38.)


Wider benefits

Although no one has studied perceived effects on organizational culture, we have evidence that indicates change has occurred. Kathleen Lynam, RN, CNAA, MPA, vice president of patient care services and chief nurse executive for Good Samaritan Hospital, Suffern, N.Y., surveyed staff members about their responses to the rapid response teams. The results showed significant improvements in many areas as a result of the rapid response teams, including increased critical thinking, reduced fear of critical changes in patient status, improved "sense of team," and reduced stress. Although the survey only included 22 respondents, it's consistent with the positive comments from the nurses interviewed for this article, who cited increased collegiality and greater staff satisfaction as a byproduct of the initiatives.


Improved staff satisfaction will have an impact well beyond reducing the financial costs of staff turnover. At a time when recruitment into the profession is critical, it can help create a positive image of nursing in the minds of potential recruits and retain older nurses in the profession.


Another effect of the Campaign interventions has been increased involvement of patients in the care of their loved ones. For example, at Columbus Regional Hospital, Columbus, Ind., families are encouraged to tell the staff if the head of the bed of the patient on a ventilator isn't elevated correctly. A red tape on the bed frame alerts both family and staff that the bed isn't elevated high enough.


Benefits extend into the community in the form of increased cooperation among stakeholders. The Arizona Hospital and Healthcare Association created a common medication form that patients can keep in their wallets. Some hospitals are touting programs such as rapid response teams in ad campaigns for the community and to recruit nurses. Researchers are currently working with the EMS community to collect data as to how long patients wait before calling for assistance; this data will help healthcare professionals improve care in their county.


Full implementation, full benefit

The IHI is calling for "six by seven," that is, all Campaign hospitals adopt all six interventions by January 2007. In conjunction with this are efforts aimed at sustaining the results. It's the next level of the Campaign-providing patients with the full benefit of full implementation. "If you do that," Berwick says, "you'll have something that will take your breath away, and you'll have something you can continue to build on."


Sharon Garretson, RN, BSN, says three steps are essential to sustainability: finding champions, gaining support from the executive team, and providing ongoing education. Garretson is manager for ICU and step-down at University Hospitals Health System (UHHS) Richmond Heights Hospital, Richmond Heights, Ohio. Her advice is consistent with that given in IHI's Getting Started Kit: Sustainability and Spread How-to Guide. It says you need to continue the quality team, set targets, and measure progress each quarter to build on accomplishments and continue to grow the program. This is no time to rest on past glory, it notes. You must continue the process and report the results at all levels, from staff to the executive team.


Organizations that sustain improvements share several characteristics. Strategies from the How-to Guide and the nurses we interviewed are listed for each of these.


[white diamond suit] Supportive management structure. The CEO and executive team can demonstrate their support for the program by assigning an executive sponsor and creating a "spread team" that helps with spreading the implementation of the interventions to all appropriate areas of the hospital. Members of the team might include midlevel administrators; senior medical, nursing, and pharmacy leadership; quality improvement leader; and representatives from units that have successfully implemented the interventions. Nurse leaders, as well as senior executive managers, also need to continue to convey the importance of the program and celebrate results. (See "Celebrate!!")


[white diamond suit] Structures to "foolproof" change. You need to find ways to make it at least difficult, if not impossible, for clinicians to return to the "old" ways of doing things. For example, requiring staff to complete checklists will cement changes.


[white diamond suit] Robust, transparent feedback systems. Keep as many people in the hospital as possible in the loop of performance results, which are compared to clear standards. You should also match the detail of information to each audience.



At Contra Costa Medical Center in Martinez, Calif., Anna Roth, RN, MS, assistant director for redesign, considers who should generate the information. Floor nurses receive succinct information of one paragraph or less from the nurse on the medication reconciliation team; the focus is only on percentages. She includes more detail for the chief executive, including breakdown of staffing and time costs. The physician on the team sends out communications to physicians, or the team leader writes the communication and the physician adds commentary. The bottom line is to tell people what it means to them and their practice.


Garretson notes that the feedback has to be relentless. "Go to the staff meetings of different units and tell them what the results are," she says. "Don't stop. Go every time so they are sick of you. Keep talking about it."


[white diamond suit] A shared sense of the systems to be improved. All stakeholders should understand what it is they're trying to improve and know how they contribute to the effort. One way to accomplish this is to create a flowchart showing the new process, which helps maintain sustainability. Kathy Duncan, RN, the Campaign's content expert for rapid response teams, reports that in some hospitals senior executives are assigned to visit units to see how the interventions are progressing and to identify any barriers. Sometimes, executives even serve on the teams.


[white diamond suit] A culture of improvement and a deeply engaged staff. A culture of pride in their work and its results promotes sustainability. At Tacoma General Hospital, Tacoma, Wash., time data for acute MI treatment is distributed not just to the staff, but even the telephone operators who make key calls. Jill Patak, RN, CPHQ, BSN, adds that it's important to bring new staff into the culture of the organization. "They have to understand how passionate we are about the interventions," she says. Patak is the quality engineering specialist at Our Lady of Lourdes Memorial Hospital, Binghamton, NY.



At Columbus Regional Hospital, conversations at the leadership level about the initiatives have led to widespread staff involvement. Leaders discussed the interventions with their staff members to see how they could support them, such as elevating the head of the bed to prevent ventilator-associated pneumonia. The clinical engineering leader talked with staff about the need to repair ICU beds promptly, and if housekeeping sees the head of the bed down, they notify the nursing staff.


[white diamond suit] Formal capacity-building programs. It's important toeducate executives and staff about applying quality improvement methods and creating a culture where improvement work is integrated into the day-to-day activity of the hospital. Advocate Health Care in Chicago, Ill., for example, has a formal training program in quality improvement and measurement techniques.



Moving forward

The 100,000 Lives Campaign has achieved remarkable success, but it's just the beginning. Keep watch for more interventions in the future. The Campaign benefits not just patients, but nurses too. As Berwick says, "If we play this right, the effect of this step is not just better care for patients but a better work life for nurses. Better care would make for a more joyous workforce."


Raising the bottom line

What can you, as a nurse leader, do to help your financial department see the value of the 100,000 Lives Campaign? Many of those interviewed for this story recommended bringing chief financial officers (CFOs) to the units so they can see what you're trying to accomplish.


Of course, it's also important to talk the business side of healthcare. Before meeting with your CFO, be sure you've asked finance for the average net revenue per case. Know the direct costs and number of cases, then do the math before and after to show effectiveness. Ward and Spragens say that if you can increase throughput by just a handful of admissions, you'll already have money going to the bottom line.



Ward Jr., WJ, Spragens L. 2006 VHA Research Series: Building a Financial Case for Clinical Improvement. VHA Inc. Available at: Accessed August 30, 2006. This monograph explains in detail the value of throughput improvement. A separate Process Improvement Case Flow Calculator can be downloaded from the same Web site.



Positive feedback is a common theme among those involved in the 100,000 Lives Campaign. Here are some examples of what hospitals have done to reward employees and recognize accomplishments. It's important to be creative and to vary the rewards as time spent on an initiative lengthens.


[white diamond suit] notices on the hospital Web site


[white diamond suit] stories in hospital newsletters


[white diamond suit] stickers or pins to reward nurses who called the rapid response teams


[white diamond suit] personal notes from the CNO and CEO to thank those who called the rapid response teams


[white diamond suit] certificates for coffee


[white diamond suit] valet parking pass


[white diamond suit] hospital quality awards


[white diamond suit] speaking about achievements at national meetings, creating pride in the staff


[white diamond suit] parties to mark milestones


[white diamond suit] bowls of LifeSavers brand candies on the unit





1. Bialik C. Studies on medical errors warrant a second opinion. Wall Street Journal. June 29, 2006. Available at: Accessed September 13, 2006.


2. Ward Jr. WJ, Spragens L. 2006 VHA Research Series: Building a Financial Case for Clinical Improvement. VHA Inc. Available at: Accessed August 30, 2006.