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Using High Reliability Medicine to Improve Care

New approaches to COPD and pneumonia drive more consistent  treatment


Innovations in Pulmonology & Sleep Medicine - Fall 2018

Joanne McKell, MD


Division of Pulmonary, Critical Care and Sleep Medicine, UH Cleveland Medical Center; Clinical Assistant Professor, Medicine, Case Western Reserve University School of Medicine

The practice of High Reliability Medicine (HRM) is built on the shoulders of traditional quality initiatives, but introduces an additional element of consistent care and patient experience across a health care organization. “In addition to safety and cost, HRM also wants to make sure patients’ experiences are consistent—and consistently good—throughout the whole hospital system,” explains Joanne McKell, MD, Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center.

UH identified certain disease categories — including COPD and pneumonia — where patient experience varied between hospitals.

“COPD is a high-volume, in-patient admission and a condition that needs a lot more consistency in its treatment and how we address it in medical systems,” Dr. McKell explains. Furthermore, in 2015, the Medicare Hospital Readmissions Reduction Program began assessing penalties on 30-day COPD readmissions.

In response, UH has assembled a multidisciplinary, multi-hospital team to address inconsistencies.

Dr. McKell and other pulmonary team members have used HRM to develop several initiatives to improve patient care.

Updated order sets. These pre-defined templates provide evidence-based guidelines for treating specific diseases. They support decision making and ensure clinicians don’t miss important components of care when treating patients, thus improving patient outcomes. Using multidisciplinary input, UH has recently built several new order sets, and others are in development.

For example, one new order set describes an ideal plan for an inpatient stay for someone with a COPD exacerbation, including dietary considerations, physical therapy, oxygen and medications for comorbidities (30 percent of patients admitted to the hospital with a COPD exacerbation have four or more comorbidities).

Another is a pre-checked respiratory therapy evaluation and treatment protocol. This places an order in a respiratory therapist’s task list so they can assess patients and determine the best way to manage their symptoms. This may require changing respiratory medications. These order sets – and others – are readily available when a patient is admitted with COPD or pneumonia.

“Clinicians can be confident that this is what the best hospitals in the U.S. would use,” Dr. McKell says.

Revitalized patient education. Studies show that when patients can successfully manage their COPD — especially with inhaler device training — it reduces respiratory and all-cause hospital readmissions.1

UH has revitalized its outreach and education programs for COPD and pneumonia patients, including reinstating the Better Breathers Club, a bimonthly seminar that provides education and social opportunities for patients with lung disease. The pulmonary medicine team has also created a new smoking cessation booklet, which clinicians can request directly from the COPD order set, and is developing a Meds to Bed program through an outside company so pharmacists can directly help patients who use inhalers transition home after a hospital stay.

Assessing risk for re-admission. Approximately one in five patients is readmitted to the hospital within 30 days after an acute COPD exacerbation. An estimated 10 to 55 percent of these may be preventable.1

Using the LACE index, caregivers can assess patients’ risk for early readmission and can implement preventive interventions where needed. LACE evaluates four parameters: Length of stay, Acuity of admission, Co-morbidities and Emergency room visits in the last six months.

“Based on how likely a patient is to be readmitted, clinicians can increase the complexity of interventions,” Dr. McKell says. “These interventions don’t require a physician’s order and can make a difference in terms of patient readmittance.”

New notes template. Rodney Folz, MD, PhD, Chief, Division of Pulmonary, Critical Care & Sleep Medicine, University Hospitals Cleveland Medical Center, has designed an evidence-based, outpatient template for writing appropriate notes for COPD patients, Dr. McKell explains. “This gathers the most important information you need to make a decision, but also records, from visit to visit, a scoring system that allows you to assess how patients are responding to treatment.”

“We took a population of patients with pneumonia and COPD, who frequently have co-morbidities, and noticed there was a lot of risk for them falling through the cracks,” Dr. McKell says. “With HRM, we’ve used resources that are already available, such as information technology and patient educators, and we all got together to share ideas and resources to help these patients. With the help of some dynamic individuals, we’ve come up with some good ideas.

“We have already made strides towards having a more consistent COPD treatment plan here at Cleveland Medical Center and throughout the system,” she says. “Now, we are working to get the word out to everyone that these resources are available for patients.”


For more information about these initiatives or care for COPD patients, email Dr. McKell at



1COPD Readmissions Addressing COPD in the Era of Value-based Health Care. Chest. 2016 Oct; 150(4): 916–926.