621 November 2006 Volume 32 Number 11 The authors were invited by the Journal to prepare a com- mentary on the Institute for Healthcare Improvement���s 100,000 Lives Campaign, which had recently observed the end of its initial 18-month effort. O n December 14, 2004, Dr. Don Berwick, the well-respected founder and chief executive offi- cer (CEO) of the Institute for Healthcare Improvement (IHI), dramatically tossed down an unprecedented gauntlet at IHI���s annual Orlando meeting. Impatient with the pace of change in patient safety and quality and with vague goals (���some is not a number, soon is not a time,��� he chanted), he announced a ���cam- paign to save 100,000 lives��� in the next 18 months in American hospitals.1 The effort���s structure and focus would be modeled on a political campaign, complete with precinct captains and campaign nodes.2 Dr. Berwick had a point. Five years after the Institute of Medicine (IOM) reports on medical errors and health care quality3,4 action was largely driven by mandates (particularly Joint Commission on Accrediation of Healthcare Organization standards) and public reporting systems (whose modus operandi is largely to shame underperforming organizations into improvement). Conceptually, the idea of a campaign catalyzed by front- line workers ���doing the right thing��� was attractive. IHI, an organization with a large reservoir of established credibility, a highly respected and charismatic leader, and close connections to many hospitals and health care systems, was well positioned to lead such a campaign, despite (or perhaps because of) its absence of regulato- ry authority or formal role in the health care hierarchy. Eighteen months later, on June 14, 2006, IHI proudly announced that the campaign had far surpassed its goal, The 100,000 Lives Campaign: A Scientific and Policy Review Forum Robert M. Wachter, M.D. Peter J. Pronovost, M.D., Ph.D. Background: On June 14, 2006, the Institute for Healthcare Improvement (IHI) announced that its cam- paign to save 100,000 lives had far surpassed its goal��� by saving 122,300 lives. The Interventions: Although many of the campaign���s six ���evidence-based practices��� are supported by rela- tively strong evidence, the use of rapid response teams (the only intervention not already required or promoted by a major federal or Joint Commission initiative) is not. The ���Lives Saved���: Secular trends could account for many of the ���lives saved,��� which IHI acknowledges (and could have adjusted for, resulting in a markedly lower ���lives saved��� estimate). Moreover, IHI���s estimates of lives saved are dependent on the case-mix adjustment��� accounting for nearly three out of four ���lives saved.��� The actual mortality data were supplied without audit by the more than 3,000 participating hospitals, and 14% of the hospitals submitted no data at all. Policy Implications: IHI established and promoted a set of achievable goals for American hospitals and gener- ated unprecedented amounts of social pressure for hospitals to participate. This remarkable achievement should be studied by other organizations seeking to gen- erate widespread change in the health care field. Conclusions: Although the 100,000 Lives Campaign succeeded in catalyzing efforts to improve safety and quality in American hospitals, the promotion of rapid response teams as a national standard is problematic, and methodologic concerns regarding the ���lives saved��� calculations make it difficult to interpret the campaign���s true accomplishments. Article-at-a-Glance Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations

622 November 2006 Volume 32 Number 11 by ���saving 122,300 lives.��� Although IHI���s background materials were replete with caveats,5,6 its press release7��� and the accompanying media coverage8,9���was not. The clear message was that the campaign and its six ���evi- dence-based interventions��� (Table 1, above) had led to this remarkable reduction in national mortality. In this article, we examine the 100,000 Lives Campaign from a scientific and policy perspective. We begin by considering the scientific underpinnings behind the campaign���s six ���planks��� and go on to analyze the validity of the campaign���s claim to have saved 122,300 lives. We end with a discussion of the policy implications of and the lessons learned from the campaign. The Interventions As the campaign���s focal point, IHI chose ���evidence- based practices��� in six clinical areas (���planks���), prac- tices whose widespread implementation would, presumably, result in the saving of 100,000 lives in 18 months. The discussion on IHI���s Web site regarding how these planks were selected, whether the practices were based on national priorities, and whether evi- dence as well as costs and benefits would favor their use is limited perhaps unsurprisingly, the six interven- tions appear to be ones that the organization had focused on (including creating tools to support imple- mentation) in the past. In fact, many of the practices promoted by the IHI campaign are supported by relatively strong evidence, including strategies to avoid ventilator-associated pneu- monia, central line infections, surgical site infections, and mortality after acute myocardial infarction (AMI Table 1). The evidence supporting medication reconcili- ation to prevent prescribing errors is more limited, and its relative importance among the various strategies to prevent adverse drug events (for example, computerized order entry and decision support, pharmacists on the wards) is uncertain.10 Interestingly, in precampaign esti- mates of the likely number of lives saved by virtue of implementation of the six interventions, the largest impact was projected to come from the implementation of rapid response teams, an intervention with reasonably high face validity but whose only randomized trial showed no benefit.11 Because the quality improvement and patient safety external environments are so active, many of these planks��� practices were already being promoted (or man- dated) by other organizations. For example, the acute MI and surgical site infection practices are part of both the Joint Commission���s and the Centers for Medicare & Medicaid Services (CMS)���s hospital quality measure sets.12 Medication reconciliation was posted on the Joint Commission���s Web site for field review in April 2004��� and was approved in May 2005 as a 2006 Joint * IHI, Institute for Healthcare Improvement JCAHO, Joint Commission on Accreditation of Healthcare Organizations CMS, Centers for Medicare & Medicaid Services NQF, National Quality Forum. ��� Institute for Healthcare Improvement: IHI Announces that Hospitals Participating in 100,000 Lives Campaign Have Saved an Estimated 122,300 Lives (press release). http://www.ihi.org/NR/rdonlyres/1C51BADE-0F7B-4932-A8C3-0FEFB654D747/0/UPDATED100kLivesCampaignJune14milestonepressrelease.pdf (last accessed Aug. 30, 2006). ��� Institute for Healthcare Improvement: 100,000 Lives Campaign: Alignment with National Healthcare Improvement Initiatives. Dec. 8, 2005. http://www.ihi.org/ NR/rdonlyres/CC960DDD-2BB3-41C1-9D56-B957876C9C1B/0/AlignmentWithNationalHealthcareImprovementInitiatives.pdf (last accessed Aug. 30, 2006). �� Authors��� assessment, based in part on Shojania K.G, et al.: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality, AHRQ Publication no. 01-EO58. http://www.ahcpr.gov/clinic/ptsafety/ (last accessed Aug. 30, 2006) and other literature. Table 1. The Six Practices (���Planks���) in IHI���s 100,000 Lives Campaign* Practice No. of Participating Hospitals��� Other Major Organizations Promoting/Mandating Practice��� Strength of Evidence�� Rapid Response Teams 1,781 None Relatively Weak Medication Reconciliation 2,185 JCAHO Weak���Medium Prevent Central Line Infections 1,925 JCAHO Strong Prevent Surgical Site Infections 2,133 JCAHO, CMS Strong Prevent Ventilator-Associated Pneumonia 1,982 JCAHO, CMS Strong Evidence-Based Care for Myocardial Infarction 2,288 JCAHO, CMS, NQF Strong Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations