When the Code White program at University Hospitals Case Medical Center (UHCMC) in Cleveland needed support to expand throughout the hospital, the board responded. Support from UHCMC trustees helped spread the program from one unit to all adult units using a dedicated staff of intensive care unit nurses. The result was a decrease in the hospital’s mortality rate and also increased engagement by practitioners and trustees.

New Direction for Quality Resources

UHCMC created Code White in response to an Institute for Healthcare Improvement’s 100,000 Lives Campaign challenge to deploy rapid response teams at the first sign of patient decline. Code White initially targeted patients who were showing clinical decline on the medical-surgical nursing floor to reduce the number of Code Blue patients, the number of patients returning to the ICU and mortality rates. The program quickly evolved into a proactive response with ICU-trained nurses assessing all recent ICU discharges and previous Code White patients. Now one Code White nurse is on-call 24 hours a day, seven days a week to respond to patients and support physicians and nurses.

William Annable, M.D., an ophthalmologist and chair of the board’s quality committee, says he was looking for a project the committee could get involved with when he heard about Code White. Annable had attended an IHI conference that shaped his thinking about the committee’s direction. For example, IHI suggests that hospital boards spend about 25 percent of their time discussing quality issues, and at the time, the UHCMC board was spending only about 5 percent of each meeting on quality.

Before identifying and suggesting supporting Code White, Annable attended Code White team meetings and talked with nurses on the floor. Then he spoke about the program to the board and board committees. “It required a change of direction and reallocation of resources,” Annable says. Hospitals have so many other reasons to spend money elsewhere, he notes. But “these kinds of projects can save you money. The quality committee was so enthusiastic,” he adds. In addition, several senior UHCMC leaders attended a three-day IHI course on the board’s role in quality and safety.

Trustees Gain Expertise

With the trustees’ support, Code White has successfully expanded and now includes 15 nurses dedicated to the program. The team also includes respiratory therapists, the medical ICU director, the vice president of medical-surgical nursing, the assistant head nurse of the medical ICU, the chief resident and quality department staff.

“Everyone is coming together as a collective team, taking care of patients,” says Tina Greig, R.N., medical ICU assistant head nurse and Code White team coordinator. “We definitely have built bridges and relationships between the different departments.”

Though the board does not run the program, “ultimately, resources go through the board,” Annable says. The process was an educational experience that will inform other board decisions, he adds. “Now [trustees] know the questions to ask. It never occurred to them to talk with nurses and patients.”

Results have been impressive. Code White has reduced mortality rates at UHCMC from 0.86 to 0.64 since 2005. The rate per 1,000 patient days of Code Blues has decreased, and the rate of Code Whites has increased. And about 55 percent of Code White patients remain on the floor rather than transferring to a higher level of care. With ICU patients receiving extra follow-up care, patient satisfaction has also improved.

Staff have benefited from improved collaboration and respect among all caregivers. Jan Dus, vice president of medical-surgical nursing, says, “It has made a difference in the lives of our patients and the lives of our practitioners.”

It also made a difference for and motivated trustees.

Cynthia Hedges Greising is a communications specialist at the AHA Quality Center, Chicago. Visit Hospitals in Pursuit of Excellence at www.hpoe.org to explore these and other topics.