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The Journey to Enhancing Value for Patients
Peter Pronovost, MD, PhD, FCCMArmstrong Institute for Patient Safety and Quality
© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System
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I Will. . .
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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ICU CLABSI Rates per 1000 catheter days in US; 1999 and 2015
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01234567
ICU CLABSI1999
ICU CLABSI2015
Pronovost BMJQS 2015
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Do you have a Performance System to eliminate all harms
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• Purpose • Principles • Governance• Leadership• Management• Technology and Information
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Purpose of Healthcare
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To help people thrive; to prevent disease when possible, to cure when you cannot prevent; to care when you cannot cure, and all along to empathically and respectfully partner with patients, their loved ones and all interested parties to end preventable harm, to continuously improve patient outcomes and experience, and to eliminate waste in health care.
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Principles
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• I am humble, curious, and compassionate
• I respect, appreciate and help others
• I am accountable to continuously improve myself, my organization, and my community
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Board Quality Committee Functions like Board Finance Committee
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Armstrong Institute
Pronovost; Academic Medicine 2015
Local Performance Improvement Committees-
Execution
Workgroups-Share and Learn
Defines Standards, Monitors
Performance
Establishes Oversight and Accountability
JHM/Armstrong Institute Patient Safety and Quality
Board Committee
OJHP Quality & Safety Joint
Council
Outcomes (Value based purchasing, MU, ACO quality)
Value (Utilization, Choosing Wisely)
Patient Safety/Risk
(CUSP, Hand Hygiene, SAQ,
Risky Units)
Patient Experience (CG
CAHPS)
JHCP JHH / East Balt
Bayview
Amb
Johns Hopkins Medicine
(JHM) Board of Trustees
Sibley
Physicians Grou
p
Region
JHU Satellite
sites
ACH Amb Site
s
JHM Ambulatory Quality & Safety Governance
OJHP Ambulatory Oversight
Committee
Patient Safety/Risk (Ambulatory
Practice based
procedures, EOC,)
Signature OB
Kravet Academic Medicine 2016
Use the levers and adaptive leadership to strengthen the links
Responsibility, Role Clarity
and Feedback
Shared Leadership Accountability
Capacity Time and Resources
12Weaver; J Healthcare Management In press
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14ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Spheres of Quality Improvement Work
Organization of Work and Framework
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Declare and communicate goals
Report transparently and create accountability system
Engage clinicians andconnect in clinical communities
Create enabling infrastructure
MEASURESRisky providers, units & systems
WORKCUSPMindful organizingCulture measurement improvementEvent reportingSafety case
PATIENTSAFETY
MEASURESNational leader
WORKPMOWork teams
EXTERNAL REPORTING
MEASURESCAHPSNarratives
WORKCommon languagePFACsInclude patientsPatient and families educationCare coordinationFamily involved in decision-making
PATIENT EXPERIENCE
MEASURESQuality versus cost
WORKMeasure developmentPMOClinical CommunitiesSupply chain
VALUE
Pronovost, Academic Medicine 2015
Systems to Support Work
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LEAN
Analytics
Marketing and Communications
Learning and Development
PATIENTSAFETY
QUALITY MEASURE REPORTING
PATIENT EXPERIENCE
VALUE
Strategic Partnerships
Research
HEALTHCARE EQUITY
Clinical Communities
What are Clinical Communities?
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• Clinical communities are self-governing networks with broad entity representation who come together to identify and achieve our purpose
• Partner with patients and their loved ones to
• Eliminate preventable harms• Continuously improve patient outcomes
and experience• Reduce cost in healthcare delivery
Clinical Communities -Framework
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▪ Led by local physicians (1 academic lead, 1 community lead) with interdisciplinary membership that includes patients and families
▪ Set and communicate clear goals and measures
▪ Create infrastructure ( PMO) – provide vertical support for project management, peer learning, analytics, and robust process improvement
▪ Work collaboratively on quality improvement projects, empowered to make changes
Clinical Communities -Framework
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▪ Work towards standardizing evidence based practice through protocols to reduce variation in care
▪ Partner with value analysis and finance teams to reduce overutilization in supplies, imaging, medications and laboratory costs
▪ Share results frequently for data transparency
▪ Implement accountability / sustainability model
Clinical Communities
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▪ Joint Replacement▪ Blood Management▪ Spine▪ Surgery▪ Cardiac Surgery▪ ICUs▪ Congestive Heart Failure▪ Diabetes▪ Palliative Care▪ Cardiac Rhythm
Management
▪ Hospitalists (EQUIP)▪ Stroke▪ Craniotomy▪ Psychiatry and Behavioral
Sciences▪ Patient and Family
Centered Care▪ Patient Centered
Care/Maternal Health▪ Cleaning, Disinfection,
Sterilization▪ Medication Safety
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Red Blood Cell Use in JHH
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Transfusion in Hip and Kneereplacement across JHHS
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HIP VolumesJHBMC: 200 cases/yearSuburban: 500 cases/yearSibley: 500 cases/year
KNEE VolumesJHBMC: 300 cases/yearSuburban: 900 cases/yearSibley: 500 cases/year
HIP KNEE
~$2,000 per case reduction In variable direct cost at JHBMC
Spine
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• Accomplishments to date:• Development and implementation of ACDF pathway
• $3.3 million savings via vendor capping initiative
• Current initiatives:• Final review and implementation of Lumbar Fusion Pathway• Development of pathway for deformity procedures• Partnership with JHHC to develop a bundling strategy for United
Healthcare
Spine Results
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• JHH ACDF Order Set Utilization and ALOS
• Cost savings of $3.3 million due to vendor capping initiative
• Moving to Lumbar Fusion pathway
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Colorectal CUSP/ERASSurgical Site Infection Rate
ACS-NSQIP d t
Baseline 27%
Post-ERAS 6%
Colorectal Operating Room CUSP ERAS
Hospital Target 15%
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Colorectal CUSP/ERAS Value = Improved Outcome, Experiences and Cost
Wick et al. JACS 2015 in press
-26.4% (1.9 days)
-17.3% ($1,1897)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline (N=67)
Integrated RecoveryPathway (N=40)
HCHAPS (Colorecta
l)
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SSI Rates in JHH GYN ONC Colon Cases: 2013 - 2014
33%
0%
25%
11% 9%
33%
Interim Goal 2014 12%
IMPLEMENTATION OF SSI BUNDLE
Systems Engineering
Current Version – Worse
Early 1980’s
Aviation
ICU
Hand Calculations
Constant False Alarms
Unreliable Systems
Devices don’t share dataLow Productivity
ICU Current State
We must think differently about preventing harms
The 7 EMERGE Harms Delirium
ICU Acquired Weakness
Ventilator-Associated Harms
DVT / PE
CLABSI
Loss of Respect & Dignity
Care Unaligned withPatient Goals
Your “home” page is your Unit View
• How many patients are in your unit today?
• How many are “not in parameter”?
36ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
37ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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I Will. . .
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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