The Journey to Enhancing
Value for Patients
Peter Pronovost, MD, PhD, FCCM
Armstrong Institute for Patient Safety and Quality
© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System
I Will. . .
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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3
ICU CLABSI Rates per 1000 catheter
days in US; 1999 and 2015
7
6
5
4
3
2
1
0
ICU CLABSI ICU CLABSI
1999
2015
Pronovost BMJQS 2015
5
6
Do you have a Performance System to
eliminate all harms
• Purpose
• Principles
• Governance
• Leadership
• Management
• Technology and Information
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Purpose of Healthcare
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
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Principles
• I am humble, curious, and compassionate
• I respect, appreciate and help others
• I am accountable to continuously improve
myself, my organization, and my community
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Board Quality Committee Functions
like Board Finance Committee
Armstrong Institute
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Pronovost; Academic Medicine 2015
Johns
Hopkins
Medicine
(JHM) Board
of Trustees
JHM Ambulatory Quality
& Safety Governance
Establishes Oversight
and Accountability
JHM/Armstrong Institute
Patient Safety and Quality
Board Committee
OJHP
Ambulatory
Oversight
Committee
Defines Standards,
Monitors
Performance
Outcomes (Value
Workgroups- based
purchasing,
MU, ACO quality)
Share and Learn
OJHP Quality &
Safety Joint
Council
Patient
Experience (CG
CAHPS)
Local Performance
Improvement
CommitteesExecution
JHCP
JHH /
East
Balt
Kravet Academic Medicine 2016
Bayvi
ew
Amb
Patient
Safety/Risk
(Ambulatory
Practice
based
procedures,
EOC,)
Sible
y
Physi
cians
Grou
p
Regi
on
Patient
Safety/Risk
(CUSP, Hand
Hygiene, SAQ,
Risky Units)
JHU
Satel
lite
sites
Value (Utilization,
Choosing Wisely)
ACH
Amb
Site
s
Sign
ature
OB
Shared Leadership Accountability
Use the levers and adaptive leadership to strengthen the links
Responsibility,
Role Clarity
and Feedback
Capacity
Weaver; J Healthcare Management In press
Time and
Resources
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13
Spheres of
Quality
Improvement
Work
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Organization of Work and Framework
Declare and
communicate goals
Create enabling
infrastructure
Engage clinicians and
connect in clinical
communities
Report transparently
and create
accountability system
PATIENT
SAFETY
EXTERNAL
REPORTING
PATIENT
EXPERIENCE
VALUE
MEASURES
Risky providers,
units & systems
MEASURES
National leader
MEASURES
CAHPS
Narratives
MEASURES
Quality versus
cost
WORK
CUSP
WORK
PMO
WORK
Common language
Mindful
organizing
Work teams
PFACs
WORK
Measure
development
Include patients
PMO
Patient and
families education
Clinical
Communities
Care coordination
Supply chain
Culture
measurement
improvement
Event reporting
Safety case
Pronovost, Academic Medicine 2015
Family involved in
decision-making
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Systems to Support Work
PATIENT
SAFETY
PATIENT
QUALITY
MEASURE EXPERIENC VALUE
REPORTING E
HEALTH
CARE
EQUITY
LEAN
Learning and
Development
Analytics
Marketing and
Communications
Strategic
Partnerships
Research
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Clinical Communities
What are Clinical
Communities?
• 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
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Clinical Communities Framework
▪ 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
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Clinical Communities Framework
▪ 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
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Clinical Communities
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
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 Knee
replacement across JHHS
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HIP
HIP Volumes
JHBMC: 200 cases/year
Suburban: 500 cases/year
Sibley: 500 cases/year
KNEE
KNEE Volumes
JHBMC: 300 cases/year
Suburban: 900 cases/year
Sibley: 500 cases/year
~$2,000 per case reduction
In variable direct cost at JHBMC
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Spine
• 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
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Spine Results
•
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/ERAS
Surgical Site Infection Rate
Baseline
27%
Hospital Target 15%
Colorectal Operating Room CUSP
ACS-NSQIP
Post-ERAS 6%
ERAS
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Colorectal CUSP/ERAS Value =
Improved Outcome, Experiences and Cost
100%
90%
80%
70%
60%
-17.3% ($1,1897)
50%
40%
30%
20%
HCHAPS
(Colorecta
l)
Baseline (N=67)
10%
0%
Integrated Recovery
Pathway (N=40)
-26.4% (1.9 days)
Wick et al. JACS 2015 in press
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SSI Rates in JHH GYN ONC Colon Cases:
2013 - 2014
33%
33%
25%
IMPLEMENTATION
OF SSI BUNDLE
11%
9%
Interim
Goal
2014
12%
0%
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Systems Engineering
Aviation
ICU
Early 1980’s
Current Version
ICU Current State
Unreliable
Systems
Hand Calculations
Constant
False Alarms
Devices don’t share data
Low Productivity
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 with
Patient Goals
Your “home” page is your Unit View
• How many
patients are
in your unit
today?
• How many
are “not in
parameter”?
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I Will. . .
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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