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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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”?

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I Will. . .

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY