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Voices for Safer Care

Insights from the Armstrong Institute

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Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

Re-engineering health care for safety and cost savings

Long-time intensive care nurse Rhonda Wyskiel (left) and engineer Alan Ravitz represent just a couple of the 18 professional disciplines involved with Project Emerge.

Despite spending $800 billion on technology last year, health care productivity is flat and preventable patient harm remains the third leading cause of death in the U.S.

One reason is that health care is grossly under-engineered: medical devices don't talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather than measured.

Other industries rely much less on heroism by individuals and more on designing safe systems and using technology to support work. Today a pilot’s cockpit is much simpler than 30 years ago; it is far more error-proof, and built-in defenses enhance safety. By comparison, hospital intensive care units, which contain anywhere from 50 to 100 pieces of separate electronic equipment, appear unchanged.

Changing this will require unprecedented collaboration between health care’s many stakeholders. That’s one reason why this fall the Armstrong Institute and the World Health Organization convened health care leaders, consumers, providers, regulators and private-industry partners to discuss such topics as how to design safer systems at the Forum on Emerging Topics in Patient Safety held in Baltimore.

One effort to design safer systems at Johns Hopkins is Project Emerge. Supported by a $9.4 million grant from the Gordon and Betty Moore Foundation, Emerge is tapping into the wisdom of a diverse team of engineers, nurses, doctors, bioethicists, and patients and family members — 18 disciplines in all from across Johns Hopkins University— to design safer care in ICUs.

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A blueprint for high reliability

Ensuring that patients who take beta blockers receive their heart medication before and after surgery is a best practice to prevent future problems. A workgroup at The Johns Hopkins Hospital is one of 40 teams across JHM focused on delivering such best practices.

Across health care, organizations constantly struggle with the challenge of achieving patient safety and quality successes on a large scale—across a hospital or network of hospitals. Too often, they are doomed at the start, because staff don’t even know what the goals are. In other cases, staff have limited capacity to carry out improvement work and few resources available to help them. Subpar performance is allowed to continue without any accountability, assuming that they know how well they are performing in the first place.

At Johns Hopkins Medicine, we are proud of an effort that has not only improved patient care, but has also provided a blueprint for how we can tackle any number of challenges in improving patient care—such as eliminating infections or enhancing the patient experience—across complex health care organizations.

Last week three hospitals within Johns Hopkins Medicine were recognized by the Joint Commission as “Top Performers” in patient safety and quality, for consistently following evidence-based practices at a very high level. Those hospitals—The Johns Hopkins Hospital in Baltimore, Sibley Memorial Hospital in Washington, D.C. and All Children’s Hospital in St. Petersburg, Fla.—benefitted from an organization-wide approach that enlisted local teams in problem solving, directed core resources to support those teams, and made units, departments and hospitals accountable for their performance.

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Rethinking how we think about preventing harm

Captain Sullenberger shared lessons that health care can adapt from aviation at the inaugural Forum on Emerging Topics in Patient Safety.

Last week the Armstrong Institute, along with our partners at the World Health Organization, had the privilege of hosting more than 200 clinicians, patient advocates, health care leaders and policy makers for our inaugural Forum on Emerging Topics in Patient Safety in Baltimore.

The event featured presentations by international experts in a dozen different industries, including aviation safety expert Captain Chesley “Sully” Sullenberger, a former space shuttle commander and the chief medical officer of the Centers for Medicare & Medicaid Services. Other speakers shared their expertise in education, sociology, engineering, nuclear power and hospitality to see what untapped lessons such fields may hold for health care.

Their collective expertise was breathtaking. What was even more impressive was the obvious enthusiasm and spirit of collaboration embodied by a group joined by a common and noble purpose: to overcome the complex challenges that allow preventable patient harm to persist.

At Johns Hopkins, we’ve already seen what’s possible when health care adopts best practices from other industries. Our work to reduce central line-associated blood stream infections (CLABSI) presents a powerful example. By coupling an aviation-style checklist of best practices to prevent these infections with a culture change program that empowers front-line caregivers to take ownership for patient safety, the program, detailed recently on Health Affairs Blog, has reduced CLABSI in hospital intensive care units across the country by more than 40 percent. Similar results have been replicated in Spain, England, Peru and Pakistan.

That effort succeeded because we challenged and changed paradigms traditionally accepted by the health care community. We helped convince teams that patient harm is preventable, not inevitable. That health care is delivered by an expert team, not a team of experts. And, most importantly, that by working together, health care stakeholders can overcome barriers to improvement.

But if there are to be more national success stories in quality improvement, I believe the health care community will need to examine a few of its other beliefs.

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A powerful idea from the nuclear industry

Where health care has fallen short in significantly improving quality, our peers in other high-risk industries have thrived. Perhaps we can adapt and learn from their lessons.

For example, health care can learn much from the nuclear power industry, which has markedly improved its safety track record over the last two decades since peer-review programs were implemented. Created in the wake of two nuclear crises, these programs may provide a powerful model for health care organizations.

Following the famous Three Mile Island accident, a partial nuclear meltdown near Harrisburg, Pennsylvania in spring 1979, the Institute of Nuclear Power Operators (INPO) was formed by the CEOs of the nuclear companies. That organization established a peer-to-peer assessment program to share best practices, safety hazards, problems and actions that improved safety and operational performance. In the U.S., no serious nuclear accidents have occurred since then.

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Patient Safety Summit: Four Years of Advancing the Science

At Johns Hopkins Medicine, we recently held our fourth annual Patient Safety Summit, a daylong gathering in which faculty and staff from across our health system share their work to reduce patient harm and foster a culture of safety. The event has quickly become a tradition, with more than 425 participants flocking annually to our East Baltimore campus to sample from a wide range of presentations and network with colleagues.

As I attended the summit, I was struck by how much our own internal patient safety movement has matured, and it gave me hope for the future of the larger patient safety effort.

When we held the first summit in 2010, the enthusiasm for patient safety was high, but the science was not always at the same level. While many of the poster presenters were excellent clinicians and staff who offered thoughtful suggestions on how to improve patient safety, their work was frequently weak on data, used simple methods and lacked theory.

This year’s summit featured 75 posters and 43 presentations, but the scope and quality of the science was breathtaking. Watch this video to hear highlights from this year’s poster presenters.

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Quality Measures: An SEC for Health Care?

If you have ever tried to choose a physician or hospital based on publicly available performance measures, you may have felt overwhelmed and confused by what you found online. The Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group, and the National Committee for Quality Assurance, as well as most states and for-profit companies such as Healthgrades and U.S. News and World Report, all offer various measures, ratings, rankings and report cards. Hospitals are even generating their own measures and posting their performance on their websites, typically without validation of their methodology or data.

The value and validity of these measures varies greatly, though their accuracy is rarely publically reported.  Even when methodologies are transparent, clinicians, insurers, government agencies and others frequently disagree on whether a measure accurately indicates the quality of care. Some companies’ methods are proprietary and, unlike many other publicly available measures, have not been reviewed by the National Quality Forum, a public-private organization that endorses quality measures.

Depending where you look, you often get a different story about the quality of care at a given institution. For example, none of the 17 hospitals listed in U.S. News and World Report’s “Best Hospitals Honor Roll” were identified by the Joint Commission as top performers in its 2010 list of institutions that received a composite score of at least 95 percent on key process measures. In a recent policy paper, Robert Berenson, a fellow at the Urban Institute, Harlan Krumholz, of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, and I called for dramatic change in measurement.  (Thanks to The Health Care Blog for highlighting this analysis recently.)

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A roadmap for patient safety and quality improvement

This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.

An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.

A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.

Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

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Ruling out the wrong diagnosis

A machine that detects minute eye movements that are difficult for most physicians to notice may be a more reliable and cost-effective way to diagnose stroke in patients with dizziness.

Although misdiagnosis may kill up to 80,000 annually—more people each year than firearms and motor vehicle accidents combined—you won’t find it on the list of the country’s leading causes of death.

Most Americans don’t realize how frequently well-meaning medical providers get it wrong. Just last year Johns Hopkins researchers found that one in 12 ICU patients die from something other than what they were being treated for. Aside from a handful of instances covered by the national media, misdiagnosis hasn’t received much attention from the public or the medical community. One such tragedy is the death of Rory Staunton, a 12-year-old boy who was treated for an upset stomach and dehydration instead of sepsis, a severe response to infection that requires immediate treatment with antibiotics. To make a complex diagnosis like sepsis, a doctor may need to assess a couple dozen different factors.

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Katie Couric, others keeping patient safety in the national spotlight

Maybe it's just wishful thinking, but it seems like we're reaching a critical mass where enough people are interested in improving patient safety that we can make a serious impact. In just the past week, several national media outlets have focused attention on this issue. At 4 p.m. Eastern today, I'll appear on a special segment of Katie Couric's program, "Katie!" that is devoted to the topic of medical mistakes. One takeaway from this program is that there are many things that patients and their loved ones can do to reduce the risk of medical errors and preventable complications.

In other news, the nationally syndicated public radio program Marketplace recently ran a segment about efforts by Johns Hopkins clinicians and safety experts to reduce harm in intensive care units. Listen to the program or read the story online to learn how the team is tapping clinicians, engineers, patients and families to design an ICU that is safer and more integrated.

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