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. . .

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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 7 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 8 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

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 9 Board Quality Committee Functions like Board Finance Committee

Armstrong Institute

Pronovost; Academic Medicine 201510 Johns JHM Ambulatory Quality Hopkins Medicine & Safety Governance (JHM) Board of Trustees

JHM/Armstrong Institute Establishes Oversight Patient Safety and Quality and Accountability Board Committee

OJHP Defines Standards, OJHP Quality & Ambulatory Safety Joint Monitors Council Performance Oversight Committee

Patient Outcomes (Value Patient Safety/Risk Workgroups- Experience (CG Value (Utilization, based purchasing, (CUSP, Hand Choosing Wisely) MU, ACO quality) CAHPS) Hygiene, SAQ, Share and Learn Patient Risky Units) Safety/Risk (Ambulatory Practice Local Performance based Improvement procedures, Committees- EOC,) Execution JHCP JHH / Bayvi Sible Regi JHU ACH Sign East ew y on Satel Amb ature Balt Amb Physi lite Site OB cians sites s Grou p Kravet Academic Medicine 2016 Shared Leadership Accountability

Use the levers and adaptive leadership to strengthen the links

Responsibility, Time and Role Clarity Capacity Resources and Feedback

Weaver; J Healthcare Management In press 12 13 Spheres of Quality Improvement Work

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 14 Organization of Work and Framework

PATIENT EXTERNAL PATIENT SAFETY REPORTING EXPERIENCE VALUE

MEASURES MEASURES MEASURES MEASURES Declare and Risky providers, National leader CAHPS Quality versus communicate goals units & systems Narratives cost

WORK WORK WORK WORK Create enabling CUSP PMO Common language Measure infrastructure Mindful Work teams PFACs development organizing Include patients PMO Engage clinicians and Culture Patient and Clinical connect in clinical measurement families education Communities communities improvement Care coordination Supply chain Event reporting Report transparently Family involved in and create Safety case decision-making accountability system

Pronovost, Academic Medicine 2015 15 Systems to Support Work

PATIENT HEALTH PATIENT QUALITY EXPERIENC SAFETY MEASURE VALUE CARE REPORTING E EQUITY LEAN

Learning and Development

Analytics

Marketing and Communications

Strategic Partnerships

Research

1 6 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

18 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 19 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

20 Clinical Communities

▪ Joint Replacement ▪ Hospitalists (EQUIP) ▪ Blood Management ▪ Stroke ▪ Spine ▪ Craniotomy ▪ Surgery ▪ Psychiatry and Behavioral ▪ Cardiac Surgery Sciences ▪ ICUs ▪ Patient and Family ▪ Congestive Heart Failure Centered Care ▪ Diabetes ▪ Patient Centered ▪ Palliative Care Care/Maternal Health ▪ Cardiac Rhythm ▪ Cleaning, Disinfection, Management Sterilization 21 ▪ Medication Safety Red Blood Cell Use in JHH

22 Transfusion in Hip and Knee replacement across JHHS

23 HIP KNEE

HIP Volumes KNEE Volumes JHBMC: 200 cases/year JHBMC: 300 cases/year Suburban: 500 cases/year Suburban: 900 cases/year Sibley: 500 cases/year Sibley: 500 cases/year

~$2,000 per case reduction

In variable direct cost at JHBMC 24 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

25 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

26 Colorectal CUSP/ERAS Surgical Site Infection Rate Baseline 27%

Hospital Target 15% Post-ERAS 6%

Colorectal Operating Room CUSP ERAS

ACS-NSQIP 27 dt Colorectal CUSP/ERAS Value = Improved Outcome, Experiences and Cost

100% 90% 80% 70% HCHAPS 60% -17.3% ($1,1897) 50% (Colorecta 40% 30% l) 20% Baseline (N=67) 10% 0% Integrated Recovery Pathway (N=40)

-26.4% (1.9 days)

Wick et al. JACS 2015 in press 28 SSI Rates in JHH GYN ONC Colon Cases: 2013 - 2014

33% 33%

25% IMPLEMENTATION OF SSI BUNDLE

Interim Goal 2014 11% 9% 12%

0%

29 Systems Engineering

Aviation

ICU

Early 1980’s Current Version – Worse ICU Current State

Unreliable Systems

Hand Calculations

Constant Devices don’t share data False Alarms 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”?

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 36 ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 37 ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 38 I Will. . .

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