1. Partnering for Quality Creating Reliability for Healthcare Peter Pronovost, MD, PhD Johns Hopkins University

2. Objectives To understand the need for creating reliability in healthcare To understand a model for creating reliability in healthcare To consider how to organize patient safety efforts To explore a vision for the future of patient safety

3. RAND Study Confirms Continued Quality Gap 10.5Alcohol dependence 22.8Hip fracture 40.7Urinary tract infection 45.2Headaches 45.4Diabetes mellitus 48.6Hyperlipidemia 53.0Benign prostatic hyperplasia 53.5Asthma 53.9Colorectal cancer 57.2Orthopedic conditions 57.7Depression 64.7Hypertension 68.0Coronary artery disease 68.5Low back pain Percentage of Recommended Care Received Condition McGlynn et al, NEJM 2003; 348(26):2635-2645

4. Central Mandate Local Wisdom Scientifically Sound Feasible x

5. ConcurrentRetrospective AutomaticDesired state ManualICU data system Current state Data Collection for Safety and Quality

6. Exercise Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average How smart am I How hard do I work How honest am I How kind am I How tall am I How good is the quality of care we provide

7. More than 5 years after IOM report No significant improvements -40% say quality of care is worse than 5 years ago - 38% feel it is the same - Only 10% feel it has improved How do we know patients are safer?

8. Model to Improve Reliability of Care Pick an important clinical area Identify what should we do? – principles of evidence-based medicine Measure if you are doing it Understand the process and context of work Ensure patients get what they should –Engage –Educate –Execute (reduce complexity, create redundancy, learn from defects) Evaluate whether outcomes are improved Health Services Research, 2006; Circulation (in press)

9. Creating Reliable Health Care Executive Leaders Team Leaders Staff Engage (adaptive) How Do I Make the World a Better Place? Educate (technical) What Do I Need to Know? Execute (adaptive) What Do I Need to Do? Evaluate (technical) How Will I Know I Made a Difference? © Quality and Safety Research Group, Johns Hopkins University

10. Ensure patients get what they should Summarize strategies in toolkit Engage –Make harm visible –Watch Josie video –Partner with other discipline experts –Tell stories –Post performance

11. Ensure patients get what they should Educate on evidence supporting the intervention –original literature, concise summaries and slide presentations –conference calls, newsletters, printed educational materials Execute –Simplify the system: protocols, order sets etc –Create redundancies: daily goals and others –Learn from defects Evaluate –Validated tools and dedicated data collection

12. Evaluate whether outcomes are improved Rigorous methods to minimize risk of inaccurate conclusions When inferences are made about the benefits of an intervention without acknowledging limitations, it is likely the inferences will be accepted as truth Consumers may believe the claims/ could be hazardous, at a minimum is misleading

13. Understand the process and context of work Observe staff performing the interventions to identify where the process may break down Walk the process to identify barriers in providing the intervention Listen to staff concerns regarding the intervention and identify what they stand to gain or lose from the improvement effort

14. Organizing Safety work Evaluating Progress in Patient Safety Translating evidence into practice (TRIP) Identifying and mitigating hazards Improving culture and communication Linking organizational characteristics to patient safety

15. As Leaders, How Can We Improve the Quality of Our Studies? First, have a clear and articulated QI plan (including hypothesis/objective, study design, sample size and explicit intervention and outcome measures)

16. As Leaders, How Can We Improve the Quality of Our Studies? Second, use data collection forms and procedures that have been tested for reliability Third, provide adequate training, supervision and quality assurance for individuals collecting the data and using the tools

17. As Leaders, How Can We Improve the Quality of Our Studies? Fourth: ensure data collected is appropriately managed to minimze the risk for data entry errors and support accurate analysis Fifth: Make certain you have the requisite knowledge and skill to appropriately describe, conduct and report the analyses. –If you dont have the in-house resources, partner with someone who does (local college or community resources)

18. As Leaders, How Can We Improve the Quality of Our Studies? Finally, Ensure that limitations and potential biases are transparently reported for all quality improvement projects

19. Vision for improving the effectiveness and efficiency of patient safety efforts Develop GAAP safety scorecard Create TRIP programs Create CAST in healthcare Understand how to improve culture and communication Link organizational characteristics to outcome

21. Requirements Build Capacity Create learning communities Develop sustainable financial model

22. Next Steps Commit to TPSC Collaborative State wide learning from Mistakes State wide Safety Culture Assessment and improvement Capacity Building Share what you learn globally