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Seeing a Way Forward Peter Pronovost, MD, PhD Johns Hopkins University.

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Presentation on theme: "Seeing a Way Forward Peter Pronovost, MD, PhD Johns Hopkins University."— Presentation transcript:

1 Seeing a Way Forward Peter Pronovost, MD, PhD Johns Hopkins University

2 Bilateral cued finger movements


4 Translation Superhighway Pronovost


6 The Safety of Healthcare Median Improvement : All Selected Measures (117)1.9% Heart Disease (n= 16) 5.6% Cancer (n=15)3.6% Maternal & Child Health (n=12) 1.5% Safety (n=25)1.0% Diabetes (n=9)0.6% National Healthcare Quality Report 2008

7 Disparities in Healthcare Quality are Staying the Same or Increasing n=number of core measures National Health Disparities Report 2008


9 Will you commit to eliminate preventable harm and suffering in your unit, organization, state, or nation?

10 Are the citizens of Tennessee less likely to harmed? How do we know?

11 ICU Safety Dashboard How often did we harm (BSI) How often do we do what we should How often did we learn from mistakes % Needs improvement in Safety climate Teamwork climate Pronovost JAMA 2007

12 Comprehensive Unit-based Safety Program (CUSP) 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter and implement teamwork tools Pronovost J, Patient Safety, 2005


14 Interventions to prevent Blood Stream Infections: 5 Key Best Practices Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines MMWR. 2002;51:RR-10

15 Senior leaders Team leaders Staff EngageHow does this make the world a better place? EducateWhat do we need to do? ExecuteWhat keeps me from doing it How can we do it with my resources and culture? EvaluateHow do we know we improved safety? Pronovost: Health Services Research 2006 Ensure Patients Reliably Receive Evidence

16 Ideas for ensuring patients receive the interventions Engage: stories, show baseline data Educate staff on evidence Execute –Standardize: Create line cart –Create independent checks: Create BSI checklist –Empower nurses to stop takeoff –Learn from mistakes: review infections Evaluate –Feedback performance –View infections as defects

17 Break Through Idea Technical versus Adaptive I thou versus I it Material versus relationship


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