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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Taking Patient Safety to the Next Level Peter Pronovost, MD, PhD 1.

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Presentation on theme: "© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Taking Patient Safety to the Next Level Peter Pronovost, MD, PhD 1."— Presentation transcript:

1 © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Taking Patient Safety to the Next Level Peter Pronovost, MD, PhD 1 The Armstrong Institute for Patient Safety & Quality

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5 Pronovost NEJM 2006: Pronovost BMJ 2010: Sawyer CCM2010 CLABSI Rates in 103 Michigan ICUs

6 Michigan ICU Safety Climate Improvement * “Needs Improvement” - Safety Climate Score <60% CCM 2011

7 Impact of Statewide Quality Improvement Initiative on Hospital Mortality Lipitz: BMJ 2011

8 ICU ClABSI Down 60% across the U.S. CDC. MMWR 2011, 60 (8):243-248.

9 Measure and Improve Patient Outcomes CUSP 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools Translating Evidence Into Practice (TRiP) 1.Summarize the evidence in a checklist. Wash your hand, clean skin with chlorhexadine, avoid femoral site, use barrier precautions, ask daily if you need the catheter 2.Identify local barriers to implementation 3.Measure performance 4.Ensure all patients get the evidence Engage Educate Execute Evaluate www.hopkinsmedicine.org/ armstronginstitute

10 Fractal- common goal

11 What Have We Learned Work must be informed by science different problems require different methods Work must be led by Clinicians Work must be guided by valid measures Work must be modified to fit local context Harm must be seen as a social problem capable of being solved Platform to deliver programs must combine e learning, data collection and reporting, social learning, and CME or MOC Armstrong Institute for Patient Safety and Quality 11

12 Armstrong Institute CLABSI Initiative Annual Hospital Survey of Patient Safety (HSOPS) Clinical Registry of CLABSI Data Comprehensive Unit Based Safety Program (CUSP) Monthly Team Checkup Clinical Communities of Practice & Tools for Improvement

13 Peer Driven QI Through Communities of Practice Topic Based Clinical Communities of Practice Share Best Practices and Results Invite All Care Team Members to Participate

14 Roll Up Performance Data Across Unit, Hospital, or Initiative View and Analyze Measure & Survey Performance

15 System (INCOSE): noun \sis-tuhm\ A system is a construct or collection of different elements that together produce results not obtainable by the elements alone. The elements, or parts, can include people, hardware, software, facilities, policies, and documents; that is, all things required to produce systems- level results.

16 Armstrong Institute for Patient Safety and Quality 16

17 Armstrong Institute for Patient Safety and Quality 17

18 Armstrong Institute for Patient Safety and Quality 18

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20 What Can you Do? Erase lines and collaborate –Safety and education aligning Ensure competency in certification Develop robust MOC program –Include learning from defects –Include clinical communities –Include peer to peer review Create moral framework for learning and accountability Armstrong Institute for Patient Safety and Quality 20

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22 Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley, JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-2020. Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli D, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. British Med J 2010;340:c309. DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Pronovost PJ. The Rhode Island ICU Collaborative: A model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide. Qual Saf Health Care 2010;19:555-561. Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson S, Goeschel CA, Pronovost PJ. An intervention to reduce ventilator-associated pneumonia in the ICU: Collaborative cohort study. Infect Control Hosp Epidemiol 2011, in press. Sexton JB, Berenholtz SM, Goeschel CA, Watson S, Holzmueller CG, Thompson DA, Hyzy RC, Marsteller JA, Schumacher K, Pronovost PJ. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med Feb 2011. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Retrospective comparative analysis. Brit Med J 2011;342:d219. Pronovost, PJ, Marsteller JA, Goeschell CA. Preventing Bloodstream Infections: A Measurable National Success Story: Health Affairs 2011;20:628-634 Dixon-Woods, M, Bosk, C, Goeschel CA, Pronovost PJ. Explaining Michigan: Milbank Quarterly 2011 Selected References

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