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

Bilateral cued finger movements 23 year old medical student who, at dinner with friends one Friday night, had episode of transient right hand tingling and dysphasia. Went to ED and found to have left frontal mass. This pre-operative fMRI was performed to help plan surgery. Results show fMRI signal changes elicited by bilateral finger movements. Some of the signal changes directly overly shortest path to tumor. Surgeon therefore elected to come in via dorsal para-sagittal approach (from high just-to-left of midline and go down towards mass). Patient awoke without deficit, and has had no evidence of recurrence in the two years since surgery. Now a third year med student.

Translation Superhighway Pronovost

Tell stockdale paradox story Tell how josie and sorrel impacted hopkins retreat, gma, are you safer. That questions led to a commitment or compact Communication model. Much far too much is implicit complex organizations like geese flying need some simple rules and from them behavior will follow. Perhaps most important rule is harm is untenable,

The Safety of Healthcare 2000 -2005 Median Improvement : 2000-2005 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% Over 30% more patients received appropriate timing for antibiotics before and after surgery in 2005 than in 2004 National Healthcare Quality Report 2008 6

Disparities in Healthcare Quality are Staying the Same or Increasing Slide Presentation of the 2007 National Healthcare Disparities Report (NHDR). March 2008. Agency for Healthcare Research and Quality, Rockville, MD. Ht tp://www.ahrq.gov/qual/nhdr07/slides/dr07slides.htm *Make bigger so I can read National Health Disparities Report 2008 n=number of core measures

Will you commit to eliminate preventable harm and suffering in your unit, organization, state, or nation? Discus polio campaign.

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

ICU Safety Dashboard 2007 2008 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

Comprehensive Unit-based Safety Program (CUSP) Educate staff on science of safety http://www.jhsph.edu/ctlt/training/patient_safety.html Identify defects Assign executive to adopt unit Learn from one defect per quarter and implement teamwork tools The intervention we used to improve culture and learn from mistakes is the comprehensive unit based safety program. Your role in the csicu was as the executive who adopted that unit. You can tell some of the defects you surfaced. Pronovost J, Patient Safety, 2005

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 I want to highlight 5 strategies specifically because they are well supported by the evidence. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. we should use MBP during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over IJ or femoral sites. The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whether you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one and I would be happy to share with you our approach. What about hand washing? MMWR. 2002;51:RR-10

How does this make the world a better place? Ensure Patients Reliably Receive Evidence Senior leaders Team Staff Engage How does this make the world a better place? Educate What do we need to do? Execute What keeps me from doing it How can we do it with my resources and culture? Evaluate How do we know we improved safety? This is the model we used for learning change. It recognizes the technical (science) part and the adaptive (emotional attitudes part. Engaging people is adaptive work done locally by telling stories and showing current evidence of harm Educate is technical. What is the evidence Execute is adaptive and local. Given my resources, how do I ensure all patients reliably receive the evidence Evaluate is technical. We have to measure in a scientifically sound way Pronovost: Health Services Research 2006

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 Feedback performance many ICUs posted graphs of number of weeks without infection

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