armstrong institute - johns hopkins hospital · patient safety expert peter pronovost (right) was...

Armstrong InstItutef o r PAt I e n t s A f e t y A n d Q uA l I t y

2012 Annual Report

The Armstrong Institute was announced in May 2011 with a $10 million gift from C. Michael Armstrong (left), chairman of the Johns Hopkins Medicine Board of Trustees. Patient safety expert Peter Pronovost (right) was named the institute’s director shortly thereafter.

Armstrong Institute Annual report 2012

Few areas of health care are more exciting today than the work of improving patient safety and quality.

While we once faced skepticism, the health care community recognizes that there is a true science to this work. Our field sees that rigorous design, measurement and evaluation are as important to methods of care delivery as they are to testing the efficacy of a new drug. Most importantly, health care has begun to believe that when our work is informed by science and embraced by clinicians, we can elimi-nate harms once thought inevitable.

Yet, despite a few breathtaking achievements, there is little proof that patients are safer overall. Patients too often do not receive the therapies that evidence shows they need. Mistakes still cause too much harm. Health care costs continue to skyrocket.

We must take our research, actions and results to the next level.

That was the challenge we took on in spring 2011, when the Armstrong Institute for Patient Safety and Quality was formed, bringing many Johns Hopkins experts under one umbrella. Our goal: to eliminate preventable harm, to improve patient outcomes and to reduce error and waste in health care delivery by partnering with providers, patients and families.

But how will we rise to the occasion? The institute’s work in its first year shows the blueprint of where we are headed.

» Mine the wisdom of the health care team. Safety and quality interventions work best when they are driven by clinicians, rather than imposed on them. We have formed five clinical communities, made up of experts across Johns Hopkins Medicine, who are tackling challenges in fields such as intensive care and hospitalist medicine. We engage frontline clinicians to identify the hazards that they see as most threatening to their patients, and we give them tools to fix those problems. We treat patients and families as members of this team and design care around their needs.

» Build a cadre of safety and quality champions. We are creating organiza-tional capacity—trained health care professionals with supportive infrastruc-ture—so that professionals can lead and sustain safety and quality efforts. The institute has designed a tiered training model for professionals at all organiza-tional levels. The pieces of that program are coming together, whether they are

Advancing the science, building the team, changing the results

Armstrong Institute Annual Report 2012 • 1

C. Michael ArmstrongChairman, Armstrong Institute for Patient Safety and Quality Chairman, Board of TrusteesJohns Hopkins Medicine

Peter J. Pronovost, M.D., Ph.D.Director, Armstrong Institute for Patient Safety and QualitySenior Vice President, Patient Safety and QualityJohns Hopkins Medicine

educational modules providing fundamental safety concepts for all employees, or a new Patient Safety Certificate program designed for unit- and clinic-level managers. We have also vastly expanded the ranks of institute-affiliated faculty who can contribute to research and lead safety and quality projects.

» Expand scientific partnerships. Clinicians alone cannot solve health care’s challenges. Broad expertise—in such areas as human factors, organizational psychology and behavioral economics—must also be brought to bear. The new faculty, from across our health system and university, will add to the diversity of the institute’s approaches. We’re bringing disciplines together in ways that have never been done before. Novel collaborations with industry, for example, could potentially bring great progress to the science and quality of care delivery.

Our first year was encouraging. We published more than 75 papers and were awarded 14 grants. Our contract and grant funding for fiscal year 2013 is about $12 million—66 percent higher than the previous year—and counting. We trained more than 650 health care professionals in skills they can use to improve the safety, quality and efficiency of health care. Yet the best measure of success is the welcom-ing, supportive reception that this new organization has received from our medi-cal communities at Johns Hopkins and elsewhere. We look forward to continued collaboration on this important journey together.

2 • Armstrong Institute Annual Report 2012

TAble of ConTenTs

Improving outcomes and ValueWe work with all members of the health care team, including patients, to prevent harm and improve outcomes at the lowest possible cost. With Johns Hopkins Medicine as our laboratory, we develop science-based interventions that can be adopted elsewhere.

truly on the same team.............................................. ............4

unraveling the onion................................................................6

frontline Wisdom.......................................................... ...........8

Consensus and Community...................................................10

excellence at our Core..........................................................11

building CapacityWe enhance organizations’ ability to drive change that improves safety and quality. Training programs, new faculty recruitment and other efforts can bring the critical mass needed for broad change.

A deep dive..............................................................................12

A Certificate for safety...........................................................14

By the numbers: learning and development...................16

expanding the mixing Bowl....................................................16

our learning, development and Capacity model............17

Advancing the scienceWe are world leaders in understanding how patients are harmed, testing interventions that prevent that harm, and widely disseminating solutions. We convene researchers from many disciplines to rethink flawed systems of care.

taking stock of a silent Killer................................................18

from Hopkins to Hawaii........................................................20

safety’s next frontier.............................................................22

Who We Are................................................................24


ImpRoVIngouTComes And VAlue

We believe that the most effective, enduring programs for improving care are born through true collaboration. safety and quality benefit when patients and family members engage as members of the care team, when frontline caregivers work across disciplines to identify and fix local safety hazards, or when groups of experts reach consensus on the best way to approach a clinical scenario. our projects bring groups together, provide them with the science, tools and organizational resources that they need to be most effective, and then join them on the journey to find the best answers. this approach results not only in better outcomes, but also produces safety champions of the future.

Rhonda Wyskiel, an intensive care nurse and senior research coordinator at the Armstrong Institute, noticed something curious as she walked ar-ound her “second home,” the Weinberg Intensive Care Unit (WICU): Family members were sitting in rooms with their loved ones with nothing to do.

Many relatives, who may come daily for months at a time, long for a way to be useful. “They want to do something but are afraid to ask,” she says.

Today they can, thanks to a tool Wyskiel designed. The Family Involve-ment Menu, attached to white boards in each WICU patient room, invites loved ones to perform helpful tasks to assist both their loved ones and

nursing staff. They select from a list of activities, ranging from feeding and brushing teeth to giving shampoos and helping with exercises.

It is part of Johns Hopkins Medicine’s commitment to patient- and family-centered care, a way of thinking that prizes communication, collaboration and medical insights gained through each patient’s—and their relatives’—personal experiences.

Quan Dong Nguyen says family involvement made a big difference for his wife, Diana V. Do, who developed sepsis and multiple organ failures after delivering their twins and was rushed to the WICU. Once his wife’s condi-tion stabilized, Wyskiel discussed with

TRuly oN THe sAMe TeAMAn innovative menu lets loved ones participate in care.

Nguyen how his extended family could help to speed her recovery.

Every morning, Diana’s sisters or mother washed and shampooed her hair and tended to her other personal needs. Then, they helped her to walk and do physical exercises. In the eve-ning, other family members walked with her again and bathed her.

Diana’s relatives “were not sure how much they could do to help,” Nguyen notes, but Wyskiel encouraged and educated them on what to do. “It has been really great,” he says. “Rhonda incorporated family members into the recovery effort. This program enables the family to participate and feel their time with their loved ones in the hos-pital is very useful.”

Some of the menu activities also give the family a role in improving out-comes. For example, providing oral care to patients on ventilators can re-duce the risk of acquiring pneumonia.

Nguyen, who, like Diana, is a retina surgeon at the Wilmer Eye Insti-tute and School of Medicine faculty member, says the family-centered care elements initiated by the WICU staff have given him a different perspective on health care. He was encouraged to join the provider team in daily rounds, where he let the staff know what he and other relatives observed and where he participated in discussions and decision-making in the management of his wife. “They really encourage such presence and input,” he adds.

While not all families volunteer their services, Wyskiel says the menu has been “a huge, innovative new tool. We are listening and learning from the family. We are changing the culture. Patients and families love it. They feel empowered. They feel they are a part of the health care team.”

Wyskiel and colleagues are currently in the process of conducting research to evaluate the benefits of the tool, not only for patients and families but also for nursing staff.


Rhonda Wyskiel, Diana V. Do,

Quan Dong Nguyen


In late December, a nurse mak-ing rounds with doctors in The Johns Hopkins Hospital’s neonatal intensive care unit (NICU) noticed an alarming trend: four babies had arrived from the operating room with hypothermia—low body temperature.

Her email prompted clinical nurse specialist Karen Frank to “run the numbers” for 2011. She found that these cases were not isolated.

Leaders from the NICU and Pediatric operating rooms imme-diately got involved, leading to the formation of a group seeking to identify the root causes and devise solutions. With help from the Armstrong Institute’s Lean Sigma team, they conducted a thorough analysis, mapping out neonate care and transport processes and ap-plying methods for reducing waste and defects.

“This problem got our attention. We were motivated to solve it,” says Genie Heitmiller, a NICU critical care doctor and Armstrong Institute faculty member who served as physician champion.

Members reviewed the data and re-search on hypothermia and uncov-ered a number of factors contribut-ing to it. Infant incubators cooled rapidly once unplugged prior to transport. The OR and NICU were using different temperature-taking methods. There were variations and flaws in measuring temperatures.

“We unraveled the onion,” says Robert Greenberg, a pedi-atric critical care physician and an Armstrong Institute associate faculty member.

The group’s collaborative work led to a number of initiatives. A check-list for transporting neonates was developed and rigorously applied. If a baby’s temperature is too low, the infant cannot be moved from the operating room until that situa-tion is resolved. NICU and surgical staffs were re-educated on how to avoid hypothermia. Battery-powered incubator attachments were purchased to keep infants warm while being moved around the hospital. A “warmer mattress” is now placed in incubators and on warmers during transport.

uNRAVelING THe oNIoNLean Sigma helps a team protect infants after surgery.

greenberg feels ‘the enabling work of the Armstrong Institute’ was pivotal in coming up with answers. ‘They empowered us as a team to discover how we could help these kids.’

last year, our lean sigma team trained nearly 400 health care profes-sionals and facilitated projects that eliminated waste, improved outcomes and enhanced safety. Here are a few examples of these efforts:

Readmission reductionsthirty-day readmissions for heart failure patients at Johns Hopkins Bayview medi-cal Center reached an all-time low, down to 17.5 percent from a baseline of 24 per-cent. the reduction translates to annual cost savings of $660,000 to payers, while interventions cost $200,000. the effort, involving physicians, nurses, physical and occupational therapists, social workers, nutritionists and others, is part of a Joint Commission Center for transforming Healthcare project in which seven health systems are applying lean sigma to pre-vent avoidable admissions.

MRI safety multiple system changes were created to ensure safe use of Johns Hopkins medicine’s first intraoperative mrI suite, in which the powerful magnetic scanner moves into surgical operating rooms. the goal was to prevent pa-tients and staff from being injured from metal objects flying missile-like toward the scanner or from electromagnetic interference with internal devices such as pacemakers. After a proactive risk assessment that identified potential failures, the team implemented several preventive measures, such as restricting access through badge-swipe technol-ogy and thorough screening processes for people in this non-traditional mrI environment.

Revenue captureInterventional radiology at Johns Hop-kins Hospital captured an additional $50,000 a month for charges related to supplies used in procedures. the proj-ect methodically examined how some manual processes for inventory manage-ment, surgical case flow and billing were allowing incomplete billing of surgical supplies. new quality control check-points now ensure accurate billing.


As a result, the average temperature of postoperative infants increased by 0.6 degrees Fahrenheit in the first three months following intervention, and there were no cases of hypothermia. Those with low temperatures tend to be just slightly below normal, Frank says, potentially because “these are very sick and very small babies who naturally lose some of their heat.”

Greenberg feels “the enabling work of the Armstrong Institute” was pivotal in coming up with answers. “They empowered us as a team to discover how we could help these kids. We found we were pretty darn good at solving problems when we work together.”

Lean Sigma’s analytical tools “put method to an undocumented process” of caring for neonates,

notes Bob Hody, the institute’s assistant director of Lean Sigma deployment.

The highly visible checklist created by the group has proved especially effective, says Carol Gentry, a nurse manager in pediatric surgery. ”Lean Sigma gave us the ability to pull teams together and effectively identify the barriers we needed to work on,” she notes. “Everyone sat at the same table. It was truly a col-laborative effort.”

Genie Heitmiller,Karen Frank,

Robert Greenberg


Infections from colorectal surgeries happen all too often—up to 30 per-cent of the time, leading to longer hospitalizations, additional pro-cedures and patient suffering. Yet unlike with some complications, there’s no tried-and-true “bundle” of evidence-based practices for preventing surgical infections in the bacteria-rich bowels.

“If there were five steps that we could follow and nail this problem, we’d do them,” says Deborah Hobson, patient safety clinical specialist with the Arm-strong Institute. “But that list just doesn’t exist.”

So when the colorectal surgery team at The Johns Hopkins Hos-

pital recognized that they had a high rate of infections, they sought answers from those closest to the problem—frontline care-givers. A host of changes, driven by technicians, nurses, nurse anesthetists, physicians and other staff, brought a 33 percent reduc-tion in infections over a year.

Their success demonstrates the power of the Comprehensive Unit-based Safety Program (CUSP), a five-step framework created at Hopkins for fostering a culture of safety and tackling local patient safety hazards.

“Our staff has a tremendous amount of knowledge,” says Arm-strong Institute faculty member sean Berenholtz, the anesthesi-ologist champion of the colorectal CUSP team. “CUSP helps us tap into their thoughts and engage them in identifying defects and then fixing them.”

An early step of CUSP involves surveying caregivers, asking them how the next patient will be harmed in their area and what can be done to prevent it.

“Right off the bat, they pointed out that not all patients were getting the right antibiotics, even though we thought they were,” says eliza-beth Wick, the CUSP team’s sur-geon champion. Penicillin-allergic patients were receiving too little of gentamicin, a substitute antibi-

otic, or none at all. By educating providers and creating a Web-based dosing calculator for gentamicin, compliance soared from 33 percent to 92 percent.

Another revelation came from scrub technicians, who noted that instruments employed to re-connect portions of the intestine were sometimes mistakenly re-used for skin closure. No longer: New systems are in place to ensure that all instruments and surgical gloves are changed before beginning wound closure.

“It was great to see the staff get engaged and excited about the project,” Wick says. “They came up with ideas to fix things that should have been fixed before.”

A host of changes, driven by technicians, nurses, nurse anesthetists, physicians and other staff, brought a 33 percent reduction in infections over a year.

FRoNTlINe WIsDoMStaff engagement uncovers hidden causes of surgical site infections.

elizabeth Wick,Deborah Hobson


The CUSP model also includes for an executive champion—in this case institute Senior Director Re-nee Demski—to provide leader-ship support and connect the team with organizational resources.

Staff-driven interventions led to a new infection-prevention checklist. To standardize procedures, a group of nurses and nurse anesthetists volunteered to handle all colorectal operations. “This improves team-work,” says Hobson, who is also the CUSP team’s coach. “They understand the checklist and have greater experience applying the interventions.”

The CUSP team is working to further drive down infections. Meanwhile, Berenholtz, Wick,

Hobson and others are helping to lead a national project, funded by the Agency for Healthcare Re-search and Quality, that’s seeking to replicate their success in surgical centers elsewhere.

Below are several of our efforts to improve safety and quality:

supporting “second victims”Hopkins caregivers who have trouble coping with their emotions after un-anticipated stressful events can get peer support through a program called rIse—resiliency in stressful events. the rIse team, which includes Arm-strong faculty and staff, developed a cur-riculum for peer responders and trained them to deliver psychological first aid to “second victims” of medical errors and other stress-producing events. rIse went hospital-wide in June 2012 after a successful pilot in Pediatrics, and it hopes to expand beyond the hospital. As of June, 18 responders were taking calls.

Negotiating a merger through teamwork

In early 2012, two pediatric units at Hopkins Hospital braced for a big change—not only moving into a new clinical building, but merging into a 40-bed unit there. to build familiarity and effective teamwork and communica-tions behaviors among staff, Armstrong faculty led interactive workshops focused on trust-building, conflict man-agement, handoffs and other scenarios. In all, 162 staff from these two units and one other unit participated in the three-hour sessions.

seeing patients’ perspectivesthe institute helped to develop an online course, “making Hospital Care Patient-Centered.” the course uses a patient story approach to familiar-ize learners with a three-pronged framework for understanding patient-centeredness: Are my needs being met? Am I involved in my hospital care? Am I prepared to care for my condition at home?

Tackling disparitiesthe institute convened the Johns Hopkins Health equity Alliance, a con-sortium of organizations across our university and health system that are dedicated to eliminating health dispari-ties. the alliance aims to better measure performance in disparities, to harness the lessons learned from prior attempts to improve outcomes for all patients, and to help translate these lessons to the bedside.


When Bob Feroli, medica-tion safety officer for The Johns Hopkins Hospital, learned about a frequent error involving a blood pressure-lowering patch, he knew exactly what to do: He informed members of the Medication Safety Clinical Community, a group of more than 40 pharmacists, nurses, physicians and quality and safety specialists across Johns Hopkins Medicine, so that they could avoid the mistake. He also shared the system changes made at his hospi-tal to prevent future occurrences.

This clinical community is one of five chartered by the Armstrong Institute in its first year that aim to improve quality and patient safety by building on the shared wisdom of their members. The model recognizes that interven-tions are more likely to be effective and embraced by clinicians when they are developed locally by a group of peers, rather than when they are imposed from above.

The concept also recognizes that peer groups often require outside resources to solve problems and keep momentum. The institute fills that need, providing support in such areas as measurement and improvement methods.

The term “clinical commu-nity” is a relatively new one, but

Armstrong Institute researchers actually have nearly a decade of experience fostering them, going back to its groundbreak-ing work to virtually eliminate bloodstream infections in Michi-gan ICUs. There, statewide groups built consensus around safety interventions, while Hopkins researchers provided tools and scientific support.

The communities facilitate dissemination of lessons learned from adverse events. “It’s a conduit for bringing like-minded people together, whereas before there was no such conduit,” says Feroli, who heads the Medication Safety Clinical Community. “Now we have a systematic way of sharing information.”

This clinical community is also working to improve their hospitals’ scores on a safety self-assessment by the Institute for Safe Medica-tion Practices. A representative from each of the six hospitals serves as champion for an im-provement area, such as eliminat-ing distractions near computer order-entry stations.

The group’s monthly meet-ings have been “an in-depth information-sharing experience,” notes Gary Roggin, a Bethesda gastroenterologist who chairs Sub-

urban Hospital’s Pharmacy and Therapeutics Committee. “It is very helpful to have six hospitals zoom in on a safety situation. Everyone’s experiences help in finding a solution.”

“It’s eye-opening to learn about different structures and processes at other hospitals that we might want to adapt,” says Blanka McClammer, director of nurs-ing excellence and patient safety at Johns Hopkins Bayview Medical Center.

One of Bayview’s tactics, a period-ic compilation of system changes made as a result of adverse event reports, has already been adopted by at least one other hospital. A goal of Safety Reports in Action, sent across the hospital, is convinc-ing staff that reports don’t go into a “black hole.”

The other clinical communities at Johns Hopkins Medicine are in the areas of hospitalist medicine, post-anesthesia care, intensive care and neonatal intensive care. More are planned.

CoNseNsus AND CoMMuNITyClinical communities take root.


Bob Feroli, Blanka McClammer

exCelleNCe AT ouR CoReHopkins Medicine sets national leadership goals.The commitment to excel in patient safety and quality is nothing new to Johns Hopkins Medicine. What is new, however, is that our hospitals have explicitly stated those goals and agreed to work together to pursue them, with mechanisms for accountability.

In March, the Johns Hopkins Medicine Board of Trustees committee that over-sees the Armstrong Institute declared that our corporate health system would demonstrate national leadership in safe-ty and quality. In concrete terms, they defined this as scoring at least 96 per-cent on all of the 30-plus core measures

reported to the Centers for Medicare and Medicaid Services, such as prompt administration of aspirin to heart attack patients. The committee, which includes hospital executives and other safety and quality leaders across the Johns Hop-kins Health System, also set a goal of achieving and sustaining hand-hygiene compliance rates of at least 85 percent in the inpatient setting and 90 percent in the outpatient setting.

The institute is supporting efforts to meet these goals by developing tool-kits that clinical managers can use to improve their area’s performance,

creating and broadly disseminating unit-level performance dashboards, and setting up systems that connect units and departments with help if their performance lags.

For Johns Hopkins Medicine, this deci-sion is historic in gathering an organiza-tion-wide commitment to meet specific goals. We hope that the lessons learned from meeting these challenges will help us define a system-wide model that helps Johns Hopkins Medicine rise to future challenges in safety, quality and value of care.


buIldIng CApACITyIn our first year, the Armstrong Institute has grown at a breathtaking pace, roughly quadrupling our faculty and doubling our staff. yet progress in safety and quality hinges on the actions of everyone whose work touches care delivery. too often, health care professionals have not gained the tools to bring about real and lasting change. We’re committed to transforming this situation. We are developing a capacity-building model that offers individuals a hierarchy of skills based on their roles in driving change, whether they are frontline caregivers, clinical managers or department heads. We’re also building these skills earlier, through programs that engage medical and nursing students, residents and fellows in safety and quality. our commitment must be no less than enlisting the entire health care community in this work, at Johns Hopkins medicine and beyond.

Nishi Rawat, an intensivist with Johns Hopkins Community Physi-cians, worries about what happens when her patients are transferred to large academic medical centers for more specialized care. Too often, she says, important information is lost, leading to redundant tests run or other adverse events.

Like many frontline clinicians, she had scarce time and resources to tackle such systemic problems. So when Rawat learned about the institute’s new

Patient Safety Fellowship, a program that provides training and mentorship to future patient safety leaders, she quickly applied.

“This was an opportunity to work on ideas I had for improving patient care,” says Rawat, who practices at Howard County General Hospital. “The fellow-ship gave me the skills to do it.”

She and six colleagues from a variety of disciplines spent six months’ worth of Fridays earlier this year in sessions taught by safety experts from the in-

A DeeP DIVeSafety fellows make an impact.

stitute and across Hopkins. With sup-port from mentors, each also initiated their own projects back on the job.

Rawat, for instance, tapped into fellowship directors Melinda sawyer and lori Paine, as well as physi-cian Brent Petty, an expert on care coordination, to bolster a proposal to explore how technology can be used to improve patient transfers from community hospitals to specialized facilities. The institute’s Small Grants Program later funded the proposal’s initial research phases.


Nishi Rawat, Melinda sawyer

The fellowship provides a founda-tion in the knowledge and skills that participants would need to take on these kinds of projects. Aside from understanding such bedrock concepts as the science of safety, measurement and culture of safety, they learned how to apply Lean Sigma, teamwork and communication strategies, and other tools.

“The Armstrong Institute ex-poses you to so many of Hopkins’ vast resources that you’d never explore on your own,” says Kevin Driscoll, a nurse anesthetist at The Johns Hopkins Hospital.

Sawyer, the institute’s assistant director of patient safety, says the fellowship’s inaugural group “exceeded expectations.”

“It was astounding to see the work they did on their safety projects,” she notes.

Driscoll, for instance, led a study to see if the number of instru-ments unwrapped in the operating room could be reduced, both to save money and reduce infec-tion risks. This led to a paring of instruments by two-thirds. Among other projects, he also had a software program implemented that uses body weight and height

to calculate the correct antibiotic dosage for surgical patients who are allergic to penicillin and must get a substitute.

Rawat says that, aside from tech-nical knowledge, she gained more intangible lessons from the group’s discussions, such as how to frame quality and safety initiatives for administrators so that they sup-port them: How does it affect the bottom line?

“I learned a lot,” says Rawat, an institute faculty member. “It’s helping me raise the profile of patient safety and quality at my hospital.”


Like most surgeons, orthopedist Rick Kinnard is driven to make sure that everything in the operat-ing room happens with precision. Surgeons, he admits, want to control every aspect of what they do and produce an instant impact on patients.

That was the mindset he brought to the institute’s new Patient Safe-ty Certificate Program, piloted over the summer of 2012 with 21 participants from across Johns Hopkins Medicine. By the end of the six-day program, though, Kin-nard says, “my eyes were opened” to a new way of viewing health care delivery.

Part of that vision is learning to recognize how flawed care delivery systems underlie safety hazards. Now, Kinnard is re-examining how he is informed about radiology and lab results, to ensure that he sees them for every patient. When a drug is

running low, he considers every-one in the procurement process, rather than focusing only on the person responsible for reordering medications.

“For a surgeon, that’s quite a change,” says Kinnard, medical director of the joint replacement program at Howard County General Hospital, with a private practice. “I’m looking beyond the immediate problems” to find underlying causes.

A linchpin in the institute’s comprehensive training model, the certificate program answers the need to prepare unit- and clinic-level leaders to lead patient safety efforts in their care areas. This includes fostering a culture of safety, supporting interdisciplin-ary teamwork, applying evidence to improve outcomes, and fully engaging patients and family as members of the care team.

“The program provides an introduction to tools and meth-ods for improving patient safety and quality, as well as leadership skills vital to effectively leading improvement work,” says sallie Weaver, an Armstrong Institute faculty member on the certificate development team.

Participant Melissa eichelberg-er, patient safety nurse coordina-tor at Johns Hopkins Bayview Medical Center, is excited about the prospect of sending three new departmental patient safety nurses to the program when it is offered again in early 2013—this time as a five-day course with some content delivered online.

“The program is ideal for someone who is coming from the frontlines and taking a position in patient safety,” says Eichelberger. “It’s a very inclusive introduction to a wide range of safety concepts.”

A CeRTIFICATe FoR sAFeTyNew program prepares local leaders to carry the torch.

sallie Weaver, Tricia Francis


Eichelberger says that she had to learn about safety in a piecemeal fashion, but the certificate provides a comprehensive range of content in one package.

“There’s no more effective way to get these concepts,” Eichelberger notes.

That was the idea when the insti-tute set out to develop the program in early 2012. At a two-day retreat in January, about 20 Armstrong faculty and staff identified the key skills and competencies that they wanted local safety leaders to possess. During the following months, these experts built the pro-gram, with guidance from Tricia Francis, an instructional design manager heading the institute’s Learning and Development team.

The certificate, which will also be available to organizations outside of Hopkins, emphasizes practical application of patient safety and quality tools. Participants were en-couraged to use the tools between sessions, and left the course with a toolbox that they can continue to draw from.

”They are dipping their toes in the pool,” Francis says. “We want them to learn about safety, then go off and apply what they have learned as soon as possible.”

Rick Kinnard

The program provides an introduction to tools and methods for improving patient safety and quality, as well as leadership skills vital to effectively leading improvement work.


Years ago, a group of Johns Hopkins safety and quality scholars began meet-ing around a small conference table in Fells Point to discuss their research ideas. Peter Pronovost, who con-vened the wide-ranging talks, referred to their approach as the “mixing bowl,” as physicians, nurses, psychologists, public health researchers and others brought their different approaches together to solve problems.

We’ve clearly outgrown that conference table. In the institute’s first year, the number of researchers available to take part in such conversations ballooned, promising to advance the science while also augmenting the ranks of those who can help lead safety and quality programs. In its first year, the institute added 44 core, associate and visiting faculty members, roughly triple the number that existed when it formed.

These new faculty, who have primary appointments elsewhere, bring ex-pertise in such fields as health policy, biostatistics, health disparities, manag-ing technology, performance measure-ment, evidence-based practices and organizational decision-making. The School of Medicine’s clinical depart-ment chairs have also joined.

“They all are very interested in getting involved in our activities,” says Jill Marsteller, a member of the insti-tute’s executive committee, which approves all faculty appointments.

Core faculty must contribute to the institute’s teaching, research and quality improvement missions. They attend meetings, education programs

and events, advise or chair at least one patient safety or quality improvement project, and work toward publishing research and winning grants. Associ-ate faculty participate in the institute’s education programs and events, make presentations and contribute to safety projects and research.

Having department chairs on the faculty is important, Marsteller notes. “We want them to plug into our ex-pertise on how to run quality improve-ment programs and the resources we offer. Their participation encourages others to become involved. And for us, it brings so much experience and ex-pertise. They can tell us what is feasible and what’s not.”

exPANDING THe “MIxING BoWl”New faculty enrich the approaches to improving care.

By the Numbers:learning and development

655total workshop participants (313 from JHM, 342 from outside JHM)

25training events, including:

• Patient safety Certificate

• lean for Healthcare

• lean sigma green Belt Certificate

• CusP Workshop

• Improving Patient safety with Human factors methods

• Improving Perioperative Care

420attendees at the 3rd Annual Johns Hopkins medicine Patient safety summit

$100,000awarded by the institute’s small grants Program to support five research projects at Johns Hopkins medicine that seek to eliminate harm, improve outcomes and enhance value

Their participation encourages others to become involved. And for us, it brings so much experience and expertise.


ouR leARNING, DeVeloPMeNT AND CAPACITy MoDel

TIeR 3: safety-quality experts educationTarget: People aiming for a career in safety-quality work

» Graduate degrees » Career development awards

TIeR 2: Role-tailored safety-quality educationTarget: Health care leaders/managers with responsibility for improving safety-quality

» Patient Safety Certificate » Safety Fellowship

TIeR 1: basic safety-quality educationTarget: All health care professionals and students in health care professions

» Patient- and family-centered care » CUSP basic training

Below are some of the institute’s other activities to build the organiza-tional capacity for improvement:

Resident programsWe offer young physicians, who often don’t get to play a role in improving patient safety and quality, two new op-portunities to do so. the Armstrong Institute Resident scholars Pro-gram accepted 16 Johns Hopkins medi-cine residents for a one-year elective fellowship to train future leaders who can bridge systems and transform the clinical health care setting. the institute also assisted in forming the Johns Hop-kins Hospital’s Housestaff Patient safety and Quality Council, a forum that gives residents a leadership role in improving quality. the council will help lead hospital-wide quality projects, as-sist in developing the hospital’s quality and safety plan and serve as a voice for residents on related issues.

Culture survey debriefing over three workshops, we trained more than 90 patient safety leaders, survey coordinators and debriefing facilitators across Johns Hopkins medicine on how to interpret and assess the results of safety culture surveys. the goal is to help teams to create action plans for improving safety culture in their areas.

speaker seriesWe launched a monthly program of grand rounds on safety- and quality-related topics, as well as monthly brown bags and research seminars, for the Johns Hopkins medicine community.


AdVAnCIng The sCIenCeWe believe that finding ways for patients to consistently receive the therapies they need, without error or complication, is no less important than inventing a life-saving drug. our researchers are expanding the world’s knowledge of how to elevate care to this level. they identify and measure the problems that demand attention. they translate scientific evidence about best practices into bedside therapies—then help spread those interventions across hospitals, states and nations. they are collaborating with experts from industry and across the university to design new clinical environments that make it easier to deliver high-quality care. the science of safety has no limits to what is possible when diverse researchers bring their talents to a challenge.

Brad Winters bemoans the fact that one of his key areas of research— diagnostic errors—has received scant attention.

“There’s almost no funding for it,” says Winters, a critical care physician and Armstrong Institute core faculty mem-ber. “The issue is not on people’s radar screens. There’s very little work being done on the root causes of diagnostic errors and no research on how to inter-vene and improve the outcomes.”

He and fellow institute faculty mem-ber David Newman-Toker hope that their recent research will help shine the spotlight on this topic. They discovered that, among critically ill patients alone, missed diagnoses of serious medical conditions result in as many as 40,500 deaths each year—as many as are attributable to breast cancer.

Their estimates are based on re-views of 5,863 autopsy findings from ICU patients. In 8 percent of these

patients, the missed diagnosis—most commonly a heart attack, blood clot, blocked artery in the lungs, pneumo-nia or a fungal infection—was serious enough to cause or directly contribute to death. Another 15 percent of these patients had major medical problems that went undetected, they reported in BMJ Quality & Safety.

Newman-Toker, the study’s senior author, says that while treatment errors are the most visible ICU mistakes, “diagnostic errors are the deeper part

TAKING sToCK oF A sIleNT KIlleRArmstrong researchers raise the profile of diagnostic errors.


Brad Winters, David Newman-Toker

of the iceberg. They are harder to see and harder to measure. They’re often quiet and unrecognized.”

The researchers also found that poten-tially fatal undiagnosed conditions are twice as likely to occur in the ICU as in other areas of hospitals. That’s due to the complexity of the ICU, where the sickest patients compete for a clinician’s atten-tion while the physician is bombarded by clinical data. “It’s a very distracting environment,” Winters says.

The next step is gaining an understand-ing as to why so many medical condi-tions are missed in ICUs and then devis-ing ways to address the problem. They realize that there’s no simple answer. Are there ways to help physicians avoid “cognitive pitfalls”? Would better display of clinical data in the ICU ensure more accurate and timely diagnoses?

“We need to predict which interventions will give us the best bang for our buck,” says Newman-Toker.


Armstrong Institute researchers, to-gether with colleagues at Hopkins and around the world, published scores of peer-reviewed articles that advanced the science of safety and quality. Among many other findings, they dis-covered that:

Medication errors serious among temporary staff

medication errors involving temporary staff in emergency departments are more than eight times as likely to be life-threatening and three times as likely to result in temporary harm as errors involving permanent staff.

ssI reporting is haphazardonly 21 states require public report-ing of hospital data on surgical site infections and, even when disclosure is required, the information is often not easily accessible. Just eight of those 21 states actually have ssI data available publicly.

Quality investments pay offsix michigan hospitals in the Keystone ICu project prevented, on average, nearly 20 catheter-related bloodstream infections and 18 cases of ventilator-associated pneumonia each year. While the cost of prevention efforts was $3,375 for each infection avoided, es-timated costs associated with those infections would range from $12,000 to $56,000 per episode. Institute research-ers also created online “opportunity estimators” that allow hospitals to calculate the potential benefit—in harm avoided and cost reduction—of prevent-ing these infections in their own ICus.

students “get” safetymedical students’ knowledge of safety, as well as their ability to see the systemic nature of medical errors, increased after they took part in a three-day patient safety curriculum at the Johns Hopkins school of medicine. ratings of self-efficacy—measured through agreement with such state-ments as “I know how to investigate a defect”—also improved.

When the opportunity arose for Hawaii hospitals to join a national project to reduce catheter-related bloodstream infections, Honolulu anesthesiologist Della lin was ready to get started. Initially, how-ever, no statewide organizations were in a position to coordinate their hospitals’ participation.

So Lin volunteered, enrolling the islands’ largest health insurer and recruiting 38 ICUs at 16 hospi-tals. Her goal: instill a sense of “ohana”—“togetherness” or “fam-ily” in Hawaiian—to improve the culture of safety and prevent harm.

The results speak for themselves: As of July 1, bloodstream infections had dropped by 78 percent overall and almost 90 percent in the state’s adult ICUs. Every hospital had gone at least six straight months without an infection. In early Sep-tember, all of Hawaii’s three neona-tal ICUs celebrated 300 consecutive infection-free days. Perhaps just as important, while the state’s active involvement in the national project ended in 2011, the drive for safety continues undiminished.

“We have sustained the reduction in infection rates on our own. It’s exciting to see,” says Lin. “The ICUs are owning it.”

Such transformations were the goal four years ago, when Arm-strong Institute researchers began a national project targeting blood-stream infections that was funded by philanthropists and later the Agency for Healthcare Research and Quality. Their approach combined simple evidence-based steps for preventing infections with adoption of the Comprehen-sive Unit-based Safety Program, a model for improving safety culture and engaging frontline caregivers in eliminating harm.

Encompassing 44 states, the District of Columbia and Puerto Rico, the project officially ended in September 2012, with prelimi-nary results showing a 40 percent national reduction in infections. Impressively, some teams push onward, tackling new challenges on their own. For instance, when Hawaii ICUs discovered that most remaining infections involved catheter maintenance, they devel-

FRoM HoPKINs To HAWAIIAs bloodstream infection project comes to a close, the collaborations continue.

National Bloodstream Infection Project

➔ 44 states ➔ 1,100 ICus➔ 2,000 infections prevented➔ 500 lives saved➔ $34+ million in costs avoidedSource: AHRQ


oped novel strategies and tools to promote correct practices, such as a special dressing-change kit.

“They’ve had great success objec-tively in terms of infection rates, but they’ve had success in other ways,” says Armstrong Institute faculty member Julius Pham, the physician coach for the Hawaii team. “They’re a cohesive group that is really engaged.”

Lin credits the institute with the protocols, instruction and coaching that energized safety teams. “Video conferences with Peter Prono-vost and the Armstrong Institute team, as well as Julius’ coaching, made a world of difference,” she notes. “It was a direct connection to help us problem-solve, bounce off ideas and find out how things were being handled in other states.”

Hopkins’ involvement gave the project credibility in clinicians’ minds, she said. Yet the Hopkins team maintained a flexible ap-proach, encouraging units to adapt the program to their environment.

Kristina Weeks, a research asso-ciate with the institute, praises Lin for “planting the seeds that made the program much easier to grow. The fact that she was an anesthesi-ologist gave her insights into how the ICU runs. Her experiences and empathetic leadership style ampli-fied all the lessons we were trying to impart.”

The nationwide bloodstream infections project proved that an effective patient safety innovation could be scaled from a single institution to a state and even to an entire nation. It is now just among many collaborative efforts under the institute’s leadership.

Cutting surgical complicationsA four-year Agency for Healthcare Research and Quality (AHRQ) contract provides for the institute and other lead-ing researchers to reduce surgical site infections (SSIs) and other preventable complications of inpatient surgery. the surgical unit-based safety Program begins in 10 states with plans for national and international spread.

safety in cardiovascular surgerythis three-year AHrQ-funded study aims to eliminate central line-associated bloodstream infections, ssIs and ven-tilator-associated pneumonia (VAP) in patients undergoing cardiovascular surgery at centers across the country. Known as the Cardiovascular surgical translational study, it also focuses on improving hand-offs at transitions of care.

Beating VAPthe institute has developed a preven-tion bundle for VAP, as well as an educa-tional program, that it is implementing in hospitals in maryland and Pennsylva-nia. the five-year project is funded by AHrQ and the national Heart, lung, and Blood Institute of the national Institutes of Health.

exporting safetyIn January 2012, the institute began a two-year project to develop a patient safety infrastructure, improve safety culture and eliminate central line-associated blood-stream infections in 12 ICus in Abu dhabi, capital of the united Arab emirates.

Reducing BsI in dialysisthe institute created and instituted a pilot program to reduce bloodstream infections in hemodialysis patients at daVita, Inc.’s 26 clinics in maryland. In a similar project, which began in october 2012, researchers are working to reduce these infections in 30 non-DaVita hemodi-alysis clinics in the state.

Della lin


For all of the sophisticated equip-ment in intensive care units, keeping patients safe often requires a triumph over technology: A phy-sician pieces together information from the physical exam, multiple monitors, and documentation systems to recognize that a patient is about to suffer a medical crisis. A nurse stops a narcotic infusion after noticing that the patient’s heart rate is dropping amidst a cacophony of alarms that are largely disregarded.

Yet clinicians are largely helpless to change the inefficient, disjointed ICU environment that requires them to make these “catches.” Devices, information technologies and other products are designed elsewhere, without a vision for how they can work together. Why, for instance, don’t most monitors and devices “talk” to and learn from each other? Such communications might be better able to signal a patient in jeopardy.

“We depend too much on the heroic actions of physicians and nurses to keep patients safe,” says Adam sapirstein, a critical care physician at The Johns Hopkins

Hospital and an institute faculty member. Such actions wouldn’t be necessary if health care fully realized the potential benefits of technology, he says.

Sapirstein is an investigator in a host of Armstrong Institute-led endeavors that aim to take a step back and re-engineer the ICU. Their goal is to better integrate technologies and create systems that ensure patients receive the therapies they need, and that clinicians work as effectively and efficiently as possible.

Recognizing that physicians and nurses alone do not have all the answers, the institute has created unique research collaborations, convening such diverse groups as device and medical product mak-ers, systems engineers, human factors experts and other research-ers from across the university.

In February, these groups partici-pated in a one-day summit, hosted by the institute, to determine ways that they might partner to create the next-generation ICU.

Robert szczerba, corporate director for health care initiatives at Lockheed Martin Corporation, a summit participant and Arm-strong Advisory board member, feels that a broad partnership holds the potential “to revolutionize the practice of medicine, from improv-ing the quality of care to reducing overall waste and errors.”

Szczerba says that health care would benefit from the approach of the aerospace industry, in which equipment from different manu-

facturers is integrated into a whole rather than put together piecemeal (as in most hospital systems).

Through a partnership with the institute’s Learning Lab—an in-novative model for academia and industry to conduct safety and quality research together—Lock-heed Martin is working with Arm-strong to build a simulated ICU for testing new concepts.

“There is no flight simulator for a hospital to test out new designs and concepts in a low-cost, low-risk environment,” Szczerba says.

The ICU redesign effort got a huge boost in August, when the Gor-don and Betty Moore Foundation announced an $9.4 million grant to the institute. The project calls for the research team, including systems engineers from the Johns

We depend too much on the heroic actions of physicians and nurses to keep patients safe.

sAFeTy’s NexT FRoNTIeRThe institute envisions the ICU of the future.


Hopkins Applied Physics Labora-tory, to better integrate ICU equip-ment so they not only communi-cate with one another but guide caregivers on the most urgent and appropriate actions to take.

ICU physicians are bombarded with data streaming separately from various patient monitoring devices—an estimated 7,000 pieces of information daily.

Part of the Moore Foundation grant will go toward building a “system of systems” that will coordinate and analyze data coming from health care provid-ers, patients, family members and ICU technologies. That should streamline the vast array of tasks performed by doctors and nurses, make it a clinician-friendly environment and reduce the stress on caregivers, according to Mike

Rosen, a human factors specialist with the institute. He envisions the new, improved ICU as “an effective network of communications for clinicians as well as for patients and their families.”

The Moore Foundation project also calls for greater involvement of patients and their families. The Johns Hopkins Berman Institute of Bioethics joined the research team to help ensure that patients are treated with dignity and respect.

“By connecting two critical aspects of health care—improved systems for delivering care and better patient and family engage-ment—the nation can improve the overall quality of care, foster greater respect for patients and their families and save money,” says steve McCormick, the foundation’s president.

The institute promotes the safe design of medical devices and products by incor-porating human factors engineering and usability concepts. Here are some of the projects we’re working on:

Designing better infusion pumpsA partnership between the institute and the Johns Hopkins Applied Physics labora-tory is producing insights for designing safer infusion pumps. supported by a $1 million AHrQ grant, the project kicked off in Janu-ary, when about 50 pharmacists, clinicians, engineers, patient safety analysts and human factors experts gathered to explore ways to adapt pumps’ design to clinicians’ needs and workflow. Infusion pumps have been connected to 710 deaths and 87 recalls over a four-year period. following the January event, researchers are working to proto-type and test pump designs that are particu-larly challenging to patient safety.

evaluating device usability the institute launched a usability testing and evaluation service, allowing companies to get a rigorous, objective assessment of potential use-related errors for medical devices, products and systems. the team combines human factors and patient safety experts from the Armstrong Institute, systems engineering experts from the Ap-plied Physics laboratory, simulation design experts from the Johns Hopkins medicine simulation Center and clinicians.

Monitoring devicesthrough its learning lab, the institute is collaborating with masimo, Inc. on projects related to improved monitoring of patients. one project will determine if a wireless, centralized vital signs monitoring system can improve recognition of, and responses to, deteriorating conditions of patients in gen-eral hospital wards. this system aims to re-place the current practice in most hospitals, where vital signs are taken intermittently and often by hand. In another project, the institute is evaluating a noninvasive hemo-globin monitoring system.

Adam sapirstein


Who We ARe

to continuously reduce preventable harm, improve patient outcomes, and enhance the value and equity of care around the world by advancing the science of patient safety and quality through discovery, implementation, education, evaluation and collaborative learning

MIssIoN sTATeMeNT

saving lives by leading the world in patient safety and quality care

VIsIoN sTATeMeNT

the Armstrong Institute embraces the core values of Johns Hopkins medicine

» excellence and discovery » leadership and Integrity » diversity and Inclusion » respect and Collegiality

the institute also embraces the core values of:

» Patient- and family-Centered Care » transparency

VAlues

» I act humbly. » I appreciate others and treat them respectfully. » I am accountable to continuously improve myself, my team and Johns

Hopkins medicine.

CoRe BeHAVIoRs


hopkinsmedicine.org/[email protected]

armstrong institute - johns hopkins hospital · patient safety expert peter pronovost (right) was...

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