© 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

Median and Mean CRBSI Rate

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Time (months)

CRBS

I Rat

e

Median CRBSI Rate Mean CRBSI Rate

Pronovost NEJM 2006: Pronovost BMJ 2010: Sawyer CCM2010

CLABSI Rates in 103 Michigan ICUs

Michigan ICU Safety ClimateImprovement

Effect of CUSP on Safety Climate

87

47

0102030405060708090

100

Pre vs. Post Intervention

% "

Nee

ds Im

prov

emen

t" *

Pre-CUSP (2004) Post-CUSP (2006)

* “Needs Improvement” - Safety Climate Score <60%

CCM 2011

Impact of Statewide Quality Improvement Initiative on Hospital Mortality

Pre-implementation (12 months: Oct 02 - Sept 03)

Project Initiation (5 months: Oct 03 - Feb 04)

Implementation (12 months: Mar 04 - Feb 05)

Post-implementation (12 months: Mar 05 - Feb 06)

Post-implementation (12 months: Mar 06 - Dec 06)

0.700000000000001

0.800000000000001

0.900000000000001

1

1.1

Study Group Adjusted OR Comparison Group Adjust OR

Adj

uste

d O

dds

Rat

io

Impact of Michigan Keystone Project on Hospital MortalityLipitz: BMJ 2011

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

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

Fractal-

• common goal

Armstrong Institute for Patient Safety and Quality11

What Have We Learned

Work must be informed by sciencedifferent problems require different methods

Work must be led by CliniciansWork must be guided by valid measuresWork must be modified to fit local contextHarm must be seen as a social problem capable of being solvedPlatform to deliver programs must combine e learning, data collection and reporting, social learning, and CME or MOC

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

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

Roll Up Performance Data Across Unit, Hospital, or Initiative

View and Analyze Measure & Survey

Performance

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.

Armstrong Institute for Patient Safety and Quality16

Armstrong Institute for Patient Safety and Quality17

Armstrong Institute for Patient Safety and Quality18

Armstrong Institute for Patient Safety and Quality20

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

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