Outcomes Take Good Systems
By Edward D. Miller,
want to share with you
something taking place at Johns Hopkins that I find truly exciting, something
that could have a dramatic impact on all academic medical centers. We
are, quite literally, reinventing how we care for patients.
Before anyone rolls his eyes, let me tell you what this initiative is
not: yet another consultant-driven "quality improvement" campaign
that will come and go with the latest management fad. Instead, we are
putting substantial resources into a new Center for Innovation in Quality
Patient Care that will systematically examine how we conduct care and
build model patient safety systems. We mean to invite every care giver
to participate, innovate, measure outcomes and make recommendations for
institutionwide application of best practices. We are committed to this
enterprise and we are putting staff on it.
What's driving this? In substantial part, the growing evidence that the
weakest link in patient care lies in systems failures. Historically, mistakes
or poor outcomes have been blamed on "dumb doctor," or "dumb
nurse." The "solution" was the ABP reaction-Accuse, Blame
and Punish. But as we are now discovering, inefficiencies and errors mostly
can be traced not to one error, but a cascade of poor or poorly executed
procedures, policies, technologies and training. A good system will provide
a good outcome; a poorly designed one will produce a poor one. So, we're
taking a hard, step-by -step look at what we do, particularly in areas
that affect patient safety and complex care.
The initiative also is driven by practical realities. Several years ago,
we began asking ourselves, "How do we deliver the quality of care
Hopkins is noted for with fewer nurses?" That led to a far broader
examination of patient care processes. At about the same time, the Institute
of Medicine issued its report on the large number of medical errors in
hospitals each year, many of them preventable. We decided to create an
evidence-based center that would make necessary and proven changes permanent.
We're fortunate to have two energetic leaders who are turning workplace
innovations into a part of the Hopkins landscape: intensivist Peter Pronovost,
M.D., Ph.D., and Richard "Chip" Davis, Ph.D., senior director
of ambulatory operations and practice management. Working with physicians,
nurses and others who know their units intimately, the Center leadership
already has identified opportunities to change a practice that are making
- In one ICU, a detailed audit showed that over a two-week period, transfer
orders listing medications and allergies often contained mistakes and
that timing was a big part of the problem. The unit piloted a new approach,
in which nurses conduct medication reconciliations whenever patients
are transferred to another unit. They match prescriptions and allergies
on the written orders with what patients have been getting. Any discrepancy
is resolved with the physician before the transfer. Result: virtual
elimination of this potentially dangerous problem. Nothing high-tech
here, just the hard work of taking a hard look at "the way we've
always done things" and figuring out how to do it better.
- A closer look at the way rounds have been carried out revealed gross
inefficiencies. You know the drill: the attending tours with residents
and interns to talk about the patients' prognosis and treatment. Not
until the end of rounds are X-rays, blood work, tests and treatments
ordered. This creates a daily avalanche that clogs order entry systems,
increasing the likelihood of mistakes and omissions, and delaying services
to patients. A pilot project on one oncology unit now uses a computerized
data cart that accompanies doctors on rounds. It's at the bedside at
each presentation. Physicians order tests and prescriptions on the spot.
No mix-ups, no clogs, no delays.
- Hopkins executives have "adopted" hospital units and taken
courses on how to measure hospital processes and identify bottlenecks
and barriers to change. We pay periodic visits, listen carefully to
what's bothering care-givers and what they need. There are a million
ways to say "no" to change in a large institution. Our job
is to knock down the roadblocks and quickly facilitate changes that
make sense. Already, there's a waiting list of units asking for executive
adoption that we intend to get to fast.
What the Innovation program seeks to build is a grass-roots enterprise,
that turns to physicians, nurses and managers to gather data, evaluate
changes and recommend and implement best practices. We will provide personnel,
training, information system support, coaches, tools and technology, along
with fast tracks to change, first on a small scale, then, if proven valuable,
on progressively larger entities. Above all, we are making it crystal
clear that improving patient care through systems changes is a top priority.
The culture of care will change.
If we've learned anything so far, it's that sometimes the simplest things
can make a huge difference in the lives of our patients and our care-givers.
Like providing cell phones to nurses on units with immunocompromised infants
so they needn't leave their tiny charges and spend time regloving and
regowning each time they take phone calls from worried family members.
Or placing tympanic thermometers and phones in every ICU area to help
nurses focus more time on patients. Or installing an electronic bed census
system so we know immediately when a patient is discharged and can automatically
The excitement generated by our early successes shows we are on the right
path. No one particularly likes change, but when it comes to patient care
and safety, it's not just vital, but the right thing to do.