Good Outcomes Take Good Systems

By Edward D. Miller, M.D.

I 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 a difference.

• 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 notify housekeeping.

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.