Johns Hopkins was an early leader in real-time, full disclosure of patient safety incidents, including the number of people harmed at the hospital. The Johns Hopkins Center for Innovation implemented the first-ever Weekly Report of Harm, which it e-mails each Friday afternoon to more than 300 people, from the board of trustees to mid-level management.
The Weekly Report of Harm was designed with a format that grabs attention and is locally important and actionable. Johns Hopkins identified the areas of highest harm and highest impact and placed them on the report, which now includes data in such measures as central line-associated bloodstream infections, certain surgical site infections, hand-hygiene performance, and medication errors. These are strategic areas of focus for Johns Hopkins, and the Weekly Report of Harm is an effective tool to focus attention the attention of our providers and hospital executives alike.
The report is designed to drive action at the unit level, and we have revised it to make sure that we meet this objective. For instance, bloodstream infection data had previously been presented as a rate. The Weekly Report of Harm first presented the data as the number of people, by unit, who got an infection in the last week. This was later changed to the number of weeks since the last bloodstream infection on each unit, because we found that this format was more engaging to frontline staff.
Our administrative and clinical leaders have embraced the measurement and reporting of robust quality metrics as an important mechanism to drive the improvement of clinical processes. The goals of measurement and reporting are realized more quickly when they are linked to an organizational commitment to learning and continuous improvement, and when providers are engaged as partners. Measurement is for improvement, not for blame. This framework saves lives.
We encourage other health care organizations to adopt the Weekly Report of Harm with indicators based on what is important to their organization.