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Dome - Measuring Up
Issue No. 646
Date: July 5, 2013
When a heart attack strikes, a silent clock starts ticking. Within minutes, the heart’s cells, starved of their typical diet of an oxygen-rich blood supply, begin to die. The longer a person goes without treatment to open a blocked blood vessel, the less likely she is to recover.
A multidisciplinary team at The Johns Hopkins Hospital has found a way to give patients the greatest chance at succeeding in this race for life. Last year, the group reduced the time between arrival and treatment for heart attack patients requiring immediate care from around 90 minutes, the national benchmark, to an average of 66 minutes.
That team is among 40 at the five Maryland- and D.C.-based hospitals in the Johns Hopkins Health System that worked to improve their 2012 performance in “core measures”: standardized best practices ranging from following recommended steps to prevent surgical complications to educating a teenager and his parents about how to manage his asthma. U.S. hospitals must report their compliance with dozens of these measures every year to The Joint Commission and the Centers for Medicare & Medicaid Services.
As part of a broader effort to demonstrate national leadership in patient safety and quality, leaders and trustees from across Johns Hopkins Medicine set a goal to reach 96 percent compliance on core measures across five hospitals. Last year, with support from the Armstrong Institute for Patient Safety and Quality, the health system exceeded that goal in seven targeted measures.
“Following core measures is about delivering the right care to the right patient at the right time,” says Renee Demski, senior director of quality improvement for the Johns Hopkins Health System and senior director of the Armstrong Institute. Ensuring that patients always receive the recommended therapies requires a well-orchestrated effort across disciplines, departments and—in some cases—beyond a hospital’s walls.
For example, The Johns Hopkins Hospital’s team of emergency medicine and interventional cardiology physicians, nurses and support staff collaborated closely with city and county emergency medicine services personnel to expedite the treatment of heart attack patients requiring immediate care. Now, the hospital’s Heart Attack Team is often activated before the patient reaches the Emergency Department—notice especially needed for team members who may not be on-site at night or on weekends.
“Everyone knows their role and how important it is,” explains quality improvement team leader Denice Duda, who facilitated the heart attack core measure workgroup. “That’s critical when you have more than a dozen different people involved in the process.”
At Suburban Hospital, the team has changed the process for giving immune-compromised and elderly patients the pneumococcal vaccine. Although compliance improved when nurses started screening patients, many patients still failed to receive the shot because it was offered on the day of discharge, says Ruth Dalgetty, Suburban’s quality adviser. “Patients were focused on what they needed to do to leave the hospital and didn’t want to wait for the shot,” Dalgetty explains. Thanks to an IT-developed electronic report that flags candidates earlier in their stay, and support from the pharmacy team, which now administers nearly all pneumococcal vaccines, more patients receive the shot.
Other improvements by clinical teams include new systems to remind providers when to start or discontinue therapy, online modules to educate staff on core measures, and revised electronic order sets with more required fields to improve documentation.
“In quality improvement, local solutions work best,” Demski explains. “What may fail in one hospital could work in another.”
The Armstrong Institute supported local teams by sharing lessons learned and best practices from across the system, developing an accountability model to communicate areas needing improvement to quality leaders, and pairing a faculty member and quality coach with each workgroup. Faculty members provided patient safety expertise in their fields while coaches trained in Lean Sigma—a business methodology designed to create more efficient processes—helped teams identify the causes of setbacks and barriers to improvement. In one such review, a coach used a failure mode analysis tool to evaluate workflow and calculate how many failures occurred at each step in the process.
“The Armstrong Institute gave us tools and a structured process for documentation so we could see bright spots and areas where we needed more work,” says Leslie Hack, clinical quality review manager at Howard County General Hospital.
Hack says adding phone calls to remind nurses to remove urinary catheters from patients within two days of surgery improved compliance with a core measure designed to prevent urinary tract infections. But a review of the team’s performance revealed a higher incidence of misses over the weekend—a time when extra staff members weren’t available to make such calls. To close the gap, the team enlisted the help of nursing shift directors, who now follow up on catheters that need to be removed over the weekend.
As a result of such efforts, the health system exceeded its goal of 96 percent compliance for seven of nine targeted core measures related to heart attack, heart failure, pneumonia, surgical care and children’s asthma care. For 2013, the system is also on track to meet the goal for the final two measures, both related to immunization. Howard County General Hospital, Sibley Memorial Hospital, Suburban Hospital and The Johns Hopkins Hospital received the 2013 Excellence Award for Quality Improvement in Hospitals from the Delmarva Foundation for their improved performance in core measures.
Now that many groups are meeting their target goals, the next challenge will be sustaining performance and focusing efforts on new measures related to stroke, blood clots, psychiatry, surgery and pregnancy care. Starting this year, Maryland hospitals also will report on hospital outpatient measures, such as how often patients left the Emergency Department without being seen, and whether a safe surgery checklist was used for outpatient procedures.
The Armstrong Institute has developed a sustainability checklist and reporting process to help teams continue their successes. Additionally, all employees will have access to an automated system-wide quality and safety dashboard that will show how each hospital is performing in core measures, hand hygiene, rates of central-line bloodstream infections in intensive care units, and patient experience survey scores.