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Managed Care Partners - Quality and the power of local wisdom

Managed Care Partners Summer 2012

Quality and the power of local wisdom

Date: June 1, 2012

The successful project to reduce central venous catheter bloodstream infections in intensive care units in Michigan hospitals proved to Armstrong Institute Director Peter Pronovost that clinical communities work.
The successful project to reduce central venous catheter bloodstream infections in intensive care units in Michigan hospitals proved to Armstrong Institute Director Peter Pronovost that clinical communities work.

As its latest foray into advancing patient safety and excellent care, Hopkins’ Armstrong Institute for Patient Safety and Quality is promoting cross-disciplinary “clinical communities,” a model that builds upon the shared wisdom of its members.

“Clinical communities are a way to tap into clinicians’ innate interest in improving quality,” says Armstrong Institute Director Peter Pronovost.

The concept is to create an officially sanctioned, system-wide forum for “identifying and solving problems together, to learn together and share, and to ensure that patient safety measures are devised by clinicians, not imposed upon them,” Pronovost says. “We learned that locally developed interventions are wiser, more likely to be effective and more likely to be implemented compared to top-down interventions.”

The Institute so far has chartered four fledgling clinical communities: ICU care, hospitalist medicine, improving medication safety and the postanesthesia care units.

At every level of care at each affiliate, the clinical community model can be replicated with central support from the Institute, adds Pronovost. He likens the model to a fern leaf, composed of smaller leaves all supported by a central stalk. Correspondingly, clinical communities are designed to devise safety and quality improvements replicated at every level of an organization to create a “unified whole” care delivery system.

Pronovost seeks to use this model to promote institutional autonomy in the face of mandates from federal regulatory groups: “By coming together as a community to determine what we want to be held accountable for and then backing up our convictions with sound science, we can find solutions that are more specific to Johns Hopkins Medicine.”

Before moving forward, however, the communities must coalesce. As recently as four months ago, many ICU personnel present at a Howard County General Hospital meeting were strangers. I-Fong Sun Lehman, the Armstrong Institute’s administrator for clinical communities, guided a lively and at times testy conversation among medical directors, nurse managers, nurse practitioners, respiratory therapists and others.

Her role provides a critical pillar of support to the communities. As ferns require a source of energy to grow, clinical communities require a vertical core of support to develop and sustain interventions across multiple levels of health care organizations, Lehman says.

The vertical core also supplies the backbone for fruitful collaborations, Pronovost says. “Human factor engineers, psychologists, sociologists, biostatisticians, epidemiologists and clinicians may all see the world a little differently, but together they can assemble a rich picture that allows us to find interventions that are likely to work.”

Comprehensive Unit-based Safety Program initiatives and other patient safety and quality improvement projects already abound in the health system, and it is not the Institute’s intention to replace such efforts, Lehman says. “We recognize local improvement efforts. We hope that each clinical group will openly communicate and consider collaborative opportunities with other safety efforts. Community members could leverage one unit’s successful project and pilot that across the health system.”

The clinical community concept has found additional acceptance as its fertile research possibilities become apparent. “Five years ago, doctors would never have embraced the idea of clinical communities,” Pronovost says. Now, the faculty is beginning to recognize their potential for research in the nascent field of patient safety and quality, he says. “They see it as a legitimate science.”

To foster discipline and progress within each clinical community, the Institute has formalized its expectations in a set of ground rules. Aspiring communities must draft a charter with goals, membership information, concrete plans for publishing findings or other accountability benchmarks to be approved by the Institute. Also required are presentations before the new enterprise-wide Patient Safety and Quality Board.

Pronovost foresees that within a year Hopkins Medicine’s first clinical communities will have improved patient outcomes, yielded impressive scholarly work and reduced medical costs. He also envisions the launch of new communities devoted to solving problems specific to certain diseases or broader priorities, such as nurturing the practice of patient- and family-centered care.

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