20 Healthcare Executive

MAR/APR 2017
BUILDING ON SUCCESS
TO CONQUER PATIENT HARM
By Maggie Van Dyke
Healthcare organizations have been
engaged in intense battles of whack-
a-mole in recent years to secure
patient safety, says Peter Pronovost,
MD, PhD, senior vice president of
patient safety and quality, Johns
Hopkins Medicine, Baltimore. The
campaigns have mostly focused on
fighting one type of patient harm
at a time such as adopting evidence-
based protocols to prevent ventilator-
associated pneumonia.
These focused crusades have pro-
duced significant wins: Hospital-
acquired conditions—from adverse
drug events to pressure ulcers—fell
by 21 percent between 2010 and
2015, saving the lives of 125,000 peo-
ple and reducing costs by almost
$28 billion (see the chart on page 22).
Just as important, healthcare organi-
zations have developed needed capac-
ities and raised staff awareness to fight
patient harm. “Twenty years ago, we
didn’t talk about safety or, when we
did, the response was often ‘Errors in
hospitals just happen,’” says Stephen
T. Lawless, MD, senior vice president
and chief clinical officer, Nemours
Children’s Health System, Talleyville,
Del., and an ACHE Member. “Today,
you can’t walk into a hospital where
patient safety is not top of mind.”
Yet the overall war against patient
harm continues. Millions of patients
still suffer from preventable harm,
both inside and outside the hospital.
What will be required to claim victory,
Pronovost believes, is for healthcare
Healthcare Executive 21
MAR/APR 2017
Reprinted with permission. All rights reserved.
 BUILDING ON SUCCESS TO CONQUER PATIENT HARM

settings to be redesigned to run as Structure Quality/Safety Similar Vertical accountability. Following

safely and seamlessly as airplane
cockpits, taking advantage of tech-
nology, big data, scientific approaches
and leadership best practices to help
clinicians prevent and respond to all
potential patient harms at once.
“This approach involves building a
performance management system like
those found in the airline and nuclear
power industries,” Pronovost says.
“They don’t view quality as a project
but as an integrated system that
addresses all harms rather than just
one harm at a time like it’s a game of
whack-a-mole.”
How can healthcare organizations
build these performance management
systems? Pronovost and other leaders
point to six key strategies.
to Finance
Recognizing the fragmented nature
of its quality and safety approach,
Johns Hopkins considered a simple
question. “We asked, ‘Does our
board quality committee function
like our board finance committee?’”
Pronovost says. “Many healthcare
organizations are complex structures.
Yet, somehow, a profit-and-loss state-
ment flows up from all those nooks
and crannies into one consolidated
statement.”
Finance also has explicit account-
ability models, Pronovost says.
“If you miss your budget, nobody
says, ‘Just try harder next month.’
You are expected to create a plan
for improvement.”
the example of finance, Johns Hopkins
created a vertical line of accountabil-
ity from the board’s patient safety
and quality board committee to every
ambulatory practice, inpatient unit
and other patient setting across its
system. The presidents of each system
entity (i.e., hospital and community
physician practices) regularly present
quality scores to the board committee
and develop an improvement plan if,
for example, a unit does not meet
targets for hospital-acquired condi-
tions. If quality scores remain off tar-
get after three reporting periods, an
audit is conducted using a shared
accountability approach.
“Our leaders hold themselves
accountable before they hold some-
one from a lower level accountable,”
Pronovost says. “They ask, ‘Did this

Reducing Estimated number of patient team have the skills, resources and

Patient Percentage3.1 million between 2010 and 2015

harm incidents prevented
➜

time it needed? Was I clear about the

1
goals?’ Too often, we think account-

due to preventing adverse drug events 42.3%

of the reduction in patient harm ability means being tough, as
Harm:
1
opposed to saying in a nurturing way,
Estimated savings from the
‘Did I set you up to be successful?’”
We’ve $28.2 billion reductions in patient harm achieved
between 2011 and 2015 1

Come a occurring per 1,000 hospital discharges in 2015 115

Number of hospital-acquired conditions still
1
Christiana Care Health System,
Wilmington, Del., believes transpar-

Long Difference in risk-adjusted patient ency is instrumental to promoting

accountability. “In our journey to
Way … 10.2-fold and least safe U.S. hospitals
safety outcomes between the most
2 zero, we give our service lines a
grade—A to F,” says Sharon L.
but Have Much Farther to Go Anderson, RN, FACHE, chief popu-
References lation health officer and senior vice
1. Agency for Healthcare Research and Quality, National Scorecard on Rates of Hospital-Acquired president, quality and patient safety.
Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer, December 2016.
http://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html “It has created a little bit of competi-
2. B. L. Rosenberg, J. A. Kellar, et al., “Quantifying Geographic Variation in Health Care Outcomes
in the United States Before and After Risk-Adjustment,” PLOS One, December 14, 2016. tion and driven our culture to con-
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166762#abstract0
stantly improve.”

22 Healthcare Executive
MAR/APR 2017
Reprinted with permission. All rights reserved.
 BUILDING ON SUCCESS TO CONQUER PATIENT HARM
The health system assigns these
grades, which are updated monthly,
based on performance metrics related
to patient harm; readmissions; and
the Triple Aim of improving health
outcomes, patient experience and
affordability. “We have interactive
tableau dashboards that every
employee can access,” says Michelle
Campbell, RN, vice president, patient
safety and accreditation. “They can
drill down to see, for example, what
contributes to their service line’s pre-
ventable harm rate so they know
where to focus their energies.”
Horizontal connections. Johns
Hopkins also created horizontal
structures, known as clinical commu-
nities, that bring together front-line
leaders and staff from across the cor-
porate health system to set quality-
related goals, learn from each other
and collaborate to reduce patient
“Get out of the
office and talk to
patients and families,
and ask staff what
keeps them awake at
night and what they
need to provide safe,
quality care.”
— Paulette Evans, RN
HSHS St. Joseph’s Hospital Breese
24 Healthcare Executive
MAR/APR 2017
Reprinted with permission. All rights reserved.
harm. Pronovost says, “It is these hor-
izontal connections that provide the
power for improvement, changing the
narrative from ‘harm is inevitable’ to
‘harm is preventable and I am
empowered to do something about
it.’” He says that because “front-line
staff alone cannot always bring about
improvements, their efforts are sup-
ported by vertical infrastructure such
as clinical analytics and process
improvement expertise.”
Christiana Care reorganized by
service line to encourage horizontal
collaboration. All of the system’s nine
service lines are charged with devel-
oping a new clinical pathway each
year to reduce variation in care and
support the achievement of the Triple
Aim. In 2015, the women and chil-
dren’s service line focused on early
identification of and follow-up for
women at risk for gestational diabetes
to prevent birth complications and
ensure these new mothers are regu-
larly screened for Type 2 diabetes,
given their elevated risk.
“We worked with our primary care
and community medicine service
line, which also was working to
improve Type 2 diabetes care across
the continuum,” says Linda T.
Daniel, RN, director, quality and
patient safety, women and children’s
line, and an ACHE Member. “A lot
of the population we serve doesn’t
follow through with doctors’ orders
due to personal or financial reasons.
For instance, they may not get their
prenatal diabetes testing done
because they don’t have insurance.
We have taken away those barriers
and are making sure these women are
identified early and monitored for a
positive outcome.”
Together, these vertical and horizon-
tal structures drive positive change by
building trust, Pronovost says. “Change
progresses at the speed of trust, and
trust flows when you do things with
rather than to people.” He continues,
“Leaders have a responsibility to
describe why and what the organiza-
tion is doing, but they have to defer
the ‘how’ to the people doing the
work. If people don’t have a voice in
co-creating the solutions, they feel
like things are being done to them
rather than with them.”
Design for High Reliability
High-risk industries with remark-
able safety records, such as nuclear
power and air travel, achieve these
results by committing to high reli-
ability and pursuing zero harm,
Pronovost says. “They standardize
work whenever possible, but more
importantly, they recognize they can
never standardize everything and
safety problems are inevitable. So
these organizations build resiliency
so staff are prepared to respond to
and bounce back from safety prob-
lems that develop.”
Standardization. Christiana Care is
taking a multipronged approach to
patient safety, focusing on achieving
high reliability as well as creating a
safe culture and leveraging
 BUILDING ON SUCCESS TO CONQUER PATIENT HARM

technology. “We assume all harm is falls—by 66 percent during the past pressure ulcers and birth traumas for
preventable,” says Anderson. By five years. more than a year, says President and
standardizing clinical practice to CEO Paulette Evans, RN.
reflect evidence-based protocols, the HSHS St. Joseph’s Hospital Breese
system has reduced leading types of (Ill.) also aims for zero harm and has While small, the 49-bed hospital is
patient harm—from catheter-related maintained a rate of zero catheter- at the forefront of patient safety and
urinary tract infections to patient related urinary tract infections, quality, earning an “A” grade from
the Leapfrog Group and a 5-star rat-
ing from the Centers for Medicare
Three Narratives Keeping Healthcare From Getting to Zero Harm & Medicaid Services. Evans credits
“Stories are the most powerful forces for change in the world,” says Peter the hospital’s committed medical
Pronovost, MD, PhD, senior vice president, patient safety and quality, staff, who have worked closely with
Johns Hopkins Medicine. “They either pin you to your current perfor- nurses to ensure evidence-based pro-
mance or propel you to new pinnacles.” tocols are consistently followed to
prevent and manage common
Reflecting on healthcare’s current safety record, Pronovost cites three nar- patient harms, from deep vein clots
ratives that are holding organizations back from attaining zero harm. to CAUTIs.

We still accept harm as inevitable rather than preventable. Pronovost first won Resiliency. Having daily safety hud-
patient safety accolades for developing a checklist with colleagues at the dles is one way St. Joseph’s Hospital
Michigan Health and Hospital Association’s Keystone Center that dra- keeps safety top of mind and ensures
matically reduced catheter-related bloodstream infections. However, staff respond quickly to any possible
Pronovost insists it was not the checklist that made the big difference. issues. “Managers are asked to bring
“The big change was clinicians saying, ‘These infections are preventable, forward any safety concerns,” Evans
and I can do something about it,’” he says. “In other words, they told a says. “For instance, physical therapy
new story. Yes, they needed the checklist tool, but without telling that new might mention a wheelchair that isn’t
story, the tool wouldn’t have been as impactful.” working correctly. The concern is
recorded, and it stays on the [track-
We still view quality and safety as a project. “We work on one harm at a time ing] board until it is corrected.”
rather than designing the health system so it doesn’t harm anyone,”
Pronovost says. The old stories of success in these one-off areas were help- The hospital also is rolling out
ful as organizations ramped up their quality improvement initiatives. TeamSTEPPS, a communications
Now, however, a new, overarching narrative is needed to usher in whole- and team-building approach
sale change. developed by the Agency for
Healthcare Research and Quality
We rely on the heroism of our clinicians rather than the design of safe systems. and the U.S. Department of
“We’ve spent a lot of money on information technology and, frankly, have Defense. “There is no hierarchy
precious little to show that it’s impacted safety because the usability is poor within TeamSTEPPS,” Evans says.
and the systems don’t talk to each other. We need to design our hospitals “Everyone can speak up—from the
and clinics to be as seamlessly integrated as the cockpit of a plane.” Heroic physician to the housekeeper—and
acts make for dramatic and impactful stories, but they place undue stress say, ‘Hey, something’s not right with
on providers and the entire system when processes aren’t well-designed. this,’ which prompts us to step back

26 Healthcare Executive
MAR/APR 2017
Reprinted with permission. All rights reserved.
and take a look. Everyone has an
equal voice in ensuring we provide
the safest possible environment for
our patients.”
Ensure IT Systems and
Devices Talk to Each Other
Several leaders noted that the quest
for IT interoperability goes hand in
hand with improving patient safety.
Despite spending enormous sums on
EHR systems, infusion pumps and
other tools, these systems often do
not talk to each other and set off fre-
quent false alarms, contributing to
alarm fatigue and inhibiting nursing
productivity, Pronovost says.
“Our nurses answer a false alarm
every 90 seconds,” he says. “It’s not
safe, and we could get 30 to 40 percent
productivity gains if we designed a
healthcare system to be like a cockpit
where all systems talk to each other.”
An integrated EHR. Lawless credits
Nemours’ exemplary 0.001 percent
medication error rate for harm in
part to the children’s hospital’s inte-
grated EHR. “We’ve spent a lot of
time ensuring everybody can talk to
everybody else via one single patient
chart,” Lawless says. “Whether you’re
an anesthesiologist, an emergency
department nurse or a parent, you
can view the same chart and see the
patient’s latest medications and other
information.”
Thanks to Delaware’s statewide
health information network, clini-
cians at Nemours and Christiana
Care also can see when their patients
have visited an ED at another hospi-
tal or been given a prescription by a
chain store’s urgent care center.
Referring physicians and school
nurses have access to the patient’s
chart as well, with permission from a
parent or guardian.
Nemours is probably five years
ahead of most health systems in
terms of interoperability, Lawless
believes. “At Nemours, we’re making
care contiguous.”
An automated checklist of all
checklists. Project Emerge is one
example of how Johns Hopkins
Medicine is working to design a
medical unit that is as technology
savvy as an airplane cockpit. The
software application, co-developed
by clinicians and engineers at Johns
Hopkins University Applied Physics
Laboratory, pulls data from the
EHR and various patient monitors
and devices to identify specific
actions clinicians should take to pre-
vent patient harm.
“Patients are at risk for a dozen
harms, and every harm may have a
checklist,” Pronovost says. “Every
checklist may have five or 10 items,
and every item may need to be done
three or four times a day. You add it
up, and patients may need 150
items a day. There’s not an EHR on
the market that gives you any visual
display of whether you’ve done
those 150 things. It takes hundreds
of mouse clicks to find out if
patients received all the recom-
mended tasks.”
The Project Emerge app creates a
harms profile for each patient, graph-
ically illustrating whether clinicians
need to, for example, raise a patient’s
head to prevent a respiratory infec-
tion. “Emerge has improved compli-
ance with best practices for all these
harms by about 70 percent,”
Pronovost says. “We’ve stopped rely-
ing on the heroism of our staff and
designed a safer system.”
“Leaders have a
responsibility to
describe why and what
the organization is
doing, but they have
to defer the ‘how’
to the people doing the
work. If people don’t
have a voice in
co-creating the
solutions, they feel
like things are being
done to them rather
than with them.”
—Peter Pronovost, MD, PhD
Johns Hopkins Medicine
Healthcare Executive 27
MAR/APR 2017
Reprinted with permission. All rights reserved.
 BUILDING ON SUCCESS TO CONQUER PATIENT HARM

Develop a Learning Culture States. The focus: methicillin- screening ICU patients for MRSA
As defined by the Institute of resistant Staphylococcus aureus. and then isolating, or isolating
Medicine, a learning health system and decolonizing, those who
commits to using data collected as a Following a learning health system tested positive.
by-product of patient care to drive approach, HCA volunteered to
continuous improvement. Nashville, serve as the study platform for a The ICUs that used universal decol-
Tenn.-based HCA has embraced this randomized trial comparing MRSA onization reduced MRSA rates by
notion to frame its quality and prevention approaches. Due to its 37 percent and all life-threatening
safety improvement approach, fueled large size, HCA was able to test bloodstream infections by 44 per-
in part by what Jonathan Perlin, three different strategies in 74 inten- cent. This decrease was on top of
MD, PhD, calls “the digital divi- sive care units across 43 hospitals, already low infection rates attained
dend” of EHR adoption. following 75,000 patients over by using previously accepted best
18 months. practices.
“Now that we have met the
successive levels of meaningful use, The study, described in a 2013 Once universal decolonization was
we have this incredible data trail article by Susan S. Huang, MD, and identified as the optimal approach,
that we have put to good use in colleagues published in The New HCA lost no time in instituting it in
some interesting ways,” says Perlin, England Journal of Medicine, found all the system’s ICUs. Within six
CMO and president, clinical that universal decolonization, months, bloodstream infection rates
services. which involves giving all ICU had fallen by 42 percent across the
patients an antiseptic sponge bath entire system.
Notably, HCA has hosted one of the and antibiotic nose drops for five
largest comparative effectiveness tri- days, was more effective than the “That’s an example of a learning
als ever conducted in the United previously accepted best practice of health system in action,” Perlin says.
“In the past, this study would have
been really cumbersome, long and
Nemours’ Behaviors for Leaders and Staff to
expensive to conduct because all the
Achieve Clinical Safety
data would have to be rolled up on
1. Be in the moment.
paper. Because of the standardization
2. Be authentic and humanistic.
of data elements—which was part
3. Volunteer discretionary effort constantly. and parcel of computerization and
4. Model high performance—desired behaviors that drive desired results. meaningful use—we were able to
5. Respect and leverage separate realities, or consider the other person’s complete in 18 months across 43 hos-
perspective to elicit a dialogue versus jumping to conclusions. pitals what might have taken one
6. Be curious versus judgmental. hospital 64 years.”
7. Look in the mirror first—be accountable.
8. Have courageous conversations. Predict Harm Before It Happens
9. Provide timely, clear and specific performance expectations and feedback. Perlin is excited to talk about the
10. Teach, coach and mentor—spend at least half of your time developing others. potential of predictive analytics and
artificial intelligence to help clini-
Source: Nemours’ Standards of Behavior adopted from LeadQuest Consulting Inc. cians spot patient threats in time to
prevent them.

28 Healthcare Executive
MAR/APR 2017
Reprinted with permission. All rights reserved.
 BUILDING ON SUCCESS TO CONQUER PATIENT HARM
Predictive modeling. Take sepsis,
for example. “This is a situation in
which the patient is deteriorating but
you can’t really see it,” Perlin says. “At
the point where you can detect that
the patient is deteriorating, they are
already falling off the cliff and have a
high likelihood of dying. The only
option at that point is to jump in and
rescue. HCA has become world class
at intervening to save patients as they
fall off that cliff, which is great. But
it is like a program where you don’t
respond to a fire until you see flames
shooting out of the building. We
don’t want to stop severe fire, we
want to smell the smoke.”
To that end, HCA data scientists
and clinicians have developed a pre-
dictive algorithm that regularly
monitors key data elements in a
patient’s EHR (e.g., vital signs, lab
results) and alerts clinicians to
patients with early-stage sepsis 13
hours before most clinicians would
have recognized the condition.
HCA is now determining how best
to integrate the predictive model
into clinical practice. The develop-
ment team has dubbed the model
SPOT—for sepsis prediction and
optimization of therapy—and cre-
ated an icon of a sniffing dog to help
promote the tool.
Pronovost’s team published a study
demonstrating that by using machine
learning tools, they could predict
who would develop septic shock 24
hours before it occurred, providing
30 Healthcare Executive
MAR/APR 2017
Reprinted with permission. All rights reserved.
an opportunity to treat and prevent
development of shock.
Artificial intelligence. Data scien-
tists at HCA also have been training
computer systems to read radiology
reports and identify patients who do
not follow up on incidental findings
such as potentially cancerous nodules
found during CT scans for shoulder
tears. “Our goal is to improve quality
by finding early disease when it is
treatable and curable,” Perlin says,
“and prevent the harm of missed
diagnosis, which is an error of omis-
sion and the No. 1 cause of lawsuits
against emergency departments.”
Equipped with natural language pro-
cessing—the ability to read text as
well as data—the artificial intelli-
gence system has reviewed 33,000
CT scan reports from three HCA
EDs. “The system is beginning to
understand the difference between a
tobacco user, which may be signifi-
cant to someone with a nodule, and a
young, healthy farmer who happens
to plant tobacco,” Perlin says.
Of those 33,000 scans, 1,055 cited
potentially cancerous incidental
findings, which were followed up on
by clinicians. “We are not quite
ready to turn over the entire diagno-
sis process to a computer, so we had
clinicians read those reports and,
indeed, the machine was right,”
says Perlin.
Fifty-five of the 1,055 patients ended
up undergoing biopsies, and 10 of
these patients were diagnosed with
early-stage, treatable lung cancer.
Model the Key Behaviors
Many hospitals with top safety
records have adopted key values and
behaviors to guide leaders and staff
during performance improvement
work. For instance, Nemours has
identified 10 values-based behaviors
to focus on, including “have coura-
geous conversations” and “be curious
versus judgmental” (see the chart on
page 28).
As hospitals work toward zero harm,
it’s vital for staff to see senior leaders
demonstrating these behaviors. “Get
out of the office and talk to patients
and families,” Evans says, “and ask
staff what keeps them awake at night
and what they need to provide safe,
quality care.”
Maggie Van Dyke is a freelance writer
and editor based in the Chicago area.
“In our journey to zero,
we give our service lines
a grade—A to F. It has
created a little bit of
competition and driven
our culture to constantly
improve.”
—Sharon L. Anderson, RN, FACHE
Christiana Care Health System