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Creating a High-Reliability Health Care System: Improving Performance on Core Processes of Care at Johns Hopkins Medicine

Pronovost, Peter J. MD, PhD; Armstrong, C. Michael; Demski, Renee MSW, MBA; Callender, Tiffany MSW; Winner, Laura MBA; Miller, Marlene R. MD, MSc; Austin, J. Matthew PhD; Berenholtz, Sean M. MD, MHS; Yang, Ting PhD, MHS; Peterson, Ronald R. MHA; Reitz, Judy A. ScD; Bennett, Richard G. MD; Broccolino, Victor A. MBA; Davis, Richard O. PhD; Gragnolati, Brian A. FACHE; Green, Gene E. MD; Rothman, Paul B. MD

doi: 10.1097/ACM.0000000000000610
Articles

In this article, the authors describe an initiative that established an infrastructure to manage quality and safety efforts throughout a complex health care system and that improved performance on core measures for acute myocardial infarction, heart failure, pneumonia, surgical care, and children’s asthma. The Johns Hopkins Medicine Board of Trustees created a governance structure to establish health care system-wide oversight and hospital accountability for quality and safety efforts throughout Johns Hopkins Medicine. The Armstrong Institute for Patient Safety and Quality was formed; institute leaders used a conceptual model nested in a fractal infrastructure to implement this initiative to improve performance at two academic medical centers and three community hospitals, starting in March 2012. The initiative aimed to achieve ≥ 96% compliance on seven inpatient process-of-care core measures and meet the requirements for the Delmarva Foundation and Joint Commission awards. The primary outcome measure was the percentage of patients at each hospital who received the recommended process of care. The authors compared health system and hospital performance before (2011) and after (2012, 2013) the initiative. The health system achieved ≥ 96% compliance on six of the seven targeted measures by 2013. Of the five hospitals, four received the Delmarva Foundation award and two received The Joint Commission award in 2013. The authors argue that, to improve quality and safety, health care systems should establish a system-wide governance structure and accountability process. They also should define and communicate goals and measures and build an infrastructure to support peer learning.

Dr. Pronovost is senior vice president of quality and safety, Johns Hopkins Medicine, director, Armstrong Institute for Patient Safety and Quality, and professor, Departments of Anesthesiology and Critical Care Medicine, Surgery, and Health Policy and Management, School of Nursing and Carey Business School, Johns Hopkins University, Baltimore, Maryland.

Mr. Armstrong is chairman, Johns Hopkins Medicine Patient Safety and Quality Board Committee, and, until October 2013, was chairman, Johns Hopkins Medicine Board of Trustees, Baltimore, Maryland.

Ms. Demski is vice president of quality improvement, Armstrong Institute for Patient Safety and Quality and Johns Hopkins Health System, Baltimore, Maryland.

Ms. Callender is senior quality and innovation coach, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

Ms. Winner is director of Lean Sigma deployment, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

Dr. Miller is Johns Hopkins Medicine chief quality officer for pediatrics, vice chair of quality and safety, and professor, Department of Pediatrics, Johns Hopkins University, and core faculty, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

Dr. Austin is assistant professor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.

Dr. Berenholtz is professor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Departments of Anesthesiology and Critical Care Medicine, Surgery, and School of Medicine, and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.

Dr. Yang is senior biostatistician, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

Mr. Peterson is president, The Johns Hopkins Hospital and Johns Hopkins Health System, and executive vice president, Johns Hopkins Medicine, Baltimore, Maryland.

Dr. Reitz is executive vice president and chief operating officer, The Johns Hopkins Hospital, and vice president for operations integration, Johns Hopkins Health System, and vice president for quality improvement, Johns Hopkins Medicine, Baltimore, Maryland.

Dr. Bennett is president, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

Mr. Broccolino was president and chief executive officer, Howard County General Hospital, Columbia, Maryland, until January 2014.

Dr. Davis is president, Sibley Memorial Hospital, Washington, DC.

Mr. Gragnolati is senior vice president, Johns Hopkins Health System, Baltimore, Maryland.

Dr. Green is president, Suburban Hospital, Bethesda, Maryland.

Dr. Rothman is dean of the medical faculty and chief executive officer, Johns Hopkins Medicine, Baltimore, Maryland.

Funding/Support: None reported.

Other disclosures: Dr. Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc. (blood pressure control improvement); honoraria from various health care organizations for speaking on patient safety and quality (the Leigh Bureau manages these engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; fees to be a strategic advisor to the Gordon and Betty Moore Foundation; and stock and fees to serve as a director for Cantel Medical. Dr. Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. Dr. Berenholtz has received support from the Agency for Healthcare Research and Quality, the National Institutes of Health, and the World Health Organization for work on other studies and receives honoraria and travel expenses from various hospitals, professional societies, and hospital associations for consulting and speaking on patient safety and quality improvement topics. The remaining authors report no conflicts of interest related to the content of this article.

Ethical approval: The Johns Hopkins institutional review board deemed that this initiative was quality improvement and exempt from review.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A252.

Correspondence should be addressed to Dr. Pronovost, 750 E. Pratt St., 15th Floor, Baltimore, MD 21202; telephone: (410) 502-6127; e-mail: ppronovo@jhmi.edu.

© 2015 by the Association of American Medical Colleges